Placental apoptosis in pregnancies with intrauterine meconium passage.

In this study we investigated the presence of placental apoptosis in pregnancies with intrauterine meconium passage. Placental tissue samples at term were obtained from 15 normal and 15 pregnancies with intrauterine meconium passage. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling method was applied to confirm apoptosis in all placental samples. The mean apoptotic ratio was significantly higher in placentas of pregnancies with intrauterine meconium passage when compared with normal ones (0.37 +/- 0.06% and 0.29 +/- 0.07%, respectively; p < 0.01). The mean apoptotic ratios in trophoblastic and stromal cells were significantly higher in placentas of pregnancies with intrauterine meconium passage than normal placentas (0.47 +/- 0.10% and 0.36 +/- 0.11% [ p < 0.05] and 0.29 +/- 0.07% and 0.22 +/- 0.07% [ p < 0.05], respectively). Increased placental apoptosis in pregnancies with intrauterine meconium passage could be a causative factor in the pathophysiology of the disorder or a direct effect of meconium on placental cells.

Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns.

OBJECTIVE: In this study, we investigated prospectively the incidence of significant hyperbilirubinemia and demographic and laboratory characteristics and pattern of serum bilirubin levels of near-term newborns (35-37 weeks' [245-265 days'] gestation) by comparing them with those of term newborns (38-42 weeks' [266-294 days'] gestation) longitudinally in the first 7 days of life; we also aimed to determine the value of an early (6th-hour) serum bilirubin measurement in predicting the development of significant hyperbilirubinemia later during the first week of life in near-term newborns. METHODS: Serum total bilirubin measurements were initially made at the 6th hour of life and repeated daily for the next 4 days, and a last measurement was performed on the 7th day (150th hour) in 219 term newborns (term group) and 146 near-term newborns (near-term group). Newborns with serum total bilirubin levels of > or =8 and > or =12 mg/dL on day 2, > or =12 and > or 15 mg/dL on day 3, and > or =14 and > or =17 mg/dL on days 4, 5, and 7 for birth weights 2000 to 2500 g and >2500 g, respectively, were defined to have significant hyperbilirubinemia, and phototherapy treatment was started. The predictive ability of the 6th-hour serum total bilirubin value in determining the development of significant hyperbilirubinemia in the near-term group was assessed on the basis of the placement of any of the first week's serum bilirubin measurements in the > or =95th percentile of the study population. A Gaussian distribution curve, the 5th, 30th, 60th, and 95th percentiles, and 4 percentile tracks were obtained from mean serum total bilirubin values. On the basis of the percentile tracks with various sensitivity, specificity, and negative and positive predictive values, a nomogram demonstrating the 4 percentile tracks as risk-zone demarcators with divided risk zones was produced. RESULTS: Twenty-three newborns (10.5%) in the term group and 37 newborns (25.3%) in the near-term group had significant hyperbilirubinemia and required phototherapy. When the daily mean serum bilirubin levels of the 2 groups were compared, the first 4 days' values did not significantly differ between the 2 groups, whereas the 5th and 7th days' values were significantly higher in the near-term group. There were significant differences between the 2 groups with respect to the incidence of significant hyperbilirubinemia, hematocrit, Apgar score, and mode of delivery. On the age-specific nomogram, the zone >95th percentile was labeled as high risk, and that <5th percentile was labeled as low risk. Serum total bilirubin values between the 5th and 30th, 30th and 60th, and 60th and 95th percentiles were designated as being in the low-intermediate, intermediate, and high-intermediate risk zones, respectively. The 5th and 95th percentiles on the nomogram had the highest sensitivity (100%) and specificity (98.2%), respectively, in predicting the subsequent development of significant hyperbilirubinemia. CONCLUSIONS: Near-term newborns should not be treated as term newborns in the approach to management of hyperbilirubinemia, because infants of 35 to 37 weeks' gestation had significantly lower birth weights, significantly higher serum total bilirubin levels on days 5 and 7, and were 2.4 times more likely to develop significant hyperbilirubinemia than those of 38 to 42 weeks' gestation in the present study. In near-term newborns of 35 to 37 weeks' (245 to 265 days') gestation, the decision to diagnose and treat significant hyperbilirubinemia should be made on the basis of risk status (percentile distribution of the serum bilirubin values on postnatal age) rather than using birth-weight-based thresholds. A nomogram constructed from daily serum bilirubin values of each population, as we present herein, can be used in assessing the age (hour)-specific jaundice risk (high, intermediate, or low) of each near-term newborn.

Early physiotherapy intervention in premature infants.

