Tocolysis for preterm labor: expert opinion.

Tocolysis is an important treatment in the improvement of outcome in preterm labor and preterm birth, provided that its use follows clear evidence-based recommendations. In this expert opinion, the most recent evidence about efficacy and side effects of different tocolytics is being reviewed and evidence-based recommendation about diagnosis and treatment of preterm labor is given. Further aspects such as progesterone administration or antibiotic treatment for the prevention of preterm birth are included. Our review demonstrates that an individualized choice of different tocolytics and additional treatments is necessary to improve short- and long-term neonatal outcome in preterm labor and preterm birth.

Antenatal corticosteroids for fetal lung maturation in threatened preterm delivery: indications and administration.

INTRODUCTION: Antenatal maternal administration of corticosteroids has been shown to reduce morbidity and mortality rates in preterm delivery. Threatened spontaneous or medically indicated preterm delivery for maternal or fetal indications between 24 and 34 weeks of gestation with unknown fetal lung maturity status are indications for antenatal corticosteroid administration. Recent studies have challenged current practice of antenatal glucocorticoid use. The goal of this expert letter is to provide recommendations based for the clinical use of antenatal glucocorticoids based on the current evidence from published studies. METHODS: The published literature (PubMed search), as well as the recommendations of other national societies, has been searched and taken into consideration for these recommendations. RESULTS/CONCLUSIONS: The standard regimen of antenatal corticosteroids involves a single course of 2 × 12 mg betamethasone administered intramuscularly within 24 h. The administration of corticosteroids usually is performed between 24 and 34 weeks gestation. However, under particular circumstances it may be beneficial even at 23 weeks and at 35-36 weeks of gestation. The evidence to date is clearly against the routine administration of multiple antenatal steroid courses. In special clinical situations, a second course of betamethasone ("rescue course") may be justifiable. Tocolysis during administration of steroids is not routinely indicated in the absence of contractions, cervical shortening or rupture of membranes.

Antiretroviral treatment during pregnancy.

OBJECTIVE: Virologic failure of HIV-positive patients is of special concern during pregnancy. We compared virologic failure and the frequency of treatment changes in pregnant and non-pregnant women of the Swiss HIV Cohort Study. METHODS: Using data on 372 pregnancies in 324 women we describe antiretroviral therapy during pregnancy. Pregnant women on HAART at conception (n = 131) were matched to 228 non-pregnant women (interindividual comparison) and to a time period of equal length before and after pregnancy (intraindividual comparison). Women starting HAART during pregnancy (n = 145) were compared with 578 non-pregnant women starting HAART. FINDINGS: The median age at conception was 31 years, 16% (n = 50) were infected through injecting drug use and the median CD4 cell count was 489 cells/microl. In the majority of pregnancies (n = 220, 59%), women had started ART before conception. When ART was started during pregnancy (n = 145, 39%), it was mainly during the second trimester (n = 100, 69%). Two thirds (n = 26) of 35 women starting in the third trimester were diagnosed with HIV during pregnancy. The risk of virologic failure tended to be lower in pregnant than in non-pregnant women [adjusted odds ratio 0.52 (95% confidence interval 0.25-1.09, P = 0.08)], but was similar in the intraindividual comparison (adjusted odds ratio 1.04, 95% confidence interval 0.48-2.28). Women starting HAART during pregnancy changed the treatment less often than non-pregnant women. CONCLUSION: Despite the physiological changes occurring during pregnancy, HIV infected pregnant women are not at higher risk of virologic failure.

Liveborn and stillborn very low birthweight infants in Switzerland: comparison between hospital based birth registers and the national birth register.

BACKGROUND AND AIM: Perinatal and infant mortality rates are considered key indicators of medical care. The aim of this investigation was to examine how representative and reliable the official national figures of Switzerland are by comparing them with the data in local birth registers. METHODS: 124 of 156 maternity hospitals in Switzerland, catering for about 80% of all newborn infants, participated in the study. The hospital based birth registers were screened for the years 1996 and 2000 for live and stillborn infants weighing less than 1500 g. These data were matched with the data in the official register (federal office for statistics). RESULTS: in 1996 a total of 753 newborn infants and in 2000 820 infants weighing between 300 and 1499 g were officially registered. In the hospital based registers in 1996 101 additional infants and in 2000 94 infants were identified that had not been officially registered; 31 of these were stillborn before 24 completed weeks. Infants registered only locally had lower birth weight and lower gestational age than those recorded in both registers. CONCLUSION: In Switzerland a significant number of very low birth weight infants who died soon after birth are not officially registered. If these infants are included, the national perinatal mortality rate would increase from 6.9 per thousand to 8.0 per thousand. Reasons for underreporting are unclear but may be due to varying definitions of stillbirth and different lower limits for reporting in various cantons. We suggest adopting the WHO-rules for reporting all births and to include gestational age, head circumference, Apgar scores and umbilical artery pH in the national birth register.

Lethargy in a newborn: lithium toxicity or lab error?

Lithium medication during pregnancy is uncommon and the problems of a neonate who has been exposed to lithium represents a rare situation in neonatology. The clinical presentation and management of a newborn whose mother received lithium during pregnancy is presented. The newborn manifested a four day course of lethargy with unexplained high lithium levels in the adult toxic range. The infant improved clinically under intravenous hydration therapy, nevertheless lithium serum levels increased again and we did not know for certain if our clinical instinct or the actual figures were correct. Finally we noticed that our confusion had resulted from test tubes containing lithium heparine.