Non-immunologic hydrops fetalis and congenital chylothorax

A child was born at the 37th week of pregnancy with hydrops fetalis. Hydramnios and hydrothorax had been proven by fetal ultrasonography. No fetal or maternal etiology was found. At age 4 days, at the beginning of enteral nutrition, the pleural effusion became characteristic of chylothorax. Recovery occurred after 2 weeks of parenteral nutrition. Chylothorax might be an unrecognized etiology of non immune hydrops fetalis. The relationships between both conditions and the interest of prenatal treatment are discussed.     

Congenital chylothorax in a patient with 21 trisomy syndrome

A female infant with 21 trisomy syndrome associated with congenital chylothorax was reported. She was born at a gestational age of 34 weeks by Cesarean section because of fetal hydrothorax and hydrops fetus, confirmed by ultrasonography at 32 weeks. Emergent resuscitation and immediate thoracentesis were performed soon after birth. After beginning breast feeding, the serous pleural fluid became opalescent and a diagnosis of congenital chylothorax was made. Feeding was changed to medium-chain triglyceride (MCT) feeding and the production of pleural effusion disappeared after thoracentesis was performed several times. Accumulating evidence suggested that MCT feeding and intermittent thoracentesis under echo guide were effective. Some reports on patients, including this one, suggest that there may be more patients with 21 trisomy associated with congenital hydrothorax. Therefore, congenital hydrothorax might be listed as a complication of 21 trisomy.     

Medical treatment of chylous effusions in newborn infants. Apropos of 3 cases]

BACKGROUND. Chylous effusions are the most frequent cause of non immunologic hydrops fetalis. They can be recognized antenatally by ultrasonography. Their evacuation is sometimes necessary and medical treatment often effective. CASE REPORTS. Case n. 1: fetal ascites was detected by ultrasonography at the 30th week of gestation. Paracentesis was performed at 36 weeks, followed 3 days later by spontaneous delivery. The newborn was fed milk formula. A second paracentesis showed a milky fluid, rich in cholesterol, triglycerides and chylomicrons. The child was fed formula rich in medium-chain triglycerides and the chylous ascites disappeared completely within 2 weeks. Case n. 2: a diagnosis of bilateral hydrothorax and hydramnios was made at the 27th week of gestation. An in utero evacuation of the hydrothorax performed at the 30th week was ineffective and a pleuro-amniotic drainage was performed 2 weeks later. The baby was born at the 35th week, and presented a moderate respiratory distress due to the hydrothorax and ascites. Aspiration of the thoracic fluid confirmed its chylous origin. The chylous effusions completely disappeared when the child was fed a high medium chain triglycerides diet. A lymphedema of legs appeared at the age of 1 month. Case n. 3: ascites, hydramnios, hydrothorax and peripheral edema were found at the 21st week of a third pregnancy (the 2 first pregnancies were complicated by lethal hydrops fetalis). Bilateral hydrothorax and peripheral edema were found again after birth at the 37th week. Diuresis and albumin-infusion led to recovery, but chylothorax and chylous ascites reaccumulated after introduction of milk formula, despite repeated evacuations and feeding medium-chain triglycerides formula. The thoracic fluid remains chylous at the age of 9 months. CONCLUSIONS. In utero, and sometimes post-natal, evacuation of fluid present in the thoracic and peritoneal cavities can be necessary, depending of the functional tolerance. Medical management including feeding a low fat and/or high medium-chain triglycerides diet, and sometimes temporary total parental nutrition, is necessary, together with salt restriction, diuresis and albumin infusion as required. Most cases recover spontaneously or as a result of therapy within a few weeks.     

Preterm elective caesarean section and early enteral feeding in gastroschisis

Aims: To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis. Methods: Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993–97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998–2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period. Results: With early elective CS, no foetal deaths occurred after 28‐ week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34–40) and 35 (34–37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7–39) and 13.0 (7–46) (p = 0.85), and 17.5 (12–36) and 22.5 (13–195) (p = 0.67), respectively. One child died of volvulus after discharge. Conclusion: Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.     

Giant hemangioma of the placenta as a cause of life-threatening anemia in the newborn infant with hydrops congenitum

A premature infant (33.-34. gestational week) delivered by caesarean section suffered from congenital hydrops and severe anaemia (7,2 g/dl) with pronounced marks of erythroblastosis; its placenta contained a haemangioma of 750 gs. A gigant haemangioma is extremely rare and can lead to a characteristic symptom complex endangering the life of mother and foetus.     

Fetal cardiac arrhythmia: antepartum diagnosis of a case of congenital atrial flutter.

