The Neurological Outcome of Isolated PVL and Severe IVH in Preterm Infants: Is It Fair to Compare?

OBJECTIVE: We compared the neurological outcome of isolated periventricular leukomalacia and severe intraventricular hemorrhage in a cohort of very low birth weight infants born and managed at single tertiary-care center in Saudi Arabia. METHODS: We undertook a descriptive retrospective chart review of the neurological status of very low birth weight infants who were born and managed over a 5-year period at King Abdulaziz Medical City, Riyadh. The neurological outcome of neonates with isolated periventricular leukomalacia and severe intraventricular hemorrhage (grades III and IV) was studied and compared in relation to developmental delay and cerebral palsy. RESULTS: A total of 20 patients with isolated periventricular leukomalacia and 26 with severe intraventricular hemorrhage (grades III and IV) were identified for this study. Of 20 patients with isolated periventricular leukomalacia, 9 (45%) had good developmental outcome and 11 (55%) had bad developmental outcome. Of 26 patients of severe intraventricular hemorrhage, 14 (54%) had good developmental outcome and 12 (46%) had bad developmental outcome (P = 0.55). Significant motor neurological deficit affecting function is distributed as follows: 11/20 (55%) in the isolated periventricular leukomalacia group and 7/26 (27%) in the severe intraventricular hemorrhage group (P = 0.05). Cerebral palsy was diplegic in 7/11 (64%) and quadriplegic in 4/11 (36%) in the isolated periventricular leukomalacia group, and hemiplegic 3/7 (43%), diplegic in 1/7 (14%), and quadriplegic in 3/7 (43%) in the severe intraventricular hemorrhage group (P = 0.03). Distribution of the neurological outcome according to periventricular leukomalacia grade was as follows: for periventricular leukomalacia grade I (n = 8), 6/8 (75%) had good neurological outcome and 2/8 (25%) had bad neurological outcome. In periventricular leukomalacia grade II (n = 4), good neurological outcome was seen in three patients (75%) and bad neurological outcome was seen in one patient (25%). All patients (n = 8) with periventricular leukomalacia grade III had bad outcome (P < 0.01). CONCLUSION: About half of patients with isolated periventricular leukomalacia and severe intraventricular hemorrhage had a poor developmental outcome. However, the severity of cerebral palsy was greater in the isolated periventricular leukomalacia patients and correlates highly with periventricular leukomalacia grade. Symmetrical diplegic cerebral palsy is the most common motor deficit associated with isolated periventricular leukomalacia, whereas asymmetrical hemiplegic cerebral palsy is seen exclusively with severe intraventricular hemorrhage.

Management of inguinal hernia in premature infants: 10-year experience.

AIM: Debatable issues in the management of inguinal hernia in premature infants remain unresolved. This study reviews our experience in the management of inguinal hernia in premature infants. MATERIALS AND METHODS: Retrospective chart review of premature infants with inguinal hernia from 1999 to 2009. Infants were grouped into 2: Group 1 had repair (HR) just before discharge from the neonatal intensive care unit (NICU) and Group 2 after discharge. RESULTS: Eighty four premature infants were identified. None of 23 infants in Group 1 developed incarcerated hernia while waiting for repair. Of the 61 infants in Group 2, 47 (77%) underwent day surgery repair and 14 were admitted for repair. At repair mean postconceptional age (PCA) in Group1 was 39.5 ± 3.05 weeks. Mean PCA in Group 2 was 66.5 ± 42.73 weeks for day surgery infants and 47.03 ± 8.87 weeks for admitted infants. None of the 84 infants had an episode of postoperative apnea. Five (5.9%) infants presented subsequently with metachronous contralateral hernia and the same number of infants had hernia recurrence. CONCLUSIONS: Delaying HR in premature infants until ready for discharge from the NICU allows for repair closer to term without increasing the risk of incarceration. Because of low occurrence of metachronous hernia contralateral inguinal exploration is not justified. Day surgery HR can be performed in former premature infant if PCA is >47 weeks without increasing postoperative complications.

Does meconium peritonitis pseudo-cyst obstruct labour?

Meconium peritonitis pseudo-cyst is very rare. Its perinatal management is controversial and can be associated with increased fetomaternal morbidity and mortality. A 34-week gestation infant with large meconium peritonitis pseudo-cyst, detected by intrapartum fetal ultrasound study, had abnormally increased ratio of fetal abdominal circumference to head circumference. Intrapartum aspiration of the pseudo-cyst was performed and was followed by a smooth vaginal delivery. The postnatal course of the baby showed that early laparotomy was essential for stabilisation of the infant's general condition.

