Maternal CD4+ microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section.

BACKGROUND: Maternal CD4+ cell microchimerism may be greater after caesarean section compared to spontaneous vaginal delivery and could cause mother-to-child transmission (MTCT) in HIV-exposed newborns. AIMS: To evaluate maternal CD4+ cell microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. STUDY DESIGN AND SUBJECTS: In this prospective single-centre study, neonates whose mothers were infected with HIV and had normal MTCT risk according to the German Austrian Guidelines were considered for study enrolment. Maternal CD4+ cell microchimerism in the newborns' umbilical cord blood was measured and compared by mode of delivery. RESULTS: Thirty-seven HIV-infected mothers and their 39 newborns were included in the study. None of the 17 (0.0%) newborns delivered vaginally had quantifiable maternal CD4+ cells (95% confidence interval (CI): 0.00-0.00) in their circulation at birth compared with four of 16 (25.0%) newborns delivered via planned caesarean section, who showed 0.01-0.66% maternal cells (95% CI: -0.06-0.16; P=0.02) in their circulation. The intention to treat analysis, which included six additional newborns delivered by unplanned caesarean section, showed quantifiable maternal CD4+ cells in one (0.05%; 95% CI: -0.02-0.04) of 23 (4.3%) newborn at birth compared to four of 16 (25.0%) born via planned caesarean section (95% CI: -0.06-0.16; P=0.04). There was no MTCT in any of the newborns. CONCLUSION: In this small cohort, spontaneous vaginal delivery in HIV-infected women with normal MTCT risk was associated with lower maternal CD4+ cell transfer to newborns compared to planned caesarean section.

[Mortality of very low birth weight infants during a 24 year period in Hesse a province of Germany - impact of variation in registration]. / Mortalität von Frühgeborenen über einen Zeitraum von 24 Jahren in Hessen - Einfluss veränderter Datensammlung auf die Ergebnisse.

AIM: To study mortality in very low birth weight infants (VLBW) and the impact variation how to register that. METHODS: Data from the Hessian neonatal register from a 24 years period were analyzed. The only outcome criterion was mortality. The whole study time was divided into 6 parts for a period of 4 years. The death rate of preterm infants of 24 weeks of gestation, of those below 24 weeks, and of preterms of 27 weeks was analyzed separately. RESULTS: During 24 years the absolute number of deaths in the group of VLBW increased from an average of 37 patients per year to 60 (p>0.05). The relative mortality decreased from 13.5% to 10.1%. There was an increasing registration of extreme preterm babies of 24 weeks or less. In the last period 13.3% of all VLBW were <25 weeks. These patients represented 54.7% of all deaths in VLBW during 2009-2012. Mortality of preterms of 24 weeks of gestation decreased significantly from 83.3% at the start of the registry to 20.8% in the last period (p=0.007) whereas death rate of preterm infants of 27 weeks dropped from 24.4% to 13.6% (p>0.05). There were also more admissions of extreme preterm infants to neonatal intensive care units. CONCLUSION: Infant death rates are influenced by variation in registration of extreme preterm infants. On the other hand increased registration of these patients seems to encourage doctors to treat them.

[Impact of preterm infants of less than 30 weeks gestation on the prevalence of special education in school beginners of a German city (Frankfurt/Main)]. / Welchen Anteil haben ehemalige Frühgeborene an der Prävalenz von sonderpädagogischen Massnahmen bei Schulkindern einer deutschen Grossstadt (Frankfurt am Main)?

BACKGROUND: To compare infants, who were born prematurely, with all school beginners in a German city in terms of the need for special education over a 2 year period, and to evaluate the educational outcome of infants at age 6-7 years. METHODS: Children, who were born premature with a gestational age of less than 30 weeks, were identified with the help of their personal health records (Gelbes Untersuchungsheft) among all school beginners of the years 2002 and 2003 in the city of Frankfurt/Main. Neonatal risk factors (intracranial bleeding, periventricular leucomalacia, retinopathy) were registered. All families and teachers of the identified children were contacted by telephone in 2005, and interviewed concerning the present school situation. RESULTS: In 2002 and 2003 a total of 10.743 children began school. 30 of them were identified as former premature infants (2.8 per 1000/year). They were treated after birth in various neonatal centres of the region. 11 of 30 infants were examined for a possible need for special education, and the others entered a regular school without any examination. 9 out of the 11 children were admitted to special schools, and in 2005 a further two children had special education. 18 children had a confirmed impairment as risk factor at discharge from neonatal unit, and 15 out of them were attending regular schools. In contrast, 6 out of 12 children with confirmed impairments could go to regular schools. CONCLUSIONS: The relative risk of need for special education in former premature born children was 30% whereas it was in whole population 10%. Ca. 70% of children, who were born with a gestational age less than 30 weeks, could attend normal school without any special education. Impairments, which were confirmed at the end of neonatal period, were of minor prognostic value for school outcome.

