Risk factors for cerebral palsy in preterm infants.

OBJECTIVE: To identify crucial factors that precipitate cerebral palsy by controlling confounding factors in logistic regression analyses. DESIGN AND PATIENTS: We retrospectively investigated a cohort of all 922 infants with gestational ages of less than 34 weeks (22-33 weeks), who were admitted to our neonatal intensive care unit between 1990 and 1998. Thirty (3.7%) were diagnosed to have cerebral palsy. We analyzed the prenatal and postnatal clinical variables of the cerebral palsy cases and compared them with 150 randomly selected controls. RESULTS: Risk factors for cerebral palsy identified in univariate analysis were: twin pregnancy, long-term ritodrine tocolysis, respiratory distress syndrome, air leak, surfactant administration, intermittent mandatory ventilation, high frequency oscillation, lowest PaCO2 levels, prolonged hypocarbia during the first 72 h of life, and postnatal steroid therapy. In a conditional multiple logistic model, long-term ritodrine tocolysis, prolonged hypocarbia and postnatal steroid therapy remained associated with an increased risk of cerebral palsy after adjustment for other antenatal and postnatal variables (OR [Odds Ratio] = 8.62, 95% CI [Confidence Interval], 2.18-33.97; OR = 7.81, 95% CI, 1.42-42.92; OR = 21.37, 95% CI, 2.01-227.29, respectively). CONCLUSIONS: Our results suggest that long-term ritodrine tocolysis underlines the development of cerebral palsy. Further assessments of the effect of ritodrine on fetal circulation and nervous system are required. Moreover, possible alternatives to systemic postnatal steroids are needed, and carbon dioxide levels should be more strictly controlled.

Pulmonary hypoplasia with an unusual prenatal history.

We describe a monochorionic, diamniotic twin with renal agenesis who received amniotic fluid from his normal co-twin by spontaneous rupture of the amniotic septum between them. By 16 weeks of gestation the presence of severe oligohydramnios in one twin had resulted in renal agenesis, but not in the other twin, who did not have oligohydramnios. By 20 weeks of gestation, the two amniotic fluid volumes had become the same in both twins. At 33 weeks, the twins were delivered by cesarean section. Despite intensive respiratory care, the twin with renal agenesis died from severe pneumomediastinum on day 3. At autopsy, pulmonary hypoplasia was demonstrated in that twin. This experiment of nature demonstrates that oligohydramnios during the early canalicular stage of pulmonary development (gestational age, 16-20 weeks) may be pathogenically important in pulmonary hypoplasia.

Cardiopulmonary arrest in pregnancy with schizophrenia: a case report.

BACKGROUND: Cardiopulmonary arrest in pregnancy has a very high maternal and fetal mortality rate. We report a case of successful maternal and neonatal survival in association with emergency cesarean section of a schizophrenic pregnant patient. To our knowledge, this is the first reported case of cardiopulmonary arrest in a pregnant woman with schizophrenia. CASE PRESENTATION: The parents were Japanese. The mother was 39 years old and had no history of prior pregnancy. Her admission to our hospital at 36 weeks and 4 days of pregnancy was due to deterioration of schizophrenia. On the first day of hospitalization, she collapsed after a seizure and vomiting, and an emergency resuscitation team was called immediately. The team identified apparent aspiration and successfully resuscitated the patient after 11 minutes of cardiopulmonary arrest. An emergency cesarean section was performed in the operating room. The newborn male infant received bag and mask ventilation at birth, and his Apgar scores were 5 at 1 minute and 8 at 5 minutes. He had a myoclonic seizure on the 2nd day of life: however, he experienced no further seizures on anticonvulsant medication after that episode. On the 18th day of life, magnetic resonance imaging of his brain revealed bilateral small hyperintensities on T1-weighted images in the basal ganglia. The mother and her newborn were discharged from our hospital without neurological disorders. CONCLUSION: We speculate that the cause of cardiopulmonary arrest was aspiration due to seizure, and it is possible that a neurological response was evoked by administration of antipsychotic drugs and/or by eclampsia. Medical staff must be aware of the possibility of cardiopulmonary arrest in pregnant women with schizophrenia.

Severe postnatal cytomegalovirus infection in a very premature infant.

Several studies have reported that postnatally acquired cytomegalovirus (CMV) infection can cause sepsis-like syndrome in premature infants. We here report a 622-gram birth weight male infant of 23 weeks' gestation who had sepsis-like syndrome and pneumonia. Substantial CMV loads were detected in peripheral blood cells, plasma, and urine when the patient was in crisis, but was decreased in parallel to clinical improvement without using ganciclovir. CMV DNA was not detected from his umbilical cord or Guthrie card, even by highly sensitive real-time PCR. Molecular profiles were indistinguishable between the CMV strain isolated from his urine and that from maternal breast milk, indicating postnatal acquisition of CMV through breast milk. Although he had transient hearing impairment, his neurodevelopmental outcome of 30 months of corrected age was normal. Further accumulation of clinical and virological data in postnatal CMV infection is necessary for evaluating the severity and selecting patients requiring antiviral therapy.