[ANTITHROMBOTIC MEDICATION IN PREGNANT WOMEN WITH PREVIOUS INTRAUTERINE GROWTH RESTRICTION].

AIM: To analyze pregnancy outcome in patients who were on antithrombotic medication (AM) because of previous pregnancy with fetal intrauterine growth restriction (IUGR). MATERIALS AND METHODS: The studied group (SG) included 21 pregnancies in 15 women with history of previous IUGR. The patients were on low dose aspirin (LDA) and/or low molecular weight heparin (LMWH). Pregnancy outcome was compared to the one in two more groups: 1) primary group (PG) including the previous 15 pregnancies with IUGR of the same women; 2) control group (CG) including 45 pregnancies of women matched for parity with the ones in the SG, with no history of IUGR and without medication. The SG, PG and CG were compared for the following: mean gestational age (g.a.) at birth, mean birth weight (BW), proportion of cases with early preeclampsia (PE), IUGR (total, moderate, and severe), intrauterine fetal death (IUFD), neonatal death (NND), admission to NICU, cesarean section (CS) because of chronic or acute fetal distress (FD) related to IUGR, PE or placental abruption. Student's t-test was applied to assess differences between the groups. P values < 0.05 were considered statistically significant. RESULTS: The differences between the SG and the PG regarding mean g. a. at delivery (33.7 and 29.8 w.g. respectively) and the proportion of babies admitted to NICU (66.7% vs. 71.4%) were not statistically significant. The mean BW in the SG (2114,7 g.) was significantly higher than in the PG (1090.8 g.). In the SG compared with the PG there were significantly less cases of IUFD (14.3% and 53.3% respectively), early PE (9.5% vs. 46.7%) moderate and severe IUGR (10.5% and 36.8% vs. 41.7% and 58.3%). Neonatal mortality in the SG (5.6%) was significantly lower than in the PG (57.1%), The proportion of CS for FD was not significantly different--53.3% in the SG and 57.1% in the PG. On the other hand, comparison between the SG and the CG demonstrated significantly lower g.a. at delivery in the SG (33.7 vs. 38 w.g.) an lower BW (2114 vs. 3094 g). There were significantly more cases with IUGR in the SG compared to the CG--total, moderate and severe (47.4 %, 10.5% and 36.8% in the SG vs. 8.9%, 6.7% and 2.2% in the CG) and NICU admissions (66.7% vs. 4.4%). There were no cases in the control group with severe PE (9.5% in the SG), IUFD (14.3% in the SG), and CS for FD (53.3% in the SG). The proportion of pregnancies without complication in the SG (23.8%) was significantly lower than in the CG (86.7%). CONCLUSIONS: The outcome of pregnancies with AM because of previous fetal IUGR is improved compared to the index ones. However, it is less favorable compared to the outcome in matched cases with no history of IUGR in previous pregnancies.

[TREATMENT WITH INO OF INFANTS WITH PPHN.]

PPHN is a life threatening disease that appears as a result of high pulmonary vascular resistance and persistent right to left shunt across foramen ovale and ductus arteriosus. The treatment of PPHN is complex and often ineffective. iNO is important part of the pathogenetic treatment of the disease. We present six infants with PPHN treated with iNO. The clinical effect of the drug was quick and the hemodynamics stabilized. All infants survived without side effects and with better neurodevelopment outcome.

[BRONCHOPULMONARY DYSPLASIA IN VERY LOW BIRTH WEIGHT INFANTS--THE OLD NEW PROBLEM].

BACKGROUND: The advances in perinatal intensive care have increased the survival rate of extremely low birthweight (ELBW) and gestational age infants. Among them the risk of developing bronchopulmonary dysplasia (BPD) remains high. AIM: To evaluate the frequency of BPD by birthweight and gestational age, to identify the main postnatal risk factors and the associated comorbidities. METHODS: 683 VLBW infants (< 1500g) were admitted in NICU from 2008 to 2010. 597 survived more than 28 days and were included in this study. BPD was diagnosed if supplemental O2 for the first 28 days was necessary; the severity was assessed by the need of O2 and/or ventilator support at 36 gestational weeks (gw). RESULTS: 27.6% (n = 164) infants were with supplemental O2 at 28d of life (BPD-group), 10.9% (n = 65) were with moderate, 3.9% (n = 23) with severe BPD (FiO2 > 30% and/or ventilator support). Infants with BPD were with significantly higher CRIB (9.9 ± 3.1) compared with those without BPD (4.0 ± 3.0), p < 0.0001. The frequency decreased progressively from almost 100% at 23gw or birthweight < 600g to single cases after 31gw and bitthweight > 1200g. Logistic regression analysis showed that each gestational week decreased the odds of BPD by 60%; each CRIB point increased the odds by 62%. Each point increment in 1/5 min Apgar-scores reduced the risk by 40%/50% respectively The need for ventilator support increased from 1.4 ± 2.7 days (no-BPD group) to 52.8 ± 5.1 days (severe-BPD infants), p < 0.05. Postnatal complications significantly increasing the odds for BPD were found to be: PDA - 19.7, Pneumothorax - 12.1 times. There was a significant correlation between BPD, severe brain injury and ROP (p < 0.000 1). CONCLUSION: The frequency of BPD strongly correlates with gestational age and birthweight and CRIB. Additional risk factors are low A pgar scores, PDA and air leak syndrome. Associated comorbidities as severe brain injury and ROP further worsen the long term prognosis.

