Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists.

OBJECTIVE: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN: Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION: In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

Neonatal arterial hypertension in nephro-urological malformations in a tertiary care hospital.

An increase in the survival of neonates with antenatal diagnosis of malformations was achieved by the recent technical advances in neonatal intensive care units. The aim of this article is to describe the experience with neonatal arterial hypertension, in newborns with nephro-urological malformations, in a tertiary care referral Nursery, in a period of 4 years. Newborn medical records from the Nursery Annex to the Maternity of Hospital das Clinicas, School of Medicine, University of Sao Paulo, with the diagnosis of nephro-urological malformations and systemic arterial hypertension (SAH) at hospital discharge, in a period from January 1999 to January 2003, were retrospectively analysed. Among 10.278 live newborns in the studied period, 15 (0.15%) newborns were compatible with our inclusion criteria. Of these 15 newborns, 12 (80%) were male and three were premature (20%). In relation to aetiology, 13 (87%) showed urological malformations, 1 (6%) chronic renal insufficiency secondary to kidney dysplasia and one (6%) autosomal recessive polycystic kidney disease. SAH control was achieved with monotherapy in eight patients (53%), five patients (33%) needed an association of two drugs (calcium-channel blocker and angiotensin converting enzyme (ACE) inhibitor), one child used three types of antihypertensive drugs (calcium-channel blocker, ACE inhibitor and hydrochlorothiazide) for pressoric control and one child's blood pressure (BP) was controlled exclusively by peritoneal dialysis. The incidence of nephro-urological malformations in our service during the studied period was 0.89%. SAH incidence among these newborns was 19%. Our data reinforce previous studies pointing to the necessity to consider children with nephro-urological malformations as a risk group for SAH, who should have the BP evaluated since the neonatal period.

Prediction of length of hospital stay in neonatal units for very low birth weight infants.

OBJECTIVE: To develop models for estimating the length of hospital stay (LOS) of very low birth weight infants (VLBW), based on perinatal risk factors present during the first week of life and during the entire hospitalization period. STUDY DESIGN: The files of 155 VLBW were analyzed, and the influence of individual risk factors were initially evaluated by univariate analysis, using multiple-regression. Two mathematical models were built to estimate the LOS. RESULTS: The first model, using risk factors present during the first 3 days of life, is as follows: LOS = -0.074A + 22.06B + 22.85C - 16.78D - 2.07E + 10.51F + 203.12 (R2 = 0.63). (The letters are added to show what each number represents: A: birth weight; B: occurrence of respiratory distress syndrome; C: endotracheal intubation during resuscitation; D: 1-minute Apgar score; E: gestational age; F: presence of complications during delivery.) The second model, using factors present during the entire hospitalization period, is: LOS = 0.61G + 29.19H + 24.68I + 14.21J + 23.56K + 9.54L + 7.41M + 20.43 (R2 = 0.82). (G: age receiving nutritional support of > or = 120 kcal/kg per day; H: occurrence of systemic candidiasis; I: birth weight < 1000 gm; J: presence of delivery complication; K: occurrence of bronchopulmonary dysplasia; L: birth weight > or = 1000 gm and < or = 1249 gm; M: occurrence of anemia). CONCLUSION: Both models are applicable for estimating the hospitalization period, and the addition of variables present during the entire hospitalization period improved the accuracy of the model.

[Propionic acidemia in the neonatal period]. / Acidemia propiônica no período neonatal.

Propionic Acidemia is an inherited disorder of organic acid metabolism characterized by a wide spectrum of clinical and biochemical findings. Many times is present in the neonatal period, when mortality is high and neurologic residua in survivors is severe. The present case concerns to a healthy male newborn who started with a picture of refusing to feed, lethargy and hypothermia at 49 hours of life. He developed a severe neurotoxicity state with metabolic acidosis. The laboratory evaluation showed high levels of 3-hidroxi-propionic, 2-metil-hidroxibutiric and metil-citric in urine, confirming the diagnosis of proprionic acidemia.

[Predictive value of the "Clinical Risk Index for Babies" for the risk of neonatal death]. / Valor preditivo do "Clinical Risk Index for Babies" para o risco de mortalidade neonatal.

OBJECTIVE: Several indicators, mainly birthweight and gestational age, have been used to predict the mortality risk in neonatal intensive care units. In order to assess the potential value of CRIB in predicting neonatal mortality, the score was used over the first 12 hours of life of the newborns admitted to this unit, during the year of 1996. METHOD: The inclusion criteria consisted of all infants without inevitably lethal congenital malformations, birthweight below 1,500 g and/or gestational age less than 31 weeks. Newborn children who died within 12 hours after delivery were excluded. The CRIB score covers birth weight, gestational age, the presence of congenital malformations (not inevitably lethal) and three indexes of physiological status during first 12 hours after birth-maximum and minimum appropriate fraction of inspired oxygen and maximum (most acidotic) base excess. RESULTS: In a prospective cohort, seventy one newborn children were studied. The birthweight (average) was 1,119 +/- 275.6 g, gestational age 30 weeks 4/7 +/- 2 weeks 3/7; male (57%); Apgar 1(0) min. score < or = 3 (36.2%) and Apgar 5 degrees min. score < 5 (5.8%). The mortality rate was 29.6% (gold standard). But mortality rate by birthweight less than 1,000 gr. or gestational age lower than 29 weeks was 60.0% and for the CRIB score above 10 was 100%. DISCUSSION: The specificity and predictive positive values for CRIB score above 10 were greater than any other two parameters. The area under the receiver operating characteristic (ROC) curve for predicting death was significantly greater for CRIB than for birthweight alone. It was concluded that the CRIB score is a better predictive indicator for mortality than are birthweight and gestational age.

