Volume 28, Issue 5

In utero infection with Toxoplasma gondii may result in congenital defects such as hydrocephalus, chorioretinitis and mental retardation; these defects may be present at birth or may develop later in life. Prevention of this disease can be achieved in different ways. The most effective measure is to prevent the acquisition of the disease during pregnancy by avoiding risk factors for Toxoplasma gondii infection. Health education may decrease the incidence of toxoplasmosis during pregnancy by 60%. A second preventive measure is based on serologic screening during pregnancy to identify infected women. Treatment during pregnancy results in a significant reduction in the incidence of sequelae including severe handicaps. A third possible intervention is treating infected neonates. Antibiotic treatment of infected children has a beneficial effect on the development of sequelae and the sooner therapy is started after birth, the better the outcome. This overview presents the potential benefits and harms of these different options available for the prevention of congenital toxoplasmosis.

In utero stem cell transplantation represents a new and still experimental therapeutic strategy for diseases related to the hematopoietic system, i. e. hemoglobinopathies, immunodeficiency diseases and metabolic disorders. To date, a total of 21 cases of transplantations using stem cells either of fetal liver or adult bone marrow origin have been reported in the literature. Success has been limited – with the exception of one case of β-thalassemia – to four cases with immunodeficiency diseases. In this review the broad therapeutic implications as well as potentials and limitations of this technique are summarized. Furthermore, ethical considerations based on the use of fetal cells are pointed out and a prospective view concerning experimental and clinical future perspectives including the possibility for gene therapy is presented.

Objective: To study the influence of pathologic umbilical and middle cerebral artery and uterine artery Doppler studies on the nucleated red blood cell count in small-for-gestational-age (SGA) fetuses. Materials and methods: Cord blood was prospectively collected during a 18-month period. 80 SGA fetuses (fetal abdominal circumference < 5 th percentile) with Doppler ultrasound of the umbilical, the middle cerebral artery and both uterine arteries were enrolled in the study. SGA fetuses with normal Doppler flow velocity waveforms were allocated to group 1 (n = 23). Group 2 (n = 13) were fetuses with abnormal umbilical Doppler studies and group 3 (n = 44) were fetuses with both, pathologic umbilical and uterine artery Doppler studies. 2 fetuses in group 3 showed evidence of brain sparing, 3 fetuses presented absent-end-diastolic flow in the umbilical artery. Outcome measures included nucleated red blood cell count, Apgar scores, arterial pH and arterial base excess, venous pH, birth weight, gestational age at delivery, mode of delivery, rate of neonatal intensive care unit admission and length of stay in the neonatal intensive care unit. Results: Highest nucleated red blood cell counts with lowest birth weight and gestational age were found in group 3. Decelerations of the fetal heart rate were more frequent in study group 3 and caesarean section for fetal indication was performed more often in this group. Those fetuses had to be transfered more often to the neonatal intensive care unit than fetuses of the other study groups. There was a tendency in group 3 towards lower arterial pH values and arterial base excess values. Fetuses with absent-end-diastolic flow in the umbilical artery presented highest nucleated red blood cell counts. Conclusion: In SGA fetuses increasing Doppler pathology seems to be correlated with increasing nucleated red blood cell count post-partum. Pathologic uterine artery flow results might have an additional impact on the number of nucleated red blood cells at birth.

Objective: The rapid improvement of lung function after exogenous surfactant treatment for respiratory distress syndrome (RDS) can affect the functions of several other systems, which includes cerebral blood flow volume (CBF). To evaluate the change in CBF after treatment with exogenous surfactant, we measured CBF in a newborn piglet model with RDS. Method: After the lung lavage with normal saline, ten animals under mechanical ventilation were administered either 120 mg/kg surfactant-TA (Surfacten ® ) or air placebo. Heart rate, blood pressure, dynamic lung compliance (Cdyn), PaO 2 , PaCO 2 , and CBF were recorded before and every 15 min after surfactant treatment up to 120 min. Results: Cdyn was improved significantly at 45 min and later after treatment; that of the control group remained unchanged. PaO 2 increased and PaCO 2 decreased significantly after surfactant treatment in both groups. However, the improvement was significantly less in the control group. CBF significantly decreased by about 30% in the control group, and by about 50% in the treated group at 120 min, with a significant difference between groups. Almost 70% of the changes in CBF were attributable to changes in PaCO 2 by multivariate regression analysis. Conclusions: Treatment with exogenous surfactant improves lung compliance, and has little effect on CBF itself. The drop in levels of PaCO 2 after treatment, however, had a strong relationship with decreases in CBF.

