Éva Görbe

Very‐low‐birthweight breech infants: Short‐term outcome by method of delivery

The purpose of this study was to determine the incidence of mortality and morbidity of the very-low-birthweight infant (< 1,500 g) in breech presentation based on mode of delivery and birthweight. A retrospective chart review of 1,009 infants who were in breech presentation at the time of delivery between January 1, 1990 and December 31, 1995 at the First Department of Obstetrics and Gynecology of Semmelweis Medical School in Budapest, Hungary. Data collected included birthweight, mode of delivery, pregnancy complications and neonatal mortality and morbidity. Comparison of groups was made based on mode of delivery, and data were analyzed using Fishers exact test and chi-square analysis. For those infants weighing less than 1,500 g at birth, vaginal delivery was associated with higher mortality than for those delivered abdominally (73.8% vs. 37.7%, P < 0.001). There was no significant difference in survival for those infants weighing 1,500 g or more. Regarding morbidity, in those infants weighing less than 1,500 g, vaginal delivery was associated with a higher incidence of 1 min Apgar below 4 (21.7% vs. 5.2%, P < 0.001), a higher incidence of 5-min Apgar scores below 4 (11.6% vs. 1.2%, P < 0.001), a higher incidence of grade III or grade IV IVH (18.8% vs. 3.5%, P < 0.001) and a higher incidence of necrotizing enterocolitis (5.8% vs. 0.6%, P < 0.05). There is an increased incidence of mortality and morbidity for the VLBW breech infant delivered vaginally. Cesarean delivery may improve outcome for these infants.

Associated malformations in congenital diaphragmatic hernia cases in the last 15 years in a tertiary referral institute

This is a review of cases of perinatally diagnosed congenital diaphragmatic hernia (CDH) with associated malformations with regard to time of diagnosis, side of hernia, associated malformations, and outcome. The authors analyzed the data of CDH cases with associated malformations from records of the I. Department of Obstetrics and Gynecology, Semmelweis University Faculty of Medicine, Budapest, between July 1, 1990 and June 30, 2005. The observed period was analyzed in two parts. The pre‐ and postnatal examinations verified CDH in 100 cases, 71% of which were associated with other malformations. In 52% (37/71) CDH was diagnosed before the 24th week of gestation. The rate of early diagnosed cases doubled in the second period. Ten percent (7/71) of cases were verified postnatally. Between 1990 and 1997, the percentage of right‐sided hernia was 6% (2/34) while in the second period it was 19% (7/37). The association with cardiovascular, chest, and craniofacial anomalies doubled in the second period, while association of central nervous system anomalies halved. Chromosome anomalies were verified in four cases. Pregnancy was terminated in 53% (34/64) and 13% (4/30) of newborn infants survived the perinatal period. Intrauterine or intrapartum death occurred in 8% (5/64) of cases. The prevalence of cardiovascular, pulmonary, and craniofacial anomalies doubled, while that of central nervous system malformations decreased. The prevalence of other associated malformations has not changed significantly between the two periods. The improvement of technical facilities and accumulated experience make it possible to identify a higher number of associated malformations before the 24th week of gestation.

IL-18 induces a marked gene expression profile change and increased Ccl1 (I-309) production in mouse mucosal mast cell homologs.

Helminthic infections, which are particularly common in the developing world, are associated with the accumulation of mucosal mast cells (MMCs) in the epithelial layer of the gut. Although intestinal parasite infection models argue that IL-18 plays a role in MMC differentiation and function, the direct effect of IL-18 on MMCs is still not well understood. To clarify the role of IL-18 in mast cell biology, we analyzed gene expression changes in MMCs in vitro. DNA microarray technology uncovered a group of chemokines regulated by IL-18, among which Ccl1 (I-309, TCA-3) showed the highest up-regulation. Ccl1 induction was only transient in mast cells and was characteristic for both immature and mature MMCs, but not for connective tissue-type mast cells. IL-18 exerts its Ccl1-inducing effect in MMCs primarily via the activation of NFkappaB. Moreover, IL-18 was effective both in the absence and the presence of IgE-antigen complex. The Ccl1 receptor (CCR8) is known to be expressed by T(h)2 cells and is involved in their recruitment. Our present findings suggest that IL-18 may contribute to mast cell-influenced Th2 responses by inducing Ccl1 production.

