Volume 30, Issue 3

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus , Enterobacteriaceae , and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

Introduction: A single course of corticosteroid reduces intracranial hemorrhage in preterm infants. The mechanism of protection is unclear. Glial fibrillary acidic protein (GFAP), expressed by astrocytes, is regulated by glucosteroids and is an important component of the cells forming the blood brain barrier. We have evaluated the effect of prenatal corticosteroid upon ovine GFAP. Methods: Date-mated ewes were studied in two protocols and lambs delivered on day 125 or 145 (term = 150). In the maternal injection protocol (n = 36) ewes were administered saline, single or repeated injections of corticosteroid. In the fetal injection protocol (n = 48) direct ultrasound-guided fetal injections of saline, single or repeated corticosteroid were administered, and an additional control group did not receive fetal injections. Optic nerve GFAP immunohistochemistry was performed and quantified. Results: At 125 days, repeated, but not single, administration of corticosteroid, by either maternal or fetal route, was associated with a significant reduction in GFAP (both p < 0.002); by 145 days, the deficit had recovered (both p > 0.05). The process of performing repeated fetal injections had an independent effect upon GFAP at 145 days (p = 0.002). Conclusion: Repeated administration of corticosteroid results in a reduction in GFAP in the developing ovine optic nerve, with recovery demonstrated by 145 days.

The aim of the study was to investigate whether deaths in term breech deliveries could have been avoided with improved care during pregnancy and delivery. All cases of intrapartum/early neonatal death of nonmalformed infants in breech presentation delivered at term in Denmark in the period 1982–92 were studied. For each of the 12 deaths two controls matched by presentation and planned mode of delivery were selected. Eleven obstetricians assessed the care through narratives that ended when the infant was delivered to umbilicus and stated if the infant died, and whether the “possible death” was potentially avoidable. The majority thought that 42% of cases and 9% of the controls had died. Antenatal and intrapartum care was suboptimal respectively in 17% and 25% of cases and 4% and 26% of controls. The assumed death was found to have been potentially avoidable in 58% of cases and 17% of controls. Care in pregnancies with IUGR, preeclampsia, placental abruption, post-maturity, the time from decision to performance of cesarean section, and compliance between patient and professionals were more often criticized in cases than in controls. Controlled audit seemed to be a valuable tool for quality improvement and for validation of litigation activities. In conclusion, infant death at term breech delivery was to a large extent potentially avoidable. However, even in controls, suboptimal care was not uncommon.

Objective: To identify clinical variables predicting adverse outcome in a group of infants with severe respiratory failure who were randomized either to referral for extra-corporeal membrane oxygenation (ECMO) or to conventional neonatal intensive care within the United Kingdom. Methods: Adverse outcome was defined by death or disability by four years of age. Receiver operator characteristic (ROC) plots were constructed for variables with continuous data and relative risk (RR) with 95% confidence intervals (CI) calculated for binominal data. Results: Of variables measurable at trial entry, congenital diaphragmatic hernia and lower birthweight was also associated with increased mortality and morbidity. Seizures or supplementary oxygen at discharge were markers of disease course, which predicted a poorer outcome amongst survivors. These variables behaved similarly in the two trial groups. Those infants in the ECMO group with an episode of sepsis, established full sucking feeds after 14 days of age or a hospital stay over 30 days were at increased risk of disability. Conclusions: This study has identified clinical variables that predict adverse outcome for term infants with severe respiratory failure. The results may assist clinicians caring for these babies, when counseling their families and in the development of guidelines for neonatal ECMO.

