Factores asociados con bajo puntaje de Apgar en la maternidad del Centro Hospitalario Pereira Rossell / Factors associated with low Apgar score in the maternity of Pereira Rossell Hospital / Fatores associados com baixa pontuação de Apgar na maternidade do Centro Hospitalar Pereira Rossell

Introducción: La depresión neonatal es una de las causas más frecuentes de ingreso de recién nacidos a unidades especializadas de atención neonatal. La asfixia perinatal es una de las causas de bajo puntaje de Apgar, siendo uno de los criterios clínicos para su diagnóstico. Los principales factores de riesgo vinculados con bajos puntajes de Apgar pueden ser maternos (edad, patologías obstétricas, nivel socioeconómico, adicciones, etc.), del trabajo de parto y parto o, alteraciones fetales. Objetivos: Determinar los factores perinatales asociados a la baja puntuación de Apgar a los 5 minutos. Diseño: Estudio retrospectivo de casos y controles en los años 2015 y 2016. Institución: Hospital de la Mujer, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay. Participantes: Se incluyeron todos los recién nacidos término con Apgar a los 5 minutos menor o igual a 5. Resultados: Hubo un total de 12.528 nacimientos de recién nacidos vivos de término en el HM. 34 casos de recién nacidos con Apgar a los 5 minutos menor o igual a 5. Esto corresponde al 0,27% de la población. No se identificaron diferencias estadísticamente significativas en cuanto a los principales factores asociados a asfixia perinatal. Conclusiones: En el análisis de esta población, la mayoría de los factores analizados no se asocia con los casos de Apgar a los 5 minutos menor o igual a 5 (depresión neonatal moderada-severa), por lo que la mayoría de estos casos pueden no ser evitables.

Introduction: Neonatal depression is one of the most frequent causes of admission of newborns to specialized units of neonatal care. Perinatal asphyxia is one of the causes of low Apgar score, and it is one of the clinical criteria for its diagnosis. Main risk factors associated with low Apgar scores can be maternal (age, obstetric pathologies, socioeconomic level, addictions, etc.), of labor and delivery or, fetal alterations. Objective: To determine the perinatal factors associated with the low Apgar score at 5 minutes. Design: Retrospective study of cases and controls in 2015 and 2016. Institution: Maternity, Women Hospital, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay. Patients: We included all term newborns with Apgar at 5 minutes less than or equal to 5. Results: There was a total of 12,528 births of term full-term newborns in the HM. 34 cases of newborns with Apgar at 5 minutes less than or equal to 5. This corresponds to 0.27% of the population. No statistically significant differences were identified regarding the main factors associated with perinatal asphyxia. Conclusions: In the analysis of this population, most of the analyzed factors are not associated with cases of Apgar at 5 minutes less than or equal to 5 (moderate-severe neonatal depression), so that most of these cases may not be avoidable.

Introdução: A depressão neonatal é uma das causas mais freqüentes de internação de recém-nascidos em unidades especializadas de atenção neonatal. A asfixia perinatal é uma das causas do baixo índice de Apgar, sendo um dos critérios clínicos para o seu diagnóstico. Os principais fatores de risco associados aos baixos escores de Apgar podem ser maternos (idade, patologias obstétricas, nível socioeconômico, dependências, etc.), de trabalho de parto e parto, ou alterações fetais. Objetivos: Determine os fatores perinatais asociados ao baixo índice de Apgar aos 5 minutos. Design: Estudo retrospectivo de casos e controles nos anos de 2015 e 2016. Instituição: Hospital da Mulher, Centro Hospitalar Pereira Rossell, Montevidéu, Uruguai. Participantes: Todos os recém-nascidos a termo com Apgar a 5 minutos menor ou igual a 5 foram incluídos. Houve um total de 12.528 nascidos vivos a termo no MB. 34 casos de recém-nascidos com Apgar a 5 minutos menor ou igual a 5. Isso corresponde a 0,27% da população. Não foram identificadas diferenças estatisticamente significantes quanto aos principais fatores associados à asfixia perinatal. Conclusões: Na análise dessa população, a maioria dos fatores analisados não está associada aos casos de Apgar em 5 minutos menor ou igual a 5 (depressão neonatal moderada a grave), de modo que a maioria desses casos pode não ser evitável.

