[THE FETAL MIDDLE CEREBRAL ARTERY PEAK SYSTOLIC VELOCITY AS A PEDICTOR OF FETAL ANEMIA IN RH-ALLOIMMUNIZED PREGNANCY].

UNLABELLED: Rh-isoimmunization is a pathological condition in which the fetal red blood cells of a Rh (+) fetus are destroyed by the isoantibodies of a Rh (-) woman sensitized in a previous event. Despite of the wide spread implementation of anti D-gammaglobolin prophylaxis this is still the most common cause for fetal anemia. Recently, sonographic measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) has been shown to be an accurate non-invasive test to predict low fetal hemoglobin levels. We present a case report of Rh-alloimmunized pregnancy with moderate fetal anemia, followed-up by weekly MCA-PSV measurements. CASE REPORT: A 37-year-old Rh (-) negative gravida 3, para 1, without anti-D gammaglobolin prophylaxis in her previous pregnancies, presented at 27+0 weeks of gestation (w.g.) for a routine third trimester scan. Subsequent ultrasound measurements of MCA-PSV confirmed a progressive increase of the peak systolic velocities from 40 to 80 cm/sec, as well as a gradual rise in the anti-D titers. The evidence of developing fetal anemia necessitated elective Caesarean section performed at 35 wg. The neonate was admitted in the intensive care unit and required resuscitation, one exchange blood transfusion and several courses of phototherapy. The patient was discharged two weeks post partum. CONCLUSIONS: There is a strong correlation between the high peak systolic velocities in the middle cerebral artery (MCA-PSV) and the low levels of fetal hemoglobin. The high sensitivity and positive predictive value concerning the development of fetal anemia, as well as its good repeatability, makes this non-invasive test a valuable asset in the management of all pregnancies complicated by severe Rh-alloimmunization.

[Frequency, severity and risk factors for bronchopulmonary dysplasia among very low birth weight premature infants admitted in the NICU of the University Obstetrics and Gynecology Hospital, Sofia].

BACKGROUND: The progress in the perinatology improved the survival rate of the infants with extremely low birth weight and gestational age. Among the most immature of them the frequency of bronchopulmonary dysplasia (BPD) remains high.. The use of different diagnostic criteria for BPD makes comparing the results difficult. AIM: To evaluate the frequency of BPD by birth weight and gestational age according to the new diagnostic criteria, and to identify the risk factors for development the disease. METHODS: 563 very low birth weight infants (<1500 g) were admitted to NICU from 01.01.2008 to 30.06.2010. 485 survived more than 28 days and were included in this study. BPD was diagnosed if supplemental 02 for the first 28 days was necessary. 02-requirements at 36 gestational weeks (gw) determine the severity level. RESULTS: 26,8% from the infants were with supplemental 02 in the first 28 d of life, but only the half of them 13,6% were with 02 > 21% at 36 gw (the classical diagnostic criteria for BPD). 10,9% were with moderate BPD, 2,7% - with severe BPD. The frequency of BPD decreased progressively from almost 100% at 23 gw or birth weight < 600 g to single cases after the 31 gw and birth weight > 1200 g. Mild or moderate BPD was more likely if gestational age was > 27 gw. The need for ventilatory support increased from 1,5 (+2,8) days (no-BPD group) to 50,2 (+/-20,1) days (severe BPD), p<0.05. Significant postnatal risk factors for developing BPD were patent ductus arteriosus - diagnosed in 25,4%; pneumothorax - in 3% of the BPD infants, compared with 1,7% and 0,5% among the infants without BPD respectively, p<0. 05. Sepsis and pulmonary hemorrhage were found slightly more frequently in the BPD group too (p>0, 05). The use of antenatal steroids was found to be a protective factor - 45% of the BPD infants had received antenatal steroids compared with 55% of those without BPD (p=0.05). CONCLUSION: According to the new diagnostic criteria, the frequency of BPD was about 2 times higher compared to the classical definition. Main risk factors were found to be ELBW, ELGA; additional risk carried the need for prolonged ventilatory support, patent ductus arteriosus and air leak syndrome.

