Optimal oxygen saturation in extremely premature neonates.

So far, great efforts have been made to understand the demands of extremely premature neonates (EPNs´; born before the 28(th) week of gestation) on postnatal care, including optimal oxygen saturation, that will allow them to survive without disability. A major yet unresolved problem is to find an "optimal range" of their oxygen saturation and to maintain it without drops or increases, i.e., without hypoxia or hyperoxia. The individual sections of this paper deal with the changes of SpO(2) (an estimate of SaO(2) measured by pulse oximetry) that occur before, during, and after premature labor, postnatal factors affecting SpO(2), and especially how to find an acceptable compromise in choosing the most effective and minimally harmful range of SpO(2) for EPNs' with the careful FiO(2) adjustment and continually monitored SpO(2). At present, the two SpO(2) ranges, narrow (90-94%) vs. wider (88-94%), are most discussed. However, the question of how much oxygen is too much or little remains unanswered. There is even a view that there is no uniform optimal SpO(2) range for EPNs, and that each newborn has its own, individually specific range that changes due to its intrinsic and/or extrinsic factors.

[Developmental impairment of children with very low and extremely low birth weight at 24 months corrected age, born in the Czech Republic in 2000-2009]. / Postizení vývoje detí s nízkou porodní hmotnostíve 24 mesících korigovaného veku, narozených v Ceské republice v letech 2000-2009.

OBJECTIVE: To evaluate the incidence of neonatal morbidity (NM), and developmental impairments (DIs) of very low (VLBW) and extremely low birth weight (ELBW) infants born in 2000-2009. DESIGN: Epidemiological study. SETTING: Outpatient clinics for children with perinatal risk at the regional neonatal centers. METHODS: Data on live born, specific neonatal mortality (SNM) and NM data were taken from the database the database of Institute of Health Information and Statistics of Czech Republic (IHIS CR). The incidence of DIs (cerebral palsy - CP, developmental delay - DD, growth retardation and sensory impairment) was evaluated at 24 months corrected age. Each cohort included newborn infants born always in the two-year periods.. Comparison of the incidence of DIs according to the birth-weight or to gestational age was performed in children born in 2009. RESULTS: 1. NM - in VLBW newborns, CNS morbidity and early indecisions decreased slightly (i.e. by 7 and 5%), other forms remained unchanged. In ELBW infants, CNS morbidity declined by 13.9% (p<0.05), early infections only by 5% (NS). - 2. DIs: - in VLBW infants, cerebral morbidity and early infections were reduced slightly (i.e. by 7 and 5% resp.). In ELBW category, CP decreased by 12%, and visual impairment by 9% (p<0.05). - 3. The occurrence of DIs by birth weight or gestational age did not differ, only in children <1000 g, in comparison with the group of <28 wks, was delayed growth increased by 6% (NS). - 4. In 2000-2007, SNM rate and also number of disabled children declined continuously. During period 2008-2009, in contrast to the previous 8 years, incidence of impaired children in both categories increased slightly (by 3%, and 1%, resp., NS). CONCLUSION: During the study period, SNM declined continuously, especially in the ELBW category. We managed to partially reduce NM (CNS and early infection), the problem remained late infection. In the period 2000-2007, incidence of DIs decreased, significantly in case of CP and visual impairment in ELBW children. Surprisingly in the last two years 2008-2009, there appeared in both categories an increase in the proportion of children with disabilities. It is a worrying finding, which should be re-evaluated.

[Changes in the developmental outcome of very low and extremely low birth weight infants at 24 months' corrected age born in 1997-2007]. / Zmeny incidence postizení vývoje u detí s velmi nízkou a extrémne nízkou porodní hmotností ve 24 mesících sicich korigovaného veku, narozených v letech 1997-2007.

OBJECTIVE: To describe the incidence of developmental impairments (DI) among very low birth weight (VLBW) infants at 24 months' corrected age, born in perinatal centers in 1997-2007, and evaluate their changing prognosis of intact development. DESIGN: Prospective epidemiological study. SETTING: Follow-up clinics of neonatal centers level III. METHODS: Live birth rate, in-hospital mortality, neonatal morbidity, DI and quality of survival were assessed. Neonatal morbidity was analyzed in periods 2000/2, 2003/5, and 2006/7 by the data of Institute of Health Informatics and Statistics. DI and quality of survival were evaluated in cohorts of VLBW infants born in 1997/9 (period I), 2000/2 (period II), 2003/5 (period III) and 2006/7 (period IV). RESULTS: Live birth rate of VLBW newborns in 1997-2007 increased in total of 39.5%, in-hospital mortality decreased, significantly in 1997-9 (fall of 10%). Neonatal morbidity, except infections, also declined. Significant decrease in DI-CP and visual impairment, was observed after period II, in category 1000-1499 g of 7/1.5%, in infants <1000 g of 8/7% resp. After period II, the prevalence of impaired children 1000-1499 g decreased of 5%, whereas in category < 1000 g only small decrease of 2% occurred in period III. Number of children without impairment increased gradually in both categories. CONCLUSIONS: The study showed significant increase in surviving VLBW infants, especially in category <1000 g. Increased survival rate at concurrent fall in severe neonatal morbidity (except infections) was not accompanied with worsened prognosis of an intact development.

