The incidence of birth trauma among live born term neonates at a referral hospital in Rafsanjan, Iran.

BACKGROUND: Some special problems of neonates are related to the adverse effects of delivery such as birth trauma with high mortality and morbidity. The aim of this study was to determine the incidence of birth trauma and related risk factors in a referral hospital in Rafsanjan, a city in the south of Iran. MATERIALS AND METHODS: In this cross-sectional study, we reviewed medical records of all 3340 live neonates that were born between March 2004 and March 2005 at Nicknafs maternity center. Special questionnaires of study were completed and data was analyzed. RESULTS: Among all neonates, 0.8% of them had birth trauma. The most common types of trauma were cephalohematoma 37.03%, massive hematoma 37.03%, and clavicular fracture 11.2%. The incidence of brachial plexus injury and clavicular fracture was higher in macrosomic neonates, whereas cephalhematoma, skin injury and massive hematoma were more prevalent in microsomic neonates. Neonatal birth trauma was more frequent in vaginal delivery than cesarean section (1.3% vs 0.1%, p = 0.0001). However, the incidence of birth trauma in instrumental delivery and normal vaginal delivery were similar (2.8% vs 1.3%, p = 0.303). CONCLUSION: The incidence of birth trauma in this region is 0.8% and birthweight and normal vaginal delivery are strong predictors for birth injuries.     

Correlating head-to-body delivery intervals with neonatal depression in vaginal births that result in permanent brachial plexus injury

OBJECTIVE: The purpose of this study was to evaluate which variables predict neonatal depression in vaginal deliveries that result in permanent brachial plexus injury. STUDY DESIGN: With the use of a data set of litigated vaginal deliveries (n = 103 deliveries) from 1978 through 1999 that resulted in permanent brachial plexus injury, detailed delivery and neonatal and pediatric information was obtained by chart review. Neonatal depression was defined as a 5-minute Apgar score of <7. Data that were extrapolated from neonates with low Apgar scores at 5 minutes were compared with neonates with Apgar scores of > or =7 with the use of the Fisher exact test, chi(2) test, or one-way analysis of variance; a two-tailed probability value of <.05 was considered significant. RESULTS: Nine of 89 neonates (10%) had low 5-minute Apgar scores. Head-to-body delivery intervals (available for 36 deliveries) were significantly longer in neonates with 5-minute Apgar scores of <7 vs > or =7 (294 +/- 68 seconds vs 147 +/- 82 seconds, P <.001). Differences in other clinical variables (ie, maternal weight, gestational age, diabetes mellitus, parity, birth weight, and sex) were not significant. None of the infants in this data set, which includes those infants with neonatal depression) died or had long-term asphyxia-related sequelae in the form of speech impediments, seizures, cerebral palsy, coma, or organ dysfunction. CONCLUSION: The head-to-body delivery interval was the only significant factor in the prediction of 5-minute Apgar score of <7 in a data set of deliveries that resulted in permanent brachial plexus injury. Despite extended times (< or =6 minutes) on the perineum that resulted in a higher reduced Apgar score rate, there was no asphyxia-related morbidity.     

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies

OBJECTIVE: To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS: We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia-related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n=49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS: Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519+/-94.3 g versus 4143.6+/-56.5 g, P<.001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION: Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.     

The association of hypotonia and depression in the term and near-term neonate with metabolic acidemia

AIMS: To determine the association of hypotonia and depression in neonates at or near term with metabolic acidemia at birth (umbilical arterial pH<7.0 and base excess <-12 mM). METHODS: This case-control study identified 87 infants without chromosomal or congenital abnormalities born at a single university hospital between 7/91 and 10/04 with hypotonia at birth requiring resuscitation and admission to the neonatal intensive care unit that had a cord gas at delivery. Controls were the subsequent delivery with a cord gas matched by gestational age. RESULTS: Cases and controls did not differ in gestational age (38.7+/-1.9, 38.6+/-1.9 weeks) or birth weight (3,066+/-664, 3,171+/-655 g, P=0.20). Cases were more likely to have a cord pH<7.0 [17 (20%) vs. 1 (1.1%), P=0.0001] and cord pH 7.0-7.1 [13 (14.9%) vs. 2 (2.3%), P=0.003]. Among the hypotonic infants, 31 (35.6%) also were depressed at birth with a 5-min Apgar <7. In the depressed subset of hypotonic neonates 14/31 (45%) had a pH<7.0. Of the 12 hypotonic neonates with seizures, 3 (25%) had pH<7.0. Multivariate analysis showed a significant association between neonatal hypotonia and hypoglycemia, umbilical arterial pH, and nucleated red blood cell count. CONCLUSIONS: Although metabolic acidemia is significantly associated with hypotonia at the time of birth, the majority of neonates with hypotonia and depression or seizures do not have objective evidence of asphyxia as measured by a cord gas at the time of delivery.     

