A study on early-onset neonatal group B streptococcal infection, Bulgaria, 2007-2011.

This study examines neonatal group B streptococcal (GBS) colonization and its relation to early-onset GBS disease (EOGBSD), based upon the experience of leading obstetrics and gynecology centers in Bulgaria. The objectives of the study were to update neonatal colonization rates and to assess relationships between clinically differentiated cases (culture-proven GBS newborns) and risk factors inherent to the infant and mother, using a computerized file. The neonatal GBS colonization rate ranged from 5.48 to 12.19 per 1000 live births. Maternal-fetal infection (MFI, a provisional clinical diagnosis in culture-proven colonized infants with initial signs of infection that is usually overcome with antibiotic treatment) and/or intrapartum asphyxia (IA) have been demonstrated as the most frequent clinical manifestations, with significant correlations for the primary diagnosis, but not affirmative for the final diagnosis at discharge, resulting from adequate treatment of neonates. MFI and IA were significantly related to prematurity, and reciprocally, prematurity was associated with the risk of MFI, indirectly suggesting that preterm birth or PPROM (preterm premature rupture of membranes, an obstetric indication associated with early labor and delivery, one of the major causes of preterm birth) is a substantial risk factor for EOGBSD. The regression analysis indicated that in the case of a newborn with MFI, a birth weight 593.58 g lower than the birth weight of an infant without this diagnosis might be expected. Testing the inverse relationship, i.e., the way birth weight influences a certain diagnosis (logistic regression) established the presence of a relationship between birth weight categories (degree of prematurity) and the diagnosis of MFI. The proportions and odds ratios, converted into probabilities that a baby would develop MFI, indicate the particularly high risk for newborns with extremely low and very low birth weight: extremely low birth weight (≤1000 g), the probability of developing a MFI is 66%; very low birth weight (1001-1500 g), 81%; low birth weight (the birth weight category including premature and small for gestational age term infants: 1501-2500 g), 40%; normal birth weight (term infants) (>2500 g), 32%. In conclusion, the need to introduce separate categories for early- and late-onset GBS disease in the registration nomenclature of neonatal infectious diseases is highlighted by these results. Drawing up intrapartum antibiotic prophylaxis (IAP) guidelines is also strongly recommended.

[Socio-demographic characteristics and vitamin D status in women born before 32 weeks'].

UNLABELLED: Deficiency of vitamin D (25-OHD) is a health problem among prematurely born women and their newborns independently of the geographical location of the country. OBJECTIVES: To study serum levels of vitamin D in patients born before 32 weeks and their newborns at birth. To analyse the socio-demographic factors, complications of pregnancy and their relationship with vitamin D status of women. PATIENTS AND METHODS: The study has been carried out in the University hospital "Maichin dom" Sofia for the period August 2013-January 2014. 35 women who gave birth before 32 gestational week and their 41 newborns with birth weight < 1500g have been investigated. The serum level of vitamin D (25-OH D) in mother-infant pairs at birth and 8 weeks of age in infants has been investigated. The ECLIA method has been used. Serum levels of vit D (25-OHD) have been estimated as sufficient:(> 30 ng/ml), insufficient (21-29ng/ml) and deficient (< 20 ng/ml). RESULTS: At delivery according to their vit D (25- OHD) serum levels 63% of the mothers are defficient /12.61 ± 4.8 ng/ml/, 28.5% are insufficient/26.66 ± 2.59/and only 8.5%/40.4 ± 8.48/sufficient with normal levels of vitamin D. For newborns data are respectively 32%/ 20.08 ± 3.69/-deficient, 49%/27.39 ± 2.70/- insufficient and 19 %- sufficient/41.6 + 10/ There is a positive correlation between mother's and children's serum levels of vitamin D (25- OHD). Statistical significant differences are observed in the levels of vitamin D and the presence of infection and preeclampsia in the mothers. During the period of the study there were no seasonal variations in vit D (25-OHD) serum levels of mother-baby pairs. All newborns received Vit D3 1334 IU/daily from 20th day of age. At eight weeks of age sufficient levels of vitamin D have 70% of the children, but 30% of the newborns remains with inadequate supplementation/27.09 ng/ml/. CONCLUSION: 91.5% of mothers are with insufficient serum levels of vitamin D (25OHD) at birth, and a deficit is present in 63% of all women. Only in 8.5% of the women had normal values. This implies more effective monitoring and vitamin D prophylaxis during pregnancy.

