Katarina Matasova

Bilateral endogenous endophthalmitis as a complication of late-onset sepsis in a premature infant

Endogenous endophthalmitis is a potentially blinding ocular infection resulting from the haematogenous spread from a remote primary source with a very poor prognosis in premature infants. The patient, a boy, was delivered by caeserean section in the 30th week of gestation because of massive bleeding caused by placenta abruptio. Birth weight was 1620 g, Apgar score 8 and 9 at 1 and 5 min respectively. His family history was unremarkable and prenatal evaluation was normal. The immediate after-birth adaptation of the baby was appropriate. Due to respiratory distress he required respiratory support by means of nasal CPAP (FiO2 0.21) for 2 days. The child did not show any clinical signs of infection; nevertheless, ampicillin was administered for antibiotic protection of the umbilical venous catheter. On the 4th NICU day, the white blood cell count revealed mild leukopenia and gentamicin was administered because of a suspected bacterial infection. The blood culture was sterile and gentamicin was withdrawn 3 days later. On the 10th NICU day there was a sudden onset of sepsis with a clinical picture of septic shock. Cefoperazon and netilmicin were started. Conventional mechanical ventilation was necessary because of respiratory failure. Two days later, blood and sputum cultures confirmed Pseudomonas aeruginosa sepsis. Antibiotic therapy was adjusted on the basis of the mean inhibitory concentration testing and ceftazidim and tobramycin were administered. At the same time, despite systemic antibiotic therapy and complete intensive care, the patient’s condition worsened and symptoms of ocular infection appeared. Both eyes were swollen and protruding with purulent conjunctivitis. Severe chemosis, hypopyon and cloudy corneas were also present. Conjunctival cultures revealed the same strain of Pseudomonas aeruginosa and topical tobramycin was administered. Over the subsequent 2 days, oedema and corneal haziness worsened and ultrasound examination of the eyes showed retinal detachment. Despite intensive conservative therapy, endophthalmitis progressed rapidly and resulted gradually in corneal perforation, eyeball atrophy and complete loss of vision.

Impact of fetal pulse oximetry and ST analysis surveillance withdrawal on rates of obstetric surgery and frequency of low birth umbilical artery pH: a cause of rising caesarean rates?

A retrospective observational study on a sample of 13,413 deliveries analysed the effect of a withdrawal of the CTG additional diagnostic methods of fetal hypoxia (fetal pulse oximetry and ST analysis of the fetal ECG) on operative delivery rates and frequency of the umbilical arterial pH < 7.15. Following the withdrawal, obstetricians are more likely to perform caesarean sections for fetal hypoxia (OR 2.23, 95% CI 1.94–2.55, p < 0.0001) and labour dystocia (OR 1.45, 95% CI 1.18–1.77, p = 0.0003), which increases the overall caesarean rate (OR 1.49, 95% CI 1.38–1.61, p < 0.0001), although decreases the incidence of birth umbilical arterial pH < 7.15 (OR 0.43, 95% CI 0.22–0.85, p = 0.015). This also leads to the significant decline in overall frequency of instrumental vaginal deliveries (OR 0.58, 95% CI 0.48–0.71). In order to decrease the overall caesarean rate, obstetricians need to be supported by more accurate and possibly automated diagnostic tools for intrapartum fetal hypoxia.

Physiological changes in blood flow velocities in the superior mesenteric and coeliac artery in healthy term fetuses and newborns during perinatal period.

Objective. The aim was to describe the course of physiological changes in coeliac artery (CA) and superior mesenteric artery (SMA) blood flow velocities (BFVs) during the perinatal period in healthy term fetuses and infants as it has not been studied in detail so far. Methods. This prospective Doppler ultrasound study included 50 infants. The examinations were performed in a fetus after the completion of 36.0 gestation weeks before the onset of labor and in infants postnatally at the ages of 2, 24, and 72 h. Results. The end-diastolic velocity (EDV) in the CA was generally higher than in the SMA (p < 0.001). The EDV in the SMA decreased postnatally (8.4 vs. −7.2, p < 0.001) and showed negative values in 92% of infants. By 24 h of postnatal age, EDV in the SMA had become positive in all of the infants (mean 13.8 cm/s, p < 0.001). The EDV in CA had only positive values. The changes in EDV in both vessels were reflected by changes in the resistance index in inverse manner. Conclusions. BFV in the CA and SMA changed dramatically in the perinatal period; the most remarkable changes occurred within the first 24 h of life.

