Alfred W. Brann

Promising Practices in Preconception Care for Women at Risk for Poor Health and Pregnancy Outcomes

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of recurrent very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the womans health and subsequent reproductive health outcomes.

Electron microscopy in the routine screening of newborns with congenital cytomegalovirus infection.

The pseudoreplica method of electron microscopy (EM) was evaluated as a rapid screening technique for the detection of cytomegaloviruria in 3056 neonates in a predominantly lower socioeconomic population. Virus isolation methods detected 49 (1.6%) CMV-positive individuals. When pools of three to five urines were tested, 26 (54%) of the culture-positive neonates were identified by EM; however, testing of individual urines increased EM detection to 33 (67%). Almost all of these urines, as well as urine or oral specimens obtained on follow-up visits, which had infectivity titers greater than or equal to 10(4)/ml were EM-positive, whereas only half of the specimens with titers less than 10(4)/ml were EM-positive. All the symptomatic neonates were detected by EM, suggesting that electron microscopy would be most valuable as a diagnostic aid in this group of CMV-infected neonates.

Very low birth weight births in Georgia, 1994–2005: trends and racial disparities

ObjectiveTo investigate the nature of very low birth weight (VLBW) births in Georgia—a major contributor to the overall and the black–white disparity in infant mortality—as a step toward elucidating strategies for reducing VLBW births.MethodsThis population-based retrospective cohort study utilized maternally linked vital records data from Georgia to examine the status of and contributors to the VLBW rate for non-Hispanic blacks and whites by comparing trends in the proportion represented by singleton versus multiple gestations, first versus recurrent events, and specific subtypes over three, consecutive 4-year periods (1994–1996 through 2003–2005); and logistic regression to model the risk of various subtypes of VLBW as a function of maternal and obstetrical characteristics.ResultsGeorgia’s VLBW rate remained unchanged from 1994–1996 to 2003–2005, although there was a significant decrease in the rates of twin and first VLBW and a significant increase in recurrent VLBW. For both first and recurrent VLBW, there was a statistically significant increase for blacks and a decrease for whites. The strongest risk factor for a VLBW birth of any subtype for blacks and whites was a prior VLBW, with recurrent VLBW accounting for 4.8–16% of all VLBW depending upon the subtype.ConclusionFrom 1994–1996 to 2003–2005, the rate of recurrent VLBW increased while the rate of first VLBW decreased in Georgia. For both first and recurrent VLBW, the black–white disparity widened. Because the strongest risk factor for a VLBW birth is a previous one, there is a need to identify strategies to prevent a woman’s first VLBW birth and to reduce recurrences.

Report of an International Conference on the Medical and Ethical Management of the Neonate at the Edge of Viability: A Review of Approaches from Five Countries

Current United States guidelines for neonatal resuscitation note that there is no mandate to resuscitate infants in all situations. For example, the fetus that at the time of delivery is determined to be so premature as to be non-viable need not be aggressively resuscitated. The hypothetical case of an extremely premature infant was presented to neonatologists from the United States and four other European countries at a September 2006 international meeting sponsored by the World Health Organization Collaborating Center in Reproductive Health of Atlanta (currently, the Global Collaborating Center in Reproductive Health). Responses to the case varied by country, due to differences in legal, ethical and related practice parameters, rather than differences in medical technology, as similar medical technology was available within each country. Variations in approach seemed to stem from physicians’ perceptions of their ability to remove the neonate from life support if this appeared non-beneficial. There appears to be a desire for greater convergence in practice options and more open discussion regarding the practical problems underlying the variability. Specifically, the conference attendees identified four areas that need to be addressed: (1) lack of international consensus guidelines in viability and therapeutic options, (2) lack of bodies capable of generating these guidelines, (3) variation in laws between countries, and (4) the frequent failure of physicians and families to confront death at the beginning of life.

1137 INTRACEREBRAL HEMORRHAGE IN HIGH RISK PREMATURES

Subependymal (SEH) and intraventricular hemorrhage (IVH) in infants less than 35 weeks gestation, requiring intensive care for 24 hours or longer, were studied prospectively. Initial computerized tomographicscan (CT scan) was obtained, and, if positive for blood, head circumference, clinical course, and serial scans were followed until ventricular size was normal.29/58 infants were shown to have SEH and/or IVH, 26 by CT scan, I by ventricular tap, 2 on autopsy. 8 infants died. 6 of these had marked IVH, 3 shown by CT scan, I by ventricular tap, 2 by autopsy. Acute hydrocephalus of only mild to moderate degree occurred in the 3 fatalities with positive scans. The 23 survivors with positive scans had follow-up scans. 18/23 did not show progressive hydrocephalus, and of these 4 had only SEH. Of the others, 10 had mild, 3 moderate, and I marked IVH. 5 survivors with IVH developed severe progressive hydrocephalus. 2/5 had only mild IVH, which resolved spontaneously. 3/5 required treatment. IVH was moderate in 1, marked in 2. Serial head circumference was not predictive of need for treatment.The incidence of SEH and IVH was 50% in study infants and was not related to gestational age. The quantity of blood may be prognostically significant. No infant with SEH or mild IVH required treatment. Progressive hydrocephalus developed in 2 and resolved spontaneously. 7/10 infants with moderate to marked IVH survived. 3 required treatment.

Neonatal Intracranial Hemorrhage and Hypoxia

Publisher Summary This chapter discusses the neonatal intracranial hemorrhage and hypoxia. The primary location of these hemorrhages is the subependymal and periventricular region, in the germinal matrix tissue over the head of the caudate nucleus at the level of the foramen of Monro. It is found that before 26 to 28 weeks of gestation, the germinal matrix is a highly vascularized zone of the developing brain, a site of proliferating neuron and glial precursors. Most of these risk factors presumably influence the development of periventricular-intraventricular hemorrhage (PVH-IVH) through their varied effects on cerebral blood flow, especially to the germinal matrix vessels. A number of clinical studies suggest that the fundamental or common thread for many of these risk factors associated with the development of PVH-IVH was a loss of cerebral autoregulation. PVH-IVH may not be the final determinant of the cerebral injury but rather the hemorrhage is followed by significant decreases in cerebral blood flow in the affected hemisphere.