Parto vaginal operatório / Operative vaginal delivery

PONTOS-CHAVE Quando utilizados na técnica correta, fórcipes e vácuo-extratores apresentam baixos índices de complicações. Para o feto com sinais de hipóxia no período expulsivo, o parto vaginal operatório tem potencial para reduzir a exposição aos fatores intraparto que promovem a encefalopatia hipóxico-isquêmica. Fórcipes médios e/ou rotacionais são opções apropriadas em circunstâncias selecionadas e exigem habilidade e experiência. Os fórcipes são mais resolutivos do que os vácuo-extratores para o parto vaginal operatório, porém são mais associados a lacerações perineais graves. Céfalo-hematoma é mais provável de ocorrer com o aumento na duração da vácuo-extração. Os vácuo-extratores de campânulas flexíveis apresentam taxas maiores de falha, porém apresentam menores incidências de trauma no couro cabeludo do neonato. (AU)

Valor predictivo del índice de líquido amniótico en las complicaciones neonatales / Predictive value of amniotic fluid index in neonatal complications

Determinar el valor predictivo del índice de líquido amniótico en las complicaciones neonatales. Se seleccionaron 120 embarazadas en las que se evaluó el valor del índice de líquido amniótico, complicaciones neonatales y eficacia diagnóstica. Las pacientes fueron divididas según el punto de corte del índice de líquido amniótico (grupo A: índice de líquido amniótico menor de 60 mm y grupo B índice de líquido amniótico igual o mayor a 60 mm). Servicio de Obstetricia y Ginecología. Hospital Central “Dr. Urquinaona”. Maracaibo. Estado Zulia. Las pacientes del grupo A presentaron una duración mayor del trabajo de parto y recién nacidos con menos peso al nacer que las pacientes del grupo B (P < 0,05). Con respecto a las complicaciones perinatales, la frecuencia de recién nacidos con sufrimiento fetal y con puntuación de Apgar menor o igual de 6 puntos al minuto fue estadísticamente superior en las pacientes del grupo A comparado con aquellas del grupo B (P < 0,05). El valor de corte de 60 mm en la predicción de sufrimiento fetal tiene una sensibilidad del 22,2 por ciento, especificidad del 96,4 por ciento, valor predictivo positivo del 72,3 por ciento y valor predictivo negativo del 74,3 por ciento; en la predicción de puntuación de Apgar menor o igual de 6 puntos al minuto tiene una sensibilidad del 25,0 por ciento, especificidad del 96,4 por ciento, valor predictivo positivo del 69,2 por ciento y valor predictivo negativo del 74,7 por ciento. El índice de líquido amniótico tiene valor en la predicción de sufrimiento fetal y puntuación de Apgar

To determine the predictive value of amniotic fluid index in perinatal complications. One hundred and twenty patients were selected. Amniotic fluid index, perinatal complications and diagnostic accuracy was evaluated. Patients were divided according to cut-off point of amniotic fluid index (group A: amniotic fluid index less than 60 mm and group B amniotic fluid index same or higher than 60 mm). Servicio de Obstetricia y Ginecologia. Hospital Central “Dr. Urquinaona”. Maracaibo. Estado Zulia. Patients in group A presented a longer labor and there newborns had less weight than those of patients in group B (P < 0.05). In relation to perinatal complications, the frequency of fetal distress and Apgar Score less than 6 points at minute was statically superior in patients of group A compared with those in group B (P < 0.05). The cut-off value of 60 mm for prediction of fetal distress has a sensivity of 22.2 percent, specificity of 96.4 percent, positive predictive value of 72.3 percent and negative predictive value of 74.3 percent; in the prediction of Apgar score equal or less than 6 points at minute had a sensivity of 25.0 percent, specificity of 96.4 percent, positive predictive value of 69.2 percent and negative predictive value of 74.7 percent. Amniotic fluid index has a value for prediction of fetal distress and Apgar score

CSF levels of hypocretin-1 (orexin-A) peak during early infancy in humans.

