Outcome of Low and Very Low Birth Weight Infants: A Case for Regionalization of Perinatal Care in Saudi Arabia
1986; King Faisal Specialist Hospital and Research Centre; Volume: 6; Issue: 4 Linguagem: Inglês
10.5144/0256-4947.1986.247
ISSN0975-4466
Autores Tópico(s)Birth, Development, and Health
ResumoOriginal ArticlesOutcome of Low and Very Low Birth Weight Infants: A Case for Regionalization of Perinatal Care in Saudi Arabia Khalid N. HaqueMB, BS, FRCPI, FRCP(Edin) Khalid N. Haque Associate Professor and Consultant in Charge of Neonatology, Department of Pediatrics, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia Published Online:1 Oct 1986https://doi.org/10.5144/0256-4947.1986.247SectionsPDFCite ToolsAdd to favoritesTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTThe morbidity and mortality of all 259 low birth weight deliveries (between 500 and 2,500 grams) born at the King Khalid University Hospital (KKUH), in Riyadh, Saudi Arabia, between the Hejira years 1403–1404 (Gregorian years: mid-October 1982 to September 1984) are reported. Of these infants, 237 (91.5%) were discharged alive. The survival rate of infants weighing less than 1,000 gm at birth was 70%. There was a short-term handicap rate of 7%, of which 5% were deemed to have a major handicap. A case is made for regionalization to improve reproductive medical care in the Kingdom.INTRODUCTIONThe advances of perinatal pediatrics in the last twenty years have been spectacular. One of the major goals in reproductive medical practice is to achieve the lowest possible perinatal mortality rate (PMR). While we have gone a considerable way towards this goal, at present in Saudi Arabia a large number of fetal deaths occur due to lack of adequate care.1The single most important variable in infant survival is birth weight. Efforts to reduce mortality among the low birth weight (LBW) and the very low birth weight (VLBW) premature infants have been extremely successful.2,3 We report the outcome of the LBW and VLBW infants born at our institution and also comment on the handicap rate among these infants on short-term follow-up.Our objective is to show what can be achieved at a high-risk perinatal center and suggest how regionalization could improve perinatal care in the Kingdom.PATIENTS AND METHODSThe King Khalid University Hospital (KKUH) is located in the Dirriyah district of Riyadh. The hospital offers all levels of care to all Saudi citizens, as well as government and university employees. Patients are referred from all over the Kingdom and are also admitted via the accident and emergency department.The obstetrical unit handles more than 1,500 births per year (currently about 2,000), the majority (82%) of which are high-risk pregnancies.4 The Neonatal Intensive Care Unit (NICU) is a custodial unit, admitting only infants born at KKUH or at the King Abdulaziz University Hospital. For the purpose of this paper, the infants born at King Abdulaziz University Hospital and transferred to the NICU at KKUH have been excluded.During the Hejira calendar year 1403 (October 1982 to October 1983) there was a total of 1,176 births, and in 1404 H (October 1983 to September 1984) the number of births had risen to 1,709. The number of babies born weighing 2,500 gm or less (LBW) was 119 (10%) in 1403 H, and 140 (8%) in 1404 H. Of these, 26 (22%) and 35 (25%), respectively, weighed less than 1,500 gm (VLBW).Information on these babies was obtained from their medical records. The obstetrical and neonatal management of these infants was very similar to the currently acceptable practice in major perinatal centers of North America.5–7 A neonatal unit resident or an experienced senior registrar in pediatrics attended all high-risk deliveries. The author was personally involved in the care of each of these babies.In the event that maintenance of intensive care was thought to be inadvisable and/or withdrawn, the decision was made by the consultant-in-charge in consultation with other colleagues and the family (mainly the father) of the baby. Mortality is reported as early neonatal death (death within first 7 days of life); neonatal death (death within 28 days of birth), and deaths after discharge.In the follow-up clinic, the infants were assessed at the 'due date' (40 weeks postmenstrual period) and at 3, 6, 9, 12, 18 and 24 