The value of a scoring system for hypoxic ischaemic encephalopathy in predicting neurodevelopmental outcome.

A numeric scoring system for the assessment of hypoxic ischaemic encephalopathy during the neonatal period was tested. The value of the score in predicting neurodevelopmental outcome at 1 y of age was assessed. Forty-five infants who developed hypoxic ischaemic encephalopathy after birth were studied prospectively. In addition to the hypoxic ischaemic encephalopathy score all but two infants had at least one cranial ultrasound examination. Thirty-five infants were evaluated at 12 months of age by full neurological examination and the Griffiths Scales of Mental Development. Five infants were assessed at an earlier stage, four who died before 6 months of age and one infant who was hospitalized at the time of the 12 month assessment. Twenty-three (58%) of the infants were normal and 17 (42%) were abnormal, 16 with cerebral palsy and one with developmental delay. The hypoxic ischaemic encephalopathy score was highly predictive for outcome. The best correlation with outcome was the peak score; a peak score of 15 or higher had a positive predictive value of 92% and a negative predictive value of 82% for abnormal outcome, with a sensitivity and specificity of 71% and 96%, respectively. For the clinician working in areas where sophisticated technology is unavailable this scoring system will be useful for assessment of infants with hypoxic ischaemic encephalopathy and for prognosis of neurodevelopmental outcome.

Fetal acidosis and Doppler velocimetry of the umbilical arteries in labor.

The objective of the study was to determine whether Doppler velocimetry indices of the fetal umbilical arteries change with the development of acidosis during labor. Repeated Doppler velocimetry was performed in selected patients with high-risk labors for the purpose of evaluating whether this might be a useful test of fetal well-being in labor. The study sample comprised 36 women with singleton pregnancies, complicated either by gestational proteinuric hypertension or by intrauterine growth retardation (or both) with a normal cardiotocographic tracing at the onset of labor. The acid-base status of the fetus was assessed after delivery by analyzing the umbilical artery blood. A total of 27 fetuses were followed through labor. Six were born with an umbilical artery base deficit of more than 10 mmol/l. No change in mean Pourcelot ratio (resistance index) was noted in both normal and acidotic fetuses. None of the acidotic fetuses showed a change in Pourcelot ratio of more than 0.03. We conclude that Doppler velocimetry of the umbilical arteries, as measured by the Pourcelot ratio, does not contribute to the diagnosis of fetal acidosis in labor.

The cost of neonatal care.

A medical and financial assessment of the Neonatal Unit at Groote Schuur Hospital showed that the emphasis was on high care provided at a cost of R265 per patient per day. Intensive care cost R530 and low care R88 per day. The average was R172 per day. Infants of very low birth weight (< 1,500 g) accounted for 58% of expenditure. Half of this amount was spent on infants of below 1,000 g; the cost was R14 621 per survivor and R344 per quality-adjusted life-year. The cost declined progressively for infants of greater birth weight. There are a paucity of comparable local data, but the cost of the care was very reasonable.

The incidence of retinopathy of prematurity at Groote Schuur Hospital, Cape Town.

Retinopathy of prematurity (ROP) continues to occur in nurseries world-wide because more immature babies are surviving the neonatal period. In order to establish the incidence and severity of this disease at Groote Schuur Hospital, 141 very-low-birth-weight infants were examined; 27 (19.2%) were found to have ROP, and among these 2 (1.56%) had a particularly severe form of the disease. None of the infants required treatment. The incidence and severity of ROP is compared with similar studies, and the monitoring of oxygen therapy and screening of infants is discussed.

The role of chorioamnionitis and prostaglandins in preterm labor.

Spontaneous preterm labor remains a significant cause of high morbidity and mortality in the newborn. Chorioamnionitis with an associated rise in prostaglandins (PGs) is thought to be one of the factors responsible for the onset of preterm labor. In this study, 52 placentas and membranes from gestations of 35 weeks' or fewer were collected. Tissue samples of membranes and placentas were incubated in pseudoamniotic fluid, and the levels of PGs and leukotriene B4 were assayed. Swallowed amniotic fluid aspirated from the infants' stomachs was analyzed for PGs and examined microscopically for the presence of degenerate neutrophilic polymorphonuclear leukocytes (pus cells) and bacterial organisms. Prostaglandins E and F and leukotriene B4 production were significantly higher in the membranes and placentas with chorioamnionitis than in those without. Although the comparison of PG levels in the gastric fluid of infants with and without chorioamnionitis did not reach statistical significance, there was a trend toward higher levels of PGs with chorioamnionitis. Prostaglandin E levels from membranes and placentas and PGF from placentas were significantly elevated in the gastric fluid of infants with pus cells and organisms. These findings support the hypothesis that chorioamnionitis may initiate preterm labor.