Improved outcome of extremely low birth weight infants with Tegaderm application to skin.

OBJECTIVE: Significant fluid and electrolyte disturbances occur in extremely low birth weight (ELBW) infants in the first few days of life. We investigated the effect of semipermeable polyurethane membrane (Tegaderm) applied to the skin shortly after birth on fluid and electrolyte status and the clinical outcome in these infants. STUDY DESIGN: We reviewed charts of ELBW infants (BW<1.0 kg) born during 24 months prior to Tegaderm application and 19 months after starting Tegaderm. Data were collected daily from the first week of life and additional clinical morbidities were compared. RESULTS: A total of 39 infants from pre-Tegaderm period (NOTEG) (mean+/-SD, BW 756+/-158 g, GA 26.1+/-1.9 weeks) were compared to 30 infants with extensive Tegaderm application to chest, abdomen and extremities (TEG) (BW 802+/-160 g, GA 26.3+/-1.8 weeks). The groups were similar in maternal demographics as well as postnatal surfactant use. Throughout the first week of life, serum Na levels, daily fluid intake and daily weight loss were significantly higher in the NOTEG infants (all P< or =0.04) while BUN/Serum creatinine levels were similar. Hypernatremia (Na>150 mEq/l) developed in 51% of NOTEG infants compared to 17% of TEG (P=0.0005) and daily fluid intake > or =170 ml/kg/day was required in 54 vs 13% (P=0.0008), respectively. The mean time to regain BW was significantly longer in NOTEG vs TEG infants, 20.7+/-7.4 vs 15.8+/-6.3 days, respectively (P<0.02). There were no statistical significant differences among the groups in incidence of IVH, NEC, PDA or nosocomial sepsis; however, respiratory outcome was better in TEG infants. They had significantly less BPD (58% in NOTEG vs 22% TEG (P=0.01)) and fewer infants in the TEG group required supplemental oxygen at discharge (58% vs 22% (P=0.01)). Survival was significantly higher in TEG 90% vs 64% in NOTEG infants (P=0.02). CONCLUSIONS: Semipermeable polyurethane membrane application to skin of ELBW infants shortly after birth decreased postnatal fluid and electrolyte disturbances and significantly improved their outcome by reducing severity of lung disease and decreasing mortality.     

Outcome of infants from mothers with anti-SSA/Ro antibodies.

OBJECTIVE: To evaluate the incidence of electrocardiographic and laboratory abnormalities in neonates born from mothers with connective tissue disease and positive for anti-SSA/Ro antibodies. STUDY DESIGN: Electrocardiogram, blood cell counts, liver and renal function tests prospectively obtained from 51 infants born from anti-SSA/Ro-positive mothers with connective tissue disease were compared with those obtained from 50 control infants born from mothers with anti-extractable nuclear antigen (ENA)-negative connective tissue disease. One infant with congenital complete heart block was excluded from analysis. RESULTS: No infant showed sinus bradycardia. A first-degree atrioventricular block at birth was observed in five study group and no control group infants, P=0.023. Atrioventricular blocks spontaneously reverted or remained stable during the first year of life. Mean corrected QT value of infants born from anti-SSA/Ro-positive mothers was slightly prolonged as compared with the control group (0.404+/-0.03 s vs 0.395+/-0.02 s; P=0.060). CONCLUSIONS: Infants exposed to anti-SSA/Ro antibodies had a significantly higher prevalence of first-degree atrioventricular block. At variance with previous studies, we observed a low frequency of hematologic abnormalities and no cases of hepatobiliary disease.     

