Willem P.F Fetter

Neonatal respiratory morbidity following elective caesarean section in term infants. A 5-year retrospective study and a review of the literature.

Respiratory morbidity is an important complication of elective caesarean section. The presence of labour preceding caesarean section reduces the risk of neonatal respiratory morbidity. Recently, it has been shown that the incidence of respiratory morbidity is lower in infants with a gestational age of at least 39(+0) weeks at elective caesarean section compared to infants with a gestational age less than 39(+0) weeks.This article describes the results of a 5-year retrospective study on the incidence of respiratory distress in term neonates delivered by elective caesarean section in relation to gestational age and provides a literature review on neonatal respiratory morbidity following elective caesarean section.

A randomised controlled trial comparing two temporising management strategies, one with and one without plasma volume expansion, for severe and early onset pre‐eclampsia

Objectives  Plasma volume expansion may benefit both mother and child in the temporising management of severe and early onset hypertensive disorders of pregnancy.

Seizure detection in the neonatal EEG with synchronization likelihood.

OBJECTIVE To investigate whether epileptic seizure activity can be distinguished from non-epileptic background activity in the neonatal electroenceplalogram (EEG), using synchronization likelihood as a measure of synchronization between EEG channels. METHODS Forty-two 21s EEG epochs and two complete EEGs from 21 different neonatal patients in a 12-channel bipolar recording were studied (AD-conversion 16bit; sample frequency 200Hz; filter setting 0.5-30Hz). For EEG of each patient, we selected one epoch with epileptic discharges and one without. Synchronization was calculated in all epochs. In two complete EEGs, synchronization was calculated and correlated with a visual scoring of the EEG. RESULTS Synchronization likelihood was higher in all the epochs with epileptic seizures as compared to the epochs without epileptic activity (P<0.01). When synchronization likelihood exceeded 0.11, the sensitivity for the presence of epileptic activity was 0.85 (95% confidence limits [CL(95)]=0.69-1) and the specificity was 0.75 (CL(95)=0.56-0.94).Analysis of EEG score and synchronization likelihood of two complete EEGs revealed a high correlation between the occurrence of epileptic seizures and elevated synchronization likelihood (Spearman r=0.707, P<0.001). CONCLUSIONS The results of this study demonstrate that synchronization likelihood is a potential tool in the automatic monitoring of high-risk infants for epileptic activity on neonatal wards.

Substandard factors in perinatal care in The Netherlands: a regional audit of perinatal deaths

BACKGROUND To determine: 1) whether substandard factors were present in cases of perinatal death, and to what extent another course of action might have resulted in a better outcome, and 2) whether there were differences in the frequency of substandard factors by level of care, particularly between midwives and gynecologists/obstetricians and between home and hospital births. METHODS Population-based perinatal audit, with explicit evidence-based audit criteria. SETTING The northern part of the province of South-Holland in The Netherlands. All levels of perinatal care (primary, secondary and tertiary care, and home and hospital births) were included. CASES Three hundred and forty-two cases of perinatal mortality (24 weeks of pregnancy--28 days after birth). MAIN OUTCOME MEASURES Scores by a Dutch and a European audit panel. Score 0: no substandard factors identified; score 1, 2 or 3: one or more substandard factors identified, which were unlikely (1), possibly (2) or probably (3) related to the perinatal death. RESULTS In 25% of the perinatal deaths (95% Confidence Interval: 20-30%) a substandard factor was identified that according to the Dutch panel was possibly or probably related to the perinatal death. These were mainly maternal/social factors (10% of all perinatal deaths; most frequent substandard factor: smoking during pregnancy), and antenatal care factors (10% of all perinatal deaths; most frequent substandard factor: detection of intra-uterine growth retardation). We did not find statistically significant differences in scores between midwives and gynecologists/obstetricians or between home and hospital births. The European panel identified more substandard factors, but these were again equally distributed by level of care. CONCLUSIONS Perinatal deaths might be partly preventable in The Netherlands. There is no evidence that the frequency of substandard factors is related to specific aspects of the perinatal care system in The Netherlands.

Surfactant replacement therapy in neonates with respiratory failure due to bacterial sepsis

We describe four newborns (gestational ages 29‐37 weeks; birthweights 1380‐3040 grams) who were mechanically ventilated for respiratory insufficiency because of bacterial sepsis. A beneficial effect of bovine surfactant (Alvofact, dosages 50 or lOOmg/kg) was found, as shown by decreases in mean airway pressures and oxygen demands. No side effects were seen after instillation.

Neuromotor Function and School Performance in 7 year old children born as high-risk preterm infants

Neuromotor behavior was studied in 63 children at a mean age of 7 years. They were born at a gestational age less than 32 weeks and/or birthweight under 1500 g and were categorized according to their medical history in conformance with the Neonatal Medical Index (from category I to V, from few to serious complications). We included only children considered at high risk as categorized in III to V. The neuromotor behavior study focuses on different subcategories, such as hand function, quality of walking, posture, passive muscle tone, coordination, and diadochokinesia. Hand preference and/or lateralization, the presence of associated movements, and/or asymmetry were noted, as was school performance. Then gender, gestational age, birthweight, and dysmaturity were investigated as confounding factors. The outcome at 7 years was correlated with the Neonatal Medical Index and the neonatal brain ultrasonography classification. None of the children scored 100% on the combined subcategories. Nineteen children (30%) had an overall score between 75 and 99%. Significant relationships between all different subcategories were found. Lack of hand preference, poor lateralization, and male gender were related to poor overall outcome. Poor motor control was correlated to special schooling and education below age level. The Neonatal Medical Index proved to have a significant influence on total outcome and the subcategories at the age of 7 years, with the worst outcome in children formerly classified in category V. Neuromotor behavior at 7 years of age was not related to birthweight, gestational age, dysmaturity, and neonatal brain ultrasonography classification only. (J Child Neurol 2002;17:325-332).