[Problems and neonatal outcome of very low birth weight newborn infants after in vitro fertilization].

UNLABELLED: The use of assisted reproduction technologies is undoubtedly successful in the treatment of sterility. However it sets up numerous of issues for the obstetricians and neonatologists. AIMS: To evaluate the incidence, the specific problems and the neonatal outcome of newborns with very low birth weight (VLBW) <1500 g born from pregnancies after in vitro fertilization (IVF). METHODS: The study enrolled all 563 VLBW infants admitted in the NICU of the "Maichin Dom" hospital from 01.01.2008 to 30.06.2010. 119 (21.1%) of them were conceived with assisted reproduction technology (IVF- group), and 444 (78.9%) were conceived naturally (control group). All infants were followed up till their discharge home or death. Poor outcome measures were in hospital neonatal death or morbidities with long term sequels: severe congenital malformations, bronchopulmonary dysplasia, severe brain injuries (intraventricular haemorrhages gr. Ill-IV periventricular leucomalacia), retinopathy of prematurity gr. Ill-V. RESULTS: There were no significant differences in terms of mean birth weight (BW) and gestational age (GA) between the groups (1170 g and 1173 g, 29,8 and 30,0 weeks of gestation respectively). Intrauterine growth retardation (BW of <10 percentile for GA) was observed in 42% in the IVF-group, versus 38.5% (NS) The frequency of the babies from multiple pregnancies was significantly higher in the IVF-group: 88.2% versus 27.5%, and the triplets were 48% versus only 0.9% in the control group. In the IVF-babies more active obstetric approach was carried out: caesarean section in 85% versus 57%, and completed antenatal corticosteroid course in 80% versus 41% in the control group. There were no significant differences of in hospital neonatal mortality rate - 14.3% in the IVF-group versus 14.9%; congenital malformations or severe morbidities at discharge - 22.7% versus 27.5%, discharged in good health - 63% versus 57.6%. CONCLUSIONS: The major problems of VLBW-newborns after IVF result from the higher incidence of multiple pregnancies with their corresponding risks. Nevertheless, strict pregnancy follow-up, more frequently use of antenatal steroids, cesarean delivery such as intensive neonatal resuscitation ensure a clinical outcome and prognosis which do not differ from the naturally conceived VLBW-newborns.

[Blood transfusions suppress erythropoiesis in anemia of prematurity].

UNLABELLED: AIM AND TASKS: The major gene regulating erythropoietin /EPO/ synthesis is hypoxia induced factor/HIF/. Proceeding from the assumption that the transfusions /HT/ remove hypoxia due to anemia and inactivate HIF, the aim of the study was to show the decreased activity of erythropoiesis after HT MATERIALS AND METHODS: PATIENTS: 40 premature infants <34 g.a. and birth weight < 1400 g with anemia of prematurity. We analyzed: Hb /g/I/, Ht%, Thrx 10(9)/I, Ret%, 24-48 hours and 7-10 days after HT The dynamics of changes of blood lactate /mmol/l/level after HT was used as an indirect index of relative hypoxia/activated HIF/. The changes of Hb /g/l/ and Ht% determined the need of haemotransfusions. RESULTS: After HT along with the increase of Hb from 89, 7+/-10,0 to 119+/-13,3, there was significant decrease in Ret % from 2,4+/-1,1 to 1,4+/-0,5 7-10 day after HT There was also a reduction of Thr from 391,5+/-131,5 to 250, 7+/-57,2 and blood lactate in mmol/l from 2,5+/-1,1 to 1,5+/-0,7. The study showed that 7-10 days after HT the values of Hb and Ht decreased to baseline levels, that required new transfusion. CONCLUSION: Transfusion of packed red blood cells in patients with anemia of prematurity suppresses erythropoiesis, which is demonstrated by the significant reduction in reticulocyte count. The decreased level of blood lactate after HT shows elimination of the relative hypoxia that is required for hypoxia- induced expression of HIF and erythropoietin synthesis.

[Congenital cystic lung lesions--review of the literature with three clinical cases].

