Prevalence and outcomes of thrombocytopenia in a neonatal intensive care unit

Background: Thrombocytopenia is a common clinical problem in neonatal intensive care units, affecting about 20 to 35% of all admitted neonates. Even most episodes are mild or moderate, severe episodes could be life-threatening or responsible for sequelae

Objectives: The aims of this study were to describe the prevalence, clinical diagnoses, and to determine risk factors for poor prognosis of thrombocytopenia in a neonatal intensive care unit

Methods: We carried out a retrospective study in the neonatal intensive care unit of Charles Nicolle Hospital of Tunis, a tertiary neonatal care center, over a four years period [January 2010 to December 2013]. All Neonates with at least one episode of confirmed thrombocytopenia were included. Poor prognosis was defined as death or intraventricular hemorrhage >/= grade 2 in survivors

Results: Of 808 admitted neonates, one hundred [12.4%] had presented at least one episode of confirmed thrombocytopenia, and 12 had presented two episodes of thrombocytopenia. A total of 112 episodes of thrombocytopenia were collected. Thrombocytopenia occurred in the first 3 days of life in 74.1% of cases. Thrombocytopenia was mild in 22.3%, moderate in 36.7% and severe in 41%. Intrauterine growth restriction was the most common cause of early thrombocytopenia. Nosocomial sepsis was the most common cause of late thrombocytopenia. We found that the outcomes of thrombocytopenic neonates depend on, birth weight, gestational age, platelet count, and the underlying cause

Conclusions: Thrombocytopenia in neonates can be life-threatening, appropriate diagnosis, preventive and therapeutic approach is necessary to prevent death or neurological impairment

[Evaluation of materno-foetal ifectious risk after isolated premature rupture of memebranes in at term new-born]

Premature rupture of membranes [PROM] is defined as rupture of membranes occurring before the onset of labor. It complicates 5 to 10% of pregnancies. It continues to be a major cause of morbidity and mortality in the newborn. To evaluate infectious risk associated with PROM in at term and asymptomatic new-born and to study this risk according to the duration of rupture. Retrospective study in neonatal unit of Charles Nicolle hospital of Tunis including all cases with isolated PROM in at term new-born during the year 2007. 299 cases were identified over 3749 live births that is an incidence of 8%, divided to: 21 cases [7%] between 6 and 12 hours, 86 cases [28.8%] between 12 and 18 hours, 61 cases [20.4%] between 18 and 24 hours and 131 cases [43.8%] more than 24 hours. Diagnosis of colonization was reported in 54% of cases when PROM occurred between 12 and 18 hours versus respectively 27.3%, 0% and 18% in respectively subset of 6 to 12 hours, 18 to 24 hours and more than 24 hours [p=0,03]. 62% of foeto-maternel infections were reported in subset of PROM more than 24 hours and 13.8% in the subset between 18 and 24 hours. Our study emphasizes the important risk of foetomaternel infection associated with isolated PROM. This risk is major when the rupture exceed 12 hours but the limit of 18 hours can unrecognized some cases of probable foeto-maternel infection

[Outcome at 2 years of very premature infants. a tunisian series]

Neurodevelopmental outcome of very premature infant can be associated with a high rate of cerebral palsy. To assess the impact of very preterm birth on neurological outcome at the age of two years. Retrospective study of all cases of very premature infants born at less than 33 weeks of gestational age, during the years 2005 to 2007. Neurodevelopmental outcome is reported. During the study period, the very premature infant rate was 1.5%. A complete information about neurological outcome at the age of two years, was obtained in 60 cases. Eight infants [13.4%] showed major handicap [cerebral palsy] and four others infants developped neurosensoriel difficulties. The incidence of neurosensoriel handicap in our population seems relatively high. A strong effort must be made for identification of risk factors of neurodevelopmental disability

[Epidemiology of domestic accidents of young children in Tunis: impact of health professionals training on data collection quality]

In Tunisia, several studies on domestic injuries have been carried out on children attending care facilities. Nevertheless, there is a lack of data on incidence and kinds of child domestic injuries amongst general population because of absence of a reliable data collect system. To estimate the incidence and kinds of domestic injuries through a prospective survey "here-there" within two cohorts of young children attending two mother and child protection centers [MCPC] in Tunis during the three first years of their life and to analyze the importance of health professional training in improving data collect. A prospective study "here-there" was carried out on two cohorts of children in two mother and child protection centers [MCPC] between January 2007 and December 2009. Only children aged less than 3 months at their first contact with the centers were included and followed up until age of 3 years. In the MCPC2 [cohort2], health personnel have been trained on data collection importance related to child domestic accident and asked to monitor accidents by calling parents while a phone line got available for this aim. In the MCPC1, health personnel was asked to work as they used to do and to collect data on child domestic injuries when children attend the center. 192/435 domestic accidents were recorded within cohort 2 vs only 1/686 within cohort 1. Annual incidence rate was 14.7% for the cohort 2. The kinds of accidents were: falls 78.2% [falls from high plans 84.6%], injuries15.1% [injury by cutting things 58.6%], burns 5.7% [burns by hot liquid 54.5%], intoxications 1%. In terms of damages, we recorded 4 cases of broken bones [thighbone, elbow, handwrist], stitches in 11 cases, broken teeth in 3 cases and nail pulled out in one case. No death was recorded. Training impact on accident prevention was not studied. Child domestic accidents are relatively frequent. Health personnel training allows to improve data. The kinds of recorded accidents indicate the need to educate parents on best practices towards strengthening prevention

