Neonatal morbidity and mortality associated with triplet pregnancy

OBJECTIVE: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time. METHODS: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period. RESULTS: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [CI] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins. CONCLUSION: When stratified by gestational age, triplet neonates delivered at 24-34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.     

The impact of major congenital malformations on mortality in a neonatal intensive care unit

Neonatal mortality due to congenital malformations or genetic disorders has not decreased despite a decrease in overall neonatal deaths with recent advances in medical technology. As a consequence, an increasing percentage of neonatal deaths is attributable to congenital malformations and genetic disorders. This study retrospectively reviewed neonatal deaths associated with congenital malformations over an 11-year period in the neonatal intensive care unit (NICU) at Kosair Children's Hospital, Louisville, Kentucky. Presently, congenital malformations are responsible for approximately 45% (range 32% to 61%) of deaths in the NICU with congenital heart disease, lethal genetic disorders, and pulmonary hypoplasia being the main contributors. Other major causes of neonatal death included extreme prematurity, respiratory disorders, necrotizing enterocolitis, sepsis, asphyxia, and primary pulmonary hypertension. It is important that clinicians are aware that improved survival is expected for most diseases because of technological advances, but that further significant reductions in neonatal mortality will depend on genetic counseling and prevention of congenital malformations.     

Effects of cisapride on QTc interval in neonates

AIM: Prospective survey of the effects of cisapride on QTc interval in neonates given cisapride. METHODS: QTc interval was determined just before and 2.9 (0.9) days after outset of the treatment in 49 neonates treated with cisapride between 1 August 1995 and 29 February 1996. RESULTS: Cisapride significantly increased QTc interval (p = 0.0001), and this was higher when birthweight or gestational age were lower. The prolongation of QTc interval above the arbitrary value of 0.450 (n = 7) was clinically asymptomatic and was significantly more common in the infants born with a gestational age < or = 33 weeks (n = 6). CONCLUSION: The findings indicate that cisapride accumulates in less mature neonates. Further pharmacokinetic studies are needed.     

Bone mineral density in pediatric patients with idiopathic hypercalciuria

Between October 1993 and April 1995, a total of 77 neonates requiring mechanical ventilation were enrolled in this study and were randomly divided into two groups. Group A consisted of 31 premature infants (mean birthweight 1.36 +/- 0.29 kg) with respiratory distress syndrome (RDS) and seven neonates (mean birthweight 3.2 +/- 0.5 kg) with meconium aspiration syndrome (MAS). Group B consisted of 31 premature infants (mean birthweight 1.31 +/- 0.3 kg) with RDS and eight neonates (mean birthweight 3.3 +/- 0.5 kg) with MAS. Infants in group A received synchronized intermittent mandatory ventilation (SIMV) and infants in group B received conventional intermittent mandatory ventilation (CIMV) therapy. In premature infants with RDS, our data showed: (i) the duration of ventilation was significantly shorter (P < 0.05) in the synchronized group (156 +/- 122 h) compared to the conventional group (242 +/- 175 h); (ii) significantly fewer (P < 0.05) patients required reintubation in the synchronized group than in the conventional group (three vs 11 patients); (iii) incidence of severe intraventricular hemorrhage (grades 3 and 4) was significantly lower (P < 0.05) in the synchronized group compared to the conventional group (one vs seven patients); (iv) incidence of bronchopulmonary dysplasia was significantly lower (P < 0.05) in the synchronized group than in the control group (one vs seven patients). In neonates with MAS, our data showed no significant difference (P < 0.05) on duration of ventilation, incidence of reintubation, incidence of pneumothorax or mortality rate between synchronized and control groups.     