[Respirtory distress in newborns of mothers with factor V-Leiden thrombophilia].

AIM: The main aim of the trial is to determine the frequency of respiratory distress syndrome / RDS/ and disorders of coagulation in infants of mothers with thrombophilia. MATERIALS AND METHODS: In 51 newborns of mothers with thrombophilia were evaluated the presence of respiratory distress and maternal-fetal infection /MFI/. The children were divided in two groups: Group I--16 newborns of mothers with thrombophilia and Group II--15 healthy children. We analyzed Hb, Ht, Er, Thr, prothrombin index /INR/, activated partial thromboplastin time /aPTT/ in both groups. RESULTS: The analysis of Hb, Ht, Er, Thr showed no evidence of anemia or coagulopathy with platelet consumption. In 64.7% of children was observed respiratory distress syndrome during the first days, 21.5% had severe respiratory distress /RD/, that required intubation and assisted ventilation. Only in 10/19.6%/ children with RDS there were data proving MFI/high CRP and positive microbiological samples/. There was no significant difference in the INR value in Group I/1.5 +/- 0.3/ and group II/1.6 +/- 0.1/. The children of mothers with thrombophilia had significantly more shortened aPTT/35, 1s +/- 4.2/ compared with the control group: aPTT/43.9 +/- 4,4/. CONCLUSION: The high incidence of RDS and shortened aPTT indicate that maternal thrombophilia is a risk factor for thrombosis in newborns. MFI that are accompanied with activated PAI also lead to thrombosis, especially in children in Neonatal Intensive Care Units. These results point out that there should be prevention of other risk factors for thrombosis such as dehydration and placement of central venous catheters.

[Gestational age of delivery in multiple gestation].

OBJECTIVES: The aim of this research was to find out the average gestational age of delivery in multiple pregnancy and to compare the results with world trend. MATERIAL AND METHODS: Retrospective and prospective comparative analysis was used. The study covered 20 years from 1991 to 2011, included 71114 births, 1436 twins, 67 triplets and I quadruplets. RESULTS: The number of multiple pregnancies in 1991 was 64 and in 2011 was 118. The frequency of twins increased from 1.56% at the beginning of the observed period to 3.44% at the end of the period. The frequency of triplets went from 0.02% to 0.26%. We discovered that the number of twins increased more than twice and the number of triplets - 13 times. Average gestational age of delivery in twins was 35+5 w.g. and in triplets - 31 w.g. 1-min Apgar score in twins was 6.1 and 5-min Apgar score was 7.5. In triplets the results showed that 1-min Apgar score was 5.6 and the 5-min Apgar score was 7.0. At the beginning of the researched period in 1991, 62% of women had vaginal delivery and only 38% Ceasarean section. In 2011 the Ceasarean section was 84% and vaginal delivery only 16%. CONCLUSIONS: There is a significant increase in the frequency of multiple gestation, observed in twins as well as in triplets. The average gestational age of delivery is earlier compared to world tendencies. The received results of the newborns' health status in the early neonatal period are good. The predominance of Ceasarean section as a mode of delivery is similar to world trend.

[Frequency, severity and risk factors for bronchopulmonary dysplasia among very low birth weight premature infants admitted in the NICU of the University Obstetrics and Gynecology Hospital, Sofia].

BACKGROUND: The progress in the perinatology improved the survival rate of the infants with extremely low birth weight and gestational age. Among the most immature of them the frequency of bronchopulmonary dysplasia (BPD) remains high.. The use of different diagnostic criteria for BPD makes comparing the results difficult. AIM: To evaluate the frequency of BPD by birth weight and gestational age according to the new diagnostic criteria, and to identify the risk factors for development the disease. METHODS: 563 very low birth weight infants (<1500 g) were admitted to NICU from 01.01.2008 to 30.06.2010. 485 survived more than 28 days and were included in this study. BPD was diagnosed if supplemental 02 for the first 28 days was necessary. 02-requirements at 36 gestational weeks (gw) determine the severity level. RESULTS: 26,8% from the infants were with supplemental 02 in the first 28 d of life, but only the half of them 13,6% were with 02 > 21% at 36 gw (the classical diagnostic criteria for BPD). 10,9% were with moderate BPD, 2,7% - with severe BPD. The frequency of BPD decreased progressively from almost 100% at 23 gw or birth weight < 600 g to single cases after the 31 gw and birth weight > 1200 g. Mild or moderate BPD was more likely if gestational age was > 27 gw. The need for ventilatory support increased from 1,5 (+2,8) days (no-BPD group) to 50,2 (+/-20,1) days (severe BPD), p<0.05. Significant postnatal risk factors for developing BPD were patent ductus arteriosus - diagnosed in 25,4%; pneumothorax - in 3% of the BPD infants, compared with 1,7% and 0,5% among the infants without BPD respectively, p<0. 05. Sepsis and pulmonary hemorrhage were found slightly more frequently in the BPD group too (p>0, 05). The use of antenatal steroids was found to be a protective factor - 45% of the BPD infants had received antenatal steroids compared with 55% of those without BPD (p=0.05). CONCLUSION: According to the new diagnostic criteria, the frequency of BPD was about 2 times higher compared to the classical definition. Main risk factors were found to be ELBW, ELGA; additional risk carried the need for prolonged ventilatory support, patent ductus arteriosus and air leak syndrome.

