Band 34, Heft 6

This article reviews the interpretation of the fetal motor repertoire in the light of neurophysiology and clinical neurology. The continuity of the maturative process from the fetus to the neonate allows us to speculate on the predictive value of optimal and non-optimal neurological function as observed in the fetus and their morphological consequences. Neonatologists know that early prediction concerning outcome is reliable only at the two ends of the spectrum, e.g., optimal and very abnormal situations. However, in intermediate situations the quality of observations achieved by 3D–4D ultrasonography already allows to demonstrate the prenatal onset of brain damage, based on morphologic and functional signs. Their identification during the second half of pregnancy may serve as a retrospective marker of a prenatal insult.

This article reviews the anatomy and physiology of the uterine circulation, with emphasis on the remodeling of spiral arteries during normal pregnancy, and the timing and anatomical pathways of trophoblast invasion of the spiral arteries. We review the definitions of the placental bed and basal plate of the placenta, their relevance to the study of the physiologic transformation of the spiral arteries, as well as the methods to obtain and examine placental bed biopsy specimens. We also examine the role of the extravillous trophoblast in normal and abnormal pregnancies, and the criteria used to diagnose failure of physiologic transformation of the spiral arteries. Finally, we comment on the use of uterine artery Doppler velocimetry as a surrogate marker of chronic uteroplacental ischemia.

Aims: To analyze maternal deaths occurring at the Mikumi Health Center in Tanzania, East Africa, to discuss causes for the high maternal mortality rate at the Health Center, and to define possible strategies for the reduction of maternal deaths. Methods: Between 2002 and 2003, a total of nine maternal deaths were identified and analyzed from hospital records of the East-African Mikumi Health Center. Results: During the two-year period, the total number of deliveries was 977 including two maternal deaths during pregnancy and seven deaths during labor or postpartum (0.7% of total deliveries). The maternal mortality ratio (MMR) was 921 per 100,000 live births. The maternal average age was 27 years (range 18–37). The average interval between the first contact with the Health Center and maternal death was 3.5 days. Conclusion: The main cause for maternal complications and subsequent deaths might have been the patient's delayed presentation at the Health Center. Aggravating circumstances such as long distance from the health services and hospital fees hinder patients from a timely and eventually life-saving presentation. The womens' low educational level affects their health as well as their nutritional state and thus increases the maternal death rate. Strategies to prevent maternal deaths at the Mikumi Health Center include measures to raise awareness about consequences of poor maternal health, to improve general education especially for young women, to increase the number of professional birth attendants in the region, to improve family planning services and sexual education with special reference to HIV/AIDS. Additionally, improvement of the first referral facilities around the Mikumi Health Center according to the “essential obstetric functions” recommended by the WHO seems crucial.

Background: To compare procalcitonin (PCT) concentrations between maternal blood and levels in umbilical cord or venous blood of neonates who were born with or without infection. Methods: Forty-six women with singleton pregnancies, complicated by premature rupture of membranes, preterm delivery and/or chorioamnionitis, were enrolled in this study. The study group comprised 15 patients and their infected newborns. The control group consisted of 31 women and their healthy newborns. We compared PCT concentrations between maternal, umbilical cord and neonatal serum, in both study and control groups. Additionally, PCT levels were compared between the corresponding compartments. Results: PCT concentrations in the umbilical cord and venous blood in infected newborns, but not in non-infected neonates, were significantly higher than maternal serum PCT levels. PCT concentrations of mothers who delivered infected newborns were comparable to those in the controls. However, PCT concentrations in the umbilical cord and in the venous blood of the infected newborns were higher than in healthy newborns. Conclusion: Measurement of maternal PCT concentration during labor does not contribute to early prediction of infection in the neonate. However, umbilical cord PCT concentrations, as well as its neonatal venous levels on the second day of life, seem to be related to intrauterine infection, and may be a useful tool in the diagnosis of early neonatal infection.

