[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.

[Protocol - indications for transfusion in newborns with low and extremely low birght weight].

OBJECTIVES: Hyporegenerative anaemia of prematurity is the cause of frequent transfusions of packed red blood cells. Wellknown is the effect of inhibiting the erythropoiesis after blood transfusions as well as the risk of transmissive infections. Therefore the main purpose of this study was to work out a protocol - indications for blood transfusions in order to achieve maximal reduction in their incidence with premature babies during their stay in ICU. STUDY DESIGN: The study includes 57 newborn babies - birth weight < or = 1400 g, gestational age < or = 34 g.w. The changes in blood count values (Hb, Ht, Er,) from day 1 until day 60-70 were followed and analyzed. The effect of blood transfusions on oxygen needs reduction was analyzed by monitoring acid-base status in 30 infants with anaemia of prematurity with different degree of oxygen dependency. RESULTS: Mean Hb and Ht at birth were 163 +/- 20,4 g/l and 48.6 +/- 6, 3%. At day 15-20 Hb was 111,02 +/- 10,9 and Ht 32,65 +/- 3,46. A significant decrease in blood count values is observed until the end of the first month /p <0.05/. Afterwards they remain relatively constant, fairly close to those at day 25-30/Hb 101,45 +/- 10,24 g/l; Ht% 29,78 +/- 3,42/. The study showed that transfusions of packed red blood cells reduce oxygen requirements by aproximately 30% in premature babies on mechanical ventilation with high oxygen concentrations\FiO2 > or = 50%/. In premature babies with good overall condition and on low concentration oxygen therapy - < 50%, no effect was observed in reducing oxygen requirements after RBC transfusion. CONCLUSION: The leading indications for RBC-transfusions are not only Hb, Ht, postnatal age, but also the clinical condition and oxygen requirements. Severely ill premature babies on mechanical ventilation with FiO2 > or = 50% require blood transfusion at higher Hb values/<120 g/l/regardless of postnatal age.

[Fracture of clavicle in newborns, an attempt to make prognostic factors].

UNLABELLED: The most common bone fracture of the newborn is that of the clavicle - frequency 0.2-3.5% of all births, according to various literature sources. The most common cause of this complication perinatally determining the weight of the newborn and the skills of those who manage second stage of labour Purpose of the study was the establishment of prognostic factors for fracture of the clavicle regardless of the way of delivery. MATERIAL AND METHODS: The study was retrospective for the period January 2005 to June 2010 and includes 38 infants with fracture of the clavicle in spontaneous and operative vaginal deliveries, as well as caesarean sections. There were examined the following factors: age, parity and maternal weight, fetal weigh and length duration of pregnancy, experience of managing labour. RESULTS: The incidence of fracture of the clavicle during the study was 0.26%, calculated to the total number of births. Eight fractures are of newborn delivered by caesarean section, 6 by vacuum extractor and 24 by normal vaginal deliveries with episiotomy mostly. The average weight of infants with fractures was 3767 gr 3 fractures are accompanied by brachial plexus paresis, and 2 were complicated with shoulder dystocia. CONCLUSIONS: It was not found statistically significant prognostic value of most of the indicators studied. Fracture of the clavicle most often dependent on the weight of the newborn and the technique of managing labour without the consequence of shoulder dystocia.

[Strategies for nutrition of the preterm infant with low and very low birth weight].

