Inflammatory Response in Preterm Newborns Born after Prolonged Premature Rupture of Membranes: Is There a Correlation with Placental Histological Findings?

BACKGROUND: Preterm birth is the leading cause of morbidity and mortality among neonates in the United States. Early recognition of sepsis in this population is a challenging task since overt clinical signs can be difficult to determine. C-reactive protein (CRP), one of the most frequently non-specific used laboratory test, can indirectly aid the diagnosis of neonatal sepsis. OBJECTIVES: To evaluate the relationship between histological findings in the placenta of preterm newborns born after prolonged rupture of membranes, CRP levels, and blood cultures. METHODS: Medical records were reviewed of all preterm newborns born after prolonged premature rupture of membranes at a medical center in Israel between 2011 and 2014. RESULTS: Of 128 newborns with prolonged rupture of membranes, 64 had evidence of histological chorioamnionitis (HCA). Gestational age, birth weight, and Apgar scores were significantly lower, while CRP levels (on admission and 10-12 hours post-delivery) were significantly higher in preterm newborns born to mothers with histological evidence of chorioamnionitis, but values were within normal ranges. Duration of the rupture of membranes and white blood cell counts did not differ between groups. CONCLUSIONS: CRP levels taken on admission and 10-12 hours after delivery were higher when HCA was present, but since there was a substantial overlap between those with and without HCA and the values for most were within normal range, the differences were not enough to serve as a tool to diagnose placental histological chorioamnionitis in preterm infants born after prolonged premature rupture of membranes and exposed to intrapartum antibiotics.

Timing of external ventricular drainage and neurodevelopmental outcome in preterm infants with posthemorrhagic hydrocephalus.

OBJECTIVE: To delineate the impact of early (≤ 25 days of life) versus late (> 25 days) external ventricular drainage (EVD) on the neurodevelopmental outcome of preterm infants with posthemorrhagic hydrocephalus (PHH) following intraventricular hemorrhage (IVH). METHODS: We retrospectively categorized 32 premature infants with PHH into two groups according to whether they underwent early (n = 10) or late (n = 22) EVD. We administered the Battelle Developmental Inventory II and a neuromotor examination (median age, 73 months, range: 29-100). RESULTS: In adjusted comparisons, early EVD was associated with better scores than late EVD in adaptive (79 ± 22.6 vs. 58.8 ± 8.1, P = .01), personal social (90.7 ± 26 vs. 67.3 ± 15.9, P = .02), communication (95.4 ± 27.5 vs. 69.6 ± 20.5, P = .04) and cognitive (78.9 ± 24.4 vs. 60.7 ± 11.5, P = .055) functions. Three (30%) early EVD infants had severe (<2.5 standard deviation) cognitive disability compared to 18 (82%) late EVD infants (P = .03). The incidences of cerebral palsy and neurosurgical complications were equal for the two groups. Subgroup analyses suggested that early EVD was beneficial in infants with original grade III IVH (n = 15, P < 0.05), but that it had no beneficial effects in infants with prior parenchymal injury (n = 17, P = NS). CONCLUSION: In this small retrospective series, early EVD is associated with lower rates of cognitive, communication and social disabilities than later EVD in infants with PHH without prior parenchymal injury. A randomized prospective trial is warranted.

No longer pregnant, not yet a mother: giving birth prematurely to a very-low-birth-weight baby.

In this article we present the findings of a qualitative examination of 30 mothers of very-low-birth-weight babies. Interviews conducted with the mothers when the babies were still in neonatal hospitalization show that virtually all the mothers described their delivery both as a traumatic event, and as a nonevent in which they felt that they barely participated. Most of them blamed themselves for not carrying full term, some blamed others, and some believed the premature delivery saved their baby's life. Following their truncated pregnancies, their "nonparticipation" in the delivery, and their separation from their newborn immediately after the delivery, virtually all the women reported difficulty grasping that they were mothers. Many reported a sense of loss, emptiness, and frustration that the baby was no longer inside. The women took a variety of measures, including magical means and parenting behaviors, to safeguard their vulnerable babies and to become mothers within the constraints of the neonatal unit.