months. Some infants were seen more frequently when clinically indicated. In the follow-up clinic, a detailed physical examination was performed, and growth parameters were measured and recorded on a Gairdner and Pearson growth chart.8 A brief developmental screening was also performed. These infants were also seen separately by a pediatric neurologist for neuromotor and developmental assessment at the ages of 6 and 9 months. When required, multidisciplinary consultations (e.g., cardiology, neurosurgery) and investigations [e.g., ultrasound of the head, computerized tomogaphy (CT) scan of the brain, evoked potentials] were coordinated through the follow-up clinic.Handicaps are reported in terms of both neurologic and functional classification as suggested by Saigal, et al.9,10 Infants with handicaps were referred to appropriate facilities for ongoing care.RESULTSBirths and DeathsDuring the two years there was a total of 259 live births of infants with birth weight between 500 and 2,500 gm (139 boys and 120 girls), and of these there were 61 who weighed less than 1,500 gm at birth. Weight-specific mortality is shown in Figure 1, and mortality according to gestational age is shown in Figure 2. The main clinical causes of early neonatal deaths (autopsy is normally not possible in the Kingdom) are shown in Figure 3. The majority (43%) of deaths in the two years were due to lethal congenital malformations.Figure 1. The mortality over a two-year period is shown to be inversely proportional to birth weight, with the highest risk of mortality among newborns of less than 750 gm.Download FigureFigure 2. Mortality is also dependent on gestational age, as shown on this graph, with newborns of 27 weeks or less gestation facing high mortality rates.Download FigureFigure 3. Lethal congenital malformations were the most common cause of death in low-birth-weight newborns, followed by sepsis and then asphyxia and respiratory causes.Download FigureDuring 1403 H, 5 (4.2%) of the infants died during the neonatal period and 7 (5.8%) died after the neonatal period. Whereas, in 1404 H, 11 (7.8%) died in the neonatal period and only 3 (2.1%) died after the neonatal period. Intensive care was not instituted in two infants because of extreme prematurity (22 weeks gestation) in one, and major multiple lethal congenital malformation in the other. Intensive care was withdrawn in another two infants for the reasons of severe birth asphyxia with unresponsiveness to intensive care over three days in one infant and a hypoplastic left heart syndrome in another infant. Thus, intensive care was either not instituted or withdrawn in a total of 4 (1.5%) infants.Out of the total of 259 infants, 237 (91.5%) were discharged home. An Apgar score of less than 5 at 5 minutes was recorded in 20% of the infants and 190 (80%) of them required respiratory support, a combination of continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV) and intermittent mandatory ventilation (IMV). The total duration of ventilatory therapy in the survivors was 1-34 days (mean 8).During the two years of this study, the perinatal mortality rate at KKUH was 13/1,000 and 19.5/ 1,000 total births and the neonatal mortality rate was 6.8/1,000 and 8.7/1,000 live births, respectively.OutcomeMajor clinical problems in the survivors were sepsis (suspected or proven) in 85 (36%); respiratory distress syndrome (RDS) in 161 (68%); bronchopulmonary dysplasia (BPD) in 7 (3%); patent ductus arteriosus (PDA) in 26 (10%); and necrotizing enterocolitis (NEC) in 38 (16%). Ultrasound of the head was done in only 86 infants; 39 (45%) of these had some degree of cerebral bleeding. Seizures occurred in 17 (7%); hydrocephalus was diagnosed prior to discharge in 2, and 1 had a shunting procedure performed. Other surgical procedures included 2 for NEC and 3 for duct ligation (duct ligation was done at Riyadh Armed Forces Hospital and infants returned to KKUH postoperatively). Eighty-four (36%) infants received one or more blood transfusions, and exchange transfusion was performed in 26. The median stay in the unit was 62 days (range 3 to 270).Follow-up of SurvivorsNineteen infants (8%) were lost to follow-up. There was a total of 10 (4.2%) postdischarge deaths. No further information could be obtained about the 19 infants lost to follow-up, so they