Volume 40, Issue 1

Background: Organization of the sleep states and a normal sleep pattern in the neonatal period and early infancy is essential for brain development and plasticity. The establishment of a consolidated circadian sleep-wake cycle occurs between 1 and 4 months of life in term infants. This period may be even longer for preterm infants who are exposed to relentless interventions in neonatal intensive care units. The sleep should be respected and protected. Objective and methods: Human milk (HM) contains bioactive sleep-promoting components, and recent evidence shows that some of these components show circadian oscillations. This article reviews the existing evidence regarding the role of these HM components on sleep. This topic is prefaced with a brief information about the basic concepts concerning sleep. Consecutively, chronobiotic and chrononutrition concepts are introduced. Results: Melatonin, tryptophan, nucleosides/nucleotides, and vitamin B12 are components of HM that have sleep-promoting characteristics. The sleep-inducing effects of these components are well-established in animal and adult human studies. Interestingly, melatonin, tryptophan, and 5′-adenosine monophosphate and 5′-guanosine monophosphate nucleotides in HM have been shown to exhibit also circadian oscillations. Although 5′-uridine monophosphate does not have a circadian rhythm, its levels increase during the night. Conclusion: HM has a potential to function as a “synchronizer,” helping the infant to consolidate a circadian sleep-wake cycle, thanks to its several bioactive components with chronobiotic characteristics. Research is warranted to address gaps in this field, such as the association between the circadian oscillations of the sleep-promoting factors in HM and the quantity/quality of infant sleep.

Aim: To propose suggestions for improvements in care based on conclusions from studies on low Apgar scores and substandard care during labor. Setting and patients: Studies on infants with low Apgar scores in a general obstetric population 2004–2006 and claims for financial compensation on the behalf of infants, based on the suspicion that substandard care in conjunction with childbirth has caused severe asphyxia or neonatal death in Sweden 1990–2005. Results: The most common flaws were related to insufficient fetal surveillance, defective interpretation of cardiotocography (CTG) tracings, not acting in a timely fashion on abnormal CTG, and the incautious use of oxytocin. Besides, in half of the infants a suboptimal mode of delivery added further trauma to the already asphyxiated infant. Additionally, resuscitation was unsatisfactory in many of these infants. The most critical flaw was defective compliance with the guidelines concerning ventilation and the early paging of skilled personnel in cases of imminent asphyxia or known complications during labor. In many case reports, the documentation of the neonatal resuscitation was insufficient to enable accurate and reliable evaluation. Conclusions: Examples of proposed improvements in care during labor are the introduction of a permanent educational atmosphere with aside time for daily educational rounds and discussion, cooperation around the use of standardized terminology in CTG interpretation, the cautious use of oxytocin, and the routine paging of a pediatrician before birth in cases of complicated delivery or imminent asphyxia. The proposed interventions need to be evaluated in clinical trials in the future.

Objective: The fetal inflammatory response syndrome (FIRS) is associated with impending onset of preterm labor/delivery, microbial invasion of the amniotic cavity and increased perinatal morbidity. FIRS has been defined by an elevated fetal plasma interleukin (IL)-6, a cytokine with potent effects on the differentiation and proliferation of hematopoietic precursors. The objective of this study was to characterize the hematologic profile of fetuses with FIRS. Study design: Fetal blood sampling was performed in patients with preterm prelabor rupture of membranes and preterm labor with intact membranes (n=152). A fetal plasma IL-6 concentration ≥11 pg/mL was used to define FIRS. Hemoglobin concentration, platelet count, total white blood cell (WBC) count, differential count, and nucleated red blood cell (NRBC) count were obtained. Since blood cell count varies with gestational age, the observed values were corrected for fetal age by calculating a ratio between the observed and expected mean value for gestational age. Results: 1) The prevalence of FIRS was 28.9% (44/152); 2) fetuses with FIRS had a higher median corrected WBC and corrected neutrophil count than those without FIRS (WBC: median 1.4, range 0.3–5.6, vs. median 1.1, range 0.4–2.9, P=0.001; neutrophils: median 3.6, range 0.1–57.5, vs. median 1.8, range 0.2–13.9, P<0.001); 3) neutrophilia (defined as a neutrophil count >95 th centile of gestational age) was significantly more common in fetuses with FIRS than in those without FIRS (71%, 30/42, vs. 35%, 37/105; P<0.001); 4) more than two-thirds of fetuses with FIRS had neutrophilia, whereas neutropenia was present in only 4.8% (2/42); 5) FIRS was not associated with detectable changes in hemoglobin concentration, platelet, lymphocyte, monocyte, basophil or eosinophil counts; and 6) fetuses with FIRS had a median corrected NRBC count higher than those without FIRS. However, the difference did not reach statistical significance (NRBC median 0.07, range 0–1.3, vs. median 0.04, range 0–2.3, P=0.06). Conclusion: The hematologic profile of the human fetus with FIRS is characterized by significant changes in the total WBC and neutrophil counts. The NRBC count in fetuses with FIRS tends to be higher than fetuses without FIRS.