Standardisation of perinatal mortality rates.

Birth weights and perinatal deaths for the Peninsula Maternal and Neonatal Service were analysed for 1974-1987. There were differences in birth-weight distribution between the ethnic groups, and within the white group, over time, and these influenced the crude perinatal mortality rates. Once birth weight had been adjusted for, there was a downward trend in the data for all groups. The improvement in the perinatal mortality rates was related to better survival in each group. There was no difference in the standardisation rates between the coloured and white infants. Blacks, however, had significantly higher rates when compared with the coloured and white births.

Current trends in infant feeding.

This study examined aspects of newborn feeding in a maternity hospital and also investigated feeding practices during the first 6 months of life. Four hundred and fifty mothers were interviewed while in the maternity hospital. The majority (93%) had booked for their confinement and had attended antenatal clinics regularly. Most had had early contact with the baby at birth and stated that they thought breast-milk was best for the baby. Despite this only 54.6% had given breast-milk as the first feed and only 10% had done so within the first hour. Most mothers (54%) stated that they preferred a timed feeding routine to demand-feeding, while 86% planned to give water between feeds. The majority indicated they would change to formula feeds should they experience problems with breast-feeding. A follow-up visit of 78 mothers 6 months later showed that 50% breast-fed exclusively for 3 - 4 months and 23% for 6 - 7 months. When feeding problems occurred only 27% of the mothers utilised the local authority baby clinic for help. The main reasons given for stopping breast-feeds were insufficient milk, the need for employment and feeding problems. The implications of these findings are discussed.

Infantile fibrosarcoma presenting as shoulder dystocia. A case report.

Congenital (infantile) fibrosarcomas are soft-tissue tumours that usually present after birth. In the case described a large tumour of the right arm caused shoulder dystocia and death of the fetus.

Blood viscosity during fluid infusion in the preterm infant.

Whole blood viscosity, haematocrit and plasma osmolality were measured in a group of preterm infants receiving a standard infusion (60 ml/kg/d) of 10,7% dextrose water with 4% sodium bicarbonate. There were no significant changes in the three parameters during the infusion period. It was concluded that although the infused solution was hypertonic, it did not result in a hyperviscous or hyperosmolar state.

Haematocrit values and blood viscosity in the newborn infant.

The haematocrit values in 51 babies were studied to observe the possible variations due to the method and time of sampling and to relate these findings to blood viscosity. A good correlation (r = 0,9536) between haematocrit values of warmed heel capillary blood and of central venous samples was found. Prediction of venous value from a known sample of capillary blood can be made using regression lines and 95% confidence limits. The correlation between venous and unwarmed blood samples from the heel is not as good. A central venous haematocrit value of 65% or greater gave a 100% risk of the infant's blood being hyperviscous. Hyperviscosity occurred in 71% of infants with a capillary haematocrit value of 65 - 68% but the figure rose to 81% when the peripheral haematocrit value was 68% or more.

Blood viscosity in the normal newborn baby.

A viscometer was tested and the results were found to be accurate and reproducible for the ranges encountered in neonates. The viscosity was determined in 80 cord blood samples and the mean and 2 standard deviations (2SD) were calculated at each shear rate. Changes in viscosity increased from birth to 12 hours, and then gradually decreased over the next 72 hours. The results are in keeping with the accepted normal values in the newborn.

Blood viscosity in modern medicine.

The understanding and measurement of blood viscosity play an important part in mordern medicine. The basic principles and relevances of fluid viscosity are discussed. Factors which alter viscosity include shear rate, haematocrit, erythrocyte deformability, internal fluidity, pH, plasma proteins, temperature, osmolality, lipids and leucocytes. In vivo changes in vascular architecture are thought to influence blood viscosity. Some of the clinical conditions in which viscosity is important are described. Hyperviscosity should be treated before complications arise.