According to many experts in neonatal nutrition, the goal for nutrition of the preterm infant should be to achieve a postnatal growth rate approximating that of the normal fetus of the same gestational age. Unfortunately, most preterm infants, especially those born very preterm with extremely low birth weight, are not fed sufficient amounts of nutrients to produce normal fetal rates of growth and, as a result, end up growth-restricted during their hospital period after birth. Growth restriction is a significant problem, as numerous studies have shown definitively that undernutrition, especially of protein, at critical stages of development produces long-term short stature, organ growth failure, and both neuronal deficits of number and dendritic connections as well as later behavioral and cognitive outcomes. Glucose should be provided at 6-8 mg/min/kg as soon after birth as possible and adjusted according to frequent measurements of plasma glucose to achieve and maintain concentrations >45 mg/dl but <120 mg/dl to avoid the frequent problems of hyperglycemia and hypoglycemia. Similarly, lipid is required to provide at least 0.5 g/kg/day to prevent essential fatty acid deficiency. However, the high rate of carbohydrate and lipid supply that preterm infants often get, based on the incomplete assumption that this is necessary to promote protein growth, tends to produce increased fat in organs like the liver and heart as well as adipose tissue. More and better essential fatty acid nutrition is valuable, but more organ and adipose fat has no known benefit and many problems. Amino acids and protein are essential not only for body growth but for metabolic signaling, protein synthesis, and protein accretion. 3.5-4.0 g/kg/day are necessary to produce normal protein balance and growth in very preterm infants = Aggressive parenteral nutrition (PN) including amino acids is recommended for low-birthweight infants to prevent energy and protein deficit. PN can be provided as a standard, usually commercial, formulation, representing the average needs of a large group of patients. Alternatively, an individualized PN compound adapted to the patient's needs can be prescribed and prepared, usually on a daily basis. A combination of standardized PN bags, prepared under strict standardization criteria, for most neonates. Many preterm infants are too ill to receive substantial enteral feeds and require prolonged PN. It was reported that normal gastrointestinal structure and function are lost, villi become shorter, mucosal DNA is lost, Enteral feeding always is indicated and to date nearly all studies have shown that minimal enteral feeding approaches (e.g., 'trophic feeds') promote the capacity to feed enterally. Milk has distinct advantages over formulas in avoiding necrotizing enterocolitis (NEC). Breast milk is the preferred source of nutrients for newborn infants. The most common methods used are continuous milk infusion and intermittent (bolus) milk delivery (usually every 3 h). Feeding promotes more "normal" feed-fasting and marked differences are observed in feeding tolerance and growth between continuous vs. bolus tube-feeding methods. Continuous feeding is associated with more significant feeding intolerance.

[Early diagnosis of Turner syndrome in a newborn].

The Turner syndrome, karyotype 45,X0 in the classical form, often remains undiagnosed until significant growth retardation is presented and sexual maturation at the puberty fails to occur. The girls are as a rule with normal IQ. We report a case of an infant of a 24 years mother after two spontaneous abortions and one birth of a normal boy. The newborn girl is with IUGR, after birth we establish edema of the feet, prominent ears and systolic murmur. The echocardiography diagnoses cardiac malformation--bicuspid aortic valve and sub aortic obstruction. The chromosomal analysis shows karyotype 45,X0. We discuss the methods for prenatal and early postnatal diagnosis. In utero and in the neonatal period there are symptoms that make the diagnosis Turner syndrome probable so that chromosomal analysis should be made to confirm it. Looking for other malformations (heart, kidney, endocrine) is necessary. The early diagnosis makes possible the beginning of appropriate hormonal treatment to achieve normal growth and to induce puberty.

[Does human recombinant erythropoetin /R-HU-EPO/ treatment for anemia of prematurity have any effect on reducing the number of blood transfusions?].

OBJECTIVES: The aim of the study is to establish the influence of r-hu-EPO treatment for anemia of prematurity on changes in blood count values and the number of inevitable blood transfusions in premature infants. STUDY DESIGN: The study includes 148 newborn babies--birth weight < or =1400 g, gestational age < or =34 g.w. They were divided in 2 groups: group I--treated with r-hu-EPO 1000 E/kg/week and Fe++ 3-6 mg/kg/day from week 3 after birth; group II--controls, treated only with transfusions of red blood cells. The changes in blood count values (Hb, Ht, Ery, Ret) from day 15-25 until day 60-70 were followed and analyzed, as well as the number of inevitable blood transfusions. RESULTS: A significant increase in Hb and Ht values was established with r-hu-EPO treated babies. At day 60-70 mean values of Hb are: in r-hu-EPO group 111.1 +/- 11.06 g/l; in control group 99.20 +/- 10.77 g/l (p < 0.001). At the end of the period Ht is 32.02 +/- 3.28% in babies treated with r-hu EPO versus 29.10 +/- 2.87% with controls (p < 0.005). Ret count is significantly higher from day 25-30 in r-hu-EPO group (5.16 +/- 3.23%) versus controls (2.75 +/- 1.33%). Mean number of inevitable blood transfusions in r-hu-EPO treated group is significantly lower (2.06 +/- 1.62) versus controls--3.75 +/- 1.95 (p < 0.001). CONCLUSION: r-hu EPO treatment has effect on changes in Hb, Ht, Ret and reduces the number of inevitable blood transfusions for anaemia of prematurity.

[Guidelines for parenteral nutrition in high risk newborn babies].

