Biological and pathological mechanisms leading to the birth of a small vulnerable newborn.

The pathway to a thriving newborn begins before conception and continues in utero with a healthy placenta and the right balance of nutrients and growth factors that are timed and sequenced alongside hormonal suppression of labour until a mature infant is ready for birth. Optimal nutrition that includes adequate quantities of quality protein, energy, essential fats, and an extensive range of vitamins and minerals not only supports fetal growth but could also prevent preterm birth by supporting the immune system and alleviating oxidative stress. Infection, illness, undernourishment, and harmful environmental exposures can alter this trajectory leading to an infant who is too small due to either poor growth during pregnancy or preterm birth. Systemic inflammation suppresses fetal growth by interfering with growth hormone and its regulation of insulin-like growth factors. Evidence supports the prevention and treatment of several maternal infections during pregnancy to improve newborn health. However, microbes, such as Ureaplasma species, which are able to ascend the cervix and cause membrane rupture and chorioamnionitis, require new strategies for detection and treatment. The surge in fetal cortisol late in pregnancy is essential to parturition at the right time, but acute or chronically high maternal cortisol levels caused by psychological or physical stress could also trigger labour onset prematurely. In every pathway to the small vulnerable newborn, there is a possibility to modify the course of pregnancy by supporting improved nutrition, protection against infection, holistic maternal wellness, and healthy environments.

Screening and diagnosis of women for chorioamnionitis: An integrative literature review.

OBJECTIVE: This integrative literature review provides an overview of current best research evidence on the screening and diagnosis of women for chorioamnionitis, as no current review has been conducted. An overview of best practices on screening and diagnosis of women for chorioamnionitis can assist midwives with an accurate diagnosis, allowing for early referral and adequate management of this infection. DESIGN: An integrative literature review was conducted using a systematic electronic literature search through EBSCOhost (CINAHL with Full Text, e-Book Collection, Health Source: Nursing/Academic Edition, MEDLINE, Open Dissertations and PsycINFO), Cochrane Online, PubMed, Scopus, followed by a manual search for grey literature using Google and a citation search. Guidelines, research studies, and reports in English related to chorioamnionitis from 2008 up until 2020 were included in the study. FINDINGS: After critical appraisal, using the Joanna Briggs Institution's checklists, Evaluation Tool for Quantitative Research Studies' tool and the Appraisal of Guidelines for Research & Evaluation instrument, 31 articles were included. More than half (64%) of the literature included ranked on the three highest levels of evidence (Level I, II and III). Data extracted regarding screening and diagnosis of women for chorioamnionitis was synthesised into four themes, namely: screening by clinical signs and symptoms, screening by causative factors of chorioamnionitis, screening of obstetric history, and essential biomarkers to diagnose chorioamnionitis. KEY CONCLUSIONS: Screening and recording of any risk factors will assist midwives in providing tailored health education to possibly prevent causative factors that could lead to chorioamnionitis. Although matrix-metalloproteinase-8 (MMP-8) seems the most suitable test to use for screening, an accurate diagnosis of chorioamnionitis requires a combination of screening methods and tests, such as clinical signs and symptoms, maternal biomarkers, amniotic fluid testing and histology. Screening for chorioamnionitis, particularly the parameters for maternal fever as a clinical symptom of chorioamnionitis, contributing factors and microbes responsible for chorioamnionitis, the usability of MMP-8 and the development of rapid, inexpensive, easy-to-use techniques for screening and diagnosis of chorioamnionitis, warrants further research. IMPLICATIONS FOR PRACTICE: Findings can be used by midwives in the screening and diagnosis of women for chorioamnionitis which allows for early referral and adequate management before maternal and neonatal complications arise.

Screening and managing women with chorioamnionitis in resource-constrained healthcare settings: Evidence-based recommendations.

