Improved neonatal prognosis following restriction in the number of transferred embryos in assisted reproduction - single center yearly comparison from Turkey.

PURPOSE: To evaluate the impact of new legislation for assisted reproductive technology (ART) restricting the number of transferred embryos on neonatal prognosis of infants born after infertility treatments. MATERIALS AND METHODS: Neonatal records of all live born infants in Ege University Maternity Ward were reviewed for 2006 and 2012. Neonatal outcome measures such as birth weight (BW), gestational age (GA), preterm birth (PTB), very low birth weight (VLBW), and neonatal intensive care unit (NICU) admission were evaluated. RESULTS: Compared to 2006 percentage of newborns conceived by medically assisted reproduction (MAR) decreased from 14.6% to 5% in all live births, from 23.8% to 8.2% in NICU patients in 2012. The number of fetuses in the last pregnancy, frequency of intrauterine reductions, spontaneous pregnancy losses, antenatal bleeding, and premature delivery decreased. Percentage of multiples among MAR newborns (31.7% vs. 55.7%), twins from 51.4% to 30.9%, triplets from 4.3% to 0.8% all decreased significantly. Mean BW and gestational age increased resulting in decreased frequency of PTB and VLBW. Consequently Level 3 NICU admission rate significantly decreased from 44.3% to 22%. CONCLUSION: The new ART legislation in Turkey resulted in decreased rate of multiple births, prematurity and related complications, and NICU admissions in MAR newborns. However the twin rates are still high. Since uncontrolled ovulation stimulation and intrauterine insemination techniques are also associated with multiple births and unfavorable neonatal outcomes, these procedures deserve close monitorization.

Genome wide analysis in a discordant monozygotic twin with caudal appendage and multiple congenital anomalies.

Caudal appendage is a rare dysmorphic feature of which etiologic mechanisms are not well understood. Here we report monozygotic (MZ) twin brothers who are discordant for the caudal appendage and multiple congenital anomalies. Twins were the product of a 33 weeks of gestation, monochorionic-diamniotic pregnancy. On admission the proband had micrognathia, beaked nose, hypospadias, caudal appendage and juxtaductal aorta coarctation. At birth, he was small for gestational age and he had transient hypothyroidism which was detected in the newborn period. Karyotype analysis showed 46,XY. Monozygosity was shown by 15 microsatellite markers plus amelogenin (AmpFlSTR Identifiler PCR Amplification Kit, Applied Biosystems). Genome-wide copy number analysis of the twins by DNA-DNA hybridization of whole genomic DNA (NimbleGen Human CGH 385K WG-T v2.0 array) showed a significant difference at two neighboring probes with Log2 ratio: 0.72088 which are located on chromosome 3p12.3. Further analysis by high resolution of chromosome 3 array (Roche NimbleGen Human HG18 CHR3 FT Median Probe Spacing 475 bp) and quantitative PCR analysis did not confirm the deletion.

Genetic factors that influence short-term neurodevelopmental outcome in term hypoxic-ischaemic encephalopathic neonates.

It is difficult to predict outcome in neonates that experience perinatal hypoxic ischaemia. Morbidity and mortality may be affected by genetic factors that augment inflammatory and coagulative responses. This prospective study analysed the effects of proinflammatory cytokine gene polymorphisms (tumour necrosis factor-α [TNFA] 308G>A and interleukin-6 [IL6] 174G>C) and prothrombotic factor gene mutations (prothrombin G20210A, factor V Leiden G1691A and methylenetetra hydrofolate reductase [MTHFR] C677T) on the early neurological prognosis in 40 term hypoxic ischaemic encephalopathic neonates. There were significant relationships for Sarnat and Sarnat staging with electroencephalographic findings, transfontanelle ultrasound (US) results, early neonatal outcome and neurological morbidity. Genetic mutations in the prothrombotic proteins, the TNFA 308G>A polymorphism and the cerebrospinal fluid levels of TNF-α protein were not related to clinical stage, electroencephalography, transfontanelle US or neurological status at discharge or at postnatal months 6 and 12. The IL6 174GC genotype demonstrated a protective role, being significantly correlated with normal electroencephalography, transfontanelle US and normal neurological findings at discharge. In conclusion, the IL6 174GC gene polymorphism seems to play a role in determining the risk and/or severity of perinatal cerebral injury.

