The early prediction of neonatal morbidity and mortality in singleton small for gestational age infants with a birthweight < 1,500 g.

OBJECTIVE: Identify factors for discrimination of "high" and "low risk" small for gestational age infants. STUDY DESIGN: Singleton infants born small for gestational age with a birthweight  <1,500 g between 1999 and 2007 were included. Maternal, placental, and infant related factors were analyzed with regard to mortality and morbidity. Patients who died or suffered from complications were defined "high risk" as opposed to "low risk". Parameters associated with "high risk" were identified and an equation established to predict the minimal expected probability to die or suffer from neonatal morbidity. RESULTS: Around 231 patients showed a mortality rate of 12.6 %, respiratory distress syndrome in 35.5 %, necrotizing enterocolitis in 8.2 % and neurological morbidities in 6.5 %. Of these, 58.9 % survived without complications. The factors for discrimination of "high" and "low risk" were Z-score of birth weight, gestational age, and pH. CONCLUSION: We facilitate prognostication by classifying small for gestational age preterms into "low" and "high risk".

Placental magnetic resonance imaging in monochorionic twin pregnancies.

OBJECTIVE: Twin-twin transfusion syndrome (TTTS) is a severe complication of monochorionic pregnancies. Placental hydrops might be a marker for TTTS. The purpose of this study was to evaluate whether differences in the placental parenchyma due to TTTS can be seen with fetal MRI. METHODS: In a retrospective study, 34 monochorionic pregnancies were investigated on a 1.5 Tesla MR. Seventeen pregnancies were affected by TTTS, and 17 showed no clinical signs of TTTS. Placental maturation and vascular pathologies, as well as the extent of the placental findings and allocation of placental tissue to each twin, were investigated. Placental findings were reported for origin, size, maturation, and placental thickness, and were correlated with the presence of TTTS. RESULTS: All placentas affected by TTTS showed abnormal maturation on MR scans, but only 64.7% of the non-TTTS group (p = 0.018). Vascular placental pathologies did not differ significantly between the TTTS and non-TTTS group. CONCLUSIONS: MR-signs of placental maturity in monochorionic twin pregnancies may indicate a lower risk of development of TTTS.

Fetal MRI for prediction of neonatal mortality following preterm premature rupture of the fetal membranes.

BACKGROUND: Lung MRI volumetrics may be valuable for fetal assessment following early preterm premature rupture of the foetal membranes (pPROM). OBJECTIVE: To evaluate the predictive value of MRI lung volumetrics after pPROM. MATERIALS AND METHODS: Retrospective cohort study of 40 fetuses after pPROM in a large, tertiary, perinatal referral center. Fetuses underwent MRI lung volumetrics. Estimated lung volume was expressed as percentage of expected lung volume (our own normal references). Primary outcome was neonatal mortality due to respiratory distress before discharge from hospital. RESULTS: Gestational age range was 16-27 weeks. Estimated-to-expected lung volume was 73% in non-survivors and 102% in survivors (P < 0.05). There were no survivors with a lung volume less than 60% of expected. By logistic regression, mortality could be predicted with a sensitivity of 80%, specificity of 86% and accuracy of 85%. CONCLUSION: Fetal MR lung volumetrics may be useful for predicting mortality due to respiratory distress in children with early gestational pPROM.

Long-term follow-up of babies exposed to azathioprine in utero and via breastfeeding.

BACKGROUND: Recommendations on breastfeeding under thiopurines are inconsistent due to limited data. AIM: To assess the risk of infections in offspring breastfed by mothers receiving azathioprine (AZA) for inflammatory bowel disease (IBD). METHODS: Babies, who were breastfed from their mothers treated either with or without AZA were included from a local pregnancy-registry. Women were asked by structured personal interview on general development, infections, hospitalisations and vaccinations of their offspring. RESULTS: A group of 11 mothers taking AZA (median 150 mg/d) during pregnancy and lactation and another of 12 patients without using any immunosuppressive therapy breastfed 15 babies each for median 6 months and 8 months, respectively. Median age of children at time of interview was 3.3 and 4.7 years, respectively. All offspring showed age-appropriate mental and physical development. Infections were commonly seen childhood diseases. Similar rates were observed for most of the various infections between offspring with and without azathioprine exposure during breastfeeding. However, common cold more than two episodes/year and conjunctivitis were numerically more often reported in the group without AZA exposure. In an exploratory analysis no difference in the rate of hospitalisations was seen between exposed (0.06 hospitalisations/patient year) versus non-exposed children (0.12 hospitalisations/patient year, p=0.8) CONCLUSION: Our study which reports the largest number of babies breastfed with exposure to AZA suggests that breastfeeding does not increase the risk of infections.