A case of antepartum atrial tachyarrhythmia was detected in the 36th week of pregnancy. Cardiotocograph recordings done twice daily enabled close surveillance of the fetal condition after oxytoxin challenge testing had failed to show evidence of hypoxia. After a diagnosis of fetal cardiac arrhythmia had been made, elective caesarean section in the 40th week of pregnancy resulted in delivery of an infant in atrial flutter and cardiac failure. Both these problems were soon resolved by cardioversion and subsequent treatment with digoxin. Cardiac catheterisation showed no underlying cardiac abnormality. Increasing use of antenatal cardiotocography may show that intrauterine tachyarrhythmias are more common than had generally been believed.     

Normal vaginal delivery is to be recommended for haemophilia carrier gravidae

Ljung R, Lindgren A-C, Petrini P, Tengborn L. Normal vaginal delivery is to be recommended for haemophilia carrier gravidae. Acta Pædiatr 1994;83:609–11. Stockholm. ISSN 0803–5253
Every child with severe or moderate haemophilia A or B, born in Sweden during the period 1970–1990, was traced in the national haemophilia register, all 117 case records being surveyed for mode of delivery and perinatal complications. Of the 117 deliveries, 13 were by caesarean section and the remaining 104 vaginal. Of the 13 caesarean sections, 2 were performed because the woman was a haemophilia carrier, the remaining 11 (5 emergency, 6 elective) for other reasons. Neonatal complications were: subgaleal or cephalic haematoma ( n = 1 2), intracranial haemorrhage ( n = 4), umbilical blecding ( n = 4), haematuria ( n = 1), retro-orbital bleeding ( n = 1) and abnormal bleeding after surgery, injection or venepuncture ( n = 28). Of the 12 infants with subgaleal/cephalic haematoma, 10 were delivered by vacuum extraction. Seven more infants were delivered by vacuum extraction and another 11 were born without abnormal bleedings after laborious (> 24 h) delivery. Of the 4 children with intracranial haemorrhage, all were sporadic cases of haemophilia, 1 was a premature birth by caesarean section in the 27th week, 1 was delivered by vacuum extraction and the remaining 2 vaginally. In these 4 cases there were no sequelae or only minor ones. We conclude that the risk of serious bleeding in conjunction with normal vaginal delivery is small, but that vacuum extraction should he avoided when delivering offspring of haemophilia carriers.     

An unusual case of intrauterine symptomatic neonatal liver failure

We present an unusual case of neonatal liver failure. Isolated ascites was diagnosed in a female fetus at week 34 gestational age upon routine ultrasound. In the 35th week of gestation a cesarean section was carried out after puncture of fetal ascites. After birth the patient showed symptoms and complications of acute liver failure with portal hypertension. High serum ferritin concentrations, MRI findings compatible with tissue iron overload and no evidence for infectious disease or inborn errors of metabolism suggested possible neonatal hemochromatosis (NH). HFE gene mutation analysis studies of the child and parents were negative. An anti-oxidative and iron chelating therapy was introduced, followed by clinical stabilisation of the newborn and normalisation of liver function. The liver biopsy at 4 month of age showed mild fibrosis with a few iron-loaded hepatocytes and macrophages. At 2 years of age the child was virtually healthy. CONCLUSION: The clinical course of our patient indicates that the pathological changes in the liver being associated with presumptive NH may be reversible when NH is diagnosed early and antioxidative and chelating therapy is immediately initiated.     

Effect of caesarean section on breast milk transfer to the normal term newborn over the first week of life

OBJECTIVE: To determine the effect of caesarean section on breast milk transfer (BMT) to the normal term infant over the first week of life. METHOD: A sample of 88 healthy nursing mothers who had a normal vaginal delivery, and 97 mothers who had a caesarean section were recruited from a teaching hospital. Mothers and midwives were instructed to weigh the infants before and after each feed throughout the study period using calibrated portable electronic scales. RESULTS: The volume of milk transferred to infants born by caesarean section was significantly less than that transferred to infants born by normal vaginal delivery on days 2 to 5 (p < 0.05), but by day 6 there was no difference between the two groups (p = 0.08). The difference could not be explained by any of the maternal and infant variables measured. Birth weight was regained by day 6 in 40% of infants born vaginally compared with 20% in those born by caesarean section. CONCLUSION: There is a lag in the profile of the daily volume of breast milk transferred to infants delivered by caesarean section compared with those born by normal vaginal delivery. This study also challenges the widely followed schedules of milk volumes considered to be suitable for the term infant, which appear to be excessive, at least for the first four to five days post partum.     