Preterm infants are more likely to have disabling cerebral palsy (CP) than term infants. It has been reported that early therapeutic approaches may be appropriate for infants at risk of neuromotor dysfunction, to minimize the degree of future handicaps. Two hundred and twenty-nine infants born at less than 34 weeks' gestation, with birth weight < or = 2,000 g, cared for in the neonatal intensive care unit of Hacettepe University Hospital between January 1997-June 1999 were included in this study. Of the 229 infants initially included, 39 (17%) were dropped from the study within the first 12 months' assessment, due to lack of participation from the families. Thirty of the remaining 190 infants were found to have perinatal hypoxia or abnormal neurosonography, and were taken as the group at risk of development of CP, thus receiving early intervention therapy; these are listed as "premature at risk". The study group consisted of 160 infants not considered at risk. These were randomly paired into two groups of 80 infants, one that was given early interventional therapy, and the control group that received no program. Eleven of the 30 infants at risk, 2 of the 80 infants from the intervention group, and 4 of the 80 from the control group were diagnosed as having CP within the first six months of life. There was no difference in the age of loss or acquisition of reflexes and general abilities between the intervention and control groups. There was no difference in the prevalence of CP between the intervention and control groups. In conclusion this study showed no effect of early intervention in premature babies without risk of CP other than prematurity.

An early (sixth-hour) serum bilirubin measurement is useful in predicting the development of significant hyperbilirubinemia and severe ABO hemolytic disease in a selective high-risk population of newborns with ABO incompatibility.

OBJECTIVE: In the era of early discharge of newborns from the hospital, newborns with ABO incompatibility are at especially greater risk for developing a subsequent significant hyperbilirubinemia because some of these infants also may present with some degree of ABO isoimmune disease. In this study, we aimed to determine prospectively the critical serum total bilirubin level to predict significant hyperbilirubinemia and severe hemolytic disease in healthy term newborns with ABO incompatibility based on a serum bilirubin measurement made at a postnatal age at which all newborns are at the hospital before discharge and at which any therapeutic intervention, if necessary, could be started as early as possible. METHODS: A total of 136 healthy term newborns with ABO (O-A or O-B) blood group incompatibility were followed prospectively with daily serum total bilirubin measurements for the first 5 days of life. Newborns with serum total bilirubin levels of > or =5 mg/dL and an increase in serum total bilirubin concentration of >0.5 mg/dL/h in the first 24 hours, > or =12 mg/dL on day 2, > or =15 mg/dL on day 3, and > or =17 mg/dL on days 4 and 5 were defined to have significant hyperbilirubinemia and were started on phototherapy treatment. Additional treatment modalities, including intense phototherapy, intravenous immunoglobulin treatment, and exchange transfusion, were used when serum bilirubin concentrations exceeded 20 mg/dL or increased by >1 mg/dL/h despite a phototherapy treatment of at least 4 hours. The additional assessment of the predictive ability of the sixth-hour serum total bilirubin value in determining the development of significant hyperbilirubinemia was made on the basis of the placement of any of the first 5 days' serum bilirubin measurements in the > or =90th percentile of the study population. On the basis of the percentile tracks constructed from the 10th, 35th, 50th, 60th, and 90th percentiles of serum total bilirubin values, a nomogram demonstrating the 3 percentile tracks as risk zone demarcators with divided risk zones was produced. RESULTS: Twenty-nine newborns (21.3%) had significant hyperbilirubinemia. There were significant differences between the newborns who did and the newborns who did not develop significant hyperbilirubinemia with respect to the reticulocyte count (4.39 +/- 3.46% vs 2.95 +/- 1.63) and the presence of a direct antiglobulin test positivity (6 of 23 vs 0 of 107) and a sibling with neonatal jaundice (6 of 23 vs 5 of 102). A mean serum bilirubin level of > or =4 mg/dL at the sixth hour of life was determined to have the highest sensitivity (86.2%) and negative predictive value (94.5%) and a positive predictive value of 39.7% to predict the newborns who would develop significant hyperbilirubinemia. At the mean serum bilirubin level of 6 mg/dL, the sensitivity, specificity, and negative and positive predictive values were 100%, 91.5%, 100%, and 35.3%, respectively, in diagnosing 6 cases of severe ABO hemolytic disease. On the hour (age)-specific percentile-based nomogram, the zone above the 90th percentile was determined as high risk and that below the 35th percentile as low risk. CONCLUSIONS: The reticulocyte count, a positive direct antiglobulin test, and the presence of a sibling with neonatal jaundice were determined to be the good predictors for the development of significant hyperbilirubinemia and severe hemolytic disease of the newborn. A serum bilirubin measurement and the use of the critical bilirubin levels of 4 mg/dL and 6 mg/dL at the sixth hour of life will predict nearly all newborns who will have significant hyperbilirubinemia and those who will develop severe hemolytic disease of the newborn, respectively. An hour (age)-specific percentile-based nomogram can be used to predict which newborn is at high risk (> or =90th percentile), intermediate risk (35th-90th percentiles), and low risk (<35th percentile) for developing significant hyperbilirubinemia. The 35th and 90th percentile tracks, approximating the serum bilirubin levels of 3.3 mg/dL and 6.5 mg/dL at the sixth hour of life, respectively, can be used as safe risk demarcators in deciding about the time of discharge of ABO-incompatible newborns from the hospital.