Interferon-α (IFα) is used for the treatment of myeloproliferative diseases and chronic viral illnesses. Because the agent has antiproliferative activity, its effects on a fetus are a concern. We encountered a 40-year-old Japanese woman who inadvertently received IFα during pregnancy for the treatment of HCV hepatitis. The patient received 5 million units of IFα 2 to 4 times per week (total dose of 315 million units) between 13 and 33 weeks gestation. The patient delivered a normally formed healthy male infant, weighing 2,252 g at 37 weeks of gestation. The infant at 20-month-old exhibited normal growth and neurological development when last examined. Literatures were reviewed to determine the effects of IFα on the fetus. There have been 27 infants born to 26 mothers, including the present case, who were exposed to IFα in utero. Six women (23%) were administered IFα inadvertently during pregnancy. Four women (15%) gave birth prematurely. Although 6 infants (22%) were affected by intrauterine growth retardation (IUGR), there were no IFα-related malformed infants. These results suggested that an inadvertent administration of IFα during pregnancy may occur, but in that case IFα may not induce congenital malformations. These findings may encourage such women to continue pregnancy.

The purpose of this study was to evaluate the fetal cardiovascular function during prolonged magnesium sulfate tocolysis. We performed a fetal ultrasonographic examination in 15 patients (Mg group) during magnesium sulfate tocolysis for the treatment of preterm labor. The maternal serum magnesium concentration was 5.7 ± 0.5 mg/dl at the time of the examination. Sixteen fetuses in normal pregnancies at similar gestational ages were used as the control group. The fetal heart rate and the middle cerebral artery pulsatility index in the Mg group were lower than in the control group (p < 0.01). Fractional shortening (FS) of the right ventricle in the Mg group was lower (p < 0.01), while FS of the left ventricle was higher (p < 0.01) than in the controls. The calculated blood flow through the tricuspid orifice in the Mg group was lower than in the control group (p < 0.01). In contrast, the blood flow through the mitral orifice in the Mg group was higher than in the control group (p < 0.01). In conclusion, in spite of the fact that the right ventricular function is depressed, the fetus maintains its cardiac output during prolonged hypermagnesemia by increasing its left ventricular function. These results indicate the different fetal intracardiac and peripheral circulation, especially in the brain, from normal fetuses.

Objective: To determine whether inflammatory cytokine concentrations (Il-1β, Il-6, Il-8 and G-CSF) in umbilical cord blood are useful predictors of an early-onset neonatal infection. Material and methods: 240 women and their newborns were enrolled in our study and umbilical cord blood samples collected from neonates (n = 240) were subjected to ELISA for Il-1β, Il-6, Il-8 and G-CSF. Clinical outcome of the neonates was followed and documented. Placenta histology was also available in majority of the cases (n = 195). Results: Early-onset neonatal infection was diagnosed in 5.4% of neonates (13/240) and placental examination showed histologic chorioamnionitis in 17.9% (35/195). Both Il-1β and Il-6 cord blood concentrations were elevated in association with histologic chorioamnionitis (Il-1β – 2.7 vs. 2.1 pg/ml, p < 0.05 and Il-6 15.6 vs. 12.8 pg/ml, p < 0.005). Only Il-6 was elevated (16.0 vs. 13.2 pg/ml, p < 0.05) in neonates with early-onset bacterial infections. ROC analysis showed acceptable diagnostic performance of Il-6 in the identification of acute histologic chorioamnionitis and clinical neonatal infection. Conclusion: Il-6 in umbilical cord blood seems to be a promising predictor for early-onset neonatal infections.