Neuronal migration disorders, agenesis of corpus callosum, preauricular skin tag and bilateral morning glory syndrome in a term newborn infant.

Schizencephaly is a congenital migrational anomaly resulting in a cleft in the cerebral hemisphere. In polymycrogyria, which is also a migrational disorder, the gyri are numerous and small, with proliferation of secondary and tertiary sulci. Agenesis of corpus callosum (partial or complete) is a relatively frequent malformation that can be associated with migrational anomalies and other brain malformations (Whitaker, 1996).

Assessment of serum interleukin-6 with a rapid test. The diagnosis of neonatal sepsis can be established or ruled out

INTRODUCTION The mortality rate from sepsis is high and the risk of sepsis increases in prematurity in proportion to the decrease in birth weight. MATERIAL AND METHOD The authors report the assessment of serum interleukin-6 levels in 12 term, at-risk newborn infants after birth and 60 VLBW neonates after detection of non-specific signs of infection or sepsis, treated in NICU at the Semmelweis University, 1st Department of Obstetrics and Gynecology in 2005-2006. The serum IL-6 level with a rapid test (Milenia Quickline IL-6 and PicoScan system) was investigated. The simultaneous assessment of C-reactive protein levels was analysed as well. RESULTS The assessment of serum interleukin-6 and CRP levels for the early diagnosis of sepsis can be established or ruled out. The sensitivity of serum IL-6 level assessment was 100%. There were no false negative cases. The positive predictive value was 93%. There was a significant difference between the sepsis and infection group of VLBW infants in the serum Il-6 levels ( p = 0.048), and between the infection and non-infection groups in the interleukin-6 levels ( p < 0.005). CONCLUSIONS In comparing the diagnostic value of IL-6 measurement in VLBW infants with signs of infection to the diagnostic methods currently in use, results showed that a combination of early assessment of IL-6 and CRP seems to increase diagnostic accuracy in attempting to differentiate between septic and nonseptic patients. Such increased accuracy will decrease neonatal morbidity as well as the financial cost of treatment.

Efficacy of prenatal ultrasonography in diagnosing urogenital developmental anomalies in newborns.

BackgroundShowing a prevalence rate of 0.5-0.8%, urogenital malformations discovered in newborns is regarded relatively common. The aim of this study is to examine the efficacy of ultrasound diagnostics in detecting developmental disorders in the urogenital system.MethodsWe have processed the prenatal sonographic and postnatal clinical details of 175 urogenital abnormalities in 140 newborns delivered with urogenital malformation according to EUROCAT recommendations over a 5-year period between 2006 and 2010. The patients were divided into three groups; Group 1: prenatal sonography and postnatal examinations yielded fully identical results. Group 2: postnatally detected urogenital changes were partially discovered in prenatal investigations. Group 3: prenatal sonography failed to detect the urogenital malformation identified in postnatal examinations. Urogenital changes representing part of certain multiple disorders associated with chromosomal aberration were investigated separately.ResultsPrenatal sonographic diagnosis and postnatal results completely coincided in 45%, i.e. 63/140 of cases in newborns delivered with urogenital developmental disorders. In 34/140 cases (24%), discovery was partial, while in 43/140 patients (31%), no urogenital malformation was detected prenatally. No associated malformations were observed in 108 cases, in 57 of which (53%), the results of prenatal ultrasonography and postnatal examinations showed complete coincidence. Prenatally, urogenital changes were found in 11 patients (10%), whereas no urogenital disorders were diagnosed in 40 cases (37%) by investigations prior to birth. Urogenital disorders were found to represent part of multiple malformations in a total of 28 cases as follows: prenatal diagnosis of urogenital malformation and the findings of postnatal examinations completely coincided in three patients (11%), partial coincidence was found in 22 newborns (79%) and in another three patients (11%), the disorder was not detected prenatally. In four newborns, chromosomal aberration was associated with the urogenital disorder; 45,X karyotype was detected in two patients, trisomy 9 and trisomy 18 were found in one case each.ConclusionIn approximately half of the cases, postnatally diagnosed abnormalities coincided with the prenatally discovered fetal urogenital developmental disorders. The results have confirmed that ultrasonography plays an important role in diagnosing urogenital malformations but it fails to detect all of the urogenital developmental abnormalities.

