Ronald Coen

Antenatal origin of neurologic damage in newborn infants. I. Preterm infants.

Currently, the diagnosis of white matter necrosis may be performed with echoencephalography when cysts are observed in the white matter adjacent to the lateral ventricles. One hundred twenty-seven infants with a gestational age

Antenatal origin of neurologic damage in newborn infantsII. Multiple gestations

Necrosis of the cerebral white matter may be identified in living infants with echoencephalography. Echoencephalographic studies were performed in 89 twins and 12 triplets at less than 36 weeks of gestation to determine the incidence and complications associated with antenatal necrosis of the cerebral white matter. Antenatal necrosis of the cerebral white matter was identified when brain atrophy or cavities in the white matter were present by day 3 of life. Fourteen infants (13.8%) were considered to have antenatal necrosis of the cerebral white matter. The incidence of antenatal necrosis of the cerebral white matter was higher in monochorionic than in dichorionic infants (30% vs 3.3%; p less than 0.001). Univariate analysis showed that antenatal necrosis of the cerebral white matter was significantly associated with polyhydramnios, intrauterine fetal death of the cotwin, hydrops, multiple placental vascular connections, and placental artery-to-artery, vein-to-vein, and artery-to-vein anastomosis. Logistic regression analysis showed that antenatal necrosis of the cerebral white matter was predicted by the presence of either artery-to-artery or vein-to-vein anastomosis and by intrauterine fetal death of a cotwin. Vein-to-vein anastomosis had the strongest association, because 89% of seven infants with vein-to-vein anastomosis demonstrated antenatal necrosis of the cerebral white matter (p = 0.003). Monochorionic multiple gestations frequently are complicated by antenatal necrosis of the cerebral white matter. Multiple vascular connections with vein-to-vein anastomosis appear as the most important associated factor for antenatal necrosis of the cerebral white matter in this population.

Detection of neonatal seizures through computerized EEG analysis

Neonatal seizures are a symptom of central nervous system disturbances. Neonatal seizures may be identified by direct clinical observation by the majority of electrographic seizures are clinically silent or subtle. Electrographic seizures in the newborn consist of periodic or rhythmic discharges that are distinctively different from normal background cerebral activity. Utilizing these differences, we have developed a technique to identify electrographic seizure activity. In this study, autocorrelation analysis was used to distinguish seizures from background electrocerebral activity. Autocorrelation data were scored to quantify the periodicity using a newly developed scoring system. This method, Scored Autocorrelation Moment (SAM) analysis, successfully distinguished epochs of EEGs with seizures from those without (N = 117 epochs, 58 with seizure and 59 without). SAM analysis showed a sensitivity of 84% and a specificity of 98%. SAM analysis of EEG may provide a method for monitoring electrographic seizures in high-risk newborns.

The effects of maternally administered magnesium sulfate on the neonate

The effects of parenterally administered magnesium sulfate on maternal and neonatal calcium and magnesium metabolism in nonasphyxiated, term pregnancies complicated by pregnancy-induced hypertension were studied prospectively. In addition, the neurobehavioral effects of neonatal hypermagnesemia were investigated by means of a neonatal assessment scale that specifically measures reflex activity and both passive and active muscle tone. Maternal magnesium sulfate infusion was associated with maternal and neonatal hypermagnesemia when compared with that of control subjects (1.8 +/- 0.10 to 3.6 +/- 0.5 mg/dl, p less than 0.001, and 1.75 +/- 0.2 to 3.6 +/- 0.5 mg/dl, p less than 0.005, respectively). Maternal serum calcium levels fell with magnesium therapy (9.3 +/- 0.18 to 7.9 +/- 0.1 mg/dl, p less than 0.001), while neonatal calcium levels were unaffected (10.8 +/- 0.44 to 10.5 +/- 0.38 mg/dl, p less than 0.05). Neurological status examinations in the neonate were similar in both the control and treatment groups. In addition, neurological performance of the neonate did not correlate with cord magnesium levels or to the total dose of magnesium administered.

