Fifth day fits in the newborn.

During the 1970s, there was an epidemic of neonatal convulsions occurring in apparently normal babies during the fourth and fifth days of life. This syndrome was noted in France as well as in Australia. A study was undertaken to review the King George V Hospital (KGV) experience with these 'fifth day fitters'. All cases of neonatal convulsions at KGV during the years 1972-85 were reviewed. A total of 94 cases of fifth day fits occurred during this period, accounting for 57% of all neonatal convulsions occurring during 1972-79. The fits occurred in healthy term infants after an uncomplicated pregnancy. They appeared on the fourth and fifth days of life. The seizures lasted an average of 24 h, were refractory to drug therapy and, despite extensive investigation, no cause was found. The infants were assessed as normal at the time of discharge from hospital. Follow-up of these infants was incomplete. However, from the data available, it cannot be assumed to be a benign entity. The 'fifth day fit' syndrome reached epidemic proportions at a number of maternity units during the 1970s. At KGV, no case has been observed since 1982.

Fetal outcome in obstetric cholestasis.

Obstetric cholestasis has been associated with a high incidence of stillbirth and perinatal complications. Between 1975 and 1984, 83 pregnancies were complicated by cholestasis. Meconium staining occurred in 45%, spontaneous preterm labour in 44%, and intrapartum fetal distress in 22%. Of 86 infants two were stillborn and one died soon after birth. Perinatal mortality fell from 107 in a previous series from this hospital (1965-1974) to 35/1000 in this series. Cardiotocography, estimations of oestriol, liver function tests and ultrasonic assessment of amniotic fluid volume failed to predict fetal compromise, whereas amniocentesis revealed meconium in 8 of 26 pregnancies. Early intervention was indicated in 49 pregnancies, 12 because of fetal compromise. This study suggests that intensive fetal surveillance, including amniocentesis for meconium, and induction of labour at term or with a mature lecithin/sphyngomyelin ratio, may reduce the stillbirth rate in this 'high-risk' condition.

Maternal features of obstetric cholestasis: 20 years experience at King George V Hospital.

Between 1965 and 1984, 139 pregnancies in 125 women were complicated by obstetric cholestasis (OC). Prevalence increased from 0.1% in the first 10-year period to 0.2% in the second (p less than 0.001), following recognition of the adverse fetal risks of this condition. Perinatal data from both series, 1965-1974 and 1975-1984 have previously been published. Mothers in the latter series were more likely to be of Anglosaxon than Mediterranean origin (p less than 0.001) and did not have underlying haemolytic conditions. Diagnostic criteria changed considerably over the 20 years, such that liver biopsy was no longer needed, gastroenterological consultation was sought less frequently (p less than 0.001) and newer diagnostic criteria of increased bile acids with negative hepatitis serology were increasingly employed. Biochemical data were broadly similar in the 2 groups. An understanding of the clinical and laboratory features of this disease facilitates early diagnosis, which is imperative if intensive fetal surveillance is to reduce the high stillbirth rate in OC.

Perinatal factors and the development of chronic lung disease in preterm infants: a case control study.

A case control study of neonates was performed to determine those factors contributing to the development of chronic lung disease (CLD). During the 5 years 1981-84 there were 487 neonatal survivors at gestations of 25-32 weeks; 391 of these developed respiratory failure (oxygen therapy required for more than 6 h). Fifty-six of the latter developed CLD (oxygen therapy required for more than 28 days and a coarse reticular pattern on chest X-ray). These neonates were predominantly of the shortest gestational ages, regardless of the initial chest X-ray diagnosis. Forty-three of these infants with CLD were matched for gestation and initial chest X-ray appearance (respiratory distress syndrome, n = 20; normal, n = 15; non-specific, n = 8) with 42 control infants. The mean duration of oxygen therapy (P less than 0.001), maximum FiO2 (P less than 0.001), incidence (P less than 0.01) and duration of intermittent positive pressure respiration (IPPR; P less than 0.05) and peak IPPR (P less than 0.05) were significantly greater in the CLD group. Mean birthweight (P less than 0.001), arterial cord pH (P less than 0.05) and base excess (P less than 0.05) were significantly lower in the CLD group. Factors that were not statistically significant in the development of CLD included antenatal fetal heart rate abnormality, hypertensive disease of pregnancy, acute intrauterine infection (chorioamnionitis or umbilical vasculitis), administration of antenatal steroids, sex, patent ductus arteriosus and pneumothorax. The association between CLD and ventilator/oxygen therapy is confirmed. Contrary to other reports, male sex, clinical patent ductus arteriosus and pneumothorax were not associated with CLD.

