Postnatal adaptation after Caesarean section or vaginal delivery, studied with the static-charge-sensitive bed.

AIM: To compare postnatal adaptation between Caesarean and vaginal deliveries, by studying sleep states, oxygenation, heart rate and body movements. Another aim was to follow the adaptation of healthy, term, vaginally born babies. METHODS: Ten vaginally born and 12 neonates born by elective Caesarean section were recorded with a movement sensor (SCSB, static-charge-sensitive bed), electrocardiogram and oximeter. The recordings started 1.5 h after birth and lasted for 12 h. For the vaginal group, another 12 h recording was performed during the third night postpartum. RESULTS: Delivery mode did not affect sleep state distribution. The vaginal group had more oxyhaemoglobin desaturation episodes <95% than the Caesarean section group (mean +/- SD: 59 +/- 10% vs 42 +/- 22% of epochs, p = 0.03), especially in active sleep, but baseline saturation was similar (96 +/- 1% vs 95 +/- 3%, p = 0.93). The vaginal group had fewer movements during sleep than the Caesarean section group (movements of 5-10 s: 5 +/- 1 h(-1) vs 10 +/- 3 h(-1), p = 0.0001). During the first 3 d, the amount of sleeping and active sleep increased, whereas wakefulness and quiet sleep decreased. Baseline oxyhaemoglobin saturation and the number of movements of over 5 s increased. CONCLUSION: Delivery mode did not affect sleep state distribution but, unexpectedly, the vaginal group had more oxyhaemoglobin desaturation events and fewer body movements than the Caesarean section group. These differences during the first postnatal day remain unexplained, but they may reflect stress and pain during labour. After a few days, changes in sleep organization, and increases in oxyhaemoglobin saturation and frequency of body movements were noted in the vaginal group, which may represent recovery and adaptation to extrauterine life.

Comparison of the effects of antenatal magnesium sulphate and ritodrine exposure on circulatory adaptation in preterm infants.

We examined the effects of maternal magnesium sulphate (MgSO4) and ritodrine treatments on the autonomic cardiovascular control in preterm neonates with respiratory distress syndrome during the first 2 days of life. Serial measurements of heart rate (HR), blood pressure (BP) and respirogram were performed during the first 2 days of life in 28 preterm infants below 33 weeks of gestation with antenatal exposure to MgSO4 (n = 13) or ritodrine (n = 15), and in 12 nonexposed preterm controls. Spectral analysis was used for the quantification of HR and BP variability. Although antenatal MgSO4 exposure had no effect on HR or the systolic, diastolic or mean BP, it was associated with significant decreased beat-to-beat changes in BP. In contrast, ritodrine exposure had no consistent effects on the autonomic cardiovascular control during the first 2 days of life. Our data suggest that maternal MgSO4 treatment decreases the neonatal high frequency changes in BP. This early vascular stabilizing effect of antenatal MgSO4 exposure may contribute to a lowered risk of cerebral vascular catastrophes, in the vulnerable areas of the brain, among the preterm infants with respiratory distress syndrome.

Neonatal monitoring after maternal fentanyl analgesia in labor.

OBJECTIVE: To characterize different methods of monitoring neonatal effects associated with maternal opioid analgesia. Special focus was on the static-charge-sensitive bed (SCSB), which could potentially serve as a non-invasive neonatal monitor. METHODS: 12 healthy, term newborns from normal pregnancies were included in this prospective, randomized, controlled study. Maternal labor analgesia was either intravenous fentanyl (n = 5) or paracervical bupivacaine blockade (n = 7). Neonatal recording from delivery to the age of 12 hours included continuous SCSB monitoring with ECG and oximeter for sleep states, respiration, oxygenation, heart rate, and body movements. In addition, umbilical blood pH, Apgar, Amiel-Tison's Neurologic and Adaptive Capacity Scoring (NACS), skin cyanosis scoring, blood pressure, rectal and skin temperatures, and skin blood flow measurements were performed. RESULTS: The study was interrupted, because one baby in the fentanyl group had a significant decrease in oxyhemoglobin saturation (SpO2) to 59%. This was considcred to be residual effect of fentanyl and was treated with naloxone. SpO2 was generally lower in the fentanyl group. Epochs with SpO2 < 90% were more frequent in the fentanyl group, especially during active sleep (mean +/- SD 11.9 +/- 10.7% vs. 2.0 +/- 1.7% of epochs, p = 0.034). Mean heart rate values were lower in the fentanyl group (121.1 +/- 6.4 vs. 132.6 +/- 6.8 beats per minute, p = 0.02), and this difference was seen during wake and all sleep states. Maximum heart rate values were lower in the fentanyl group, too. The opiate group had less quiet sleep than controls (9.6 +/- 2.8% vs. 18.3 +/- 8.3%, p = 0.05). NACS after birth was lower in the fentanyl group (median [range] 15 [13-26] vs. 22 [20-25], p = 0.004). CONCLUSIONS: Several differences were seen between the fentanyl and the control group babies. The SCSB method proved sensitive enough to find neonatal effects of maternal analgesia. Together with ECG and SpO2 monitoring, SCSB gives plentiful information on neonatal well-being in a non-invasive way. Results of this study emphasize the importance of neonatal monitoring after maternal opiate use in labor.