Endodermal sinus tumor diagnosed in pregnancy: a case report.

Pure endodermal sinus tumor (EST) of the ovary is an uncommon germ cell tumor characterized by rapid growth. Its occurrence during pregnancy is extremely rare. The case of a 34-year-old woman with EST stage IC diagnosed in the 22nd week of gestation is presented. She received four cycles of cisplatin monotherapy during pregnancy. Further, three cycles of combination chemotherapy (cisplatin, bleomycin, and etoposide) were administered. Twenty-eight months posttreatment the patient was in complete remission with good health. A healthy female infant was delivered by cesarean section in the 35th week of pregnancy. The child showed normal laboratory, pediatric, and neurologic examination at the time of discharge from hospital and during the first and second years of her life. We conclude that the prognosis of EST is very good if patient receives adjuvant therapy. Cisplatin monotherapy seems to be effective and safe during pregnancy.

Assessment of exhaled gases in ventilated preterm infants.

Hydrogen peroxide (H2O2) production in exhaled air was measured in ventilated preterm newborns at 5, 24 and 48 hours after delivery, using originally designed method of exhaled breath condensate (EBC) collection. H2O2 production in expired gas was 812+/-34 pmol/20 min during the first measurement and then declined to 389+/-21 at 24 hours and 259+/-26 pmol/20 min at 48 hours.

Immature lung and acute lung injury.

Acute lung injury occurs mostly in the very low birth weight and extremely low birth weight infants. The pathological process leading to acute lung injury includes immature and/or diseased lung that experienced oxidative stress, inflammation and mechanical insult with the bronchial, alveolar and capillary injuries and cell death. It may be the first step to the subsequent development of chronic lung disease of prematurity or bronchopulmonary dysplasia. The mechanisms of lung injury are extensively investigated in the experimental models and clinical studies, mostly performed on the adult patients. At present, the explanations of the mechanism(s) leading to lung tissue injury in tiny premature babies are just derived from these studies. Acute lung injury seems to be rather a syndrome than a well-defined nosological unit and is of multifactorial etiology. The purpose of this review is to discuss the main factors contributing to the development of acute lung injury in the very low or extremely low birth weight infants--lung immaturity, mechanical injury, oxidative stress and inflammation. Nevertheless, numerous other factors may influence the status of immature lung after delivery.

[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.

[The exogenous surfactant and its effect on the respiratory distress syndrome (RDS)]. / Exogenní surfaktant a jeho vliv na syndrom respiracní tísne (RDS).

In this article the pathophysiology and diagnosis of neonatal respiratory distress syndrome as a primarily form of surfactant deficiency is disclosed. Attention is paid to surfactant composition, productive and secretion in the alveoli and metabolic turnover as well. From clinical point the view basic principles concerning the surfactant replacement is discussed. Surfactant minimizes the surface tension and friction between the gas molecules and lung tissues during breathing. It also helps keep lung tissues dry and alveoli patent. At 26 to 28 weeks of gestation alveolar ducts and bronchioles are present but pulmonary capillaries are not in close contact with them. Alveoli may not even be distinguishable. Surfactant develops all through gestation but does not surge until about the 34th week. Infants born before 35 weeks of gestation are at risk for respiratory distress syndrome which is at first characterised by decrease of lung compliance. It leads to progressive respiratory failure.

[Functional determination of C1-inhibitor in plasma with a low level of prekallikrein]. / Funkcní stanovení C1-inhibitoru v plazmách se snízenou hladinou prekalikreinu.

