Group B streptococcal infections in the perinatal period: current approaches.

Group B streptococcal (GBS) infection in the neonate is the most common infectious cause of perinatal morbidity and mortality. There is much confusion in the literature regarding screening and treatment for this disease. The authors review recent literature on perinatal GBS infection and present their clinical opinions in favor of routine screening during pregnancy. Treatment protocols for the GBS positive mother, as well as the infant delivered of a GBS positive mother are considered.

The next baby: parents' responses to perinatal experiences subsequent to a stillbirth.

This study examines the responses experienced in the perinatal period by parents who have had an infant subsequent to a stillbirth. Interview findings from eight couples in a stillbirth study group (SSG) who had this experience and eight couples in a comparison group (CG) whose live-born children were delivered at similar time intervals as the SSG were compared. In contrast to a comparison group, half of the SSG mothers did not make preparations for their babies until after delivery and seven of eight SSG mothers wanted the hospital staff to recognize their previous loss and give them special understanding. The parents in the SSG reported that because of their loss, they were likely to spend more time (p less than 0.01), to be more attentive to fussing (p less than 0.01), and to hold their babies more (p less than 0.01). Over half of the SSG parents also noted that after having another baby, they experienced greater relaxation, happiness, and closeness with their spouse. After their subsequent baby, the SSG parents observed that thinking about the stillbirth was easier, but resented being told by others to feel grateful.

State reporting of live births of newborns weighing less than 500 grams: impact on neonatal mortality rates.

The National Center for Health Statistics reports that in 1983 65% of all infant deaths in the United States occurred in the neonatal period. Of these reported neonatal deaths, 17% were of infants weighing less than 500 g at birth. There was, however, variation in state-reported incidence of live births of newborns in this weight cohort (0.2 to 2.2 per 1,000 live births). The states with the lowest neonatal mortality rate have the lowest incidence of birth weights less than 500 g (rho = .77). If it is assumed that mortality for this weight category is nearly 100%, there is marked variation (5% to 32%) in the contribution of this weight cohort to a state's total neonatal mortality rate. Contributing to this variation may be definitions of live birth used by states. The World Health Organization defines a live birth as the product of conception showing signs of life "irrespective of the duration of pregnancy" and this definition is used by 33 states. Only one state (Ohio) includes the gestational criteria of "at least 20 weeks" in its definition of live birth. There is evidence to suggest that definitions are not uniformly used within individual states. For example, in 1983, 20 states did not report any live births with weights less than 500 g among their "other" populations of nonwhite, nonblack residents. Half of these states, however, use the World Health Organization definition of live birth. Despite the exclusionary wording in Ohio's definition of liver birth, 16% of newborns who died in that state had birth weights less than 500 g.(ABSTRACT TRUNCATED AT 250 WORDS)

Parental response to perinatal death. Mother-father differences.

Depression and social interaction of mothers and fathers following a perinatal loss were studied using the questionnaire responses of 58 married couples. In the first six weeks following their loss, differences observed in responses of mothers and fathers are most apparent. During this time, mothers have more depressive symptoms, more often would like others to open a conversation with them about the baby, and are more likely to find their spouse helpful. At a mean of 25 months after the death, mothers' and fathers' differences with respect to depression become less apparent. However, fathers with more depressive symptomatology have increasing needs for social interaction and do not perceive that their marriage has grown stronger. Maternal depression has no correlation with perceptions of marital strength. Family counseling should reflect the possible variations in timing of the grief reaction and potential capabilities of parents to be supportive of one another.

Idiopathic arterial calcification of infancy in newborn siblings with unusual light and electron microscopic manifestations.

