摘要:

AbstractWe wished to determine the optimal method for cord obliteration to perform selective reduction in complicatedmonochorionic (MC) twin pregnancies under different clinical conditions. For this purpose, we reviewedour experience and the available published literature and unpublished reports. Indications were acardiac twinpregnancy, twins discordant for fetal anomaly, and severe feto-fetal transfusion syndrome where one twinhad a very poor prognosis. Data were available for the following techniques: cord embolization, fetoscopiccord ligation, laser coagulation, monopolar coagulation and bipolar cautery. Unfortunately the data are heterogeneous,incomplete and reports are only sporadic.Cord embolization using coils or sclerosants has a high failure rate and can no longer be recommended. In 23published cases of fetoscopic cord ligation a failure rate of 10% was reported. After successful ligation an overallfetal survival rate of 71% but a risk of preterm prelabor rupture of the membranes (PPROM) of 30% wasdocumented. Four cases of monopolar coagulation have been published—all in acardiac twin pregnancies. In three cases the abdominal aorta was coagulated prior to20 weeks and complete cessation of flow was demonstrated. In 10 cases of bipolar cord coagulation, all procedureswere technically successful. Nine of 10 were performed under ultrasound guidance through a singleport. In 2 cases, frank PPROM occurred, leading to induction of labor. The other eight fetuses were born at35 weeks or more. Nd:YAG coagulation of the cord was much more sporadically described; the success of theprocedure seems to be clearly dependant on gestational age. In all our attempts prior to 20 weeks, we failed inonly one out of 6 cases. In summary, there is little data to perform meaningful comparisons of available techniquesfor umbilical cord occlusion. Based on practical and technical considerations we use the following clinicalalgorithm: prior to 21 weeks, we attempt to coagulate the cord with Nd:YAG laser. If this is unsuccessful,or for gestations beyond 21 weeks, bipolar cord coagulation is currently our other method of choice. Sonoendoscopiccord ligation is reserved as backup procedure if neither of these methods are successful.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.046

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractObjectives: Our purpose was to evaluate the perinatal mortality and morbidity of deliveries with fetuses presentingby the breech comparing outcomes of two groups according to mode of delivery: vaginal and cesareansection.Results: Of 756 fetuses studied, 271 were delivered vaginally and 485 by cesarean section. In infants weighing≥ 1500 grams, “further corrected” mortality and morbidity rates were low and similar for both deliveryroutes: one neonatal death (NNM) in each. Among very low birth weight (VLBW) infants (<1500 grams) the “further corrected” mortality rate was higher in the vaginalgroup: 57.4%, and 18.0% in abdominal deliveries (odds ratio [OR]= 6.1, 95% CI: 3.1 to 12.1). Likewise, rate of depression at five minutes were higher in thevaginal group (p<0.001). However, the average fetal weight among the vaginal deliveries VLBW (787grams) was 250 grams less than in the cesarean section group (1040 grams). After adjustment for fetal weight,gestational age, and other prognostic variables the odds ratio for neonatal death was no longer statistically significant(adjusted OR = 2.1, 95% CI: 0.9 to 5.2, p = 0.105). Comparison of planned vaginal deliverywith elective cesarean section yielded smaller differences (adjusted OR for neonatal death = 1.3, 95% CI:0.6 to 2.9, p = 0.525).Conclusion: The poor perinatal outcomes of breech delivered infants are due primarily to VLBW, congenital malformations, and premature labor. Although abdominaldelivery had a lower NNM rate than vaginal delivery, the difference was not significant after adjustmentfor confounding factors. The results confirm the findings of a previously analyzed similar series delivered atour institution between 1980 and 1987. They suggest that, with appropriate technique, abdominal delivery isnot mandatory in breech presentation.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.047

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractObjective:To contribute to the establishment of reference values of blood flow velocity assessed by cerebral Doppler in healthy infants related to gestational age andbirth weight during the first week of life.Methods:Five arteries and three veins were evaluated respectively in 120 (74 premature) newborns and in 10070 preterm) infants. In a quarter of the latter three recordings at 5-minute intervals were made to assess reproducibility.The relation between flow measurements and gestational age was assessed by linear regression, means byanalysis of variance (or Kruskall-Wallis test) and paired samples by Student's t test.Results:There was a significant increase of arterial velocities with increasing gestational age and birth weight, but not for venous velocities. Significant higher valueswere found in the internal carotid artery followed by the medium cerebral artery. The venous velocities werehighly reproducible and the main patterns observed were bandlike and sinusoid type.Conclusion:The knowledge of normal cerebrovascular physiology is essential to understand the pathogenesisof neonatal brain damage and can help pediatricians in an accurate interpretation of the flow profile in neurologicalpathology.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.048