Delayed adaptation of the pulmonary hemodynamics in infants with mild to moderate meconium aspiration syndrome.

Early postnatal pulmonary hemodynamic changes were investigated with Doppler echocardiography in 17 infants with mild or moderate meconium aspiration syndrome (MAS) and 16 healthy infants in a control group. The results indicate that the physiologic adaptation of the pulmonary hemodynamics is delayed in mild and moderate forms of MAS. Thus infants with clinical evidence of MAS need careful cardiovascular monitoring during postnatal circulatory transition.

Delayed postnatal adaptation of pulmonary hemodynamics in infants of diabetic mothers.

OBJECTIVE: To test the hypothesis with Doppler ultrasound method that the postnatal adaptation of the pulmonary and ductal hemodynamics in infants of diabetic mothers is disturbed. STUDY DESIGN: Infants of diabetic mothers are prone to respiratory distress caused by characteristic fetal metabolic abnormalities such as hyperglycemia and hyperinsulinemia with subsequent excess fetal growth. However, the postnatal course of the pulmonary and ductal hemodynamics is poorly known in these neonates. The presence of ductal shunting and the mean aortopulmonary pressure difference across the ductus arteriosus reflecting pulmonary artery pressure, as well as the left ventricular output, were serially evaluated with Doppler ultrasound method at 2, 12, 24, 48, and 72 hours of age in 47 infants of diabetic mothers and 37 control neonates of nondiabetic mothers. RESULTS: The infants of diabetic mothers had a higher incidence of patent ductus arteriosus at 12 (p = 0.03) and 48 hours (p = 0.006) of life than control infants, but none of the infants of diabetic mothers needed ductal closure. Bidirectional ductal shunting was found more frequently in infants of diabetic mothers than control infants during the first day of life. The mean ductal aortopulmonary pressure difference was significantly higher in the control infants than in infants of diabetic mothers during the first 24 hours of life (p = 0.002). The mean systemic pressure values were higher in the infants of diabetic mothers than control infants (p = 0.002), but no significant differences in the left ventricular output were seen between the study groups during the first 3 days of life. CONCLUSIONS: The closure of the ductus arteriosus and postnatal decrease in pulmonary artery pressure are delayed in infants of diabetic mothers when compared with control infants during the first days of life. Left ventricular output values in infants of diabetic mothers do not differ from those of the control infants.

Intravenous fentanyl PCA during labour.

PURPOSE: To evaluate the usefulness of intravenous patient-controlled analgesia (PCA) fentanyl for labour analgesia, its effectiveness for maternal pain and safety for the fetus and newborn. METHODS: Twenty primigravidas were randomised to receive intravenous PCA fentanyl or epidural analgesia for labour pain. Maternal pain, heart rate and arterial oxyhaemoglobin saturation (SpO2) were monitored. Fetal and neonatal monitoring included cardiotocogram (CTG), APGAR, neurological scoring and static-charge-sensitive bed (SCSB) recording for 12 hr postnatally with ECG and SpO2. Fentanyl concentrations and pH of umbilical artery and vein were analysed. RESULTS: Initially, epidural analgesia was more effective (P = 0.01), and three patients in the fentanyl group were given epidural due to unsatisfactory pain relief. Overall satisfaction for analgesia did not differ between the groups. Maternal side-effects were more frequent in the fentanyl group (dizziness and tiredness most often, P = 0.0001). Severe side-effects were not reported. In CTG there were no differences between groups. All the newborns were healthy, APGAR and pH were normal. Naloxone was not used. Neurological scoring was similar in both groups. In 12 hr monitoring heart rate, breathing frequency and movement time were similar in both groups, but SpO2 was lower in the fentanyl group (P < 0.001). Umbilical cord fentanyl concentrations were low or beyond the detection limit. CONCLUSION: Intravenous fentanyl can be used for labour analgesia with the doses reported here as an alternative to epidural analgesia. However, the fetus and neonate must be appropriately monitored. Naloxone and oxygen should be available if neonatal distress occurs.

Hemodynamic prediction of complications in neonatal respiratory distress syndrome.