STUDY OBJECTIVES: Hypocretin (orexin) is a unique neuropeptide involved in the consolidation of wakefulness and sleep. Although hypocretin-1 levels in the cerebrospinal fluid (CSF) are stable after infancy, how levels change in preterm and term human infants is unknown. DESIGN, PATIENTS, AND SETTING: Hypocretin-1 levels were measured in CSF samples, obtained from 284 preterm (25-37 gestational weeks) and full-term infants in the first 4 months of life and 35 older children (ages 0.5-13 years), in a tertiary hospital. MEASUREMENTS AND RESULTS: Detailed clinical and laboratory data were collected for each of the 319 participants. Based on that data, 108 neurologically intact children were selected (95 infants [43 preterm and 52 term] and 13 older children). CSF hypocretin-1 was measured by direct radioimmunoassay. Hypocretin-1 levels at the first weeks of the 3rd embryonic trimester (gestational age [GA] 28-34 weeks) were 314 ± 65 pg/mL (n = 17). The levels linearly increased during the third trimester and early infancy (r = 0.6), peaking in infants of 2-4 months ages (476 ± 72 pg/mL; n = 16) and decreasing thereafter; hypocretin levels in 2- to 4-month-old infants were significantly higher than those in children 0.5-13 years old (353 ± 78 pg/mL, n = 13; P = 0.0001). CONCLUSIONS: The present findings indicate that in human infants, CSF hypocretin-1 increases during the third embryonic trimester and is highest at 4 months of life. Thereafter, and consistent with previously published results, hypocretin levels are lower and stable until the geriatric age. This pattern may reflect the role of hypocretin in the dramatic process of sleep and wakefulness consolidation that occurs during early infancy.

A randomized study to validate a midspinal canal depth nomogram in neonates.

Improving the accuracy of lumbar puncture (LP) in neonates should reduce the incidence of hemorrhagic contamination of cerebrospinal fluid (CSF) samples. We have previously demonstrated a linear correlation between neonatal weight and midspinal canal depth (MSCD), generating a nomogram and simple formula to allow MSCD estimation. In this study, we attempted to validate the nomogram by improving the quality of the CSF samples obtained. We consecutively randomized 99 infants in whom LP was clinically warranted to receive either a standard, "blind" ( N = 48) or "measured" ( N = 51) procedure. If allocated to the measured technique, the operator marked the LP needle with a Steri-Strip (TM) at the predicted depth of insertion (i.e., MSCD) derived from the weight-based nomogram. CSF samples were classified as clear (<500 red blood cells [rbc]/mL), mildly bloodstained (500 to 10,000 rbc/mL), heavily bloodstained (>10,000 rbc/mL or clotted), or failed procedures. Clear and mildly bloodstained LPs were "successful." Heavily bloodstained or failed procedures were considered "unsuccessful." We also recorded the number of attempts required to obtain a CSF sample. The overall success rate (

Cerebrospinal fluid xanthochromia in newborns is related to maternal labor before delivery.

OBJECTIVE: The purpose of this work was to investigate whether xanthochromia in newborns is related to maternal labor before delivery. METHODS: We reviewed the medical charts of all of the infants < or = 30 days of age who had a lumbar puncture performed in a single pediatric emergency department between 2003 and 2005. Xanthochromia was detected by the hospital laboratory using the qualitative visual inspection method. We used logistic regression to determine the relationship between maternal labor before birth and the presence of cerebrospinal fluid xanthochromia, adjusting for factors known to be associated with xanthochromia. RESULTS: Of the 478 newborns who had a lumbar puncture performed during the study period, 134 (28%) had xanthochromia. Of the 449 infants with delivery method recorded in the medical chart, 332 (74%) were born via vaginal delivery, 24 (5%) via cesarean section after maternal labor, and 93 (21%) via cesarean section without maternal labor. After excluding patients with hyperbilirubinemia (total bilirubin > or = 15 mg/dL) and adjusting for factors known to be associated with xanthochromia (cerebrospinal fluid red blood cells > or = 20,000 cells per mL and cerebrospinal fluid protein > or = 150 mg/dL), infants born after maternal labor had a higher rate of cerebrospinal fluid xanthochromia than infants born without any labor. CONCLUSIONS: Xanthochromia is a common finding in the cerebrospinal fluid of newborns and is associated with maternal labor preceding delivery.