We report two cases of idiopathic arterial calcification of infancy (IACI) occurring in newborn siblings. Unusual gross and light microscopic findings included calcification of multiple nonarterial tissues, renal infarction, and macroscopic aortic involvement. One case manifested an extensive acute panarteritis suggesting that IACI may be the result of an inflammatory or infectious process. Ultrastructural examination confirmed that the mineral deposits were hydroxyapatite and also indicated that they contained iron. Calcified tissue components included smooth-muscle cells, fibroblasts, and collagen fibers, as well as elastic fibers. No matrix vesicles or mitochondrial calcifications that may serve as nucleation sites for crystalline calcium phosphate were identified. Thus, the mechanism of calcification in IACI may be unique, and may relate to altered iron metabolism.

Consistency of care in an intensive care nursery staffed by nurse clinicians.

Variables related to both the process and outcome of newborn intensive care were studied to evaluate care consistency in a level 3 Newborn Intensive Care Unit (NICU) where neonatal nurse clinicians function in a role usually held by pediatric house officers. In routine delivery of intensive care, there were no statistically significant diurnal variations in the overall mortality, maintenance of intravenous infusions, tolerance of oral feedings, or respiratory care except a decrease in frequency of blood gas sampling during the weekday days as compared with nights. Our data suggest that a tertiary NICU in which medical coverage by neonatologists is supplemented by carefully trained and supervised neonatal nurse clinicians provides a consistent level of care that does not vary between night and day or day of the week.

What physicians know about the prognosis of preterm newborns.

A questionnaire assessing physicians' understanding of the prognosis of preterm newborns was sent to every pediatrician, obstetrician, family practitioner, and general practitioner in South Dakota. Fifty-three percent of the total sample completed and returned the questionnaire that covered the mortality, general care, and physical, developmental, and psychosocial morbidity of the preterm newborn. The average physician answered 75% of all items with responses consistent with our interpretation of the medical literature. The physicians did better on items concerning mortality and physical morbidity than on those items related to psychosocial or developmental morbidity. Stepwise multiple regression analysis showed that a physician's years of experience was the most significant predictive variable and was negatively related to his or her overall score.

The death of a newborn twin: an analysis of parental bereavement.

The emotional responses of eight families who lost a singleton newborn were compared with those of eight families who lost a twin. The mean gestational age of the babies in both groups was 31 weeks. At a mean time of 15 months following their loss, parents were sent a questionnaire which requested that they report their responses during the first six weeks following their baby's death and their present response to this experience. Embedded in the questionnaire was a 20-item depression symptom inventory. Analysis of variance indicated that although mothers experienced significantly more depressive symptoms than fathers (F = 59.48, P = .001) and that all symptoms had diminished greatly over time (F = 6.02, P = .032), there was no significant difference between the parents who had lost a twin and those who had lost a singleton. However, family, friends, and hospital staff frequently ignored or downplayed the death of the twin assuming that the grief of the parents would be minimal because of the surviving twin. Results of this study indicate that the presence of a living twin in no way lessens the grieving process and that a conscious effort needs to be made to allow parents to express openly their feelings of loss when a twin dies.

Alternative pathway of complement activation in full term and premature infants.

Classical and alternative pathway complement levels were measured in the cord blood sera of 60 newly born infants, with weights ranging from 1200--4165 g. The impact of maternal illness and infant illness on the complement levels was also evaluated. The mean values for CH50, C3, C4, PH50, factor B, and properdin were all significantly less than normal adult levels (P less than 0.0001). All of the above determinations were significantly correlated with one another except for the relationship between properdin and factor B. CH50, PH50, C4, and properdin levels were significantly correlated with birth weight although there was much residual scatter. Neither maternal illness nor mild to moderate illness in the newborn altered the birth weight-complement relationships. Severe infant illness did significantly alter the relationship between birth weight and complement. However, the impact of this variable on the birth weight-complement relationships was not consistent among the various components. These inconsistencies and the small sample size preclude drawing any strong conclusions about severe illness and complement levels.

Immunofluorescence in group B streptococcal infection and idiopathic respiratory distress syndrome.