Objective: To determine the combination of amniotic fluid (AF) tests with the best diagnostic accuracy for predicting intrauterine infection/inflammation (IUI) in patients with clinical suspicion of chorioamnionitis. Study design: This is a retrospective study of 34 pregnant women who presented with uterine tenderness, maternal fever, maternal tachycardia, and/or fetal tachycardia and underwent AF analysis. IUI diagnosis was based on placental histology, positive AF bacterial cultures, and/or Gram stain. Result: Logistic regression analysis revealed a significant relationship between IUI and AF glucose. Glucose is more sensitive than culture or Gram stain (64% vs. 40% and 20%, [iw-0.3]respectively). Culture and glucose combined achieved the best diagnostic accuracy (sensitivity, 71%; specificity, 100%; positive and negative predictive values, 100–83%, respectively). Conclusion: Positive AF Gram stain or glucose <15 mg/dL strongly suggests IUI in symptomatic patients. If both tests are negative, the result of culture should aid the management.

Aims: To identify factors associated with preterm delivery in cases of sonographically identified placenta previa. Methods: Pregnancies with sonographic evidence of placenta previa at ≥28 weeks were identified. Demographic information, antepartum course, and delivery information were extracted from electronic medical records. Statistical analysis was performed with Fisher’s exact test, Mann-Whitney U , Spearman’s ρ (correlation), and logistic regression. Continuous data are presented as median (interquartile range). Results: Of 113 singleton pregnancies with placenta previa, 54 (48%) delivered at term and 59 (52%) delivered preterm. Fifty-one (45%) experienced antepartum bleeding at a median gestational age of 31 weeks (29–33 weeks) with a median interval of 20 days (11–33 days) between first bleeding episode and delivery. Women with antepartum bleeding were more likely to be delivered for hemorrhage (36 of 51 vs. 8 of 62, P<0.001) and delivered emergently (40 of 51 vs. 14 of 62, P<0.001). Antepartum bleeding before 34 weeks had a positive predictive value of 88% for preterm birth and 83% for emergent delivery. Conclusion: In pregnancies with placenta previa, antepartum bleeding is a strong predictor of preterm delivery.

Objective: To evaluate the effectiveness of human recombinant activated factor VII (rhFVIIa, NovoSeven) in avoiding hysterectomy postpartum in the management of severe postpartum hemorrhage (PPH). Methods: We performed a prospective cohort study at our university tertiary care center. Patients with severe post partum hemorrhage (blood loss >2000 mL) and failed medical and uterus-preserving surgical management, were treated with intravenous bolus administration of rhVIIa. Main outcome measures were cessation of bleeding, postpartum hysterectomy and thromboembolic events. Results: In 20/22 patients included, PPH was caused primarily by uterine atony, including 7 (32%) with additional lower genital tract lesion; in two women, it was due to pathologic placentation (placenta increta, 9%). One case of amniotic fluid embolism and one woman with uterine inversion were included. Recombinant hFVIIa was successful in stopping the PPH and in preventing a hysterectomy in 20/22 women (91%). The remaining two patients with persistent bleeding despite rhFVIIa treatment, who underwent postpartum hysterectomy, had placenta increta. No thromboembolic event was noticed. Conclusions: This study describes the largest single center series of rhFVIIa treatment for fertility preservation in severe postpartum hemorrhage published to date. Our data suggest that administration of rhFVIIa is effective in avoiding postpartum hysterectomy after conservative medical and surgical measures have failed. Although randomized studies are lacking, rhFVIIa should be considered as a second-line therapeutic option of life-threatening postpartal bleeding, in particular if preservation of fertility is warranted and hysterectomy is to be avoided.

Objective: To evaluate the possible association between protease inhibitor (PI) and premature birth and low birth-weight in HIV-infected pregnancies. Materials and methods: Data were collected retrospectively for maternal and pregnancy characteristics, antiretroviral medication, lowest CD4 count and highest viral load during pregnancy, and pregnancy outcomes. χ 2 Analysis, Student’s t -test, and multiple logistic regression analysis were performed. Results: Data from 161 HIV-infected women who delivered singleton gestation were analyzed. Fifty-three received an antepartum regimen with PI, 84 received a regimen without PI, and six did not receive antepartum treatment. The mean estimated gestational age (EGA)±SD at delivery was 37.7±3.2 weeks. The premature birth rate was 18.4%. No difference was detected between women receiving the antiretroviral regimen including PI and those on the regimen without PI or on no antepartum medication with regard to: EGA±SD at delivery (37.7±3.2 vs. 37.6±3.1 weeks, respectively, P=0.87), rate of premature birth (14% vs. 20.6%, respectively, P=0.32) and low birth-weight (12.5% vs. 20.2%, respectively, P=0.25). In multiple logistic regression analysis, PI was not associated with premature birth or low birth-weight. Conclusion: Women receiving antiretroviral therapy with PI have a similar rate of premature birth and low birth-weight as women receiving antiretroviral therapy without PI or on no medication.