Mepivacaine for spinal anesthesia in parturients undergoing elective cesarean delivery: maternal and neonatal plasma concentrations and neonatal outcome.

OBJECTIVE: Worldwide, long-acting bupivacaine is most commonly used for spinal anesthesia in parturients undergoing elective Cesarean delivery. However, advances in surgical technique and shorter duration of surgery make short-acting local anesthetic like mepivacaine appropriate, particularly if combined with opioids to enhance postoperative maternal pain relief. MATERIAL AND METHODS: We assessed the effect of 4% hyperbaric mepivacaine (60 mg) plus 10 microg fentanyl for spinal anesthesia in 11 parturients undergoing elective Cesarean delivery. Sensory, motor and analgesic block characteristics, neonatal outcome (Apgar scores, umbilical cord blood analysis, neurologic and adaptive capacity score) as well as fetal and maternal mepivacaine plasma concentrations at delivery were determined (HPLC/UV). RESULTS: Motor block (Induction-Bromage 0) duration lasted 113 +/- 20 min. Effective analgesia (VAS < or = 40) was 128 +/- 35 min. Maternal and fetal mepivacaine free plasma concentration were 0.18 +/- 0.05 microg/ml and 0.10 +/- 0.03 microg/ml, respectively. The fetal to maternal (UV/MV)-ratio for mepivacaine free plasma concentration was 0.56. Apgar scores, NACScores and the umbilical blood analysis showed no evidence of neonatal depression. CONCLUSIONS: Particularly with short duration of surgery (21 +/- 5 min) intrathecal mepivacaine combined with fentanyl offers a favorable clinical alternative in parturients undergoing elective Cesarean delivery.

[Cerebral perfusion in newborn infants treated with high-frequency oscillation ventilation]. / Zerebrale Perfusion bei Neugeborenen unter Hochfrequenz-Oszillations-Beatmung.

UNLABELLED: The effects of high-frequency oscillatory ventilation (HFOV) on hemodynamic parameters have been shown in animal as well as in clinical studies. In a further study we could demonstrate, that after change of a conventional positive pressure ventilation (CMV) to HFOV flow velocities in cerebral arteries decreased. In the following we added to the dopplerflow method the continuous examination of cerebral oxygenation with near infrared spectroscopy (NIRS). PATIENTS: 19 measurements were prospectively conducted in 18 neonates. The infants were mechanically ventilated with HFOV and were in a stable condition. METHODS: Before change from HFOV to CMV doppler signals of the anterior cerebral artery were measured. We repeated this at the end of the study in each patient. NIRS-optodes were placed on the front and the os parietale of each infant. After stabilization of the system we changed from HFOV to CMV without disconnection of the patient from the machine. PCO2 was registered continuously via a transcutaneous probe, as well as oxygen saturation via pulse oxymetry. Statistical analysis was performed with Wilcoxon test. RESULTS: There were no significant changes of doppler-signals during the study (median vs. 25 cm/s (+/- 6) during HFOV, 28 cm/s (+/-/) during CMV). The parameter of NIRS, oxygenated hemoglobin HbO [-1.5 U (+/- 22.78)] at 15 minutes after change), reduced hemoglobin HbR [-1.17 U (+/- 5.26)] and total hemoglobin HbT [-2.68 U (+/- 18.7)] remained stable during the change from HFOV to CMV, too. In five infants there was a decrease and in two an increase of HbO 15 minutes after change, which correlated with decrease or increase of pCO2. CONCLUSION: In a combined measurement of dopplerflow and NIRS we found no special effect of HFOV on cerebral hemodynamics comparing with CMV. Changes of cerebral oxygenation in NIRS correlated with pCO2.

