Volume 29, Issue 4

Single courses of prenatal corticosteroids have many beneficial effects including reduction in respiratory distress syndrome, intraventricular hemorrhage and neonatal mortality. Postnatal corticosteroids, however, have both beneficial and harmful effects. The beneficial effects include shortened time on the ventilator and a reduction in chronic lung disease. Dexamethasone treatment started within the first 4 days of life is associated with an increased risk of abnormal neurodevelopment including cerebral palsy. Other adverse effects include metabolic disturbances, cardiac hypertrophy, reduced growth and gastrointestinal perforation. The risks of early dexamethasone treatment in currently used doses outweigh the benefits. Further research is needed to determine the optimal corticosteroid drug, its dose and timing of administration to maximize benefit and reduce risk to a minimum. Other non-drug interventions should be used to minimize the risk of chronic lung disease in very preterm infants.

Aims. We wanted to investigate whether experimental dietary manipulations during early pregnancy influence placental growth and subsequently the cardiovascular system as assessed non-invasively by ultrasonography in the sheep fetus. Methods. 21 ewes bearing singletons of uniform age were randomly assigned for the first half of pregnancy to one of the following study groups: fed 100% of their nutritional requirements (i. e. controls), global reduction in total intake by 30% (i. e. 70% global) and reduction in protein intake by 30% (i. e. 70% protein). Results. Placentas from the 70% protein group had significantly more small placentomes, but significantly fewer large placentomes compared to the 70% global group. However, there were no significant differences between the three dietary groups for either the aortic or the umbilical Doppler velocimetry parameters and the fetal heart rate or heart size. Conclusions. The present study shows that early mild maternal undernutrition produces subtle changes in cotelydonary weight. However, Doppler and echocardiographic parameters were not affected by these changes.

Aim: To assess the modifications of the main fatty acids (FA) in plasma and red blood cells during pregnancy. Methods: A longitudinal study of 36 normal pregnant women was carried out with 3 cut-off points: first trimester, second trimester and third trimester. 14 FA in plasma and erythrocyte phospholipids were measured using capillary gas chromatography. Measurements were expressed in percentages and in absolute values. Results: In plasma there was a significant increase in the proportion of saturated FA and a decrease in the proportion of long chain polyunsaturated fatty acids (PUFA) both in the omega 6 (ω6) and omega 3 (ω3) series. On the other hand, in erythrocyte phospholipids there was a decrease in the proportion of eicosapentaenoic acid and an increase in that of docosahexaenoic acid. In the ω6 series, dihomo-gamma-linolenic acid increased, whereas the ω6 docosapentaenoic acid decreased. Conclusion: There was a significant decrease in the proportion of ω3 PUFA in plasma from the first to the third trimester. Thus, it is suggested that the ω3 PUFA intake during pregnancy should be increased in the last trimester.

Aims: To determine women's perceptions and experiences of childbirth in United Arab Emirates [UAE]. Methods: A consecutive sample of 715 women who delivered during a 3 month period were interviewed on the third postnatal day about their experience and satisfaction with maternity care using a structured questionnaire. Results: 95 (13.2 %) women had negative feelings including fear, anger, sorrow and regret, guilt, jealousy, sense of failure and disappointment while the rest felt that childbirth was enjoyable and that they had been well-informed, especially by nurses, about their perinatal care. Subjects delivered by cesarean (N = 104, 14.5 %) were significantly less satisfied with the information provided by their caregivers and their involvement in decision-making before the operation than the vaginal group (p = 0.001). Irrespective of mode of delivery, most participants strongly agreed that cesarean is worse than vaginal delivery whatever the reason and should be performed only for medical reasons. Adverse maternal experiences were significantly more frequent with cesarean delivery (p = 0.00001), older age (p = 0.04), primiparity (p = 0.03), higher education (p = 0.03), lack of antenatal care (p = 0.03) and prolonged labor (p = 0.04). Conclusions: Childbirth experience and the prevalence and correlates of postnatal psychosocial morbidity in UAE are not different from those observed elsewhere.

