Overt diabetes in pregnancy.

Of 45 diabetic pregnancies, 80% were Class C, D, or R. The perinatal mortality rate was 4.4% (corrected 2.2%); however, neonatal morbidity was high. Of the infants, 28% developed respiratory distress syndrome (RDS); 18%, asphyxia; and 42%, hypoglycemia. Thus, the woman with overt diabetes needs delivery in an institution where neonatal expertise and modern neonatal facilities exist. Of the mother 28% had a family history that was negative for diabetes mellitus. Four neonates developed RDS despite mature lecithin/sphingomyelin ratios.     

The effect of a perinatal center on perinatal mortality.

The evolution of a perinatal center over the past 12 years was reviewed. Factors in obstetric practices, maternal morbidity, and perinatal mortality were evaluated. The reduction in conditions leading to uteroplacental insufficiency (toxemia, hypertension, high parity) has been the most significant result. This in turn has led to a decrease in deaths from abruption, asphyxia, and respiratory distress syndrome (RDS). The practice of referring high-risk mothers to a perinatal center for delivery can continue to reduce perinatal mortality significantly.     

Mortality of neonatal respiratory failure from Chinese northwest NICU network

Objectives: We aimed to evaluate the efficacy of respiratory support and surfactant in incidence, management and outcome of neonatal hypoxemic respiratory failure (NRF) in Chinese emerging regional neonatal–perinatal care system in the era of universal health insurance policy.

Study design: Clinical data of NRF were prospectively collected in 12 consecutive months from 2011 to 2012 in 12 neonatal intensive care units (NICU) in major cities of Northwest China. NRF was defined as hypoxemia requiring nasal continuous positive airway pressure (nCPAP) or intratracheal ventilation combined with surfactant for at least 24?h, with associated risk factors, mortality rate and major co-morbidities analyzed.

Results: Among 9816 admissions, there were 1324 NRF cases with 60.2% being preterm. The incidence of NRF was 13.4% with a mortality of 15.5%. The major underlying diseases were respiratory distress syndrome (RDS, 38.9%) and pneumonia/sepsis (38.0%). Only 15.9% of NRF and 33.8% of RDS received surfactant, which contributed to?>70% and?>85% survival in RDS patients of birth weight (BW)?1500?g, respectively. Multivariate logistic regression analysis showed that premature rupture of membrane ≥?24?h, very low BW and gestational age Conclusions: Surfactant significantly improved the survival of neonates with NRF and RDS, reflecting the respiratory care standard in emerging regional neonatal–perinatal care network with limited resources.     

Neonatal nucleated red blood cell count and postpartum complications in growth restricted fetuses

AIMS: To study relationships between nucleated red blood cell count (NRBC), persistence of NRBC count elevation and neonatal complications in growth restricted fetuses (IUGR). METHODS: Observational study of IUGR neonates (birthweight < 10th percentile). NRBC's/100 WBC were ascertained in a peripheral blood sample. Subsequent daily samples were analyzed until NRBC's fell < 10/100 WBC. NRBC count and days of NRBC elevation were related to complications (respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotising enterocolitis (NEC), circulatory insufficiency (CI), day 28 oxygen requirement, mortality). RESULTS: 157/298 IUGR neonates (52.7%) had complications, which were associated with a higher NRBC count and persistence of NRBC elevation (12 vs. 189 NRBC's and 1 vs. 4 days; p < 0.0001 respectively). This relationship applied to each complication. Prematurity was the main determinant of RDS, BPD and mortality, while IVH was related to mechanical ventilation, CI to birthweight percentile and NEC to degree of acidemia. Persistence of NRBC count elevation was a statistical contributor for RDS, CI and mortality and the NRBC count to day 28 oxygen requirement. CONCLUSION: NRBC count elevation and persistent NRBC count elevation are associated with perinatal complications in IUGR. Wide ranges in numbers, complex relationships between triggering factors and impacts of other perinatal variables limit the use of NRBC parameters as predictors of complications.     