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractObjective:We theorize that excessive degradation of the fetal membrane extracellular matrix (ECM) by specificmatrix metalloproteinases (MMPs) results in preterm premature rupture of the membranes (PROM).Active, inhibitor free MMP2 and 9 (gelatinase A and B respectively) can degrade the amniochorion basementmembrane Type IV collagen to initiate rupture. This study examines the levels of the gelatinases and their natural inhibitors (tissue inhibitor of matrix metalloproteinases -TIMPs) in the amniotic fluid during PROM,preterm labor (PTL) and at term.Methods:A total of 51 AF samples were collected from the following groups of patients. Group 1: Women with PTL and no ROM (n = 16) Group 2: Women with PROM (n = 16) irrespective of laborstatus Group 3: Women at term with intact membranes undergoing cesarean delivery irrespective of labor status (n = 19). ELISA was used to assayMMP2, MMP9, TIMP1 and TIMP2 levels in the amniotic fluid. The active, TIMP free levels of MMP2were quantitated by zymography followed by computerized densitometry. Active MMP9 was measuredusing a bioassay that specifically detects MMP9 activity. Statistical analysis was performed by Tukey-Kramer multiple comparison method.Results:PROM is associated with increased MMP2 levels (mean 2125 ng/ml;) when compared with term(mean 1455 ng/ml; p<0.01) or PTL where a non significant increase was seen (mean 1862 ng/ml;p = ns). MMP9 levels were higher in PROM (mean 15.03 ng/ml) than at term (mean 1.14 ng/ml;p<0.001) or PTL (mean 3.75 ng/ml; p<0.01). TIMP1 levels were slightly increased during PROM (mean 3143 ng/ml) compared to term (mean 1892 ng/ml; p<0.05) pr PTL where a non significant change was seen (mean 2406 ng/ml; p 5 ns). TIMP2 levelswere decreased in PROM (mean 98 ng/ml) compared with term (mean 176 ng/ml; p<0.05) and PTL (mean 236 ng/ml; p<0.001). Active, TIMP free MMP2 levels were increased during PROM (mean 233 pg/ml) compared to those at term (mean 132 pg/ml;p<0.05) or PTL (mean 132 pg/ml; p<0.05). Active forms of MMP9 were seen only during PROM (mean632 pg/ml).Conclusion:Active, TIMP free forms of MMP2 and 9 are increased in the amniotic fluid of women withPROM. These MMPs can degrade the amniochorion basement membranes and other ECM components resultingin PROM.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.049

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractOur objectives in this study of pulmonary hemorrhage (PH) were to define common characteristics of infantswho develop PH, identify factors associated with PH and report the outcome. Neonates (42/2980 admissions)with PH and matched controls were identified. Early gestation ≤35 weeks) infants with PH [EGPH](n = 34; 12 survived) had occurrence of PH at 3.6 ± 1.1 (mean ± sem) days and were significantly associatedwith multiple births (p = 0.03), RDS (p<0.01) and use of Survanta (p<0.02). Among EGPH, small for gestational age (SGA) infants (n = 7) had a 100% mortality rate. Late gestation (≥ 36 weeks)infants with PH [LGPH] (n = 8; 6 survived) had occurrenceof PH at 0.7 ± 0.3 days and were significantly associated with low 1 minute (p = 0.04) and 5 minutes(p = 0.01) Apgar scores. All infants were managed with increases in mean airway pressure (MAP) and/or use ofcocaine/epinephrine through the endotracheal tube. We have identified 2 groups of neonates with distinctfactors associated with PH; use of 1:10,000 epinephrine (0.1 ml/kg) and/or 4% cocaine (4 mg/kg) may be usefuladjuncts to increases in MAP for management of PH.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.050

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractObjective:This study aims to determine if nucleated red blood cells are elevated in pregnancies that continuebeyond 289 days of gestation.Study design:Cord blood was prospectively collected from term and post-term singleton gestations from August1 to December 31, 1998. Umbilical artery nucleated red blood cells were counted per 100 white bloodcells. The comparison was made between pregnancies ending at 261–289 days (37.1–41.2 weeks) of gestationand those ending after 289 days (≥41.3 weeks) of gestation.Results:Cord blood from 304 cases was obtained and evaluated for nucleated red blood cells per 100 whiteblood cells. The mean value of nucleated red blood cells per 100 white blood cells in the post-term neonate group was significantly higher than in the termneonate group (median 6.5, range 0–24 vs. median 3.7, range 0–14; p<0.05). The values did not vary by fetal presentation, mode or duration of delivery.Neonatal outcome was comparable between both study groups.Conclusion:In post-term gestation after 289 days nucleated red blood cells in cord blood are significantlyincreased. These results point towards a different fetal oxygenation in post-term pregnancies beyond 289 daysof gestation and support the current practice of very close testing of fetal well-being under those circumstances.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.051