Is caesarean delivery associated with sensitization to food allergens and IgE-mediated food allergy: A systematic review

Several studies have shown differences in the composition of the gastrointestinal flora of children who develop sensitization to food allergens compared with non-allergic children. It has been hypothesized that changes in the gut microbiota resulting from caesarean section delivery could increase a child’s risk of developing food allergy; however, studies examining the relationship between mode of delivery and food allergy have produced conflicting results. The objective of this review was to determine whether there is sufficient evidence to support an association between delivery by caesarean section and the development of sensitization to food allergens and immunoglobulin E (IgE) mediated food allergy. Using predefined inclusion and exclusion criteria, MEDLINE and PubMed were searched for studies investigating the relationship between caesarean section delivery and food allergy. The information on the quality of the studies and results were extracted and analysed systematically. The search identified four relevant studies as per our protocol. Symptomatic food allergy was used as the outcome in two studies and was found to occur more frequently in children born by caesarean section in one study while the second study found no association between food allergy diagnoses and mode of delivery. The other two studies measured levels of food antigen-specific IgE, with both studies showing an increase in sensitization to food allergens among children born by caesarean section. Overall, there is evidence that the risk of developing IgE-mediated sensitization to food allergens is increased among children delivered by caesarean section, however further studies using objectively diagnosed food allergy as the outcome are needed to verify whether this equates to an increase in confirmed food allergy. Future birth cohort studies should control for the effects of mode of delivery when investigating environmental modifiers of food allergy.     

Single kidney and ureteral atresia in a newborn girl: a treatment concept

Objective

To demonstrate a rare case of urological pathology, we report a combination of a single kidney and ureteral atresia. The treatment concept and outcome are outlined.

Patient and method

Antenatal ultrasound had revealed urinary ascites which lead to caesarean section in the 34th gestational week. Persisting anuria was confirmed postnatally and peritoneal dialysis started on the second day of life. Subsequent laparotomy revealed ureteral atresia after 3 cm of patent ureter. We created an ileum conduit after discussing various other therapeutic options.

Result and conclusion

A follow up of 12 months has shown steady function of the stoma with stable renal parameters. An ileal conduit represents a good option if high drainage is necessary in early childhood.     

Unusual course of a chlamydia pneumonia in an infant with IgG2/IgG4-deficiency

An unusual case ofChlamydia trachomatis (C. trachomatis) pneumonia, complicated by the development of a pneumothorax, is reported in an IgG₂/IgG₄ deficient infant delivered by caesarean section.C. trachomatis was isolated initially from a throat smear and subsequently from pleural effusions. Serological examinations using the complement fixation test were negative in sera of both mother and child. However, using immunofluorescence the presence of an acute or recent infection was confirmed by IgM-antibodies in the serum of the infant and IgA-antibodies in the serum of the mother. At the age of 7 months the girl suffered from impetigo contagiosa which was partially resistant to antibiotic treatment. IgG-subclass deficiency was diagnosed after the onset of this disease and the girl was then treated by immunoglobulin transfusion.Abbreviations C. trachomatis Chlamydia trachomatis - ELISA enzyme linked immuno assay - IFT immunofluorescence technique     

Alterations in head shape of newborn infants after caesarean section or vaginal delivery.

Alterations of head shape in preterm, small-for-dates, and term normal infants were studied by measuring occipitofrontal circumference (OFC), biparietal diameter (BPD), and occipitofrontal diameter (OFD) at intervals after birth. In 9 preterm infants born by elective caesarean section ther was a 5-2% reduction in BPD and 2-0% reduction in OFC at the age of 7 days. In 18 term infants born by elective caesarean section these changes were 2-4% and 0% respectively in BPD and OFC. In 25 preterm infants born by vertex vaginal delivery there was a significant fall in OFC of 0-7% at the age of 7 days and of 2-4% in BPD, but no significant change in OFD. In 19 small-for-dates infants born vaginally OFC increased 1-0% and OFD 2-7% at 7 days, but BPD decreased 2-5%. After the first week all three measurements increased in both groups of vaginal deliveries. The results show that shrinkage and biparietal flattening of the skull occur during the first week of life in preterm and term infants born by caesarean section and in preterm infants born vaginally. This fact should be borne in mind when comparing the measurements of an infant''s head size with published norms.     

FETAL RISKS DUE TO WARFARIN THERAPY DURING PREGNANCY

Abstract. Two mothers with heart valve prosthesis were treated with warfarin during pregnancy. In the first case a caesarean section was done one week after replacement of warfarin with heparin. The baby died of cerebral and pulmonary hemorrhage. The second mother had a male infant by caesarean section. The baby showed warfarin-induced embryopathy with nasal hypopiasia and stippled epiphyses (chondrodysplasia punctata). Nasal hypopiasia with or without stippled epiphyses has now been reported in 11 infants born to mothers treated with warfarin during the first trimester, and a causal association is probable. In view of the risks to both mother and fetus in women with prosthetic cardiac valves it is recommended that therapeutic abortion be advised as the first alternative.     