Congenital cystic lung lesions are rare. Mainly affects the lower respiratory patishta.i are congenital cystic malformation and adematozna bronchopulmonary sequestration (BPS). The pathogenesis of the occurrence of these malformations is not clear but they have a common clinical course. In most cases, the anomaly is asymptomatic and occurs with infections of the lung during the first year of life. Currently congenital lung lesions were classified into five types and is considered by most authors. The anomaly is due to the abnormal proliferation of terminal bronchioles accompanied by inhibition of alveolar development between 7-17 weeks, obstructed airway dysplasia and metaplasia of normal lung tissue. Early diagnosis is vital in making a medical decision on how to treat CCAM. Associated with abnormalities of the urinary tract, cardiovascular system, gastrointestinal atresia, diaphragmatic hernia skeletal abnormalities. In pregnancies in which prenatal lung lesions weighs registered necessary series of ultrasound examinations to track finding and using the Doppler to assess how the blood supply of the fault. The clinical presentation of malformations is respiratory distress, respiratory infection, and dyspnea. The use of CT and MRA allows better visualization of the pulmonary lesions. With its combination with arteriography and bronchoscopy are used to differentiate CCAM and pulmonary sequestration. We present three cases with lung lesions were born in Neonatologia clinic at the University Hospital of Obstetrics and Gynecology "Maternity" Sofia for the period 2010-2012 three cases CCAMs type 1, operated by 5 meters after birth with a good final outcome without complications in the postoperative period and lack of pulmonary symptoms up to 1 year after birth.

[Blood lactate measurments as a diagnostic and prognostic tool after birth asphyxia in newborn infants with gestational age > or = 34 gestational weeks].

UNLABELLED: Blood lactate at birth as result of activated anaerobic glycolysis is a marker of perinatal asphyxia. AIM: To evaluate the dynamics of blood lactate, pH and base excess (BE) as a tool for assessing the severity of fetal hypoxia and predicting neonatal outcome. METHODS: 79 neonates (> or = 34 gestational weeks) were included and followed up until discharge: 43 with pathologic fetal hearth rate patterns and/or 1-minute Apgar score < 7 ("asphyxia group"); 36 without obstetric or clinical signs of asphyxia (control group). Samples from umbilical artery (u.a.), capillary blood at 2h and 12-24 h after birth were analyzed for blood lactate, pH and BE. RESULTS: Lactate value (u.a.) was significantly higher (5.3 +/- 3.4 mmol/l), pH and BE were lower (7.29 +/- 0.05 and -14.1 +/- 5.9 mmol/l) in the "asphyxia group" compared to the control group (2.7 +/- 1.2 mmol/l, 7.29 +/- 0.05 and -5.9 +/- 3.3 respectively). The 2 h lactate-values increased significantly in infants with asphyxia (6,.7 +/- 4.7) compared to the controls (3.2 +/- 1.1), the 12-24 h values were reduced in the main group (4.6 +/- 1.5) and without changes in the controls (3.2 +/- 0.88). Values of pH and BE at 2 h and 12-24 h increased progressively in both groups without significant differences between them. Hypoxic-ischemic encephalopathy (HIE) stage II-III was observed in infants with u.a. pH < 7.05, BE < -15 if u.a. lactate was high and progressively increased in next 2 h. CONCLUSIONS: High u.a. lactate values correlate with low pH and BE and is a reliable tool for assessing the severity of fetal asphyxia. Increasing lactate concentration after birth is better predictor of severe HIE.

[Respirtory distress in newborns of mothers with factor V-Leiden thrombophilia].

