Perfusion Index and Pulse Oximetry Screening for Congenital Heart Defects.

OBJECTIVE: To evaluate the efficacy of combined pulse oximetry (POX) and perfusion index (PI) neonatal screening for severe congenital heart defects (sCHD) and assess different impacts of screening in tertiary and nontertiary hospitals. STUDY DESIGN: A multicenter, prospective study in 10 tertiary and 6 nontertiary maternity hospitals. A total of 42 169 asymptomatic newborns from among 50 244 neonates were screened; exclusion criteria were antenatal sCHD diagnosis, postnatal clinically suspected sCHD, and neonatal intensive care unit admission. Eligible infants underwent pre- and postductal POX and PI screening after routine discharge examination. Targeted sCHD were anatomically defined. Positivity was defined as postductal oxygen saturation (SpO2) ≤95%, prepostductal SpO2 gradient >3%, or PI <0.90. Confirmed positive cases underwent echocardiography for definitive diagnosis. Missed cases were identified by consulting clinical registries at 6 regional pediatric heart centers. Main outcomes were incidence of unexpected sCHD; proportion of undetected sCHD after discharge in tertiary and nontertiary hospitals; and specificity, sensitivity, positive predictive value, and negative predictive value of combined screening. RESULTS: One hundred forty-two sCHD were detected prenatally. Prevalence of unexpected sCHD was 1 in 1115 live births, similar in tertiary and nontertiary hospitals. Screening identified 3 sCHD (low SpO2, 2; coarctation for low PI, 1). Four cases were missed. In tertiary hospitals, 95% of unsuspected sCHDs were identified clinically, whereas only 28% in nontertiary units; in nontertiary units PI-POX screening increased the detection rate to 71%. CONCLUSIONS: PI-POX predischarge screening provided benefits in nontertiary units, where clinical recognition rate was low. PI can help identify coarctation cases missed by POX but requires further evaluation in populations with higher rates of missed cases.

Radiological contrast media in the breastfeeding woman: a position paper of the Italian Society of Radiology (SIRM), the Italian Society of Paediatrics (SIP), the Italian Society of Neonatology (SIN) and the Task Force on Breastfeeding, Ministry of Health, Italy.

OBJECTIVES: Breastfeeding is a well-recognised investment in the health of the mother-infant dyad. Nevertheless, many professionals still advise breastfeeding mothers to temporarily discontinue breastfeeding after contrast media imaging. Therefore, we performed this review to provide health professionals with basic knowledge and skills for appropriate use of contrast media. METHODS: A joint working group of the Italian Society of Radiology (SIRM), Italian Society of Paediatrics (SIP), Italian Society of Neonatology (SIN) and Task Force on Breastfeeding, Ministry of Health, Italy prepared a review of the relevant medical literature on the safety profile of contrast media for the nursing infant/child. RESULTS: Breastfeeding is safe for the nursing infant of any post-conceptional age after administration of the majority of radiological contrast media to the mother; only gadolinium-based agents considered at high risk of nephrogenic systemic fibrosis (gadopentetate dimeglumine, gadodiamide, gadoversetamide) should be avoided in the breastfeeding woman as a precaution; there is no need to temporarily discontinue breastfeeding or to express and discard breast milk following the administration of contrast media assessed as compatible with breastfeeding. CONCLUSIONS: Breastfeeding women should receive unambiguous professional advice and clear encouragement to continue breastfeeding after imaging with the compatible contrast media. KEY POINTS: • Breastfeeding is a well-known investment in the health of the mother-infant dyad. • Breastfeeding is safe after administration of contrast media to the mother. • There is no need to temporarily discontinue breastfeeding following administration of contrast media.

How to administrate erythropoietin, intravenous or subcutaneous?