High risk newborn babies, admitted and treated at the Intensive care units often have to be started on intravenous nutrition--total or partial. The guidelines which we propose are adapted to the specific needs of the various groups of critically ill newborns--daily intake of liquids and essential nutritional substances according the day of life and the birth weight, as well their variations depending on the clinical condition and the morbidity of the baby.

[Treatment of anaemia of prematurity with SS-R-Hu-erythropoietin and significance of hypoxia-inducible factor].

UNLABELLED: The main cause of anaemia of prematurity is low erythropoietin levels. A few years ago hypoxia-inducible factor/HIF/gene transcriptor was established, regulating not only the synthesis of erythropoietin /EPO/, but also other growth factors as well as enzymes of anaerobic glycolysis, activated by hypoxia. OBJECTIVES: The aim of the study is to establish in clinical practice the role of hypoxia, respectively, activated HIF during treatment with erythropoietin by analyzing variations in hematological values; to examine blood lactate levels as an indicator of activated HIF and anaerobic glycolysis with Hb values 110-120 g/l; to analyze the number and impact of red blood cells transfusions on different categories of babies. STUDY DESIGN; The study includes 112 premature infants born before 34 weeks of gestation and below 1400 g. 90 babies, treated with EPO (700-1000 E/kg weekly dose in 2-3 applications, for 2-4 weeks), values of Hb g/l, Ht%, Ret%, Platelets 109/l were followed and compared. Treated babies were divided in two groups: group I--treatment (starting at Hb below 106 g/l, Ht less than 31%); group II--late prophylaxis (starting at Hb > or = 106 g/l, Ht > or = 31%). Blood lactate was examined in 22 non oxygen dependent premature babies without EPO treatment, with Hb 110-120 g/l, Ht 29-32%. RESULTS: We found that in group II during the first 7-10 days Hb decreases to 105.6 (+/- 9.4) g/l, rising up afterwards to 113.5 (+/-11.0) g/l at day 25-30. Ret reach maximal values at day 15-20 when Hb drops below 110 g/l and Ht below 31%. In group I at day 25-30 of treatment is observed a rise in Hb up to 117.3 (+/-11.3) and of Ht up to 32.7% (+/- 2.6) and no decrease of Hb and Ht values during the first 7-10 days, while Ret rise up to maximal values 6.5% (+/- 3.6) at day 7-10. With Hb levels of 116.4 (+/- 4.6) g/l we found an increase in blood lactate levels up to 2.6 (+/- 0.7) mmol/l as an indicator of relative hypoxia and activated HIF. Mean number of blood transfusions in group I is 3.01(+/- 1.7), versus 2.15 (+/- 1.7) in group II (statistically non-significant). In 29 infants in group II treatment was started at Hb 110-120 g/l and the mean number of red blood cell transfusion is 1.8 (1.5)--statistically significant difference with group I. In 32% from the treated infants we found platelets count rising above 500 x 109/l. CONCLUSIONS: The presence of hypoxia at low levels of Hb and Ht leads to more rapid activation of erythropoiesis. Nevertheless, these babies need more red blood cell transfusions due to clinical symptoms of hypoxia. Normoxia after red blood cell transfusion leads to decrease of reticulocytes count by 30% and platelets by 35% in spite of treatment. The presence of relative hypoxia with Hb 110-120 g/l u Ht 31-32% is optimal for starting treatment with EPO--levels, low enough for activation of HIF and high enough to avoid blood transfusions.

[Early parenteral nutrition with very low and extremely low birth weight infants--practical approach].