The method of assessment of the C1-inhibitor (C1-INH) based on activation of plasma precallicrein (PC) by the fragment of Hageman's factor (HFf) was described in a previous publication (6). It was recommended as an alternative of already described methods used for assessment of C1-INH. To define the reliability of the recommended method in plasma with a reduced PC level the authors used plasma of mothers where during childbirth as a rule a steep drop of this proenzyme occurs. In a group of 23 parturient women the plasma PC levels were assessed and were within the range from 0.067-0.397 U/ml incl. only 6 plasma specimens where the PC level varied within the range of normal donors, i.e. 0.319-0.438 U/ml (mean value mean = 0.369 +/- 0.035). The mean value in plasma of the mothers was 0.237 +/- 0.100. In both groups the C1-INH was assessed by the recommended method and by the method of callicrein inactivation. In the group of mothers the results of C1-INH correlated with estimations in plasma where the PC level was within the range from 42.5 to 107.6% of the mean PC value of donors (r = 0.82). In plasmas of mothers whose levels varied from 18.2 to 50.2% of the mean value of PC donors the assessment of C1-INH by the method of HF fragment activation gave lower results in all instances. The dependence of C1-INH estimation on the amount of PC was demonstrated on deficient plasma with a defined PC level.(ABSTRACT TRUNCATED AT 250 WORDS)

[C1-inhibitor plasma levels in neonates and mothers during labor]. / Hladiny C1-inhibitoru v plazme novorozencu a matek pri porodu.

The authors investigated C1-inhibitor (C1-INH) plasma levels in blood collected from mothers during delivery: mothers with a normal pregnancy and a group of mothers who displayed during the perinatal period direct or indirect signs of infectious disease. Both groups, as compared with a group of healthy donors, had low C1-INH levels. The neonates were divided into two groups (normal children and children with perinatal risk of infection) with sub-groups of mature full-term neonates (38-41 weeks of gestation) and premature infants (29-36 weeks of gestation). In the group of normal infants the neonates had on average somewhat lower C1-INH levels, as compared with healthy donors, in premature neonates of this group the lowest mean C1-INH level was recorded. In this group the authors observed a correlation between the inhibitor level and the gestation period. The results of C1-INH assessment in the group of neonates with a perinatal risk of infection were different. In premature neonates a higher average C1-INH level was observed than in mature neonates and the relationship between the C1-INH level and the gestation period was a linear negative regression. The postnatal increase of C1-INH levels on the 1st to 5th day was more rapid in premature neonates of both groups.

[Levels of plasma amino acids in normal neonates within the context of their postnatal adaptation]. / Hladiny plazmatických aminokyselin u fyziologických novorozencu v rámci jejich postnatálni adaptace.

The authors present values of plasma amino acid concentrations assessed on an automatic analyzer in a group of 12 mature neonates whose early and late post-partum adaptation and subsequent psychosomatic development followed-up to the age of 18 months was normal. The amino acids were assessed at the time of delivery, during the maximal weight loss of the infant after the third day and the last estimation was made before discharge from the maternity hospital when the body weight curves of all infants had a rising trend. None of the infants had neonatal jaundice and all were discharged fully breastfed.

[Treatment of neonates with extracorporeal membrane oxygenation]. / Lécba novorozencu mimotelní membránovou oxygenací.

ECMO is a therapeutic method which markedly improved the prognosis of premature or near term infants with severe cardiorespiratory insufficiency where conventional intensive care, incl. pulmonary ventilation and medicamentous support of the circulation did not help. It is method which needs the necessary technical equipment, perfect laboratory facilities and well trained teamwork. It is associated with risks which are not negligible, clearly defined indications as well as contraindications. The programme of ECMO, when introduced, should be regional and departments which use it should be in the area of large university hospitals. Despite the considerable costs associated with establishment of a therapeutic ECMO unit, it pays, as in the most threatened group of neonates it shortens the period these infants spend at the intensive care unit and reduces their mortality rate and severe forms of late postasphyctic morbidity.

[Retinopathy of prematurity over 3 decades]. / Nekolik pohledu na retinopatii nedonosených detí v prubehu trí desetiletí.

The authors give an account of 190 premature infants they treated in 1956-1988, suffering from retinopathy of prematurity--ROP, and for prolonged subsequent periods. As the head of the team followed up all the children, there is an integrated view of the problem. The birth weight of the infants was 640 g--1,900 g. From the total number 76.8% infants had a birth weight of 1,500 g or less, 13.7% had a birthweight of 1,000 g or less. Evidence of the increasing rate is provided by the number of patients treated since birth at the department for premature and pathological infants FNM as well as by the number of children admitted from other departments after development of ROP. In 1956-1970, i. e. in 15 years, the authors looked after 34 patients, in 1971-1988, i. e. in 18 years there were 156 children with ROP. In 1956-70 cases of ROP predominated which developed as a result of absolute or relative hypoxia. They were successfully treated by individually adjusted and carefully controlled oxygen therapy (6.9% blind children). In 1971-1975 the possibility to use this therapy declined briskly because after introduction of modern medical technique the number of findings suggesting a hyperoxic insult increased. At that time the results deteriorated greatly (50% blind children). In 1976-1980 the results were favourably influenced by individual dosage of oxygen therapy in all infants, based on regular monitoring of blood gases (10.5% blind children).(ABSTRACT TRUNCATED AT 250 WORDS)

[Determination of prekallikrein in the plasma of neonates]. / Stanovení prekallikreinu v plazme novorozencu.