Cerebrospinal fluid leucocyte counts in healthy neonates.

OBJECTIVES: To determine the cerebrospinal fluid (CSF) white blood cell (WBC) count of normal term neonates, and compare the CSF WBC profile of normal and symptomatic infants without infection of the central nervous system (CNS). METHOD: Neonates were included if (a) they were at risk of congenital Toxoplasma infection and had undergone a lumbar puncture to assess CNS involvement, and (b) serial specific serum IgG and IgM determinations had ruled out congenital infection. According to neonatal chart reviews, 30 consecutive patients without CNS infection were classified as normal (absolutely asymptomatic) or symptomatic (any kind of symptoms). RESULTS: CSF WBC count was higher in 11 symptomatic (7/mm(3), 0-30/mm(3)) than in 19 normal (1/mm(3), 0-5/mm(3)) neonates (p<0.01). CONCLUSION: Normal neonatal CSF contains up to 5 WBCs/mm(3). Mild pleocytosis can be found in symptomatic infants without CNS infection.

CSF 5-HIAA and family history of antisocial personality disorder in newborns.

OBJECTIVE: The relationship between genetic liability for antisocial behavior and CSF 5-hydroxyindoleacetic acid (5-HIAA) in newborns was explored. METHOD: The authors assayed 5-HIAA in "leftover" CSF from 193 neurologically normal newborns and obtained family psychiatric histories of the newborns' first- and second-degree relatives. RESULTS: Levels of 5-HIAA were significantly lower in the infants with family histories of antisocial personality disorder than in the newborns without such family histories. CONCLUSIONS: These findings support the possibility that serotonin mediates one component of genetic liability to antisocial outcome, but the magnitude of that component may be less than what has been inferred from previously published reports.

Erythropoietin is present in the cerebrospinal fluid of neonates.

Erythropoietin (Epo) was measured by enzyme-linked immunosorbent assay in 80 cerebrospinal fluid (CSF) samples to determine whether Epo is present in the CSF of infants, CSF Epo concentrations correlate with age, and CSF Epo concentrations correlate with Epo therapy. Epo was present in the CSF of normal neonates. CSF Epo concentrations correlated negatively with increasing age. Recombinant Epo therapy did not affect CSF Epo concentrations, although values ranged somewhat higher in this group.

Monoamine metabolites in 'leftover' newborn human cerebrospinal fluid--a potential resource for biobehavioral research.

Although variations in monoamine neurotransmission have been implicated in a variety of psychopathologic outcomes in man, little is known about how monoamines influence or are affected by developmental processes early in childhood. In this study, assays for 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) were obtained from leftover cerebrospinal fluid (CSF) of 119 human newborns. The levels of these monoamine metabolites were in keeping with pre-existing 'normative' data from two small previously published studies. The levels were largely unaffected by variations in the infants' physiologic condition at the time of lumbar puncture, and exhibited evidence for circadian rhythms. Among 32 infants (8 neurologically normal, 24 neurologically compromised) for whom more than one CSF sample was obtained during the first year of life, the correlations between baseline and follow-up measurements for 5-HIAA and HVA were on the order of 0.75. Correlations between twins (four sets) were significantly higher than those between unrelated individuals for 5-HIAA and HVA. At 9-month follow-up, neurologically normal infants in the lower extreme 15% of the distribution for 5-HIAA exhibited a trend toward lower scores for sociability on the Colorado Childhood Temperament Inventory (maternal report) than their counterparts at the upper extreme of the 5-HIAA distribution. Leftover CSF is a readily available resource for measurements of monoamine metabolites (and possibly other CSF constituents) in population-based samples of human newborns.

Cerebrospinal fluid of newborn infants contains a deglycosylated form of the intermediate filament nestin.