[Blood transfusions suppress erythropoiesis in anemia of prematurity].

UNLABELLED: AIM AND TASKS: The major gene regulating erythropoietin /EPO/ synthesis is hypoxia induced factor/HIF/. Proceeding from the assumption that the transfusions /HT/ remove hypoxia due to anemia and inactivate HIF, the aim of the study was to show the decreased activity of erythropoiesis after HT MATERIALS AND METHODS: PATIENTS: 40 premature infants <34 g.a. and birth weight < 1400 g with anemia of prematurity. We analyzed: Hb /g/I/, Ht%, Thrx 10(9)/I, Ret%, 24-48 hours and 7-10 days after HT The dynamics of changes of blood lactate /mmol/l/level after HT was used as an indirect index of relative hypoxia/activated HIF/. The changes of Hb /g/l/ and Ht% determined the need of haemotransfusions. RESULTS: After HT along with the increase of Hb from 89, 7+/-10,0 to 119+/-13,3, there was significant decrease in Ret % from 2,4+/-1,1 to 1,4+/-0,5 7-10 day after HT There was also a reduction of Thr from 391,5+/-131,5 to 250, 7+/-57,2 and blood lactate in mmol/l from 2,5+/-1,1 to 1,5+/-0,7. The study showed that 7-10 days after HT the values of Hb and Ht decreased to baseline levels, that required new transfusion. CONCLUSION: Transfusion of packed red blood cells in patients with anemia of prematurity suppresses erythropoiesis, which is demonstrated by the significant reduction in reticulocyte count. The decreased level of blood lactate after HT shows elimination of the relative hypoxia that is required for hypoxia- induced expression of HIF and erythropoietin synthesis.

["In vitro" babies--dreams, that turned real, but a lot of questions and unknown items].

UNLABELLED: In vitro babies bring happiness to a lot of families. Their development, health and social problems are being studied in details. OBJECTIVES: To establish the well being of babies, born at the University Maternity Hospital "Maichin dom" following assisted reproduction (AR), probable risk factors immediately after birth and afterwards. Aims of the study are to look for a correlation between AR and the incidence and importance of medical problems, arising during the neonatal period: multiple pregnancy; prematurity; intrauterine growth retardation; neonatal mortality; inborn malformations and chromosomal diseases; CNS impairment; duration of hospitalization. STUDY DESIGN: This is a retrospective study including all 440 babies born thanks to AR (according to the available medical records) during the period 2008-2010 at the University Maternity Hospital "Maichin dom". A correlation between the main items observed and the number of babies in each pregnancy was investigated for the period 01.01.2010-31.12.2010. RESULTS: During the period 2008-2010 there are 99 babies from single pregnancy, 15 (15%) admitted to the NICU; 384 twin pregnancies (186 of them after AR)--733 babies and 15 foetus mortus. 114 IVF couplets (31%) or 221 babies (7 foetus mortus) are admitted to physiological neonatal ward, while 72 (63%) couplets or 137 babies (7 foetus mortus) are admitted to the NICU. There are 48 triplet pregnancies or 141 babies (3 f. mortus), 40 being IVF (83%) or 117 babies, all 40 AR triplets are admitted to the NICU. 269 babies (61% of all AR babies) need intensive treatment--mostly (94%) babies from multiple pregnancies. Mean birth weight was established to be 2060 g; with babies, requiring intensive treatment is 1408 g. Gestational age at birth is from 25 to 39 g.w.; with NICU patients mean gestational age is 32 g.w. Mean maternal age is relatively high--34 years with a wide range (24-50 years). A high incidence of operative deliveries is established--mostly with couplets and triplets. CONCLUSIONS: Rules of good clinical practice should be introduced with AR, aiming at reducing the number of multiple pregnancies. This should be priority for all national programs for assisted reproduction.