Polycythaemia in infants of diabetic mothers: ß-hydroxybutyrate stimulates erythropoietic activity.

This study tested whether elevated maternal ß-hydroxybutyrate (ß-OHB) levels contribute to polycythaemia in infants of diabetic mothers. Pregnant diabetic women (n = 27) and non-diabetic controls (n = 20) and their singleton infants were included. Maternal glycosylated haemoglobin and ß-OHB levels were studied at 34-36 weeks' gestation; levels were significantly higher in mothers with diabetes than in controls. Birth weights and cord blood levels of insulin and fetal haemoglobin were significantly higher in infants from diabetic mothers compared with control infants, as were haematocrit levels in venous blood samples taken from each infant at 4 h following delivery. Cord blood erythropoietin levels were similar in both groups. There was a positive strong correlation between maternal ß-OHB levels and polycythaemia in newborn infants, indicating that ß-OHB could activate erythropoiesis independently from intrauterine hyperinsulinaemia and/or erythropoietin levels, and may be important in the pathogenesis of polycythaemia in infants born to diabetic mothers.

Experience with teicoplanin in the treatment of neonatal staphylococcal sepsis.

We aimed to evaluate retrospectively the clinical and bacteriological efficacy and potential side-effects of teicoplanin treatment in neonates with proven staphylococcal infection. There were 37 episodes of staphylococcal septicaemia in neonates with a mean gestational age of 34.2 +/- 2.3 weeks; 26 were caused by coagulase-negative staphylococcal (CoNS) sepsis and 11 by Staphylococcus aureus sepsis. All episodes were treated with teicoplanin (intravenous loading dose 16 mg/kg followed by a maintenance dose of 8 mg/kg daily). The methicillin resistance and antibiotic susceptibilities of both micro-organisms were evaluated. Bacterial eradication was achieved in 89.1% of cases and mortality was 16.2%. The mean duration of treatment of the survivors was 11.6 +/- 2.3 days. There were no drug-related adverse events and the biochemical and haematological tests showed no clinically significant changes in relation to teicoplanin therapy. Our results suggest that teicoplanin is highly effective in neonatal staphylococcal sepsis.

A comparison of efficacy between two natural exogenous surfactant preparations in premature infants with respiratory distress syndrome.

The mortality and various morbidity rates have been substantially reduced by means of exogenous surfactant replacement, the cornerstone in the treatment of respiratory distress syndrome (RDS) in premature infants. The objective of this study is to compare two natural surfactant preparations (Alveofact(R), Survanta(R)) in terms of effectiveness and side-effects. A total of 50 infants with RDS were given surfactant due to RDS were taken into the scope of this study. Survanta(R) and Alveofact(R) were administered to randomized infants with RDS and the results obtained during clinical observations were compared. Second hour mean FiO (2), MAP and a/APO (2) values showed changes in favour of Alveofact(R) (n = 25) group compared to the Survanta(R) (n = 25) group (p < 0.05 for each parameter). However, this difference disappeared in the 6 (th) hour. No statistical difference was established between the two groups with regard to sideeffects (pneumothorax, sepsis, intraventricular hemorrhage, bronchopulmonary dysplasia), duration of mechanical ventilation in survivors, duration of hospitalization in survivors and mortality before the 28 (th) day. It was concluded that results obtained with different surfactant preparations having dissimilar compositions were not different in terms of final impacts and side-effects.

Transient fetal myelosuppressive effect of D-penicillamine when used in pregnancy.