OBJECTIVE: To describe the development of evidence-based recommendations on screening and managing women at risk for chorioamnionitis in resource-constrained healthcare settings. DESIGN: A qualitative study, using data from an integrative literature review to develop the evidence-based recommendations was conducted. The NICE guideline development principles were followed to format the recommendations, which were reviewed by expert reviewers using the AGREE II tool. FINDINGS: Four main recommendations were developed, which were: screening by clinical signs and symptoms; screening by causative factors of chorioamnionitis; screening of obstetric history; and prevention and management of chorioamnionitis. A screening tool and algorithm based on the recommendations were also developed. KEY CONCLUSIONS: Recommendations will assist midwives in identifying women at risk for chorioamnionitis and managing them before referral. The recommendations contribute to the quality care of women who are at risk for chorioamnionitis. The developed screening tool and algorithm based on the recommendations provide user-friendly guides for midwives in similar, resource-constrained settings, such as in South Africa, where these recommendations were developed. Screening using the recommended screening tool, therefore, is by far the least expensive tool when considering treatment costs and legal compensation for preventable deaths related to chorioamnionitis.

The effect of concomitant histologic chorioamnionitis in pregnancies complicated by fetal growth restriction.

INTRODUCTION: We aimed to investigate the effect of placental histologic chorioamnionitis (HC) on neonatal outcomes in pregnancies complicated by fetal growth restriction (FGR). METHODS: - The computerized medical files of all pregnancies diagnosed with FGR (birthweight <10th percentile) at 24-42 weeks of gestation between 2008 and 2019 were reviewed. Maternal and neonatal outcomes were compared between FGR with and without evidence of placental HC. Placental lesions were classified according to "Amsterdam" criteria. Composite adverse neonatal outcome-included any of the following complications: neurological morbidity, neonatal respiratory assistance, RDS, NEC, sepsis, blood transfusion, phototherapy, hypoglycemia, or neonatal death. Composite severe adverse neonatal outcome included any of the following complications - neurological morbidity, blood transfusion, NEC, sepsis, RDS, neonatal death. RESULTS: - Compared to FGR without HC (n = 446), FGR with HC (n = 57) was characterized by more advanced gestational age at delivery 39.2 (38.3-39.9) vs. 38.2 (36.9-39.2), weeks respectively, p < 0.001), higher rate of nulliparity (73.7% vs. 45.1%, p < 0.001), less vascular lesions of MVM (1.8% vs.11.2%, p = 0.02), higher rate of Apgar scores at 5 min <7 (10.5% vs. 2%, p = 0.004), increased neonatal death (7.0% vs. 0.9%, p = 0.007), higher rates of both composite adverse neonatal outcome (31.1% vs. 17.3% p = 0.02), and composite severe adverse neonatal outcome (16.3% vs. 8.2% p = 0.04). By multivariate regression analysis HC was found to be independently associated with composite adverse neonatal outcome (aOR = 1.21, 95% CI 1.08-2.38) and with severe composite adverse neonatal outcome (aOR = 1.39, 95% CI 1.16-3.76). CONCLUSIONS: Pregnancies complicated by FGR with concomitant HC were associated with higher rates of adverse neonatal outcomes.

Determinants of adverse neonatal outcome in vaginal deliveries complicated by suspected intraamniotic infection.

PURPOSE: Intraamniotic infection, categorized into isolated maternal fever, suspected intraamniotic infection (SII), and confirmed intraamniotic infection, is associated with neonatal morbidity. However, there is paucity of data regarding the association between intraamniotic infection duration and neonatal outcomes among term singleton vaginal deliveries. We aimed to study the risk factors for adverse neonatal outcome among vaginal deliveries complicated by SII. METHODS: A retrospective observational study conducted at a tertiary medical center. All consecutive singleton term deliveries with SII were included between 2011 and 2019. Maternal and obstetrical characteristics were evaluated to identify risk factors for adverse neonatal outcome. Correlation between SII duration and neonatal adverse outcome was analyzed. RESULTS: Overall, 882 were analyzed. Most women (85.4%) were primiparous. Median gestation age at delivery was 40 2/7 weeks. Median time from SII to delivery was 170 min. Adverse neonatal outcomes occurred in 113 (12.8%) of deliveries. Duration of SII was not associated with adverse neonatal outcome. Analysis for determinants of adverse neonatal outcome revealed that oligohydramnios was more common in pregnancies with adverse neonatal outcome (7/113 (6.2%) vs. 41 (5.4%) OR [95% CI] 2.47 (1.02-5.98), p = 0.03). Duration of second stage of labor was longer in the adverse outcome group (median 179 min vs. 126 min, p = 0.008). Prolonged second stage was more common in the adverse outcome group (60 (53.1%) vs. 273 (35.5%) OR [95% CI] 2.05 (1.38-3.06), p < 0.001). On logistic regression analysis, prolonged second stage was the only modifiable factor independently associated with adverse neonatal outcome [adjusted OR 2.09 (1.37-3.2), p = 0.001]. Other variables tested did not differ between groups. Only phototherapy and base excess ≥ 12 mmol/L were significantly associated with the duration of second stage of labor; for each additional hour of the second stage, the OR for the former increased by 0.34 (p = 0.008), and for the latter by 0.69 (p = 0.007). CONCLUSION: Duration of suspected intraamniotic infection was not associated with increased neonatal morbidity among women delivering vaginally at term. Prolonged second stage was a strong independent predictor of an adverse neonatal outcome among fetuses exposed to intraamniotic infection.

