Birth trauma in preterm spontaneous vaginal and cesarean section deliveries: A 10-years retrospective study.

OBJECTIVE: We compared birth injuries for spontaneous vaginal (VD) and caesarean section (CS) deliveries in preterm and term pregnancies. METHODS: A retrospective cohort study was conducted in a single tertiary center, between January 1st, 2007, and December 31st, 2017. The study included 62330 singleton pregnancies delivered after 24 0/7 weeks gestation. Multivariable analyses compared trauma at birth, birth hypoxia and birth asphyxia in term and preterm deliveries, stratified by mode of birth, VD versus CS. Main outcome measure was trauma at birth including intracranial laceration and haemorrhage, injuries to scalp, injuries to central and peripheral nervous system, fractures to skeleton, facial and eye injury. RESULTS: The incidence of preterm deliveries was 10.9%. Delivery of preterm babies by CS increased from 37.0% in 2007 to 60.0% in 2017. The overall incidence of all birth trauma was 16.2%. When stratified by mode of delivery, birth trauma was recorded in 23.4% of spontaneous vaginal deliveries and 7.5% of CS deliveries (aOR 3.3, 95%CI 3.1-3.5). When considered all types of birth trauma, incidence of trauma at birth was higher after 28 weeks gestation in VD compared to CS (28-31 weeks, aOR 1.7, 95% CI 1.3-2.3; 32-36 weeks, aOR 4.2, 95% CI 3.6-4.9; >37 weeks, aOR 3.3, 95% CI 3.1-3.5). There was no difference in the incidence of birth trauma before 28 weeks gestation between VD and CS (aOR 0.8, 95% CI 0.5-1.2). Regarding overall life-threatening birth trauma or injuries at birth with severe consequences such as cerebral and intraventricular haemorrhage, cranial and brachial nerve injury, fractures of long bones and clavicle, eye and facial injury, there was no difference in vaginal preterm deliveries compared to CS deliveries (p > 0.05 for all). CONCLUSION: CS is not protective of injury at birth. When all types of birth trauma are considered, these are more common in spontaneous VD, thus favoring CS as preferred method of delivery to avoid trauma at birth. However, when stratified by severity of birth trauma, preterm babies delivered vaginally are not at higher risk of major birth trauma than those delivered by CS.

Physicians' Opinion and Practice of Vitamin K Administration at Birth in Romania.

(1) Background. Vitamin K is recommended worldwide as a standard of care for the prophylaxis of vitamin-K-deficiency bleeding (VKDB). This is also a standard practice in Romania, but due to the rising number of refusals by parents of basic interventions in the neonatal period, we aimed to assess the Romanian neonatologists' opinions and current practice regarding vitamin K administration at birth. (2) Methods. We designed and conducted an electronic survey addressed to 110 physicians working in Romanian hospitals. (3) Results. Half of respondents are accustomed to receiving refusals for vitamin K administration once or twice a year. When parents refuse vitamin K administration, they usually refuse other neonatal interventions, according to 90.9% of the responding physicians, and this situation has occurred more frequently during the last two years. The number of refusals and especially their increase are more frequent in level III hospitals (p = 0.0304, p = 0.0036, respectively). Only 22.7% of the physicians responded that they would recommend an oral preparation of vitamin K in the absence of intramuscular prophylaxis. (4) Conclusion. Efforts should be made to address parents' concerns and to have available alternatives to the intramuscular administration of vitamin K.

Fatal neonatal persistent pulmonary hypertension caused by vegetations of infective endocarditis - case report and review of the literature.

Neonatal infective endocarditis is a rare condition and usually pertains to a specific class of immunologically depressed preterm infants, with a long history of invasive procedures in the Neonatal Intensive Care Unit. We report the case of an aggressive and fatal neonatal infective endocarditis in a full-term infant, who developed massive endocardial vegetations on the tricuspid valve, leading to persistent pulmonary hypertension of the newborn, unresponsive to nitric oxide ventilation. Post-mortem cardiac cultures were positive with Serratia marcescens, an unusual germ for an early-onset infection, which was absent in blood cultures.

Better prediction for FGR (fetal growth restriction) with the sFlt-1/PIGF ratio: A case-control study.