Flexible fiberoptic bronchoscopy--a bedside technique for neonatologists.

BACKGROUND: Flexible fiberoptic bronchoscopy (FFB) is an under-used technology in neonates, mostly performed by external consultants from either pulmonology or otolaryngology. Modern ultra-thin scopes offer the neonatologist new diagnostic and therapeutic opportunities at the bedside. OBJECTIVE: To describe the diagnostic value, therapeutic potential, and safety profile of FFB in neonates when performed by neonatologists as a bedside procedure. METHODS: This was a retrospective case series that included 19 term and preterm infants who underwent FFB in two Neonatal Intensive Care Units (NICU). RESULTS: Twenty-five procedures were performed for the following indications: suspected airway pathology (15); BAL (8), noisy breathing (4), aid to difficult endotracheal intubation (1), investigation for failure of weaning from ventilation (6), and evaluation of tracheotomy or endotracheal tube patency (5). Thirteen procedures had more than one indication. Airway pathology was observed in 15 of 25 (60%) procedures. Treatment of atelectasis was successful in 7 of 10 cases. BAL culture results influenced antibiotic therapy in 5 of 10 cases (50%). No procedure-related mortality occurred. One serious adverse event (1/25, 4%), namely bilateral pneumothorax occurred 1 h after FFB. CONCLUSIONS: FFB is a useful and safe procedure that belongs in the neonatologists' armamentarium.

Reducing blood transfusion requirements in preterm infants by a new device: a pilot study.

OBJECTIVE: To test a new device designed to salvage red blood cells (RBCs) from blood samples drawn from preterm infants, with the intent of decreasing blood loss and lowering the requirements for RBC transfusions. DESIGN: A case-controlled pilot study was conducted in two Israeli neonatal intensive care units in large municipal hospitals. Twenty low-birthweight preterm infants were randomly and equally divided into the ErythroSave group or a control group. All blood tests in the study group (except for complete blood count and coagulation parameters) were obtained during the first week of life by the new device in the study group and by ordinary syringes in the control group. The main outcome measure was the total number of units of blood needed. RESULTS: The average volume of blood obtained for laboratory analyses from each infant was 27 mL in the ErythroSave group and 24 mL in controls (not significant). The average volume of transfused packed cells was 6.4 mL for the ErythroSave group and 21.3 mL for the controls (p = 0.008). CONCLUSION: The use of ErythroSave for sampling blood significantly reduced blood transfusion requirements in premature infants compared to sampling by conventional syringes.

Optimizing high-frequency-oscillation ventilation using acoustic parameters of the newborn lung: a feasibility study.

Ventilation using high-frequency oscillation (HFO) has become a standard care for the ventilatory management of critically ill newborns. In recent years, there has been growing recognition that maintenance of an optimal lung volume during high-frequency oscillation plays an important role in minimizing ventilator-induced lung injury. The primary variable affecting lung volume is the mean airway pressure (MAP). To effectively maintain lung recruitment and optimal gas exchange without overstretching (or collapsing) the lung, MAP should be set between two well defined points in the pressure-volume curve of the lung. To determine optimal MAP during high frequency ventilation, an acoustic monitoring system was developed and tested. The system was based on transmission of audible acoustic bursts and reception of echoes from the lungs. The results suggest that these acoustic measurements reflect the mechanical properties of the lungs. The acoustic measurements indicated an increase in lung volume following the administration of exogenous surfactant into the lungs as expected. Hysteresis in the amplitude of acoustic reflection was also measured as expected. Despite the fact that we had no "gold standard" to compare with, our results suggest that acoustic properties of the lung as measured by our system, have the potential to indicate the degree of lung recruitment during HFO and to define the optimal region of MAP.

The outcome of preterm neonates with intraventricular hemorrhage delivered with intravenous meperidine or epidural analgesia.