Accuracy of transcutaneous bilirubin measurement in newborns after phototherapy

Objective:We tested the accuracy of transcutaneous bilirubin (TcB) measure in newborns undergoing phototherapy.Study Design:In a prospective study of 150 term Caucasian neonates, 255 measurements of total serum bilirubin (TSB) and TcB concentration were obtained 2 h after discontinuing phototherapy. TcB measurements obtained on the forehead, sternum, abdomen and covered lower abdomen were statistically compared with the corresponding TSB.Result:TcB consistently underestimated TSB levels significantly. The smallest but significant difference between TSB and TcB was found on the lower abdomen. The correlation between TSB and TcB was found to be moderately close (r=0.4 to 0.5). TcB measurements were inaccurate, regardless of phototherapy technique (Bilibed, conventional phototherapy).Conclusion:Phototherapy significantly interferes with the accuracy of transcutaneous bilirubinometry. TcB measurements performed 2 h after stopping phototherapy were not reliable, even if they were carried out on the unexposed body area. TSB assessment remains necessary, if treatment of hyperbilirubinemia is being considered.

Apnea in preterm newborns: determinants, pathophysiology, effects on cardiovascular parameters and treatment

Abstract Apnea, especially in preterm newborns (AoP) is one of the common problems encountered at neonatal units. Numerous factors are likely to play a role in the etiology of apnea. Recent data sugest a role for genetic predisposition of AoP. It seems, that physiological rather than pathological immaturity of the respiratory, or cardiorespiratory control, play a major part in the pathophysiology of AoP. Immaturity of the brainstem, cerebral cortex, receptors of the lungs and the airways as well as of the chemoreceptors contribute to the development of apnea in preterm newborns. Several neurotransmitters (GABA, adenosin, endorphins) and their maturational changes are including in pathogenesis of apnea, too. The instability of the upper airway in preterm infants, asynchrony of musculature of the upper airway and diaphragm, pathological changes in the upper airway and malformations of the central nervous system might also contribute to the occurrence and severity of AoP. In newborns, apnea occurs more frequently in active sleep than in quiet sleep and the frequency of apnea in active sleep is higher in the warm conditions. Durations of apnea correlate with the body heat loss. Cardiovascular changes during apnea - bradycardia, peripheral vasoconstriction and various changes in peripheral blood flow and pressure occur together with changes in ECG. The standard clinical management of apnea includes non-pharmacological treatment (eliciting arousal reactions and reflex breathing by mechanical skin, or mucosa stimulations), pharmacological treatment (methylxanthines are preferred) and application of continuous positive airway pressure (CPAP) or in severe apnea - mechanical ventilation.

The assessment of intracranial dynamics by transcranial Doppler sonography in perioperative period in paediatric hydrocephalus

PurposeTo evaluate Doppler parameters of anterior cerebral artery (ACA) and relationship to morphological parameters of cerebral ventricles and periventricular brain tissue in paediatric hydrocephalus before and after drainage procedure.MethodsForty newborns with hydrocephalus were evaluated before and after the drainage procedure. The morphological parameters of brain (ventricular index, width of ventricles, haemorrhagic lesions, asymmetric ventricular dilatation and dynamics of ventricles) were measured by transcranial ultrasonography. The haemodynamic parameters of ACA (peak systolic blood flow velocity, end-diastolic blood flow velocity and resistance index/RI/) were evaluated by Doppler ultrasonography. The correlation between morphological and haemodynamic parameters was analysed.ResultsWe found significant decrease of ventricular dilatation, which was accompanied with significant decrease of basal and compressive RI-ACA after drainage procedure. The correlation between basal RI-ACA, compressive RI-ACA and the dynamics of ventricular dilatation was not significant before and after drainage operation, as well. The significant correlation between preoperative basal RI-ACA, postoperative compressive RI-ACA and asymmetry of cerebral ventricles was confirmed. Statistical analysis showed significant correlation between basal RI-ACA, compressive RI-ACA and haemorrhagic lesions after drainage operation.ConclusionsThe results of our study showed the alteration of Doppler parameters of cerebral circulation in newborns with hydrocephalus before the drainage procedure. The successful drainage operation leads to the improvement of haemodynamic parameters of cerebral circulation. However, the statistical analysis showed the influence of some intracranial factors—the asymmetry of dilatation of lateral cerebral ventricles and periventricular haemorrhagic lesions on the Doppler parameters of cerebral circulation.