UNLABELLED: Newborn infants with birth weight 1500 g and less (VLBW/ELBW) have higher nutritional needs, but enteral feeding is often insufficient or impossible. Parenteral nutrition (PN) as an important component of intensive care with them minimizes the risk of nutritional deficiency. OBJECTIVE: To evaluate the safety and efficacy of early PN administration in VLBW/ELBW infants. STUDY DESIGN: The prospective study includes 23 newborn babies with birthweight below 1500 g who were admitted to the NICU from 01.03. to 20.04. 2009. With all babies a PN was started from the first day of life with dextrose and amino acid solutions, adding lipid solutions in gradually increasing quantity on the second day. During the first 20 days of life for each baby were calculated on a daily basis the exact quantities of energy and the essential nutritional substances as well as the balance among them. All babies were followed up for weight gain, presence or absence of complications, related with parenteral nutrition as well as for: blood sugar, acid-base status, total serum protein, electrolytes, urea, triglycerides, billirubin, alkaline phosphatase, ASAT ALAT RESULTS: We found that due to the small infusion volumes during the first days, the minimal daily needed nutrition levels are reached at day 4-5. Nutritional intake at day 7-10 in most children is enough for growth. A positive mean weight gain for the whole group 6.6 g/kg/d (SD 6.2) is observed. Negative weight gain during the first 20 days is observed only with two critically ill babies with substantial reduction of infusion volume. In 9 babies a transient increase in urea levels was observed during the first week, 5 babies had an increase in triglycerides as a symptom of bad lipid tolerance. In 7 babies on prolonged total PN an increase in alkaline phosphatase is observed. Conclusions. Early and sufficient PN in newborn babies below 1500 g guarantees the daily intake of energy and essential nutritive substances for adequate growth and is a basic component of intensive therapy. It should be corresponding to the nutritional needs as well as to the clinical condition; matching the severity of complications and carried under strict laboratory control.

[Prenatal diangosis of hypospadia--case reports].

Hypospadia is abnormal sex differentiation of the external genitalia with ventral and proximal displacement of the urethral orifice from its usual location on glans penis. Three prenatally diagnosed cases of hypospadia are presented and the major ultrasound findings of this entity are discussed.

[Effect from surfactant therapy in extremely low birth weight infants depending on the method of delivery].

OBJECTIVES: To look for a correlation between way of delivery and the effect from surfactant therapy with extremely low birth weight infants. METHODS: The is a retrospective study and includes babies < or = 1000 g, < or = 28 g.w., born in University Maternity Hospital Maichin dom during the period 2001-2005. Babies were treated with surfactant because of RDS. Babies with severe inborn malformations and those, who died before 28-th day due to severe IVH were excluded from the study. All babies were treated and monitored according to the protocols for surfactant and intensive care therapy. Babies were divided in two groups: group N--33 babies; born by normal delivery, group S--27, born by Cesarean Section. RESULTS: There are no significant differences between the groups according birth weight, gestational age, gender; severity of RDS, incidence of IUGR; kind of surfactant, timing and number of doses. In both groups there is a slight prevalence of female sex. Incidence of full course corticosteroid prophylactics and of inborn infections is definitely higher in gr. N. Babies were followed for: duration of mechanical ventilation (8 days in gr. S vs 20 in gr. N); duration of O2 therapy (34 days in gr. S vs 55 in gr. N); incidence of IVH: gr. S 74% are IVH grade I-II, 11% are grade III-IV; while in gr. N IVH I-II cm. are 38%, IVH grade III-IV are 56%; incidence of BPD--gr. S 14%, vs gr. N --30%; incidence of rethinopathy--23% in gr. S vs 56% in gr. N; incidence of anaemia--100% in both groups. CONCLUSIONS: With ELBWI treated with surfactant chosing the least traumatic way of delivery is important, ensuring smaller duration of mechanical ventilation and O2 therapy, less severe IVH, BPD and ROP.

[Using the CRIB as an early prognostic index for very low birthweight infants, treated in neonatal intensive care unites].

UNLABELLED: The illness severity by admission in NICU reflects the intensity of the therapy, the prognosis for the newborn and the hospital costs. Using the CRIB (Clinical Risk Index for Babies) as an objective and easy method for measuring the illness severity in the first 12 h of life allows assessing the risk of death until discharge. AIM: To apply the CRIB for assessing the illness severity and to investigate its prognostic value for life and risk of permanent disabilities among very low birthweight (VLBW) and gestational age (VLGA) infants. METHODS: The study includes the inborn babies in the Specialized Obstetrics & Gynaecology Hospital "Maichin dom" with birthweight < 1500g and gestational age < 32 weeks of gestation, who are admitted in the NICU for 2 periods: I group--250 newborns in the period 01.2002-06.2004 and II group--186 newborns in the period 07.2004-06.2006. The CRIB is estimated based on data collected in the first 12 h of life. An analysis was made about the prognostic value of the CRIB score and the outcome. Criteria for outcome are: the in hospital mortality rate and disabilities such as severe intraventricular hemorrhages (IVH gr. III and IV), chronic lung disease (CLD) and retinopathy of prematurity (ROP). RESULTS: We establish that the CRIB score is significantly higher among the infants who died--12.7%/13% in the I / II period compared with survivors--6.2% / 5.7% (P < 0.001). The mortality rates raise progressively with the CRIB score: among the newborns with CRIB 0-5 they are 2.9% / 2.6% and reaches up to 78.6% / 90% when the CRIB is > 15. The infants with permanent disabilities were with significantly higher CRIB scores too: 11.7 / 11.4% among the infants with IVH III-IV compared to 6.2 / 5.2 without; 9.6 / 10.1 among infants with CLD compared to 5.7 /5.2 without; 10.1 / 10 among infants with ROP compared to 5.5 / 5.1 without. CONCLUSIONS: The CRIB score is useful and easy to apply early and objective prognostic criterion about the risk of in hospital death and permanent disabilities among VLBW newborns. It can be used as a basis for comparing the results of the different NICUs too.