We aimed to study, retrospectively, the neonatal outcome of 45 preterm neonates with intraventricular hemorrhage (IVH) who were delivered vaginally with intravenous meperidine (n = 23) or epidural analgesia (n = 22). Neonates in the epidural group had a better outcome in terms of a first-minute Apgar score of 7 or less, in 31% vs 69% (P = 0.001); 5-min Apgar score of 7 or less, in 18% vs 82% (P = 0.003); a lower incidence of respiratory distress syndrome (RDS; 23% vs 30%; P = 0.03); a lower dopamine requirement during the first neonatal week (13% vs 72%; P = 0.01); and a higher survival rate (91% vs 58%, respectively; P = 0.008). It is concluded that preterm neonates with IVH had a better outcome when delivered to mothers receiving epidural analgesia as compared to those receiving intravenous meperidine.

Risk factors for seizures in very low birthweight infants with periventricular leukomalacia.

This population-based observational study aimed to determine the perinatal factors that were associated with the occurrence of seizures in very low birthweight infants with periventricular leukomalacia. The study sample consisted of 545 infants from the Israel National Very Low Birthweight Infant Database, gestational age 24 to 36 weeks, who survived beyond 28 days of age, in whom a late cranial ultrasonographic examination was performed and in whom periventricular leukomalacia was diagnosed. To evaluate the association between periventricular leukomalacia and confounding variables on the occurrence of seizures, the chi-square test, univariate analysis, and a logistic regression model were used. Of the 545 infants who developed periventricular leukomalacia, 102 (18.7%) had seizures. Significant independent predictors of seizures among these infants were decreasing gestational age, intraventricular hemorrhage, posthemorrhagic hydrocephalus, sepsis, and necrotizing enterocolitis. Infants with both sepsis and necrotizing enterocolitis had a 4.6-fold increased risk of seizures, further suggesting a possible role of infection in the pathogenesis of brain injury in preterm infants.

An outbreak of new, nonmultidrug-resistant, methicillin-resistant Staphylococcus aureus strain (sccmec type iiia variant-1) in the neonatal intensive care unit transmitted by a staff member.

A methicillin-resistant Staphylococcus aureus (MRSA) strain was recovered in a neonatal intensive care unit from 3 blood and 3 sputum specimens with antibiotic susceptibility profile characteristic of community-acquired MRSA. Epidemiologic survey resulted in isolation of an identical strain from the nares of one nurse. All isolates carried a new SCCmec type IIIA variant. Treatment of the nurse with topical mupirocin resulted in cessation of the outbreak.

Neonates with extra-renal pelvis: the first 2 years.

Extra-renal pelvis (ERpel) is a common ultrasonographic finding among neonates who have undergone recurrent ultrasound examinations for a better definition of prenatal renal pelvic dilatation. This study tries to determine whether or not ERpel has important prognostic implications. Seventy-nine neonates (17 female) were examined. All had a diagnosis of prenatal renal pelvis dilatation, which was shown by postnatal ultrasound to be ERpel. Sixty ERpel neonates were examined 1.5 months to 2.5 months after the ultrasound (US) diagnosis by both Tc-99m diethylene triamine penta-acetic acid (DPTA) dynamic renal scanning and (99m)Tc-pertechnetate direct cystography. Clinical assessment, urine cultures and renal ultrasound follow-up were maintained for 2 years. The proportion of urinary tract infections (UTIs) in patients with ERpel was compared with that of the total neonatal and infantile population with normal US scans in the region of our hospital. Associated minor congenital malformations were found in 12 of 79 neonates (15.2%). Four had a family history of ERpel. Among 60 neonates who underwent renal scanning, 36 (60%) were found to have urinary retention in the collecting system. Another nine (15%) had vesico-ureteral (VU) reflux, of which seven had urinary retention. Fifteen (25%) showed normal isotope imaging. Urinary tract infection was diagnosed in 16 ERpel neonates in whom only one exhibited VU reflux (grade 2). The incidence of neonatal UTI in the ERpel group was more than that of either neonatal or infantile UTI in those with normal US scans in the local population (20.2% vs 1.2% and 4.3%, respectively). Fifty-three infants completed a 2-year follow-up. Repeat renal ultrasonography indicated that one infant (1.8%) had developed bilateral hydronephrosis, 12 (22.6%) had unchanged findings, 18 (40%) showed an improvement (decrease of ERpel width or resolution in one side) and, in 22 (41.5%) infants, the condition had resolved. No clinical or kidney function deterioration was observed. Seven patients (13.2%) each had one episode of UTI during the 2-year follow-up period; none of them had VU reflux. Neonatal ERpel is more frequent in male infants. It is associated with greater rates of minor congenital malformations, VU reflux and UTI than in the general population of the same ages. The increased UTI incidence is not attributed to VU reflux.