OBJECTIVES: We hypothesized that the absence of an increase in the Doppler-derived aortopulmonary pressure gradient (APPG) across the ductus arteriosus, which reflects pulmonary artery pressure during the first day of life, can predict clinical complications in preterm infants with neonatal respiratory distress syndrome (RDS) STUDY DESIGN: Twenty-nine healthy preterm infants weighing 2210 +/- 244 gm (mean +/- SEM) and 63 infants with RDS weighing 1645 +/- 86 gm were studied with the Doppler ultrasound technique for measurement of the mean APPG at 2, 24, 48, and 72 hours of age. Of infants with RDS, 67% were treated with synthetic surfactant. RESULTS: Spontaneous closure of the ductus arteriosus on the first day of life led to exclusion of 11 infants with RDS and 17 control subjects from the study. Of the remaining 52 infants with RDS, 26 had an increase in the APPG from 2 to 24 hours of age, and APPG values remained low in the other 26 infants. Neonatal complications appeared more frequently (p < 0.001) in distressed infants with little change in APPG values (delta APPG) (22/26) than in infants with high delta APPG (6/26). Six of the infants with high delta APPG values (23%) needed medical or surgical closure of the ductus, but no other acute neonatal complications occurred; 14 (54%) of the infants with low delta APPG required ductal closure. Between the ages of 24 and 58 hours, five of the latter 26 infants had severe pulmonary hemorrhage, which was fatal in two cases. Severe (grade III or IV) intraventricular hemorrhage was seen in three infants with RDS and a low delta APPG; one of these infants also had severe pulmonary bleeding. Pneumothorax occurred in six infants with a low delta APPG. Infants without an increase in the APPG value during the first day of life required a significantly higher fraction of inspired oxygen. CONCLUSIONS: Noninvasive measurement of the change in APPG during the first day of life may provide a useful method for identifying infants with RDS at high risk of neonatal complications.

Doppler-derived systolic pulmonary artery pressure in acute neonatal respiratory distress syndrome.

OBJECTIVE: To determine the course of systolic pulmonary artery pressure (PAP) in association with ductal shunting and cardiac output (CO) in preterm neonates. DESIGN: During the acute phase of respiratory distress syndrome (RDS) with and without surfactant treatment, serial Doppler ultrasound examinations were performed at the ages of 2, 12, 24, 48, and 72 hours in 51 neonates with RDS and 21 healthy, preterm controls. Twenty-eight of the distressed neonates received two or four doses of synthetic exogenous surfactant at intervals of 12 hours. Measurements of hemodynamic variables in these neonates were performed before and after 8 hours following surfactant treatments. PAP was estimated by the Doppler method from the maximal tricuspid regurgitant flow velocity. Doppler ultrasound was also used to determine simultaneously CO, and the direction and magnitude of the ductal shunting. RESULTS: The PAP was initially at the same level, but remained significantly higher in distressed than in healthy, preterm control neonates between the ages of 12 to 48 hours. The systolic systemic arterial blood pressures did not differ between the distressed and control neonates, but increased gradually during the study period. Consequently, the ratio of systolic pulmonary and systemic pressure was also higher in neonates with RDS than in controls during the first day of life. Bidirectional ductal shunting disappeared in all neonates studied after 2 days of life. Significant left-to-right shunting through the ductus arteriosus persisted more frequently in distressed neonates, especially those with surfactant treatment, than in control neonates during the study period, and more often caused the need for medical or surgical closure. Doppler-derived CO remained stable throughout the study in the distressed neonates, being significantly higher in surfactant-treated neonates than nontreated distressed neonates or healthy controls at 72 hours of life. CONCLUSIONS: The data of the present study confirms that the postnatal decrease in PAP is delayed in acute RDS. Further, significant patent ductus arteriosus shunting persists longer in RDS and may contribute to elevated CO during the resolution of the disease.

Excitatory amino acids in cerebrospinal fluid in neonatal asphyxia.

Of the excitatory amino acids, glutamic and aspartic acid were studied in the cerebrospinal fluid of six infants 4-32 hours after a documented episode of severe neonatal asphyxia. Aspartic acid concentration was definitely increased in the cerebrospinal fluid of these patients, whereas glutamic acid concentration varied considerably. Aspartic acid was always increased, even hours after the period of asphyxia, but values were greater in samples taken less than 12 hours after the asphyxial event. The patients with the highest cerebrospinal fluid aspartic acid concentrations had more severe outcomes.

Impact of prematurity on perinatal mortality and morbidity.