Aim : To investigate the effect of tobacco smoke on cord blood cortisol concentrations. Methods: Cortisol concentrations were measured in cord blood from 211 term newborns of smoking and 211 term newborns of nonsmoking mothers; 48 and 36 newborns were delivered by cesarean section, respectively. In 16 cases, in addition to cord blood, maternal venous blood was obtained at delivery. Results: The median cord blood cortisol concentration in neonates of the smoking and the nonsmoking mothers was 23 and 13 μg/dL, respectively (P<0.0001). Cortisol concentrations were greater in the newborns whose mothers smoked, when compared to corresponding controls, whether they were delivered vaginally or by cesarean section. In the newborns delivered by cesarean section, there was a positive correlation between number of cigarettes smoked/day and cortisol concentrations, as well as a negative correlation between cortisol concentrations and neonatal length. There was no significant correlation between cortisol concentrations and birth weight or head circumference. Cortisol concentrations in the cord blood of neonates whose mothers were smokers and nonsmokers were by 29% and 45% lower from those measured in their mothers, respectively. Conclusions: Although a causal relationship between maternal smoking and high cortisol concentrations in cord blood was not established, the findings are in accordance with previous reports indicating elevated stress-hormones in newborns whose mothers smoked during pregnancy.

Aim: To find out whether the quantity of fetal facial expression and quality of body movements can be used as an additional diagnostic criterion for prenatal brain impairment in fetuses with growth restriction. Subject and methods: A prospective study was conducted in 50 uncomplicated healthy women as control group with reliably dated pregnancies and 50 pregnant women with a growth restriced fetus as study group in the third trimester of pregnancy. 4D ultrasound observation is specially designed to assess whether functional brain impairment and fetal growth restriction had prenatally occurred by the utilization of several behavioral patterns. Results: The median value of all movement patterns in the normal fetuses differed from fetuses with intrauterine growth restriction (IUGR). Statistical evaluation revealed significant differences in the distribution of the movements between these groups (P<0.05). We noted a tendency that IUGR fetuses have less behavioral activity than normal fetuses in all observed movement patterns. Correlation reached statistical significance between normal and IUGR fetuses in the third trimester in hand to head, hand to face and head retroflexion. Statistically significant differences could be shown in the distribution of the median values of observation over the five qualitative categories of head and hand movements (P<0.05). Conclusions: Recent data on IUGR fetuses obtained by 4D sonography are stimulating and might result in a more effective strategy to assess development before birth. The results of this study may encourage future use of 4D ultrasound for quantitative and qualitative assessment of fetal behavior as possible indicators of the neurological condition in IUGR fetuses.

Objective: To compare the impact of electronic fetal monitoring (EFM) alone vs. EFM with additional fetal blood sampling (FBS) in vaginal deliveries complicated by pathologic fetal heart rate (FHR). Methods: All deliveries in Hesse between 1990 and 2000 were evaluated for participation in this study. Inclusion criteria comprised (1) pathologic fetal heart rate, (2) singleton pregnancy, (3) cephalic presentation, (4) vaginal delivery, and (5) gestational age at delivery of more than 35 weeks' gestation. In order to analyze the meaning of additional risk factors at birth for the effectiveness of FBS two subgroups were selected depending on the presence of additional risk factors at birth. To examine the impact of FBS in deliveries with pathologic FHR on the mode of delivery and on neonatal outcome, univariate regression analysis was performed and odds ratios (OR) and their corresponding 95% confindence intervals (95% CI) were calculated. Results: The study population comprised 49,560 deliveries, among deliveries complicated by pathologic FHR, 26% underwent FBS. Deliveries with pathologic FHR and controlled by FBS, with no additional antepartum risk factors, were associated with an increase in spontaneous births OR 1.41 (95% CI 1.27–1.58), and in the presence of additional risk factors OR 1.24 (1.19–1.30). Short-term neonatal outcome parameters were characterized by a lower frequency of severe fetal acidosis (umbilical artery pH <7.0) OR 0.55 (0.42–0.72), and Apgar score <5 after 5 min, OR 0.71 (0.55–0.90). Conclusion: In vaginal deliveries with pathologic FHR the use of FBS as an additional means of intrapartum fetal surveillance is associated with less vaginal operative deliveries, and with an improved short-term neonatal outcome.