AIM: The main aim of the trial is to determine the frequency of respiratory distress syndrome / RDS/ and disorders of coagulation in infants of mothers with thrombophilia. MATERIALS AND METHODS: In 51 newborns of mothers with thrombophilia were evaluated the presence of respiratory distress and maternal-fetal infection /MFI/. The children were divided in two groups: Group I--16 newborns of mothers with thrombophilia and Group II--15 healthy children. We analyzed Hb, Ht, Er, Thr, prothrombin index /INR/, activated partial thromboplastin time /aPTT/ in both groups. RESULTS: The analysis of Hb, Ht, Er, Thr showed no evidence of anemia or coagulopathy with platelet consumption. In 64.7% of children was observed respiratory distress syndrome during the first days, 21.5% had severe respiratory distress /RD/, that required intubation and assisted ventilation. Only in 10/19.6%/ children with RDS there were data proving MFI/high CRP and positive microbiological samples/. There was no significant difference in the INR value in Group I/1.5 +/- 0.3/ and group II/1.6 +/- 0.1/. The children of mothers with thrombophilia had significantly more shortened aPTT/35, 1s +/- 4.2/ compared with the control group: aPTT/43.9 +/- 4,4/. CONCLUSION: The high incidence of RDS and shortened aPTT indicate that maternal thrombophilia is a risk factor for thrombosis in newborns. MFI that are accompanied with activated PAI also lead to thrombosis, especially in children in Neonatal Intensive Care Units. These results point out that there should be prevention of other risk factors for thrombosis such as dehydration and placement of central venous catheters.

["In vitro" babies--dreams, that turned real, but a lot of questions and unknown items].

UNLABELLED: In vitro babies bring happiness to a lot of families. Their development, health and social problems are being studied in details. OBJECTIVES: To establish the well being of babies, born at the University Maternity Hospital "Maichin dom" following assisted reproduction (AR), probable risk factors immediately after birth and afterwards. Aims of the study are to look for a correlation between AR and the incidence and importance of medical problems, arising during the neonatal period: multiple pregnancy; prematurity; intrauterine growth retardation; neonatal mortality; inborn malformations and chromosomal diseases; CNS impairment; duration of hospitalization. STUDY DESIGN: This is a retrospective study including all 440 babies born thanks to AR (according to the available medical records) during the period 2008-2010 at the University Maternity Hospital "Maichin dom". A correlation between the main items observed and the number of babies in each pregnancy was investigated for the period 01.01.2010-31.12.2010. RESULTS: During the period 2008-2010 there are 99 babies from single pregnancy, 15 (15%) admitted to the NICU; 384 twin pregnancies (186 of them after AR)--733 babies and 15 foetus mortus. 114 IVF couplets (31%) or 221 babies (7 foetus mortus) are admitted to physiological neonatal ward, while 72 (63%) couplets or 137 babies (7 foetus mortus) are admitted to the NICU. There are 48 triplet pregnancies or 141 babies (3 f. mortus), 40 being IVF (83%) or 117 babies, all 40 AR triplets are admitted to the NICU. 269 babies (61% of all AR babies) need intensive treatment--mostly (94%) babies from multiple pregnancies. Mean birth weight was established to be 2060 g; with babies, requiring intensive treatment is 1408 g. Gestational age at birth is from 25 to 39 g.w.; with NICU patients mean gestational age is 32 g.w. Mean maternal age is relatively high--34 years with a wide range (24-50 years). A high incidence of operative deliveries is established--mostly with couplets and triplets. CONCLUSIONS: Rules of good clinical practice should be introduced with AR, aiming at reducing the number of multiple pregnancies. This should be priority for all national programs for assisted reproduction.

[Antenatal ambroxol administration for prevention of respiratopry distress syndrome in preterm infants: preliminary report].