Risk factors associated with the development of perinatal asphyxia in neonates at the Hospital Universitario del Valle, Cali, Colombia, 2010-2011 / Factores de riesgo asociados con el desarrollo de asfixia perinatal en neonatos en el Hospital Universitario del Valle, Cali, Colombia, 2010-2011

Abstract Introduction: Perinatal asphyxia is one of the main causes of perinatal mortality and morbidity worldwide and it generates high costs for health systems; however, it has modifiable risk factors. Objective: To identify the risk factors associated with the development of perinatal asphyxia in newborns at Hospital Universitario del Valle, Cali, Colombia. Materials and methods: Incident cases and concurrent controls were examined. Cases were defined as newborns with moderate to severe perinatal asphyxia who were older than or equal to 36 weeks of gestational age, needed advanced resuscitation and presented one of the following: early neurological disorders, multi-organ commitment or a sentinel event. The controls were newborns without asphyxia who were born one week apart from the case at the most and had a comparable gestational age. Patients with major congenital malformations and syndromes were excluded. Results: Fifty-six cases and 168 controls were examined. Premature placental abruption (OR=41.09; 95%CI: 4.61-366.56), labor with a prolonged expulsive phase (OR=31.76; 95%CI: 8.33-121.19), lack of oxytocin use (OR=2.57; 95% CI: 1.08 - 6.13) and mothers without a partner (OR=2.56; 95% CI: 1.21-5.41) were risk factors for the development of perinatal asphyxia in the study population. Social difficulties were found in a greater proportion among the mothers of cases. Conclusions: Proper control and monitoring of labor, development of a thorough partograph, and active searches are recommended to ensure that all pregnant women have adequate prenatal care with the provision of social support to reduce the frequency and negative impact of perinatal asphyxia.

Resumen Introducción: La asfixia perinatal constituye una de las principales causas de morbilidad y mortalidad perinatal en el mundo, tiene factores de riesgo modificables y genera altos costos para los sistemas de salud. Objetivo: Determinar los factores de riesgo asociados al desarrollo de asfixia perinatal en recién nacidos en el Hospital Universitario del Valle, Cali, Colombia. Materiales y métodos: Se llevó a cabo un estudio de casos incidentes y controles concurrentes. Los casos se definieron como neonatos con asfixia perinatal moderada a grave, de edad de gestación mayor o igual a 36 semanas, que requirieron reanimación avanzada y presentaron, al menos, una de las siguientes condiciones: alteraciones neurológicas tempranas, falla orgánica múltiple o aparición de un evento centinela. Los controles se definieron como neonatos sin diagnóstico de asfixia, nacidos hasta con una semana de diferencia con respecto al caso y de edad de gestación comparable. Se excluyeron los pacientes con malformaciones congénitas mayores y síndromes. Resultados: Se estudiaron 56 casos y 168 controles. El desprendimiento prematuro de la placenta (odds ratio, OR=41,09; IC95% 4,61-366,56), un trabajo de parto con fase expulsiva prolongada (OR=31,76; IC95% 8,33-121,19), no usar oxitocina (OR=2,57; IC95% 1,08-6,13) y ser madre soltera (OR=2,56; IC95% 1,21-5,41) fueron factores de riesgo para el desarrollo de asfixia perinatal en la población bajo estudio. En las madres de los casos se encontraron dificultades sociales en mayor proporción. Conclusiones: Se recomienda un control adecuado y una vigilancia apropiada del trabajo de parto, hacer un estricto partograma, y una búsqueda activa, de manera que cada mujer embarazada tenga un adecuado control prenatal y reciba apoyo social.

Prolonged second stage of labor is associated with low Apgar score.