Incidents associated with mechanical ventilation and intravascular catheters in neonatal intensive care: exploration of the causes, severity and methods for prevention

Objectives To systematically investigate the causes and severity of incidents with mechanical ventilation and intravascular catheters in neonatal intensive care units (NICUs) in the Netherlands, in order to develop effective strategies to prevent such incidents in the future. Design Prospective multicentre survey. Methods Inclusion criteria were: incidents with mechanical ventilation and intravascular catheters reported to a voluntary, non-punitive, incident-reporting system which had been systematically analysed using the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method. The type, severity and causes of incidents reported from 1 July 2005 to 31 March 2007 are described. Local interventions performed as a result of systematic analysis of incidents are also described. Results 533 of 1306 (41%) reported incidents with mechanical ventilation and intravascular catheters (n=339/856 and n=194/450, respectively) had been PRISMA analysed and were included in the study. Four incidents resulted in severe harm, 18 in moderate harm and 222 in minor harm. Tube-related incidents accounted for the greatest proportion of harm. 1233 root causes were identified, with most being classified as human error (55%). Of the remaining failures, 20% were organisational, 16% technical, 6% patient-related and 4% unclassifiable. The majority of failures were rule-based errors. Conclusion Incidents with mechanical ventilation and intravascular catheters occur regularly in NICUs, and frequently harm patients. Multicentre, systematic analysis increases our knowledge of these events. Continuous training and education of all NICU personnel is required, together with preventive strategies aimed at the whole system – including the technical and organisational environment – rather than at human failure alone.

Substandard factors in perinatal care in The Netherlands

Background. To determine: 1) whether substandard factors were present in cases of perinatal death, and to what extent another course of action might have resulted in a better outcome, and 2) whether there were differences in the frequency of substandard factors by level of care, particularly between midwives and gynecologists/obstetricians and between home and hospital births.

Streptococcal pharyngitis and epiglottitis in a newborn infant

We describe a newborn infant withStreptococcus sanguis septicaemia and concomitant upper airway obstruction due to epiglottitis and pharyngitis. This rare infection of the supraglottic region was treated with endotracheal intubation and antibiotics. Full recovery occurred within 4 days.

Fatal outcome of neonatal group A beta-haemolytic streptococcal infection.

Sir: Endemic episodes of neonatal infections with group A beta-haemolytic streptococci were well known in the early days of neonatal intensive care [2]. Nowadays, neonatal streptococcal septicaemia is mainly caused by beta-haemolytic group B streptococci. Neonatal infections with group C, group D, and group G streptococci are reported sporadically. Neonatal group A streptococcal infections are usually asymptomatic or present as omphalitis. Infection can occur following passage through a colonized vaginal tract or from contact with hospital staff [1]. Maternal pharyngitis has also been described as the source of infection [7]. In the last decade an increasing amount of serious group A streptococcal infections in children as well as in adults has been reported, pointing to a changing epidemiology [3]. Recently we treated a newborn with sepsis due to an infection with group A beta-haemolytic Streptococcus. The mother was admitted to a local hospital because of fever and influenza like symptoms. The membranes were intact. Antibiotics were not prescribed, and she delivered spontaneously the next day, at 32 weeks of gestation. The baby, a girl, weighed 1900 g and did well directly after birth. Mild respiratory distress was treated with extra oxygen. At the age of 3 h a fever developed (> 38 ~ C). After an interval of 4 h antibiotic therapy was started (Amoxycillin and Tobramycin). Two hours later she went into severe respiratory and circulatory failure, and was transferred to our neonatal intensive care unit while on mechanical ventilation. During transport severe hypotension was treated with plasma and dobutamin. Ventilatory failure and shock persisted despite mechanical ventilation and extensive treatment with plasma infusions and inotropic support (Dopamin and Dobutamin). Persistent fetal circulation was treated with Tolazotin and Prostacyclin without success. The baby died 2 h after admission because of massive pulmonary haemorrhage. Autopsy was not obtained. Cultures of gastric aspirate, tube tip, and blood grew group A beta-haemolytic Streptococcus. After delivery the mother developed puerperal fever. She was treated with antibiotics and recovered. Group A betahaemolytic Streptococcus was cultured from the placenta. Serious infections with group A betahaemolytic streptococci are resurging, as demonstrated by an outbreak of acute rheumatic fever [5], and toxic shock syndromes [4, 6]. These clinical entities are caused by exotoxins A and B, produced by group A beta-haemolytic streptococci, especially those belonging to the M-type 1, M-type 3 and M-type 18 strains [5, 6]. The M protein is type-specific and indicates the agressivity of the Streptococcus to leucocytes. An increase in the prevalence of virulent group A beta-haemolyfic streptococci may account for the increased incidence of severe infections. In the absence of antibodies against these M-type strains, serious and even fatal disease can occur. The reason for the Sow incidence in newborns is probably the transplacentally acquired passive immunity. Preterm babies are relatively immunocompromised, particularly as a result of their low immunoglobulin status, which may predispose them to the acquisition of fulminant infectious diseases. Our case report shows the fatal outcome of perinatally acquired group A beta-haemolytic streptococcal infection. More neonatal infections caused by these bacteria may be expected in the future.