Immunofluorescence was performed on lung tissue obtained at necropsy from 18 newborn infants, including five with group B streptococcal (GBS) sepsis, seven with idiopathic respiratory distress syndrome (IRDS), and six control infants who died from other causes. Deposits of C3, IgG, and fibrin were found within hyaline membranes of infants who died with GBS sepsis or IRDS within 48 hours after birth. In some cases C4, factor B, and IgM were also observed. In five infants with IRDS who died more than five days after birth, immunofluorescent lung findings were less common and less intense. Hyaline membranes, attributed to mechanical ventilators and oxygen therapy in two infants who did not have GBS infection or IRDS, were negative for complement and immunoglobulins although fibrin was detected in one specimen. These data suggest that immunologic processes may contribute to the pathogenesis of certain types of acute lung injury, particularly in infants who die from GBS infection or IRDS during the early neonatal period.

Evaluation of colistin and nalidixic acid in Todd-Hewitt broth for selective isolation of group B streptocci.

Todd-Hewitt broth (THB) containing colistin and nalidixic acid was compared with four other media with respect to efficacy of isolation of group B streptocci. It was effective as plain THB, THB with gentamicin and nalidixic acid and blood, and THB with colistin, nalidixic acid, and blood. THB with gentamicin and nalidixic acid, but without blood, was inhibitory to group B streptocci. The value of THB with colistin and nalidixic acid lies in its ability to successfully inhibit gram-negative organisms and still promote group B streptococcal growth without the addition of blood. This greatly reduces the time and expense of media preparation and permits early determination of bacterial growth, so that other means of rapidly identifying group B streptocci can be applied at the earliest possible time.

Direct use of counterimmunoelectrophoresis in detection of group B streptococci in specimens containing mixed flora.

Isolation procedures for the group B streptococci were bypassed by applying counterimmunoelectrophoresis (CIE) directly to the broth containing the initial inoculum. A total of 458 tests were performed on 389 specimens received from 93 mothers and 81 babies. Of all tests, 19.4% were positive group B streptococci by the Lancefield precipitin method. Twenty hours of incubation were required to produce a positive CIE result in 54% of those specimens which were eventually proven a contain group B streptococci by Lancefield technique. There were no false positive CIE results. It is recommended that the initial broth culture be sampled and tested with CIE after an overnight incubation in those cases where another 24 h may be critical in terms of identifying the group B streptococci. A positive result with CIE can be clinically relied upon, but a negative result is indeterminate, and routine isolation procedures would need to be followed in that case.

Complement activation and group B streptococcal infection in the newborn: similarities to endotoxin shock.

Serial measurements of CH50, C3, C4, and factor B were performed on three newborn infants with group B streptococcal sepsis. Two of the septic infants had a colonized but noninfected identical twin. All three infants with group B streptococcal sepsis had hypotension, prolonged coagulation times, neutropenia, and respiratory failure. During the course of the sepsis, factor B was depressed 30% to 35%, C3 was depressed 40% to 60%, and CH50 was depressed by 100% when compared to their cord blood levels. Two of the infants also had a 50% to 70% depression of C4. In contrast, no significant decrease in complement levels occurred in the siblings of the twins or in two additional control infants. These data are characteristic of older patients with Gram-negative sepsis and strongly suggest that the group B Streptococcus has endotoxin-like properties.

The determination of aspirin levels in the presence of hyperbilirubinemia.

Many major medical centers are presently utilizing a shortened method (Keller) for determining serum aspirin levels which does not remove interfering compounds. This report documents that the presence of even 1 mg of bilirubin/dl of serum is sufficient to cause a falsely high aspirin level. It is suggested that any method for determining serum bilirubin which does not remove interfering substances constitutes a danger to many groups of patients and should be discontinued.

Congenital syphilis after maternal treatment with erythromycin.

A case is reported in which erythromycin was used successfully to treat maternal syphilis but failed to adequately treat the fetus. This report and similar studies suggest that oral erythromycin is not a reasonable alternative drug for the treatment of lues in the penicillin-allergic gravid female.