Objective: To evaluate the difference in prevalence, distribution and prenatal detection rate of congenital heart disease (CHD) in both newborns and second trimester termination of pregnancy (TOP) in two separate time periods. Patients and methods: At the University Hospital of Bari, an observational study was performed, which included all cases of CHD in newborns and second trimester TOP during the periods 1998–99 and 1992–93. Prevalence, distribution and prenatal diagnosis in each group were evaluated, also selecting cases with and without known risk factors. Results: Prevalence of CHD in livebirths and aborted fetuses did not change between the two periods and the same was observed for distribution of CHD spectrum. In the more recent period antenatal detection of CHD significantly increased only in TOP. Moreover, classifying all cases as low or high risk, detection rates were significantly increased in high risk cases while they were unchanged in the general population. Conclusion: Our data show that antenatal detection of CHD is ameliorated by concentrating expertise and good equipment on high risk cases, while it remains low in the general

The aim: To record blood flow velocimetry in the fetal superior mesenteric artery in normal pregnancy and to evaluate if blood flow recordings in the vessel might predict adverse outcome in high-risk pregnancy. Methods: The fetal superior mesenteric artery blood velocimetry was recorded in a cross sectional manner in 75 normal pregnancies between 27 and 41 weeks of gestation. Reference curves were performed for pulsatility and resistance indices. The superior mesenteric artery was also located in 48 singleton pregnancies complicated by pregnancy-induced hypertension and/or intra-uterine growth retardation. Middle cerebral artery, umbilical artery and vein and uterine artery velocimetry were also recorded. Results: Superior mesenteric artery PI and RI values expressed an increase in resistance to blood flow with gestational age after 32 weeks of gestation. In all except eight high-risk pregnancies the fetal mesenteric artery PI values were within normal range. Among the pregnancies with absent or reversed blood flow in the umbilical artery, all had abnormal mesenteric artery pulsatility index (PI) (>97.5 th percentiles), one fetus died intrauterine and two others died after delivery due to prematurity, growth retardation and necrotizing enterocolitis. In the remaining fetuses with increased mesenteric artery PI, necrotizing enterocolitis was diagnosed in three cases. Conclusions: Increased vascular resistance in the mesenteric artery might be a late sign of fetal circulation redistribution and frequently related to necrotizing enterocolitis in the newborn.

Aims. In the face of major tendency towards midwiferyled- care it was our purpose to investigate the extent of the influence of the midwife on the rates of obstetric procedures and perinatal outcome. Methods. 5384 consecutive deliveries at the Department of Obstetrics and Gynecology, University of Graz, were enrolled in the study. The following data were collected: mode of delivery, pH of umbilical artery, Apgar score. Firstly, data were investigated for interindividual differences and, secondly, for relationship with age of the midwife as a measure of experience. Results. Interindividual differences were significant for episiotomy rates (minimum: 31.6%; maximum 76.9%; p<0.001), forceps rates (minimum: 1.7%; maximum 11.1%;p=0.002) and pH of umbilical arteries (minimum: 7.21; maximum: 7.28; p=0.001) but not for cesarean section rates and Apgar scores. Linear regression analysis was significant between age of midwives and pH of umbilical arteries (p<0.001; r=0.055) and for one-minute Apgar score (p=0.009; r=0.050) but not for episiotomy rates, cesarean section rates, forceps rates and five-minutes Apgar score. Conclusions. There are large interindividual differences in obstetric intervention rates which cannot be explained by the midwives' age. Provision of health care should be primarily determined by need and not by the personal characteristics of the health care provider, thus interindividual differences should be reduced and more often taken into account when analyzing any kind of data.