There is no consensus on the effects of a prolonged second stage of labor on neonatal outcomes. In this large Swedish population-based cohort study, our objective was to investigate prolonged second stage and risk of low Apgar score at 5 min. All nulliparous women (n = 32,796) delivering a live born singleton infant in cephalic presentation at ≥37 completed weeks after spontaneous onset of labor between 2008 and 2012 in the counties of Stockholm and Gotland were included. Data were obtained from computerized records. Exposure was time from fully retracted cervix until delivery. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Adjustments were made for maternal age, height, BMI, smoking, sex, gestational age, sex-specific birth weight for gestational age and head circumference. Epidural analgesia was included in a second model. The primary outcome measure was Apgar score at 5 min <7 and <4. We found that the overall rates of 5 min Apgar score <7 and <4 were 7.0 and 1.3 per 1000 births, respectively. Compared to women with <1 h from retracted cervix to birth, adjusted ORs of Apgar score <7 at 5 min generally increased with length of second stage of labor: 1 to <2 h: OR 1.78 (95% CI 1.19-2.66); 2 to <3 h: OR 1.66 (1.05-2.62); 3 to <4 h: OR 2.08 (1.29-3.35); and ≥4 h: OR 2.71 (1.67-4.40). We conclude that prolonged second stage of labor is associated with an increased risk of low 5 min Apgar score.

Tracheal suctioning improves gas exchange but not hemodynamics in asphyxiated lambs with meconium aspiration.

BACKGROUND: Current neonatal resuscitation guidelines recommend tracheal suctioning of nonvigorous neonates born through meconium-stained amniotic fluid. METHODS: We evaluated the effect of tracheal suctioning at birth in 29 lambs with asphyxia induced by cord occlusion and meconium aspiration during gasping. RESULTS: Tracheal suctioning at birth (n = 15) decreased amount of meconium in distal airways (53 ± 29 particles/mm(2) lung area) compared to no suction (499 ± 109 particles/mm(2); n = 14; P < 0.001). Three lambs in the suction group had cardiac arrest during suctioning, requiring chest compressions and epinephrine. Onset of ventilation was delayed in the suction group (146 ± 11 vs. 47 ± 3 s in no-suction group; P = 0.005). There was no difference in pulmonary blood flow, carotid blood flow, and pulmonary or systemic blood pressure between the two groups. Left atrial pressure was significantly higher in the suction group. Tracheal suctioning resulted in higher Pao2/FiO2 levels (122 ± 21 vs. 78 ± 10 mm Hg) and ventilator efficiency index (0.3 ± 0.05 vs.0.16 ± 0.03). Two lambs in the no-suction group required inhaled nitric oxide. Lung 3-nitrotyrosine levels were higher in the suction group (0.65 ± 0.03 ng/µg protein) compared with the no-suction group (0.47 ± 0.06). CONCLUSION: Tracheal suctioning improves oxygenation and ventilation. Suctioning does not improve pulmonary/systemic hemodynamics or oxidative stress in an ovine model of acute meconium aspiration with asphyxia.

Maternal overweight and obesity and risks of severe birth-asphyxia-related complications in term infants: a population-based cohort study in Sweden.

BACKGROUND: Maternal overweight and obesity increase risks of pregnancy and delivery complications and neonatal mortality, but the mechanisms are unclear. The objective of the study was to investigate associations between maternal body mass index (BMI) in early pregnancy and severe asphyxia-related outcomes in infants delivered at term (≥37 weeks). METHODS AND FINDINGS: A nation-wide Swedish cohort study based on data from the Medical Birth Register included all live singleton term births in Sweden between 1992 and 2010. Logistic regression analyses were used to obtain odds ratios (ORs) with 95% CIs for Apgar scores between 0 and 3 at 5 and 10 minutes, meconium aspiration syndrome, and neonatal seizures, adjusted for maternal height, maternal age, parity, mother's smoking habits, education, country of birth, and year of infant birth. Among 1,764,403 term births, 86% had data on early pregnancy BMI and Apgar scores. There were 1,380 infants who had Apgar score 0-3 at 5 minutes (absolute risk  = 0.8 per 1,000) and 894 had Apgar score 0-3 at 10 minutes (absolute risk  = 0.5 per 1,000). Compared with infants of mothers with normal BMI (18.5-24.9), the adjusted ORs (95% CI) for Apgar scores 0-3 at 10 minutes were as follows: BMI 25-29.9: 1.32 (1.10-1.58); BMI 30-34.9: 1.57 (1.20-2.07); BMI 35-39.9: 1.80 (1.15-2.82); and BMI ≥40: 3.41 (1.91-6.09). The ORs for Apgar scores 0-3 at 5 minutes, meconium aspiration, and neonatal seizures increased similarly with maternal BMI. A study limitation was lack of data on effects of obstetric interventions and neonatal resuscitation efforts. CONCLUSION: Risks of severe asphyxia-related outcomes in term infants increase with maternal overweight and obesity. Given the high prevalence of the exposure and the severity of the outcomes studied, the results are of potential public health relevance and should be confirmed in other populations. Prevention of overweight and obesity in women of reproductive age is important to improve perinatal health.