[Osteopenia of prematurity--prophylaxis, diagnostics and treatment].

UNLABELLED: Osteopenia of prematurity is a metabolic bone disease of premature infants with birth weight < 1500 g and gestational age < 32 weeks. Sub-optimal bone matrix, poor skeletal support and an increased risk of fractures characterized the disease. Its importance is determined by relatively high frequency--between 30-70% of infants at risk, multifactorial etiology and impact on early and late morbidity of the newborns. The prevention and treatment of bone disorders are important aspects of the care of preterm babies. OBJECTIVE: To identify of the risk factors, to determine early diagnostic criteria and to create a prevention program for osteopenia in infants with very low and extremely low birth weight. MATERIALS AND METHODS: The prospective study includes 39 preterm babies with birth weight below 1500 gr. and < 32 g. w who were admitted to the NICU from September 2011-January 2012. Bone metabolism was monitored by calcium, phosphate and alkaline phosphatise at 2-weeks intervals. Vitamin D levels of the neonates were registered at birth, and at 8th week. PTH was measured at the second and the 8th weeks. RESULTS: The following biochemical abnormalities were found. Hypophosphatemia in two weeks (P < 1,6 mmol/l), a gradual increase in phosphorus levels and normalization at eight weeks of age. There was a significant positive correlation between 25OHD/phosphorus at eight weeks/r = 0.353/. Significantly elevated levels of parathyroid hormone in eight weeks, correlating with low levels of vitamin D (negative correlation between 25OHD/parathormone r = -0.581). Blood levels of calcium and alkaline phosphatase were in normal limits. IN CONCLUSION: Risk factors for osteopenia are: the low gestational age and low levels of vitamin D at birth. Biochemical markers of osteopenia are: changes in levels of parathyroid hormone, phosphorus and vitamin D at eight weeks of age. Prevention includes: early supplementation of vitamin D in the risk neonates with individual dose adjustment. Upon biochemical evidence of osteopenia treatment should begin in the second week of life with supplementation of phosphorus, and vitamin D 1320 IU/daily and appropriate physiotherapy.

[Vitamin D levels in maternal--VLBW infants pairs].

UNLABELLED: Normal foetal growth depends on sufficient mother's vit D intake. Premature birth interrupts vit D and mineral mother-to-foetus transfer and leads to vit D deficiency and disturbs newborn mineral bone metabolism. OBJECTIVES: To determine vit. D plasma levels in mothers and their very low birth weight- (VLBW) newborns and the prevalence of vit D deficiency in this population, to investigate seasonal variation and analyse babies' vit D levels from birth to the 8 postnatal week. PATIENTS AND METHODS: The study has been carried out in the University hospital "Maichin dom" Sofia for the period 09.2011-01.2012 and there have been investigated 32 women and their 39 VLBW infants as a target group. 25-OHD level has been measured in maternal and newborn cord blood samples. The ECLIA method has been used. 25-OHD level has been tested second time at eight weeks of age in 34 infants. According to the maternal vit D levels the patients have been divided into 3 groups: Group. 1--vit D reference range level (> 30 ng/ml); Group. 2--vit D insufficiency (21-29 ng/ml), Group. 3--vit D deficiency (< 20 ng/ml). RESULTS: Low Vit. D levels have been estimated in 62.5% of mothers' group. Nevertheless, only 38.6% of all babies have been Vit. D deficient. In 61.4% of them vit D has been in normal range (32.4-35.7 ng/ml). A significant positive correlation between maternal and infants' vit D level at birth has been established (r = 0.516; p = 0.002). There have been found a significant seasonal dependence of vit D level at birth in the group too: vit D plasma levels have been estimated higher in September-October group compared to those in November-January group. Most of the blood samples in winter months showed lower vit. D levels than the autumn group. At 8 weeks of age 67.6% of the babies have been with vit D insufficiency. There has been a significant positive correlation between 25-OHD levels at birth and at weeks (r = 0.425; p = 0.012). CONCLUSION: Vit. D insufficiency has been found in 62.5% of the mothers at birth. Maternal vit. D deficiency is a significant risk factor for neonatal vit D deficiency. There is a clear seasonal dependency with a significantly lower 25-OHD level in the mothers and their VLBW babies in winter months.

[A study on early-onset group "B" streptococcal neonatal infection].