AIM: To determine whether adding recombinant erythropoietin to the intravenous (IV) solution and administering it as a 24-h continuous infusion would result in an erythropoietic effect not inferior to that seen with subcutaneous (SC) administration. METHODS: Infants weighing ≤1500 grams and ≤32 weeks of gestational age were randomly assigned at 72 h of life to receive erythropoietin (300 units/kg, 3 times a week until 36 complete weeks of postmenstrual age or discharge), either subcutaneously [erythropoietin subcutaneous (ESC) group] or added to IV fluids [erythropoietin intravenous (EIV) group]. RESULTS: One hundred infants were randomized (50 in the EIV group and 50 in the ESC group). The incidence of transfusions was comparable in the two groups, similar in baseline characteristics and haematologic values at study entry. Phlebotomy losses did not differ between groups, and at the end of the study, there were no differences in reticulocyte counts, transferrin saturation and ferritin. No differences in the incidence of side effects were observed. CONCLUSIONS: In preterm infants, continuous intravenous administration of erythropoietin was not inferior to SC dosing.

ABO hemolytic disease of the fetus and newborn: an iatrogenic complication of heterologous assisted reproductive technology-induced pregnancy.

BACKGROUND: ABO hemolytic disease of the fetus and newborn (ABO HDFN) may manifest itself in cases of mothers belonging to blood group O and newborns of groups A or B and more frequently in group A and less so in group B. CASE STUDY: The case subjects are twin-birth newborns with ABO HDFN, of group AB born to a mother of group O. These cases of ABO HDFN prove inconsistent with Mendel's law of segregation. RESULTS AND CONCLUSION: This case study finds its explanation in new methods of assisted reproduction, particularly heterologous in vitro fertilization with ovodonation.

Recombinant human erythropoietin in the prevention of late anemia in intrauterine transfused neonates with Rh-isoimmunization.

The majority of neonates with Rh-isoimmunization develops late anemia between the second and the sixth week of life. We report the effectiveness of recombinant human erythropoietin (rHuEPO) in preventing late anemia in 25 intrauterine and nonintrauterine-transfused neonates. The neonates were treated from 11+/-4 days after birth to 26+/-14 days (400 U/kg/d of rHuEpo, administered subcutaneously). During rHuEpo therapy, vitamin E, calcium folinate, and iron maltose were administered intramuscularly on a daily basis. Hematocrit, platelet, and neutrophil counts did not differ significantly before and after 21-days therapy. However, average values for reticulocyte showed a significant increase. The hematocrit values in the non-intrauterine transfusion (IUT) group increased progressively from the beginning to the end of the treatment, whereas that in the IUT group remained stable. Reticulocyte count increased during treatment in both groups, but it was significantly elevated in the non-IUT group only. Moreover, we observed that only neonates transfused with IUTs needed transfusions before and after treatment. This study suggests the effectiveness of rHuEpo therapy in the treatment of neonates with Rh-isoimmunization and it highlights how IUTs decrease the neonatal response efficacy. Larger, better if multicentric, randomized controlled trial are needed to definitely state whether rHuEPO safely decreases the incidence of late onset anemia.

Safety and efficacy of galactogogues: substances that induce, maintain and increase breast milk production.

Poor production of breast milk is the most frequent cause of breast lactation failure. Often, physician prescribe medications or other substances to solve this problem. The use of galactogogues should be limited to those situations in which reduced milk production from treatable causes has been excluded. One of the most frequent indication for the use of galactogogues is the diminution of milk production in mothers using indirect lactation, particularly in the case of preterm birth. The objective of this review is to analyze to the literature relating to the principal drugs used as galactogogues (metoclopramide, domperidone, chlorpromazine, sulpiride, oxytocin, growth hormone, thyrotrophin releasing hormone, medroxyprogesterone). Have been also analyzed galactogogues based on herbs and other natural substances (fenugreek, galega and milk thistle). We have evaluated their mechanism of action, transfer to maternal milk, effectiveness and potential side effects for mother and infant, suggested doses for galactogogic effect, and recommendation for breastfeeding.

Infants born to mothers with anti-SSA/Ro autoantibodies: neonatal outcome and follow-up.

Neonatal lupus syndrome is considered a model of passively acquired autoimmune disease. The first 10 newborns born to mothers with connective tissue disease and positive for anti-SSA/Ro antibodies enrolled in a follow-up program to evaluate the incidence of cardiac, hepatobiliary, hematologic, echoencephalographic, and cutaneous manifestations until 9 months of age are described in this study. No congenital heart block was observed, but only transient rhythm alterations were observed. In all, 1 infant showed typical neonatal lupus syndrome skin lesions at 3 months of age. During the neonatal period, echoencephalographic alterations were found more frequently, whereas at follow-up, hepatic and hematologic alterations were more often observed. In all, 1 baby showed persistent neutropenia. A standard program that enrolls all infants born to mothers with anti-SSA/Ro autoantibodies, who are at risk of developing neonatal lupus syndrome, should also include tests performed some time after birth, as a number of clinical manifestations might appear at a late stage.

