Volume 37, Issue 6

Recent retrospective publications have suggested that cesarean delivery may be beneficial for the extremely premature fetus. This article displays the available evidence and discusses this issue, including many aspects such as the difficulty in deciding when delivery is imminent, the negative impact on maternal morbidity and mortality and the cost to society of such a policy. The available scientific evidence does not support a recommendation for cesarean delivery for improving survival or decreasing morbidity for the extremely premature fetus.

Since the 19 th century, devices termed incubators were developed to maintain thermal stability in low birth weight (LBW) and sick newborns, thus improving their chances of survival. Remarkable progress has been made in the production of infant incubators, which are currently highly technological devices. However, they still need to be improved in many aspects. Regarding the temperature and humidity control, future incubators should minimize heat loss from the neonate and eddies around him/her. An unresolved issue is exposure to high noise levels in the Neonatal Intensive Care Unit (NICU). Strategies aimed at modifying the behavior of NICU personnel, along with structural improvements in incubator design, are required to reduce noise exposure. Light environment should be taken into consideration in designing new models of incubators. In fact, ambient NICU illumination may cause visual pathway sequelae or possibly retinopathy of prematurity (ROP), while premature exposure to continuous lighting may adversely affect the rest-activity patterns of the newborn. Accordingly, both the use of incubator covers and circadian lighting in the NICU might attenuate these effects. The impact of electromagnetic fields (EMFs) on infant health is still unclear. However, future incubators should be designed to minimize the EMF exposure of the newborn.

Our aim was to evaluate the literature on survival and major disability rate in preterm infants born at 22– 25 weeks of gestational age (GA). Thirty-three studies were identified and reviewed. Survival was lower in population-based studies (2% at 22, 13% at 23, 35% at 24, and 56% at 25 weeks) than in center-based study (15% at 22, 41% at 23, 58% at 24, and 74% at 25 weeks). The severe disability rate was slightly higher in population-based studies than in center-based studies at 23 (29 vs. 32%) and at 24 (30 vs. 27%) week of GA, whereas it was similar in population and center-based studies at 25 (21 vs. 22%) weeks of GA. Survival rate seems to improve with time, whereas the change of severe disability rate cannot be adequately evaluated due to the paucity of available data. We conclude that the survival of infants born at 22 weeks is still an uncommon event, whereas the survival of infants born at 23, and mostly at 24 and 25 weeks of GA is significant in the majority of studies.

Aims: To investigate candidate genes in peripheral blood mononuclear cell (PBMC) that are associated with early onset severe preeclampsia (ES-PE) and to describe candidate genes function using microarrays and real-time polymerase chain reaction (PCR). Methods: PBMC RNA was extracted from six patients with ES-PE and five uncomplicated pregnancies. The HG_U133 plus 2.0 Affymetrix GeneChips that represented 47,000 genes were used to measure gene expression in each sample. Significance analysis of microarray identified potential signature genes characterizing ES-PE vs. uncomplicated pregnancies. Eight genes were selected for confirmation by real-time PCR of 32 patients with ES-PE and 24 uncomplicated pregnancies, matched for maternal age, parity, race and gestational weeks. Results: Using a whole-genome approach to study the molecular determinants of ES-PE, 72 genes were found to be differentially expressed between cases and controls, including 38 up-regulated genes and 34 down-regulated genes in the group of ES-PE. Killer cell immunoglobulin-like receptor, three domains, long cytoplasmic tail, 2 (KIR3DL2), aldo-keto reductase family 1, member C3 (AKR1C3), churchill domain containing 1 (CHURC1), and solute carrier family 25, member 13 (SLC25A13) were validated to be down-regulated in the patients with ES-PE by real-time PCR. Conclusions: Expression of genes with diverse function is associated with ES-PE risk, providing opportunities for the development of non-invasive diagnosis.