Objective: To investigate the effects of resuscitation with three different oxygen concentrations on cerebral intra- and extra-cellular calcium, sodium and potassium changes in asphyxiated rat fetuses. Methods: Fifty-six fetal rats of gestational age of 20 days were randomly assigned into five study groups: sham operation group (control, n=11), room-air resuscitation group (n=10), and 3 oxygen-resuscitated groups (n=14, 11, and 10 respectively). Different inhaled oxygen concentrations and different timings of oxygen delivery were assigned. Except for control all fetal rats were rendered ischemic and hypoxic in utero by interrupting the placental circulation. After re-circulation, intra- and extra- cellular concentrations of calcium, sodium, and potassium in the brains were measured for each individual group. Results: The mean intracellular free calcium concentration of fetal rat brains was similar for the room-air resuscitation group (552.1±93.5 nmol/L) and the group resuscitated with 92.8% oxygen (520.6±79.1 nmol/L), and both were significantly higher than in the control (315.3±86.9 nmol/L) (P<0.001). After resuscitation with 65% oxygen, be it instituted before or immediately after hypoxia, their mean intracellular free calcium concentrations in the brain cells (441.5±47.9 and 452.9±36.4 nmol/L respectively) were significantly lower than those in the room-air resuscitation (P<0.01) and 92.8% oxygen group (P<0.05), though still higher than in the control (P>0.05). There was no difference in the total concentrations of calcium, sodium, or potassium among all groups. Conclusion: Resuscitation with 92.8% oxygen or room air exerted a similar effect on the parameters measured, indicating that resuscitation of asphyxiated neonates using 100% oxygen might not be superior to using room air. Resuscitation with 65% oxygen resulted in lower cerebral intracellular calcium concentrations and might produce a better outcome than using 100% oxygen or room air.

Objective: To investigate whether V-shaped decelerations in fetal heart rate tracing are a physiologic response to fetal movements or secondary to cord compression. Study design: Six pregnant sheep and their fetuses (115–125 days of gestation) were surgically instrumented and studied. Fetal electrocardiogram, carotid blood flow, arterial blood pressure and fetal movement were continuously monitored for 24 hours. Following the undisturbed 24 hour recording, these parameters were monitored during umbilical cord compression (n = 6). Differences in these parameters between V-shaped decelerations and decelerations provoked by cord compressions were examined. Results: Elevation of blood pressure and decreased carotid blood flow were observed coincidentally with the initiation of V-shaped decelerations. In cord compression, elevation of both blood pressure and carotid blood flow were followed by a decreased heart rate. V-shaped decelerations exhibited a different alteration of carotid blood flow compared to decelerations caused by umbilical cord compression. Conclusion: V-shaped deceleration is a physiologic response secondary mainly to fetal movements and is not caused by cord compression.

A fatality from a tracheoesophageal fistula (TEF) in two extremely low birth weight infants is presented. The sudden onset of intractable respiratory failure accompanied by the absence of chest movement and breathing sounds was observed. The typical clinical symptoms were concealed because the infants required mechanical ventilation and nasogastric feedings. When ventilated infants with these symptoms are suspected of the diagnosis of TEF, prompt reintubation under the guidance of a flexible bronchoscopy may be life saving because the endotracheal tube passes through the fistulas into the esophagus with ease.

Acardia is the most severe complication in monozygotic twinning. Acardius acormus is an uncommon phenotype among acardias. We report on an acardius acormus using thorough gross and light microscopic examination of the brain. Neuropathological examination revealed a severely disorganized cerebral cortex, agenesis of cerebellum and brain stem, and undeveloped basal ganglia and thalamus. In particular, the cerebral cortex was characterized by no clear lamination, almost complete loss of neurons, extensive gliosis, angiogenesis and focal mineralization. Neurohistology of the acardius acormus clearly demonstrated two types of lesions: developmental arrest of the brain and hypoxic-asphyxic damage to the brain with reactive gliosis and angiogenesis. Both types of lesions may be induced by the same teratogen: early onset of persisting hypoxia due to a reversed arterial perfusion. The quality of the description contributes valuably to a better understanding of the basic mechanism underlying the acardius phenotype.

Diabetes insipidus during pregnancy is an uncommon medical problem, and its cause is not entirely clear. We present a woman with twin pregnancy associated with HELLP syndrome, who developed diabetes insipidus during postpartum period. A hypertonic saline infusion study with measurement of plasma arginine vasopressin concentrations confirmed the diagnosis. She had mild response to 1-desamino-8-d-arginine-vasopressin (dDAVP) during the immediate postpartum period. On the 3rd postpartum day two doses of 100μl of dDAVP were administered, and her urinary volume gradually decreased. We could stop dDAVP on the 30th postpartum day. This exacerbation may result from increased vasopressinase activity caused by the excessive production in the placenta due to twin pregnancy, together with the insufficient degradation in the liver due to HELLP syndrome.