Gestational diabetes--infant malformations and subsequent maternal glucose tolerance.

The frequency of abnormal glucose tolerance in the first 12 months after gestational diabetes was found to be 33.3%, which is much higher than previously accepted. Women with gestational diabetes (Group 1 = 54 requiring insulin, Group 2 = 32 treated with diet alone) attending a metropolitan teaching hospital over a 3 1/2 year period were followed-up after delivery to determine their subsequent glucose tolerance. Of 86 seen 3 months after delivery, 2 had developed insulin-dependent diabetes mellitus (IDDM) and 2 noninsulin dependent diabetes mellitus (NIDDM), diagnosed by glucose tolerance testing. Another 38 returned for follow-up glucose tolerance testing at 12 months; of these 3 had impaired glucose tolerance (IGT), 7 had NIDDM, and one who had had NIDDM at 3 months now showed IGT after 9 months dietary treatment. Thus, 12 months after delivery, the cumulative prevalence of abnormal glucose tolerance was 14/42 (33.3%), 10 of the 42 being frankly diabetic (26%). Of the remaining 44 patients, 21 have not yet reached 12 months or were pregnant again, and 23 did not attend for glucose tolerance testing. Although the trend was for gestational diabetes mellitus (GDM) to recur earlier and more severely in subsequent pregnancies, in 3 instances the diabetes did not recur. Major congenital malformations occurred in 4 of the 86 babies (4.7%); minor malformations were found in a further 13 (15%) with no difference in frequency between Group 1 and Group 2.

Outcome of pregnancy complicated by diabetes: experience with 232 patients in a 4 year period.

The outcome of pregnancy was reviewed in 232 women with diabetes (Group 1 = 72 Insulin Dependent Diabetes; Group 2 = 9 Non Insulin Dependent Diabetes and 151 Gestational Diabetes) seen at a major metropolitan teaching hospital in the 4 yr period 1978-1981 inclusive. The perinatal mortality was 5.6% and there was a high rate of congenital malformations (5.6% major, 7.7% minor) with no difference in incidence between the 2 groups. Infants of women whose pregnancies extended beyond 37 weeks of gestation had a reduced incidence and severity of respiratory distress syndrome. Measurement of amniotic fluid lamellar body phospholipid proved accurate in predicting this complication. Neonatal hypoglycaemia correlated with poor maternal blood glucose control in the third trimester and during parturition.

Lamellar body phospholipid content of amniotic fluid and L/S ratio compared in assessing fetal lung maturity.

A micro-method has been devised for isolating a lung-derived membranous fraction from human amniotic fluid. The phospholipid content of this fraction, known as lamellar body phospholipid, provides an indication of fetal lung maturity (Ann. Clin. Biochem 16: 191, 1979). This method has now been applied to 479 samples of amniotic fluid from 330 pregnancies. The lecithin/sphingomyelin ratio has also been determined for each of the samples by the routine method currently in use in the hospitals providing the samples. Hyaline membrane disease was associated with a low concentration of lamellar body phospholipid (less than 35 mg/L) in all eight cases encountered in this study. In contrast, in 182 of the 185 cases where the lamellar body content of the amniotic fluid, collected within two days of delivery, exceeded 35 mg/L, the infants were free from serious respiratory problems. Data are presented which suggests that the lecithin/sphingomyelin ratio falsely indicated lung immaturity in many cases, amounting to 44% or more of all values indicating immaturity that were reported.

Fluorometric determination of "albumin-titratable bilirubin" in the jaundiced neonate.

We report a fluorometric technique for determination of albumin-titratable bilirubin in the jaundiced neonate. Although bilirubin alone has very little native fluorescence, considerable emission is observed in the presence of albumin under acid conditions. Analysis of the plasma sample alone and in the presence of excess human serum albumin solution appears to reflect the bilirubin tightly bound to albumin and the total serum bilirubin, respectively. The difference between these two values has been designated as "albumin-titratable bilirubin". Where the concentration of albumin-titratable bilirubin is considerable, a typical saturation effect is observed. In samples where the circulating bilirubin is strongly bound to endogenous alumin, no change in fluorescence is seen when exogenous albumin is added. Results correlate well with the clinical picture.