Aim: To develop a clinical model to assess the risk of preeclampsia in women with gestational diabetes mellitus (GDM). Methods: We studied clinical characteristics of 813 consecutive women who had GDM between January 2003 and February 2008 at our institution. The clinical features which were significantly associated with preeclampsia by multiple logistic regression analysis were integrated into a risk model. The diagnostic performance of this model was then evaluated from a receiver-operating characteristic (ROC) curve analysis. Results: A total of 78 women with GDM (9.6%) developed preeclampsia. In a multivariable analysis, first-trimester BMI ≥27 kg/m 2 (P<0.001), GDM diagnosed within 20 weeks of gestation (P<0.001), and poor glycemic control (P<0.001) were associated with preeclampsia. These three factors were incorporated into a risk-scoring model which ranged from 0 to 3 points. At the optimal cut-off score of ≥2, the sensitivity, specificity, and area under the curve (AUC) for preeclampsia were high at 76.9% [95% confidence interval (CI) 69.0–85.2], 92.8% (95% CI 85.9–98.1), and 0.849 (95% CI 0.792–0.905), respectively. Conclusion: A model based on clinical data yielded predicted the development of preeclampsia in women with GDM.

Objective: Several mechanisms of disease have been implicated in the pathophysiology of small-for-gestational-age (SGA) including an anti-angiogenic state, and an exaggerated intravascular pro-inflammatory response. Adiponectin plays a role in a wide range of biological activities including those that have been implicated in the pathophysiology SGA. Thus, the aim of this study was to determine if third trimester adiponectin concentrations differed between women with normal weight infants and those with an SGA neonate. Study design: This cross-sectional study included women with: 1) a normal pregnancy (n=234); and 2) an SGA neonate (n=78). SGA was defined as a birth weight below the 10 th percentile for gestational age at birth. The study population was further stratified by first trimester body mass index (BMI) (normal weight <25 kg/m 2 vs. overweight/obese ≥25 kg/m 2 ). Maternal serum adiponectin multimers [total, high-molecular-weight (HMW), medium-molecular-weight (MMW) and low-molecular-weight (LMW)] concentrations were determined by ELISA. Non-parametric statistics were used for analyses. Results: 1) The median maternal serum concentrations of total, HMW and MMW adiponectin were significantly lower in patients with an SGA neonate than in those with normal pregnancies; 2) patients with an SGA neonate had a significantly lower median HMW/total adiponectin ratio and higher median MMW/total adiponectin and LMW/total adiponectin ratios than those with a normal pregnancy; 3) among patients with an SGA neonate, neither maternal serum concentrations of adiponectin multimers, nor their relative distribution differ between normal weight and overweight/obese patients. Conclusion: 1) Pregnancies complicated by an SGA neonate are characterized by a alterations in the maternal serum adiponectin multimers concentrations and their relative abundance; 2) the findings reported herein suggest that maternal adipose tissue may play a role, in the pathogenesis of SGA.

Objective: Adiponectin, an adipokine with profound insulin-sensitizing effect, consists of heterogeneous species of multimers. These oligomeric complexes circulate as low-molecular-weight (LMW) trimers, medium-molecular-weight (MMW) hexamers and high-molecular-weight (HMW) isoforms and can exert differential biological effects. The aims of this study were to determine whether there is a change in circulating adiponectin multimers in the presence of gestational diabetes mellitus (GDM), overweight/obesity or with a treatment with sulfonylurea or insulin in patients with GDM. Study design: This cross-sectional study included women with: 1) normal pregnancy (n=149); and 2) patients with GDM (n=72). Thirty-three patients with GDM were managed with diet alone. Among the others 39 diabetic patients, 17 were treated with Glyburide and 22 with insulin. The study population was further stratified by first trimester body mass index (BMI) (normal weight <25 kg/m 2 vs. overweight/obese ≥25 kg/m 2 ). Serum adiponectin multimers (total, HMW, MMW and LMW) concentrations were determined by ELISA. Results: 1) The median maternal serum of total, HMW, MMW and LMW were lower in patients with GDM than in those with normal pregnancies (P<0.001 for all comparisons); 2) patients with GDM had a lower HMW/total adiponectin ratio and a higher MMW/total and LMW/total adiponectin ratio than those with a normal pregnancy (P<0.001 for all comparisons); and 3) among GDM patients, there were no differences in the concentrations and relative distribution of adiponectin multimers between those who were managed with diet, and those who were treated with pharmacological agents. Conclusion: 1) GDM is characterized by a distinctive pattern of concentrations and relative distribution of adiponectin multimers akin to Type 2 diabetes mellitus; 2) dysregulation of adiponectin multimeres can provide a mechanistic basis for the association between adiposity and GDM.