Risk factors for neonatal seizures in very low birthweight infants: population-based survey.

The developing brain has an increased susceptibility to seizure activity, and neonatal seizures can adversely affect neurodevelopmental outcome. This study aimed to determine the incidence of neonatal seizures in very low birthweight infants and to identify perinatal and postnatal factors associated with the occurrence of clinical seizures. A population-based cohort of 6525 very low birthweight infants born from 1995 through 1999 comprised the study group. Maternal, perinatal, or postnatal variables that showed a significant association with neonatal seizures in a univariate analysis were tested by a multiple logistic regression to assess the independent effect of each variable on the risk of seizures. The overall incidence of seizures was 5.6%. Significant independent predictors of neonatal seizures were decreasing gestational age, male gender, respiratory distress syndrome, pulmonary air leak (pneumothorax and pulmonary interstitial emphysema), intraventricular hemorrhage, periventricular leukomalacia, patent ductus arteriosus, surgical ligation of patent ductus arteriosus, necrotizing enterocolitis, and surgical treatment of necrotizing enterocolitis. Neonatal seizures appear to be associated with major morbidities and surgical interventions in very low birthweight infants. Continuous electroencephalographic monitoring could be warranted in infants following surgical treatment.

Esophageal pH study and symptomatology of gastroesophageal reflux in newborn infants.

A retrospective study was undertaken to assess the association between esophageal pH monitoring variables and signs such as regurgitation, vomiting, apnea, bradycardia, and cyanotic episodes attributable to gastroesophageal reflux (GER) in neonates. One hundred thirty-four infants with one or more of the above-described signs underwent 24-hour distal esophageal pH monitoring in the neonatal intensive care unit, and were divided into 2 groups by gestational age. Group 1 (preterm infant group) consisted of infants aged 25 to 36 weeks of gestation ( n = 45) and group 2 (term infant group) consisted of infants aged 37 to 42 weeks gestation ( n = 89). Esophageal pH monitoring variables were compared by gestational age group and within preterm infants by theophylline treatment and, separately, by nasogastric tube using the Mann-Whitney U test. Comparisons of nominal data were made using the chi square test. Logistic regression analysis was used to assess the net effect of each independent variable on the risk of developing GER. The prevalence of GER was not influenced by gestational age. The prevalence of gastrointestinal signs did not differ between groups. Cardiorespiratory signs attributed to GER were more frequent in preterm infants than in term infants. The number of episodes with pH < 4 in 24 hours was greater in the term compared with the preterm infant groups. Logistic regression analysis failed to detect an association between acid GER and gestational age, apnea, bradycardia, cyanotic episodes, vomiting, or regurgitation. Theophylline treatment and the presence of a nasogastric tube did not significantly affect the esophageal pH monitoring variables in preterm infants. Preterm infants have a smaller number of reflux episodes compared with term infants. In addition, treatment with theophylline for apnea of prematurity and the presence of a nasogastric tube in preterm infants did not significantly affect pH-monitoring variables in preterm infants.

Herpes simplex virus infection after vacuum-assisted vaginally delivered infants of asymptomatic mothers.