Background/objectives: To assess vitamin D status during normal pregnancy and in the postpartum lactation period. Subjects/methods: The study comprised 141 healthy, ethnic Danish women with normal pregnancies, who were residents in Greater Copenhagen. Serum 25-hydroxy-vitamin D 2 +D 3 (25-OH-vitamin D) was measured at 18, 32 and 39 weeks’ gestation and 8 weeks postpartum. Results: There was a significant increase in 25-OH-vitamin D from 18 to 32 weeks’ gestation (P=0.0001) followed by a significant decrease from 32 to 39 weeks (P=0.001) as well as from 39 weeks to 8 weeks postpartum (P<0.0001). At 18, 32, 39 weeks’ gestation and 8 weeks postpartum, median 25-OH-vitamin D values were 77, 98, 91, and 73 nmol/L, respectively. During pregnancy and postpartum, none of the women displayed severe vitamin D deficiency (values <13 nmol/L). Between 1.4% and 4.3% of the participants displayed moderate vitamin D deficiency (values 13–24 nmol/L), 16–19% displayed vitamin D insufficiency (values 25–50 nmol/L), 77–84% had values >50 nmol/L and 0.7–2.8% had values >200 nmol/L. Conclusions: Low vitamin D status is frequent among pregnant Danish women, especially in late pregnancy and during lactation. Median dietary intake of vitamin D in women of reproductive age was 2.4 μg/day (10–90 percentile range=1.4–5.0). The recommendations for vitamin D supplementation prior to conception, during pregnancy and lactation should be reconsidered.

Objective: To analyze the relationship of the time interval between two deliveries, done by one obstetric team, on the delivery mode of the subsequent birth; to define the length of this interval; and to evaluate this time interval as a risk factor for increased perinatal mortality in a population-based cohort. Methods: All singleton deliveries at ≥24 weeks’ gestation in Lower Saxony, Germany, between 2001 and 2005 (a total of 317,663 deliveries including 402 cases of perinatal mortality) were analyzed. The mode of the previous and the subsequent delivery, the time interval between the two deliveries, the time of birth, the hospital volume, and the existence of an affiliated neonatal ward were investigated. Results: When the first vaginal delivery was <45 min, there was a reduced probability that the subsequent birth would be a cesarean section. In case of a previous cesarean section, the cesarean rate of the following birth was influenced up to 165 min. In a multivariate analysis, vaginal deliveries following an earlier vaginal birth and occurring within <45 min were associated with increased perinatal mortality. Repeated cesarean sections within <165 min were associated with increased perinatal mortality when occurring at night or on weekends. Conclusion: A short time interval between two deliveries in an obstetric unit constitutes an independent risk factor for perinatal mortality.

The aims of this study were to evaluate the cardiac effects of subcutaneous terbutaline on the mother and fetus. Terbutaline was given in 250 or 500 μg doses to term gravidas not in labor. The mean arterial pressure (MAP), pulse, and uterine activity were measured. The fetal heart rate (FHR), accelerations, and decelerations were recorded. There were significant increases in maternal heart rate, FHR, and FHR accelerations, and a decrease in uterine basal activity after 500 μg, but not significantly after 250 μg of terbutaline. MAP was not significantly increased with either dose, although a small mean increase was observed. Terbutaline has a direct effect on the fetal heart apart from the effect of uterine relaxation.

This study evaluated in vitro immune responses to Escherichia coli lipopolysaccharide in maternal and fetal blood. Samples were concurrently obtained from maternal venipuncture and umbilical cord blood samples and cultured with the E. coli endotoxin, and cytokines were assayed. There were statistically significant correlations between maternal and fetal samples. This demonstrates maternal and fetal immune communication and mutual programming during pregnancy. Subclinical infection, which predisposes to premature labor, could be detectable from a maternal blood sample even if derived only from the fetal compartment. A maternal blood panel test might serve as a diagnostic screen for subclinical infection in patients at risk for preterm labor.

