Volume 39, Issue 1

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Advanced transvaginal neurosonography has revealed normal and abnormal intracranial morphology. Transvaginal three-dimensional (3D) sonography demonstrates bony structure, multiplanar analysis of inside detailed morphology, tomographic ultrasound imaging in any cutting sections, 3D sonoangiography and volume calculation of ventricles and/or intracranial lesions. Longitudinal assessment of normal and abnormal central nervous system (CNS) development is done by serial scanning. However, the transvaginal high-frequency approach has several limitations due to lack of penetration and cranial bone ossification with advanced gestational age. Magnetic resonance neuroimaging enabled observation of the whole intracranial cavity, brainstem and cortical gyral/sulcal development. On the other hand, neuro-sonography has advantages in detecting intracranial calcification, vascular abnormalities, intratumoral vascularity and bone dysplasia. Moreover, 3D ultrasound demonstrates extra CNS abnormalities, strongly associated with CNS abnormalities. Any less-invasive modalities can be used for a CNS anomaly screening scan and ultrasound is no doubt the first choice. Once CNS abnormality is suspected, it is suggested to use the different technologies according to what is looked for in each abnormal CNS case. Of course, MR and 3D ultrasound imaging should be complementary as well as alternative.

The number of multiple pregnancies has increased, mainly due to the uncontrolled use of the assisted conception techniques. Multifetal pregnancy reduction (MFPR) has been used to reduce the risks associated with these high-risk pregnancies. It is performed in the first trimester of pregnancy by transabdominal injection of potassium chloride into the fetal heart. The risk of miscarriage seems to be associated with the final number of fetuses. A review of the literature suggests that MFPR results in better pregnancy outcome, regardless of the initial number of fetuses. The reduction to a lower number of fetuses reduces fetal losses, prematurity, infant mortality and morbidity.

Objective: To evaluate whether uterotrophic agents increase the risk of fatal hemorrhagic brain stroke. Methods: Between 1991 and 1992, there were 230 maternal deaths among 2,420,000 pregnant women in Japan and the causes of these deaths was investigated in 1994. Using information provided in this report, we identified 35 women who died from or were assumed to die from hemorrhagic brain stroke. We assumed that 93% of women would have tried vaginal delivery. The risk of fatal hemorrhagic brain stroke after uterotrophic agent use was calculated according to the assumption that 5.0–40% of women received uterotrophic agents. Results: Use of uterotrophic agents for induction/augmentation of labor was confirmed in five (14.3%) of the 35 women who died from hemorrhagic brain stroke. The incidence of fatal brain stroke after the use of uterotrophic agents was only significantly higher than that for spontaneous hemorrhagic brain stroke if these agents were administered in ≤6.0% of women. Conclusions: Because more than 6.0% of women received uterotrophic agents, these agents are unlikely to increase the risk of fatal hemorrhagic brain stroke.

Aim: To determine parental, especially paternal factors associated with the weight of the placenta and offspring. Methods: This population-based birth-cohort study includes 2947 singleton children born from April 2006 to 2007 and living in Drenthe, The Netherlands. Placental weight and birth weight were measured and questionnaires were filled out for this cohort. Associations between parental factors, and the weight of the placenta and the offspring were evaluated using univariate and multivariate linear regression models. Results: Univariate regression revealed that the paternal birth weight and body mass index (BMI) of the father were predictors for placental and birth weight of the offspring. However, they were not independent predictors. Independent predictors for placental weight were the maternal factors of pre-pregnancy BMI, birth weight, and diabetes. The maternal factors of weight gain during pregnancy, birth weight, smoking during pregnancy, and diabetes were independent predictors for birth weight of the offspring. Conclusion: Paternal as well as maternal factors influence the weight of the placenta and the offspring.