The aim of this study was to check whether the sFlt-1/PIGF ratio, established as the biomarker for preeclampsia, reduces the false positive rate of late fetal growth restriction (FGR) detection by ultrasound biometry.This was a prospective case-control study, conducted at one regional maternity hospital in Romania. Study participants included singleton pregnancy women for whom the estimated fetal weight (EFW) at 28 to 35 weeks was < 10 percentiles and as controls, pregnant women with EFW >10 percentiles. All pregnancies were dated in the first trimester by crown-rump-length. We also recorded maternal characteristics, pregnancy and neonatal outcomes.The primary outcome measures were the relation between the sFlt-1/PIGF ratio and incidence of FGR. Secondary outcome was establishing a threshold for statistical significance of the marker and influence of other conditions (e.g., pre-eclampsia) on the accuracy of the marker in FGR prediction.Included in the study were 37 pregnant women and 37 controls.When we used ultrasound (US) biometry and maternal risk factors to estimate EFW <10 percentiles, the sensitivity was 44.4% with a specificity of 89% for an FPR (false positive result) of 10%. When we combined the US biometry and maternal risk factors with sFlt1/PIGF ratio, for a cut off of 38, the sensitivity was 84.21%, and the specificity was 84.31% for an FPR of 10%. The cut off value (36) did not change if we considered all cases of SGA, including those with associated preeclampsia or if we considered only FGR cases without associated preeclampsia.When associated with maternal factors and US biometry, the sFlt1/PIGF ratio enhanced the sensitivity for detecting late FGR.

Influence of refrigeration or freezing on human milk macronutrients and energy content in early lactation: Results from a tertiary centre survey.

BACKGROUND: Neonates with severe conditions that cannot be breastfed should receive fresh or preserved expressed human milk in addition to parenteral nutrition. OBJECTIVE: To identify the time during lactation when the macronutrients provide maximum energy and evaluate the effect of refrigeration and freezing. METHODS: We analyzed the composition of fresh milk, refrigerated at +4°C and frozen at -20°C, expressed by mothers of 60 preterm and 30 term infants from a level III maternity, in colostrum, transitional, and mature milk. RESULTS: In fresh milk, the protein level constantly decreases during lactation, with a significant difference after 3 weeks of lactation. Preterm milk of day 21 and day 30 had significantly lower protein than term milk (1.27 versus 1.43 g/dL, P=0.015 and 1.13 versus 1.28 g/dL, P=0.001). Refrigeration for 72 hours of term milk decreased protein content less than freezing. Preterm colostrum has significantly less protein after 48 hours of refrigeration or freezing. Preterm milk from day 60 lost carbohydrates if refrigerated 72 hours or frozen for 2 months. Lipids in preterm colostrum decrease after 8 weeks of freezing. Refrigeration for up to 72 hours did not change significantly the energy value of colostrum or transitional milk. Freezing preterm milk more than 2 weeks leads to significant loss of energy. CONCLUSIONS: Milk frozen for more than 2 weeks contains less protein and energy than milk refrigerated for up to 72 hours. In the absence of milk bank access, in common settings, short-term refrigeration is preferable to long-term freezing.

Endocan - a potential diagnostic marker for early onset sepsis in neonates.

INTRODUCTION: Neonatal early onset sepsis assessment is based on the history of pregnancy and delivery and nonspecific clinical signs. None of the biomarkers currently in use for clinical practice has adequate prognostic value, so it is not possible to clearly distinguish neonates with culture-proven sepsis from those with only risk factors or clinical suspicion. Endocan is an endothelial mediator involved in the inflammatory response that is present in low concentrations in the serum of healthy subjects, and in much higher concentrations in patients with SIRS and septic shock. The purpose of this study is to evaluate the utility of serum endocan serum levels as a biomarker for the diagnosis of neonatal early onset sepsis (EOS). METHODOLOGY: Serum endocan concentration was measured in newborns with clinical suspicion of EOS admitted to the Neonatal Intensive Care Unit on day 1, 3 and 7. RESULTS: Serum endocan levels were significantly increased in septic compared to non-septic neonates in the early stages of sepsis (2.43 ± 0.95 vs. 1.77 ± 0.57, p = 0.004), continued to rise up to 72 hours from onset and then decreased by the seventh day under treatment. CONCLUSIONS: These results suggest a potential role for endocan as an early marker for diagnosis and follow-up in neonatal EOS. Studies on a larger number of cases are needed in order to establish the practical utility of this molecule as a diagnostic tool for clinical practice.