Perinatal outcome in 41 sets of triplets

OBJECTIVE: To determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery. METHODS: Retrospective analysis of maternal and neonatal medical records of 41 triplets. 21 were delivered vaginally and 20 were delivered by cesarean section. MAIN OUTCOME: To measure perinatal mortality and early neonatal complications. RESULTS: Between January 1, 1994, and June 30, 1999, there were 41 triplets delivered at our institution. Of these 21 triplets were delivered vaginally and 20 triplets were delivered abdominally. The perinatal mortality rate was 32/123 (26.0%), primarily due to the respiratory distress syndrome. The perinatal deaths are mainly at a birth weight of 500-1,500 g (29/32; 90.6%). Breech presentation was associated with a significantly higher perinatal mortality rate than vertex presentation (62.5 vs. 37.5%). Cesarean delivery was associated with a higher perinatal mortality rate than vaginal delivery (30.0 vs. 22. 2%). CONCLUSIONS: Abdominal delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal deaths are increased with low birth weight (500-1,500 g) and with breech presentation. The main cause of neonatal mortality is the respiratory distress syndrome.     

Gastric aspirate lecithin/sphingomyelin ratio and neonatal breathing difficulties

Gastric aspirate lecithin/sphingomyelin (L/S) ratios in newborn infants at risk to develop breathing difficulties were studied. 51.6% of the infants with an immature L/S value developed clinical respiratory distress syndrome (RDS). In the RDS infants, the gastric aspirate L/S value was immature in 94.1%. The gastric aspirate L/S values of the infants with transient tachypnea or perinatal asphyxia did not differ significantly from those of the healthy infants. The severity of RDS correlated inversely to the gastric aspirate L/S value (r = -0.63, p less than 0.001, n = 17). The gastric aspirate L/S value can be used in differential diagnosis between RDS and other neonatal breathing difficulties. It is also a predictor of the severity of the developing RDS.     

Umbilical artery pulsatility index in pregnancies complicated by insulin-dependent diabetes mellitus without hypertension

OBJECTIVE: In a group of diabetic pregnant women, the umbilical artery pulsatility index (PI) was compared with both pregnancy complications and perinatal outcomes. METHOD: We evaluated 67 women with pregnancies complicated by insulin-dependent diabetes mellitus (IDDM), without hypertension. For the study we took the last umbilical PI value before delivery into consideration. Doppler results were not used for patient management. Umbilical artery PI was correlated with the route of delivery and the following perinatal complications: intrauterine growth retardation; cesarean sections for acute fetal distress; respiratory distress syndrome (RDS); neonatal hyperbilirubinemia; hypocalcemia; hypoglycemia; macrosomia, and neonatal intensive care unit (NICU). RESULTS: Among the 67 diabetic patients enrolled in this study, 44 (66%) had umbilical PIs ranging from the 5th to the 95th percentile (PI mean +/- SD = 1.2 +/- 0.3), while 23 (34%) had PIs above the 95th percentile (PI mean +/- SD = 1.6 +/- 0.3). Among the group with pathologic umbilical PIs, analysis of the data revealed a significantly higher incidence of both cesarean sections for acute fetal distress and perinatal complications: RDS; hyperbilirubinemia; hypoglycemia, and the need for NICU, respectively. CONCLUSION: In 34% of the diabetic pregnant women without hypertension, we found increased vascular resistances. Among these patients the incidence of perinatal complications was higher, and both closer maternal metabolic control and stricter care of fetal conditions are needed.     

Intraperitoneal fetal transfusion under direct ultrasound guidance

The outcomes of 77 fetal intraperitoneal transfusions in 35 pregnancies managed with direct ultrasound guidance and intensive perinatal management were reviewed. Patients were monitored with amniocentesis, and standard indications were used for timing of transfusions. The mean gestational age at first transfusion was 27.3 weeks (range 22-33). The overall mortality rate was 14% (five of 35). No immediate transfusion-related deaths occurred; all fetuses who were not hydropic at first transfusion survived (26 of 26). The mean gestational age at delivery was 33.6 weeks (range 25-36). One infant developed respiratory distress syndrome (RDS). Transfusion-related complications occurred in five cases (fetal colon infusions in two, fetal retroperitoneal infusion in two, and fetal abdominal wall hematoma in one). None of these infants required urgent delivery or suffered long-term sequelae. In nonhydropic fetuses, intraperitoneal transfusions under direct ultrasound guidance had a low incidence of morbidity and no mortality. These results should provide baseline data against which to compare new techniques, such as direct cord transfusion. With neonatal mortality rates of 10% and significant morbidity rates of 10-20% in infants delivered at 32 weeks who develop RDS, intraperitoneal transfusion should be considered in the 32- to 33-week fetus with marked pulmonary immaturity.     