have been excluded from further analysis. Catch-up growth was observed in 175 infants (80.5%) using the Gairdner and Pearson growth charts.8 There was no sex difference in the catch-up growth pattern. Eight (3.6%) of the infants developed chronic problems due to the intensive care (BPD, short bowel syndrome) and required frequent hospitalization.Twelve (5.5%) infants were diagnosed as having major handicaps including eight with cerebral palsy,11 and blindness due to retrolental fibroplasia in two infants (0.9%). Some had more than one problem. According to the functional classification suggested by Saigal,10 6 had major and 4 had moderate dysfunction, and 2 were classified as having only minor dysfunction.Survival improved with increasing birth weight (Figure 1). There seems to be a 'cut off or a 'threshold' birth weight at which the outcome changes markedly. For an infant weighing < 750 gm, the chances of survival were 25%, but with a birth weight of > 751 gm, the chances of survival increased to 72.5% or greater. Survival was also related to gestational age with survival at 73% for those born after 26 weeks and over 90% for infants born at 33 weeks or more. Survival below 25 weeks was less optimistic and seemed to improve with increasing postnatal age. Two-thirds of the deaths occurred within the first 24 hours of postnatal life.DISCUSSIONReports have appeared in the literature on the continued improved outcome of LBW and VLBW infants.1,2,12–14 Many reports about health and perinatal care in Saudi Arabia have also appeared in the local literature,15–20 but none deal specifically with the problems of LBW and VLBW infants, their outcome, and the impact aggressive neonatal intensive care has had on their survival in this country.Contemporary literature5–7,13,14 has shown that survival rates of infants weighing < 1,000 gm at birth vary between 30 and 80% with the handicap rate between 5 and 50%. Our rates for survival for such infants are 70% with a handicap rate of 7%. Ohlsson1 has attempted to compare the PMR at various institutions of the Kingdom. Such comparisons are fraught with danger of being erroneous. As Ohlsson found, the definition of PMR varies from hospital to hospital and from author to author, occasionally resulting in different figures from the same institution.21,22 The variability in the outcome may also be explained by sociodemographic, racial, inborn versus outborn ratio, selection criteria, lack of uniformity in both the age of assessment and definition of handicap, frequent correction of PMR for lethal congenital malformations and others.Another potential bias which is reported infrequently is the philosophical issue regarding the institution or withdrawal of intensive care for the very tiny babies. It is evident from our data that our PMR rose in 1404H as compared to 1403H, as we made efforts to salvage smaller and smaller infants of shorter and shorter gestation.We have shown that survival rates for LBW and VLBW infants, comparable to those achieved in the developed world, can be achieved here in Saudi Arabia with acceptable rates of morbidity. However, weight-specific neonatal mortality rates only indicate the relative excellence of hospital reproductive health care perinatal services.23,24 The main marker for the quality of reproductive care preventive medicine is the incidence of low birth weight infants in the community.25 This, unfortunately, remains high in the Kingdom.The level of perinatal care in the Kingdom is variable. It varies from deliveries in institutions equipped with the most modern facilities to unattended home deliveries. In developed countries, approximately 15% of all pregnancies can be defined antenatally as at risk.25 The incidence of high-risk pregnancies in Saudi Arabia is much higher. It is reported to be between 25% and 54.4%16,25–27 and 82%4 from our institution. The reasons for this include: a high incidence of consanguinity; high parity (10% of women have 7 or more children);16,25–27 and the fact that over 60% of the pregnancies occur in women under 20 years of age.If we are to improve our perinatal care and reduce our PMR then it is clear that the emphasis must shift from 'neonatal' to the 'perinatal' concept, and perhaps even further to the concept of the whole reproductive cycle in its context in society. Thus, the