The results achieved with 80% reduction in the incidence of early-onset neonatal group B streptococcal (GBS) sepsis following the implementation of the preliminary (1996, 2002) and subsequently the revised (2010) guidelines for intrapartum antibiotic prophylaxis imposed the discussion on a large scale of the updated:--algorithms for GBS screening (35-37 weeks of gestation) with the recommended dosage of penicillin-G for intrapartum antibiotic prophylaxis for women having normal labor and delivery;--algorithms for GBS screening and intrapartum antibiotic prophylaxis for women with preterm labor (PPROM) or premature rupture of membranes (PROM);--intrapartum antibiotic prophylaxis regimens for women with penicillin allergy;--algorithm for management of newborns with respect to risk of early-onset GBS disease. The present study is aimed at studying the distribution of the early-onset GBS disease in our country based on the data of leading obstetrics & gynecology clinics and wards. The aim is to diferrentiate clinically the cases and investigate the influence of the known risk factors on the part of the mother. A special accent is put over the microbiological diagnostics of cases in view of CDC expanded recommendations on the laboratory methods for identification of GBS. As a final conclusion the necessity for introduction of an official registration of the early- and late-onset GBS disease in the country is emphasized.

[Protocol - indications for transfusion in newborns with low and extremely low birght weight].

OBJECTIVES: Hyporegenerative anaemia of prematurity is the cause of frequent transfusions of packed red blood cells. Wellknown is the effect of inhibiting the erythropoiesis after blood transfusions as well as the risk of transmissive infections. Therefore the main purpose of this study was to work out a protocol - indications for blood transfusions in order to achieve maximal reduction in their incidence with premature babies during their stay in ICU. STUDY DESIGN: The study includes 57 newborn babies - birth weight < or = 1400 g, gestational age < or = 34 g.w. The changes in blood count values (Hb, Ht, Er,) from day 1 until day 60-70 were followed and analyzed. The effect of blood transfusions on oxygen needs reduction was analyzed by monitoring acid-base status in 30 infants with anaemia of prematurity with different degree of oxygen dependency. RESULTS: Mean Hb and Ht at birth were 163 +/- 20,4 g/l and 48.6 +/- 6, 3%. At day 15-20 Hb was 111,02 +/- 10,9 and Ht 32,65 +/- 3,46. A significant decrease in blood count values is observed until the end of the first month /p <0.05/. Afterwards they remain relatively constant, fairly close to those at day 25-30/Hb 101,45 +/- 10,24 g/l; Ht% 29,78 +/- 3,42/. The study showed that transfusions of packed red blood cells reduce oxygen requirements by aproximately 30% in premature babies on mechanical ventilation with high oxygen concentrations\FiO2 > or = 50%/. In premature babies with good overall condition and on low concentration oxygen therapy - < 50%, no effect was observed in reducing oxygen requirements after RBC transfusion. CONCLUSION: The leading indications for RBC-transfusions are not only Hb, Ht, postnatal age, but also the clinical condition and oxygen requirements. Severely ill premature babies on mechanical ventilation with FiO2 > or = 50% require blood transfusion at higher Hb values/<120 g/l/regardless of postnatal age.

[Fracture of clavicle in newborns, an attempt to make prognostic factors].

UNLABELLED: The most common bone fracture of the newborn is that of the clavicle - frequency 0.2-3.5% of all births, according to various literature sources. The most common cause of this complication perinatally determining the weight of the newborn and the skills of those who manage second stage of labour Purpose of the study was the establishment of prognostic factors for fracture of the clavicle regardless of the way of delivery. MATERIAL AND METHODS: The study was retrospective for the period January 2005 to June 2010 and includes 38 infants with fracture of the clavicle in spontaneous and operative vaginal deliveries, as well as caesarean sections. There were examined the following factors: age, parity and maternal weight, fetal weigh and length duration of pregnancy, experience of managing labour. RESULTS: The incidence of fracture of the clavicle during the study was 0.26%, calculated to the total number of births. Eight fractures are of newborn delivered by caesarean section, 6 by vacuum extractor and 24 by normal vaginal deliveries with episiotomy mostly. The average weight of infants with fractures was 3767 gr 3 fractures are accompanied by brachial plexus paresis, and 2 were complicated with shoulder dystocia. CONCLUSIONS: It was not found statistically significant prognostic value of most of the indicators studied. Fracture of the clavicle most often dependent on the weight of the newborn and the technique of managing labour without the consequence of shoulder dystocia.