Perinatal Factors and the Developmental Outcome of Preterm Infants

To determine the developmental outcome of sick preterm infants, a retrospective analysis of 101 preterm infant survivors, cared for at a teaching hospital's neonatal intensive care unit, was conducted. Information regarding the one-year developmental outcome was compared with significant perinatal factors: birth weight, gestational age, neonatal mortality index, respiratory distress syndrome (RDS) severity, and high-risk pregnancy factors. Eighteen percent of all infants studied had developmental delays indicating an improved prognosis for preterm infants. Severe RDS survivors had the greatest incidence of developmental delays and the most high-risk pregnancy histories.     

Do Racial Disparities Persist in Infant Mortality From Respiratory Distress Syndrome?

ObjectiveTo examine the subset of the infants who died in 2005 from respiratory distress syndrome to determine if racial disparities persist.DesignA secondary data analysis was performed on the data set of infants who died of respiratory distress syndrome (RDS) in the 2005 period linked birth‐infant death data file (N=774).MethodsLogistic regression was performed to evaluate the contribution of race to RDS‐related mortality.ResultsWhen analyzed independently, Black infants were 1.3 times more likely to die of RDS mortality than White infants. After the known predictors of gestation, birth weight, and gender were added to the model, Black race was no longer a significant predictor of RDS.ConclusionsDespite Black race having been identified as a contributor to RDS mortality in the past, race was not a predictor of RDS mortality in the 2005 cohort. Previous analyses comparing pre‐ and postsurfactant era mortality assumed that all eligible infants received surfactant, and Black infants did not respond as well as White infants. The 2003 birth certificate revision included surfactant administration, but only 12 states reported that data in the 2005 data set. Only 22% of eligible infants had documentation of surfactant administration. Future research is needed to confirm that eligible infants are receiving surfactant and to evaluate the response of infants by race. If Black infants do not respond to the available surfactant replacement products, genomics research is needed to explore targeted therapies for this group.     

Intrauterine tobacco smoke exposure and hyaline membrane disease amongst triplets.

We assessed the association between prenatal smoking and respiratory distress syndrome (RDS) among triplets using a population-based retrospective cohort of 12,169 triplet live births in the United States between 1995 and 1997. Analysis was conducted using the generalised estimating equation framework to adjust for intra-cluster correlations. A total of 938 cases of RDS were reported comprising 35 among smoking (7.2%) and 903 among non-smoking gravidas (7.7%). The likelihood of RDS was comparable in both smoking categories [adjusted odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.65-1.32]. The risk for RDS due to smoking diminished with declining birth weight albeit non-significantly: low birth weight (OR = 0.99; 95% CI = 0.40-2.42), very low birth weight (OR = 0.85; 95% CI = 0.39-1.86), and extremely low birth weight (OR = 0.69; 95% CI = 0.30-1.58). In conclusion, among triplet neonates, smoking during pregnancy was not associated with respiratory distress syndrome.     

Outcome of neonates less than 30 weeks gestation with histologic chorioamnionitis

The purpose of this study was to determine the short-term outcome of newborns less than 30 weeks gestation when there is definite placental histologic chorioamnionitis. A retrospective analysis was performed of records of all neonates delivered at our institution from January 1989 through January 1999. This information was retrieved from our perinatal database and pathology database. The population was stratified according to the presence or absence of histologic chorioamnionitis. Statistical analysis was performed using student t-test and Mann-Whitney method. Logistic regression was used to control for potential confounding variables. There were 392 neonates less than 30 weeks gestation delivered during this time period. Complete placental histology was available for 342 patients (87.4%). Histologic chorioamnionitis was identified in 140 (40.9%) cases. Those with histologic chorioamnionitis delivered sooner (26.3 versus 27.5 weeks), were of lower birth weight (920.1 versus 1029.8 g), and had lower 5-minute Apgarscores. Neonatal septicaemia and pneumonia were strongly associated with underlying histologic chorioamnionitis. There was a significant reduction in the incidence of respiratory distress syndrome (RDS) when histologic chorioamnionitis was present. Severe histologic chorioamnionitis increases the risk of premature delivery and is strongly associated with neonatal sepsis. There is a significant reduction in the incidence of RDS and neonatal mortality.     