Normal fertility is sustained by progress in the medical therapy of Wilson's disease; however, pregnancy complications are encountered more frequently. The mother we present is a Wilson's disease patient who had been compliant with D-penicillamine for the preceding 13 years. She was admitted with unplanned pregnancy at the 16th gestational week. The dose of D-penicillamine could be reduced to 600 mg/d related to the underlying disease. Pregnancy ended with premature labor and delivery at the 29-30th weeks. The baby experienced type I respiratory distress and was treated by surfactant and mechanical ventilation. Neutropenia and leucopenia were documented at 6th postnatal hours. The baby showed neutropenia and leucopenia for 5 days and resolving without any further therapy. Intrauterine D-penicillamine was suspected to cause transient neonatal myelosuppression.

Supplementation with Saccharomyces boulardii ameliorates hypoxia/reoxygenation-induced necrotizing enterocolitis in young mice.

Intestinal bacterial proliferation is an important aspect of gastrointestinal injury in neonatal necrotizing enterocolitis (NEC). In the present investigation, we examined the protective action of oral supplementation with Saccharomyces boulardii (S. boulardii), non-pathogen probiotic yeast, against hypoxia-reoxygenation (H/R)-induced NEC in young mice. Young mice were divided into three groups; Group 1 mice (untreated) were subjected only to hypoxia-reoxygenation; Group 2 mice were subjected to hypoxia-reoxygenation and were then given lyophilized S. boulardii (10 mg suspended in 0.5 ml saline) twice a day by orogastric intubation for 10 days. Group 3 mice served as controls. Hypoxia was induced by placing young mice in a 100 % CO (2) chamber for 5 min. After hypoxia, the young mice were reoxygenated for 10 min with 100 % oxygen. We examined the intestinal lesions by light microscopy and measured intestinal generation of PAF and TNF-alpha in the H/R-induced model of NEC. In the probiotic group, NEC-induced intestinal tissue damage was greatly attenuated, with necrosis partially limited to the mucosa. Both intestinal tissue PAF and TNF-alpha concentrations were significantly higher in the untreated group than in controls (p < 0.001). S. boulardii-supplemented young mice showed a significant decrease in intestinal generation of PAF compared with untreated young mice (p < 0.05). On the other hand, no significant difference was observed in the intestinal concentration of TNF-alpha between untreated and probiotic groups ( p > 0.05). The present study suggests that hypoxia/reoxygenation plays an important role in the pathogenesis of NEC and supports hypothesis that especially PAF and TNF-alpha are involved in the pathophysiological mechanism of H/R-induced NEC. This study also demonstrates that dietary supplementation with S. boulardii ameliorates the histologic evidence of H/R-induced intestinal injury. Based on these findings, the beneficial effects of probiotic S. boulardii in this model of NEC are mediated via mechanisms inhibiting intestinal proinflammatory mediator release.

The effect of dietary supplementation with n-3 polyunsaturated fatty acids on the generation of platelet-activating factor and leukotriene B4 in hypoxic-ischemic brain in young mice.

Platelet-activating factor (PAF), leukotriene B(4) (LTB(4)) and other cytokines have been indicated to be responsible for the neuronal damage in hypoxic-ischemic brain. Diets in omega-3 (n-3) fatty acids appear to have an antiinflammatory effect, which is thought to be due to decrease in active prostaglandins and leukotrienes production after incorporation of these fatty acids into cell membrane phospholipids. We investigated the effect of dietary supplementation with n-3 fatty acids on endogenous PAF and LTB(4) biosynthesis in hypoxic-ischemic brain of young mice. Young mice were randomly divided into four groups: Group 1 mice were fed standard chow (n-3 polyunsaturated fatty acids free); Group 2 and Group 3 mice were given standard diet supplemented with 10% by weight of fish oil, as source of n-3 polyunsaturated fatty acids, for 3 and 6 weeks, respectively. Group 4 mice served as control. We injured the right cerebral hemisphere of young mice by ligating the right common carotid artery and exposing the mice to 8% oxygen for 60 min. Approximately 10-fold increase in PAF concentration was determined in hypoxic-ischemic brain tissue of Group 1 mice. Tissue concentration of PAF showed a profound decline in Group 3 mice compared to Groups 1 and 2 (P<0.01, P<0.05, respectively). LTB(4) was also significantly elevated in the brain of Group 1 mice when compared to the brain of control mice (P<0.001). A striking decline was observed in the concentration of LTB(4) in both Group 2 and Group 3 mice compared to Group 1 mice (P<0.05, P<0.01, respectively). The present study shows that n-3 fatty-acid-enriched diet inhibits endogenous PAF and LTB(4) generation in hypoxic-ischemic brain tissue; however it demonstrates that 6 weeks of dietary supplementation with n-3 fatty acids results in a significant decrease in tissue level of PAF in the brain.