Objective: To analyze the characteristics and trends of maternal deaths due to obstetric hemorrhage in urban and rural areas during the period of 1996–2005 in China, and to provide evidence for decision-making for further reducing the national maternal mortality ratio (MMR). Methods: We analyzed national maternal mortality data collected from the Maternal and Child Health Surveillance System of China. Results: The decline of MMR due to obstetric hemorrhage contributed to 91.98% of the overall MMR decline. The adjusted average annual decline rate (AADR) of MMR due to obstetric hemorrhage was 7.30% in rural areas and 2.07% in urban areas. The maternal deaths due to postpartum hemorrhage accounted for the vast majority of maternal deaths due to hemorrhage, and the adjusted AADR was higher in rural areas (7.45%) than in urban areas (1.56%). Conclusion: Although the risk of maternal deaths from hemorrhage decreased substantially, the gap between urban and rural areas is obvious. Efforts to lower MMR should focus on obstetric hemorrhage, especially postpartum hemorrhage, in rural areas. It is recommended that policy-makers should focus on improving the accessibility to and quality of obstetric service in rural areas.

Objectives: We assessed the accuracy of predicting severe twin birth weight discordance (>25%) using the estimated fetal weights (EFW) and abdominal circumference (AC) ratio. Method: A cohort of twin gestations underwent ultrasound examinations within two weeks from birth. We focused on the accuracy of EFW and on the diagnosis of severe birth weight discordance by the difference in EFWs and the AC ratio. Results: The 661 eligible twin pairs included 51 (7.7%) severely discordant pairs. The accuracy of an EFW to predict the actual birth weight was quite poor, with an acceptable specificity (96.4%), but low sensitivity (28.6–40.5%), to detect severely discordant pairs, whereas an AC ratio of 1.3 detected these discordant pairs with sensitivity and specificity of 97.3–100% and 99.6–99.7%, respectively. Conclusion: By comparing EFWs, 59.5–71.4% of discordant pairs >25% are missed, whereas an AC ratio >1.3 would identify almost all cases.

Objective: To evaluate whether National Institute of Child Health and Human Health and Development (NICHD) fetal heart rate categories were predictive of neonatal survival in periviable pregnancies. Methods: We reviewed the charts of 57 infants delivered at 23 and 24 weeks' gestation. Fetal heart rate tracings were evaluated following the NICHD 2008 criteria, using the acceleration height of 10 bpm and duration of 10 s. Multiple logistic regression analyses were performed using survival, fetal morbidities, and cord pH <7.1 as dependent variables. Independent variables included fetal heart rate category, mode of delivery, resuscitation, and histological chorioamnionitis. Outcomes of infants delivered at 23 and 24 weeks were also compared. Results: In 23-week pregnancies, fetal heart rate category 2 was associated with improved short-term survival compared to category 3 (OR 1.3, 95% CI 0.11–15.7). Cesarean delivery and histological chorioamnionitis were not predictive of survival [(OR 0.5, 95% CI 0.04–7.1, and OR 0.4, 95% CI 0.02–6.85), respectively]. Long-term survival for infants born at 23 and 24 weeks was 8% and 56%, respectively. Conclusions: The NICHD fetal heart rate category during labor may be associated with survival for infants born at 23 and 24 weeks of gestation. Cesarean delivery was not associated with improved survival.

Objective: To calculate a population-based prospective risk of fetal death in monochorionic-diamniotic twins. Study design: We evaluated 387 monochorionic-diamniotic twin pregnancies that were followed and delivered after 24 weeks in Slovenia during the period 1997–2007. Surveillance was not standardized. The prospective risk of fetal death was calculated as the total number of deaths after the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Results: Fetal death rate was 32 of 774 fetuses (4.1%; 95% confidence interval (CI), 3.0%–5.9%); the prospective risk of stillbirth per pregnancy after 33 weeks of gestation was 6.2% (95% CI, 4.2%–9.1%). Conclusion: The Slovenian population-based prospective risk of fetal death in monochorionic-diamniotic pregnancies that remained undelivered after 33 weeks' gestation is higher than previously reported from hospital-based studies.