The perinatal factors associated with the development of neonatal RDS in cases of placenta previa

Sixty-two cases of preterm placenta previa were managed in our hospital since September, 1979 through August, 1983. These were reviewed and analysed retrospectively for the perinatal factors in terms of the development of respiratory distress syndrome (RDS). Conservative management was employed in 56 cases (90%), which consisted of antepartum blood transfusion (7 cases: 11.3%), tocolysis for inhibition of premature labor (37 cases: 59.7%), and prenatal steroid administration (8 cases: 12.9%). Nineteen cases (31%) were delivered from 28 to 33 weeks, 20 cases (32%) from 34 to 36 weeks, and 23 cases (37%) after 37 weeks. When regular uterine contractions occurred at less than 10 minute intervals at the initiation of tocolysis, the majority of the cases had to be delivered within 7 days or less. Ten of the 39 preterm neonates in this study developed clinical RDS. All of these were delivered at between 28 and 33 weeks, associated with neonatal asphyxia. Three perinatal factors were significantly associated with the development of clinical RDS in comparison with the control group of non-RDS preterm neonates. These were neonatal asphyxia, maternal bleeding (greater than 500 ml) and no prenatal steroid administration.     

Treatment of severe pulmonary hemorrhage with activated recombinant factor VII (rFVIIa) in very low birth weight infants.

Clinically apparent pulmonary hemorrhage (PH) occurs in 5% to 7% of very low birth weight (VLBW) infants with respiratory distress syndrome (RDS). It is associated with a mortality rate as high as 50% and significant pulmonary and central nervous system morbidities. There is no consensus on treatment modality. We present two VLBW infants with severe PH that did not respond to conventional treatment but were successfully treated with activated recombinant factor VII (rFVIIa). No untoward side effects were noted.     

Maternal intravenous ethanol in the prevention of respiratory distress syndrome.

The occurrence of respiratory distress syndrome (RDS) was studied in 68 premature neonates whose mothers were treated with at least one six-hour course of intravenous ethyl alcohol within 48 hours before delivery. At the gestational interval of 28 to 32 weeks, significant differences were observed in the incidence of RDS (p = less than 0.05), in severe RDS (p = less than 0.005), and in the mortality rate from RDS ( = less than 0.05), when compared to premature neonates not treated with alcohol and delivered during the same time interval. Several high-risk factors were found unevenly distributed between treated and control groups of patients, and their relevance to RDS was discussed. Premature rupture of membranes of more than 24 hours did not protect infants from RDS in the patients studied. Explanations for possible mechanisms of action are discussed.     

The management of severe toxemia in patients at less than 36 weeks' gestation

Fifty-five patients at less than 36 weeks' gestation with severe toxemia were treated conservatively. The pregnancies were continued for a mean duration of 19.2 days and the mean gestation at delivery was 35.2 weeks. Fifty-three percent of the deliveries were by cesarean section. Of the neonates, 56.5% showed severe intrauterine growth retardation (IUGR), 17% had asphyxia neonatorum, and 13.2% developed respiratory distress syndrome (RDS). There were 3 stillbirths and 2 neonatal deaths for a mortality rate of 8.9% and a corrected rate of 7.1%.     

The surfactants

Surfactants have been routinely used since 1990 for the treatment of respiratory distress syndrome (RDS). The use of surfactant has coincided with a decrease in mortality in infants due to RDS. This review focuses on clinical aspects of surfactant use. New information, particularly effects of ventilatory styles on surfactant function, is presented.     

