Low Dose Aspirin in high-risk pregnancies: The volatile effect of acetylsalicylic acid on the inhibition of platelets uncovered by G. Born's light transmission aggregometry.

Preeclampsia still represents a life-threatening pregnancy complication, associated with severe maternal and neonatal morbidity and mortality. Low-dose Aspirin is advised to avoid preeclampsia in high-risk pregnancies worldwide. As Aspirin does not cover all women at risk, the prescription raises questions concerning optimal target population, dosage, and onset of therapy. The aim of this study was to test platelet responsiveness on Aspirin by optical aggegrometry, to gain robust biochemically assessment data of Aspirin in an obstetric cohort. 248 women at high risk for development of preeclampsia were included in the study. Aspirin-prophylaxis was administered either in 100 mg (n = 229) or 150 mg (n = 90) daily. Dosing of 100 mg Aspirin was maintained if testing revealed a sufficient platelet inhibition. If platelet inhibition was insufficient, dosage was increased to 150 mg Aspirin and re-testing was advised. 91 patients (91/229 = 39.7%) presented a sufficient inhibitory Aspirin effect at a dosage of 100 mg, but in 138 patients LTA showed an inadequate Aspirin response (138/229 = 60.3%). In 19 women 150 mg Aspirin was administered as starting dose due to new recommendations. Of all women at 150 mg Aspirin 64 did not properly respond (35.4%). The overall rate of sufficient responding women regardless the Aspirin dose was 64.6%. This study demonstrates still an insufficient inhibition of platelet aggregation in about 1/3 of women even with a dosage of 150 mg Aspirin daily, who might potentially benefit from further increase. These data show, that there is a need for further research to allow a personalized approach for individualized Aspirin therapy, maximizing the preventive benefit for mother and child.

Pregnancy, child bearing and prevention of giving birth to the affected children in patients with primary immunodeficiency disease; a case-series.

BACKGROUND: Patients with primary immunodeficiency disease (PID) who survive to adulthood and willing to have a child mostly are worried whether their disease affects their fertility and/or pregnancy and also if their child would be predisposed to PID. CASE PRESENTATION: We report the outcome of conception, pregnancy and their management in 9 families with definite diagnosis of PID. A chronic granulomatous disease subject with an uneventful pregnancy developed fungal sacral osteomyelitis few weeks after delivery. A pregnant common variable immunodeficiency disease (CVID) patient with idiopathic thrombocytopenia had platelet count dropped before delivery. A sever neutropenic mother who refused to get IFNγ delivered two healthy children. A CVID case intolerant to IVIg with eclampsia and PTE delivered a baby. Another CVID female gave birth to a baby without being on any treatment since she was not diagnosed with immunodeficiency disease at that time. A healthy girl was implanted via preimplantation gender selection in a family who owned a Wiskott Aldrich-affected son. A family who had two children with Ataxia Telangiectasia used donated oocyte for their 3rd child. Prenatal genetic diagnosis was used to screen the fetus for the impaired BTK and CVID genes detected in sibling and father respectively in 2 separate families. CONCLUSION: Pregnancy in PID patients is more complex than normal population. Because, not only it has the chance of being inherited by the offspring, but also there are some risks for the mother if she has any kind of immunity component defects. So consultation with a clinical geneticist is crucial to choose the best available approach. They also should be observed and followed by a clinical immunologist to take the best possible safe care.

Frequency of anti- Toxoplasma gondii IgA, IgM, and IgG antibodies in high-risk pregnancies, in Brazil.

INTRODUCTION: Toxoplasmosis during pregnancy can be severe; thus, it is essential to diagnose the disease via serological tests. METHODS: An enzyme-linked immunosorbent assay (ELISA) was used to investigate anti-Toxoplasma gondii immunoglobulin A (IgA), M (IgM) and G (IgG) antibodies in 62 high-risk pregnant women. RESULTS: Forty-three (69.4%) women were positive for IgA, 31 (50%) for IgG, and 57 (91.9%) for IgM; 4 (6,5%) were positive for IgA but negative for IgM; 10 (16.1%) were negative for IgA and IgM but positive for IgG. CONCLUSIONS: Testing for these antibodies can help diagnose infection in pregnant women, thereby contributing to clinical management.

Successful Pregnancy and Delivery in a Heart Transplantation Recipient.

