[Acute or expectant management in premature labour with preterm premature rupture of the membranes?]. / Akutní, nebo expektacní prístup u predcasného porodu s predcasne odteklou plodovou vodou?

OBJECTIVE: To evaluate current knowledge about the management of preterm premature rupture of the membranes (PPROM). DESIGN: Review article. SETTING: Perinatological center, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical School of Charles University, Prague. METHODS AND RESULTS: Expectant management in case of PPROM increases the incidence of infection/ inflammation but does not statistically increase mortality and serious morbidity of the infants. The incidence of infants morbidity corresponds with gestational age. The most serious complications occur in the lower gestational age. It is necessary to take an individual approach. The acute management increases the number of operative deliveries and respiratory distress syndrome (RDS) in the infants. The combination of RDS, extremely prematurity and hypoxia during the labour decreases the infants survival rate. CONCLUSIONS: The prolongation of the latency period in pregnancies above 28th week does not deteriorate the neonatal mortality or morbidity.

[Spontaneous preterm birth in mother in an artificial sleep on ECMO with severe form of H1N1 infection]. / Spontánní predcasný porod u rodicky v umelém spánku na ECMO pri závazné forme infekce H1N1.

OBJECTIVE: The authors demonstrate a premature birth of a pregnant woman, who was for heavy Respiratory Distress Syndrome (ARDS), on the basis of pulmonary infection H1N1, connected to venovenous extracorporeal membrane oxygenation (ECMO). Patient spontaneously delivered after being connected to the ECMO for 30 hours. SETTING: Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague. DESIGN: Case report. CONCLUSION: Preterm birth at 24 week of pregnancy. During pregnancy, the labor and postpartum was the pregnant woman connected to extracorporeal membrane oxygen therapy.

Five-year survival without major disability of extremely preterm infants born at 22-27 weeks' gestation admitted to a NICU.

AIM: To compare the 5-year survival without major disability in infants born at the threshold of viability at 22-25 weeks who were actively treated in the delivery room and admitted to a NICU to that of those born at 26-27 weeks of gestation. METHODS: All infants between 22(+0) and 27(+6) weeks of gestation admitted to a regional intensive care unit during 1999-2003 were enrolled prospectively. The survival and major disability at 5 years of age were analysed by gestational age. RESULTS: Of 242 treated infants, 202 survived (83.5%). Although the overall survival rate was significantly higher in the 25-27 weeks' gestation infants than the 22-24 weeks' gestation infants (p < 0.001), the survival rate among infants 22-24 weeks (63.6%, 63.6%, and 70%) did not significantly differ, likewise infants 25-27 weeks (88.7%, 90.6%, and 92%) had similar results. Overall, 28 children (14.4% of assessed) had major disability. Both survival and survival without major disability were positively influenced by increasing gestational age, increasing birth weight, being born at 25-27 weeks and being female child. CONCLUSION: With an active approach in treatment, the outcome of infants born at 25 weeks is comparable to those born at 26-27 weeks. Thus, the 'grey zone' in which the risk of adverse outcome is high narrows to 22-24 weeks.

High-frequency jet ventilation improves gas exchange in extremely immature infants with evolving chronic lung disease.

Extremely preterm infants often develop chronic lung disease (CLD) characterized by heterogeneous aeration; poorly supported, floppy airways; and air trapping. High-frequency jet ventilation (HFJV) with high end-expiratory pressure (optimal lung volume strategy [OLVS]) may improve airway patency, lead to better gas distribution, improve gas exchange, and facilitate extubation. In a pilot trial, this study sought to explore the effect of HFJV on oxygenation, ventilation, and ease of extubation in preterm infants with evolving CLD and refractory respiratory failure (RRF). From September 2002 to October 2004, 12 episodes of RRF developed in 10 ventilated extremely immature infants with evolving CLD (10 on conventional and two on high-frequency oscillation). Chorioamnionitis was confirmed in all infants, patent ductus arteriosus was ligated in five patients, and UREAPLASMA UREALYTICUM was cultured from trachea in four patients. HFJV with OLVS was initiated when oxygenation index (OI) > 10 or exhaled tidal volume (V TE) >or= 7 mL/kg were required to maintain partial pressure of carbon dioxide, arterial (Pa CO2) < 60 mm Hg. Inspiratory time (0.02/s) and frequency (310 to 420/min) were set initially with adjustment of pressure amplitude to keep Pa CO2 between 45 and 55 mm Hg. Ventilatory stabilization and weaning from mechanical ventilation with extubation to nasal continuous positive airway pressure (CPAP) were the goals of this approach. Gas exchange data were analyzed by Analysis of variance for repeated measures. Ten patients on 11 occasions of RRF were extubated to nasal CPAP successfully in a median of 15.5 days. Nine of 10 patients survived (one died of pentalogy of Cantrell), all required supplemental O2 at 36 weeks. Pa CO2 decreased within 1 hour after the initiation of HFJV, and OI decreased by 24 hours. Both remained significantly lower until successful extubation ( P < 0.02). Compared with conventional ventilation or high-frequency oscillatory ventilation, HFJV used with OLVS appears to improve gas exchange and may facilitate weaning from mechanical ventilation (MV) in extremely immature infants with evolving CLD. These encouraging pilot data need to be confirmed in a larger clinical trial.