recognition of the need, and consequent provision of appropriate facilities are necessary. Preventive treatment of the high-risk pregnancy and care of the newborn are highly cost effective, despite the relatively expensive nature of the facilities required.The problem is to identify the individuals at risk and to make available the required facilities and care over a given geographical area. In developed countries, risk is considered to be either absent or low in 85% of pregnancies, moderate in 12% and serious in only 3%,27 The figures for Saudi Arabia are quite different and it is generally agreed that there is a strictly limited need for sophisticated skills and expensive facilities to remedy the situation. It is not possible, nor economically feasible, to make these available in every hospital providing obstetric care, though this has been done in Sweden by concentrating deliveries in large district hospitals equipped to deal with all levels of risk. In a large country like Saudi Arabia, given its terrain and population distribution, this is neither possible nor practical. Rather, regionalization of reproductive medical care should be envisaged and adopted. This concept involves the provision within certain geographical regions for three levels of care appropriate to normal or low risk (Level I), moderate risk (Level II) and high risk (Level III). The Level III regional centers would provide guidance, leadership and, perhaps most importantly, necessary referral. The logistics of setting up such a system of care have been eloquently described by Swyer.28Though the final outcome of each individual is determined by many interacting influences, from genetic endowment to educational achievement, it should be our objective to ensure that infants reach adult life in the best possible state – that they are given the best possible start towards a reasonably satisfying and useful life.ARTICLE REFERENCES:1. Ohlsson A. "Better perinatal care in Saudi Arabia" . Ann Saudi Med. 1985; 5(3): 169–78. Google Scholar2. Hack M, Fanaroof AA, Merkatz IR. "Current concepts: the low-birth-weight infant: evolution of a changing outlook" . N Engl J Med. 1979; 301(21): 1162–5. Google Scholar3. Yu VYH, Hollingsworth E. "Improving prognosis for infants weighing 1,000 g or less at birth" . Arch Dis Child. 1979; 55:422–6. Google Scholar4. Baakeel H. High risk pregnancies at King Khalid University Hospital, Riyadh [abstract]. Proceedings of Symposium on High-risk Pregnancy. Riyadh, 1985. Google Scholar5. Driscoll JM, Driscoll YT, Steir ME, et al.. "Mortality and morbidity in infants less than 1001 grams birth weight" . Paediatrics. 1982; 69(1):21–6. Google Scholar6. Hirata T, Epcar JT, Walsh A, et al.. "Survival and outcome of infants 501 to 750 gm: a six-year experience" . J Pediatr. 1983; 102(5): 741–8. Google Scholar7. Hoskins EM, Elliot E, Shennan AT, et al.. "Outcome of very low-birth weight infants born at a perinatal center" . Am J Obstet Gynecol. 1983; 145(2): 135–40. Google Scholar8. Gairdner D, Pearson J. "A growth chart for premature and other infants" . Arch Dis Child. 1971; 46: 783–7. Google Scholar9. Saigal S, Rosenbaum P, Stoskopf B, Milner R. "Follow-up of infants 501 to 1,500 gm birth weight delivered to residents of a geographically defined region with perinatal intensive care facilities" . J Pediatr. 1982; 100(4): 606–13. Google Scholar10. Saigal S, Rosenbaum P, Stoskopf B, Sinclair JC. "Outcome in infants 501 to 1,000 gm birth weight delivered to residents of McMaster Health Region" . J Pediatr. 1984; 105(6): 969–76. Google Scholar11. Bax M. "Terminology and classification of cerebral palsy" . Dev Med Clin Neurol. 1964; 6: 295–7. Google Scholar12. Koops BL, Morgan LJ, Battaglia FC. "Neonatal mortality risk in relation to birth weight and gestational age: update" . J Pediatr. 1982; 101(6): 969–77. Google Scholar13. Bennett FC, Robinson NM, Sells CJ. "Growth and development of infants weighing less than 800 grams at birth" . Pediatrics. 1983; 71(3): 319–23. Google Scholar14. Rothberg AD, Maisels MJ, Bagnato S, et al.. "Infants weighing 1,000 grams or less at birth: developmental outcome for ventilated and non-ventilated infants" . Pediatrics. 