Objective: Traditional measure of postnatal growth failure assessment has poor discriminatory power for long-term outcomes. Our objective was to identify measure of postnatal growth failure associated with long-term outcome in preterm infants born at <28 weeks' gestation. Patients and methods: Four measures of defining postnatal growth failure at 36 weeks corrected gestational age: (1) weight <10 th centile, (2) weight <3 rd centile, (3) z score difference from birth >1 and, (4) z score difference from birth >2; were compared for their predictive values and strength of association with adverse neurodevelopmental outcomes at 18–24 months. Results: Postnatal growth failure defined as a decrease in z score of >2 between birth and 36 weeks corrected gestational age had the best predictive values compared to other postnatal growth failure measures, however, it was significantly associated with psychomotor developmental (P=0.006) but not with mental developmental indices (P=0.379). Conclusion: Postnatal growth failure defined by z score change influenced psychomotor but not mental tasks in this cohort. This method of ascertainment could be useful to identify infants who might benefit from nutritional interventions.

Aim: Previous data from our Kaulsdorf Cohort Study (KCS) suggest that early neonatal ingestion (1 st week) of breast milk from diabetic mothers (diabetic breast milk, DBM) may increase the risk of being overweight and delay speech development in offspring of diabetic mothers (ODM). Late neonatal DBM ingestion (2 nd –4 th week), however, not independently influenced the risk of overweight. We investigated whether late neonatal DBM ingestion might independently influence neuro-development. Methods: Achievement of developmental milestones according to late neonatal DBM intake was analyzed in 242 ODM. Results: No impact of DBM ingestion on psychomotor parameters was observed. In contrast, it negatively influenced onset of speaking (no DBM: median 44.0 weeks, range 31.0–72.0; some DBM: 48.0, 24.0–100.0; DBM only: 52.0, 28.0–84.0; P=0.037) and halved the probability of reaching this milestone at any time point (hazard ratio: 0.53, 95% confidence interval: 0.31–0.91). However, adjustment for DBM volume ingested during the early neonatal period weakened the hazard ratio towards non-significance. In the fully adjusted model, the hazard ratio was halved, but insignificant. Conclusions: Our results underscore that neonatal DBM ingestion, particularly during the first week of life, may delay speech development, an important indicator of cognitive development. Further studies are urgently recommended on consequences of breast-feeding for neurodevelopment in ODM.

Aims: Previous studies reported an increasing temporal trend of hypospadias and a significant association with poor intrauterine growth. It remains unclear whether the association relates to birth weight, degree of prematurity or intra-uterine growth. The objective was to study the incidence of hypospadias and to examine the association with various risk factors. Methods: A retrospective case-control study was carried out of infants admitted to a neonatal unit from January 1 st , 1999 to December 31 st , 2005. Results: Of 6538 male live births, 27 (0.41%) infants had hypospadias. Incidence increased from 2.85 per thousand in 1999 to 6.89 per thousand in 2005. Hypospadias occurred significantly more frequently in babies born small for gestational age (SGA), in very low birth weight (VLBW) infants, those born preterm and to mothers with preeclampsia (PET). Logistic regression revealed that VLBW (OR 14.12, CI 5.48–36.39), maternal PET (OR 3.90, CI 1.50–10.14) and SGA (OR 3.23, CI 1.25–8.37) as independent risk factors. Conclusions: Hypospadias is associated with VLBW, maternal PET and poor intra-uterine growth, but not with preterm birth. A rising trend in the incidence of hypospadias was noted in our population of Asian babies, suggesting a universal phenomenon.