Etiological risk factors for brachial plexus palsy.

AIM: To investigate risk factors for brachial plexus palsy in newborns. We analyzed 45 544 live-born children, born over a nine-year period from January 1, 1996 to December 31, 2004. METHODS: The analysis was retrospective and based on the medical documentation of the Clinic for Gynecology and Obstetrics, Clinic for Neurology, and Clinic for Physical Medicine and Rehabilitation of the University Clinical Center Tuzla. We compared study and control groups of newborns. Rates among groups were compared using Chi-square, with significance at p < 0.05, and with significance at p < 0.01. RESULTS: Examining epidemiological characteristics, 86 newborns with brachial plexus palsy had been recorded, thus, the prevalence was 1.86 per 1000 live-born children. Analyzing maternal and neonatal factors, and the labor pattern itself, it was found that the highest factors of risk for brachial plexus injury were birth weight of over 4000 g, a precipitous second stage of labor (<15 minutes), and vacuum-extractor assisted labor. Brachial plexus palsy was more frequent when the mothers were overweight, with a body mass index >or=29 kg/m2. None of the parturient women, whose newborns were diagnosed with brachial plexus palsy, had external conjugate diameter <18 cm. Newborns delivered vaginally were not diagnosed with a higher frequency of brachial plexus palsy when compared to newborns who were delivered by cesarean section, but newborns who were vaginal breech-delivered were diagnosed to have a higher incidence of brachial plexus palsy. Newborns whose mothers were older than 35 years were diagnosed to have brachial plexus palsy more frequently, but a statistically significant difference between primiparas and multiparas was not found. A total of 39 newborns (45.2%) were diagnosed with a fracture of the clavicle, which was the most frequently combined damage with brachial plexus injury. Forty-two newborns (48.8%) had an Apgar score of 相似文献   

Can delivery room management impact the length of hospital stay in premature infants?

OBJECTIVES: To evaluate the impact of initiating early nasal continuous positive airway pressure (ENCPAP) on the length of hospital stay (LOS) for the very low birth weight (VLBW) infants. STUDY DESIGN: LOS at the George Washington University Hospital (GW) after the institution of ENCPAP policy was compared to benchmark values using two-tail t-tests. The incidence of neonatal morbidity was calculated using Bonferroni corrected 95% confidence interval as compared to benchmark rates (alpha=0.001). Comparisons were repeated after stratification of the population into four birth weight subcategories: group A (GrpA) (501 to 750 g), GrpB (751 to 1000 g), GrpC (1001 to 1250 g) and GrpD (1251 to 1500 g). RESULTS: We studied 228 consecutive VLBW infants (birth weight: 995+/-294 g and gestational age: 27.7+/-2.7 weeks). Compared to benchmark values, the GW experience was associated with a significant reduction of 5.1 days in LOS (55.9+/-25.2 vs 61+/-32 days; P=0.04). The decrease in LOS was consistent in all subgroups, but was most noticeable in infants of the smallest weight subcategory (LOS in GrpA=86+/-21 vs 104+/-32, P=0.004; in GrpB=69.9+/-16.7 vs 79+/-27, P=0.018; in GrpC=48.2+/-13 vs 56+/-22, P<0.001 and in GrpD=31.7+/-12.5 vs 40+/-19, P=0.003).In the overall population, a lower incidence of chronic lung disease (CLD) (17.8 vs 29%, P<0.001) was also noted. There were no differences in mortality rates (9 vs 14%), or the incidence of necrotizing enterocolitis (NEC) (8 vs 6%) or intraventricular hemorrhage (6.2 vs 9%) between GW and the established benchmark rates. CONCLUSION: ENCPAP may reduce LOS in VLBW infants in our study population. This relatively shorter LOS was associated with a lower incidence of CLD, which may be a contributing factor.     