[The influence of ecological and socio-biological risk factors on the course of for pregnancy, birth, and fetal state].

The features of prenatal and social history of 857 children in Kirov, as well as indices of aerotechnogenic pollution in the place of their residence have been studied In the investigated region the existence of ecological (aerotechnogenic pollution) and socio-biological (maternal smoking and psychological trauma) risk factors for prenatal pathologies affecting the mother organism during pregnancy was established. Habitation in this region complicates the course of pregnancy and childbirth (increasing the risk of complicated course of pregnancy and maternity aid), worsens the condition of the fetus (increased risk of neonatal asphyxia) and increases the chance of twins.

Neuroprotective treatment for perinatal asphyxia.

BACKGROUND: Perinatal asphyxia can cause serious illness or death. By taking steps in the «latent phase¼, which occurs 6-24 hours after the hypoxic event, the neurological damage caused by perinatal asphyxia can be limited. We wish to present a selection of such measures that are either established treatment today or that appear promising. METHOD: We searched in the Medline and Cochrane Library databases for options for treating perinatal asphyxia. RESULTS: An overwhelming number of potential treatments were identified. From among them we selected 44 indexed, peer-reviewed original articles in English on strategies for neuroprotective treatment after perinatal asphyxia. The treatments target different cellular mechanisms that cause neurological damage following perinatal asphyxia. In randomised clinical trials, only hypothermia treatment has improved the long-term outcome for newborns with perinatal asphyxia. Xenon gas, erythropoeitin and allopurinol are undergoing clinical testing. INTERPRETATION: The efficacy of xenon gas, erythropoeitin and allopurinol in combination with the established treatment form of hypothermia must be studied more closely. Antioxidants, stem cell treatment and DNA repair mechanisms can pave the way for new opportunities in the future.

Reference ranges for lymphocyte counts of neonates: associations between abnormal counts and outcomes.

BACKGROUND AND OBJECTIVE: Both high and low lymphocyte counts at birth have been associated with adverse outcomes. However, the validity of defining a lymphocyte count as "abnormal" depends on having an accurate reference range. We established a reference range for neonatal lymphocyte counts by using multihospital data and used this to assess previously reported relationships between abnormal counts and early onset sepsis (EOS), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), periventricular leukomalacia, and birth asphyxia. METHODS: We first created a data set that excluded counts from neonates with diagnoses previously associated with abnormal lymphocyte counts. Then the complete data (counts excluded plus included in the reference range) were used to test associations between abnormal counts and EOS, IVH, ROP, periventricular leukomalacia, and outcomes after birth asphyxia. RESULTS: Lymphocyte counts were retrieved from 40 487 neonates, 10 860 of which were excluded from the reference range. A count >95th percentile was associated with EOS (2.07; 95% confidence interval [CI]: 1.80-2.38) and IVH ≥grade 3 (2.93; 95% CI: 1.83-4.71). A count <5th percentile was associated with EOS (odds ratio:1.24; 95% CI: 1.04-1.48), IVH ≥grade 3 (3.23; 95% CI: 1.95-5.36), and ROP ≥stage 3 (4.80: 95% CI: 2.38-9.66). Among 120 meeting criteria for birth asphyxia, those with a low count and a high nucleated red cell count had higher mortality (37% vs 11%, P = .001), more transfusions (P = .000), and more neurology referrals (P < .01). CONCLUSIONS: A reference range for lymphocytes can identify neonates with abnormal counts, which can be useful because these neonates are at higher risk for certain adverse outcomes.

Polymicrogyria: correlation of magnetic resonance imaging and clinical findings.