For 6 years after heart transplantation, a 23-year old female recipient had been treated with immunosuppressants including tacrolimus and mycophenolate mofetil (MMF), without any major rejection or graft dysfunction. She unexpectedly became pregnant for the first time, and we converted MMF to azathioprine (AZA), but she soon experienced a spontaneous abortion. After careful counseling under the continuation of AZA, she became pregnant again 3 months after the abortion. We closely monitored the concentration of immunosuppressive agents, cardiac function, fetal condition, and serological assay including human leukocyte antigen (HLA) sensitization, and she eventually delivered a normal male infant at 38 weeks gestation without any complications. AZA was converted to MMF soon after the delivery. There have been no complications in either the patient or infant after the delivery.Because pregnancy itself involves a risk of cardiac graft rejection in the recipient as well as fetal complications, it is important to educate HTx recipients about planned pregnancy and to conduct careful follow-up after pregnancy.

Antenatal management of recurrent fetal goitrous hyperthyroidism associated with fetal cardiac failure in a pregnant woman with persistent high levels of thyroid-stimulating hormone receptor antibody after ablative therapy.

High titer of maternal thyroid-stimulating hormone receptor antibody (TRAb) in patients with Graves' disease could cause fetal hyperthyroidism during pregnancy. Clinical features of fetal hyperthyroidism include tachycardia, goiter, growth restriction, advanced bone maturation, cardiomegaly, and fetal death. The recognition and treatment of fetal hyperthyroidism are believed to be important to optimize growth and intellectual development in affected fetuses. We herein report a case of fetal treatment in two successive siblings showing in utero hyperthyroid status in a woman with a history of ablative treatment for Graves' disease. The fetuses were considered in hyperthyroid status based on high levels of maternal TRAb, a goiter, and persistent tachycardia. In particular, cardiac failure was observed in the second fetus. With intrauterine treatment using potassium iodine and propylthiouracil, fetal cardiac function improved. A high level of TRAb was detected in the both neonates. To the best of our knowledge, this is the first report on the changes of fetal cardiac function in response to fetal treatment in two siblings showing in utero hyperthyroid status. This case report illustrates the impact of prenatal medication via the maternal circulation for fetal hyperthyroidism and cardiac failure.

[Immunized pregnant woman with rare Rh fenotype--case report].

INTRODUCTION: Rh blood group system is one of the most polymorphic systems of human blood and consists of 50 antigens. Antigen D is the most important antigen in the Rh system and next to ABO, is the most clinically significant in transfusion medicine. The aim of this paper was to present a case of a rare Rh phenotype ccDEE in an immunized pregnant woman, whose fourth pregnancy ended with birth of a female newborn infant with hemolytic disease of the lower level. CASE REPORT: The history of a 42-year-old pregnant woman stated that she had had four pregnancies. She was transfused with 1500 ml of whole blood, three units of packed red cells and two units of fresh frozen plasma. Due to her high-risk pregnancy she was referred to the Clinic of Gynecology and Obstetrics in Novi Sad. Blood sample was tested in the Department of Prenatal Care of the Institute for Blood Transfusion Vojvodina. ABO and Rh were tested, antibody screening was done by indirect antiglobulin test and the detected antibodies were identified by gel technology. The results of testing were: O RhD positive, Rh phenotype ccDEE, positive screening for red blood cells antibodies by indirect antiglobulin test, alo anti-e antibody. According to the literature data, it is a very rare Rh phenotype whose incidence in the population ranges from 0.34% to 1.99%. The compatible blood products for the patient and her newborn were searched for on the basis of the immunoserology tests. CONCLUSION: Two major problems within transfusion medicine have emerged in our case: the problem of immunization of pregnant woman with a rare blood type and the problem of finding compatible blood. Health care of pregnant women can be improved by following pregnancies according to the national antenatal testing algorithm and better teamwork of gynecologists and transfusions.

Manejo del HIV/SIDA en el Embarazo

El control obstétrico de las pacientes y sus implicaciones donde se detalla el historial clínico, estudios cervicovaginal para detectar el estadio clínico de la infección por VIH. Esta guía contiene los pasos para el diagnóstico y tratamiento del SIDA en la mujer embarazada. Aunque es importante mencionar el bajo peso en pacientes infectadas, los tratamientos antirretrovirales permiten una mejoría y expectativas en pacientes infectadas por el VIH.