OBJECTIVE: To determine whether vacuum extraction technique is associated with an increased risk of herpes simplex virus (HSV) infection in infants born to asymptomatic mothers. PATIENTS AND METHODS: We reviewed the charts of all infants born at the Edith Wolfson Medical Center and admitted to the hospital's neonatal intensive care unit from January 1999 to June 2002 diagnosed with HSV infection. RESULTS: During the study period, 6953 infants were delivered at our institution and 11 infants had HSV infection. The prevalence of neonatal HSV infection was 1.6 per 1000 live births. In 699 infants, vacuum extraction was used for delivery. Five out of the 11 infants delivered vaginally by vacuum extraction developed HSV infection at the site of the vacuum extractor application. They were born to mothers who were asymptomatic at delivery and had no history of HSV genital infection. HSV type 2 was isolated from the vesicular fluid in all infected infants delivered by vacuum extraction, and none had central nervous system involvement. The prevalence of neonatal HSV infection in vacuum-assisted births was seven per 1000 live births as compared to 0.95 in 1000 in infants delivered vaginally or by cesarean section (p<0.0001). The relative risk of HSV infection in infants born in vacuum-assisted births was 7.45 (95% confidence interval (CI) 1.99 to 27.42, p=0.001). All patients were treated with intravenous acyclovir and no recurrences of HSV infection have been noticed at follow-up. CONCLUSIONS: Laceration of the fetal scalp by vacuum extraction technique may enhance the acquisition and the early appearance of cutaneous infection in infants exposed to HSV shedding in the genital tract of asymptomatic mothers, as the virus gains access through the lacerated scalp.

Nitric oxide inhalation and high frequency oscillatory ventilation for hypoxemic respiratory failure in infants.

BACKGROUND: High frequency oscillatory ventilation has proved valuable in recruiting and sustaining lung volume; the combined treatment may augment nitric oxide delivery to target vessels. NO therapy lowers pulmonary resistance and improves oxygenation. OBJECTIVE: To retrospectively review data on changes in oxygenation-indicated by arterial/alveolar PO2 ratio, oxygenation index, and outcome--in a cohort of 10 infants with hypoxemic respiratory failure in whom nitric oxide inhalation was instituted in a compassionate-use protocol after deteriorated oxygenation. METHODS: NO inhalation was administered at a range of 0.12-122 days of life using the SensorMedics system in 10 infants who developed hypoxemic respiratory failure associated with a variety of lung diseases while on HFOV. RESULTS: The infants' birthweight was 1,717 +/- 1,167 g and their gestational age 31.1 +/- 6.5 weeks. Mean exposure to NO inhalation was 14.2 days and ranged from 3-59 days. Oxygenation index decreased from 39.3 +/- 13.2 to 12.7 +/- 6.9 (P < 0.0002) after NO therapy. Despite an initial prompt response to NO inhalation, two patients died of progressive intractable respiratory failure and one term infant died of extrapulmonary complications (hypoxic ischemic encephalopathy grade III and multiorgan failure). CONCLUSION: Our results indicate that the combined treatment of HFOV and NO inhalation is superior to HFOV alone for improving oxygenation in a selected cohort of infants ventilated for a variety of lung diseases.

Survival of a 300-g infant ventilated by high-frequency oscillatory ventilation for respiratory distress syndrome.

We report a case of an infant delivered before the completion of 26 wks' gestation, weighing 300 g at birth, and treated with high-frequency oscillatory ventilation for respiratory distress syndrome. Her neurologic examination at 18 months of age is compatible with mild delay in gross and fine motor skills.

Massage therapy by mothers and trained professionals enhances weight gain in preterm infants.

BACKGROUND: The method of "massage therapy" has consistently shown increased weight gain in preterm infants. The weight gain was apparent during massages administered by professionals. AIMS: To replicate the results of increased weight gain in the course of "massage therapy" in preterm infants, and utilize a new, cost-effective application of this method by comparing maternal to nonmaternal administration of the therapy. STUDY DESIGN: Random cluster design. SUBJECTS: The study comprised 57 healthy, preterm infants assigned to three groups: two treatment groups--one in which the mothers performed the massage, and the other in which a professional female figure unrelated to the infant administered the treatment. Both these groups were compared to a control group. RESULTS: Over the 10-day study period, the two treatment groups gained significantly more weight compared to the control group (291.3 and 311.3 vs. 225.5 g, respectively). Calorie intake/kg did not differ between groups. CONCLUSIONS: Mothers are able to achieve the same effect size as that of trained professionals, allowing cost-effective application of the treatment within the neonatal intensive care unit.