Effect of single versus multiple courses of antenatal corticosteroids on maternal and neonatal outcome

OBJECTIVE: Treatment of pregnant mothers with a single course of antenatal corticosteroids significantly reduces neonatal mortality and morbidity. Multiple weekly courses are often given. However, the safety and efficacy of repeated courses of antenatal corticosteroids have not been adequately studied.Study Design: A retrospective study was performed for 609 mothers and their 713 infants who were treated with 1 to 12 courses of antenatal corticosteroids. Data for 369 singleton preterm infants born at < or =34 weeks' gestation, 210 multiple gestations, and 134 infants delivered at > or =35 weeks' gestation were analyzed separately. RESULTS: The incidence of respiratory distress syndrome was 45% for single-course and 35% for multiple-course groups (P =.005; odds ratio, 0.44; 95% confidence interval, 0.25-0.79). The multiple-course group also had significantly less patent ductus arteriosus (20% vs 13%; P =.016). Incidence of death before discharge and other neonatal morbidities were similar. The multiple-course group had a reduction of 0.46 +/- 0.19 cm in head circumference at birth (P =.013) when adjusted for gestational age and preeclampsia. The 2 groups had similar birth weights. Infants born at > or =35 weeks' gestation, multiple-gestation infants, and infants who were born >7 days after the last corticosteroid dose had similar outcomes, regardless of the number of courses they received. Mothers treated with multiple courses compared with a single course had a significantly higher incidence of postpartum endometritis (P =.013), even though they had a lower incidence of prolonged rupture of membranes (24% vs 33%, P =.06) and similar cesarean delivery rates. CONCLUSION: Exposure to multiple courses of antenatal corticosteroids compared with a single course resulted in a significant reduction in the incidence of respiratory distress syndrome in singleton preterm infants delivered within a week of the last corticosteroid dose. This was associated with a reduction in birth head circumference and an increased incidence of maternal endometritis. Whether the potential benefits of repeated therapy clearly outweigh the risks will ultimately be determined in randomized prospective controlled trials.     

Intrapartum risk factors for permanent brachial plexus injury

OBJECTIVE: The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury. STUDY DESIGN: Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant. RESULTS: There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured). CONCLUSION: No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.     

Shoulder dystocia and brachial plexus injury: a population-based study.

The objective of this work was to identify and evaluate risk factors for shoulder dystocia and for brachial plexus injury in a population-based study. In all, 1,397 parturients with shoulder dystocia occurring in Sweden between 1987 and 1996 were identified among 1,076,545 deliveries using information stored in the Medical Birth Registry (MBR) of the National Board of Health and Welfare, Stockholm. Information is missing for about 1.0% of singleton deliveries in the MBR. Validation of the diagnosis 'shoulder dystocia' in the MBR was performed using data of 4 of 63 delivery units and was confirmed in 96.5% of the original medical records. A total of 368 infants had brachial plexus injury (26.3%). However, a considerable variation in the rate of recorded shoulder dystocia was evident when comparing the 63 delivery units throughout Sweden. Overall, the incidence was 1.3 per 1,000 deliveries. A close association was found between birth weight and shoulder dystocia, with an odds ratio (OR) over 30 for a birth weight > or = 5,000 g. In the presence of maternal diabetes mellitus or gestational diabetes, the OR for shoulder dystocia was significantly increased in newborns weighing > or = 4,000 g. The overall perinatal mortality because of shoulder dystocia was 1.2%. This was increased to 6.4% if the mother had diabetes mellitus. About 25% of all infants suffered a brachial plexus injury. This potentially serious injury even occurred in connection with birth by cesarean section, and an OR for plexus injury over unity was seen in 7 of 9 weight groups; a significantly increased OR was seen for birth weights > or = 4,500 g. The birth weight is a strong risk factor for shoulder dystocia, as is diabetes mellitus. A considerable variation in the rate of shoulder dystocia was observed among the different delivery units, probably reflecting difficulties in definition. Brachial plexus injury is observed even after cesarean section, especially if the birth weight is > or = 4,500 g.     