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractSome infants, despite being born at low gestations (<28 weeks gestational age) do not develop RDS and are notsurfactant treated. The changes in lung function during the neonatal period in such infants have not been explored,hence it is unknown whether they are similar to those of surfactant treated infants with RDS of similargestational age. Such data would facilitate assessment of the impact of surfactant administration on the lung functionabnormalities of very immature infants with RDS. We, therefore, compared the results of neonatallung function measurements from immature infants with RDS who received surfactant to those from infants withnon-RDS respiratory distress not so treated and matched to the RDS infants for gestational age and within 10% of birthweight. Compliance and functional residual capacityFRC) were measured daily for the first five days and then at 1, 2 and 4 weeks in 16 infants, median gestational age27 weeks (range 25–27 weeks). Although exogenous surfactant administration to the immature infants withRDS was associated with improvements in lung function, the non RDS, non surfactant treated infants had bothhigher compliance (p<0.05) and lung volumes p<0.01) throughout the perinatal period. These results demonstrate surfactant administration does not fully correctthe perinatal lung function abnormalities of very immature infants with RDS.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.052

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractDoppler examinations of the umbilical artery, both uterine arteries, and the fetal middle cerebral artery wereperformed in the third trimester in 18 patients with pregnancy induced hypertension, 52 patients with preeclampsia,and 32 patients with HELLP syndrome and the results were correlated with the parameters fetal outcome.For 74% of the patients this was the first pregnancy, in 93% of the cases a cesarean section was necessary;66% of the newborn babies were dystrophic and 90% of them were born prematurely. The blood flowin one uterine artery was restricted in 95% of all 102 pregnant women, only 5% did not show any pathologicalfindings. A pathological blood flow was observed on Doppler sonography in the umbilical artery in 70%of the group and 39% showed a pathologically increased perfusion of the fetal middle cerebral artery.The average birth weights and gestational ages in the study group were markedly reduced in comparison withhealthy pregnant women (pregnancy induced hypertension: 1620 g/35 weeks; preeclampsia: 1660 g/34 weeks; HELLP syndrome: 1160 g/31 weeks, respectively). Thelowest values for average birth weight and gestational age occurred when all four investigated blood vesselsshowed pathological Doppler findings: 1180 g/31 weeks (0 to 1 pathological vascular findings: 2780 g/38 weeks;2 pathological vascular findings: 1845 g/34.5 weeks; 3 pathological vascular findings: 1330 g/31 weeks).This Doppler study underlines the importance of examining four blood vessels: the uterine, the umbilical,and the fetal middle cerebral arteries for a complete analysis of the fetoplacental hemodynamics. On accountof the severely impaired hemodynamics observed in the placentas of our patients with hypertensivediseases in pregnancy or HELLP syndrome, we believe the early diagnosis of these disorders byDoppler sonography and an early start of therapy to be essential.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.053

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractPreterm infants may be susceptible to chronic lung disease and retinopathy of prematurity because of deficientantioxidant mechanisms including deficiency of vitamin E. The aim of this study was to evaluate the status ofthe antioxidant vitamin E among preterm and term livebirths. Umbilical cord blood samples collected from40 preterm and 180 term babies were analyzed for vitamin E levels using high performance liquid chromatography.Linear regression analysis was used to examine the relationship of vitamin E with gestational age, birthweight and appropriateness of weight for gestational age. The median vitamin E level of preterm babies (2.61 mg/L) was not significantly different from that ofterm babies (2.77 mg/L), p 5 0.2. Linear regression analysis demonstrated a weak but statistically significantcorrelation between cord blood vitamin E levels and gestational age (r = 0.14, p = 0.046). Vitamin Elevels did not correlate with birth weight or weight for gestational age. Preterm babies had a higher incidenceof vitamin E deficiency compared to term babies (38% v 19%, p = 0.02). Our findings lead us to conclude thatvitamin E accumulates in the fetus throughout the third trimester so that preterm infants are likely to have vitaminE deficiency.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.054

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter

摘要:

AbstractWe describe the case of a patient with a neonatal giant cutaneous hemangioma with high-output cardiac failureand Kasabach-Merritt syndrome and successfully treated with transcutaneous arterial embolization aimedat controlling severe congestive heart failure and consumption coagulopathy. A patient was admitted to the neonatal care unit on the first day of age because of alarge hemangioma on his right lateral chest wall and respiratory distress, associated with cardiac failure resultingfrom arteriovenous shunting. On the second day of age the platelet count decreased to 5.7 × 104/μl and fibrinogen level was 85 mg/dl. The values of prothrombin time and activated partial thromboplastin time wereprolonged. Intravenous predonisone therapy was started immediately, but bleeding tendency was getting worseand the evidence of congestive heart failure persisted. On the third day the patient then underwent embolizationof feeding arteries with microcoils. The cardiac failure and thrombocytopenic coagulopathy had improved significantly without complications. We concludethat transcutaneous arterial embolization is an effective and safe treatment in this neonate and shouldbe considered for the treatment of control high-output cardiac failure and coagulopathy in infants with hemangiomaand Kasabach-Merritt syndrome.

ISSN:0300-5577    

DOI:10.1515/JPM.1999.055

出版商:Walter de Gruyter    

年代:1999

数据来源: Degruyter