Risk factors for isolated periventricular leukomalacia.

Periventricular leukomalacia, a major cause of neurologic disabilities in preterm infants, can be isolated or associated with intraventricular and periventricular hemorrhage. To determine the risk factors for isolated periventricular leukomalacia, we retrospectively studied the characteristics of all very low birth weight infants affected by isolated periventricular leukomalacia who were delivered over a 5-year period and compared them with a control group of very low birth weight infants, matched within 2 weeks for gestational age, with no central nervous system pathology, and born during the same period. In total, 20 affected infants were compared with 98 control infants. Neonatal sepsis caused by coagulase-negative Staphylococcus (P = 0.014) and neonatal seizure (P = 0.026) were associated with isolated periventricular leukomalacia only on univariate analysis. Three variables demonstrated statistically significant associations with isolated periventricular leukomalacia on both univariate and multivariate logistic regression analysis as independent risk factors: birth weight (odds ratio, 4.31; 95% confidence interval, 1.54-12.06; P = 0.005), early neonatal hypotension requiring combined inotropic therapy (odds ratio, 4.90; 95% confidence interval; 1.22-19.68, P = 0.025), and delayed surgical closure of hemodynamically significant patent ductus arteriosus beyond age 7 days (odds ratio, 1.20; 95% confidence interval, 1.06-1.35; P = 0.003).

Traumatic facial nerve palsy in newborns: is it always iatrogenic?

We sought to report an updated incidence, risk factors, and outcome of traumatic facial palsy (TFP) in newborn infants born at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. We performed a 12-year retrospective study at KAMC. The records of infants with the diagnosis of TFP during the study period were reviewed and compared with 148 healthy term infants born during the same study period. Among 83,067 infants delivered between January 1994 and December 2005, 29 infants were diagnosed with TFP for an incidence of 0.03%. Forceps delivery and maternal primiparity were the only significant risk factors for TFP. Only 7 (24.1%) of these infants were delivered by cesarean section. The other 22 cases of TFP (75.9%) were delivered without any forceps application. Almost all infants (93%) with TFP had spontaneous recovery within 2 months. Only one child suffered from permanent facial weakness when he was last examined at the age of 12 years. Although forceps delivery was considered the most significant risk factor, currently most of the cases occur spontaneously without forceps application. The majority of infants with TFP will recover spontaneously within the first 2 months of life.

Hypoparathyroidism-retardation-dysmorphism (HRD) syndrome in triplets.

We report female triplets with the clinical and biochemical manifestations of hypoparatyroidism-retardation-dysmorphism (HRD) syndrome also known as Sanjad-Sakati syndrome. They were born at 35 weeks gestation after assisted pregnancy (in vitro fertilization). The parents are first degree cousins from Saudi Arabia.

Symptomatic spontaneous pneumothorax in term newborn infants.

The association between congenital major urinary tract anomalies (CMUTA) and spontaneous pneumothorax in term newborn infants (SPTNI) is controversial. We conducted a case-control study to test the hypothesis that SPTNI is associated with CMUTA. We compared 80 term infants with spontaneous pneumothorax to 80 healthy control infants. We recorded risk factors, clinical course, therapy, and outcome. Only 1 infant of 60 infants (1.7%) had CMUTA with SPTNI, as revealed by renal ultrasound studies. This is comparable to the 1.4% rate reported for CMUTA in healthy newborn infants by Steinhart et al. ([1988] Pediatrics 82:609-614). SPTNI were significantly more likely in males with higher birth weights and with vacuum delivery. Sixty-seven (84%) infants with SPTNI had follow-up for a mean and median of 46.4 and 39 months, respectively (range, 1-126 months), without manifesting any renal or pulmonary complications.

Air emboli in the intracranial venous sinuses of neonates.

Air bubbles in the intracranial venous sinuses are known as a consequence to different causes including trauma, infection, and administration of intravenous contrast. Most of the previous reports demonstrated such cases in adults, with subsequent complications. We are presenting two premature babies who developed asymptomatic air bubbles in the right cavernous and left transverse sinuses, introduced accidentally upon cannulation of scalp veins. In both babies the air embolism disappeared in a few days without complications. Our cases suggest that these accidents could happen more frequently in neonates following scalp vein cannulation, which is a common procedure in sick babies, but they were overlooked as the outcome was uneventful. However, the precise nature and clinical significance of this lesion is not well understood in neonates.