Prophylactic Intra-Uterine ß-Cyclodextrin Administration during Intra-Uterine Ureaplasma parvum Infection Partly Prevents Liver Inflammation without Interfering with the Enterohepatic Circulation of the Fetal Sheep.

Chorioamnionitis can lead to inflammation and injury of the liver and gut, thereby predisposing patients to adverse outcomes such as necrotizing enterocolitis (NEC). In addition, intestinal bile acids (BAs) accumulation is causally linked to NEC development. Plant sterols are a promising intervention to prevent NEC development, considering their anti-inflammatory properties in the liver. Therefore, we investigated whether an intra-amniotic (IA) Ureaplasma parvum (UP) infection affected the liver and enterohepatic circulation (EHC) and evaluated whether an IA administered plant sterol mixture dissolved in ß-cyclodextrin exerted prophylactic effects. An ovine chorioamnionitis model was used in which liver inflammation and the EHC were assessed following IA UP exposure in the presence or absence of IA prophylactic plant sterols (a mixture of ß-sitosterol and campesterol dissolved in ß-cyclodextrin (carrier)) or carrier alone. IA UP exposure caused an inflammatory reaction in the liver, histologically seen as clustered and conflated hepatic erythropoiesis in the parenchyma, which was partially prevented by IA administration of sterol + ß-cyclodextrin, or ß-cyclodextrin alone. In addition, IA administration of ß-cyclodextrin prior to UP caused changes in the expression of several hepatic BAs transporters, without causing alterations in other aspects of the EHC. Thereby, the addition of plant sterols to the carrier ß-cyclodextrin did not have additional effects.

Vitamin D Sufficiency Has a Limited Effect on Placental Structure and Pathology: Placental Phenotypes in the VDAART Trial.

Vitamin D insufficiency during pregnancy is widespread. The effects of active vitamin D on the human placenta in vivo are unknown. We test the hypotheses that 25(OH)D sufficiency (arbitrarily defined as 25(OH)D ≥32 ng/mL) modulates placental structure and function in vivo in a population of women whose offspring are at risk for childhood asthma, and that placental pathology is more common in offspring that evolve asthma at age 3. Pregnant volunteers in the St. Louis, MO, cohort of the Vitamin D Antenatal Asthma Reduction Trial (VDAART, NIH grant #HL091528) participated in a nested case-control study and consented for the study of placentas after delivery. Maternal concentrations of 25(OH)D were measured at trial entry and in the third trimester. The histopathology of the placentas from women with sufficient 25(OH)D, versus insufficient, showed no clinically significant differences, but morphometry revealed villi of women with sufficient third-trimester 25(OH)D had a higher villous surface density. Notably, analyses of transcripts, extracted from formalin-fixed paraffin-embedded specimens, revealed higher expression of INTS9, vWF, MACC1, and ARMS2, and diminished expression of the CNTN5 genes in the insufficient group. A larger proportion of placentas showed chronic chorioamnionitis in offspring with versus without asthma at age 3. These findings suggest that maternal 25(OH)D insufficiency has a limited effect on human placental villous histopathology and morphometry, but attenuates a small number of placental gene expression profiles in this selected population. The association of placental chronic chorioamnionitis and offspring asthma is worthy of further study.