AIM: The aim of this study is to evaluate the correlation between clinical presentation and the extent of cortical involvement in patients with polymicrogyria. MATERIALS AND METHODS: The magnetic resonance imaging findings of 26 patients were evaluated for the location and distribution of polymicrogyria. Presence of asphyxia at birth and serological tests for TORCH infections, the presence and type (spastic, flaccid) of motor deficits, mental development,microcephaly, and epilepsy were noted. RESULTS: Nineteen patients had bilateral, whereas seven had unilateral involvement. Patients with unilateral polymicrogyria presented later with milder symptoms. The most encountered symptom in patients with bilateral involvement was mental motor retardation (MMR) (89%) and speech problems (84%).The clinical presentations of patients with asphyxia and positive serological tests for cytomegalovirus (CMV) were worse.All patients with positive serological tests for CMV had bilateral involvement. The perisylvian region was affected in five(71%) patients with unilateral involvement. The most encountered presenting symptom in these patients was epilepsy. Cerebral palsy was seen in three (43%) of the patients, and all of them had left hemiparesis. Microcephaly, MMR, and speech delay were detected in one (14%) of the patients. CONCLUSIONS: Late presenting epilepsy may be a predictor of aunilateral polymicrogyria and is associated with relatively good prognosis. CMV infection and the presence of asphyxia are predictors of worse prognosis.

Challenges in the management of early versus late presenting congenital diaphragmatic hernia in a poor resource setting.

BACKGROUND: Despite the advances in management, congenital diaphragmatic hernia (CDH) has continued to pose a significant challenge to paediatric surgeons. This is amplified in a setting like ours where there is a dearth of facilities to cope with the problem of CDH. This study was undertaken to highlight the peculiarities of the management of CDH in a poor resource setting. METHODS: All confirmed cases of CDH were prospectively documented from 2003 till date. RESULTS: Seven children were treated from 2003 till date. The diaphragmatic defect was on the left side in six (83.8%) and on the right side in one (17.7%). All the patients had primary closure of the defect without patch via an abdominal approach. The three patients presenting at birth died while the remaining four patients survived. CONCLUSION: With inadequate neonatal intensive care facilities, the severe early presenting CDH has a dismal prognosis. In contrast, the late presenting CDH poses more diagnostic challenges; but once identified and appropriate treatment instituted, it has an excellent prognosis. We recommend that physicians should include CDH in the differential diagnosis of patients with birth asphyxia and in patients with chronic respiratory symptoms with failure to thrive.

Obstetrical and fetal outcomes of a new management strategy in patients with intra-hepatic cholestasis of pregnancy.

PURPOSES: To determine the incidence, obstetrical, and fetal complication rates of intrahepatic cholestasis of pregnancy (ICP) in patients managed expectantly to 40-weeks gestation. METHODS: In a prospective cohort study conducted between February 2008 and January 2010, a total of 21,960 pregnant women in Qassim Region of Saudi Arabia were screened for ICP using specific criteria for diagnosis. The course of pregnancy was monitored to 40-weeks gestation or spontaneous onset of labor, whichever comes first. The measured outcomes were compared with a cross-matched group of healthy pregnant women. Continuous variables were analyzed with t test, while χ(2) test was used for comparing percentages. RESULTS: The incidence of ICP was 0.35% (76/21,960). There was no significant difference between groups in gestational age at delivery, preterm labor, intrauterine fetal death, cesarean section, or respiratory distress syndrome. There was significantly higher intrapartum non-reassuring fetal heart rate patterns and meconium-stained amniotic fluid in ICP group (P < 0.01 and <0.0001, respectively). CONCLUSIONS: The incidence of ICP in this region is low compared to worldwide range. Expectant management to 40-weeks gestation is associated with obstetrical and fetal outcomes comparable to normal pregnancy; however, intrapartum fetal asphyxia is more likely.

Hipotermia en recíen nacidos con asfixia perinatal / Hypothermia in newborns with perinatal asphyxia

Se ha demostrado que la hipotermia controlada puede reducir la muerte o discapacidad grave, la mortalidad y los trastornos del neurodesarrollo en recién nacidos que han sufrido asfixia perinatal. Con el objetivo de implementar la realización de hipotermia se analizó su aplicación en 10 recién nacidos de término que cumplieron con criterios de inclusión en dos centros neonatales de Montevideo en un período de dos años. Se alcanzó la temperatura objetivo (33,5°C) en las primeras 6 horas de vida de los pacientes y se mantuvo en ese rango durante 72 horas en 7/10 pacientes. En 8/10 pacientes se utilizó un gorro con agua fría circulante y en 2/10 placas de gel congelado para el enfriamiento encefálico directo y de todo el cuerpo en forma indirecta. Tres pacientes se retiraron del protocolo luego de 48 horas de hipotermia por alteraciones de la coagulación, bradicardia mantenida y paro cardiorrespiratorio, respectivamente. El recalentamiento se logró en todos los casos en seis horas sin alteraciones. El 60% de los pacientes presentaron convulsiones durante su internación y el 100% recibieron fenobarbital. En el grupo analizado se produjeron dos muertes, uno de ellos próximo a la supresión de la terapia y otro en la evolución alejada. De manera complementaria se presentó la caracterización del impacto de la hipoxia severa y de la inducción de hipotermia sobre las variables más relevantes en un modelo de cerdo recién nacido. Se concluye que el desarrollo de hipotermia controlada es una estrategia terapéutica posible y segura, que brinda una oportunidad a los pacientes que han sufrido asfixia perinatal

