Barbara Frentzen

Congenital diaphragmatic hernia : Epidemiology and outcome

Congenital diaphragmatic hernia is a relatively common birth defect. It affects about 1114 babies a year in the United States. Reported survival averages 60% but may be significantly lower. We do not understand the etiology of CDH. Its association with other anomalies and several distinct patterns of presentation suggest that more than one cause may exist. There is a high degree of variability in both treatment and outcomes, but no data exist to allow a rigorous comparison of the efficacy of various treatment strategies. Stratification of patients into more homogeneous groups will be a necessary prerequisite for the design of meaningful comparative trials. The incidence of the lesion prevents any single institution from accruing sufficient patients to conduct such a trial. An ad hoc multicenter study group (the Congenital Diaphragmatic Hernia Study Group) has been formed for this purpose. This organization has begun collecting data with an initial goal of developing a stratification scheme. Prospective data collection should allow verification of several of the estimates made in this article. Current data make it clear that CDH represents a major cause of perinatal morbidity and mortality.

Excessive maternal weight and pregnancy outcome

OBJECTIVES This study was undertaken to determine the influences of increased maternal prepregnancy weight and increased gestational weight gain on pregnancy outcome. STUDY DESIGN This was a longitudinal retrospective study of 7407 term pregnancies delivered from 1987 through 1989. After excluding cases with multiple fetuses, stillbirths, fetal anomalies, no prenatal care, selected medical and surgical complications, and those with incomplete medical records, 3191 cases remained for analyses by determination of odds ratios for obstetric outcomes, by chi 2 tests for significant differences and by adjustment for risk factors with stepwise logistic regression. RESULTS Both increased maternal prepregnancy weight (body mass index) and increased maternal gestational weight gain were associated with increased risks of fetal macrosomia (p less than 0.0001), labor abnormalities (p less than 0.0001), postdatism (p = 0.002), meconium staining (p less than 0.001), and unscheduled cesarean sections (p less than 0.0001). They were also associated with decreased frequencies of low birth weight (p less than 0.001). The magnitude of the last was less than that of the other outcomes. CONCLUSIONS Increased maternal weight gain in pregnancy results in higher frequencies of fetal macrosomia, which in turn lead to increased rates of cesarean section and other major maternal and fetal complications. Because these costs of increased maternal weight gain appear to outweigh benefits, weight gain recommendations for pregnancy warrant careful review.

Risk factors for neonatal sepsis.

Objective To determine the associations between maternal characteristics, intrapartum events, and neonatal sepsis by multivariate analysis. Methods We enrolled 823 women from a high-risk population and analyzed maternal and neonatal demographic and outcome variables with univariate analysis and multivariate logistic modeling. Results Two-hundred sixteen women (26%) were colonized with group B streptococci, 82 (10%) developed chorioamnionitis, and 141 (17%) delivered prematurely. Cultureproven neonatal sepsis or meningitis was found in 15 of 833 (1.8%) neonates, and 101 of the remaining 818 (12.3%) infants were suspected to have sepsis or pneumonia. Multivariate analysis of risk factors for proven neonatal sepsis demonstrated a statistically significant association with decreasing gestational age, duration of internal monitoring for more than 12 hours (odds ratio [OR] 7.2, 95% confidence interval [CI] 1.6–32.2), maternal group B streptococcal infection (OR 4.2, 95% CI 1.4–13.1), chorioamnionitis (OR 4.4, 95% CI 1.2–16.1), and endometritis (OR 6.4, 95% CI 1.2–34.2). Conclusion Through the use of multivariate modeling, we determined that chorioamnionitis or endometritis, preterm delivery, group B streptococcal colonization, and a prolonged duration of internal monitoring are independent risk factors for neonatal sepsis. We postulate that the presence of a foreign body that traverses the birth canal may facilitate ascending peripartal infection.

