Relationship between fetal monitoring and resuscitative needs: fetal distress versus routine cesarean deliveries.

BACKGROUND: There is debate as to whether pediatricians should be present at all cesarean deliveries. Little published data exist regarding the differences in resuscitative needs of infants delivered by cesarean section for "fetal distress" versus those without this diagnosis. OBJECTIVE: To describe the differences in resuscitative and immediate postnatal intervention needs for neonates with fetal distress delivered by cesarean section and those without fetal distress delivered in the same manner. Also, to devise an evaluation tool to assess and compare levels of neonatal resuscitation between infants and groups of infants. METHODS: The delivery records of 1411 term infants delivered by cesarean section after uncomplicated pregnancies at Los Angeles County/University of Southern California Medical Center from March 3, 1995 through March 8, 1997 were examined retrospectively. Apgar scores and resuscitative needs were assigned to a newly devised, weighted scoring system. Resuscitation subscores and total resuscitation scores were compared using non-parametric methods. RESULTS: The fetal distress group (n = 80) had a significantly greater resuscitative needs mean score (p < 0.001) and subscores (p < 0.001 to p = 0.004) than did the non-fetal distress group (n = 419). Of the non-fetal distress group, 48.7% still received some active form of intervention. CONCLUSION: In our study group, infants with fetal distress had significantly greater intervention needs than infants without fetal distress.

A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation.

OBJECTIVE: To prospectively compare the incidence of respiratory failure in premature infants randomized to receive either nasopharyngeal continuous positive airway pressure (NPCPAP) or nasopharyngeal-synchronized intermittent mandatory ventilation (NP-SIMV) in the immediate postextubation period. STUDY DESIGN: This is a prospective study of very low birth weight (VLBW) infants randomized at the time of extubation to receive either NPCPAP or NP-SIMV in a university-based level III neonatal intensive care unit. Statistical analysis were performed with the Mann-Whitney U test for continuous and ordinal variables, and with the chi-squared test or Fisher's exact test for categorical variables. RESULTS: A total of 41 VLBW infants were studied; 19 were in the NPCPAP group, and 22 were in the NP-SIMV group. Respiratory failure after extubation in the NP-SIMV group was significantly lower that in the NPCPAP group (5% vs 37%, respectively (p = 0.016). No statistically significant differences between groups with regard to demographics, severity of initial illness and associated complications, time to extubation, ventilatory management before extubation, weight, age, or nutritional status at the time of extubation were noted.

Subgaleal hemorrhage in a premature infant with congenital diaphragmatic hernia following vacuum-assisted delivery.

An infant with congenital diaphragmatic hernia was delivered by vacuum extraction, with a resultant subgaleal hemorrhage that excluded him from ECMO. The literature regarding vacuum-assisted delivery and birth trauma is reviewed in the context of congenital anomalies that may require ECMO support, and recommendations for perinatal management are suggested.

C-reactive protein levels in the extremely premature infant: case studies and literature review.

Sepsis continues to be a significant source of morbidity and mortality in the neonatal intensive unit. At the same time, we need to contain medical costs and prevent the rapid growth of resistant organisms by limiting unnecessary antibiotic use. Among laboratory indexes studied as indirect indicators of the presence and resolution of infection and inflammation, C-reactive protein (CRP) has gained more recent widespread use. CRP usually increases in a delayed manner with the onset of inflammation and decreases as inflammation resolves. We follow serial CRP values in our neonatal intensive care unit from the start of a sepsis evaluation until antibiotic therapy is withdrawn. We describe two extremely low birth weight patients who improved clinically with therapy and whose CRP levels normalized in the face of continued positive blood cultures. The implications for the use of CRP in deciding when to halt therapy in premature infants are discussed.

All-trans retinoic acid for the treatment of acute promyelocytic leukemia in pregnancy.

BACKGROUND: Acute promyelocytic leukemia, a subset of acute myelogenous leukemia, is commonly associated with disseminated intravascular coagulation (DIC). All-trans retinoic acid is effective in the treatment of acute promyelocytic leukemia and may prevent an exacerbation of DIC. There is limited information, however, regarding the use of this agent in pregnancy. CASE: A 29-year-old woman with acute promyelocytic leukemia and DIC at 24 weeks' gestation was treated successfully with all-trans retinoic acid during the pregnancy, delivering a viable, normal infant at 33 weeks. CONCLUSION: This case illustrates the successful use of all-trans retinoic acid in pregnancy for the treatment of acute promyelocytic leukemia. With the combined, intensive efforts of the perinatal, neonatal, and hematology-oncology services, a favorable outcome was achieved.