Effectiveness of multidose antenatal steroids

OBJECTIVE: To compare effectiveness between single and multiple courses of antenatal steroids in preterm births and determine adverse effects attributable to multiple courses. METHODS: We studied retrospectively the neonatal outcomes of infants who weighed 1750 g or less at birth between January 1990 and December 1997. Infants exposed to a single course were compared with those exposed to two or more courses of antenatal steroids, with respect to various perinatal outcome variables. RESULTS: Ninety-three neonates were exposed to two or more courses of antenatal steroids and 261 neonates had been given single courses. The mean (+/- standard deviation) gestational age (29.6 +/- 2.8 weeks compared with 28.7 +/- 2.7 weeks; P = .007) and birth weight (1252 +/- 321 g compared with 1159 +/- 339 g; P = .013) were significantly higher among neonates exposed to multiple courses. There were no significant differences between groups in perinatal outcomes; however, those exposed to multiple courses had a significantly lower rate of respiratory distress syndrome (RDS) (17 [18%] compared with 107 [41%]; P < or = .001) and surfactant use (40 [43%] compared with 149 [57%]; P = .02). Adjusting for confounding variables, multiple courses of steroids were significantly associated with a 65% reduction in the incidence of RDS (odds ratio 0.35; 95% confidence interval = 0.18, 0.70; P = .003). CONCLUSION: Compared with single courses, multiple courses of antenatal steroids reduced significantly the incidence of RDS with no apparent increase in neonatal sepsis or disturbances in fetal growth.     

Maternal hypertensive disorders are an independent risk factor for the development of necrotizing enterocolitis in very low birth weight infants

OBJECTIVE: The purpose of this study was to compare complications and outcome of preterm neonates weighing < or =1,500 g who developed necrotizing enterocolitis (NEC) to neonates without NEC. STUDY DESIGN: During January, 1995 to December, 1998, 211 live preterm neonates were born with birth weight < or =1,500 g. A cross sectional prospective study was designed and two groups were defined: 17 neonates who developed NEC and 194 without NEC. Multiple logistic regression analysis was performed to determine independent risk factors for the development of NEC. RESULTS: The prevalence of NEC was 8% (17/211). The following complications were found to be significantly higher among mothers of neonates with NEC: mild pre-eclampsia (11.8 vs. 2.6%, p=0.04); severe pre-eclampsia (35.5 vs. 12.9%, p=0.01); chronic hypertension (29.4 vs. 5.7%, p<0.001) and low birth weight (968 +/- 233 vs. 1,123 +/- 257 g, p=0.02). In contrast, mean maternal age, mean gestational age at delivery and parity were not significantly different between the groups. A multivariate analysis including the following factors: maternal hypertensive disorders, pregestational diabetes mellitus, birth weight and gestational age at delivery, found only maternal hypertensive disorders to be independent risk factors for NEC (OR=5.21, 95% CI 1.64-16.58). CONCLUSIONS: Maternal hypertension is an independent risk factor for the development of NEC in preterm neonates weighing <1,500 g. Thus, maternal vascular disorders may play an important role in the pathophysiology of NEC.     

Perinatal and maternal outcomes of fetal macrosomia.

OBJECTIVE: To determine the perinatal and maternal outcome of the macrosomic infants. STUDY DESIGN: A case-control, retrospective study is performed in the Department of Gynecology and Obstetrics, Istanbul University Cerrahpasa Medical Faculty, between 1988-1992. The maternal and neonatal records of infants with birthweight of at least 4000g (n=1000) were reviewed. Another 1000 cases amongst the newborns delivered in the same period between 2500 and 3999g formed the control group. The obstetrical outcome variables of the groups including mode of delivery and the incidence of maternal and perinatal complications were compared. RESULTS: A total of 16,112 deliveries occurred during the study period. The rate of macrosomic deliveries was 6.21% and the rate of the deliveries (4500g or heavier) was 1.04%. The mean birthweight of the study group was 4272+/-239 and 3277+/-316g of the control group (P<0.001). While the cesarean section rate was 28.8% for the study group and it was 16.6% for the control group (P<0.001). In the study group, 17 cases of brachial plexus palsy (2.4%), 16 cases of clavicular fracture (2.3%) and one case of humeral fracture were observed (P<0.001). The rate of perinatal mortality was 0.8% in the study group. No perinatal mortality was recorded in the control group. There were 14 cases (1.4%)of asphyxia related to delivery in the study group (P<0.01). The rate of maternal complications, were significantly higher in the study group (P<0.01). CONCLUSION: The macrosomic infants are in increased risk for birth trauma and asphyxia. The risk of birth trauma for the infants weighing 4500g or more is even greater.     