Impact of antenatal dexamethasone administration on respiratory distress syndrome in surfactant-treated infants

Neonatal lung disease is primarily responsible for the perinatal morbidity and mortality associated with preterm birth. Recently exogenous surfactant replacement therapy has been used to prevent or treat respiratory distress syndrome. As part of a multicenter, preventive trial between February 1986 and December 1988 using calf-lung surfactant extract, we treated 147 infants with single dose calf-lung surfactant extract. We analyzed this experience to evaluate the possibility that antenatal steroids may be additive (with calf-lung surfactant extract) in reducing both the incidence and severity of respiratory distress syndrome. Although a reduction in the incidence of respiratory distress syndrome was observed among the 33 neonates exposed to antenatal dexamethasone when compared with the 114 infants given calf-lung surfactant extract alone, the difference was not significant (37.7% vs. 24.2% p = 0.15). However, comparison of neonatal subsets previously shown to benefit most from steroid use revealed an additive effect between calf-lung surfactant extract and dexamethasone in reducing both the incidence and severity of respiratory distress syndrome. Of the 99 singleton pregnancies, only 2 of 16 infants treated with calf-lung surfactant extract and dexamethasone developed respiratory distress syndrome, compared with the 33 of 83 calf-lung surfactant extract cases (p less than 0.05). A similar reduction was observed in infants between 28 and 32 weeks' gestation (calf-lung surfactant extract, 21 of 79 vs. calf-lung surfactant extract and dexamethasone, 0 of 24; p less than 0.05). A reduction in disease severity was observed in male offspring (moderate or severe respiratory distress syndrome only; 22 of 63 vs. 2 of 22; p less than 0.05). Potential confounding variables (e.g., gestational age at birth, birth weight, exposure to tocolytics before delivery, fetal pH at birth) were similar in all comparisons. We conclude that an additive effect between dexamethasone and calf-lung surfactant extract is observed in selected cases. It may therefore be appropriate to maximize antenatal steroid use in centers where exogenous surfactant is available.     

Neonatal lung function in very immature infants with and without RDS

Some infants, despite being born at low gestations (< 28 weeks gestational age) do not develop RDS and are not surfactant 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 similar gestational age. Such data would facilitate assessment of the impact of surfactant administration on the lung function abnormalities of very immature infants with RDS. We, therefore, compared the results of neonatal lung function measurements from immature infants with RDS who received surfactant to those from infants with non-RDS respiratory distress not so treated and matched to the RDS infants for gestational age and within 10% of birthweight. Compliance and functional residual capacity (FRC) were measured daily for the first five days and then at 1, 2 and 4 weeks in 16 infants, median gestational age 27 weeks (range 25-27 weeks). Although exogenous surfactant administration to the immature infants with RDS was associated with improvements in lung function, the non RDS, non surfactant treated infants had both higher compliance (p < 0.05) and lung volumes (p < 0.01) throughout the perinatal period. These results demonstrate surfactant administration does not fully correct the perinatal lung function abnormalities of very immature infants with RDS.     

Should fetal scalp blood sampling be performed in the case of meconium-stained amniotic fluid?

Objective: To investigate the effect of using fetal scalp blood sampling on the risk of neonatal respiratory distress syndrome (NRDS) with meconium-stained amniotic fluid (MSAF).

Methods: Prospective data collection with regard to MSAF during labor for low-risk term cephalic singleton live birth from 2012 to 2014. Maternal, obstetric and neonatal data were compared according to the occurrence of respiratory distress syndrome (RDS group) or not (no RDS group).

Results: Of 515 newborns born through MSAF, 46 experienced RDS and from them 10 experienced meconium aspiration syndrome. No difference was observed according to maternal characteristic, abnormal fetal heart rate tracing pattern irrespective of its category and cesarean rate. Apgar at one?minute was lower in the group RDS (7.6 versus 8.5, p?<?0.05). The mean umbilical artery pH values did not differ between the two groups. Significant difference between newborns with and without RDS in terms of fetal scalp lactate sampling during the labor (71.1% versus 55.1%, p?<?0.05), and neonatal care unit (NCU) admissions (22.8% versus 10.8%, p?<?0.05). Secondary rather than primary meconium was associated with RDS when performing fetal scalp blood assessment (p?<?0.05). A significant correlation between RDS, fetal scalp blood assessment and MSAF diagnosed during the first stage of labor (after spontaneous rupture of membranes or at amniotomy) was found.

Conclusion: In case of MSAF, fetal scalp blood sampling did not reduce the risk of RDS.