Peripartum bilateral uterine rupture in a patient with mixed connective tissue disease with favorable outcome for the severely asphyctic newborn after hypothermia.

PURPOSE: Information about fetal and maternal outcome in pregnant women with mixed connective tissue disease (MCTD) is rare and in part contradictory. The purpose of this study is to review published literature about MCTD in pregnancy in the context of a rare case of peripartum bilateral uterine rupture in a patient with MCTD with favorable outcome for the severely asphyctic newborn after hypothermia. METHOD: The study included a selective literature review based on a PubMed search using the search terms MCTD, Sharp syndrome, uterine rupture and hypothermia, and a detailed report of our case with regard to the MCTD of the patient. RESULTS: Rupture to the backside of the uterus during delivery, independent of prior cesarean section, was unpredictable and its cause remains unclear. The clinical outcome of the newborn was surprisingly favorable and there were no signs of neurodevelopmental sequelae in spite of the fact that the newborn was asphyctic and had a large excess of acids in the umbilical cord blood gas analysis. The favorable outcome is due to treatment with whole body hypothermia. CONCLUSIONS: Any type of prior surgery of the uterus puts the patient at risk during delivery. MCTD might be a risk factor during birth. These patients should be followed closely during pregnancy and should deliver at a center, which provides all options for immediate surgical and neonatological intervention.

Increased umbilical cord plasma interleukin-1 beta levels was correlated with adverse outcomes of neonatal hypoxic-ischemic encephalopathy.

To explore whether or not the umbilical blood levels of cytokines can be used to indicate the adverse outcomes of hypoxic-ischemic encephalopathy (HIE) patients. Umbilical artery blood and peripheral venous blood samples were collected on the 1st, 3rd and 7th days after birth to detect the levels of IL-1 beta, IL-8 and TNF-alpha. Neurological examination and Denver developmental screening test (DDST-II) were performed at the 6 and 12 months evaluations to detect any neurodevelopmental abnormalities. The results showed: (i) the serum concentrations of IL-1 beta, IL-8 and TNF-alpha in umbilical and peripheral blood were significantly higher in HIE patients than control groups; (ii) the umbilical blood concentrations of IL-1 beta exhibited the best positive correlation with HIE grades, when compared with IL-8 and TNF-alpha; and (iii) abnormal neurological outcomes at 6 and 12 months of age were best predicted by umbilical levels of IL-1 beta. Thus, umbilical concentrations of IL-1 beta were associated with the grades and adverse outcomes of HIE.

Inhaled nitric oxide treatment inhibits neuronal injury after meconium aspiration in piglets.

BACKGROUND: Meconium aspiration-induced hypertensive lung injury is frequently associated with neuronal damage. Inhaled nitric oxide (iNO) is widely used in the treatment of pulmonary hypertension, but its effects on the brain are poorly known. AIMS: The aim of this study was to determine the effects of iNO treatment on the neuronal tissue after meconium aspiration. STUDY DESIGN: 71 anesthetized, catheterized and ventilated newborn piglets were studied for 6 h. Thirty-five piglets were instilled with a bolus of human meconium intratracheally and 36 piglets with saline instillation served as controls. Nineteen meconium piglets and 17 control piglets were continuously treated with 20 ppm of iNO, started at 30 min after the insult. The extent of neuronal injury was analysed histologically, and the levels of brain tissue lipid peroxidation products, reduced glutathione (GSH), myeloperoxidase activity and oxidized DNA were analysed as indicators of oxidative stress. RESULTS: iNO treatment diminished the pulmonary hypertensive response caused by meconium aspiration, but did not change systemic or carotid hemodynamics. NO administration was associated with reduced neuronal injury and diminished amount of oxidized DNA in the hippocampus of the meconium piglets. Further, iNO treatment was associated with decreased level of GSH in the cortex, but no change in lipid peroxidation production or myeloperoxidase activity was detected in any of the studied brain areas. CONCLUSIONS: Our results suggest that iNO treatment may inhibit DNA oxidation and neuronal injury in the hippocampus, associated with newborn meconium aspiration.

