Volume 34, Issue 3

Epidemiological research designed to explore causality of illness has produced increasing evidence to verify that exposure to toxic agents is contributing to the escalating burden of chronic affliction, including congenital disorders. While endeavoring to facilitate optimal health and well-being for patients, the medical profession is currently challenged by the consequences of environmental factors unique to the modern era. In the last half century, there have been profound shifts in health-related habits of individuals and population groups, and recent research suggests that changes in the home and workplace environment are responsible for many common health problems including various congenital anomalies. As a result of increasing concern about environmental influences on health, ‘Human Exposure Assessment,’ the investigation and study of specific patient exposures and related health concerns, is a rapidly expanding area of scientific research. Practitioners of clinical medicine, including providers of maternity care, should acquire the skills to elicit a proper environmental exposure history and the necessary tools to implement proactive patient education relating to precautionary avoidance.

Aim: To determine if risk of adverse neonatal outcomes among term breech infants delivered by cesarean section differs by volume of such births at the delivering hospital. Methods: We conducted a population-based cohort study using Missouri linked birth and death certificate files. The study population included 10,106 singleton, term, normal birth weight infants in breech presentation delivered by cesarean section. Infants were linked to hospitals where delivered. These hospitals were divided into terciles (low, medium, and high volume) based on the median number of annual deliveries during 1993–1999. The primary outcome was presentation of at least one adverse neonatal outcome. Adjusted odds ratios and 95% confidence intervals (CI) were calculated using logistic regression analysis Results: The rate of any adverse outcome was 17.8, 15.0, and 5.9 cases per 1,000 deliveries at low-, medium-, and high-volume hospitals, respectively. All component adverse outcomes occurred more frequently in low- or medium-volume hospitals than in high-volume hospitals. Compared to breech infants delivered at high-volume hospitals, those delivered at low-volume and medium-volume hospitals were 2.7 (CI 1.6, 4.5) and 2.4 (CI 1.4, 4.1) times, respectively, more likely to experience an adverse outcome after adjusting for significant confounders. Conclusions: Prospective studies should explore the source of these risk differences.

Aims: To evaluate whether primary application of mezlozillin in preterm premature rupture of membranes (pPROM) prolongs pregnancy and lowers neonatal morbidity. Methods: In this prospective, randomized, double blind, placebo-controlled multicenter study a total of 105 pregnant women with pPROM between 24+0 and 32+6 weeks of gestation were examined receiving i.v. injections of corticoids and tocolytics as well as mezlocillin (3×2 g/d) or placebo. Assessed factors were prolongation of pregnancy and neonatal morbidity such as neonatal infection, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC). Results: Prolongation of pregnancy by more than 7 days was achieved in 63.8% of the mezlocillin group versus 44.8% of the placebo group (P<0.05). The babies of mothers treated with anibiotics had fewer neonatal infections, RDS, IVH and NEC. Total morbidity was significantly lowered in the verum group (P=0.02). Conclusions: Antibiotic administration following preterm premature rupture of membranes is associated with a prolongation of pregnancy and a reduction of neonatal infectious morbidity.

Aims: The present longitudinal study sought to explore the relationship between parental grief following perinatal bereavement and subsequent pregnancy, according to the particular facets of grief and pregnancy state being considered. Method: The study participants were 63 couples who had been bereaved by stillbirth (n=31) or neonatal death (n=32). The relationship of self-reported grief (Perinatal Grief Scale-33 Active Grief, Difficulty Coping and Despair) 1 month and 13 months after the loss to subsequent pregnancy status (Pregnant, n=20, Live Baby, n=10, Trying, n=11, Not Trying, n=22) at 13 months was investigated with repeated measures analysis of variance. Results: There were statistically significant main effects for Active Grief and Difficulty Coping in women and men and Despair in women, but not in men. There was a statistically significant Active Grief by pregnancy status interaction in women (F(3, 59)=2.89, P=0.04), but not in men. Simple main effects analysis indicated a statistically significant decrease in Active Grief in women who were pregnant (F(1, 59)=52.8, P<0.0005), women who were not pregnant and not trying to conceive (F(1, 59)=27.5, P<0.0005), and women who had had a live baby (F(1, 59)=9.62, P=0.003). There was no statistically significant decrease in Active Grief in women who were not pregnant but trying to conceive (F(1, 59)=3.44, P=0.07). The Difficulty Coping in women and men and Despair in women by pregnancy status interactions were not statistically significant. None of the between-subjects main effects for pregnancy status was statistically significant in women or men. Conclusion: The relation between grief and subsequent pregnancy differed with the sex of the parent and the particular facets of grief and pregnancy state being considered. Subsequent pregnancy was related to Active Grief in women, but not to Difficulty Coping or Despair that are known to be predictors of chronic grief.

Objective: To examine whether X-ray pelvimetry data to evaluate the likelihood of vaginal birth after previous cesarean section. Design: Retrospective study Setting: University hospital Population: Patients with a previous cesarean delivery who underwent X-ray pelvimetry and gave birth at gestational age 37 weeks during a seven-year period. Methods: 1190 patients with a scarred uterus were compared with 15,189 patients without a scarred uterus. In the scarred uterus group, 760 patients with a transverse pelvic diameter ≥12 cm were compared with 430 patients with a transverse pelvic diameter <12 cm. Main outcome measures: The obstetrical outcomes were spontaneous or induced labor, and mode of delivery. The maternal morbidity outcomes were hemorrhage requiring transfusion of packed red cells, uterine rupture, bladder injury, and hysterectomy due to hemorrhage. The neonatal morbidity outcomes were the 5-min Apgar score, transfer to intensive care, and intubation. Results: Patients with a scarred uterus had a significantly higher rate of cesarean section (35.5%) than those with no prior cesarean section (9%). Among patients with a scarred uterus who were selected for vaginal delivery, 81% delivered vaginally when the transverse diameter (TD) of the pelvic inlet was greater than 12 cm, 68% when the TD was between 11.5 and 12 cm, and 58% when the TD was less than 11.5 cm. Maternal morbidity was significantly higher in the patients with a scarred uterus. The neonatal results were comparable in the different groups. Conclusion: X-ray pelvimetry tailors the information given to each patient about the likelihood of having a vaginal delivery. It can also be used to optimize the selection of patients allowed to enter labor.