Renal failure, comorbidity and mortality in preterm infants.

OBJECTIVE: To evaluate patient characteristics and risk factors for mortality in critically ill preterm infants with renal failure, with a special focus on infants with extremely low birth weight. DESIGN: Retrospective cohort study with five year follow-up of all premature infants who were treated in the neonatal intensive care unit in 2002 and developed postnatal serum creatinine > or =1.5 mg/dl and/or urine output <1 ml/kg per h. SETTING: Tertiary Care University Hospital of the Medical University of Vienna PATIENTS: Sixteen of 359 premature infants (9 boys, 7 girls) fulfilled the inclusion criteria for renal failure. Their median gestational age was 30 weeks (range 24-36) with a median birth weight of 811.5 g (range 588-2662). MEASUREMENTS AND MAIN RESULTS: The most common causes of renal failure were sepsis and ischemic events. All infants were managed conservatively with corrections of fluids, electrolytes and acidosis, including medication with diuretics and dopamine. Eleven infants with renal failure (69%) died in multiorgan failure. Infants with low urine output, higher scores for failed organs or low birth weight were significantly more likely to die. Infants with very low birth weights had higher scores for failed organs (all P < 0.05). CONCLUSION: Oliguria/anuria, multiorgan failure and immaturity were significant risk factors for mortality in preterm infants with renal failure. Further studies and/or more registry data are needed to determine whether these infants died with or from renal failure, and whether dialysis would improve outcome in this special population.

Preterm birth and disruptive cerebellar development: assessment of perinatal risk factors.

OBJECTIVE: Abnormal cerebellar development was recently recognized to be related to prematurity. Aim of the present study was to evaluate preterm birth and possible peri- and postnatal risk factors associated with this type of brain injury. PATIENTS AND METHODS: We report on a series of 35 very low birth weight infants (birth weight 986+/-257g S.D.) born between 24 and 32 weeks of gestation (27.0+/-1.8 weeks of gestation S.D.) sustaining disruption of cerebellar development after preterm birth. Perinatal medical records of study patients were compared to 41 preterm control infants (birth weight 900+/-358g S.D., gestational age 26.3+/-2.1 weeks S.D.) with normal cerebellar development on MRI scan. RESULTS: A severely compromised postnatal condition with consecutive intubation and catecholamine support was found to be significant risk factor. Additional supratentorial hemorrhagic brain injury followed by posthemorrhagic hydrocephalus, neurosurgical interventions and hemosiderin deposits on the cerebellar surface were significantly related to disruptive cerebellar development. No other differences in perinatal factors were found between the groups. CONCLUSION: Premature birth between 24 and 32 gestational weeks associated with poor postnatal conditions and complicated supratentorial hemorrhagic brain lesions represents a high-risk situation for disruption of cerebellar development.

Disrupted cerebellar development in preterm infants is associated with impaired neurodevelopmental outcome.

The unfavorable impact of prematurity on the developing cerebellum was recently recognized, but the outcome after impaired cerebellar development as a prematurity-related complication is hitherto not adequately documented. Therefore we compared 31 preterm patients with disrupted cerebellar development to a control group of 31 gender and gestational age matched premature infants with normal cerebellar development. Supratentorial brain injuries during the neonatal period were comparable between the groups. At a minimum age of 24 months motor and mental development was assessed by standardized tests. Disrupted cerebellar development was associated with significantly poorer scores both in the subtests for neuromotor (p < 0.001) and mental development (p < 0.001), respectively. Mixed CP was diagnosed in 48% of affected patients, whereas none of the patients of the control group had mixed CP. Microcephaly and epilepsy were significantly related to disrupted cerebellar development. Preterm patients with disrupted cerebellar development exhibit poorer outcome results in all investigated variables. The role of the cerebellum in neurodevelopment after prematurity seems to be underestimated so far.

