H Trotman

The Mechanisms of Low Birth Weight in Infants of Mothers With Homozygous Sickle Cell Disease

OBJECTIVE. A low mean birth weight is a constant finding in pregnancies of women with homozygous sickle cell disease. The factors responsible are largely unknown and have now been investigated in an 11-year retrospective analysis. METHODS. Records for 126 pregnancies of mothers with homozygous sickle cell disease and 126 pregnancies of control women with an AA phenotype, matched according to age and date of delivery, were examined. Events during pregnancy and outcomes of pregnancy were recorded. RESULTS. Pregnancy outcomes for mothers with homozygous sickle cell disease confirmed the lower birth weight, gestational age, and placental weight. A low birth weight in infants of mothers with homozygous sickle cell disease was strongly related to gestational age and placental weight and weakly related to reticulocyte counts and a history of preeclampsia in univariate analyses, but only gestational age and placental weight remained significant in multivariate analyses. No relationships were seen with maternal age, parity, anthropometric features, other hematologic features (hemoglobin levels, fetal hemoglobin levels, mean cell volume, and α-thalassemia), pregnancy-induced hypertension, or prepartum hospital admissions (expressed as number or total days). Compared with Jamaican standards, birth weight was affected more than head circumference or length in infants of mothers with homozygous sickle cell disease, indicating asymmetric growth retardation, which occurred for 27% of boys and 38% of girls (compared with 4% and 9%, respectively, among infants of control mothers). CONCLUSIONS. A chronic condition such as homozygous sickle cell disease might have been expected to cause symmetric growth retardation throughout pregnancy. The finding of asymmetric retardation might indicate adverse factors emerging late in pregnancy and might have relevance for the poor pregnancy outcomes in such mothers.

Body composition in pregnancies of adolescents and mature women and the relationship to birth anthropometry

Objective:To investigate differences in body composition between adolescent girls and mature women during pregnancy and the relationship to newborn anthropometry.Design:A prospective study.Setting:The antenatal clinic at the University Hospital of the West Indies, Kingston, Jamaica.Subjects:Four hundred and twenty-five women were invited to join the study. Three hundred and sixty-one women (84.9%) completed the study.Interventions:Study participants were divided into two groups: adolescents and mature women, who were all less than 15 weeks pregnant and had no systemic illness at the time of entry into the study. A questionnaire was administered which retrieved information on demographics, age, marital status, menstrual history, parity, socio-economic status, medical history and smoking/drinking habits. Anthropometric measurements including weight, height, triceps, biceps, subscapular and suprailiac skinfolds, as well as blood pressure measurements and urine analysis were performed at the first antenatal visit and repeated at 15, 25 and 35 weeks gestation. Anthropometric measurements of the newborn were performed at birth.Results:There were significant differences between anthropometry and skinfold thickness at the first antenatal visit between the adolescents and the mature women where the adolescents had lower measurements compared to the mature women. In the newborn anthropometry, the only significant difference seen was in the triceps skinfold thickness and the mid-upper arm circumference where the newborn of the adolescents had significantly smaller values (P=0.04; P=0.02, respectively). The percentage fat, fat mass and lean body mass were significantly lower in the adolescent compared to the mature women (P<0.0001), both at the first antenatal visit and at 35 weeks gestation. A greater gain was seen in these measurements throughout the pregnancy in the adolescents (P<0.0001). Linear regression analyses showed that the gain in lean body mass was the most important predictor of birth anthropometry.Conclusion:Body composition differs in pregnancy between adolescents and mature woman, and if adequate weight and lean body mass are attained, it impacts positively on birth size irrespective of age.Sponsorship:This study was supported by a grant from the Caribbean Health Research Council, 25A Warner Street, St Augustine, Trinidad, West Indies.

Neonatal sepsis in very low birthweight infants at the university hospital of the West Indies

A retrospective review was conducted on the charts of all very low birthweight (VLBW) infants with culture proven sepsis admitted to the neonatal unit of the University Hospital of the West Indies (UHWI) during the period January 1, 1995 to December 31, 2000. During the study period, 22 VLBW infants were admitted to the neonatal unit with culture proven sepsis, 16 (73%) survived and 6 (27%) died As birthweight and gestational age increased, outcome improved There was no difference in survival based on age at presentation. Neonates with early onset disease had a significantly longer mean duration of rupture of membranes than those with late onset disease (p = 0.009) and babies with late onset disease had a significantly lower mean Hb level than those with early onset disease (p = 0.000). Predominant isolates were Klebsiella sp (10, 37%), Streptococcus Group D (4, 15%), Escherichia coli (3, 11%) and Group B Streptococcus (3, 11%). Klebsiella sp accounted for 8/13 (62%) of late onset infections. Complications included anaemia, thrombocytopenia, bleeding and multi-organ failure. Strategies aimed at prevention, such as limiting the excessive use of broad-spectrum empiric antibiotics and the periodic review and continuous reinforcement of infection control policies will help decrease the mortality and morbidity associated with nosocomial infection in the VLBW infant.