Impact of pregnancy on maternal AIDS

OBJECTIVE: To assess the impact of pregnancy on maternal acquired immunodeficiency syndrome (AIDS) among tribal women in India. STUDY DESIGN: From February 1992 to February 1996, 71 tribal women from Manipur, India, with AIDS (Centers for Disease Control stage iii/iv), matched for age, parity, CD4 lymphocyte count and demographic characteristics, were recruited into a prospective study. Thirty-two (49%) of these women were pregnant (8-10 weeks) (group A) and 38 (51%) nonpregnant (group B). RESULTS: Pneumocystis carinii pneumonia followed by miliary tuberculosis and wasting disease were the most common AIDS-defining illness and cause of maternal death in both groups. A total of 28 (39%) women died as a direct result of their AIDS-defining illness; 10 (27%) of them were among the nonpregnant women as compared to 18 (56%) deaths among the pregnant women (P = .17, odds ratio 3.7285, 95% confidence interval 1.23, 11.58). Three (16%) of these 18 deaths occurred within 14 weeks of an uneventful first-trimester medical termination of pregnancy. Thirteen women (41%) died undelivered at 30-34 weeks' gestation, and two died within 3 weeks of delivery. Fourteen (44%) women vaginally delivered 14 preterm infants, between 28 and 35 weeks' gestation. Eleven of these infants died within six weeks; nine deaths were a direct result of prematurity and clinical diagnosis of an AIDS-defining illness. The mean survival time was 9.72 months for the pregnant women and 22.6 months for the nonpregnant women (P = .066). CONCLUSION: Pregnancy increased maternal and fetal mortality in these AIDS-infected women.     

Cardiac effects of short course dexamethasone in preterm infants

AIM: To examine the incidence and natural history of left ventricular hypertrophy (LVH) associated with the shorter 2-3 week course of dexamethasone, now more usual, for chronic lung disease. METHOD: Thirty one infants, gestational age 23-34 (median 26) weeks, birthweight 500-2054 (median 815)g, received dexamethasone, starting at 0.4-0.6 mg/kg/day, at a median of 11 days of age (range 2-34), weaning over a period of 2-3 weeks. Eighteen preterm neonates were studied as controls over a similar time period. Serial echocardiographic measurements of end diastolic interventricular septum (IVSd) and left ventricular posterior wall (LVPWd) thicknesses were taken before, and up to 48 days after, starting dexamethasone. Maximum Doppler blood flow velocities from the left ventricular outflow tract (LVOT) were measured. RESULTS: Left ventricular hypertrophy (LVH) occurred in 29 babies (94%). Median hypertrophy of the IVSd in those receiving dexamethasone was 67% and LVPWd 56% of baseline measurements, significantly greater than control infants (p < 0.001). LVH appeared by a median of three days, peaking by a median of 10 days. All resolved by a median of 27 days. LVOT obstruction was not seen. There was no significant correlation with birthweight, gestation, blood pressure, or glucose tolerance. CONCLUSIONS: LVH developed in almost all preterm neonates receiving a 2-3 week course of dexamethasone, but was of little clinical importance and always resolved. Echocardiography is probably not required routinely in infants receiving such short course dexamethasone for chronic lung disease.     