Total antioxidant status in fresh and stored human milk from mothers of term and preterm neonates.

BACKGROUND: Antioxidant defense of the body is assured by both endogenous and exogenous factors comprising several enzymes, vitamins, protein components and derivates and oligoelements. Breast milk has been proven to have important and essential antioxidant composition to prevent and protect against diseases in infancy. The objective of this study was to determine the total antioxidant status (TAS) of human milk and to evaluate the differences between premature milk and term milk at different moments of lactation (colostrum, transitional milk and mature milk). A second objective was to evaluate how TAS varies whether the human milk is refrigerated or frozen. METHODS: Pumped human milk samples of the third, seven and 30th day were collected from women who had term deliveries (30 cases) and preterm deliveries (60 cases). Samples were refrigerated (+4 °C) or frozen in domestic conditions (-20 °C) for various durations and TAS was determined using the ABTS® technique with Randox® reagents and compared for the two groups. RESULTS: Higher values were found in term versus preterm fresh milk at 30 days of lactation. A slight reduction in TAS was found after 72 h of refrigeration, while 1 week freezing produced significant decrease of total antioxidants. Freezing for 12 weeks reduced more than 50% of TAS in fresh milk. CONCLUSION: Breastfeeding provides the optimal antioxidant for neonates, regardless of gestational age. Fresh milk has the higher antioxidant power. When it is not available, refrigerated milk for 24 h is better than for 72 h and preferable than frozen milk. Freezing human milk for 3 months in household conditions markedly diminishes TAS.

The Role of Follow-up in Monitoring the Outcomes of Prematurity in a Cohort of Romanian Infants.

BACKGROUND: The rate of preterm births in Romania is one of the highest among European countries. However, there is little information regarding the ways in which premature birth affects the outcome in Romanian preterm infants. AIMS: To investigate the effects of early developmental intervention after discharge from the hospital on motor and cognitive development in preterm infants. STUDY DESIGN: Longitudinal observational study. METHODS: We performed the Amiel-Tison neurologic evaluation at discharge and the Bayley Scales of Infant Development from 3 to 24 months. Based on these evaluations, an outcome score was formulated. RESULTS: Between 2007 and 2010, 1157 of 2793 premature infants were included into the study. There was a negative correlation between the number of evaluations and the risk of developing neurologic sequelae (p<0.001). The correlation analysis demonstrated a significant association between the final category of risk at the end of the follow up program and the degree of compliance (p<0.01). At 24 months evaluation, there was a correlation between the low gestational age and the risk of developing severe neurologic sequelae (p<0.001). CONCLUSION: This study shows the importance of follow up program in decreasing the risk of developing neurologic sequelae in preterm infants.

Pulse Oximetry During the First 24 Hours as a Screening Tool for Congenital Heart Defects.

INTRODUCTION: Although screening for congenital heart defects (CHD) relies mainly on antenatal ultrasonography and clinical examination after birth, life-threatening cardiac malformations are often not diagnosed before the patient is discharged. AIM: To assess the use of routine pulse oximetry in the delivery room and at 24 hours postpartum, and to study its feasibility as a screening test for CHD. MATERIAL AND METHODS: In this prospective study, all infants born in "Cuza Voda" Maternity Hospital, Iasi, Romania, were enrolled over a thirteen-month period. Preductal oximetry was assessed during the first hour, and postductal oximetry was evaluated at twenty-four hours postpartum. Data were then analyzed to establish the sensitivity and specificity of pulse oximetry, as a screening test for CHD. RESULTS: 5406 infants were included in the study, with a mean gestational age of 38.2 weeks and a mean birth weight of 3175 grams. During the first minute, blood oxygen saturation varied between 40% and 90% and at 24 hours of life, it ranged between 90% and 100%. Following oximetry assessment, 14 infants with critical CHD were identified. Blood oxygen saturation values in infants with CHD were lower throughout the entire period of evaluation. Pulse oximetry had good sensitivity and specificity at 1 hour (Se=87.5%, Sp=95.5%) and 24 hours (Se=92.5%, Sp=97.4%) for the diagnosis of CHD. Blood oxygen saturation values at one minute, 1 hour and 24 hours are strong discriminative parameters for the early diagnosis of CHD. CONCLUSION: Routine pulse oximetry during the first 24 hours postpartum represents an early indicator of CHD to facilitate timely intervention. Pulse oximetry provides excellent sensitivity and specificity and has tremendous potential as a standard screening test for CHD during the first 24 hours of life.