1983; 71(4): 599–602. Google Scholar15. Al-Yousuf S. "Development of pediatric services in the Kingdom of Saudi Arabia" . Saudi Med J. 1982; 3(1): 4–7. Google Scholar16. Hartley RW. "One thousand obstetric deliveries in the Asir Province, Kingdom of Saudi Arabia: a review" . Saudi Med J. 1980; 1(4): 187–96. Google Scholar17. John P. "Study of perinatal and infant death in 1967 in Dhahran, Saudi Arabia" . J Trop Pediatr. 1970; 18: 43–7. Google Scholar18. Ohlsson A, Serenius F. Perinatal mortality at King Faisal Specialist Hospital and Research Centre 1976–81 [abstract]. 8th Saudi Medical Conference Abstracts. Riyadh, 1983:157. Google Scholar19. Abu-Osba YK, Thalji AA, Al-Dousary N, et al.. The impact of newborn intensive care medicine on neonatal mortality and morbidity in Dhahran Health Centre [abstract]. Seventh Saudi Medical Meeting. Dammam, 1982:103–4. Google Scholar20. Infant mortality. Dhahran: The Arabian American Oil Company. Epidemiology Bulletin. 1983; 21(15): 1–6. Google Scholar21. Antonsen BJ. The first, 1,000 newborn babies in King Faisal Military Hospital, Khamis Mushayt [abstract]. Fourth Saudi Medical Conference Abstracts. Dammam, 1979:24–5. Google Scholar22. Khwaja SS, Al-Sibai MH, Awadah SA, et al.. Pregnancy in adolescence: obstetric implications [abstract]. 8th Saudi Medical Conference Abstracts. Riyadh, 1983:124. Google Scholar23. Lee KS, Paneth N, Gartner LM, Pearlman M. "The very low-birth-weight rate: principle predictor of neonatal mortality in industrialized populations" . J Pediatr. 1980; 97(5):759–64. Google Scholar24. Lee KS, Paneth N, Gartner LM, et al.. "Neonatal mortality: an analysis of the recent improvement in the United States" . Am J Public Health. 1980; 70(1): 15–21. Google Scholar25. Swyer PR, Effer SB. A regionalized system for reproductive medical care in Ontario. Report of the Advisory Committee on Reproductive Care of the Minister of Health for Ontario. Toronto, 1979. Google Scholar26. Chatterjee TK, Al-Awdah A, Rahman J, et al.. A review of high risk factors in 586 patients delivered at the Al-Khobar Teaching Hospital [abstract]. Seventh Saudi Medical Meeting Abstracts. Dammam, 1982, 1982:95. Google Scholar27. Chattopadhyay SK, Sengupta BS, Chattopadhyay C, et al.. "Maternal mortality in Riyadh, Saudi Arabia" . Br J Obstet Gynaecol. 1983; 90(9): 809–14. Google Scholar28. Swyer PR. "Regionalization of perinatal care" . Child health and Development. 1984; 3:90–109. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Almidani E, Barkoumi A, Elsaidawi W, Al Aliyan S, Kattan A, Alhazzani F, bin Jabr M, Binmanee A, Alsahan N and Alazmeh S Maternal Vitamin D Levels and Its Correlation With Low Birth Weight in Neonates: A Tertiary Care Hospital Experience in Saudi Arabia, Cureus, 10.7759/cureus.14528 Al-Mulhim A and Al-Najashi S (2009) Perinatal mortality in Saudi Arabia: A six year study, Journal of Obstetrics and Gynaecology, 10.3109/01443619609020710, 16:4, (230-234), Online publication date: 1-Jan-1996. Opaneye A, Villegas D and Abdel Azeim A (2016) Islamic Festivals and Low Birthweight Infants, Journal of the Royal Society of Health, 10.1177/146642409011000313, 110:3, (106-107), Online publication date: 1-Jun-1990. Haque K, Basit O and Shaheed M (1989) Periventricular/Intraventricular Hemorrhage in the Newborn, Annals of Saudi Medicine, 9:4, (360-364), Online publication date: 1-Jul-1989. El‐Shafei A, Sandhu A and Dhaliwal J (2008) Perinatal Mortality in Bahrain, Australian and New Zealand Journal of Obstetrics and Gynaecology, 10.1111/j.1479-828X.1988.tb01685.x, 28:4, (293-298), Online publication date: 1-Nov-1988. Dawodu A, Al Umran K and Al Faraidy A (2016) Neonatal vital statistics: a 5-year review in Saudi Arabia, Annals of Tropical Paediatrics, 10.1080/02724936.1988.11748567, 8:3, (187-192), Online publication date: 1-Sep-1988. Haque K and Bashir O (2019) Perinatal Mortality at King Khalid University Hospital, Riyadh, Annals of Saudi Medicine, 8:3, (190-193), Online publication date: 1-May-1988. Wahid M and Fathi S (1987) Nutrition and the unborn baby, La Ricerca in Clinica e in Laboratorio, 10.1007/BF02912532, 17:3, Online publication date: 1-Jul-1987. Cited by Literature Volume 6, Issue 4October 1986 Metrics History Accepted8 March 1986Published online1 October 1986 KeywordsInfantlow birth weightPrenatal care – Saudi ArabiaInformationCopyright © 1986, Annals of Saudi MedicinePDF download
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