[Hemodynamic effects of high-frequency oscillating ventilation in preterm and term infants]. / Hämodynamische Auswirkungen der hochfrequenten Oscillationsbeatmung bei Früh- und reifen Neugeborenen.

To study the effects of high frequency oscillating ventilation (HFOV) on cerebral and abdominal circulation we measured blood flow velocities in three cerebral arteries and in the A. mesenterica superior by pulsed doppler ultrasound in 13 preterm (mean gestational age 28 weeks [25-31]) and 3 term infants during conventional ventilation (intermitted positive pressure ventilation, IPPV) and HFOV. In the preterm infants systolic blood flow velocities decreased under HFOV in all cerebral arteries. Statistically significant differences were found in the A. cerebri anterior (45.8 cm/s [sd +/- 20.6] versus 34.3 [sd +/- 10.8]; p < 0.02) and in the A. basilaris (52.8 cm/s [sd +/- 26.4] versus 44.1 [sd +/- 18.7]; p < 0.05). There was also a distinct decrease of systolic blood flow velocity in the A. mesenterica (111 cm/s [ +/- 31.3] versus 61.8 cm/s [sd +/- 18.6]; p < 0.002). The enddiastolic blood flow velocity and the Resistance Index of Pourcelot did not change significantly. The systemic blood pressure did not change during conventional ventilation or HFOV. Mean airway pressure and pCO2 were lower during HFOV, but there was not strong correlation with the reduction of flow velocities in the studied arteries (r = 0.48). In the three term infants presenting with a persistent pulmonary hypertension of the newborn, there was an increase in systolic and enddiastolic flow velocities in all studied arteries under HFOV.

[High-frequency oscillating ventilation in premature infants under 1500 gram birth weight]. / Hochfrequente Oszillationsbeatmung bei Frühgeborenen unter 1500 g Geburtsgewicht.

In 58 premature infants with a birthweight < 1500 g High-Frequency-Oscillating-Ventilation (HFOV) was initiated within the first 48 hours of life. Indications for HFOV were: no response to surfactant application (N = 41), respiratory distress syndrome without surfactant application (N = 9), pulmonary interstitial emphysema (N = 8). Mean gestational age of the enrolled patients was 27.6 weeks (24-32) and mean birthweight was 964 g (490-1450). 23 infants died, 5 from non-pulmonary causes. Of the remainder 2 had B-Strept.-septicemia, 1 lunghypoplasia, and 1 patient died on the 70th day of life from chronic lung disease. There were no statistical differences between survivors and nonsurvivors in gestational age, birthweight, umbilical pH, 1 min APGAR score or time on conventional ventilation prior to HFOV. Alveolar-arterial-O2-difference dropped in the group of surviving patients from x487 mm Hg (sd +/- 60) to 252 mm Hg (sd +/- 89) after 6 hours (p < 0.0001) and in the nonsurvivors from x517 mm Hg (sd +/- 74) to x373 mm Hg (sd +/- 106) (p = 0.002). Oxygenationindex fell from x25 (sd +/- 10) to x5 (sd +/- 1.5) in the survivors and from 25 (sd +/- 11) to x9 (sd +/- 5.5) in the nonsurvivors within 6 hours (p < 0.0001). Mean airway pressure could be lowered in survivors from x7.6 cm H2O (sd +/- 0.6) to 5.3 cm H2O (sd +/- 0.8) and in nonsurvivors from x8.6 cm H2O (sd +/- 0.6) to 5.7 cm H2O (sd +/- 0.9) (p = 0.0002). The promising results of HFOV as a rescue therapy require a controlled study for its use as a primary mode of ventilation in premature infants.

[Congenital candida infections]. / Kongenitale Candidainfektionen.

Congenital candida infection is a rare disease, although the incidence of candida vaginitis during pregnancy is high. We report on five cases each showing patterns considered typical for candida infection. The infective agent can cause chorioamnionitis even in the presence of intact fetal membranes. An intrauterine device (IUD) has been proved to be a risk factor for a congenital candida infection. The pathogenetic significance of contamination with candida for the fetus appears to depend largely on gestational age. A premature infant with a birth-weight less than 1500 g presented with bilateral candida endophthalmitis which was cured by intravenous Fluconazole therapy. Another premature infant weighing 800 g at birth developed a systemic candida infection. The other three more mature infants had milder symptoms, two of them presented with cutaneous candidiasis.