Neonatal sepsis in Jamaican neonates.

Abstract Aim: To determine the incidence and causative organisms of bacterial sepsis in neonates at The University Hospital of the West Indies. Methods: A retrospective review of all neonates with culture-proven sepsis admitted to the hospital between January 1995 and December 2000 was conducted. Incidence rates and antimicrobial susceptibility patterns were determined. Results: There were 4702 admissions to the neonatal unit during the study period. Of these, 135 had culture-proven sepsis and 115 were inborn, giving an incidence of 6.7/1000 live births. There were 89 positive blood cultures, 51 positive urine cultures and two positive CSF cultures. The single most common organism was Klebsiella spp (28%). Other organisms included Escherichia coli (16%), group B Streptococcus (11%) and Enterobacter spp (10%). The aminoglycoside resistance rate of Klebsiella spp was 46% and seven isolates had multiple resistance to antibiotics. There was a case fatality rate of 6.7%. Conclusion: Physicians involved in newborn care at The University Hospital of the West Indies need to recognise the important role Klebsiella now plays in neonatal sepsis and its contribution to neonatal mortality. Empirical antibiotic regimens for gram-negative sepsis must take into consideration the high rates of aminoglycoside resistance that are now prevalent.

Hypernatraemic dehydration in Jamaican breastfed neonates: a 12-year review in a baby-friendly hospital

Abstract A 12-year retrospective review of neonates admitted with hypernatraemic dehydration to the neonatal unit of the University Hospital of the West Indies was conducted between 1 January 1990 and 31 December 2001. Twenty-four infants fulfilled the criteria for hypernatraemic dehydration. Nineteen (79%) women were either nulliparous or primiparous with a mean (SD) age of 26.9 (4.4) yrs. Modal length of hospital stay for mothers was 24 hrs. Twenty (83.3%) infants were exclusively breastfed. Mean (SD) age at presentation was 7.4 (3.8) days. Mean (SD) percentage weight loss between birth and presentation was 18.9% (6.3). Mean (SD) serum sodium at presentation was 164.8 (13.9) mmol/L. Babies visited at home by nurses had a lower mean serum sodium, were less dehydrated and were significantly less acidiotic. Their mean (SD) length of hospital stay was also significantly less [4.2 (1.4) days] than those who were not visited [7.9 (3.8) days] (p < 0.05). Complications occurred in 19 (79%) of infants and included renal failure (19, 79%), seizures (3, 13%) and intraventricular haemorrhage (1, 4%), and one died (4%). Hypernatraemic dehydration is an uncommon complication of failure to establish breastfeeding but is associated with severe morbidity and mortality. Education programmes are needed to increase awareness amongst health-care workers and mothers in order to prevent the problem.

The neonatal intensive care unit at the University Hospital of the West Indies: the first few years' experience

A retrospective analysis of neonates admitted for ventilatory support to the neonatal intensive care unit at the University Hospital of the West Indies between August 2001 and December 2004 was conducted. One hundred and thirty-eight neonates fulfilled criteria for admission into the study. Ninety-eight (71%) were inborn, 88 (64%) survived and 50 (36%) died. The median age at death was 72 hours and 72% of non-survivors died within one week of life. The main reasons for admission into the unit were respiratory distress syndrome 87(63%), followed by hypoxic ischaemic encephalopathy 15 (11%), surgical indications 13 (9%) and meconium aspiration syndrome 11 (8%). Babies with meconium aspiration syndrome and surgical problems had the best survival 82% and 85% respectively. Survival rates increased with increasing birthweight and gestational age. The most common complication seen was air leaks. The judicious use of neonatal intensive care measures in a developing country can result in a reduction of morbidity and mortality. However to maximize on benefits versus cost in an atmosphere of budgetary constraint evidence based management policies and protocols must be developed and implemented