The joint use of human and electronic eye: visual assessment of jaundice and transcutaneous bilirubinometry.

Our aim was to study the usefulness of jaundice visual assessment combined with skin bilirubin determination in 517 healthy newborns. Yellowness assessment was made and babies were included in three different bilirubin classes. Skin bilirubin and total serum bilirubin were determined within 10 minutes from the visual assessment. This latter led to underestimation of serum bilirubin in 16.7-40.4% and overestimation in 4.9-35.7% of newborns. Skin bilirubin measurement after the visual assessment decreased the risk of underestimation to 0-9.2% and the risk of overestimation to 2.1-11.1%. The majority of visual assessment errors were performed in the more lighted hours of the morning (75%), while the smallest number (39%) occurred during the afternoon. Skin bilirubin measurement significantly corrected these diagnostic errors (p < 0.001, p < 0.02) without differences during the day. Clinical estimate is unreliable for evaluating the need for serum bilirubin assay. Using the addition of skin bilirubin determination is a more advisable approach.

Neonatal lupus: Follow-up in infants with anti-SSA/Ro antibodies and review of the literature.

Neonatal Lupus Syndrome (NLS) is a distinct clinical entity caused by transplacental passage of maternal anti-SSA/Ro antibodies (Ab). Mothers may have systemic lupus erythematosus, Sjögren syndrome, or other connective tissue disease, or may be completely healthy at the time of giving birth. NLS includes several clinical manifestations: complete congenital heart block (CCHB) and cutaneous lupus are the most common, while hepatobiliary disease, hematological manifestations and central nervous system involvement may occur. Data from literature on the incidence of the different clinical manifestations of NLS are difficult to compare because they come mostly from retrospective studies or prospective studies, but up to date no systematic follow-up was carried out. We performed a large prospective single-center study with a systematic clinical and instrumental follow-up until 9months of life, in order to evaluate the incidence and the clinical impact of NLS features. From 2004 to 2014 all infants born in our center to mothers with anti-SSA/Ro Ab were enrolled in a specific diagnostic and follow-up (FU) program. At birth, 50 infants born to mothers with anti-SSA/Ro Ab were found positive for anti-SSA/Ro Ab. Infants were tested for anti SSA/Ro Ab at 3months of life, if positive they were re-tested at 6 and 9months. At 9months anti-SSA/Ro Ab were positive in 10% of children. In two cases (4%) a CCHB was identified during pregnancy and required pacemaker implantation at birth. In 10% of cases a transient ECG alterations was found during follow-up. Hematological NLS features (anemia, neutropenia, thrombocytopenia) were found at birth and during FU in several patients, in all cases without clinical manifestations and in most cases with complete normalization at 9months. Mild and transient elevation of aminotransferases between 3 and 6months of life were found in 56% and 40% of patient, respectively; non-specific ultrasound cerebral anomalies in absence of clinical neurological signs were found at birth in 9 patients (18%), subsequently normalized. Prenatal maternal screening is of primary importance in order to early detect CCHB, which requires maternal treatment and pacemaker implantation at birth. Infants born to mothers with anti-SSA/Ro Ab should be monitored for all NLS features at birth. However, during the first months of life, these infants seem to develop only mild, transient and self-limited clinical manifestations, which in most cases are completely solved at 9months of life. This consideration, together with the evidence that only 10% of infants had anti-SSA/Ro Ab persistent in blood at 9months, suggests that follow-up of these children can be performed until 6-9months of life with good clinical safety. Moreover, a clinical and laboratory monitoring at 3months of life, when the highest incidence of hematological features and liver tests alterations are observed, is strongly recommended. In the future, it would be clarified if a follow-up until adulthood would be indicated in cases with persistent anti SSA/Ro or in all infants born to mother with anti SSA/Ro.