The maternal and fetal outcome of 122 triplet pregnancies

INTRODUCTION The wide use of infertility drugs and assisted reproduction has resulted in 4- to 5-fold increase in the incidence of triplet pregnancies, which carry an extremely high risk of maternal complications and adverse perinatal outcome. In Hungary, reduction of multifetal pregnancies is available for all pregnant women with multifetal gestation since 1998. The goal of the procedure is to ensure better outcome for surviving fetuses. Counseling of pregnant patients should include the maternal and fetal risks of triplet gestation without multifetal pregnancy reduction. AIM To assess the risk of maternal complications, stillbirth, perinatal and neonatal mortality rates, and risk of neonatal morbidity in non-reduced triplets in a large case series, representing the Hungarian triplet population. METHODS The study population consisted of triplets delivered between July 1st, 1990 and June 30th, 2006, at the 1st Department of Obstetrics and Gynecology. All three fetuses had to be alive on the 18th-week ultrasound scan to be eligible. RESULTS Out of the 122 cases, 8 (6.6%) ended in midtrimester miscarriage, 114 (93.4%) ended in delivery. There were no maternal deaths. The most common antepartum maternal complications were pregnancy-induced hypertension (16.7%), gestational diabetes mellitus (18.4%), thrombocytopenia (20.2%), anemia (16.7%) and intrahepatic cholestasis (9.7%). Preterm labor requiring tocolysis occurred in 57.9%, preterm premature rupture of membranes in 32.5%. Prophylactic cerclage was performed in 15.8% of cases, and 69.3% of patients received steroid prophylaxis. The mean gestational age at delivery was 32.3 +/- 3.2 weeks. The rates of very early (<28 weeks) and early (<32 weeks) preterm deliveries were 8.8% and 42.1%, respectively. The mean 5-minute Apgar score was 9.2 +/- 0.8, and the mean birth weight at delivery was 1664 +/- 506 g. 38.0% of infants were very low birth weight (<1500 g). Stillbirth, crude perinatal mortality and corrected perinatal mortality rates were 23.4 per thousand, 64.3 per thousand and 27.4 per thousand, respectively. 11.7 per thousand of infants had some major congenital anomaly. 54.4% of infants required ventilation or oxygen therapy or both. The most common neonatal complication were respiratory distress (17.1%), transitory tachypnea (5.2%), sepsis or pneumonia (25.5%), intraventricular hemorrhage (4.3%) and jaundice (11.4%). CONCLUSIONS Both the maternal and neonatal risks should be considered when patients with triplets are counseled before the decision to continue the triplet gestation or to choose multifetal pregnancy reduction is made.

Mutation in the factor V gene associated with inferior vena cava thrombosis in newborns.