Gut and immune effects of bioactive milk factors in preterm pigs exposed to prenatal inflammation.

Prenatal inflammation may predispose to preterm birth and postnatal inflammatory disorders such as necrotizing enterocolitis (NEC). Bioactive milk ingredients may help to support gut maturation in such neonates, but mother's milk is often insufficient after preterm birth. We hypothesized that supplementation with bioactive ingredients from bovine milk [osteopontin (OPN), caseinoglycomacropeptide (CGMP), colostrum (COL)] supports gut, immunity, and NEC resistance in neonates born preterm after gram-negative infection before birth. Using preterm pigs as a model for preterm infants, fetal pigs were given intraamniotic injections of lipopolysaccharide (LPS; 1 mg/fetus) and delivered 3 days later (90% gestation). For 5 days, groups of LPS-exposed pigs were fed formula (FOR), bovine colostrum (COL), or formula enriched with OPN or CGMP. LPS induced intraamniotic inflammation and postnatal systemic inflammation but limited effects on postnatal gut parameters and NEC. Relative to FOR, COL feeding to LPS-exposed pigs showed less diarrhea, NEC severity, reduced gut IL-1ß and IL-8 levels, greater gut goblet cell density and digestive enzyme activities, and blood helper T-cell fraction. CGMP improved neonatal arousal and gut lactase activities and reduced LPS-induced IL-8 secretion in intestinal epithelial cells (IECs) in vitro. Finally, OPN tended to reduce diarrhea and stimulated IEC proliferation in vitro. No effects on villus morphology, circulating cytokines, or colonic microbiota were observed among groups. In conclusion, bioactive milk ingredients exerted only modest effects on gut and systemic immune parameters in preterm pigs exposed to prenatal inflammation. Short-term, prenatal exposure to inflammation may render the gut less sensitive to immune-modulatory milk effects. NEW & NOTEWORTHY Prenatal inflammation is a risk factor for preterm birth and postnatal complications including infections. However, from clinical studies, it is difficult to separate the effects of only prenatal inflammation from preterm birth. Using cesarean-delivered preterm pigs with prenatal inflammation, we documented some beneficial gut effects of bioactive milk diets relative to formula, but prenatal inflammation appeared to decrease the sensitivity of enteral feeding. Special treatments and diets may be required for this neonatal population.

Premature Infant with Haemophilus parainfluenzae Sepsis: Case Report and Literature Review.

Haemophilus parainfluenzae is an unusual causative organism of invasive bacterial infection in adults and children. Mortality and morbidity secondary to Haemophilus parainfluenzae have been documented in the literature. We present a rare case of a premature infant with early onset sepsis caused by Haemophilus parainfluenzae, who was born to a primigravida with chorioamnionitis. The infant was successfully treated for 10 days with antibiotics with no complications.

Ginger ( Zingiber officinale ) prevents severe damage to the lungs due to hyperoxia and inflammation

Background/aim: Hyperoxia- and inflammation-induced lung injury is an important cause of the development of bronchopulmonary dysplasia (BPD) in premature infants. We aimed to ascertain the beneficial effects of ginger ( Zingiber officinale ) on rat pups exposed to hyperoxia and inflammation. Materials and methods: Thirty-six newborn Wistar rats were randomly divided into 3 groups as the hyperoxia (95% O 2 ) + lipopolysaccharide (LPS) group, the hyperoxia + LPS + ginger-treated group, and the control/no treatment group (21% O 2 ). Pups in the hyperoxia + LPS + ginger group were administered oral ginger at a dose of 1000 mg/kg daily during the study period. Histopathologic, immunochemical (SMA and lamellar body), and biochemical evaluations including total antioxidant status (TAS), total oxidant status (TOS), malondialdehyde (MDA), myeloperoxidase (MPO), tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1ß), interleukin-6 (IL-6), and caspase-3 activities were performed. Results: Better weight gain and survival rates were shown in the hyperoxia + LPS + ginger group (P < 0.05). In the histopathologic and immunochemical evaluation, severity of lung damage was significantly reduced in the hyperoxia + LPS + ginger group, as well as decreased apoptosis (ELISA for caspase-3) (P < 0.05). Tissue TAS levels were significantly protected, and TOS, MDA, and MPO levels were significantly lower in the hyperoxia + LPS + ginger group (P < 0.05). Tissue TNF-α, IL-1ß, and IL-6 concentrations were significantly decreased in the ginger-treated group (P < 0.05). Conclusion: Ginger efficiently reduced the lung damage and protected the lungs from severe damage due to hyperoxia and inflammation. Therefore, ginger may be an alternative option for the treatment of BPD.