Objective: Degradation of the extracellular matrix in fetal membranes has been implicated in the process of parturition and rupture of membranes. Matrix metalloproteinases (MMPs) are enzymes capable of degrading extracellular matrix including collagen. Tissue inhibitors of matrix metalloproteinases (TIMPs) inhibit the activity of MMPs by covalently binding to the enzymes. MMP-2 degrades Type IV collagen and TIMP-2 is its specific inhibitor. The objective of this study was to determine if human parturition, rupture of membranes (term and preterm) and microbial invasion of the amniotic cavity (MIAC) are associated with changes in the concentrations of MMP-2 and TIMP-2 in amniotic fluid. Study design: A cross-sectional study was conducted with women in the following categories: 1) term with intact membranes, in labor and not in labor; 2) preterm labor and intact membranes who delivered at term, who delivered preterm and preterm labor with MIAC; 3) preterm premature rupture of membranes (PROM) with and without infection; 4) term and preterm PROM not in labor; and 5) midtrimester. MMP-2 and TIMP-2 concentrations in amniotic fluid were determined using sensitive and specific immunoassays. Results: The concentration of TIMP-2 increased with advancing gestational age (r = 0.6, p < 0.001). No correlation was found between MMP-2 concentrations and gestational age. Human parturition and rupture of membranes (term and preterm) and in patients with intact membranes were not associated with changes in the amniotic fluid MMP-2 concentrations. In contrast, 1) patients with spontaneous labor (term and preterm) had significantly lower median concentrations of TIMP-2 compared to those not in labor (p < 0.05 for both); 2) MIAC in women with preterm labor and preterm PROM was associated with a significant decrease in amniotic fluid TIMP-2 concentrations (p < 0.04 for both comparisons); 3) Rupture of the membranes (term and preterm)was also associated with a significant decrease in the amniotic fluid TIMP-2 concentrations (p < 0.05 and p < 0.03, respectively). Conclusions: Human parturition (preterm and term), rupture of fetal membranes (term and preterm) and intraamniotic infection are associated with a significant decrease in amniotic fluid TIMP-2 concentrations.

Object: To assess whether transvaginal ultrasound is helpful in predicting the post-term onset of labor (≥ 1 weeks). Setting: Antenatal clinic of a University hospital and referral center. Subject and mehods: One hundred and twenty singleton uncomplicated pregnancies in primiparous women were enrolled at 37 weeks of gestation. Ultrasound examination of the cervical length by a transvaginal probe was performed at recruitment and at weekly intervals until 40 completed weeks. Subjects were divided into Group A (those with spontaneous onset of labor ≤ 1 completed weeks) and Group B (those not in labor by that date). Results: Eighty women delivered ≤ 41 completed weeks, forty were not in labor by that date. The cervix was significantly shorter at 39 and 40 weeks in group A, but no particular cervical length was predictive of post-term delivery. Discussion: There is a significant difference in cervical length in women delivering at term compared with those due to have a post-term delivery. This difference is significant from 39 weeks of gestation onwards. We speculate that targeted transvaginal ultrasound may be useful in predicting the post-term onset of labor and possibly in assisting its active management.

Objective: To assess the prevalence of cesarean section (CS) related maternal complications and to evaluate post-CS complications in relationship with relative risk factors. Method: 3010 patients who had a CS in the University Hospital of Bari during the period 1988–98 were retrospectively included into the study and 1007 women delivered vaginally at the same institution and in the same period of time, were randomly selected as the control group. For each single patient delivered by CS, the following risk factors were taken into account: age, parity, pre-pregnancy body mass index (BMI), and any disease antedating pregnancy or diagnosed during pregnancy. Additionally, therapeutic procedures such as blood transfusion, number of days in hospital, and admission into intensive care were followed. The prevalence of puerperal complications was assessed for vaginal deliveries and CS by Student's t-test and a correlation of CS complications with risk factors was performed by multivariate analysis. Results: In the cohort of abdominal delivery, puerperal complications were significantly more frequent compared with those following vaginal delivery (p < 0.05). In the group of CS, obese women have higher prevalence of maternal complications, particularly hypertension and intestinal complications (p < 0.05). Conclusion: Compared with vaginal delivery, CS delivery carries a higher number of postpartum complications, and the higher rate is mainly related to obesity.