Active management of prolonged pregnancy

OBJECTIVES: We assessed perinatal morbidity and mortality of prolonged pregnancies (> or = 294 days) compared with those of term gestations. We also evaluated the impact of induction of labor compared with spontaneous onset of labor. STUDY DESIGN: This observational study included consecutive cases treated at Chicago Lying-In Hospital from July 1980 to December 1984. Complications, presence of meconium, indications for cesarean section, mode of delivery, perinatal morbidity (and mortality), meconium aspiration, and duration of labor were compared with those in the total hospital population, in infants weighing > or = 2500 gm, and within prolonged gestation groups; spontaneous onset and induced ("active management") labors were also compared. The chi 2 analysis was used. RESULTS: Of 12,930 deliveries there were 707 prolonged gestations (5.5%) and 10,698 with infants > or = 2500 gm. Among the prolonged gestations 67% were in multiparous women and 33% in primiparous women. Labor started spontaneously in 62%, and 38% underwent induction; the overall cesarean section rate was 17% with similar indications in both spontaneous onset and induction groups. Meconium was present in 34%; it was present in 23% of inductions, which is fewer (p < 0.01) than among those with spontaneous onset of labor (40%). Also there were fewer depressed neonates at 5 minutes (p = 0.03) among inductions. Meconium aspiration was seen in 24, with nine deaths. The perinatal mortality was 14 per 1000 (corrected 12.7/1000), significantly more than in the general population. Among those with spontaneous onset of labor it was 20.5 per 1000; there were no deaths among inductions. Postpartum maternal morbidity was 16% among cesarean sections and 4% among vaginal deliveries. CONCLUSIONS: Prolonged gestation has a high perinatal morbidity and mortality rate. All perinatal deaths were observed among patients whose labor started spontaneously. "Active management" (induction at 42 weeks) did increase the primary cesarean section rate compared with that of the general obstetric population; it did not do so among prolonged gestations and prevented perinatal deaths in this group. From this experience an active approach seems justified.     

Increasing social variation in birth outcomes in the Czech Republic after 1989

OBJECTIVES: This study investigated social variation in birth outcome in the Czech Republic after the political changes of 1989. METHODS: Routinely collected records on singleton live births in 1989, 1990, and 1991 (n = 380,633) and 1994, 1995, and 1996 (n = 286,907) were individually linked to death records. RESULTS: Mean birthweight fell from 3,323 g to 3,292 g (P < .001) between 1989 and 1991 and then increased to 3,353 g by 1996. The gap in mean birthweight between mothers with a primary education and those with a university education, adjusted for age, parity, and sex of infants, widened from 182 g (95% confidence interval [CI] = 169, 19) in 1989 to 256 g (95% CI = 240, 272) in 1996. Similar trends were found for preterm births. Postneonatal mortality declined most among the better educated and the married. The odds ratio for postneonatal death for infants of mothers with a primary (vs university) education, adjusted for birthweight, increased from 1.99 (95% CI = 1.52, 2.60) in 1989 through 1991 to 2.39 (95% CI = 1.55, 3.70) in 1994 through 1995. CONCLUSIONS: Despite general improvement in the indices of fetal growth and infant survival in the most recent years, social variation in birth outcome in the Czech Republic has increased.     

Three-dimensional electron microscopy of the photosystem II core complex

Risk factors for central venous catheter (CVC)-related bacteraemia among infants admitted to a neonatal intensive care unit (NICU) were analysed and the impact of surveillance and continuing education on the incidence of this complication investigated. Among patients admitted to a NICU, CVC-related bacteraemia increased from 1/15 (7%) in 1987 to 11/26 (42%) in 1988 (P = 0.01). Coagulase-negative staphylococci isolated from bacteraemia patients showed clonal diversity by plasmid and chromosomal fingerprinting. A review of CVC care procedures suggested breaches in aseptic techniques. Catheter-care technique was revised to ensure maximal aseptic precautions, including the use of sterile gloves, gown and drapes. The new policy was promoted by a continuing education programme and regular feed-back of CVC-related bacteraemia incidence to NICU staff. In the four-year follow-up period, the attack-rate of CVC-related bacteraemia decreased to 18/156 (12%) patients [relative risk (RR): 0.27, 95% confidence interval (CI); 0.15-0.51; P < 0.001 vs the previous period]. By using the Cox's model proportional hazards, very low birthweight and the period before use of strict aseptic CVC care were found to be predictors of increased risk of catheter-related bacteraemia after adjustment for duration of catheterization. These data provide further evidence that strict aseptic precautions during the maintenance and utilization of CVC can contribute to lower the risk of catheter infection in critically ill neonates. Regular feedback of surveillance data was associated with a progressive decrease in incidence of infection, suggesting that it improved staff compliance with aseptic precautions.     