Aim: To determine whether maternal obesity is associated with dysfunctional labor patterns. Methods: In a case-control design we compared the graphic labor patterns of a group of 105 very obese subjects [body mass index (BMI) >35 kg/m 2 ] with those of 113 lean controls (BMI<26 kg/m 2 ). All entered spontaneous labor at term. Cases with birth weights >4 kg, diabetes mellitus, hypertension and prior cesarean delivery were excluded. Results: The obese group had a significantly higher frequency of arrest of dilatation (17.6 vs. 5.2%; P=0.005). Conclusions: Maternal obesity is associated with active phase labor dysfunction, specifically arrest of dilatation.

Objective: We have previously described placental oxygenation capacity as an index of placental function. The aim of this study was to utilize this test to evaluate placental gas exchange capacity in pre-eclampsia and fetal growth restriction (FGR). Study design: Two nested case-control studies were conducted between: (i) pre-eclamptic appropriate-for-gestational-age fetus (AGA) and non-pre-eclamptic AGA; and (ii) pre-eclamptic FGR and non-pre-eclamptic FGR based on gestational age match. Umbilical A-V gas differences were compared between groups. Results: Pre-eclamptic AGA was associated with smaller A-V pO 2 and A-V pCO 2 differences compared to non-pre-eclampsia (A-V pO 2 , 7.1±3.8 mm Hg vs. 11.3±5.9 mm Hg, P=0.001; A-V pCO 2 , 7.8±5.7 mm Hg vs. 10.7± 5.9 mm Hg, P=0.01). Pre-eclamptic FGR was associated with smaller A-V pO 2 and A-V pCO 2 differences compared to non-pre-eclampsia (A-V pO 2 , 6.6±3.1 mm Hg vs. 10.8±8.1 mm Hg, P<0.001; 6.7±4.5 mm Hg vs. 10.9±10.3 mm Hg, P=0.044). Pre-eclamptic FGR also had significantly lower venous pO 2 but not arterial pO 2 (Venous pO 2 , 20.3±6.3 mm Hg vs. 25.4±11.9 mm Hg, P=0.003). Conclusion: Pre-eclampsia decreases the placental oxygenation capacity as measured by the umbilical arterial-venous oxygen difference.

Aim: Evaluate the practice and appropriateness of requesting echocardiograms in patients with suspected or documented cardiac disease during gestation and puerperium, using the American College of Cardiology Foundation (ACCF) appropriateness criteria, in conjunction with clinical picture. Methods: Retrospective observational study, to analyze echocardiograms performed during pregnancy and puerperium at a teaching hospital from 2001 to 2006 for appropriateness criteria and studying its impact on management. Sixty-seven patients pregnant or in the puerperal stage had an echocardiogram performed during that period; 58 met our criteria for inclusion. Results: Based on clinical information and criteria of the ACCF, 51 of the 58 echocardiograms met the appropriateness criteria. Of the 51, results of 40 impacted on management; 14 of the 40 echocardiograms that had an impact were abnormal. Conclusions: Although the ACCF appropriateness criteria have not been specifically studied in pregnancy, our study demonstrates that the criteria are applicable if used appropriately in pregnancy. Most indications in our study correlated with the appropriateness criteria. Although most findings were normal, information from echocardiograms impacted on management in the majority of patients, contributing to therapeutic decision-making. The reliability of echocardiograms performed according to appropriate criteria to assist clinical decisions was excellent even in patients with physiologic cardiovascular changes.

Background: Decreasing the maximum force applied during traction to the base of the fetal skull using a less rigid polyurethane forceps is the basis of this study. Our hypothesis was that less force would be generated with polyurethane forceps than with steel forceps. Objective: To test a new soft polyurethane obstetrical forceps for maximal force generated to the base of the skull during simulated occiput anterior deliveries and to compare this to a similar shaped steel forceps. Methods: After designing a prototype polyurethane forceps, we used a pelvic manikin model and a fetal manikin model. Force and load sensors were attached at the inner tips of the distal forceps blade. A Tekscan 201 (accurate for measuring 0–25 pounds of force) 0.0008 inches flexible printed circuit was used that measured contact forces. Forceps with an attached calibrated sensor were applied to the fetal head while inside the pelvic model. Results: The median maximum traction force at the base of the fetal skull was 4.60 pounds (range 4.3–4.62) for polyurethane forceps vs. 9.52 pounds (range 9.22–9.52) for steel forceps (P=0.027). Conclusion: The polyurethane forceps applied 50% less overall mechanical force than the steel forceps at the tip of the forceps and base of the skull during simulated occiput anterior outlet deliveries.