Severe prematurity is a prime factor causing perinatal mortality or morbidity. In Finland 1% of babies are born before 32 completed weeks of pregnancy and 0.9% are delivered with a birth weight of 1500 g or less. Since transport of a baby in utero is preferable to transporting a neonate, approximately 85% of infants below 1000 g and 90% of infants between 1000 to 1499 g are delivered in departments with facilities for neonatal intensive care. The rate of caesarean delivery is approximately 50% in pregnancies between 26 and 28 weeks, while the overall caesarean section rate is 15%. Deaths of low birth weight babies account for 66% of the total perinatal mortality and those of very low birth weight babies 46%. Intrauterine deaths constitute two thirds and neonatal deaths one third of perinatal mortality among very low birth weight babies. In Turku, neonatal survival rate for infants of 500 to 749 g was 61.5% and for infants of 750 to 999 g, 77.3%. In Turku respiratory distress syndrome is one of main complications of prematurity that has led to death in 11.2% of infants in recent years. Of the survivors, 85% have been healthy at the age of two years. The incidence of the bronchopulmonary dysplasia among very low birth weight infants has been 19.7%. In recent years, the incidence of severe brain haemorrhage has been 32% among infants with a birth weight below 1000 g.

Risk factors associated with severely small for gestational age neonates.

Risk factors were studied in 118 severely small for gestational age (SGA) infants. The control infants were matched for gestational age and mode of delivery. A low maternal prepregnancy weight and a maternal history of a previous SGA infant were the most important prepregnancy risk factors, whereas poor weight gain during pregnancy, toxemia, and smoking were the most important pregnancy-related risk factors associated with severely SGA infants. The two groups were similar for primiparity, previous abortions, and placental abnormalities in mothers and for parental ages and heights. Thirty percent of SGA infants were diagnosed antenatally. Most of the risk factors cannot be avoided, but the effects of these risk factors on the fetus and neonate can be minimized by careful screening and observation of mothers with these risk factors.

Saccular cyst of the larynx in infants.

A saccular or congenital cyst of the larynx is a mucus-filled dilatation of the laryngeal saccule and can distort the aryepiglottic fold, the false cord or the laryngeal ventricle. The most common symptom of the laryngeal cyst is respiratory distress with inspiratory stridor and the diagnosis can usually be made by laryngoscopy. Treatment includes incision and drainage together with extirpation of the cranial wall of the cyst through a laryngoscope. Sometimes tracheostomy is also needed. Usually there are no complications afterwards and the development of these infants is perfectly normal. Our 3 cases and clinical features of this very unusual disorder are presented.

Intraesophageal pressure monitoring and the severity of respiratory distress syndrome.

The intraesophageal pressure difference (delta Pes) was measured in 46 preterm infants, 36 with respiratory distress (RDS). It was 12.7 +/- 2.9 mm Hg (mean +/- SEM) in severe RDS, 9.6 +/- 3.2 mm Hg in moderate RDS, and 5.2 +/- 1.6 mm Hg in infants with mild disease, measured at the age of 8 h. These intergroup differences were highly significant (P less than 0.001). During the first 96 h of life the delta Pes decreased to 6.1 +/- 1.1 mm Hg in severe RDS and to 4.8 +/- 1.2 mm Hg in moderate RDS. These changes were also highly significant (P less than 0.001) when compared with respective initial values. In infants with mild disease and in healthy preterm infants, the delta Pes did not alter significantly during the first 96 h of life. The correlations between gastric aspirate L/S ratio and the delta Pes at the age of 8 h (r = -0.65, P less than 0.001) and at the age of 24 h (r = -0.73, P less than 0.001) were highly significant. It is concluded that intraesophageal pressure monitoring is a valuable tool in the intensive care evaluation of the severity of RDS.

Plasma progesterone in the respiratory distress syndrome.

Seventeen newborns suffering from RDS (verified by X-ray and clinical parameters) had a mean plasma progesterone of 13.9 +/- 1.2 ng/ml (mean +/- S.E.) at 24h of age. This is only 62% of the normal level (22.6 +/- 1.5 ng/ml).

Comparison between clinical and radiological classification of infants with the respiratory distress syndrome (RDS).

Clinical and radiological classifications of the severity of the respiratory distress syndrome (RDS) were made in 55 infants. According to the clinical classification 17 infants belonged to the first class (mild RDS), 22 to the second (moderate RDS), and 16 to the third class (severe RDS). In the classification based on radiological findings the numbers of infants in classes 1, 2 and 3 were 18, 19 and 18 respectively. On the basis of both the clinical and radiological findings, 11 infants belonged to the mild RDS class, 11 to the moderate, and 12 to the severe RDS class. Thus, 34 infants had the same clinical and radiological classification. In 21 infants there were discrepancies between the clinical and the radiological classifications, but only one infant with the most severe radiological findings belonged to the mild RDS class and only one infant with mild radiological findings belonged to the worst RDS class.