[Pallister-Killian syndrome with additional manifestations of cleft palate and sacral appendage]

Report of a rare congenital abnormalities. We report a rare case of Pallister-Killian syndrome in a 33 weeks gestation infant. In addition to the characteristic phenotype, this patient had a cleft palate, diaphragmatic hernia and sacral appendage. These additional manifestations are not among the Pallister-Killian syndrome's features. The diagnosis was made in antenatal period by cytogenetic studies and showed mosaic 47, XY +I [12p]. Presence of diaphragmatic hernia makes this syndrome, prenatally letal, similar to the Fryns syndrome and then requires skin biopsy and fiboblast chromosome examination for cytogenetic diagnosis

[Neonatal respiratory morbidity after elective caesarean section at term]

Incidence of elective caesareans at term is increasing these last decades with an associated increase of neonatal respiratory morbidity. To analyse the influence of elective Caesarean delivery at term on the incidence of neonatal respiratory distress in order to propose an effective strategy of prevention. It is an analytical study compiling all births resulting from elective Caesarean at term [gestationnel age ranging between 37 and 41+6 GA], reported over two years period at the Charles Nicolle hospital [Tunis-Tunisia]. We compared 250 live births, without maternel risk factors, delivered by elective Caesarean to 250 births delivered by vaginal way. Frequency of the elective Caesarean at term was of 3.6% live births; it was mainly indicated in the presence of a cicatricial uterus. The incidence of respiratory morbidity was 6% [15/250] in the group exposed to the elective caesarean versus 1.6% [4/250cas] in the reference group, OR = 3.9; 95%CI: [1, 28-11, 99] p<0.01. Before the term of 39 GA, OR = 5.22; 95%CI: [1.14-23.87] p=0.01. After 39 GA, the risk of respiratory distress decreased: OR = 1.86 95%CI: [0.30, 11.35] NS. The principal etiology of respiratory distress in the exposed group was the transitory tachypnea of the newborn. Incidence of respiratory distress was higher at newborn babies born from elective Caesarean with a significant reduction in this incidence after the term of 39 GA

[Neonatal hearing screening with transient otoacoustic emissions: polit study]

Bilateral hearing loss is present in 1-3 per 1000 newborn infants, and in 2-4 per 100 infants in the intensive care unit population. All infants with hearing loss should be identified before 3 months of age and receives intervention by 6 months. If undetected, this will impede speech, language, and cognitive development. In Tunisia, we do not have an exhaustive information on the real importance of the auditive handicap. The aim of our study was to evaluate the feasibility and the practical aspects of a pilot tunisian universal neonatal hearing screening [UNHS] program based on transient evoked otoacoustic emission reporting the incidence of hearing impairment in this population. A prospective study during one year [01/05/2006 to the 30/04/2007]. Transient evoked otoacoustic emission was planned for all live births. If the test could not be practised in maternity or that research was negative, an appointment was delivered for a research of the O.T.E A P in an interval of I week-1 month. Infants who did not meet TEOAE pass criteria underwent diagnostic auditory brainstem response [ABR] testing. During the study period, 3342 live births were recorded, 3260 were included. Total coverage rate was of 41%[1333/3260]. We recorded 3 cases of bilateral hearing loss [0.9%screened infants] and 5 with unilateral sensorineural hearing loss [1.5%screened infants] The incidence of congenital hearing loss in our population seems relatively high. Hearing screening for all neonates using transient evoked otoacoustic emission is feasible but several practical aspects should be revised

[Determinants of neonatal mortality in a Tunisian population]