Plasma exchange and immunoadsorption effectively remove antiphospholipid antibodies in pregnant patients with antiphospholipid syndrome.

Conventional therapy with aspirin and/or heparin is at times incapable of preventing complications in high risk pregnancies of patients with antiphospholipid syndrome (APS). In those cases, a so-called second-line treatment protocol is used in addition to conventional therapy strategies. This manuscript is a report on three APS pregnant patients who were successfully treated with plasma exchange (PE) (two cases) or with immunoadsorption (IA) (one case) as a second-line treatment strategy. The efficacy of these procedures in removing anticardiolipin (aCL) and anti-ß(2)glycoprotein I (aß(2)GPI) antibodies from blood was evaluated. Serum samples were collected before and after 87 apheretic treatment sessions. Serum IgG/M aCL and IgG/M aß(2)GPI antibodies were determined using an "in-house" enzyme-linked immunosorbent assay and showed that all three patients had medium/high IgG aCL and aß(2)GPI titers. All three women had a successful pregnancy. A significant decrease in IgG aCL (P = 0.0001) and aß(2)GPI (P = 0.0001) antibody titers was observed after PE and IA sessions. There was moreover a significant, steady fall in serum IgG aCL pretreatment levels during the course of all three pregnancies (P = 0.0001, P = 0.0001, P = 0.001). The fall in IgG aß(2)GPI was significant in two of the patients (P = 0.0001, P = 0.0001) both with high antibody titers, but not in one with medium antibody titers, who was treated with PE (P = 0.17).

Hemolytic disease of newborn due to anti-Jk b in a woman with high risk pregnancy.

This case illustrates the importance of blood group antibodies in antenatal serology other than Rh system as a cause of hemolytic disease of newborn (HDN). In India, antenatal antibody screening is done at majority of transfusion centers in only Rh (D) negative mothers. In this multigravida woman with high risk obstetrical history, an antenatal antibody screening by indirect antiglobulin test (IAT) was not performed as she was Rh (D) positive. Postnatal work up for the pathological jaundice in the neonate revealed that red cell alloimmunization had occurred due to anti-Jk(b). We conclude that antenatal antibody screening should be done in all pregnant women irrespective of the D antigen status to detect and manage red cell alloimmunization to any other clinically significant blood group antigens.

Obstetric antiphospholipid syndrome: still a challenge.

Obstetric complications such as fetal death, premature delivery, preeclampsia and recurrent abortions (since chromosomal or anatomic defects have been excluded) are characteristic manifestations of antiphospholipid syndrome (APS). They can occur in patients with known APS with previous arterial or venous events in any tissue or organ, or be its first and only manifestation. Pregnancy in a patient with APS is considered high risk and the full prenatal clinical follow-up must be carried with this in mind, eliminating or minimizing concomitant thrombotic risk factors.

Pregnancy and rheumatic disease: "by the book" or "by the doc".

Pregnancy is an important condition that can affect and be affected by rheumatic disease. Overall, pregnancy is viewed as a Th2-predominant state, but several Th1-related cytokines are vital to early pregnancy. In rheumatoid arthritis for example, the majority of women improve by the beginning of the second trimester, but the majority (90%) will flare in the first 3 to 4 months postpartum. In contrast, systemic lupus erythematosus has an unpredictable course in pregnancy, leaving most rheumatologists to recommend a disease-quiescent state prior to conception. Other diseases such as scleroderma are less clear because the disease less commonly presents in the childbearing period. Many immunosuppressive medications for the rheumatic diseases are contraindicated in pregnancy because of their mechanisms of action leaving only a select few "safe" medications. Significant heterogeneity between the Food and Drug Administration (FDA) category for a medication and what a rheumatologist does in clinic leads to confusion on how a patient should be treated for active rheumatic disease both peripartum and postpartum, particularly if the patient is breastfeeding. We review the general state of pregnancy and how it is affected by prototypical rheumatic diseases including rheumatoid arthritis and systemic lupus erythematosus. In addition, we present the most commonly used disease-modifying antirheumatic drugs and immunosuppressants and explain the difference between the FDA category and clinical practice among rheumatologists. Finally, we provide some general recommendations on how to manage a rheumatic disease during pregnancy including: (a) preconception planning to ensure no teratogenic medications on board, (b) early disclosure of pregnancy to all caregivers including the rheumatologist, family physician, obstetrician, and maternal-fetal medicine specialist, and (c) planning of safe medication use for acute flare-ups and disease suppression peripartum and postpartum.