Clinical examination and pulse oximetry as screening for congenital heart disease in low-risk newborn.

OBJECTIVE: To assess sensitivity, specificity, positive predictive value and negative predictive value of the cardiovascular physical examination (CPE) and of pulse oximetry in screening for congenital heart diseases (CHD) in asymptomatic newborn when prenatal ultrasound evaluation is negative for structural cardiac abnormalities. METHODS: In this observational cohort study, 5750 asymptomatic newborns, admitted to nursery in a period of 2 years, underwent to CPE and determination of arterial oxygen saturation by pulse oxymetry between 48th and 72nd h of life. RESULTS: Two hundred and ninty-eight newborns presented a suspected CPE; in 70% of cases, we found a transitional alteration and in only 17% of cases, the echocardiography examination performed for suspected CPE were completely negative. Three newborns were positive to pulse oximetry screening test but negative at CPE. After discharge, one case of critical CHD was diagnosed. CONCLUSIONS: An accurate CPE performed by trained and experienced pediatricians is indicative of important cardiac structural alteration in more than 25%. The association of CPE and pulse oximetry allows to further improve the diagnostic accuracy.

Influence of maternal preeclampsia on recombinant human granulocyte colony-stimulating factor effect in neutropenic neonates with suspected sepsis.

AIM: To evaluate the effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) in preterm neonates with suspected sepsis and severe neutropenia (<1500 mm(3)), and to define the influence of maternal preeclampsia on rhG-CSF activity. METHODS: Twenty neonates of normotensive mothers (NNMs) (GA 29.2+/-0.5 weeks and BW 1.024+/-81 g) and 20 born to preeclamptic mothers (NPMs) (GA 29+/-0.4 weeks and BW 946+/-55 g) were treated with rhG-CSF, 10 microg/kg per day for 3 days. Complete blood counts were obtained at day 0 (before rhG-CSF administration) and 1-4, 6, 9, 20 and 30 days later. RESULTS: Absolute neutrophil count (ANC) increased rapidly (three-fold within 24h), and significantly (maximum approximately 20-25 times starting values) and remained within normal range in both groups. However, in NNMs a two-phase increase occurred with an early peak on day 2 and a further peak on day 6 giving significantly higher ANC (P<0.001) than for NPMs at days 2-4 and 6. NPMs showed a gradual ANC increase with a single late peak occurring 3 days later than NNMs (day 9). The highest peak values for ANC were similar (15,900+/-1395 mm(-3) for NNMs and 13,880+/-1097 mm(-3) for NPMs). Neutropenia was completely resolved within 2 days in NNMs and within 4 days in NPMs. CONCLUSION: Preeclampsia seemed to influence the course of the ANC in spite of rhG-CSF administration, and a higher daily-dose for NPMs with neutropenic sepsis may more rapidly resolve neutropenia by overcoming the preeclampsia-associated inhibitor of rhG-CSF through a dose-dependent mechanism.

Epidural analgesia, neonatal care and breastfeeding.

The objective of our study is to evaluate the correlation between epidural analgesia during labor, start of breastfeeding and type of maternal-neonatal care.Two different assistance models were considered: Partial and Full Rooming-in.In this cohort study, 2480 healthy infants were enrolled, 1519 in the Partial Rooming-in group and 1321 in the Full Rooming-in group; 1223 were born to women subjected to epidural analgesia in labor.In case of Partial Rooming-in the rate of exclusive or prevailing breastfeeding is significant more frequent in newborns born to mothers who didn't receive analgesia. Instead, in case of Full Rooming-in the rate of exclusive or prevailing breastfeeding is almost the same and there's no correlation between the use or not of epidural analgesia.The good start of lactation and the success of breastfeeding seems to be guaranteed by the type of care offered to the couple mother-infant, that reverses any possible adverse effects of the use of epidural analgesia in labor.

Individualized follow up programme and early discharge in term neonates.

BACKGROUND: Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration. METHODS: During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge. RESULTS: During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%). CONCLUSIONS: Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

BiliCheck vs JM-103 in identifying neonates not at risk of hyperbilirubinaemia.