Oxytocin-associated rupture of an unscarred uterus in a primigravida.

BACKGROUND: Intrapartum rupture of the unscarred uterus is an uncommon event, usually associated with such risk factors as grand multiparity, malpresentation, history of gestational trophoblastic disease, or instrumented delivery. Rupture during first pregnancy is extremely rare. CASE: A 30-year-old primigravid woman was admitted for labor augmentation with oxytocin at 40.5 weeks of gestation. The oxytocin infusion rate was increased during the first and second stages of labor despite contractions occurring at a rate of 4-5 per 10 minutes. The uterus ruptured during second stage. Despite emergency cesarean delivery, the baby had evidence of severe asphyxia. CONCLUSION: This case of uterine rupture in a primigravida with no prior uterine surgery and a structurally normal uterus underscores the importance of careful contraction monitoring and judicious control of oxytocin infusion rates.

IL-1beta, IL-6 and TNF-alpha and outcomes of neonatal hypoxic ischemic encephalopathy.

The role of cytokines in the pathogenesis of brain injury and their relation to neurological outcomes of asphyxiated neonates is not fully defined. We hypothesize that interleukin-1 beta (IL-1beta), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in cerebrospinal fluid (CSF) correlate with the severity of brain injury and can predict neurological deficits in infants who suffered from hypoxic ischemic encephalopathy (HIE). A prospective study was conducted on 24 term infants diagnosed with HIE and 13 controls. HIE was clinically classified into mild, moderate and severe according to Sarnat and Sarnat grading. Blood and CSF samples were obtained from all infants in the first 24h of life as part of routine investigations for suspected meningitis and/or sepsis. Neurological examination and Denver Developmental Screening Test II (DDST II) were performed at 6 and 12 months of life. IL-1beta, IL-6 and TNF-alpha were all significantly increased in HIE infants when compared to control. IL-1beta in the CSF correlated with the severity of HIE (r=0.61, P=0.001) more than IL-6 (r=0.45, P=0.004) or TNF-alpha (r=0.47, P=0.003). IL-1beta exhibited the highest CSF/serum ratio among the three studied cytokines suggesting its local release in the brain after the initial hypoxic injury. Abnormal neurological findings and/or abnormal DDST II at 6 and 12 months were best predicted by IL-1beta in the CSF (sensitivity=88% and specificity=80%). This study confirms the role of IL-1beta in the ongoing neuronal injury that occurs in the latent phase following the original HIE insult.

Meconium aspiration induces neuronal injury in piglets.

AIM: Meconium aspiration-induced hypertensive lung injury, especially when connected with perinatal asphyxia, has been associated with brain damage. We aimed to determine the neuronal injury induced by pulmonary meconium contamination alone and with concurrent asphyxia. METHODS: 36 anaesthetized and ventilated newborn piglets were haemodynamically monitored for 6 h. Seven piglets without concurrent asphyxia and seven piglets with asphyxia were instilled with a bolus of human meconium intratracheally. Seven piglets had only asphyxia and 15 piglets served as controls. The brains were studied histologically. RESULTS: Meconium aspiration did not change systemic haemodynamics acutely, while its combination with asphyxia diminished the abrupt postasphyxic systemic hypertensive peak and resulted in a transient increase in carotid artery flow, not seen after isolated asphyxia. Systemic pressure declined after 4 h in all insulted groups, but only isolated asphyxia was associated with a sustained decrease in carotid artery flow. Arterial oxygenation remained normal, except during the acute insults. Brain examination after meconium instillation indicated neuronal injury, especially in the CA3 region of the hippocampus. Asphyxia resulted in neuronal injury in the cortical, cerebellar and hippocampal hilus regions. CONCLUSION: Severe meconium aspiration itself may result in hippocampal neuronal injury.