Objective: While socioeconomic status (SES) and race/ethnicity are known predictors of breastfeeding practices, the added disparity caused by the rising rates of obesity among women of childbearing age remains untested. The purpose of this study was to examine differences in breastfeeding initiation and duration among black, white and Hispanic women of low and middle SES within the context of prepregnancy body mass index (BMI). Methods: Data from the Early Childhood Longitudinal Study-Birth Cohort were analyzed. Adjusted logistic regression models were built to examine differences in breastfeeding initiation and duration for the three racial/ethnic groups of low and middle SES. Results: Normal BMI Hispanic women of low SES demonstrated higher rates of breastfeeding initiation (74%) compared to other groups. Overweight/obese black women of low SES had lower rates of breastfeeding initiation. Overweight/obese Hispanic women of middle SES were significantly less likely to continue breastfeeding up to 4 months (OR: 0.65, 95% CI: 0.41, 0.98) compared to their white counterparts. Among women who initiated breastfeeding, overweight/obese white women of low SES had the highest rate of stopping within two months of giving birth (66.7%). Conclusions: Examination of SES and racial/ethnic differences within the context of prepregnancy weight revealed specific groups with low rates of breastfeeding initiation and duration. Interventions tailored for these at-risk groups are needed to increase the overall proportion of mothers and infants who benefit from the positive health outcomes associated with breastfeeding.

Fetuses with gastroschisis and omphalocele frequently show intrauterine growth restriction (IUGR). The aim of our study was to evaluate the intrauterine course of IUGR and the neonatal outcome in a large patient collective. We retrospectively included all euploid fetuses with gastroschisis and omphalocele between 2001 and 2009 in a single tertiary center. Patients’ characteristics, serial ultrasound examinations and neonatal outcomes were evaluated. From 39 fetuses (28 gastroschisis, 11 omphalocele) 61.5% had IUGR <5 th percentile and 15.4% had IUGR<10 th percentile. The rate of IUGR did not differ significantly between the two groups during pregnancy. Newborns with gastroschisis showed an average weight of 2386 g, and those with omphalocele showed an average weight of 3148 g (P<0.001). Nevertheless, newborns with omphalocele were more frequently eutrophic than those with gastroschisis (88.8% vs. 52.2%, P=0.079). On average, only one surgical intervention was necessary for the definitive repair of the defect (65.5% of the newborns). Children with gastroschisis remained hospitalized nearly twice as long as children with an omphalocele (38 vs. 20 days). IUGR rates during pregnancy did not differ significantly between fetuses with gastroschisis and omphalocele although patients with defects of omphalocele were more frequently eutrophic at birth. Most newborns needed only one operation for definitive surgical treatment. The mean hospitalization time after this intervention was 4 weeks.

Aims: To explore the association between total serum bilirubin (TSB) level in umbilical cord blood (UCB) and the occurrence and/or severity of respiratory distress syndrome (RDS) in very low birth weight (VLBW) infants. Methods: We performed a prospective study of 579 VLBW infants. The mean TSB level in UCB (1.8 mg/dL) was used to divide the cohort into two groups: neonates with levels <1.8 mg/dL and those with levels >1.8 mg/dL. Demographic and clinical characteristics of the 2 groups, including diagnosis of RDS, need for ventilation, peak fraction of inspired oxygen (FiO 2 ), oxygenation index (OI), and duration of respiratory support, were compared. Results: Three hundred and twenty-four infants were included in the low-TSB group and 255 infants were included in the high-TSB group. RDS was less frequent in the high TSB group than in the low one (46.3% vs. 56.6%, P=0.01). A negative association between TSB level in UCB and the occurrence of RDS [odds ratio (OR)=0.620; 95% confidence interval (CI) 0.440–0.873, P=0.006] was observed. However, lower TSB in UCB was not associated with the maximum FiO 2 , OI, or duration of mechanical ventilation. Conclusions: VLBW infants with low TSB levels in UCB were more likely to develop RDS. However, in conjunction with surfactant replacement therapy, no correlation was found between TSB levels in UCB and the severity of RDS. The negative association between high TSB in UCB and RDS warrants further investigation.

Objective: Our objective was to evaluate whether using a standardized shoulder dystocia delivery form improved documentation. A standardized delivery form was added to our institution’s obstetrical record in August 2003. Methods: A retrospective cohort study was conducted comparing 100 vaginal deliveries complicated by shoulder dystocia before, and 81 after implementation of the standardized delivery form. The two groups were compared in terms of obstetric characteristics, neonatal outcomes and documentation components. Results: Charts that included the standardized delivery form were more likely to contain documentation of estimated fetal weight (82.7% vs. 39.0% without the form, P<0.001) and head-to-shoulder delivery interval (76.5% vs. 15.0% without the form, P<0.001). Both groups were statistically similar in terms of documenting estimated blood loss and fetal weight, umbilical cord pH, type and order of maneuvers utilized to relieve the shoulder dystocia, and second stage duration. Conclusions: Inclusion of a standardized form in the delivery record improves the rate of documentation of both shoulder dystocia-specific and general delivery components.

No abstract available

No abstract available