Nestin is an intermediate filament protein found in CNS progenitor cells. Nestin reappears in CNS tumor cells and reactive astrocytes after CNS injury. In this study we investigated whether nestin could be detected in the cerebrospinal fluid (CSF) of newborn infants and whether expression levels change with gestational age (GA) and/or brain injury. Using Western blot analysis, we examined the expression of nestin in the CSF of newborn infants (GA 25-42 wk) with asphyxia (n = 14), periventricular leukomalacia and peri(intra)ventricular hemorrhage (n = 7), and in a control group (n = 11). Protein extract from the periventricular brain tissue of a 1-wk-old infant was also analyzed. Nestin was detected in all the CSF samples and in the protein extract from the periventricular brain tissue. Although the CSF levels of nestin expression did not change with increasing GA, the asphyxia group had significantly lower levels of nestin in the CSF. An unexpected finding was that brain-derived nestin had an apparent molecular mass of approximately 240 kD, whereas all analyzed CSF samples contained two nestin-immunoreactive proteins at 200 and 220 kD. Experimental deglycosylation of the 240-kD form reduced the molecular mass to 220 kD, indicating that nestin undergoes a specific deglycosylation upon release into the CSF.

gamma-Aminobutyric acid concentrations in the cerebrospinal fluid of newborn infants determined by high performance liquid chromatography.

gamma-Aminobutyric acid (GABA), a major inhibitory amino acid, has a central role in cardiorespiratory regulation. Its measurement in the cerebrospinal fluid (CSF) complements the study of neurotransmission systems. Forty-one children were studied (postnatal age < 1 year). For each child, date of birth, date of sampling and current treatments were collated and their postnatal (days) and postconception (weeks) ages were calculated. CSF samples were studied using reverse phase high performance liquid chromatography (HPLC) with o-phthaldialdehyde derivation and spectro-fluorimetric measurement. A clear increase in levels of GABA was observed around 41 weeks postconception, followed by a progressive decrease, with levels stabilizing after 57 weeks postconception. GABA-regulated neuromodulation therefore appears to be mature at 41 weeks postconception and not at birth. The data could be used in further studies investigating amino acid metabolism in relation to brain function in various neurological disorders.

Endogenous tissue plasminogen activator in neonatal cerebrospinal fluid.

Tissue type plasminogen activator (tPA) plays a role in differentiation of neurones and activity-dependent structural changes in neurones. We hypothesised that tPA would also be present in CSF during fibrinolysis after intraventricular haemorrhage. We measured tPA antigen in CSF from 13 normal newborn infants and 14 infants with post-haemorrhagic ventricular dilatation (PHVD). tPA was undetectable or at the limit of detection (1 microgram/l) in normal CSF. The CSF tPA concentration ranged from 1.3 to 3.5 micrograms/l in the infants with PHVD. Serial tapping in one infant showed persistence of tPA in the CSF from 3 to 8 weeks of age. We conclude that endogenous tPA may be part of the physiological response to intraventricular haemorrhage or may be present as a result of passive diffusion into the CSF.

Endogenous fibrinolysis in neonatal cerebrospinal fluid.

Although many infants with intraventricular haemorrhage (IVH) recover without hydrocephalus, little is known about how blood is cleared from the CSF pathways. Fibrinolytic activity was measured by the fibrin plate method in CSF from 11 normal infants and 17 infants with IVH. Normal CSF showed no fibrinolytic activity. All the samples taken less than 17 days from diagnosis of IVH failed to show fibrinolytic activity. All but 1 of the CSF samples taken between 17 and 60 days of IVH showed fibrinolytic activity. In 1 infant where 14 serial samples were taken, there was no detectable fibrinolysis up to 16 days after IVH but from 19 to 52 days there was definite fibrinolytic activity. Delayed endogenous fibrinolysis in the CSF is common after IVH but may, in some cases, be insufficient to prevent hydrocephalus.

Transfer of specific IgG and IgG subclasses to herpes simplex virus across the blood-brain barrier and placenta in preterm and term newborns.

The kinetics of virus-specific IgG subclasses (IgG 1-4) among newborns and their mothers has not yet been determined. In this report, we examined anti-herpes simplex virus IgG activities (HSV-IgG) and its subclasses in CSF and serum of premature or term newborns without HSV infection and in the serum of their mothers using ELISA. We found that CSF/serum ratios of HSV-IgG and IgG subclasses (IgG 1-4) in newborns with a gestational age less than 38 weeks were higher than those of term newborns. These findings indicate that the blood-brain barrier against HSV-IgG and IgG subclasses is insufficient in newborns. Furthermore, we found that HSV-IgG subclasses, which were transferred across the placenta and later transferred across the blood-brain barrier had a tendency to be proportional to each of the maternal HSV-IgG subclasses.