The authors assessed plasma prekallikrein (PK) after its conversion into the active enzyme kallikrein from the rate of breakdown of the specific chromogenic substrate NO-Pro-Pre-Arg-pNA. Activation of PK was achieved by the parallel contact method, using dextran sulphate (DS) and by direct activation by the Hageman's factor fragment (HFf). Contact activation assumes the presence of Hageman's factor (HF) and high molecular kininogen (HMW-K) in plasma. Both methods of activation and x = 0,451 +/- 0.146 U/ml in HFf activation). The mean PK value in neonates assessed by activation of DS was lower [mean = 0.105 +/- 0.068 U/ml] than the value assessed by activation of HFf [mean = 0.175 +/- 0.072 U/ml]. In adults the PK values varied at a significantly higher level, the results being higher when HFf was used as activator [mean = 0.346 +/- 0.087 U/ml in DS activation and mean = 0.451 +/- 0.146 U/ml in HFf activation]. The increase of mean values of PK assessed in umbilical blood and on the 3rd and 5th day after delivery was more marked in direct HFf activation. The correlation coefficient of both ways of assessment in neonates was r = 0.79, in the group of adults there was a close correlation r = 0.92. The lower correlation in neonates can be explained by the low level of co-factors, in particular HMW-K, necessary for complete activation of PK by the contact method. In some neonates the PK value assessed by DS expresses only the total activating plasma capacity and not the actual PK level.

[Cryocoagulation in the treatment of retinopathy of prematurity]. / Kryokoagulace v lécbe retinopatie nedonosených.

The authors give an account on cryotherapy of retinopathies in the premature--130 eyes of 93 children treated during 1984-1988. Almost in all children cryocoagulation was made, using a transconjunctival approach, in the avascular periphery of the retina under local instillation anaesthesia. Twenty-eight eyes were coagulated already in stage 2 of the proliferative phase (along with the other more severely affected eye), the results being very satisfactory. In this stage, however, spontaneous regression cannot be ruled out. This is the reason why only 102 eyes were evaluated in detail, i.e. those coagulated in stage 3a and the latter were compared with findings in 90 eyes equally affected where cryocoagulation was not performed. In the group after coagulation 51% of the eyes had findings in stage I and II of the cicatricial phase with good and very good vision, in 17.6% the final finding is stage III with vision in the zone of visual debility and 31.4% of the eyes with findings stage IV and V are blind. In the group without coagulation there were 4.4% eyes in stage I and II, 28.9% eyes in stage III and 66.7% in stages IV and V. In eyes after coagulation the percentage of adverse results (31.4%) is by one half lower than in untreated eyes (66.7%).

[Risk of morbidity in neonates in Prague 1980-1984]. / Riziková morbidita novorozencu v Praze v letech 1980-1984.

An epidemiological analysis of 3427 hospitalized neonates at four Prague intensive care and intermediary care units in 1980-1984 revealed that of the total neonatal risk morbidity, 5.6%, the greatest ratio is accounted for by non-inflammatory respiratory diseases, 3.3%, followed by infections, 1.5%, and serious congenital defects, 0.7%. The incidence of the above groups is higher in Prague, as compared with Scandinavian countries. The lethality of inflammatory diseases and serious congenital defects is the same, in the group of non-inflammatory disease it is markedly higher in particular in the sub-group of pulmonary maladaptation--early asphyctic syndrome. The perspective of reduction of neonatal mortality calls in particular for a reduced incidence of risk morbidity and better care of critically ill neonates.

[Evaluation of pulmonary function in children of preschool age treated in the neonatal period with distension methods]. / Hodnocení plicních funkcí u detí predskolního veku, lécených v novorozeneckém veku distencními metodami.

Within the framework of a long-term follow up of the development of neonates with low birth-weight the authors investigated pulmonary functions in a group of 20 children aged 5.5 years treated during the neonatal period on account of early asphyctic syndrome, hyaline membrane syndrome and bronchopulmonary dysplasia by the distension method, using a continual positive pressure. The birth-weight of the investigated children varied between 600 and 1500 g. While the authors observed a significant reduction of the forced vital capacity, as compared with the appropriate values for the given age, sex and anthropometric data in almost 40% of the children, the values indicating obstructive changes (one-second vital capacity - FEV1 and mean flow rate - FEV25-75%) were reduced only in 15% of the investigated children. The revealed changes detected during the symptom-free period with a normal clinical picture are the functional background for aimed prevention of chronic bronchopulmonary disease and effective rehabilitation.