[Does the decreasing rate of neonatal mortality increase severe neonatal neurosensory morbidity?]. / Zvysuje klesající mortalita závaznou neonatální neurosenzorickou morbiditu?

OBJECTIVE: To investigate relation between the mortality and the incidence of serious neonatal neurosensoric morbidity in very low birth weight newborns (VLBWN, birth weigh < or = 1499 g) during the three periods as defined by different quality of the parinatal and neonatal care. DESIGN: Retrospective analysis. SETTING: Perinatal center of the General Faculty Hospital. 1st Medical Faculty Charles University, Prague. SUBJECT AND METHODS: All live-born VLBWN in 1987-2001 were divided according to their birth-date to three five-year periods characterized by different quality of the perinatal and neonatal care. Ist period 1987-1991: the presurfactant area with no standard use of antenatal steroids and without defined border of the fetus viability; IInd period 1992-1996: the transient aera; IIIrd period 1997-2001: the surfactant aera with standard use of the antenatal steroids, and defined border of the fetus viability. VLBWN were divided according to birth weight to three subgroups (p. h. < 750 g, p. h. = 750-999 g, p. h. = 1000-1499 g). Mortality was defined by a death in our department until the discharge. VLBW newborns classified as newborns with serious neonatal neurosensoric morbidity (NNsM) had to have one of the following diagnoses at least: severe intraventricular haemorrhage (IVH gr. 3-4), posthemorhagic hydrocephaly (PHH), cystic periventricular leukomalacia (cPVL), meningitis, ventriculitis, encephalitis (M/E), retinopathy of prematurity > or = stage III (ROP > or = III st.). The chi 2 test was used for statistic evaluation. RESULTS: There were 873 VLBWN born and 208 of them died in the whole period (1987-2001). Mortality decreased in 5 year periods gradually: 1st period 111/226 (49%); IInd period 55/217 (25%); IIIrd period 42/430 (10%). The decrease of mortality was significant in all weight categories (p < 0.001). The incidence of NNsM was evaluated in 612 newborns and was similar in all periods regarding weight subcategories < 1000 g, but decreased significantly in the weight category 1000-1499 g (14/215 (6%) vs 13/73 (18%), p < 0.01). CONCLUSION: Improvement in survival of extremely low birth-weight infants did not increase the incidence of serious neurosensoric morbidity and evenmore NNsM was reduced in haevier very premature newborns during the nineties.

[Successful postponement of delivery in twin pregnancy]. / Uspesne odlozený porod tehotenství dvojcat.

OBJECTIVE: Description of twin pregnancy after IVF preterm rupture of membranes of fetus A in 22nd gestational week. Abortion of fetus A and successful delayed delivery of twin B. DESIGN: Case report. SETTING: Obstetrics and Gynecology Department, 2nd Medical Faculty Charles University and Faculty Hospital Motol, Obstetrics and Gynecology Department, 1st Medical Faculty Charles University and General Faculty Hospital, Prague. METHODS: Patient A. S. 34 years old, admitted to the hospital in 23rd gestational week with preterm rupture of membranes of fetus A, after appearing spontaneous uterine contractions terminated the abortion of fetus A. The uterine contractions stopped with toxolytics and after one week of expectation interval the cerclage suture of cervix was performed. The following course of pregnancy was protected with antibiotics and 48 hours toxolysis with beta mimetics. The pregnancy continued without any serious complications till 37th gestational week, when infectious markers elevated. Cerclage suture was taken away and after 12 hours interval the labor started. The labor was terminated with s.c. because of imminent fetal hypoxia. CONCLUSION: After the abortion of twin A we succeeded to delay delivery interval for 4 months. The borderline mature neonate was born in good clinical condition and survived without any serious complications.

Recurrent ACTH-independent Cushing's syndrome in multiple pregnancies and its treatment with metyrapone.