Sensitive assays for hepatitis A antibodies

Serum thyroxine values were determined prospectively over a 6-month interval in 97 newborn infants with birth weight < 2200 gm or gestational age < 37 weeks. There were 89 survivors and 8 deaths. Infants with thyroxine values of < 2.5 micrograms/dl (32.2 nmol/L) had a significantly higher mortality rate (p < 0.001) compared with infants with higher thyroxine levels. In neonates there may exist a critical thyroxine value below which there is an increased risk of mortality.     

Sperm cytology in azoospermia

BACKGROUND: To progress the clinical treatment of neonates, especially in the management of respiration, we have to be able to measure their pulmonary function appropriately. Various methods have been developed, but little is known about the pulmonary function of very low birthweight infants (VLBWI) because of the difficulty in taking their measurements with existing equipment. We have developed a very low dead space pneumotachograph to measure lung function in VLBWI. METHODS AND RESULTS: We used our pneumotachograph on 30 infants each weighing less than 1500 g at birth. The infants were intubated with endotracheal tubes of 2.5 or 2.0 mm diameter to measure tidal volume and minute ventilation in the prone and supine position. The tidal volume in the supine position was 6.99 +/- 0.42 mL/kg and 7.58 +/- 0.38 mL/kg in the prone position (mean +/- SE). The tidal volume was significantly larger in the prone than the supine position (P < 0.05). However, no significant difference was observed in minute ventilation and respiratory rates. CONCLUSION: The tidal volume significantly increased in the prone position in VBLWI, confirming the previous observation of larger healthy infants is also applicable to the very low birthweight infants.     

Continuing evolution of regionalized perinatal care: community hospital neonatal convalescent care

We describe the convalescent care of 169 back-transported (to community hospitals) and 285 eligible but not back-transported very low birth weight (VLBW) infants. Eligible infants who were not back transported to a level I or II community hospital were transferred to a level II nursery within the Medical University of South Carolina (MUSC) for convalescent care. Study infants were admitted to the neonatal intensive care unit (NICU) at MUSC from July 1985 through June 1989. They were admitted after maternal transport to MUSC for imminent delivery (N = 159), out-born community delivery (N = 55), or in-born MUSC delivery (N = 240). The mean +/- SD birth weight and gestational age and the NICU admission diagnoses for the back-transported and non-back-transported neonates were similar. The mean +/- SD weight of neonates at the time they were back transported was significantly greater than the weight of neonates at the time of intrahospital transfer. In contrast, the discharge weight to home and total days hospitalized were significantly less in the back-transported infants. Five back-transported neonates (3%) and 12 non-back-transported neonates (4%) were readmitted to the NICU. The back-transported infants used more than 3,800 bed days at community hospitals that would otherwise have been spent in the regional center, thus facilitating increased parental and primary physician involvement in their care.     

Group B streptococcus: maternal carriage rate and early neonatal septicaemia

Between January 1984 and December 1994, 30 cases of early neonatal group B streptococcus (GBS) septicaemia were managed in the Neonatal Unit, University Hospital, Kuala Lumpur. Two neonates were outborn and 28 were inborn, giving an average annual incidence of neonatal GBS septicaemia of 0.4/1000 livebirths among inborn babies. In a separate survey over a three-month period, GBS genital carriage rate among 196 parturients was found to be 9.7%. Of the infants with GBS septicaemia, the mean gestational age was 37.5 +/- 3.8 weeks and the mean birthweight was 2540 +/- 716 g. Twelve (40%) were preterm infants and 14 (47%) were low birthweight infants. Male and female infants were almost equally affected. Prolonged rupture of membranes and maternal pyrexia accounted for only 5 (17%) and 3 (10%) of the cases respectively. Twenty-four (80%) neonates had onset of symptoms within 6 hours of life and respiratory symptoms were observed in 24 (80%) of the cases, while meningitis was uncommon. Six (20%) neonates died. Preterm and low birthweight infants had higher mortality than their term counterparts: 42% versus 6% and 36% versus 6% respectively. Of those who died, 4 (67%) required respiratory support right from birth and the mean time of onset of symptoms was 4 hours (range 0 to 21 hours) and the duration of survival was only 28.8 hours (range 12 to 38 hours). As the incidence of neonatal GBS septicaemia was low, mass screening and chemoprophylaxis for GBS were not recommended. All the GBS isolates were sensitive to penicillin and ampicillin, thus one of these antibiotics should be included in the antimicrobial therapy of septic neonates.     