Anti-KEL7 (anti-Js(b)) alloimmunization diagnostic supported by molecular KEL*6,7 typing in a pregnant woman with previous intrauterine deaths.

Anti-KEL7 (anti-Js(b)) is a rare antibody that has been related to haemolytic transfusion reactions and HDN. We report a case of anti-KEL7 alloimmunization detected in a pregnant woman who had an obstetric previous history of four miscarriages and one stillborn. Employing classical immunohematological techniques, we studied the propositus and her available relatives. Due to the unavailability of commercial anti-KEL6 and anti-KEL7 reagents, we used a KEL*6,7 genotyping method as an alternative tool to contribute with the identification of the alloantibody origin. The results of KEL genotyping showed that the propositus was KEL*6/6 homozygous, while her second partner was KEL*7/7 homozygous.

Questions about dexamethasone use for the prevention of anti-SSA related congenital heart block.

BACKGROUND: Mothers with anti-SSA/Ro antibodies who have had a previous fetus with congenital heart block (CHB) have a risk of recurrence estimated to be up to 16%. OBJECTIVE: To improve the management of these "high risk patients" by determining (a) whether or not prophylactic treatment is efficient; (b) whether or not fluorinated steroids (betametasone and dexamethasone) that do cross the placenta in an active form are safe for the fetus; and (c) which prophylactic treatment should be used. METHODS: Retrospective study performed on seven mothers sent to a university hospital owing to a past history of one (six mothers) or two children (one mother) with CHB. RESULTS: 13 subsequent pregnancies occurred. No CHB was observed. All four pregnancies in women treated with 10 mg/day prednisone were uneventful. Three pregnancies in women receiving no steroids resulted in two early spontaneous abortions and one live birth. The six pregnancies in women treated with dexamethasone (4-5 mg/day) ended in one early and one late spontaneous abortion, two stillbirths, and two live births with intrauterine growth restriction and mild adrenal insufficiency. A histological study of one stillbirth disclosed intrauterine growth restriction and marked adrenal hypoplasia. CONCLUSION: Adverse obstetric outcomes were often seen here and major concerns have been raised by paediatricians about the safety of fluorinated steroids, owing to the results of animals studies, retrospective data, and randomised trials. Because fluorinated steroids have not been shown to improve prophylactic treatment of CHB in pregnant women at high risk, their use is questionable.

Pregnancy in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is an autoimmune disease that predominantly affects women of reproductive age. Pregnancy and its outcome is a major concern to most SLE patients. Queries regarding the risk of disease flares during pregnancy, chance of fetal loss, and the safety of various drugs are often raised. With the improvement in the understanding of the pathogenesis of SLE and the judicious use of immunosuppressive drugs, better disease control can now be achieved and SLE patients should not be deprived of the opportunity for bearing children. Prepregnancy counselling and close collaboration with other specialists such as the obstetricians and the perinatologists is essential in optimising the maternal and fetal outcome in lupus pregnancies. In this review, important issues regarding the fertility rate, optimal timing of conception, risk of disease flares during lupus pregnancy, pregnancy course, fetal outcome, safety of various drugs used for disease control during pregnancy and lactation, and contraceptive advice are discussed.

Hallazgos inmunohistoquímicos en material histopatológico de abortos recurrentes espontáneos / Immunohistochemical findings in histopathological material of spontaneous recurrent abortions