We describe the histological examination of 18 aborted fetuses that had increased nuchal translucency (NT) between 11 +0 and 13 +6  weeks' gestation. The aim of this study was to assess the corresponding NT anatomic features by immunohistochemical (IHC) investigation. A morphological study was performed using lymphatic and blood endothelial specific markers, as well as smooth muscle actin (SMA). We found that all 18 cases were D2-40 positive, CD31 positive, and CD34 negative, suggesting the presence of nuchal lymph vessel ectasia. We found that 12/18 cases were SMA staining positive and 6/18 cases were SMA negative, suggesting that 6/18 cases had nuchal cystic lymphangiectasia, whereas 12/18 had cystic hygromas. The present data seem to confirm the reasonable hypothesis that lymphangiogenesis plays a relevant role in nuchal edema, increased NT, and that increased NT is the result of a lymphatic malformation or a delayed development of the lymphatic system.

Aim: To identify factors associated with compliance of scheduled outpatient developmental follow-up appointments in an effort to better ensure future care. Methods: This retrospective observational cohort study looked at patients born between January 7 th 2006 and June 30 th 2007 and discharged from a regional neonatal intensive care unit (RNICU). Discharge summaries were reviewed to attain information regarding 16 patient descriptives and 12 patient morbidities. Data were recorded and analyzed utilizing the statistical software SPSS 11.5. Results: Children of older mothers were more likely to attend follow-up (compliant: 30 years vs. non-compliant: 27 years). Factors which significantly improved compliance with follow-up care were patient contact after discharge (compliant: 65% vs. non-compliant: 35%) and early intervention referral (compliant: 64% vs. non-compliant: 36%). Factors which significantly hindered compliance were maternal drug use during pregnancy (compliant: 11.8% vs. non-compliant: 88%), and patient transfer to outside NICUs [(transferred out: compliant: 3 (10.3%), non-compliant 25 (89.3%)]. Conclusions: Several factors associated with compliance have been identified. Direct patient contact after discharge positively correlated with improved follow-up attendance. The severity of patient disease in the NICU did not impact follow-up rates. As a result close attention needs to be paid to factors which influence compliance with outpatient follow-up for developmental screening.

Aims: To study circulating levels and distribution of adiponectin multimers [low molecular weight (LMW)-, medium molecular weight (MMW)- and high molecular weight (HMW)-adiponectin] in preterm and full-term infants. Methods: Total serum adiponectin and its multimers were measured in 40 healthy infants at the age of one month and associations with anthropometric parameters [body weight and length, body mass index (BMI)], weight gain and metabolic indices (glucose, insulin) were examined. Twenty of the infants were born preterm (gestational age 33.2±1.6 weeks). Results: LMW-adiponectin level and its fractional ratio to total adiponectin were significantly higher in full-term than in preterm infants (P<0.001 and P<0.01, respectively), whereas, MMW-adiponectin level and its ratio were significantly lower (P=0.03 and P=0.01, respectively). HMW-adiponectin did not differ significantly between full-term and preterm infants and accounted for almost 60% of total adiponectin levels in both groups. HMW-adiponectin, but not MMW adiponectin or LMW adiponectin, correlated significantly with anthropometric measurements, similarly to total adiponectin; in addition, HMW adiponectin correlated significantly with weight gain. Conclusions: HMW adiponectin is the most prevalent form in infants. Circulating levels and distribution of MMW- and LMW-adiponectin differ between full-term and preterm infants, but the role of these adiponectin multimers needs to be studied further.