Aim: To evaluate the effect of ibuprofen on bilirubin-albumin binding affinity and unbound bilirubin in premature infants. Study design: A prospective study with subjects serving as their own controls was performed on <30 weeks' gestational age infants with unconjugated hyperbilirubinemia and who received ibuprofen for patent ductus arteriosus. Infants with congenital malformation, TORCH infections, and conjugated hyperbilirubinemia were excluded. Total serum bilirubin (TSB) and unbound bilirubin (modified peroxidase test) were measured prior to (baseline) and after (follow-up) initiation of ibuprofen. The bilirubin/albumin equilibrium association binding constant was calculated using albumin, TSB, and unbound bilirubin. Results: Ten infants were studied. The mean TSB between baseline (5.9±1.7 mg/dL) was higher than that at follow-up [4.9±1.7 mg/dL]. Mean unbound bilirubin at baseline (0.75±0.65 μg/dL) was similar to that at follow-up (0.63±0.46 μg/dL). No difference existed between mean baseline binding constant (49±50 L/μmol) and that at follow-up (44±36 L/μmol). The ratio of unbound bilirubin with and without ibuprofen, index of displacing effect, was 0.88 (95% CI 0.63–1.14). Conclusions: Ibuprofen may not be associated with bilirubin displacing effect in relatively stable premature infants with mild to moderate unconjugated hyperbilirubinemia.

Introduction: The term “euthyroid sick syndrome” (ESS) has been used to describe a pattern of thyroid hormone changes during the course of critical illness in adult patients without thyroid disease, often associated with reduced thyroid hormone secretion. Objective: To describe the thyroid hormone profile in full-term newborns critically ill compared with thyroid hormone profile of healthy infants, and determine if alterations could be related to the severity of the disease and outcome. Methods: A cross-sectional, observational, and prospective study of full-term infants admitted to the neonatal intensive care unit (NICU) of the Hospital de Pediatría J.P. Garrahan between July 2007 and April 2008. Serum T3, T4, and thyroid stimulating hormone (TSH) levels were measured at admission and severity of the disease was evaluated through SNAP, lactic acid, respiratory assistance and number of organs affected. Results: Sick newborns showed significantly lower T3 and T4 levels compared with healthy infants [T3: –0.97 μg/dL (95% CI –0.89, –1.13) and T4: –4.37 μg/dL (95% CI –2.95, –5.78)]. Only 29 out of 94 (31%) infants presented a normal profile; 37 (39%) infants showed isolated low T3 levels, 20 (21%) infants had low T3 and T4 levels and eight (9%) infants had low TSH, T3, and T4. Of this latter group, five of eight (62%) children died suggesting a significantly higher risk of death for patients with low T3 associated with low T4 and TSH [Risk ratio (RR) 10.75 95% CI 3.93, 29]. Conclusions: Full-term sick newborns frequently have lower thyroid hormone levels than healthy ones. These observed thyroid hormones changes might be related to the underlying disease and could be used as a prognostic marker of the severity and fatal outcome of the patient.

Background: Thrombocytopenia (TP) is a common finding among preterm neonates and has been associated with mortality and morbidities. Yet, there is no consistent classification for neonatal TP. TP in adults has recently been graded by the National Cancer Institute (NCI) Common Toxicity Criteria and has been shown to predict clinical outcomes. Objective: To use the NCI classification for TP in preterm neonates and elucidate its association with clinical outcomes. Methods: Retrospective chart review was done on neonates born at gestational age (GA) ≤28 weeks and survived for ≥7 days. TP was classified as per NCI guidelines at 7 days and 28 days of age and their association with mortality, major morbidities and hospital length of stay (LOS) were investigated. Results: A total of 286 patients were included in the study with a mean GA of 26.3±1.5 weeks and birth weight of 899±215 g. NCI TP grades at 7 days were significantly (P<0.001) associated with mortality, LOS, intraventricular hemorrhage and Gram negative infections. In addition to these outcomes, necrotizing enterocolitis, Gram positive and fungal infections were also significantly associated with NCI TP grades at 28 days. Conclusions: Classification of TP using the NCI criteria in extreme preterm neonates is clinically applicable. This grading system of platelet counts is significantly associated with mortality, morbidity and LOS in preterm neonates.

