Cynthia J. Holcroft

Neonatal nucleated red blood cells and the prediction of cerebral white matter injury in preterm infants.

OBJECTIVE: To estimate whether neonates with cerebral white matter injury have significant elevations in nucleated red blood cell counts and to estimate their predictive ability in identifying injury. METHODS: This case–control study identified 176 infants born at 23–34 weeks of gestation between November 1994 and October 2004 at a single university hospital and with cerebral white matter injury characterized by periventricular leukomalacia (PVL) or ventriculomegaly due to white matter atrophy. A control was matched to each case using the subsequent delivery within 7 days of that gestational age without brain injury. RESULTS: The gestational age at birth was 27 weeks for both groups, but the cases had a significantly lower birth weight (mean ± standard deviation: 958 ± 306 g compared with 1,038 ± 381 g, P = .001). There was no difference in cesarean delivery (48% cases compared with 44% controls, P = .59). The cases had a significant increase in nucleated red blood cells per 100 white blood cells (WBC) (median, 5th percentile and 95th percentile: 22, 3 and 374 cases compared with 14, 1 and 312 controls; P = .02). Markers of chronic hypoxia, such as intrauterine growth restriction and oligohydramnios, and markers of acute hypoxia, such as an umbilical arterial pH less than 7.0 or base excess less than −12 mM, were both associated with significantly elevated neonatal nucleated red blood cell counts. A neonatal nucleated red blood cell count of 18 per 100 WBCs had a sensitivity of 56.9%, specificity of 57.9%, positive predictive value of 57.9%, and negative predictive value of 56.9% in predicting the development of cerebral white matter injury in this matched case–control sample. CONCLUSION: Preterm neonates with cerebral white matter injury have significant increases in nucleated red blood cell counts. Both acute and chronic hypoxia–ischemia can increase these counts, which limits their usefulness in timing injury. The predictive value of nucleated red blood cell counts at birth in identifying injury is poor. LEVEL OF EVIDENCE: II-2

Large Fetal Sacrococcygeal Teratomas: Could Early Delivery Improve Outcome?

Objective: To determine if gestational age (GA) at delivery or tumor size impacts outcome in neonates with very large sacrococcygeal teratomas (SCTs). Methods: Retrospective chart review from 1990 to 2006 of live-born infants with very large SCTs, defined as diameters exceeding 10 cm. Data analyzed using the independent t test and Fisher’s exact test, with p values <0.05 considered significant. Results: Nine infants with very large SCTs were identified. Six of the 9 infants survived, 4 of whom had evidence of early hydrops. Mean GA of survivors was 32.2 ± 3.7 versus 31.7 ± 0.6 weeks in nonsurvivors (p = 0.85). Infants with the largest SCTs did not survive. Conclusion: Risks of preterm delivery must be weighed against complications from further enlargement of very large SCTs and against the risks of in utero intervention.

Small fetal abdominal circumference in the second trimester and subsequent low maternal plasma glucose after a glucose challenge test is associated with the delivery of a small-for-gestational age neonate.

To evaluate the predictive value of a combination of the 1 h 50‐g glucose challenge test (GCT) and second‐trimester ultrasound measurement of fetal abdominal circumference (AC) in identifying patients who will go on to deliver small‐for‐gestational age (SGA) neonates. The individual predictive power of these tests has been indicated by previous studies, but this study examines the combined use of these indicators in predicting SGA.

Phimosis as a cause of the prune belly syndrome: comparison to a more common pattern of proximal penile urethra obstruction

Abstract. The pathogenesis of the prune belly syndrome (PBS) remains controversial, but two theories predominate. The first theory supports an obstructive phenomenon early in gestation leading to irreversible damage to the genitourinary tract and abdominal wall. The second theory suggests mesodermal injury between the 6th and 10th weeks of gestation as the primary abnormality. This paper reports of two fetuses with the PBS phenotype that were examined postmortem at our institution. Thorough examination of the lower urinary tract allowed demonstration of anatomic obstruction of the urethra in both cases. One case illustrated a relatively common pattern of proximal penile urethral obstruction, a flap-like obstruction between the prostatic and penile urethra. The other case provided what we believe to be the first description of PBS caused by severe phimosis.

Evidence of intrapartum hypoxia-ischemia is not present in the majority of cases of neonatal seizures

OBJECTIVE To determine the extent to which neonatal seizures are associated with intrapartum hypoxia-ischemia. METHODS In this case-control study, all neonates diagnosed with seizures at a single institution from 1988 to 1999 were compared to a control group without seizures matched in a 2:1 fashion for gestational age at delivery, birth weight and mode of delivery. Data were abstracted from the maternal and neonatal charts. Parametric variables were compared using an independent samples t test, and non-parametric variables were compared using a Fisher exact test, with p < 0.05 being considered significant. RESULTS There were 13 cases of neonatal seizures identified, of which one was chromosomally abnormal and excluded from further analysis. For the cases, the mean gestational age at delivery was 34.8 +/- 6.9 weeks, with four preterm and eight term deliveries. The mean birth weight for the cases was 2684 +/- 1369 g (range 590-4350 g). For both cases and controls, 83% were delivered vaginally and 17% by Cesarean section. For term neonates with seizures, the mean length of stay was 11.6 +/- 5.0 days, as compared to 2.5 +/- 0.9 days in the control group (p < 0.001). A 1-min Apgar score of < 7 was found in six of 12 (50%) cases and seven of 24 (29%) controls, and a 5-min Apgar score of < 7 was found in four of 12 (33%) cases and four of 24 (17%) controls (non-significant). In the controls, the mean base excess was -2.8 +/- 2.6 mEq/l, and the mean umbilical arterial pH was 7.28 +/- 0.09. In the case group, two infants born at 24 weeks did not have an umbilical arterial blood gas obtained; in the remaining cases, the mean base excess was -7.6 +/- 6.9 mEq/l (p = 0.02), and the mean cord pH was 7.17 +/- 0.23 (p = 0.065), with only three of ten (30%) having a pH < 7.00 (p = 0.02). CONCLUSION Clinically significant acidosis was found in only 30% of neonates who developed seizures, and only one of 12 cases (8%) could possibly have met the criteria of the American College of Obstetricians and Gynecologists for neurological morbidity linked to intrapartum asphyxia. The majority of cases of neonatal seizures were not associated with evidence of intrapartum hypoxia-ischemia.