Primiparity: a risk factor for brachial plexus injury in the presence of shoulder dystocia?

The objective of the study was to assess the risk factors associated with obstetric brachial plexus injury. It was a retrospective analysis over a 7-year period, of women whose labours were either complicated by shoulder dystocia or had neonates who sustained brachial plexus injury. The 133 women included were divided into two groups: (1) Non-brachial plexus injury (Non-BPI) group: 106 women with labours complicated by shoulder dystocia. (2) Brachial plexus injury (BPI) group: 27 women whose neonates sustained BPI. Comparison of ante-partum, intra-partum and post-partum factors was done. In the BPI group, there were significantly more nulliparous women, with more use of oxytocin. The neonatal variables were similar in both groups. Mean birth weight was more than 4 kg in both groups. In the presence of similar neonatal variables, brachial plexus injury is more likely to occur in neonates of primiparous women in the presence of shoulder dystocia, if labour is accelerated.     

Repeated fetal betamethasone treatment and birth weight and head circumference

OBJECTIVE: To assess the effect of repeated courses of betamethasone on birth weight and head circumference. METHODS: We conducted a historical cohort study of inpatients receiving betamethasone therapy over 5 years. We compared birth weights and head circumferences of infants whose mothers received one course of betamethasone with those of infants whose mothers received multiple courses. Multiple regression analysis was used to adjust for potential confounding variables. Sufficient power (80%) existed to detect a 20% difference between the groups (alpha = 0.05). RESULTS: Mean birth weights (+/-SD) were 1717 +/- 707 g in the single-course group (n = 107) and 1783 +/- 647 g in the multiple-course group (n = 45) (P =.59, Student t-test). Mean head circumference was 28.2 +/- 3.6 cm in the single-course group and 29.2 +/- 2.9 cm in the multiple-course group (P =.15, Student t-test). In regression analysis, birth weights (1757 g and 1752 g) and head circumferences (28.5 cm and 29.0 cm) did not differ significantly different between the single-course and multiple-course groups. CONCLUSION: Multiple courses of betamethasone do not reduce birth weight or head circumference in neonates compared with single-course therapy.     

Traumatic injury in large-for-date infants

The risk of traumatic injury and low Apgar score was studied in 473 infants with a birth weight of 4500 g or more at term (LFD) and 473 infants with normal weight (NFD, birth weight +/- 1 SD of mean for the respective gestational age). The LFD group comprised 3.2% of all infants delivered during a 5-year period. Traumatic injuries were observed in 8.0% of the LFD versus 0.6% of the NFD group. The injuries in the LFD group were 28 fractured clavicles, four fractured humerus and 12 brachial plexus injuries. Six of the LFD infants had multiple injuries. The injuries in the NFD group were three fractured clavicles. All infants with traumatic injuries were delivered vaginally. Contributory obstetrical factors for traumatic injury were forceps, post-term pregnancy and vacuum extraction. High birth weight was correlated to a low Apgar score at one minute, as also was post-term pregnancy.     

Neonatal nucleated red blood cells and the prediction of cerebral white matter injury in preterm infants