Molybdenum cofactor deficiency associated with Dandy-Walker complex.

Molybdenum cofactor deficiency is a rare and devastating disease leading to intractable seizures in the neonatal period. Severe loss of neocortical neurons, gliosis, and cystic necrosis of cerebral white matter resulting in significant cerebral volume loss are the neuropathological findings. The mechanism of cerebral injury is unknown, but sulphite excess, and sulphate or uric acid deficiencies are possible factors. We present here a new case of Molybdenum cofactor deficiency associated with Dandy-Walker complex with a history of three dead siblings, the latter also having Dandy-Walker malformation. We speculate that severe cerebral volume loss due to the above mentioned mechanisms may lead to an appearance resembling Dandy-Walker malformation.

The role of recombinant human erythropoietin in lipid peroxidation and platelet-activating factor generation in a rat model of necrotizing enterocolitis.

In the present study we examined the effect of recombinant human erythropoietin (rhEPO) on intestinal malondialdehyde (MDA) as an index of lipid peroxidation, related to iron-catalysed free radical reaction and platelet-activating factor (PAF) synthesis in the experimental model of necrotizing enterocolitis (NEC). Three groups, each consisting of eight 1-day-old Wistar albino rat pups, were studied; Group 1, hypoxia-reoxygenation; Group 2, hypoxia-reoxygenation and rhEPO pretreatment; Group 3, control. rhEPO was given 750 U/kg/week by intraperitoneal injection three times a week for 2 weeks. On day 15th of life, hypoxia was induced by placing rat pups in a 100% CO2 chamber for 5 min. After hypoxia, the rat pups were reoxygenated for 10 min with 100% oxygen and returned to their mothers. All pups were killed at 4h following hypoxia-reoxygenation. The abdomen was opened and representative samples of injured areas were taken for histopathologic examination. MDA and PAF levels were determined in the intestine. Significantly increased intestinal MDA content was found in Group 1 rat pups compared to Group 2 and Group 3 pups (p < 0.001 and p < 0.001, respectively). However, PAF concentrations were highly elevated in the intestine of Group 1 and Group 2 pups (p>0.05) when compared to the intestine of Group 3 pups (p < 0.001 and p < 0.001, respectively). Histopathologic findings did not differ between Groups 1 and 2. The present study demonstrates that oxygen-derived free radicals and PAF are involved in the pathophysiological mechanism of the development of NEC. This study also shows that administration of rhEPO significantly decreases lipid peroxidation; however, PAF generation was not inhibited in hypoxia-induced bowel necrosis.

Effect of recombinant human erythropoietin administration on lipid peroxidation and antioxidant enzyme(s) activities in preterm infants.