En 1994 en un estudio realizado por nuestro grupo en colabaración con la Dra. Fuksman sobre 1.200 placentas correspondientes a embarazos de alto riesgo, se halló la presencia de villitis en el 5.6 por ciento de las mismas. La histopatología detectada en ese momento fue deciduitis linfocitaria y aumento de fibrina perirvellositaria asociada con hipoirrigación e infarto placentario. Hallamos que en el 55 por ciento de las placentas con villitis los recién nacidos presentaban RCIU con respecto al 10 por ciento de los controles, con un PA de 32 por ciento en las villitis y el 83 por ciento en los controles (3). En ese material se estudiaron 68 placentas con villitis y 68 placentas sin villitis como grupo control. En 1996 demostramos en ese mismo material mediante la técnica de anticuerpos monoclonales, sobre cortes de placenta estudiando las subpoblaciones linfocitarias de las villitis, que el 50 por ciento eran CD4 (linfocitos helper), 18 por ciento CD8 (linfocitos supresoreslcitotóxicos) y 10 por ciento Leu19 (Natural Killer) pero lo significativo y anormal es que hallamos que el 65 por ciento de los linfocitos expresaban antígenos de histocompatibilidad clase II DR (40). En 1998 Jacques y Col publicaron datos similares. En 1999 comunicamos que en el informe histopatológico de material de legrado de pacientes abortadoras de causa inmunológica la descripción de villitis en un 20 por ciento de los casos. Estudios realizados en colabaración con la Dra. Zenclussen con ese material nos permitió publicar recientemente la presencia de altos niveles de Interleuquina 6(IL-6) y receptor de IL-6 en suero. El objetivo de este estudio es investigar en placentas de pacientes abortadoras recurrentes la expresión de IL-6 y sus receptores gp80 y gp130 en trece muestras de material de raspado de abortos del primer trimestre mediante la técnica de inmunofluorescencia. Como control se utilizaron cortes de placentas de embarazos normales a término. Nuestros hallazgos muestran la presencia de depósitos de IL-6 y de receptores de IL-6 con un patrón granular para las tres moléculas especificamente en el sinciciotrofoblasto mientras que fue negativo para tres en el citotrofoblasto. En los cortes de placentas normales no se hallaron en ningún caso dichos depósitos. Concluímos de todos los hallazgos antes sintetizados...(AU)

Hallazgos inmunohistoquímicos en material histopatológico de abortos recurrentes espontáneos / Immunohistochemical findings in histopathological material of spontaneous recurrent abortions

En 1994 en un estudio realizado por nuestro grupo en colabaración con la Dra. Fuksman sobre 1.200 placentas correspondientes a embarazos de alto riesgo, se halló la presencia de villitis en el 5.6 por ciento de las mismas. La histopatología detectada en ese momento fue deciduitis linfocitaria y aumento de fibrina perirvellositaria asociada con hipoirrigación e infarto placentario. Hallamos que en el 55 por ciento de las placentas con villitis los recién nacidos presentaban RCIU con respecto al 10 por ciento de los controles, con un PA de 32 por ciento en las villitis y el 83 por ciento en los controles (3). En ese material se estudiaron 68 placentas con villitis y 68 placentas sin villitis como grupo control. En 1996 demostramos en ese mismo material mediante la técnica de anticuerpos monoclonales, sobre cortes de placenta estudiando las subpoblaciones linfocitarias de las villitis, que el 50 por ciento eran CD4 (linfocitos helper), 18 por ciento CD8 (linfocitos supresoreslcitotóxicos) y 10 por ciento Leu19 (Natural Killer) pero lo significativo y anormal es que hallamos que el 65 por ciento de los linfocitos expresaban antígenos de histocompatibilidad clase II DR (40). En 1998 Jacques y Col publicaron datos similares. En 1999 comunicamos que en el informe histopatológico de material de legrado de pacientes abortadoras de causa inmunológica la descripción de villitis en un 20 por ciento de los casos. Estudios realizados en colabaración con la Dra. Zenclussen con ese material nos permitió publicar recientemente la presencia de altos niveles de Interleuquina 6(IL-6) y receptor de IL-6 en suero. El objetivo de este estudio es investigar en placentas de pacientes abortadoras recurrentes la expresión de IL-6 y sus receptores gp80 y gp130 en trece muestras de material de raspado de abortos del primer trimestre mediante la técnica de inmunofluorescencia. Como control se utilizaron cortes de placentas de embarazos normales a término. Nuestros hallazgos muestran la presencia de depósitos de IL-6 y de receptores de IL-6 con un patrón granular para las tres moléculas especificamente en el sinciciotrofoblasto mientras que fue negativo para tres en el citotrofoblasto. En los cortes de placentas normales no se hallaron en ningún caso dichos depósitos. Concluímos de todos los hallazgos antes sintetizados...

[Analysis of HLA class I and II antigens composition in high-risk pregnancy]. / Analiza wystepowania antygenów HLA klasy I i II w ciazy wysokiego ryzyka.