Assisted ventilation for hyaline membrane disease

OBJECTIVES: To study the outcome and complications of assisted ventilation in neonates with hyaline membrane disease (HMD). DESIGN: Retrospective study. SETTING: Hospital based. SUBJECTS: Seventy five premature neonates with HMD needing assisted ventilation born over a period of five years. MAIN OUTCOME MEASURES: Survival rate among those ventilated and complications of assisted ventilation. RESULTS: Survival on assisted ventilation improved from initial 22.2% in 1989 to 77.8% in 1993. Of 19 babies weighing between 750-1000 g, 8(42.1%) survived. Twelve of 27 babies (44.4%) with a gestation of less than 28 weeks survived. Survival rates in babies with gestation of more than 33 weeks was 94%. Intraventricular hemorrhage was the leading cause of death in 52% babies. Nosocomial infections were common and occurred in 50.6% of infants on ventilation and accounted for one-third of deaths. Pneumothorax occurred in one-fifth of babies and was responsible for 3 deaths. Pulmonary interstitial emphysems was observed in 6 babies. Six babies developed bronchopulmonary dysplasia while 7 had retinopathy of prematurity. CONCLUSIONS: Outcome of neonates needing assisted ventilation for HMD has shown consistent improvement over the period of study. Nosocomial infections continue to be a major complication of assisted ventilation in neonates.     

Detection of digitalis compounds using a surface plasmon resonance-based biosensor

A prospective national investigation comprising 633 extremely low birthweight (ELBW) infants born alive in the 2-y period 1990-1992 with a birthweight of < or = 1000 g and gestational age of > or = 23 completed weeks was conducted regarding neurosensory outcome and growth. Three-hundred and sixty-two (98%) surviving ELBW infants were assessed at a median age of 36 months, using a specially designed protocol. At follow-up, mean height, weight and head circumference in both boys and girls were significantly lower than the reference values. The incidence of cerebral palsy was 7% among all children and 14%, 10% and 3% in children born at 23-24, 25-26 and > or = 27 gestational weeks, respectively. At least one obvious handicap was present in 14%, 9% and 3% of these three groups of children, respectively. After adjustment for gestational age, a significantly increased risk of handicap was found in children with intraventricular haemorrhage grade > or = 3 and/or periventricular leucomalacia and in children with retinopathy of prematurity stage > or = 3. The results show that more than 90% of ELBW children born at > or = 25 completed gestational weeks were without neurosensory handicap at 36 months of corrected age. In infants born at 23-24 weeks of gestation, both survival and long-term outcome were less favourable.     

Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome

BACKGROUND: The purpose of this study was to estimate the annual morbidity and mortality among fetuses and infants that can be attributed to the use of tobacco products by pregnant women. METHODS: Published research reports identified by literature review were combined in a series of meta-analyses to compute pooled risk ratios, which, in turn, were used to determine the population attributable risk. RESULTS: Each year, use of tobacco products is responsible for an estimated 19,000 to 141,000 tobacco-induced abortions, 32,000 to 61,000 infants born with low birthweight, and 14,000 to 26,000 infants who require admission to neonatal intensive care units. Tobacco use is also annually responsible for an estimated 1900 to 4800 infant deaths resulting from perinatal disorders, and 1200 to 2200 deaths from sudden infant death syndrome (SIDS). CONCLUSIONS: Tobacco use is an important preventable cause of abortions, low birthweight, and deaths from perinatal disorders and SIDS. All pregnant women should be advised that smoking places their unborn children in danger. The low success rate of smoking cessation among pregnant women suggests that efforts to reduce the complications of pregnancy attributable to tobacco use by pregnant women should focus on preventing nicotine addiction among teenaged girls.     