Maternal Glucose Supplementation in a Murine Model of Chorioamnionitis Alleviates Dysregulation of Autophagy in Fetal Brain.

Fetal brain injury induced by intrauterine inflammation is a major risk factor for adverse neurological outcomes, including cerebral palsy, cognitive dysfunction, and behavioral disabilities. There are no adequate therapies for neuronal protection to reduce fetal brain injury, especially new strategies that may apply promptly and conveniently. In this study, we explored the effect of maternal glucose administration in a mouse model of intrauterine inflammation at term. Our results demonstrated that maternal glucose supplementation significantly increased survival birth rate and improved the neurobehavioral performance of pups exposed to intrauterine inflammation. Furthermore, we demonstrated that maternal glucose administration improved myelination and oligodendrocyte development in offspring exposed to intrauterine inflammation. Though the maternal blood glucose concentration was temporally prevented from decrease induced by intrauterine inflammation, the glucose concentration in fetal brain was not recovered by maternal glucose supplementation. The adenosine triphosphate (ATP) level and autophagy in fetal brain were regulated by maternal glucose supplementation, which may prevent dysregulation of cellular metabolism. Our study is the first to provide evidence for the role of maternal glucose supplementation in the cell survival of fetal brain during intrauterine inflammation and further support the possible medication with maternal glucose treatment.

Treatment of Preterm Premature Rupture of Membranes with Oligo-/Anhydramnion Colonized by Multiresistant Bacteria with Continuous Amnioinfusion and Antibiotic Administrations through a Subcutaneously Implanted Intrauterine Port System: A Case Report.

Bacterial infection is one of the main causes of preterm premature rupture of membranes (PPROM) leading to preterm delivery, pulmonary hypoplasia, sepsis and joint deformities. Expectant management, broad-spectrum antibiotics and antenatal corticosteroids are routinely used in this condition with very limited success to prevent bacteremia, chorioamnionitis, funisitis and intra-amniotic infection syndrome. Here, we report a case in which we attempted to treat PPROM at 26+3 weeks of gestation with anhydramnion colonized by multiresistant Klebsiella. A perinatal port system was implanted subcutaneously at 28+0 weeks of gestation, enabling long-term continuous lavage of the amniotic cavity with a hypotonic aqueous composition similar to human amniotic fluid combined with intra-amniotic antibiotic application. The patient gave birth to a preterm female infant at 31+1 weeks without any signs of infection. The girl was discharged with a weight of 2,730 g in very good condition. In the follow-up examinations at 5 months and 1 year of age, there was no apparent neurological disturbance, developmental delay or Klebsiella colonization.

Placental Lesions in Meconium Aspiration Syndrome

BACKGROUND: Meconium aspiration syndrome (MAS) is defined by respiratory distress requiring supplemental oxygen in a meconium-stained neonate. MAS is clinically subclassified as mild, moderate, and severe according to the oxygen requirement. The aims of this study were to compare the histological findings in the placentas of MAS neonates with those of meconium-stained but non-MAS neonates and to analyze the correlation between the severity of MAS and the grade of its histological parameters. METHODS: We collected 160 singleton term placentas from neonates with meconium staining at birth from a tertiary medical center, Seoul, Republic of Korea. We reviewed hematoxylin and eosin sections of tissue samples (full-thickness placental disc, chorioamniotic membranes, and umbilical cord). RESULTS: Funisitis was present more frequently in MAS than in non-MAS (p < .01), of which the stage was correlated with the severity of MAS (p < .001). The histological findings consistent with maternal underperfusion and chronic deciduitis were more frequent in MAS than in non-MAS (p < .05). There was a correlation between the degree of chorionic vascular muscle necrosis and the severity of MAS (p < .05). CONCLUSIONS: Our results suggest that fetal inflammatory response evidenced by funisitis occurs prenatally in MAS and that the stage of funisitis and of chorionic vascular muscle necrosis may be a predictive marker of the severity of MAS.