Aims: To evaluate complications of surgical and pharmacological treatment of symptomatic patent ductus arteriosus (PDA) in very low birthweight (VLBW) infants. Patients and methods: Of 931 VLBW infants consecutively admitted 1987–1998, a significant PDA prompted first-choice treatment by indomethacin in 101 infants, and surgery in 55 infants. PDA closed or became asymptomatic after indomethacin in 64 patients (63 %), while 34 went on to surgery. PDA closure was achieved in all 61 infants after ligation and in 26 of 28 infants after clipping. Results: Transient renal impairment after indomethacin treatment was recorded in 40 of 101 infants (40 %), compared to renal impairment in 9 of 55 infants (16 %) undergoing surgery without prior indomethacin. No differences in necrotizing enterocolitis and intracranial hemorrhage rates were seen. Air leak occurred in 6 of 89 infants after surgery, two of which had fatal tension pneumothorax. Intraoperative hemorrhage requiring emergency transfusion occurred in 2 infants, wound infection occurred in 2 infants and phrenic palsy in one infant. Based on an intention-to-treat analysis, the overall fatality rates were 16 of 101 (16 %) for indomethacin and 14 of 55 (25 %) for surgery. Conclusions: Despite the short-comings inherent to retrospective analyses, we propose that surgery should be reserved for infants not responding to pharmacological PDA closure.

Background: Changes in regional brain blood flow and hemoglobin oxygen saturation occur in the human cortex in response to neural activation. Traditional functional radiologic methods cannot provide continuous, portable measurements. Imaging methods, which use near-infrared light allow for non-invasive measurements by taking advantage of the fact that hemoglobin is a strong absorber at these wavelengths. Aims: To test the feasibility of a new optical functional imaging system in premature infants, and to obtain preliminary brain imaging of passive motor activation in this population. Methods: A new optical imaging system, the Diffuse Optical Tomography System (DOTS), was used to provide real-time, bedside assessments. Custom-made soft flexible fiberoptic probes were placed on two extremely ill, mechanically ventilated 24 week premature infants, and three healthier 32 week premature infants. Passive motor stimulation protocols were used during imaging. Results: Specific movement of the arm resulted in reproducible focal, contralateral changes in cerebral absorption. The data suggest an overall increase in blood volume to the imaged area, as well as an increase in deoxyhemoglobin concentration. These findings in premature infants differ from those expected in adults. Conclusions: In the intensive care setting, continuous non-invasive optical functional imaging could be critically important and, with further study, may provide a bedside monitoring tool for prospectively identifying patients at high risk for brain injury.

The effects on pulmonary artery pressure (PAP) and plasma Endothelin-1 (ET-1) were studied in piglets during severe hypoxemia and reoxygenation for 2 h with selective inhibition of the endothelin receptors. Two groups were subjected to selective ET A (ET A group) or ET B (ET B group) receptor inhibition. During hypoxemia there was an initial increase in PAP to 36.3 and 34.3 mm Hg in the ET A and ET B groups respectively, with a decrease to the end of hypoxemia. During reoxygenation PAP reached a maximum at 5 min with a mean of 29.6 and 38.4 mm Hg in the ET A and ET B groups respectively, and then PAP gradually declined towards baseline. During the 2 h reoxygenation period PAP was higher in the ET B group than in the ET A group (p = 0.02). Plasma ET-1 increased from 1.50 and 1.17 ng/L at baseline to 2.07 and 3.18 ng/L at the end of hypoxemia in the ET A and ET B groups respectively. Conclusion: ET B receptor inhibition leads to increased pulmonary vasoconstriction during reoxygenation following hypoxemia compared to ET A receptor inhibition. Not only the ET B receptor, but also the ET A receptor plays a role in maintaining plasma ET-1 levels.

We reported two case studies of meconium aspiration syndrome (MAS) with pulmonary hemorrhage in which we applied surfactant lavage and replacement. Surfactant lavage and replacement of MAS with pulmonary hemorrhage appears to be effective and safe adjunctive therapy. The relatively small replacement doses of surfactant required may be attributed to surfactant lavage followed by surfactant replacement. We suggest that surfactant lavage and replacement of MAS with pulmonary hemorrhage should be further investigated by a randomized controlled trial.

We describe a 4-month-old Japanese infant with West syndrome with gelastic seizures in clusters. Smile developed around 3 months and gradually increased in frequency and intensity. Positron emission tomography showed hypoperfusion in bilateral hypothalamus. Interictal electroencephalogram (EEG) showed hypsarrythmia. Simultaneous video/EEG monitoring was performed. At first, a smile-like episode developed every several seconds, gradually increased to an abrupt flexion of the neck and extremities, and gradually decreased to a smile-like episode at the end. Ictal EEG revealed desynchronization. ACTH was effective. Smiles are common emotional responses in infancy. However, EEG and neuroimaging should be considered in a case of perinatal asphyxia and delayed development.