BACKGROUND: Transcutaneous bilirubinometry is widely used to predict hyperbilirubinemia by using several devices. The aim of this study was to compare the predictive ability of BiliCheck vs JM-103 in identifying neonates not at risk of significant hyperbilirubinemia, putting the data obtained with the two instruments on our transcutaneous bilirubin nomogram built with the BiliCheck. METHODS: Transcutaneous bilirubin (TcB) measurement was performed when jaundice appeared in newborn babies and/or just before discharge from the hospital. It was performed at the forehead with the two instruments within 5 minutes by two experienced neonatologists, each one blind to the value obtained by the other. Blood samples were drawn to obtain total serum bilirubin (TSB) levels soon after TcB measurements. RESULTS: A total of 627 paired-sample measurements were obtained from 298 newborn babies. Out of the total population studied, 16 newborn babies (5.4%) showed significant hyperbilirubinemia defined as TSB value >17 mg/dL, or as need for phototherapy treatment according to the AAP guidelines. TcB measurements showed false negative results in the first 60 hours of life using both devices. After the 60th hour of life, TcB measurements using both devices successfully predicted newborn babies not at risk of significant hyperbilirubinemia, being the JM-103 more reliable than BC because of fewer false positive results. CONCLUSIONS: Our study shows that both BC and JM-103 can exclude subsequent significant hyperbilirubinemia when the measurements are performed after the 60th hour of life. Nevertheless, the transcutaneous pre-discharge screening should be considered only as the first step, and it has to be followed by a follow-up through the first days after discharge.

Hyperbilirubinemia in healthy newborns born to immigrant mothers from southeastern Asia compared to Italian ones.

OBJECTIVE: To compare the characteristics of jaundice and hyperbilirubinemia in the newborn population of both immigrant and Italian mothers. METHODS: The authors studied a group of 1,680 infants born at "A. Gemelli" hospital during 1 y. All were with appropriate weight for gestational age, weighting more than 2,500 g, born to low-risk pregnancy. Maternal ethnicity, clinically evident jaundice (that is total serum bilirubin (TSB) > 7 mg/dL), hyperbilirubinemia (TSB > 12 mg/dL), the duration of hospital stay and their need of phototherapy were evaluated. RESULTS: In infants born to Asian mothers, hyperbilirubinemia was significantly more frequent (48.8 % vs. 26.5 %, p = 0.003) and they reached mean TSB peak significantly later (86.5 ± 38.5 vs. 74.5 ± 20.6 h, P = 0.0001) compared with Italian infants. The average length of hospitalization of infants of Asian and Latin American mothers is significantly longer compared to Italian newborns (4.5 ± 1.9 vs. 3.6 ± 1.1, p <0.0001 and 4.2 ± 1.6 vs. 3.6 ± 1.1, p = 0.0004). With regard to the use of phototherapy, and to its duration, there are no significant differences between the populations studied. CONCLUSIONS: Having studied all infants at low risk, the greater length of hospitalization is due to later peak and the higher frequency of jaundice in newborns of immigrant mother, especially in Asia. Therefore, as it happens to the Italian newborns, it would be desirable to build forecasting nomograms in these populations, to reduce the length of hospitalization and facilitate protected discharge.

Transcutaneous bilirubin measurement: comparison of Respironics BiliCheck and JM-103 in a normal newborn population.

OBJECTIVES: To compare the accuracy of BiliCheck™ (Respironics, Marietta, GA) and Konica-Minolta Air Shield JM-103 (Drager Medical Inc, Telford, PA) to evaluate total serum bilirubin (TSB). METHODS: Prospective blinded study comparing two diagnostic devices in 630 neonates requiring TSB measurement. RESULTS: Linear regression analysis showed a good correlation between BiliCheck™ and TSB (r=0.8212) as well as between JM-103 and TSB (r=0.8686). BiliCheck shows a tendency to underestimate TSB. The mean difference in TSB-TcB was -1.4 mg/dL for BC (-4.7/+1.8 mg/dL) and 0.3 mg/dL for JM-103 (-2.6/+3.2mg/dL). ROC analysis for TSB≥ 12 mg/dL showed area under the curve for BiliCheck™ significantly lower than those for JM-103 (p<0.0001). JM-103 resulted less time expensive than BiliCheck. CONCLUSIONS: In spite of similar diagnostic accuracy JM-103 could be preferred for some practical advantages, but its suitability in performing universal screening for severe hyperbilirubinemia deserves further investigations.