In Tunisia, perinatal mortality remains a public health problem, currently estimated at 28%, including 15% of still birth rate and 10 to 15% of early neonatal mortality rate. The recent investigations show that about half of the deaths at less than five years old are of perinatal origin and that neonatal mortality represents two thirds of infant mortality. Published data regarding neonatal mortality and the causes of death are sparse. to evaluate the neonatal mortality rate over a 2 year period in our population study and to present data collected prospectively on the risk factors and the causes of all neonatal deaths. a prospective cohort compiling all live births reported between January 2007 and December 2008 at Charles Nicolle hospital [Tunis-Tunisia]. All the neonatal deaths that occurred before or after discharge or transferred to other hospitals and subsequently died are included. Births from termination of pregnancy were excluded from all the analyses. Causes of deaths were assigned according the International Classification of Diseases, Tenth Revision [ICD10]. 88 neonatal deaths were recorded over 7285 live births [LB] that is a NMR of 12%o LB. Early neonatal death occurred in 79 cases [88.7%], that is an ENMR of 10.8%o LB. Risk factors directly related to neonatal mortality were prematurity [aOR=6.03- 95%CI: [2-18.13] p=0.001], neonatal respiratory distress [aOR=16.12 - 95%CI: [5.67-45.78] p<10 [-3]], perinatal asphyxia [aOR=11.49- 95%CI: [3.68-35.92] p<10[-3]], nosocomial infection aOR=8.71- 95%CI: [1.77-42.70] p=0.008, and small for gestational age aOR-7.11- 95%CI: [2.23-22.69] p=0.001. 80.6% of underlying causes and 88.6% of immediate causes of death are gathered in the chapter [Certain conditions originating in the perinatal period]. Maternal hypertensive disorders and extreme immaturity due to spontaneous prematurity were respectively responsible for 13.6% and 10.2% of underlying causes of neonatal death. Neonatal mortality remains high, dominated by the conditions originating in the perinatal period. The multitude of the risk factors implies the need for a multidisciplinary strategy of intervention, engaging the pre and perinatal prevention

[Postpartum levels of glycosylated hemoglobin in mothers of large baby: a prospective study]

The delivery of a large baby may indicate that the mother had abnormal glucose tolerance during pregnancy. Glycosylated hemoglobin [HbA1c] concentration might be expected to identify women who had high blood glucose concentration before delivery. The aim of this study was to identify retrospectively, gestational diabetes in mothers of large baby and determine the HbA1c cutoff value. HbA1 was measured in 216 patients within the first three days of postpartum: 100 had large babies: weighing over than 4000g and 113 had normal-sized babies [control group]. We exclude mothers who had preterm, hypotrophy baby, stillborn, and diabetic mothers. The mean concentration of HbA1c was significantly higher in group with large babies than in group control [6.17%+ 085 vs 5.17+0.571=9.78 p<0.001]. The value of HbA1c=5.85%, evaluated by ROC curve, was considered as risk factor of macrosomia and then gestational diabetes. 83.5%of mothers with large babies had HbA1c 7 5.85 vs 7.8%of those with normal sized babies [p<0.0001]. No other significant differences were found between the two groups in other parameters. HbA1 c level may be of value as a postpartum screen for unrecognized diabetes and may help discriminate between a constitutionally large but otherwise normal newborn and a large infant of a diabetic mother. HbA1c measurements should be obtained in women with large babies, and, if upper than cutoff value found by curve ROC: 5.85%, maternal and fetal surveillance is recommended

[Neonatal mortality and morbidity in newborn newborns of single mothers]

Newborns of single mothers constitute a high risk population for intra-uterine growth retardation [IUGR] and neonatal mortality. Our study analysed the influence of this socio-economic factor on neonatal mortality and morbidity. A retrospective cohort compiling all births resulting from illegitimate pregnancies reported between January 2001 and December 2003 at the Charles Nicolle hospital [Tunis-Tunisia] "IG= illegitimate group" [n=75], apparied for mothers gestity, parity and age, to 75 legitimate births "LG=legitimate group" reported after or before each illegitimate birth. The mean age for mothers in the "IG" was 24.3 years. The mean of prenatal consultations was 0.5 in the "IG" vs 5.2 in the "LG" [p<0.001]. Delivery by caesarean section was of 6.7% in the "IG" vs 18.7% in the "LG" [p=0.049]. Prematurity was observed in 17% in the "IG" vs 8% in "LG". IUGR was observed in 29% of "IG" vs 4% in "LG" [p<0.001]. Neonatal mortality was of 4.1% in "IG" vs 1.3% in "LG". These results indicate the importance of illegitimate pregnancies as a demographic risk factor of neonatal morbidity. The IUGR was the most significant risk factor associated to illegitimate pregnancies

[Early-onset neonatal bacterial infections: a series of 144 cases]

Early-onset neonatal bacterial infections continue to be a major cause of morbidity and mortality in the newborn. The aim of this study was to determine the incidence, the risk factors and bacterial epidemiology of these infections. All cases of early-onset neonatal bacterial infections were identified for the years 2001-2003 using data from obstetric and neonatal reports at the neonatal unit of Charles Nicolle Hospital. 144 cases were identified over 11 201 live births, that is an incidence of 12.85%, of which 22 cases of sepsis infections. 22.9% of all newborns were premature and 18% had a low birth weight. Membrane rupture occurred more than 12 hours before delivery in 63.2% of cases and an intra-partum fever in 57.7% of cases. Half of newborns were symptomatic with a mean age of 7.5 hours at onset of symptomatology. The principal etiologic agents were Group B Streptococcus [GBS] and Escherichia coli [E.coli], responsible respectively of 50% and 29.1% of proved infections. GBS had been recognised as the most prevalent agent in term newborn [58.9%] and the E.coli in premature newborn [38.5%]. The neonatal mortality before discharge was 2.77% of all cases. Neonatal bacterial infections continue to be a major cause of morbidity in the newborn. The most common etiologic agents remain GBS and E.coli