[Criteria for diagnosis and therapy of hyporegeneratory anemia in premature newborns below 33 week of gestation and body weight below 1500 grams].

AIM: The aim of the present study is to define criteria for erythropoietin therapy of hyporegeneratory anemia in premature newborns according to hemoglobin (Hb) and hematocrit (Hct) concentration, and reticulocyte count (Ret). MATERIALS AND METHODS: The prospective study includes two groups of 20 newborns with anemia of prematurity, body weight at birth below 1500 grams and gestation age below 33 gestation week. The newborns in the first group have been treated with beta-erythropoietin for four weeks--750-1000 E/kg weekly dose, divided q48h. Hb, Hct and Ret have been monitored and compared with that of control group newborns. The therapy of newborns in the control group consisted of blood transfusions. RESULTS: The hematological parameters in the newborns from the first group have been increased permanently after the first week of therapy, with Ret being most sensitive to the therapy. In the second group of newborns, due to blood transfusions, transient increase of Hb and Hct, and decrease of Ret have been observed in next days after the blood transfusions. CONCLUSIONS: The erythropoietin therapy of hyporegeneratory anemia in preterm newborns leads to rise in Hb, Hct and Ret. The therapy with blood transfusions suppresses erythropoiesis. This leads to decrease in Ret and transient rise in Hb, Hct and erythrocytes. That's why each blood transfusion leads to another one.

[Congenital cystic adenomatoid malformation of the lung--report of two cases].

Congenital cystic adenomatoid malformation (CCAML) is a rare anomaly of the fetal lung which can be diagnosed prenatally by ultrasound. We present two cases of CCAML with different pregnancy outcome diagnosed at 17 and 24 weeks gestation, respectively, and discuss the major aspects of the obstetrical and therapeutical management.

[Use of aminoglycoside antibiotic gentamycin in extremely premature infants--administration schedule and suggested dosage based on pharmacokinetic studies in plasma].

The pharmacokinetics of Gentamycin administered to 22 infants intravenously at currently recommended doses (2-2.5 mg every 24 h for infants less than 7 days of life and 28 g.a. and 12 h for infants 32 g.a). The results showed a statistically significant relation between half-life and postconsiptional age and direct correlation between total body clearance and postconsiptional age. These pharmacokinetics data were used to calculate a new dosage schedule for preterm infants. Ondoing therapeutic drug monitoring is essential to tailor the dosage to the individual patient. Gentamycin.

[Prevention of brain hemorrhage in infants with low and extremely low birth weight and infants treated with surfactants. Late observation].

Prematurely born infants with intraventricular haemorrhage (IVH) suffer significant morbidity and mortality, particularly those infants with high grade haemorrhage. The more premature infants have a higher incidence, experiencing more severe IVH. The etiology of IVH is clearly multifactorial. Prevention, both prenatal and postnatal. These include efforts to prevent preterm delivery. Postnatally, the importance of optimal resuscitation and neonatal care practices is stressed, particularly those which minimize cerebral blood flow fluctuation. 130 premature infants of less than 32 weeks gestation with a very low birth weight (VLBW) and extremely low birth weight (ELBW) were studied. They were divided in four groups: group I (n=35) received Indocid; group II (n=42) received Indocid and Phenobarbital; group III (n=53) received Indocid and Phenobarbital; surfactant. These three groups were compare to a reference group (n=45). Newborns from the main group were given Indocid 0.1 mg/kg from 6-12 h of life and during next three days, Phenobarbital 5 mg/kg first five days after delivery and surfactant in the first 4 hours of life according to the protocol provided with the specific surfactant replacement product. Cerebral netrasaund in 24 hours, day 3, 5 and 10 of life and follow up till one year age were performed. We found that IVH/PVH percentage is lowest in newborns from group III, followed by newborns from group II and group I.