Indicaçöes clínico-epidemiológicas para investigação ecocardiográfica no período neonatal: valor dos grupos de risco / Clinical-epidemiologic indications for echocardiography investigation in the neonatal period: value of risk groups

OBJETIVO - Estudo ecocardiográfico em recém-nascido (RN) de grupos de risco para cardiopatia congênita, a fim de se determinar a prevalência que justifique esse exame no período neonatal. MÉTODOS - Estudaram-se, de novembro/91 a abril/93, 156 RN do berçário anexo à Maternidade do HC-FMUSP, sendo RN de mães com cardiopatia congênita ou diabetes mellitus, crianças de muito baixo peso, com malformaçöes extracardíacas ou presença de sinais cardíacos, caracterizados por sopro, cianose, ou arritmia, todos submetidos ao ecocardiograma. RESULTADOS - A prevalência encontrada foi de 21,8 'por cento', superior ao da população geral (0,8 a 1,2 'por cento'), sendo que a maior entre os grupos, de 40,7 'por cento', ocorreu no grupo de malformaçöes extracardíacas. CONCLUSÄO - Nossos dados justificam a realização de ecocardiograma em RN pertencentes a um destes grupos de risco para cardiopatia congênita.

[Captopril use in pregnancy and its effects on the fetus and the newborn: case report]. / Uso de captopril durante a gestação e suas repercussões sobre o feto e o recém-nascido: relato de caso.

Angiotensin-converting enzyme (ACE) inhibitors have been widely used to control hypertension, but their use during gestation may result in fetal death, intra-uterine growth retardation, oligoamnium sequence, hypotension, acute renal failure and ductus arteriosus patency in the newborn. The aim of this case report is to highlight the risks of using this drug during gestation. The authors present a case of captopril use during pregnancy, whose newborn developed acute renal failure and ductus arteriosus patency early in the newborn period. This presentation strengthens the importance of not only monitoring amniotic fluid volume and fetal growth, but also, during the newborn period, control the weight gain, diuresis, systemic arterial pressure and renal function, mainly in the first 72 hours of life.

[Clinical-epidemiologic indications for echocardiographic assessment in the neonatal period. Value of risk groups]. / Indicações clínico-epidemiológicas para investigação ecocardiográfica no período neonatal. Valor dos grupos de risco.

PURPOSE: An echocardiographic study was performed in newborns from risk groups, with the aim of to determining prevalence and to evaluate the indications for this test in the neonatal period. METHODS: One hundred fifty six newborns were studied. They were admitted to the Newborn ward of the Department of Obstetric of the HC-FMUSP, in the period of November 91 to April 93, from mothers with congenital heart disease or diabetes, low birth weight newborns, with extracardiac malformations, cardiac signs and/or congenital infections. RESULTS: The observed prevalence was 21.8%, greater than that of the general population (0.8-1.2%). The group composed by 27 children with extracardiac abnormalities presented the largest prevalence when compared with the other groups (40.7%). These data justify the use of echocardiography in high risk newborns for the detection of congenital heart disease.

Bloqueio átrio-ventricular congênito: características neonatais e evoluçäo / Congenital complete heart block

Säo apresentados 9 casos de RN portadores de bloqueio átrio-ventricular congênito (BAVC) com detecçäo da anomalia no terceiro trimestre de gestaçäo através de ecocardiografia fetal. Todos os RNs foram de termo ou limítrofes e a maioria nasceu de parto cesáreo, em boas condiçöes. Imediatamente após o nascimento, foi realizado avaliaçäo cardiológica completa, através de exame clínico, ECG, Rx de tórax, ecocardiografia e monitorizaçäo de FC pelo Holter contínuo de 24 horas. Cinco RNs apresentaram BAVC com FC basal ao redor de 60 bat/min e, em destes, a sorologia para LES (anti SS-AA/Rô) foi positiva. Os 5 evoluiram bem, tendo recebido alta antes do primeiro mês de vida sem medicaçäo e com acompanhamento ambulatorial. Um RN apresentou BAVC com FC basal ao redor de 50 bat/min, tendo evoluido para ICC ao final do primeiro mês, compensada com o uso de digitálico e diurético. Três casos eram associados com cardiopatia congênita complexa, sendo 2 do tipo átrio-ventricular communis (AVC) e um do tipo transposiçäo corrigida dos grandes vasos da base. Os 2 casos com AVC foram os únicos que descompensaram precocemente (primeira semana de vida). Estes casos mostram que a detecçäo precoce de alteraçöes de ritmo cardíaco no pré-natal, um preparo adequado para a recepçäo do RN ao nascimento, avaliaçäo cardiológica completa, säo fatores decisivos para uma boa evoluçäo pós-natal