A 17-year-old primigravid woman presented with Cushing's syndrome. Typical clinical symptoms and signs developed at the beginning of pregnancy. By week 17 of gestation, plasma cortisol diurnal rhythm was absent and there was a paradoxical increase in plasma cortisol after a 1-mg dexamethasone overnight suppression test. Basal urinary free cortisol was 10 times above the upper limit (in pregnancy) and ACTH levels were suppressed. The diagnosis of ACTH--independent Cushing's syndrome was established. MRI scans revealed normal adrenal and pituitary glands. To control hypercortisolism, the patient was treated with metyrapone. At 34 weeks of gestation, the patient developed preeclampsia and underwent caesarean section. A female infant weighing 1070 g was delivered. No apparent metyrapone-induced teratogenic effects were observed. Cushing's syndrome in the patient resolved within three weeks of delivery. No corticosteroid replacement therapy either for child or mother was needed. Eight months after delivery the patient became pregnant again and rapidly developed Cushing's syndrome with typical clinical symptoms and signs and laboratory results (urinary free cortisol 6464 nmol/24 h). This second pregnancy was unwanted and terminated by artificial abortion that was followed by rapid resolution of hypercortisolism. A third pregnancy, 12 months after delivery was also accompanied by the rapid development of hypercortisolism which recovered after artificial termination. The mechanisms by which pregnancy-induced Cushing's syndrome occurred in this patient are unclear. Aberrant responsiveness or hyperresponsiveness of adrenocortical cells to a non-ACTH and non-CRH substance produced in excess in pregnancy should be considered. Metyrapone suppression of hypercortisolism currently represents the best treatment for these rare cases.

[Ileus and intestinal perforation in premature infants--current trends in diagnosis and treatment]. / Ileus nedonosených a perforace streva--soucasné trendy v diagnostice a v lécbe.

OBJECTIVE OF STUDY: a) assessment of the relationship between ileus of premature infants and the development of intestinal perforation in premature infants, b) suggestions of an optimal therapeutic procedure. In the study children (n = 50) are included a) with intestinal perforation in conjunction with impaired excretion of meconium (n = 22), b) with an ileus state based on obstruction of the ileum by a viscous meconium treated either surgically or conservatively (n = 28). Surgical treatment involved: a) establishment of a double ileostomy (n = 28), b) insertion of a T drain into the terminal ileum (n = 8), c) removal of meconium from the gut and its primary closure (n = 2). Conservative treatment in 11 children involved irrigography with an liquid contrast substance under X-ray control. The group of children with perforation was compared with the group of children without perforation, risk factors were evaluated by statistical methods. The necessity of ventilation (P = 0.051) and gestation age (P = 0.006) proved to be statistically significant risk factors for the development of perforation. Survival was not influenced by perforation. All 11 children treated conservatively survived, of 39 operated children 26 survived (66.7%). An early start of conservative treatment of ileus of premature infants reduces markedly the risk of intestinal perforation and can thus influence the survival of low birth weight neonates.

[Treatment of male infertility after oncologic therapy: preventive autologous sperm preservation versus testicular biopsy and oocyte fertilization with testicular spermatozoa]. / Lécba neplodnosti muzu po onkologické lécbe: preventivní autokonzervace versus biopsie varlete a oplodnení oocytu testikulárními spermiemi (TESE).

The prognosis of oncological therapy of some malignancies is favourable. Unfortunately the majority of young patients remain sterile. Sperm cryopreserved before treatment was successfully used in IVF-ICSI (in vitro fertilization-intracytoplasmic sperm injection) cycles. Testicular biopsy (TESE) was performed after successful oncological treatment in three men without previous sperm cryopreservation. No spermatozoa were found for oocyte fertilization. TESE could not ensure sperm recovery in all patients after oncological treatment. Sperm cryopreservation should be highly recommended to all patients before any treatment is offered.

[Effect of combined administration of TRH and dexamethasone in pregnant women and the course of their pregnancy]. / Vliv kombinovaného podávání TRH a dexametazonu na tehotné zeny a samotný prubeh jejich tehotenství.

UNLABELLED: Extremely immature neonates are threatened during the first days after delivery by many conditions which are due to incomplete development.--A key role is played during the first days of extrauterine life by the incidence and degree of the respiratory distress syndrome (RDS). Its incidence in neonates born before the completed 32nd week of gestation is very common. Causal treatment of RDS is not known. To overcome it the neonatologist must use in the majority of infants invasive techniques of controlled ventilation which are associated with the risk of further complications such as barotrauma, retinopathy and later the development of bronchopulmonary dysplasia. Attempts to influence intrauterine maturation of the lungs were started in the fifties. As a routine procedure nowadays corticoids are administered antenatally. Their limited effect divert the attention of perinatologists to other substances which could enhance maturation of pulmonary tissue. In human medicine ambroxol was introduced, in animals opiates are tested as well as beta-mimetics, aminophylline. The greatest hopes were aroused by trials with the use of T-hormones. T-hormones have a maturating regulating function in the foetal organism. They have an affinity for pneumocytes and in animal experiments they have a positive effect on surfactant formation. Moreover they act synergically when combined with corticoids. OBJECTIVE OF STUDY: a) to evaluate the safety of the method from the aspect of undesirable side-effects of hormone administration to the mother b) evaluation of hormone levels: TSH, total T4, total T3, TRH and prolactin in maternal serum.