In the present investigation, we studied the effect of recombinant human erythropoietin (r-HuEPO) on serum malondialdehyde (MDA) as an index of lipid peroxidation, related to iron-catalyzed free radical reaction and erythrocyte superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPX) activities in very-low-birth weight (VLBW) infants. Forty premature infants, at gestational ages were less than 33 weeks and birthweights were less than 1,500 g, were enrolled in the study. The study population was randomly divided into 2 groups. Twenty infants in Group 1 (treatment group) were given r-HuEPO, and 20 infants in Group 2 served as the control. r-HuEPO treatment (750 U/kg a week) was initiated on the 10th day of life and continued for 6 weeks. Preterm infants given erythrocyte transfusions during the study were excluded from the results. Serum ferritin and MDA levels, and erythrocyte superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPX) activities were analyzed at the end of the first week of life (at the beginning of the study). Subsequently, serum ferritin, and MDA levels were measured at the end of the 3rd and the 6th week. SOD, CAT, and GPX activities in the hemolysate were analyzed at the end of the 4th week. Six infants in the control group and 1 infant in the r-HuEPO group received transfusions through the end of the study, and these infants were excluded from the results. Significantly decreased serum ferritin concentrations were found in the r-HuEPO group compared to those in the control group both at the end of the 3rd and the 6th week (P < 0.05, and P < 0.01, respectively). In addition, serum MDA levels were also significantly reduced in Group 1 compared to control both at the end of the 3rd and the 6th week (P < 0.01 and P < 0.05, respectively). A good correlation was found between serum MDA and ferritin levels in Group 1. When the 2 groups were compared with respect to activities of SOD, CAT, and GPX at the end of the 4th week, no differences were observed. Our findings in this study show that administration of r-HuEPO significantly decreases lipid peroxidation, but does not affect erythrocyte antioxidant enzyme(s) activities in preterm infants. The mechanism responsible for the r-HuEPO-induced decrease in lipid peroxidation may concern inhibition to iron-catalyzed free radical reactions.

Plasma concentrations of granulocyte-macrophage colony-stimulating factor and interleukin-6 in septic and healthy preterms.

UNLABELLED: Plasma granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-6 (IL-6) concentrations were determined in 21 preterm infants with sepsis and nine healthy preterm neonates of the same postnatal age at sampling. Plasma GM-CSF levels were elevated at diagnosis in the septic preterms as compared to the healthy preterms (P = 0.01), but did not differ significantly on recovery. IL-6 levels were also elevated markedly at diagnosis (P = 0.0003), but decreased to normal on recovery as compared to the healthy preterm infants. GM-CSF levels were more prominent in septic preterms with neutropenia than those of non-neutropenic infants (P = 0.03). CONCLUSION: Preterm infants can produce high levels of granulocyte-macrophage colony-stimulating factor and interleukin-6 in response to bacterial sepsis.

Platelet-activating factor concentrations in healthy and septic neonates.

Platelet-activating factor levels were measured in nine preterm infants with Klebsiella pneumonia septicaemia, eight healthy preterm infants of similar gestational age and ten healthy full-term infants of the same postnatal age at sampling. The platelet-activating factor levels of the healthy preterm and term groups did not differ significantly, but were elevated compared to the other two groups in the septic preterm infants (P < 0.01). Platelet-activating factor levels increase upon stimulation by Gram negative bacteraemia and are a important mediator of neonatal sepsis.

Serum lipid and lipoprotein composition in infants of diabetic mothers.

Diabetes mellitus (DM) alters carbohydrate and lipid metabolism to a great extent. This study was planned to determine whether infants of insulin dependent and gestational diabetic mothers have abnormal lipid metabolism. Three groups of newborns were included in the study; group I consisted of 7 infants of diabetic mothers (IDM) with insulin dependent DM (Type 1 DM), group II of 18 infants of gestational diabetic mothers and group III of 20 control neonates whose mothers had no history of DM. Total cholesterol (TC), triglyceride (TG) and high density lipoprotein-cholesterol (HDL-C) values in groups I and II were no different compared to those in group III (p > 0.05). However, low density lipoprotein-cholesterol (LDL-C) and LDL-C/HDL-C ratio were similar between groups I and II (p > 0.05) but significantly higher in both infants of type 1 diabetic mothers and gestational diabetic mothers compared to control infants (p < 0.05). Apolipoprotein A-I (Apo A-1) and apolipoprotein B (Apo B) levels, Apo A-I/Apo B and HDL-C/Apo A-I ratios were similar in between groups. However, Apo B/LDL-C ratio was significantly lower in groups I and II compared to control group (p < 0.05). In conclusion, diabetes in pregnant women causes a tendency to LDL hypercholesterolemia in the offspring. These infants should be longitudinally followed up to assess whether this observation imposes an increased risk for atherosclerosis for advanced ages.