Prolactin and dopamine concentrations in the cerebrospinal fluid during the neonatal period.

UNLABELLED: Prolactin (PRL) has been detected in the cerebrospinal fluid (CSF) in humans and the absolute level appears to reflect the serum PRL concentration. Because PRL is thought to be involved in the regulation of brain water and electrolyte content attempt has been made to determine CSF and plasma PRL and dopamine (DA) concentrations, osmolality, and sodium level in 21 newborn infants undergoing lumbar punction because of apneic spells, fever, or perinatal asphyxia. The mean of gestational age was 36.5 weeks (range: 31-41) and birthweight was 2572 g (range: 1140-3550). The lumbar puncture was performed at the 8.3 postnatal day (range: 1-38). The plasma concentration of PRL was 106.52 +/- 14.43 ng/ml, significantly higher than the CSF PRL level (43.24 +/- 7.39 ng/ml, p < 0.01). This elevated level was observed in all individual cases. DA concentration in the plasma was much higher than the value detected in the CSF (64.75 +/- 13.83 vs 8.64 +/- 0.72 ng/ml, p < 0.01). No difference was observed between the sodium content of the CSF and plasma (138.94 +/- 1.28 vs 138.04 +/- 1.03 mmol/l), however, the osmolality of the plasma tended to be higher than the CSF osmolality (286.7 +/- 3.81 vs 276.76 +/- 2.19 mosm/kg, p < 0.05). In the CSF osmolality, PRL, DA, and sodium concentrations did not show any correlation. IN CONCLUSION: in the CSF PRL probably does not play a primary role in controlling the osmolality and sodium content. PRL in CSF seems to be independent from CSF DA concentration.

Changes in CSF neurotransmitters during the first year of life.

Changes in cerebrospinal fluid neurotransmitter metabolites in 25 children younger than 1 year of age were analyzed to assess maturation of the central nervous system and were compared to cerebrospinal fluid from older children and adults. Significant inverse correlations (P less than .05) with aging were observed for tryptophan, 5-hydroxytryptophan, 5-hydroxyindoleacetic acid, kynurenine, tyrosine, dopa, dopamine, dihydroxyphenylacetic acid, homovanillic acid, norepinephrine, and 3-methoxy-4-hydroxyphenylglycol concentrations. There were no significant differences observed with respect to age in the cerebrospinal fluid serotonin, 3-hydroxykynurenine, and 3-methoxytyramine concentrations. This study suggests that changes in the major cerebrospinal fluid neurotransmitters occur with increasing age during the neonatal period. Because these findings are preliminary, additional patients require study.

Cerebrospinal fluid ascorbic acid levels during the neonatal period.

Corresponding plasma and cerebrospinal fluid ascorbic acid levels were determined in 13 term and 17 preterm newborn infants during the neonatal period. On the first day of life preterm C.S.F ascorbate value of 5.2 +/- 0.8 mg/dl (mean +/- S.E.) was higher than the 3.8 +/- 0.3 mg/dl value in term infants (P less than 0.1). Later determinations during the neonatal period did not demonstrate a difference between term and preterm C.S.F ascorbate values and levelled at 2.9 +/- 0.2 mg/dl. There was a significant negative correlation between the C.S.F/plasma ascorbate ratio and the plasma ascorbate levels and the shape of the regression line was suggestive of a saturable active ascorbate transport from the plasma into the cerebrospinal fluid. Ascorbic acid in the C.S.F of additional six neonates with a neurological disorder was lower than expected on the basis of their plasma levels, the C.S.F/plasma ascorbate ratios being 8.3 +/- 0.9 in the apparently normal infants and 3.7 +/- 0.6 in the neurological patients, (P less than 0.025). The possible mechanism of ascorbate loss from the central nervous system is discussed and it is speculated that ascorbic acid administration following a neurological insult may prove beneficial.