Clinical chorioamnionitis at term: the amniotic fluid fatty acyl lipidome.

Clinical chorioamnionitis at term (TCC) is the most common obstetrical infliction diagnosed in labor and delivery units worldwide and is associated with a substantial increase in maternal and neonatal morbidity and mortality. This obstetrical complication is a heterogeneous condition, as only half of patients have detectable microorganisms in the amniotic cavity. Because bioactive lipids play a key role in the initiation and resolution of an inflammatory response, we aimed to characterize the amniotic fluid lipidome in patients with TCC. We studied the amniotic fluid of patients in the following groups: 1) spontaneous labor at term without clinical chorioamnionitis (TLB) and 2) spontaneous labor at term with clinical chorioamnionitis (TCC). The TCC group was subdivided into a) those with microbial invasion of the amniotic cavity (TCC-MIAC) and b) those without microbial invasion of the amniotic cavity (TCC-noMIAC). The amniotic fluid concentration of proinflammatory lipid mediators did not differ between patients in TLB with TCC. In contrast, concentration of lipids with anti-inflammatory/proresolution properties was significantly lower in all patients with TCC than in those with TLB. These results suggest that while proinflammatory lipid mediators are involved in infection-driven intra-amniotic inflammation, a relative deficiency of anti-inflammatory/proresolution lipid mediator biosynthesis is a characteristic of TCC.

The role of cervical cultures to guide perioperative antibiotics in cervical cerclage - a retrospective analysis of 65 consecutive cases.

OBJECTIVE: The objective of this study is to examine results of bacterial cultures of the cervix prior to cerclage placement and how these may be used to guide prophylactic antibiotics. METHODS: All patients undergoing cerclage between 2000 and 2003 in a single, large community hospital were evaluated for indication for cerclage, signs and symptoms on presentation, transvaginal ultrasound cervical length findings, type of cerclage placed, type of anesthesia used, cervical culture taken, tocolytics given, gestational age at delivery, and complications surrounding delivery. RESULTS: Sixty-five cerclages were performed between 2000 and 2003, 13 (20%) prophylactic, 47 (72%) therapeutic, and five (8%) emergent. Cervical cultures were obtained in 85% of patients, of which 40% were negative resulting in no antibiotics given. In the remaining 45%, one or more pathogens were isolated and antibiotics were given according to sensitivities reported. Fifty-five of 65 patients (84%) delivered after 32 weeks gestation and a latency > 60 d was seen in 84%. The incidence of chorioamnionitis and PPROM was low. CONCLUSION: Bacterial cultures of the cervix prior to cerclage show variable colonization and antibiotic sensitivities and, there is no single antibiotic, chosen empirically, that will cover all pathogens.

Oral Infections and Pregnancy: Knowledge of Gynecologists/Obstetricians, Midwives and Dentists.

PURPOSE: To establish an inventory of knowledge, attitudes and daily pratice of dental and medical practitioners in France regarding oral health care and its relationship to pregnancy, particularly to preterm delivery and low birth-weight infants. MATERIALS AND METHODS: A questionnaire was distributed to health-care professionals (n= 460), consisting of 100 prenatal care practitioners (obstetricians, midwives) and 360 dentists, about their knowledge of oral alterations during pregnancy, the possible association between periodontal disorders and preterm/low birth weight, and their conduct toward their patients. RESULTS: Bleeding gums and pregnancy gingivitis were the oral manifestations most often cited by all the practitioners. In contrast, prenatal care practitioners were unaware of epulis and a greater percentage of them than dentists believed caries risk to increase during pregnancy. The most adverse pregnancy outcomes cited were risk of premature delivery and chorioamniotis. Only dentists had received initial training on pregnancy complications. Finally, all health professionals point out the lack of continuing education on this topic. CONCLUSION: The present results underline the need for a better initial professional education and continuing education regarding pregnancy and oral health conditions and emphasise the need to update the guidelines in health care practices for pregnant women for a more effective prevention of risk-related adverse pregnancy outcomes, such as pre-term birth or pre-eclampsia.