Early intrauterine development of mixed giant intracranial teratoma in newborn: a case report.

UNLABELLED: Teratoma is one of the most frequent fetal intracranial tumors, but it usually grows very quickly and the fetus is generally a stillborn. Rare cases have slow development or are located in areas that afford immediate surgery after birth with variable chances of survival. Even more rare cases survive days or weeks, but with no chance of surgical treatment and with prolonged palliative care. We present a 34 weeks premature infant, born by C-section with a giant intracranial tumor, whose origin could not be ascertained, occupied almost all-intracranial space and survived 25 days with supportive care. The histological examination established a G3 mixed teratoma, predominantly with immature cells from all three embryonic layers. The cerebellum was normal and infra-mesencephalic structures were present. The infant presented with severe anemia and mild respiratory distress, and was out of neurosurgical therapeutic resources. Antenatal examination was normal until 30 weeks, when fetal ultrasound described a degree of hydrocephalus, but no tumor was individualized. CONCLUSIONS: G3 type complex teratoma, even rare, can be localized at cerebral level and get giant development and growth only in the third trimester of pregnancy, ending with a neonate that has no chance of survival. Such cases cannot benefit of therapeutic interruption of pregnancy and generate serious difficulties for parents and clinicians.

Correlations Among Parental and Neonatal Anthropometric Parameters, Feeding Practices and Infant Obesity.

BACKGROUND AND AIMS: Infant and adult obesity is becoming a real public health concern in Romania, similar to other countries of the European Union. Maternal obesity and excessive weight gain during pregnancy are proven risk factors for the obesity of the child. The protective role of the breastfeeding against obesity has also been demonstrated. The most important issue is whether the choice of a milk formula with the right protein composition could or not protect the newborn from becoming a future obese infant and child. Our study aims to describe the characteristics of a group of macrosomic newborns, in relation to the mothers' weight gain during pregnancy, mode of delivery, birth weight, complications at birth, time of first feeding and type of feeding during maternity stay. PATIENTS AND METHODS: We conducted a retrospective study on 179 newborns with birth weights >4000 grams, born over a period of three months (March-May) in 6 large maternity hospitals in Romania. RESULTS: the newborns had a mean gestational age of 39.5 weeks and a mean birth weight of 4195 grams. Male newborns were prevalent (74%). More than half were born by Cesarian section and had Apgar scores with a median of 9. Macrosomes are prone to complications at birth and in our study those were mainly hypoglycemia and birth trauma. Time at first feeding was 95 minutes (mean), with a high percentage of formula/mixed feeding (68%). CONCLUSION: Macrosomia itself attracts the risk of birth by cesarean section (54% of study group), birth trauma and a low rate of exclusive breast milk feeding (32% of study group) at discharge.

High-dose phenobarbital or erythropoietin for the treatment of perinatal asphyxia in term newborns.

BACKGROUND: The aim of this study was to compare two neuroprotective strategies to supportive care in the treatment of perinatal asphyxia. METHODS: A total of 67 term newborns with perinatal asphyxia were included and randomized into three groups: one group received supportive treatment; another group received a single dose of 40 mg/kg phenobarbital; and the third received three daily doses of 1000 IU/kg erythropoietin. The following parameters were analyzed: gestational age, birthweight, Apgar scores, cord blood pH, total serum antioxidant status (TAS), superoxide dismutase (SOD), glutathione peroxidase (GPx) and malondialdehyde (MDA). The newborns were included in the follow-up program and examined up to 18 months of age. RESULTS: TAS was higher in the erythropoietin group than in the other groups. SOD and GPx were lower for infants treated with phenobarbital or erythropoietin compared to control infants. MDA was lower in the erythropoietin group compared to the other groups, although the difference was not statistically significant (P > 0.05). The mortality rate was lower in the phenobarbital and erythropoietin groups (both 4.6%) than in the control group (17.4%). Long-term neurologic follow up showed a high incidence of sequelae in the control group compared to the phenobarbital and erythropoietin groups. Follow-up results were better in the phenobarbital group than in the erythropoietin group for motor and cognitive function at 3 and 6 months and worse for expressive language. At 18 months, however, the differences between these two groups were not significant. CONCLUSION: High-dose phenobarbital or erythropoietin along with supportive treatment has a positive influence on the outcome of newborns with perinatal asphyxia. Phenobarbital has the advantage of low cost and simplicity.