DESIGN: We have analyzed the frequency of HLA class I and II antigens in high-risk pregnancy. MATERIAL AND METHODS: Altogether, 22 gravida hospitalized at the Department of Pathology of Pregnancy and Labour, Pomeranian Medical University in Szczecin formed group I (PE) with 12 cases of preeclampsia and group II with 10 cases of the antiphospholipid syndrome (APS). The control group included 40 multigravida. Typing of HLA class I and II antigens was done using the two-stage microcytotoxic test (NIH) of Mittal. RESULTS: Antigen B35 was found more frequent in preeclampsia and antiphospholipid syndrome groups than in multigravida. Furthermore, a statistically significant difference in the frequency of homozygotes for the HLA-DR locus was noted between groups PE and APS on one hand, and controls on the other. CONCLUSIONS: Identical HLA-DR3, DR4 and DR5 antigens were found more frequently in preeclampsia, while identical DR4 and DR6 in the antiphospholipid syndrome.

[Antiphospholipid antibodies in high-risk pregnancy]. / Przeciwciala antyfosfolipidowe w ciazy wysokiego ryzyka.

UNLABELLED: Recently the connection of antiphospholipid antibodies (aPLs) presence with pregnancy loss and complications in pregnancy has been observed APLs related obstetric complications include: miscarriages after 10 weeks, IUGR, intrauterine foetal death, preeclampsia and severe preeclampsia. Our objective was to determine the aPLs prevalence in patients with recurrent pregnancy loss and/or complicated pregnancy. We examined 154 pregnant women aged 19-42 (average of 29.1) with recurrent pregnancy loss, current pregnancy complicated by preeclampsia and severe preeclampsia and/or IUGR, thrombotic episodes, thrombocytopenia or autoimmune disease. In all the patients anticardiolipin antibodies (aCL) were determined at least twice using ELISA and their coagulation system was tested including lupus anticoagulant (LA) test. In justified cases immunological examinations detecting connective tissue systemic diseases were conducted. Increased aCL titre was detected in 54 (34.4%) women. Statistically significant risk of increased aCL titre was observed in patients with autoimmunological diseases (RR = 4.3). Increased, but Statistically insignificant, risk of high aCL titre was observed in patients with venous thrombosis (RR = 2.45) as well as in patients with thrombocytopenia (RR = 2.45). LA prevailed significantly more often in patients with venous thrombosis episodes (RR = 6.33) and with autoimmunological diseases (RR = 17.4). Preterm deliveries were significantly more frequent in pregnant women with increased aCL titre and/or LA. Moreover, in this group foetal death and preterm stillbirth more often occurred. The above mentioned risks increased when aCL and LA coexisted. No relation between increased aPLs and miscarriage frequency was observed. CONCLUSIONS: 1) Increased aPLs titre prevail in multiparas with bad obstetrical anamnesis and with pathological course in present pregnancy, 2) increased aPLs titre prevail in patients with autoimmunological diseases, 3) increased aPLs titre are connected with pregnancy pathology manifested by frequent preterm deliveries and intrauterine foetal deaths.

[The influence of perinatal risk factors on the number of CD3+ lymphocytes and CD25+ cells in full-term neonates]. / Wplyw perinatalnych czynników ryzyka na liczbe limfocytów T i komórek CD25+ u noworodków donoszonych.

In 39 full-term neonates aged from 1 to 7 days of life, among them 24 with perinatal risk factors and 15 healthy as the control group, immunophenotyping of CD3+ and CD25+ cells using Becton Dickinson flow cytometer and monoclonal antibodies and CD3+ and CD25+ was performed. It was stated, that the mean relative and absolute number of CD3+ T lymphocytes in high risk neonates did not differ from the mean values in control group. The premature rupture of fetal membranes in mothers caused a significant increase of mean relative number of CD3+, whereas it did not influence on the absolute number of these cells. Significant increase of mean relative and absolute number of CD25+ cells in neonates with perinatal risk factors in comparison with the control group was noted. Mean relative and absolute number of CD25+ cells were significantly higher in neonates with non-infectious risk factors than in neonates with infectious risk factors. Authors emphasize that, evaluation of CD25+ cells is useful in the assessment of immunological changes in high risk neonates.