[Inborn bacterial infections during neonatal period].

Considering the high mortality and serios morbilidy associatent with neonatal infections. A competent diagnostic marker also needs to have reasonably high specificity. Good evidence exists to support the use of CRP measurements in conjunction with other established diagnostic tests (such as a white blood cell (WBC) count with differential and blood culture) to establish or exclude the diagnosis of sepsis in full-term or near-term infants. Sepsis was suspected within the first 3 days after birth in. There were 20% early-onset and 53% late-onset episodes of proven sepsis. CRP had sensitivities of 39.4% and 64.6% for proven or probable sepsis and 35.0% and 61.5% for proven sepsis in early-onset and late-onset episodes, respectively. To compare the clinical informative value of and C-reactive protein (CRP) plasma concentrations in the detection of infection and sepsis and in the assessment of severity of sepsis. PCT is a better marker of sepsis than CRP. The course of PCT shows a closer correlation than that of CRP with the severity of infection and organ dysfunction. Diagnostic markers are useful indicators of neonatal bacterial infections C-reactive protein (CRP), procalcitonin (PCT) Intralevcin 6, 8 are early sensitive markers of infection.

[A case report of two incidents of acute abdomen in a woman during pregnancy and in the early puerperium].

The authors present a case of a 32 year old pregnant woman who is admitted to the Obstetric clinic in the 16th gestational week with a pain in the ileoceacal region of the abdomen and vomitting. The woman has clinical signs of acute abdomen. A clinical diagnosis of acute appendicitis was suggested. During the operation under general anesthesia was found a phlegmonous inflammation of a Mekel diverticulus with perforation as well as local peritonitis and a catharal inflammation of the appendix. The appendix and the Mekel diverticle were removed during the operation. No comlications were observed during the post operative period. No fetal distress was observed during and after the operation Three months later the same patient was admitted to the obstetric clinic in the 32nd gestational week with a diagnosis Threatened premature delivery in ml VIII status post resection of a Mekel diverticle and appendectomy. The patient had pain to the right of the umbilicus and vomiting. The labor was induced and a viable premature infant was born. Two days after delivery there was again a clinical symptoms and signs of an acute abdomen due to ileus. A strangulation of the terminal ileum was found due to adhesions A Debridman and a lavage were performed No complications were observed during the postoperative period. The authors discuss the difficulties which might ensue when the diagnosis acute abdomen is made in a pregnant woman

[French-Bulgarian program "Resuscitation of the newborn in a delivery room"--results and perspectives].

Since the year 2000 in Republic Bulgaria was started the French Bulgarian Program "Resuscitation of the Newborn in Delivery Room" (DR). The main goal was to reduce the neonatal mortality rate due to perinatal and intrapartal asphyxia and their consequences. This was achieved by providing the Delivery rooms in the City hospitals with resuscitation equipment and improving the qualification of the personal. The French foundation Medecines du Monde has ensured the materials--Baby balloons for ventilation, laryngoscopes and Magiles for each DR and a handbook with the guidelines of the neonatal resuscitation for each of the participants. In the period 2000-2003 French and Bulgarian neonatologists from the university obstetric hospitals visited all the DR in the country and two training seminars for resuscitation of the newborn were carried out in each of them. The first positive results of this program are: reduced neonatal mortality rate from 7.8% in 2001 to 6.8% in 2003 (P < 0.05). Asphyxia as a mean cause for death in the neonatal period was 9% in 2001 and dropped to 8% in 2003. To keep on improving this results is necessary to continue improving the qualification of personal working in DR--neonatologists, obstetricians and midwifes and be sure that resuscitation equipment is always ready for action.

[Upper extremity gangrene in an infant of a diabetic mother, presenting at birth].

In utero gangrene of an extremity because of an arterial thrombosis is rare. More than 20% of the reported cases concern infants of diabetic mothers (IDM) with poor control of diabetes. Changes in coagulation related to deviation of clotting factors and low plasminogen activity may be the cause. We report a case of an IDM who presented at birth with upper extremity gangrene. The Dopplersonography has shown missing pulsations and thrombosis of a.brachialis sin, which was confirmed after amputation of the arm on the 5th day. The postoperative period was complicated by septicaemia, necrotising enterocolitis and disseminated intravasal coagulation resulting in the baby's death 10 days after birth.