Despite widespread prenatal serological screening, the Centers for Disease Control recently reported that from 2005 to 2008, congenital syphilis increased by 23%, many being born to black women in the southern United States. We collected data on the epidemiology of this condition in our institution for the past 18 years (January 1, 1991–December 31, 2008). There has been a marked decrease in the incidence of active infection since the 1990s. Through the 18 years period reviewed, only 21 cases of active neonatal infection were documented among 699 babies who had a positive rapid plasma reagin test. Of these 21 cases, only one was symptomatic. As compared to previous studies, poor prenatal care has still the greatest correlation with active infection. This study might contribute towards the reinforcement of current programs and the formulation of newer strategies towards control and elimination of this condition.

Background: To describe a simple, rapid, quantitative ultramicrotest (UMTEST) based on the fluorometric method introduced by Fujimura et al. adapted to an Ultra Micro Analytic System (SUMA) for the detection of total galactose (GAL) in dried blood specimens. Methods: The assay uses 3 mm discs of dried blood on Whatman 903 filter paper and small volumes of each reagent. A methanol/acetone/water solution is used for deproteination, and a specially designed 96-well polystyrene opaque ultramicroplates, with a maximum capacity of 30 μL per well, are used for the reading. Results: The UMTEST GAL is completed in 2 h, with measuring range of 0.28–3.92 mmol/L. The intra- and inter-assay coefficients of variation were 2.3%–8.9% and 6.8%–11.1%, respectively, depending on the total GAL concentrations. Percentage recovery ranged from 97.7% to 103%. Limit of detection and limit of quantitation were 0.06 and 0.16 mmol/L, respectively. The mean GAL concentration, in 2510 dried blood samples from the National Neonatal Screening Program was 0.23 mmol/L. Our assay showed high concordance correlations with the commercially available ICN Immuno-Chem™ GAL-MW EA kit. Conclusions: The analytical performance characteristics of this assay is suitable for mass newborn screening of galactosemia in Cuba.

Perinatal brain damage may result in impaired neurological development in extremely preterm infants. The underlying pathophysiological mechanisms are complex, and biomarkers of prognostic value are not available. The aim of this study was to analyze soluble Fas (sFas) concentrations in the cerebrospinal fluid (CSF) representative for involvement of apoptotic processes in preterm infants developing posthemorrhagic hydrocephalus (PHHC) and to link them to white matter damage (WMD) diagnosed by cranial ultrasound. A total of 29 preterm infants with PHHC were included in the study; 17 of them had signs of cystic WMD (cWMD) on ultrasound examinations. CSF samples were obtained at first ventriculostomy, and results were compared to those of a reference group of 24 preterm and term infants without neurologic diseases. sFas concentrations were elevated in CSF samples of PHHC patients compared to the reference group. In patients with cWMD, sFas concentrations were significantly higher than in patients without cWMD. These results indicate that apoptosis via the Fas pathway is involved in the pathogenesis of cWMD in the context of PHHC, and that sFas in the CSF may serve as a marker of cWMD development.

Aim: To evaluate the cardiac function in premature infants born to preeclamptic mothers and its clinical consequences. Methods: This was a prospective observational cohort study performed in a tertiary neonatal intensive care unit. Fifty-three premature infants born to preeclamptic mothers comprising the study group were evaluated and compared with 42 premature infants born to normotensive mothers (control group). Relationship between echocardiographic measures and neonatal morbidity were assessed as the main outcome measures. Results: Left ventricle end-diastolic dimension (LVEDD), peak flow velocities during early diastole (peak E wave), peak flow velocities during atrial contraction (peak A wave), and peak E/A ratio were significantly lower in the study group. Within the study group, these parameters were also significantly lower in infants with respiratory problems. LVEDD was significantly smaller in preeclamptic infants with intrauterine growth retardation (IUGR). Conclusion: Left ventricle diastolic dysfunction (LVDD) was detected in premature infants born to preeclamptic mothers in the first week after delivery. LVDD was associated with higher incidence of respiratory problems, transient tachypnea of the newborn, longer duration of oxygen requirement, and IUGR.

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