UNLABELLED: The rate of preterm births has remained unchanged for the recent years despite of the persistent attempts to diminish it. Preterm births are responsible for about 70% of neonatal morbidity and mortality. One of the main problems of preterm newborns is their lung immaturity. The aim of this study is to assess the effect of Ambroxol, given prenatally on the rate and severity of neonatal respiratory distress syndrome (NRDS) in preterm infants and its potential to replace the corticosteroid prophylaxis in cases where steroids are contraindicated or undesirable. MATERIALS AND METHODS: The trial consisted of 33 pregnant women between 27 and 32 week of gestation. 17 of them represented our work group and were given Ambroxol syrup 15 mg/ml, per os 30 ml in three intakes, for 7 days. 16 were controls and were not given any kind of NRDS prophylaxis. RESULTS: severe NRDS was diagnosed in 2.5 times more cases in the control group compared to the work group. All infants in the control group had clinical signs of NRDS, while 23.5% of the infants in the work group were asymptomatic. Bronchopulmonary dysplasia was diagnosed in 25% of the infants in the control group, compared to none diagnosed in the work group. Newborns with no antenatal NRDS prophylaxis had to be kept in intensive care units for an average period of time twice longer than the newborns to mothers who had received Ambroxol. CONCLUSIONS: Antenatal Ambroxol administration diminishes the rate of NRDS, decreases the duration, scope and price of the intensive care, lessens the duration of assisted ventilation and oxygen needs and hence improves the long-term outcome. Ambroxol and steroids have cumulative effect on fetal lung maturation and therefore should both be a part of the preterm delivery therapeutic scheme.

[Group B streptococcus (GBS) infection in newborns in university hospital "Maichin Dom" EAD Sofia for the period 2008-2010].

For the period 2008-2010 in the University Hospital "Maichin Dom" EAD were born 10 774 babies. The newborns in the intensive care clinic (according to Apgar 1-5 min, the severity of RDS, the birth weight, gestational age, C-reactive protein and the values of blood tests) were screened for mother-fetal infections immediately after birth. The tests performed were blood culture, stomach aspirate, ear, anal and nose secretion, throat and tracheal aspiration (if intubation was performed). In case of meningitis liquor was tested. Standard therapy included Ampicillin/Sulbactam. The healthy, eutrophic children were also screened for bacterial mother-fetal infections--routinely ear and stomach aspiration. The babies, without clinical and paraclinical symptoms, but positive for GBS colonization, were also treated with Ampicilin. As a result from the screening and therapy no cases with meningitis were detected, as well as late neonatal sepsis caused by GBS.

A study on early-onset neonatal group B streptococcal infection, Bulgaria, 2007-2011.

This study examines neonatal group B streptococcal (GBS) colonization and its relation to early-onset GBS disease (EOGBSD), based upon the experience of leading obstetrics and gynecology centers in Bulgaria. The objectives of the study were to update neonatal colonization rates and to assess relationships between clinically differentiated cases (culture-proven GBS newborns) and risk factors inherent to the infant and mother, using a computerized file. The neonatal GBS colonization rate ranged from 5.48 to 12.19 per 1000 live births. Maternal-fetal infection (MFI, a provisional clinical diagnosis in culture-proven colonized infants with initial signs of infection that is usually overcome with antibiotic treatment) and/or intrapartum asphyxia (IA) have been demonstrated as the most frequent clinical manifestations, with significant correlations for the primary diagnosis, but not affirmative for the final diagnosis at discharge, resulting from adequate treatment of neonates. MFI and IA were significantly related to prematurity, and reciprocally, prematurity was associated with the risk of MFI, indirectly suggesting that preterm birth or PPROM (preterm premature rupture of membranes, an obstetric indication associated with early labor and delivery, one of the major causes of preterm birth) is a substantial risk factor for EOGBSD. The regression analysis indicated that in the case of a newborn with MFI, a birth weight 593.58 g lower than the birth weight of an infant without this diagnosis might be expected. Testing the inverse relationship, i.e., the way birth weight influences a certain diagnosis (logistic regression) established the presence of a relationship between birth weight categories (degree of prematurity) and the diagnosis of MFI. The proportions and odds ratios, converted into probabilities that a baby would develop MFI, indicate the particularly high risk for newborns with extremely low and very low birth weight: extremely low birth weight (≤1000 g), the probability of developing a MFI is 66%; very low birth weight (1001-1500 g), 81%; low birth weight (the birth weight category including premature and small for gestational age term infants: 1501-2500 g), 40%; normal birth weight (term infants) (>2500 g), 32%. In conclusion, the need to introduce separate categories for early- and late-onset GBS disease in the registration nomenclature of neonatal infectious diseases is highlighted by these results. Drawing up intrapartum antibiotic prophylaxis (IAP) guidelines is also strongly recommended.