Neonatal tuberculosis: an experience that teaches.

OBJECTIVE: This study reports on an experience following contact by a large number of newborn babies with a nurse infected by active tuberculosis (TB). METHODS: A large number of newborn babies were checked for possible contact with Mycobacterium tuberculosis (MTB) using interferon-gamma tests (IGTs) to determine specific treatment. RESULTS: One hundred and seven infants showed a positive IGT positive and were not affected by active TB. All were treated with anti-tubercular drugs and were followed-up for 1 year. None of the infants developed active TB and all infants showed normal tuberculin skin tests and chest-x-rays, as well as IGT results at the end of treatment. CONCLUSIONS: Our experience suggests that newborns are at low risk of infection after contact with a nurse with active TB. IGTs can be used to assess possible contact with MTB and to determine a reduced number of infants to treat.

Ophthalmia neonatorum: what kind of prophylaxis?

OBJECTIVE: Conjunctivitis during neonatal period occurs in 1-12% of all babies. Ophthalmia neonatorum is an acute muco-purulent conjunctivitis occurring in the first month of birth. It is essentially an infection acquired during vaginal delivery. The most frequent infectious agents involved in ophthalmia neonatorum are Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS: Topical ocular prophylaxis must be instituted early after birth. Recommended prophylactic regimen are: 1% nitrate solution; 1% tetracycline solution; 1% erythromycin solution; 2.5% povidone-iodine solution; and fusidic acid. RESULTS: Evidence suggests better outcomes using 1% tetracycline solutions even if there is the risk of selecting drug resistant bacteria. However, even the widespread used nitrate solution can cause a chemical conjunctivitis, arguing against its widespread use. CONCLUSIONS: Fusidic acid is a relatively new promising therapy even if there are still few data about its use. None of the used regimens has the optimal risk-benefit profile to suggest a widespread use.

Maternal and neonatal characteristics of an immigrant population in an Italian hospital.

OBJECTIVE: The objective of this study was to evaluate clinical and epidemiological characteristics of the maternal and neonatal immigrant population and to compare it with the Italian population in the Agostino Gemelli Hospital (Rome). METHODS: This study was a prospective population-based study. We compared 595 newborns from immigrant mothers with 2413 newborns from Italian mothers. Neonatal characteristics included in this study were sex, gestational age, birth weight, Apgar score, transfer to pathology units, minor pathologies, and type of breastfeeding at discharge. Maternal characteristics included nationality, age, parity, type of delivery, twin birth, and pathology during the pregnancy. RESULTS: Immigrant newborns comprised 20% of the total births included in the study. No statistically significant differences were found between immigrant and Italian newborns in gestational age, birth weight, or Apgar score. Immigrant newborns were transferred to the Paediatric Infectious Disease Unit more frequently than Italian newborns, had a significantly higher incidence of hyperbilirubinemia and a higher rate of exclusive and prevalent breastfeeding at discharge. Immigrant mothers came predominantly from Eastern Europe, were younger and had caesarean sections less frequently than Italian mothers. CONCLUSION: No significant differences in biological and clinical characteristics or in medical practice were found between groups, except for a higher frequency of neonatal hyperbilirubinemia and an inclination among immigrant mothers toward breastfeeding.

Different fetal-neonatal outcomes in siblings born to a mother with Graves-Basedow disease after total thyroidectomy: a case series.

INTRODUCTION: We describe three different fetal or neonatal outcomes in the offspring of a mother who had persistent circulating thyrotropin receptor antibodies despite having undergone a total thyroidectomy several years before. CASE PRESENTATION: The three different outcomes were an intrauterine death, a mild and transient fetal and neonatal hyperthyroidism and a severe fetal and neonatal hyperthyroidism that required specific therapy. CONCLUSIONS: The three cases are interesting because of the different outcomes, the absence of a direct correlation between thyrotropin receptor antibody levels and clinical signs, and the persistence of thyrotropin receptor antibodies several years after a total thyroidectomy.