Background : Growth factor-binding proteins influence the growth of infants starting in utero . Adaptation of the fetus to an adverse uterine environment is associated with changes in the growth hormone-growth factor-insulin axis. Aims: To evaluate serum levels of IGF-I and IGFBP-3 in small and appropriate for gestational age newborn infants. Methods: Fifty-four newborn infants, small (SGA, n=28) or appropriate (AGA, n=26) for gestational age were matched by gestational age and sex. Blood was collected on the first day of life, and anthropometric measurements were taken at birth. The serum levels of IGF-I and IGFBP-3 were compared, and correlated with the anthropometric measurements. Results: On the first day of life, mean serum IGFBP-3 levels were significantly lower in SGA babies and correlated with weight, length, head circumference, and ponderal index (weight/length 3) (P<0.0001). In contrast, no associations were found between IGF-I serum levels and these anthropometric measurements. Conclusion: Our data show that SGA babies have significantly reduced IGFBP-3 concentrations at birth.

Objective: To explore birth rate, delivery mode, medical problems, requirement of respiratory support, and acute outcomes of late preterm infants in Zhejiang province in eastern China. Methods: Eleven tertiary hospitals were recruited. Clinical data of every nursery admission from January to December 2007 were collected and analyzed. Results: During the study period, 44,362 infants were born with an overall preterm birth rate of 8.9%, and late preterm birth rate of 6.2%. Late preterm infants had higher cesarean section rate than the whole population (64.9% vs. 58.2%). One-fifth of the nursery admissions were late preterm infants, of whom, 63.8% were delivered by cesarean section. Respiratory distress (42.1%) was the most common medical problem of late preterm infants. Hyperbilirubinemia (17.6%), hypoglycemia (8.7%) and sepsis (5.9%) were also common. The first three primary diagnoses of respiratory distress included pneumonia (39.5%), transient tachypnea of newborn (TTN) (22.5%) and respiratory distress syndrome (RDS) (19.0%). Compared with term infants, late preterm infants with respiratory distress needed more respiratory support with nasal continuous positive airway pressure (nCPAP) (21.4% vs. 11.6%) or with a mechanical ventilator (15.4% vs. 11.0%), and also had higher in-hospital mortality (0.8% vs. 0.4%). Conclusions: Late preterm infants are associated with very high cesarean section rate and have more medical problems and poorer short-term outcomes than term infants in China.

Aims: To compare the effect of fasting period duration on complication rates in neonates managed conservatively for necrotizing enterocolitis (NEC) Bell stage II. Methods: We conducted a multicenter study to analyze retrospectively multiple data collected by standardized questionnaire on all admissions for NEC between January 2000 and December 2006. NEC was staged using modified Bell criteria. We divided the conservatively managed neonates with NEC Bell stage II into two groups (those fasted for <5 days and those fasted for >5 days) and compared the complication rates. Results: Of the 47 conservatively managed neonates Bell stage II, 30 (64%) fasted for <5 days (range 1–4 days) and 17 (36%) for >5 days (range 6–16 days). There were no significant differences for any of the patient characteristics analyzed. One (3%) and four (24%) neonates, respectively, developed post-NEC bowel stricture. One (3%) and two neonates (12%) suffered NEC relapse. None and five (29%) neonates developed catheter-related sepsis. Conclusion: Shorter fasting after NEC appears to lower morbidity after the acute phase of the disease. In particular, shorter-fasted neonates have significantly less catheter-related sepsis. We found no benefit in longer fasting.

Aim: To evaluate serum level of proinflammatory cytokine interleukin-8 as a biochemical marker of local infections in patients with clinical symptoms of preterm deliveries. Methods: We studied 74 pregnant women at 24–36 gestational weeks (GW) with preterm delivery. Serum interleukin-8 was measured. Results: The mean value of interleukin-8 in the study group (n=36) was 19.13 pg/mL vs. 5.02 pg/mL in the controls (n=38). Conclusions: The results indicate that serum level of interleukin-8 might be used as non-invasive marker of infections in pregnancy, as well as a marker of preterm deliveries.

Objective: We examined the obstetric outcomes of low-risk labors at the ‘Japanese tatami’ mat compared with Western-style delivery room. Methods: A retrospective cohort study was performed on 201 deliveries at the ‘Japanese tatami’ delivery room and 360 deliveries at the standard Western-style delivery room. Results: There were no measurable differences in the duration of labor, the incidence of perineal laceration, total maternal blood loss and the incidence of low Apgar score and umbilical artery pH between the two groups. Conclusions: We found no evidence that the Japanese room is unsafe for low-risk infants and mothers in comparison with the standard Western-style delivery room.

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