Early Postnatal Changes in the Superior Mesenteric Artery Blood Flow Parameters in Late Preterm Newborns - A Pilot Study

Abstract Significant hemodynamic changes happen in the abdominal region at the moment of birth and during the first week of life in premature newborns. The aim of the study was to assess early postnatal changes of Doppler sonographic blood flow parameters in the superior mesenteric artery (SMA) occurring during the first three days of life in late preterm infants. 10 infants were enrolled into the prospective study. Abdominal blood flow velocities (ABFV) in the SMA were obtained at the age of 2, 24 and 72 hours (h), before feeding. Screening parameters included the peak systolic velocity (PSV), end-diastolic velocity (EDV), time-averaged mean velocity (TAMV). Doppler indices (DI) - resistance index (RI) and pulsatility index (PI) were calculated. EDV changed significantly from 2 h to 24 h [-13.08 cm/s (-20.46 - -9.34) to 12.79 cm/s (11.83 - 24.72); p < 0.01] with a further statistically insignificant increase within 72 h [12.79 cm/s (11.83 - 24.72) to 17.90 cm/s (16.93 - 19.25)]. The EDV values were negative in 9 out of l0 neonates at 2 h of age. The SMA PSV showed a daily increase from 2 h to 72 h. The ABFV and characteristics of vascular resistance (DI) in the SMA change significantly in near term infants within the first 3 days. At 2 h of age a negative blood flow and elevated parameters characterizing vascular resistance were documented in the superior mesenteric artery.

Changes in heart rate variability in a premature infant with hydrocephalus.

Objective To define changes of heart rate variability in premature infant with hydrocephalus before and after drainage procedure. Study Design The authors report a case of a premature infant with hydrocephalus with analysis of heart rate variability before and after drainage procedure. Three subsequent recordings of the electrocardiography and heart rate variability were done: the first at the age of 22 days before insertion of ventriculoperitoneal shunt, the second at the age of 36 days with functional shunt, the third at the age of 71 days (before discharge). Results Before drainage operation, there was reduced heart rate variability in time and spectral domains, and sympathetic activity was dominant. After surgery, an increase in heart rate variability parameters was found, particularly with spectral analysis. The ratio of low-frequency/high-frequency band and relative power of the low-frequency band decreased, reflecting enhanced parasympathetic activity. Conclusion Results of the heart rate variability analysis in a preterm infant with hydrocephalus before and after drainage procedure showed marked improvement in chronotropic cardiac regulation. Evaluation of heart rate variability in premature infants with hydrocephalus with increased intracranial pressure can be an additional method for monitoring of cardiac dysregulation and improvement of the cardiovascular control after successful drainage procedure.

Splanchnic Circulation in Small for Date Newborns

Abstract Hypotrophic newborn is a newborn with birth weight below the 5th percentile weight of corresponding gestational age. Hypotrophic infants have higher morbidity and mortality in comparison with eutrophic neonates. A higher incidence of hypoglycemia, polycythemia, hyperbilirubinemia, thrombocytopenia, perinatal asphyxia and caesarean section occurs typically in hypotrophic newborns. Both, intrauterine hemodynamic dysbalance and centralization of circulation due to hypotrophy cause decreased blood flow to the splanchnic circulation after the birth. There was observed a lower increase in blood flow through the coeliac artery and superior mesenteric artery in comparison with eutrophic newborns during the first postnatal week. These facts are likely to be associated with a higher frequency of abdominal problems and necrotizing enterocolitis.

Comparison of intraparenchymal circulation in various areas of the kidneys of newborns by means of Doppler ultrasound

Sir,I am delighted to have an opportunityto present the results of our study.In our previous Doppler study [1]we set normal values of renal circu-lation for a population of healthynewborns. Comparisons of Dopplerparameters of intraparenchymal (IP)renal arteries in various areas of thekidney in this age group have, how-ever,notyetbeenpublished.Availablesources of information are not suffi-cient [2, 3], and are not targeted to theneonatal period.Thirty physiologically normal termneonates (17 girls and 13 boys) withnegative perinatal history were en-rolled in this study. The examinationwas performed on day 4. No sedationwas required. Colour Doppler ultra-sound scanners were used with linear5–12-MHz multifrequency transduc-ers. Babies were examined in theprone position and kidneys werescanned from the dorsolateral view.Colour-flow mapping was performedto display renal blood flow. The lon-gest possible segment of the artery wasexamined under the optimal insonatingangle (less than 30°), keeping the sam-plevolumeassmallaspossible(1mm).IP arteries (arcuate and interlobulararteries) fromtheupperpole,themid-dlepartandthelowerpoleofthekidneywereassessed. Onemeasurement ofeacharterywasobtained.V