Periodic lateralized epileptiform discharges in asphyxiated neonates

Electrographic seizures (EGS) were detected in 13 of 16 asphyxiated neonates who were undergoing continuous electroencephalographic monitoring for detection of evidence of central nervous system injury. Five of the 13 neonates with EGS also had periodic lateralized epileptiform discharges (PLEDs). The electrographic characteristics of PLEDs in these infants were similar to those reported in neonatal herpes simplex encephalitis and in older children and adults. Of the 5 neonates with PLEDs, 2 died, 2 are developmentally delayed and only 1 is normal at 12 months. This is in contrast to the normal outcome for 8 of the 11 infants who did not have PLEDs. One other was neurologically normal but died of pulmonary disease at 3 months and the other two were developmentally delayed. PLEDs in neonates, as in other age groups, lack diagnostic specificity, but when associated with neonatal asphyxia, may indicate a poor prognosis. Continuous EEG monitoring is helpful in identifying PLEDs in these cases.

Management of hydrocephalus secondary to intracranial hemorrhage in the high risk newborn.

&NA; The experience of the Special Care Nursery of the University of California Medical Center, San Diego, in the management of the high risk newborn with progressive ventricular enlargement is reviewed, and the physiopathological basis of progressive ventricular enlargement is analyzed. (Neurosurgery 14:612‐618, 1984)

1243 ASSOCIATION OF EARLY AORTOGRAMS & PDA LIGATION WITH INTRAVENTRICULAR HEMORRHAGE (IVH)

Thirty-three sick infants (<34 wk gest.) with RDS, PDA & subependymal hemorrhage (SEH) &/or minor IVH (without ventricular enlargement) were followed with frequent ultrasound brain studies to detect changes in IVH/SEH. Twenty-six had PDA ligation before 96 hours of life (“early”) & 7 after 96 hrs (“late”). Sixteen of 23 infants increased their IVH/SEH after early ligation. No changes occurred in those ligated late.Ligated infants who increased tneir IVH/SEH had aortograms more frequently than infants without IVH/SEH change. Both procedures might result in an acute increase in arterial blood pressure in infants lacking cerebral blood flow autoregulation. Early PDA ligation preceded by aortogram may be a risk factor for major IVH/SEH.

Postpartum glycosylated hemoglobin levels in mothers of large--for--gestational age infants.

Glycosylated hemoglobin levels were determined in 19 women who were delivered of large--for--gestational age (greater than 4,082 grams) infants and compared to control values. Although the mean level for each group did not differ significantly (6.7% +/- 1.5% versus 6.5% +/- 0.2%) three women had increased hemoglobin glycosylation. In this series the birth of a large infant correlated with prepregnancy obesity and greater weight gain during pregnancy.

1240 LARGE INTRAVENTRICULAR HEMORRHAGE (IVH) AND LABOR IN INFANTS ≥11000g

Seventy-five infants ≤34 weeks gestation & birthweight ≥1000g had ultrasound brain studies to diagnose IVH and subependymal hemorrhages (SEH) on the first day of life (30′ to 23 hrs. after birth). They were grouped according to delivery (with & without labor). Diagnosis in the first 24 hours after birth & major IVH/SEH (IVH/SEH associated with ventricular enlargement) were considered.Infants born after labor had a higher incidence of major IVH/SEH even if those without RDS, PDA and asphyxia born with labor were compared with sick infants born without labor (2 Rh-hydrops, 14 RDS & PDA, 2 severe asphyxia). Labor seems important in the pathogenesis of large IVH/SEH in infants BW≥1000g.

1241 EARLY PDA TREATMENT WITH INDOMETHACIN (INDO) S INTRAVENTRICULAR HEMORRHAGE (IVH)

Thirty sick infants (BW≥1200g) without IVH or subependymal hemorrhage (SEH) or with minor IVH/SEH (without ventricular dilation) on the 1st day of life had frequent ultrasound studies during the 1st week to detect changes in IVH/SEH. Eleven infants with RDS & PDA were treated with Indo before 96 hrs. of life. These treated infants were compared with 19 sick infants who did not receive Indo.There was no difference in proportion of infants who increased IVH/SEH size in treated & untreated groups. Early Indo treatment of PDA does not seem to increase the incidence of major IVH/SEH in sick infants with BW ≥1200 g.