A dose-response study of the effect of flutamide on benign prostatic hyperplasia: results of a multicenter study

OBJECTIVE: To compare morbidity and mortality rates of low birth weight (LBW) and appropriate birth weight infants born at term, focusing on diarrheal and respiratory infections. STUDY DESIGN: A cohort of 133 LBW infants (1500 to 2499 gm) and 260 appropriate birth weight infants (3000 to 3499 gm), individually matched by sex and season of birth, were followed for the first 6 months of life. None had congenital anomalies and all were from poor families living in the interior of Pernambuco, northeast Brazil. Data on infant deaths, hospitalizations, and morbidity were collected prospectively through daily home visits (except Sundays) from birth through week 8, then twice weekly for weeks 9 to 26. The effects of birth weight were assessed with a variety of multivariable techniques, controlling for confounders. RESULTS: Of the LBW infants, 56% were wasted (thin), 23% were stunted, and 17% were both wasted and stunted. The LBW infants (median 2380 gm) experienced a sevenfold higher mortality rate and fourfold higher rate of hospitalization than appropriate birth weight infants. Almost all deaths and hospitalizations were in the postneonatal period. The LBW infants also experienced 33% more days with diarrhea and 32% more days with vomiting (p = 0.003 in each case). The prevalences of cough and fever were not significantly different. CONCLUSIONS: Infant deaths, hospitalizations, and diarrheal morbidity are increased in term LBW infants who have only a modest weight deficit.     

CBC and differential in VLBW infants

PURPOSE: This study tested the adequacy of established leukocyte indices in infants < or = 1,200 gm birth weight and < or = 32 weeks gestation. DESIGN: Charts of all admissions to the NICU from March 1991 through September 1994 were retrospectively reviewed. SAMPLE: All infants (n = 131) were outborn and admitted to the NICU within 24 hours after birth. MAIN OUTCOME VARIABLE: The leukocyte indices obtained during the first 72 hours after birth were plotted as a function of time in hours. RESULTS: Mode of delivery significantly affected total leukocyte count and absolute neutrophil count; sex and use of prenatal steroids did not. Ranges for total leukocyte count, absolute neutrophil count, and immature/total neutrophil (I:T) ratio demonstrate that normal values are variable and change over time. PRACTICE RECOMMENDATIONS: The wide distribution of values found, coupled with differences noted by mode of delivery, make normative data difficult to apply. The clinician must question the appropriateness of routinely obtaining a complete blood count and the clinical utility of the results.     

Early histopathologic and ultrastructural changes in the heart of Sprague-Dawley rats following administration of soman

Anaemia of prematurity, a postnatal fall in haemoglobin concentration and haematocrit, is particularly common in those born at less than 32 weeks of gestation. Experimental and clinical data implicate inadequate erythropoietin production as an important reason. In this study recombinant human erythropoietin (r-HuEpo) was used in an attempt to treat or prevent this anaemia and thereby provide an alternative to erythrocyte transfusions. Premature infants (birth weight < or = 1250 g and gestational age < or = 32 weeks), who were likely to need transfusions, were randomly assigned to receive 4 weeks of treatment with either subcutaneously administered r-HuEpo (200 U; n = 12) or placebo (n = 12), three times weekly. All patients had oral supplements of elemental iron at a dose of 3 mg/kg/day. Treatment was started in the third week of life. Reticulocyte counts were significantly raised (P < 0.05) in the group treated with r-HuEpo at the end of treatment. The neonates in the group treated with r-HuEpo needed fewer erythrocyte transfusions than those in the placebo group during treatment. There were no toxic effects attributable to r-HuEpo. The results indicate that treatment of infants with very low birth weights with r-HuEpo will reduce their need for erythrocyte transfusions.