[Procalcitonine--early marker of neonatal infection]. / Procalcitonina marker rapid al infectiei neonatale.

UNLABELLED: Neonatal infection represents the third most important cause of mortality in Neonatal Intensive Care Units (NICU), following perinatal asphyxia and respiratory distress syndrome. The incidence varies according to the level of care, between 5% in level II neonatal wards and 20% in the NICUs. The lack of specific early markers for infection could be partially responsible for the lack of antibiotic treatment or unnecessary treatment. In this context, many variables were examined as markers for sepsis. Large concentrations of C-reactive proteine (CRP) and procalcitonine (PCT) were positively correlated with the severity of the infection and generally indicated a poor outcome. AIM: The aim of this study is to demonstrate the utility of PCT as a fast, early and routinely used marker of neonatal infection, correlated with CRP, clinical symptoms and blood cultures. MATERIALS AND METHODS: this is a retrospective-prospective study on 2 lots of newborns from two neonatal wards of different levels of care (Lot I - 32 newborns from the Cuza-Voda NICU in Iasi, born in 2010, Lot II - 127 newborns from the Buna Vestire Maternity in Galati, born during 2008-2009). PCT was assessed before the beginning of the antibiotic treatment in newborns with high risk of sepsis or newborns with proven sepsis as corroborated with complete blood counts, CRP, fibrinogen, clinical symptoms and blood cultures. RESULTS: Among risk factors for neonatal infection, those found more often in newborns with proven sepsis are: ruptured membranes over 18 hours (p=0.043), Gram-negative bacilli colonization (p=0.003), respiratory distress syndrome (p=0.0008), abdominal distention (p=0.0042), oedema (p<<0.05) and necrotizing enterocolitis (p<<0.05). High values for PCT in premature newborns show the high risk for infection for this category of newborns, due to immunological imaturity and the presence of risk factors. High sensitivity and specificity of PCT (specificity =88.98%, sensitivity=87.5%) showed that the accuracy of PCT assessment in studied lots was 88.68% during the 24-72 hours of life time frame. CONCLUSION: High serum levels of PCT in studied lots plead for the usage of PCT for the fast and early diagnostis of neonatal infection. In those cases with positive PCT and negative blood cultures or positive CRP and clinical symptoms of infection, PCT would be a useful tool, aiding in the initiation or termination of antibiotic treatment, which would ultimately lead to lowering costs. PCT as a screening tool for cases with risk factors for infection is still to be analysed in terms of costs versus benefits and the longterm implications of neonatal sepsis and antibiotic treatment.

[Germ circulation in neonatal units--risk factors for maternal-foetal infection]. / Circulatia germenilor in sectiile de nou-nascuti factori de risc pentru infectia materno-fetala.

UNLABELLED: Infections are the third most important cause of morbidity and mortality in neonatal units. Infection rates are 2-5% in I-II level units, 10% in IIIrd level units and 7-24% in NICUs. AIM: To identify risk factors contributing to maternal-foetal and hospital infections in neonatal units of different levels in two maternity hospitals in Romania: Buna Vestire Obstetrics and Gynaecology Hospital in Galati (Lot A) and Cuza-Voda Obstetrics and Gynaecology Hospital in Iasi (Lot B). MATERIAL AND METHODS: This is a retrospective and prospective study during four years in two neonatal units in maternity hospitals of different levels from Moldova: level II - Lot A and level III - Lot B. RESULTS: Neonatal infection rates were significantly higher in preemies compared to term newborns (5.91% - Lot A vs. 9.9% - Lot B). Predominant maternal colonization and infection bacteria were E. coli (16.12% - Lot A vs. 12.6% - Lot B) and S. aureus (1.3% - Lot A vs. 2.03% - Lot B). Personnel colonization, predominantly with MRSA, presented little hazard for neonatal infection (RR 0.9 - Lot A, RR 0.7 - Lot B). Hospital environment contamination also presented minor risk for neonatal infection (RR 1.7 - Lot A, RR 0.2 - Lot B). CONCLUSIONS: The main risk factors for neonatal infections were gestational age (premature infants have immunological underdevelopment) and maternal colonization. Personnel colonization and hospital contamination are of little importance in the development of neonatal infections.