To the Editor : Although inferior vena cava thrombosis is uncommon in newborns (and rarer still among neonates with diabetic mothers), it is responsible for serious complications in neonates. Adrenal haemorrhage and renal vein thrombosis can complicate this condition with asphyxia, dehydration, cyanotic congenital heart disease and hyperosmolarity, sepsis, shock and birth trauma (1, 2). A male infant born of a healthy mother (birthweight 3750 g, Apgar score 9/10), via uncomplicated vaginal delivery following 38 weeks of unremarkable gestation, was recently seen at our clinic. The newborn infant was diagnosed with cardiac prolapse and hypotension shortly after delivery. During the first 24 h postdelivery, the neonate demonstrated macroscopic haematuria, hypoglycaemia and a reduced platelet count (121 and later 80 G/l). Physical findings included oedema and cyanosis of the lower trunk and body. Abdominal ultrasonography revealed bilateral adrenal haemorrhaging, renal vein thrombosis on the left side, an enlarged left kidney and a 3 cm inferior vena cava thrombus located under the diaphragm (Fig. 1). A persistent ductus arteriosus was detected by echocardiography. Infection, asphyxia and birth trauma were absent. Intravenous dopamine–dobutamine and low doses of heparin were administered. On day 27, persistent clinical signs prompted a ligation of the ductus, with mechanical ventillation employed during the postoperative period. On day 32, haematuria disappeared and normal blood pressure and renal function returned. After obtaining informed consent, peripheral blood was drawn from both the child and the biological parents and assessed for mutation in the factor V gene according to established techniques (3, 4). DNA from both the newborn and the child’s biological mother was found to be heterozygous for the Leiden mutation in the factor V gene. The factor V Leiden mutation (V506 Arg-Gln mutation in blood coagulation factor V gene) is associated with resistance to activated protein C (3). Mutation of factor V is associated with thromboembolic disease in neonates. Here we report a newborn infant who is heterozygous for factor V Leiden mutation and who developed renal vein thrombosis and inferior vena cava thrombosis. This suggests that the factor V Leiden mutation is an important cause of thrombosis in this neonate and underscores the potential importance of screening for this mutation in cases of inferior vena cava thrombosis among newborns (5–7).

Expression of VEGF in neonatal urinary obstruction: does expression of VEGF predict hydronephrosis?

Background In animal studies, the inhibition of VEGF activity results in high mortality and impaired renal and glomerular development. Mechanical stimuli, like mechanical stretch in respiratory and circulatory systems, results in an elevated expression of VEGF. In animal models, the experimental urinary obstruction is associated with stretching of tubular cells and activations of the renin-angiotensin system. This results in the upregulation of vascular endothelial growth factor (VEGF) and TNF-alfa. Material/Methods Tissue samples from urinary tract obstruction were collected and immunohistochemistry was performed in 14 patients (average age: 7.1±4.1 years). The control histology group consisted of ureteropelvic junction tissue from 10 fetuses after midtrimester artificial abortion. The fetuses did not have any failure at ultrasound screening and pathological examination. The mean gestational age was 20.6 weeks of gestation (±2.2SD). Expression of VEGF was detected with immunohistochemistry method. Results Expression of VEGF was found in varying intensity in the submucosa and subserosa layers, but only in the test tissue (placental tissue). The tissue of the patients with urinary obstruction and the tissue of the fetal ureteropelvic junction without urinary obstruction were negative for expression of VEGF. The repeated examination showed negative cells and no color staining. Conclusions The pressure due to congenital urogenital obstruction resulting in mechanical stress in cells did not increase the expression of VEGF in young children in our study. To find a correlation between urogenital tract obstruction and increased expression of VEGF, we need to perform more examinations because the connection may be of therapeutic significance.

Incidence and causes of maternal thrombocytopenia in triplet gestation

Abstract Objective: To determine the incidence, clinical significance and causes of maternal thrombocytopenia in triplet gestations. Study design: The study population consisted of 150 patients with triplet gestation that delivered at our department between 1990 and 2008. Thrombocytopenia was defined as a platelet count <150,000/μL. Patients were classified on the basis of the lowest recorded platelet count observed during pregnancy. Results: A low platelet count was observed during the triplet gestation in 36 cases (24.0%), and after delivery in another 19 cases (12.7%). Thrombocytopenia was mild, moderate, and severe in 75% (27/36), 16.7% (6/36), and 8.3% (3/36) of the cases, respectively. During pregnancy, thrombocytopenia was associated with pregnancy-induced hypertension in 25.0% (9/36) of patients, while gestational thrombocytopenia was diagnosed in 72.2% of the cases (26/36). The mean platelet count showed a strong negative correlation with gestational age (r=–0.953, P<0.001), and at 36 weeks approached the limit of thrombocytopenia. Conclusions: Thrombocytopenia occurs more frequently in triplet gestations than in the general pregnant population, and the rate of moderate and severe forms is higher. The distribution of causes is comparable to that of the general pregnant population. The average platelet count in triplet gestations decreases with gestational age.