Aims: The goal of the present retrospective study was to examine the peripheral blood lymphocytes for expression of phenotypic and activation markers concerning the development of hypertension in pregnancy. Methods: 16 women (aged 25–43 years; mean 35.1) developing hypertension in the third trimester (week 25–34) have had blood samples taken in the first (< 14 weeks), the second (week 14–23), the third trimester (week 24–35), in late pregnancy (week 36-termination of pregnancy) and within 1 week post-partum, The control group consisted of 16 age-matched pregnant healthy women, who underwent the same regime. All blood samples were taken in the morning, stored at room temperature and stained within 6 hours and measured within 24 hours. Kruskal-Wallis analysis of variance between both groups was done with multiple comparison according to Dunn. Results: Comparing both groups, the total white cell count was significantly increased in all pregnancies and post-partum. In case of hypertension in pregnancy the cell numbers of suppressor/cytotoxic (CD 8+) and CD 56+-activated T cells showed a significant increase in the first trimester (< 14 weeks) [p < 0.05] and decreased thereafter to normal values. In the second trimester (week 14–23) helper/inducer lymphocytes and CD 56+1/CD 3+ lymphocytes decreased in case of pre-ecclampsia and cytotoxic lymphocytes elevated [p < 0.05]. In the third trimester (week 24–35) there was no difference in both study groups and in late pregnancy (week 36-termination) there were only small differences without statistical significance. Within 1 week postnatal the value of Il-2 receptor T lymphocytes decreased in the group of pre-eclampsia in comparison to normal pregnancies [p < 0.05]. Conclusions: Regarding the major changes in activated T cells in both study groups no specific pattern of lymphocyte subsets in case of pre-eclampsia could be found in comparison to healthy pregnant women. Further investigations should focus on functional activation and / or suppression of the cellular immune system. Perhaps this could lead to a screening test for pre-eclampsia in future, which is non-invasive for the patient and economic for our social community because it might reduce medical costs.

The purpose of this study was to determine the association between maternal plasma purine bases levels and fetal well-being indices. The research included pregnant women with pregnancy-induced hypertension (PIH) and women with physiologic pregnancy between 32 nd and 41st week of gestation. To characterize the pregnant women, their age, number of gestations, and blood pressure values were used. To evaluate condition of the fetus, the values of biophysical profile and FHR tracing were assessed. The purine bases (hypoxanthine, xanthine and uric acid) concentrations in plasma were determined using high pressure chromatography. Hypoxanthine levels, oxypurine pool, hypoxanthine to xanthine molar ratio and the ratio of uric acid to the oxypurine pool were significantly different in patients with PIH in comparison with women with physiologic pregnancy. It was found that increased adenyl nucleotide catabolism in the PIH group can be related to fetal well-being indices, particularly to FHR tracings. Increased percentages of suspected and pathologic FHR tracings were found in patients with PIH in comparison with physiologic pregnancy. The unfavorable influence of increased metabolism of adenyl nucleotides on the condition of the fetus was further confirmed by significant negative correlation between the oxypurine pool and the FHR tracings. The multiple regression analysis choosing the optimal subgroup of independent variables showed significant correlation between the parameters describing the well-being of the fetus and newborn and the levels of inosine, uric acid and xanthine. In the group of women with physiologic pregnancy, the most significant correlation was found in the diastolic blood pressure and hypoxanthine levels.

Endocarditis is an uncommon complication of invasive candidiasis. We present a fatal case of endocarditis caused by Candida albicans in a very low birth weight infant. The 780-g male infant did not have any structural heart disease and a central venous catheter was not placed. Endocarditis developed in spite of parenteral fluconazole treatment. Echocardiography was a valuable tool in making the diagnosis. The infant died on the 40 th day of life. The development of Candida endocarditis in a premature infant who was treated with fluconazole had not been previously reported. In the case of systemic candidiasis, premature infants require very careful monitoring for the progression of the disease, even if antifungal therapy is administered.

On prenatal ultrasound atrioventricular septal defect is often diagnosed in infants with Down syndrome based on an abnormal four-chamber view of the heart. A unique case of atrioventricular septal defect with dextroposition of the heart in an infant with trisomy 18 is presented.

A 29-year-old Japanese primipara with fetal sacrococcygeal teratoma and hydronephrosis was referred to our department at 22 weeks of gestation. The preload index of the inferior vena cava (PLI) was 0.75 and fetal cardiac failure was suspected at 28 weeks of gestation. The sodium and chloride concentrations and osmolarity of the fetal urine were 96 mEq/L, 81 mEq/L and 204 mOsm/L, respectively, and we predicted a good renal function. Then, a vesico-amniotic shunting operation was performed at 28 weeks of gestation to keep the renal function and PLI decreased 0.41 after this operation. At 30 weeks of gestation, the fetus was delivered by a cesarean section owing to preterm PROM and a huge growing sacrococcygeal teratoma. The baby was female, weighing 2,020 g, and the 1 minute Apgar score was 1. She died almost 7 hours after birth due to respiratory insufficiency. An autopsy confirmed bilateral hydronephrosis, urethral stenosis, sacrococcygeal immature teratoma, and pulmonary hypoplasia. The size of this tumor revealed 80 × 70 × 45 mm in intrapelvic cavity and 130 × 90 × 50 mm out of body, and this tumor was classified as Type II according to the American Academy of Pediatrics Surgery Section classification.