Reconsidering the Current Preterm Premature Rupture of Membranes Antibiotic Prophylactic Protocol.

OBJECTIVE: The purpose of our study was to determine whether the current antibiotic regimen for preterm premature rupture of membranes (PPROM) is adequate for covering the current causative agents and sensitivities of chorioamnionitis and early-onset neonatal sepsis. STUDY DESIGN: During a 3-year period, we retrieved the results from placental and amniotic membrane cultures obtained at delivery in cases of maternal fever, chorioamnionitis, and PPROM, and from blood cultures obtained from neonates with early-onset sepsis (EOS) in three participating hospitals. Sensitivity of pathogens to antimicrobial agents was performed using routine microbiologic techniques. RESULTS: There were 1,133 positive placental or amniotic cultures, 740 (65.3%) were from gram-negative Enterobacteriaceae. There were 27 neonates diagnosed with EOS with positive blood cultures. Aerobic Enterobacteriaceae accounted for 14 cases (52%) and group B streptococcus for 7 cases (26%). Of the Escherichia coli and Klebsiella sp., only 38% were sensitive to ampicillin. CONCLUSION: Local pathogens and their antibiotic sensitivity profiles should be explored every few years and an effective antibiotic protocol chosen to cover the main pathogens causing chorioamnionitis and EOS. Consideration should be made for changing ampicillin in women with PPROM to a regimen with better coverage of gram-negative Enterobacteriaceae.

The enigma of low bilirubin kernicterus in premature infants: why does it still occur, and is it preventable?

Low bilirubin kernicterus in preterm neonates, though rare, remains an unpredictable and refractory form of brain injury. Hypoalbuminemia, co-morbid CNS insult(s), infection, and inflammation are contributing causes that, in many cases, appear to interact in potentiating bilirubin neurotoxicity. Despite compulsive attention to serum bilirubin levels, and clinical and laboratory indices of neurotoxicity risk, low bilirubin kernicterus continues to be seen in contemporary NICUs. While efforts to refine and improve current treatment guidelines are certainly needed, such revision(s) will also have to take into account the risks and benefits of any intervention, including phototherapy.

When the womb is no longer safe: chorioamnionitis.

Intrauterine infections are a leading cause of preterm birth, cerebral palsy and neonatal sepsis. This article investigates current ideas about prevention, diagnosis and treatment from a midwifery point of view.

Epidemiology of stillbirth and strategies for its prevention in Vietnam.

OBJECTIVE: To describe major epidemiologic and placental findings regarding stillbirth in Vietnam. METHODS: A cross-sectional study of all stillbirths in a tertiary referral facility in Ho Chi Minh City, Vietnam, was performed. Detailed examination of each infant, placental pathology, and semi-structured maternal interviews were conducted according to the Perinatal Society of Australia and New Zealand Perinatal Death Classification guidelines. Maternal, fetal, and placental characteristics were examined. RESULTS: Between December 8, 2008, and January 9, 2009, there were 4694 live births and 122 stillbirths at the facility. In total, 107 (87.7%) cases were included in the study. Low education level was associated with a lack of prenatal care; induced abortion accounted for 34.6% of fetal deaths (gender selection was not the reason); 35.5% of infants were born at 22-28 weeks of gestation; 31.8% of stillbirths were small for gestational age; histologic evidence of chorioamnionitis was present in 40.2% of cases. Calcium supplements were less likely to have been taken in cases in which death from hypertension occurred. alpha-Thalassemia was the main cause of fetal hydrops (6.2%). CONCLUSION: Improving access to prenatal care and prenatal calcium and iron supplementation, and screening for congenital abnormalities and alpha-thalassemia may help to reduce rates of perinatal death in Vietnam.