OBJECTIVE: To estimate whether neonates with cerebral white matter injury have significant elevations in nucleated red blood cell counts and to estimate their predictive ability in identifying injury. METHODS: This case-control study identified 176 infants born at 23-34 weeks of gestation between November 1994 and October 2004 at a single university hospital and with cerebral white matter injury characterized by periventricular leukomalacia (PVL) or ventriculomegaly due to white matter atrophy. A control was matched to each case using the subsequent delivery within 7 days of that gestational age without brain injury. RESULTS: The gestational age at birth was 27 weeks for both groups, but the cases had a significantly lower birth weight (mean +/- standard deviation: 958 +/- 306 g compared with 1,038 +/- 381 g, P = .001). There was no difference in cesarean delivery (48% cases compared with 44% controls, P = .59). The cases had a significant increase in nucleated red blood cells per 100 white blood cells (WBC) (median, 5th percentile and 95th percentile: 22, 3 and 374 cases compared with 14, 1 and 312 controls; P = .02). Markers of chronic hypoxia, such as intrauterine growth restriction and oligohydramnios, and markers of acute hypoxia, such as an umbilical arterial pH less than 7.0 or base excess less than -12 mM, were both associated with significantly elevated neonatal nucleated red blood cell counts. A neonatal nucleated red blood cell count of 18 per 100 WBCs had a sensitivity of 56.9%, specificity of 57.9%, positive predictive value of 57.9%, and negative predictive value of 56.9% in predicting the development of cerebral white matter injury in this matched case-control sample. CONCLUSION: Preterm neonates with cerebral white matter injury have significant increases in nucleated red blood cell counts. Both acute and chronic hypoxia-ischemia can increase these counts, which limits their usefulness in timing injury. The predictive value of nucleated red blood cell counts at birth in identifying injury is poor. LEVEL OF EVIDENCE: II-2.     

Antenatal exposure to magnesium sulfate and the incidence of patent ductus arteriosus in extremely low birth weight infants.

OBJECTIVE: Magnesium sulfate (MgSO(4)) is the most commonly used tocolytic agent in the US and is also employed as a prophylactic agent against seizures in pre-eclamptic women. MgSO(4) crosses the placenta and its concentration in the newborn usually exceeds that of maternal levels. The purpose of this study was to explore the relationship between antenatal exposure to MgSO(4) and the incidence of patent ductus arteriosus (PDA) in extremely low birth weight infants. STUDY DESIGN: A total of 954 neonates with birth weights between 500 and 1000 g, born at the University of Miami/Jackson Memorial Hospital between January 1995 and December 2004 and surviving for more than 3 days, were followed until death or discharge from the hospital. The incidence of PDA in infants exposed to MgSO(4) was compared with those not exposed and comparisons were also made between infants exposed to different maternal doses of MgSO(4). RESULTS: The incidence of PDA was significantly higher in the group of infants exposed to MgSO(4) compared with the unexposed control group (67 vs. 60%, P<0.018). When stratified by gestational age the differences were significant only in the group of infants with a gestational age of >or=26 weeks (58 vs. 49%, P<0.039). Logistic regression analysis to adjust for co-variables indicated an increased risk of PDA with higher doses of MgSO(4) (odds ratio 1.33 confidence interval (CI) 1.12 to 1.58, per 50 g of MgSO(4)). CONCLUSION: Antenatal exposure to MgSO(4) is associated with a higher risk of PDA in extremely low birth weight infants and this effect is more significant and dose-related in more mature infants.     

Neonatal pneumothorax: comparison between neonatal transfers and inborn infants

OBJECTIVE: To assess the differences in clinical characteristics, management and outcome between the neonatal transfers and inborn neonates with pneumothorax. METHODS: The records of 36 neonatal transfers (Group A) and 25 inborn (Group B) neonates with symptomatic pneumothorax were retrospectively analyzed. RESULTS: In Group A, gestational age (36+/-2 vs. 31+/-4 weeks; P<0.01), birth weight (2720+/-537 vs. 1736+/-1028 g; P<0.01), exclusive oxygen-therapy before the event (47% vs. 20%; P<0.05) and tube thoracostomy (78% vs. 44%; P<0.05) were significantly higher than in Group B. The need of resuscitation at birth (19% vs. 44%; P<0.05), conventional mechanical ventilation (20% vs. 56%; P<0.05), presence of associated major congenital malformations (0% vs. 20%; P<0.01), length of hospital stay (9+/-6 vs. 32+/-32 days; P=0.01) and mortality (0% vs. 16%; P=0.01) were significantly lower in Group A than in Group B. CONCLUSIONS: Neonatal transfers and inborn neonates with pneumothorax have different clinical characteristics and outcome. This information could be useful for all persons involved in the interhospital care of perinatal patients.