The impact of the establishment of a neonatal intensive care unit on the outcome of very low birthweight infants at the University Hospital of the West Indies

A retrospective analysis of the outcome of inborn very low birthweight infants admitted to the neonatal unit of the University Hospital of the West Indies pre- (period 1) and post- (period 2) establishment of a neonatal intensive care unit was conducted. During the study, 250 infants were admitted to the neonatal unit, 132 (53%) during period 1 and 118 (47%) during period 2. There was improved survival during period 2 when 81 (69%) infants survived compared to period 1 when 73 (55%) survived (p = 0.02). This increased survival was due to an increase in survival of infants weighing 750-999g in period 2 when 17 (65%) infants survived compared to 9 (29%) in period 1 (p < 0.05). There was an increase in the number of infants ventilated in period 2, 39 (33%) compared to 12 (9%) period 1 (p < 0.001). Infants who were ventilated in period 2 were less likely to die than those ventilated in period 1 (OR 0.05, CI 0.01, 0.66). After controlling for gender, weight, gestational age and ventilation, infants born in the second time period were less likely to die than those born in the first time period (OR 0.33, CI 0.14, 0.76). The establishment of a neonatal intensive care unit has resulted in improved survival of very low birthweight infants; further improvement in survival of these infants will be dependent on increased accessibility to surfactant therapy, initiation of total parenteral nutrition and availability of trained personnel.

Predictors of poor outcome in neonates with bacterial sepsis admitted to the University Hospital of the West Indies

To determine factors that affect outcome in neonates with culture-proven sepsis, the charts of all neonates with culture-proven sepsis admitted to the University Hospital of the West Indies between January 1995 and December 2000 were reviewed retrospectively. Neonates who survived without developing any complications (favourable outcome group) were compared with those who died and/or developed severe complications during the course of treatment (poor outcome group). Chi-square tests were done to determine factors associated with poor outcome; univariate and multivariate logistic regression analyses were also performed. One hundred and thirty-five neonates had culture-proven sepsis, of which 89 (66%) were term infants and 46 (34%) were preterm. Male to female ratio was 1.6:1. One hundred and twenty-six (93%) survived and 9 (7%) died. Case fatality rates were higher for premature infants (15%) than for term infants (2%). Twenty-four (18%) of the neonates with culture proven sepsis had a poor outcome. Gram negative organisms accounted for 19 (70%) of the cases with poor outcome. Prematurity (p < 0.001), very low birthweight (p < 0.001) and female gender (p < 0.05) were factors associated with poor outcome. Strategies aimed at decreasing morbidity and mortality in neonates with sepsis must include measures that will decrease the incidence of prematurity and low birthweight.

Fetal growth and birth size is associated with maternal anthropometry and body composition

The objective was to investigate the association of maternal weight, height and body composition with fetal growth. We recruited 425 women at the University Hospital of the West Indies, Jamaica, who had singleton pregnancies, were less than 15 weeks gestation and had no systemic illness. Maternal weight, height and skinfold thicknesses were measured at the first antenatal visit and lean mass was calculated. Sonographic measurements of the fetus were made at 15, 25 and 35 weeks gestation. Weight, crown-heel length and head circumference were measured at birth. Analyses were confined to 360 (85%) women; 65 women did not complete the study. Maternal height was positively associated with femoral length at 25 and 35 weeks gestation and with head circumference at 35 weeks (all P < 0.02). Maternal weight was positively associated with abdominal circumference and femoral length at 25 weeks, and with larger head and abdominal circumference and longer femur at 35 weeks (all P < 0.02). Maternal lean mass had similar associations to maternal weight and they were both positively associated with estimated fetal weight (all P < 0.02). All three maternal measurements were positively associated with birthweight, length and head circumference. Maternal size was associated with fetal size as early as 25 weeks gestation, with height strongly associated with femoral length, and with weight and lean mass strongly associated with abdominal circumference.

Outcome of neonates ventilated in the main intensive care unit at The University Hospital of the West Indies: a 15-year experience.

A 15-year retrospective review of neonates ventilated in the main intensive care unit at the University Hospital of the West Indies was conducted. During the study period, 153 neonates were ventilated, of whom 80 (52%) survived. The most common reason for admission was respiratory distress syndrome, which accounted for 67% (102/153) of admissions, 53 (52%) of these infants survived. Improving outcome will require strategies directed at improving neonatal intensive care.