Embryonal rhabdomyosarcoma diagnosed antenatally]

A case of congenital embryonal rhabdomyosarcoma of the right shoulder is described. The patient was the first child born to a 24 year-old woman who had previously been treated for sterility. The diagnosis was made by echography during the 36th week of gestation. This full term white boy was born by cesarean section because of the tumor size. Surgical treatment was completed by chemotherapy. Despite 4 courses of VAC, local recurrence was noted that led to a second surgical excision followed by a new cyclic chemotherapy (IVA). The treatment was fairly well tolerated. The child is well 24 months later.     

Iatrogenic pleuropneumonia as a complication of nutritional treatment of preterm-delivery newborn

Our study presents a case of pleuropneumonia caused by a leak of nutritional formula to pleural cavity, which was caused by perforation of the oesophagus. The child was born in 28 hbd with 1400 g birth weight and was fed with mother's milk by a nasogastric tube. From day 11 of life general state of the neonate worsened and on chest X-ray the contrast showed leaking into the right pleural cavity and the end of gastric tube was seen in the right lung area. With this diagnosis the child was admitted to the University Hospital in Bydgoszcz. The child was conservatively treated and in two contrast X-ray examinations there was no pathology of the oesophagus. CT of chest showed pleural empyema which was repeatedly punctured. On the 19th day of hospitalization thoracotomy with resection of interior pulmomery lobe was performed. From the 14th day after surgery, the child was again enterally fed and in good general state. He was discharged on the 51st day of hospitalization. This case should pay our attention to the fact that respiratory distress syndrome of preterm-delivery newborns may be caused by iatrogenic proceedings not only infections and lack of surfactant. Some complications can be accomplished with the nutrition treatment in every dimension.     

Isolated Bilateral Severe Fetal Hydrothorax: Complete Resolution following a Single Postnatal Thoracocentesis

Isolated pleural effusion is a rare condition in a fetus or neonate with high mortality. When there are no other findings of hydrops fetalis or documented etiology such as inflammatory, iatrogenic or cardiac problems exist, isolated pleural effusion is considered. Timely diagnosis and management not only avoids mortality but also results in excellent prognosis. For fetal hydrothorax, intrauterine management is usually recommended. For those who present late, postnatal management includes intubation, thoracocentesis, ventilation and supportive care. The authors present isolated bilateral severe hydrothorax in a preterm neonate that resulted in severe respiratory compromise at birth. A single postnatal thoracocentesis resulted in complete resolution. No definite etiology for hydrothorax could be established. He had normal growth and development during his follow up till 1 year of age.     

Neonatal gastric necrosis]

BACKGROUND. Neonatal necrotizing gastritis is rare. It is usually a complication of acute anoxia or shock and its diagnosis is essentially radiological. CASE REPORTS. Case no. 1: a boy was born at the 36th week of a pregnancy complicated by preeclampsia. Perinatal asphyxia necessitated delivery by cesarean section. He presented with neonatal respiratory distress which was complicated by pneumothorax. On the 5th day of life, the abdomen was distended and the newborn had still not been fed. On the 6th day, X-rays showed pneumatosis of the gastric wall associated with pneumoperitoneum. Surgery showed an area of necrosis on the posterior surface of the stomach with a small perforation, which was stitched. The child was fed 5 days later and was in good condition at the age of 6 months. Case no. 2: a girl was born at the 35th week of a pregnancy complicated by asthma during the second trimester. Perinatal asphyxia and abnormal fetal rhythm led to delivery by cesarean section. At 24 hour of life, she vomited blood and fibroscopy confirmed the presence of blood in the stomach. On the 3rd day, blood vomiting appeared again, associated with abdominal distension. X-rays showed pneumatosis of the gastric wall; fibroscopy showed necrosis of the lower 2/3 of the stomach. Feeding was stopped and the child was given cimetidine. Refeeding was possible when the girl was 10 days old, and she was in good condition at the age of 6 months. CONCLUSION. Neonatal gastric necroses and necrotizing enterocolitis have many similar features. Medical therapy is often effective, but surgery is mandatory when necrotizing gastritis is complicated by perforation.     

Breathing patterns in term infants delivered by caesarean section

AIM: To compare the breathing patterns of infants born by elective caesarean section to those infants delivered by caesarean section after a failed trial of labour. METHODS: Healthy term infants born by caesarean section were studied. The study group (n = 13) had no trial of labour, whereas infants in the control group (n = 13) failed a trial of labour. Polysomnographic study was performed at 36 h of age. Heart and respiratory rate, type and duration of apnoeas, arterial oxygen saturation and lower limb movements were analysed. RESULTS: Term infants born by elective caesarean section had a shorter duration of pregnancy and weighed less. Their heart rate was faster, they had more mixed apnoeas, and during quiet sleep they had more central apnoeas of longer duration. CONCLUSION: Cardiorespiratory patterns in infants delivered by elective caesarean section are different from those delivered by caesarean section after a failed trial of labour.