Disruption of cerebellar development: potential complication of extreme prematurity.

BACKGROUND AND PURPOSE: Infants with very low birth weight are at high risk for cerebral lesions. Although supratentorial brain damage is a common radiologic finding, posterior fossa pathologies are rare. We studied the morphology of cerebellar involvement in a large series of 28 premature infants born before the 30th week of gestation to define typical patterns and identify possible risk factors for this pathology. METHODS: Cranial sonograms were obtained in the early neonatal period. MR imaging was performed between the 2nd month and the 6th year of life. Morphologic patterns of cerebellar involvement were evaluated. RESULTS: Three morphologic patterns of cerebellar involvement were recognized: (1) symmetric volume reduction of the cerebellar hemispheres, which were floating immediately beneath the tentorium, and a small vermis with preserved shape; (2) symmetrical reduction in hemispheric volume with an enlarged, balloon-shaped fourth ventricle and a small, deformed vermis; and (3) normal overall cerebellar shape with extensive reduction of its dimensions. A small brain stem with flattened anterior curvature of the pons and loss of supratentorial white matter was present in all patients. CONCLUSION: Symmetric cerebellar volume reduction was found as a consequence of extreme prematurity. Selective vulnerability of the developing cerebellum in the window of 24-30 weeks of gestation, combined with several additive perinatal risk factors (eg, hemosiderin deposits) seems to lead to destruction of immature structures and developmental arrest. Therefore, the resulting condition is the consequence of disrupted cerebellar development.

Fetal and early postnatal magnetic resonance imaging--is there a difference?

AIM: To evaluate whether fetal magnetic resonance imaging (MRI) could replace early postnatal MRI in fetuses with central nervous system (CNS) anomalies. METHODS: Thirteen pregnancies presenting with fetal CNS anomalies were investigated using MRI. Indications included ventriculomegaly combined with additional CNS anomaly (n=5), isolated ventriculomegaly (n=2), arachnoid cyst (n=2), holoprosencephaly (n=1), complex malformation syndrome (n=1), Dandy walker malformation (n=1) and midline cyst (n=1). Early postnatal MRI followed within the first six weeks of life. RESULTS: Investigation with early postnatal MRI confirmed the fetal MRI diagnosis in all cases. Investigation with postnatal MRI presented additional information in two cases. However, there was no change in patient care. CONCLUSIONS: Fetal MRI should replace early postnatal MRI in infants with CNS anomalies.

Diagnosis and prevention of neural tube defects.

PURPOSE OF REVIEW: Neural tube defects, including anencephaly, meningomyelocele and encephalocele, are among the most common birth defects that result in severe mortality and morbidity. Neural tube defects occur with an incidence of 1-5 per 1000 births, showing marked geographic, ethnic and temporal variations. Although clear evidence exists on preventability of a large proportion of neural tube defects by periconceptional folic acid intake, only a low percentage of women are following the recommendations. RECENT FINDINGS: In the past few decades diagnostic modalities have undergone a change from blood screening tests, such as alpha-fetoprotein, to imaging methods. Ultrasound has become the standard tool for early diagnosis, whereas fetal magnetic resonance imaging has gained importance in evaluating distinct coexisting anomalies of the central nervous system. Since the United States authorized the addition of folic acid to grain products in 1996, many other countries are considering folic acid fortification of their grain products, or have started fortification. Hitherto there is no consensus either to the duration of supplementation or to the best dose. SUMMARY: Ultrasound and magnetic resonance imaging offer the possibility of early and accurate diagnosis of neural tube defects, and have therefore improved medical counseling and parents' decision making. Food fortification is the most practical way of ensuring sufficient folate supplementation and is warranted during the periconceptional period.