Antioxidant defense systems in newborns undergoing phototherapy.

This paper was designed to investigate whether phototherapy is an oxidative stress in newborn infants undergoing phototherapy. A day-light continuous phototherapy was given to jaundiced 20 term and 16 preterm newborns for 72 hours. We measured serum vitamin E and the activities of red blood cell anti-oxidation enzymes (superoxide dismutase, catalase and glutathione peroxidase) before and after 72 h of phototherapy. Serum vitamin E levels were not different before and after 72 h of phototherapy in both preterm and term infants. In several studies, antioxidant enzyme activities have been shown to increase in response to oxidative stresses. In this study, however, the antioxidant enzyme activities in the hemolysate were similar before and at the end of the phototherapy in both preterm and full term. In conclusion, the results of our in vivo study do not confirm the thesis that phototherapy is an oxidative stress in newborn infants. Therefore, phototherapy would preferably seem to be safe and efficient method of treatment for all neonates presenting with hyperbilirubinemia.

Plasma platelet-activating factor levels in newborn infants with and without perinatal asphyxia: is it an additional marker of perinatal asphyxia?

BACKGROUND: Hypoxic-ischemic encephalopathy (HIE) is still a very important cause of neonatal mortality and morbidity. Recently platelet-activating factor (PAF) has been accused of being responsible for the neuronal damage in hypoxic-ischemic brain. METHODS: Therefore, we conducted a study in newborns with perinatal asphyxia to try to show the relationship between the clinical severity and plasma PAF levels. RESULTS: Mean plasma levels of 19 asphyxiated infants (997.8 +/- 363.5 pg/mL) were significantly higher than that of 20 healthy infants (410.2 +/- 148.6 pg/mL, P < 0.0001). Patients with clinically severe HIE had significantly higher levels of PAF (1494.2 +/- 386.6 pg/mL) when compared with patients with mild HIE (815 +/- 114.5 pg/mL) and with moderate HIE (828.3 +/- 61.1 pg/mL). There was a significant correlation between plasma PAF concentration and arterial pH and base deficit, but no correlation with platelet and leukocyte counts. CONCLUSIONS: Plasma PAF levels correlating with the severity of HIE is interpreted to mean that high PAF levels may be an indicator of clinical severity and probably the poorer prognosis of patients with HIE.

The effect of L-carnitine on platelet activating factor concentration in the immature rat model of hypoxic-ischemic brain injury.

Recent data suggested that platelet-activating factor (PAF) could play a pathophysiologically important role in the progression of hypoxic-ischemic brain injury. We investigated brain tissue PAF concentration in the hypoxic-ischemic brain of immature rats. Endogenous PAF concentration in brain tissue showed a marked increase in hypoxic-ischemic pups (Group 1, 85.6 +/- 15.5 pg/mg protein) when compared to that of the control (9.1 +/- 3.1 pg/mg protein). In addition, we studied the effects of pretreatment with L-carnitine (5 days and 2 h before the hypoxia) on endogenous PAF concentration in the hypoxic-ischemic brain. Endogenous PAF concentration in the short-term pretreatment group (Group 2, 81.6 +/- 9.7 pg/mg protein) was not different than in Group 1 rat pups. However, a significantly decreased PAF concentration was found in the group of pups that received carnitine pretreatment for 5 days (Group 3, 30.5 +/- 11.0 pg/mg protein). These results indicate that PAF is an important mediator in the immature rat model of cerebral hypoxic-ischemic injury. The suppressor effect of L-carnitine on PAF production may give new insight into the treatment of hypoxic-ischemic brain injury.