Correlation of Prenatal Renal Pelvic Anteroposterior Diameter with Outcome in Infancy

PURPOSE We attempted to correlate prenatal renal pelvic anteroposterior diameter with outcome in infancy. MATERIAL AND METHODS Between May 1992 and March 1994 we identified 27 cases of fetal hydronephrosis in which renal pelvic anteroposterior diameter was 4 mm. or greater before 33 weeks of gestation and 7 mm. or greater at or after 33 weeks of gestation. RESULTS Hydronephrosis was bilateral in 18 fetuses and unilateral in 9. Shortly after birth radiological assessment revealed vesicoureteral reflux in 6 neonates, ureteropelvic junction obstruction in 6, extrarenal pelves in 3 and persistent nonobstructive hydronephrosis in 4. Radiological evaluation was normal in 8 newborns. CONCLUSIONS When these screening criteria for hydronephrosis are met prenatally a complete radiological assessment should be done following birth.

Maternal weight gain: Effect on infant birth weight among overweight and average-weight low-income women

A study was performed to compare the influence of pregnancy weight gain on infant birth weight and outcome among two groups of indigent women from the rural South: those who were highly overweight before pregnancy (greater than or equal to 135%) and those who were of average weight (90% to 120% of standard weight for height). The groups had comparable numbers of black and white subjects. Pregnancy weight gain affected birth weight in the average-weight group but did not significantly affect birth weight in the highly overweight group. Infant outcomes for both groups were similar. These findings suggest that consideration should be given to not requiring a minimum weight gain for women whose degree of overweight equals or exceeds 135% of standard body weight for height.

Ultrasonographic diagnosis of congenital anomalies in twins

To determine whether serial ultrasonographic examinations with basic anatomic surveys provide an adequate screen for congenital abnormalities that are more common in twins, we compared the results of prenatal sonograms and neonatal examinations for 314 twins (157 pairs) delivered during a recent 42-month period. An anomaly was defined as major if it potentially required surgical repair or precluded normal life expectancy; otherwise it was defined as minor. Thirty-three twins (9.5%) had 40 anomalies; 28 (9%) were major and 12 (4%) were minor. Prenatal ultrasonography with cardiac screening limited to the four-chamber view provided detection of 39% of all major anomalies, 55% of noncardiac major anomalies but none of the cardiac lesions, and 69% of the major anomalies for which routine prenatal management should be altered. No false-positive diagnoses incorrectly altered management. We conclude that serial prenatal ultrasonographic examinations are useful in detecting noncardiac anomalies for which twins are at increased risk, but the four-chamber view is not an adequate screen for the cardiac malformations of twins.

Human Kinetics of Orally and Intravenously Administered Low-Dose 1,2-13C-Dichloroacetate

Dichloroacetate (DCA) is a putative environmental hazard, owing to its ubiquitous presence in the biosphere and its association with animal and human toxicity. We sought to determine the kinetics of environmentally relevant concentrations of 1,2‐13C‐DCA administered to healthy adults. Subjects received an oral or intravenous dose of 2.5 μg/kg of 1,2‐13C‐DCA. Plasma and urine concentrations of 1,2‐13C‐DCA were measured by a modified gas chromatography‐tandem mass spectrometry method. 1,2‐13C‐DCA kinetics was determined by modeling using WinNonlin 4.1 software. Plasma concentrations of 1,2‐13C‐DCA peaked 10 minutes and 30 minutes after intravenous or oral administration, respectively. Plasma kinetic parameters varied as a function of dose and duration. Very little unchanged 1,2‐13C‐DCA was excreted in urine. Trace amounts of DCA alter its own kinetics after short‐term exposure. These findings have important implications for interpreting the impact of this xenobiotic on human health.

Continuous-wave Doppler ultrasound and decreased amniotic fluid volume in pregnant women with intact or ruptured membranes

The cause(s) of decreased amniotic fluid in the absence of fetal anomalies and intrauterine growth retardation is not clear. A prospective study was performed to evaluate umbilical and uterine artery Doppler velocimetric results in pregnancies complicated by decreased amniotic fluid. Three medically high-risk groups were studied: women with (1) normal fluid and intact membranes, (2) decreased fluid and intact membranes, and (3) decreased fluid and ruptured membranes. The decreased fluid/intact membranes group had a significantly increased incidence of abnormal uterine artery waveforms (diastolic notching or absence of end-diastolic velocity); however, uterine systolic/diastolic ratios were not significantly different. The umbilical systolic/diastolic ratios were marginally higher in the intact membranes/decreased fluid group when compared with the ruptured membranes group. This study suggests that problems with maternal blood supply to the placenta may be related to decreased amniotic fluid when membranes are intact.