Malformations of the umbilical vein are rare abnormalities diagnosed on prenatal ultrasound. They might be associated with fetal hydrops and fetal death. We report two newborn infants with prenatal diagnosis of umbilical vein dilatation who developed venous thrombosis and discuss the pre- and postnatal management of the constellation with special emphasis on antithrombotic treatment

Perinatal asphyxia has a high impact on neonatal mortality, morbidity, and neurological outcome. The hypoxic effects on brain, kidney and gastrointestinal system are well recognized in newborns. While it is known that hypoxia also effects cardiac function, there are few studies of quantitative myocardial injury in premature infants who suffered hypoxia. Aim: To investigate usefulness of cardiac troponin (cTnT) and creatinine kinase MB (CK-MB) in the diagnosis of myocardial injury due to birth hypoxia and to correlate these markers with cardiac functions as measured by echocardiogram. Methods: We studied 43 preterm infants: 21 with birth asphyxia and 22 controls. Echocardiographic studies and quantitative determination of cTnT and CK-MB in blood serum was performed between the 12 th and the 24 th h of life. Results: cTnT and CK-MB levels were higher in asphyxiated infants compared to controls (0.287±0.190 vs. 0.112±0.099 ng/mL, P<0.001) and (18.35±14.81 vs. 11.09±5.17 ng/L, P<0.05). Among controls, we observed an elevated value of cTnT in those with respiratory distress syndrome (RDS). We found a decrease in fractional shortening (P<0.05) and an increase in tricuspid insufficiency (P<0.01) in asphyxiated newborns. Conclusions: cTnT and CK-MB levels are strong indicators of myocardial injury due to perinatal hypoxia. The cTnT level was most strongly related to RDS.

Objective: To examine fetal brain injury in the Göttingen minipig following intrauterine asphyxia and infection/inflammation induced at 3/4 of gestational length. Methods: We performed laparotomy after anesthesia in six pregnant sows. We randomized 29 fetuses to one of four groups: pretreatment with saline or endotoxin followed by 30 min of umbilical cord occlusion or no occlusion. After 48 h we performed a re-laparotomy and examined the fetal brains. Results: After total asphyxia, brain stem injury was present in the group pretreated with saline (P<0.01 vs. controls) and with endotoxin (P<0.005 vs. controls). Microglia activation was more marked in the brain stem (P<0.05) and posterior white matter (P<0.05) in the asphyxia group than in controls. Two of five fetuses in the asphyxia group had white matter injury, while no white matter lesions were found in the asphyxia/inflammation or endotoxin only groups. Conclusions: In this Göttingen minipig model, a species closer to humans than animals commonly used in experimental studies of perinatal brain injuries, intrauterine asphyxia following pretreatment with saline caused brain stem and white matter injury. This model can be further developed to study the impact of other intrauterine exposures on brain injury.

Aims: Humans with low birth weight exhibit evidences of vascular dysfunction. Recent findings indicate a microvascular rarefaction in skeletal muscles soon after postnatal development in rats suffered by intrauterine protein restriction. Methods: To examine the effects of intrauterine growth restriction on capillary density, muscle fiber distribution and accompanying muscular and systemic circulation immediately after birth, studies were conducted on 1-day-old anesthetized normal weight (n=7) and intrauterine growth restricted (n=6) piglets. Cardiac output and hind limb muscle blood flow were measured by colored microspheres. Counting of type I fibers and skeletal capillary numbers was done by immunohistochemical staining. Results: Increased proportion of type I fibers and capillary density was found in the flexor digitalis superficialis and gastrocnemius medialis (P<0.05) in newborn IUGR piglets. Furthermore, a marked correlation was shown between capillary density and type I fiber fraction for all flexor muscles studied (P<0.05). Moreover, cardiac output and muscular blood flow were markedly increased in IUGR piglets (P<0.05). Correspondingly, total peripheral resistance, as well as vascular resistance, of hind limb flexors appeared significantly decreased (P<0.05). Conclusions: Compromised intrauterine environmental conditions leading to fetal growth restriction provokes coordinated structural and functional adaptation of skeletal muscles.

Background: There are two approaches to close gastroschisis. Primary closure (PC) is reduction and fascial closure; silo closure (SC) places viscera in a preformed-silo and reduces the contents over time. We have shifted from PC to SC. This study compared the outcomes of these two techniques. Methods: Records of babies with gastroschisis from 1994–2004 were reviewed. Closure type, ventilator days, days to full-feeds, hospital days, complications, and mortality were recorded. Results: Twenty-eight patients underwent PC; 20 patients had SC. Differences in ventilator days, days to full-feeds, and hospital days were not statistically significant. Nine PC patients developed closure-related complications vs. none in SC (P<0.05). Eight PC vs. two SC patients had non-closure-related complications (P<0.05). Four PC vs. zero SC patients developed necrotizing enterocolitis (P<0.05). Five PC vs. one SC patients had ventral hernia (P<0.05). No patient died. Conclusion: PC resulted in higher incidence of reclosure, non-closure-related complications, and necrotizing enterocolitis. Consequently, we recommend SC as the preferred treatment.