[THE FETAL MIDDLE CEREBRAL ARTERY PEAK SYSTOLIC VELOCITY AS A PEDICTOR OF FETAL ANEMIA IN RH-ALLOIMMUNIZED PREGNANCY].

UNLABELLED: Rh-isoimmunization is a pathological condition in which the fetal red blood cells of a Rh (+) fetus are destroyed by the isoantibodies of a Rh (-) woman sensitized in a previous event. Despite of the wide spread implementation of anti D-gammaglobolin prophylaxis this is still the most common cause for fetal anemia. Recently, sonographic measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV) has been shown to be an accurate non-invasive test to predict low fetal hemoglobin levels. We present a case report of Rh-alloimmunized pregnancy with moderate fetal anemia, followed-up by weekly MCA-PSV measurements. CASE REPORT: A 37-year-old Rh (-) negative gravida 3, para 1, without anti-D gammaglobolin prophylaxis in her previous pregnancies, presented at 27+0 weeks of gestation (w.g.) for a routine third trimester scan. Subsequent ultrasound measurements of MCA-PSV confirmed a progressive increase of the peak systolic velocities from 40 to 80 cm/sec, as well as a gradual rise in the anti-D titers. The evidence of developing fetal anemia necessitated elective Caesarean section performed at 35 wg. The neonate was admitted in the intensive care unit and required resuscitation, one exchange blood transfusion and several courses of phototherapy. The patient was discharged two weeks post partum. CONCLUSIONS: There is a strong correlation between the high peak systolic velocities in the middle cerebral artery (MCA-PSV) and the low levels of fetal hemoglobin. The high sensitivity and positive predictive value concerning the development of fetal anemia, as well as its good repeatability, makes this non-invasive test a valuable asset in the management of all pregnancies complicated by severe Rh-alloimmunization.

[BRONCHOPULMONARY DYSPLASIA--WHAT DO WE KNOW TODAY?].

The survival of great number of extremely premature newborn babies is associated with increased risk of damage of the newborn lung and development of chronic lung disease/Broncopulmonary dysplasia. The lower the gestational age and weight, the greater the frequency of BPD. The disease leads to impairment of the normal alveolization and vascularization of the premature lung. There are new theories for the pathogenesis of BPD and new staging of the disease. These changes lead to new therapeutic strategies.

[Pulmonary hypertension of the newborn - mechanisms of failed circulatory adaptation after birth, clinical presentation and diagnosis].

This article reviews the recent advances in understanding the mechanisms of the persistent pulmonary hypertension of the newborn, the pathways for persistence of high pulmonary vascular resistance and disruption of the normal perinatal fetal to neonatal circulatory transition. Despite the advancements of the neonatal intensive care in the last decades pulmonary hypertension of the newborn represents a clinical, diagnostic and treatment challenge for neonatologists. In most cases pulmonary hypertension is a secondary complication of a primary disease of the fetus and newborn characterized by failure to decrease the pulmonary vascular resistance after birth associated with right to left shunts, severe hypoxemia and respiratory failure. This review discuss the factors involved in the regulation of the transition from fetal circulation with high pulmonary vascular resistance to postnatal circulation with low pulmonary vascular resistance, the balance between the vasoconstrictor and vasodilator mediators. The better understanding of these mechanisms is helpful for accurate diagnosis and appropriate treatment of pulmonary hypertension of the newborn.

[Pulmonary hypertension of the newborn--recent advances in the management and treatment].

Pulmonary hypertension of the newborn is a clinical syndrome with diverse etiology in which the transition from fetal circulation with high pulmonary vascular resistance to postnatal circulation with low pulmonary vascular resistance failed. The persistence of high pulmonary vascular pressure leads to right-left shunts and marked cyanosis. Despite of the advances in neonatology, the treatment of some forms of PPHN is often difficult and mortality rate remains high. In infants with PPHN appropriate interventions are critical to reverse hypoxemia, improve pulmonary and systemic perfusion and preserve end-organ function. Our understanding for management of PPHN has evaluated over decades. This review summarizes the current strategies for treatment of pulmonary hypertension of the newborn: general care, cardiovascular support, the advantages and limitations of different ventilatory strategies, oxygen therapy, extracorporal membrane oxygenation, and the evidence-based inhaled nitric oxide therapy. The balance between pulmonary vasoconstrictor and vasodilator mediators plays an important role for pulmonary vascular resistance. Recent studies are designed to develop evidence-based therapies for regulation of pulmonary vascular tone, safe medications for selective pulmonary vasodilatation effective for treatment of PPHN and other forms of pulmonary hypertension in the neonatal intensive care unit.

[Neonatal bacteremia--frequency, spectrum of organisms and correlation between clinical symptoms and laboratory data for early onset sepsis].

UNLABELLED: Improved obstetrical management and evidence-based peripartum antimicrobial therapy in the last decades reduce the frequency of early-onset neonatal sepsis (EONS) and improve the outcome. The spectrum of the microrganisms is different according to regions, countries and periods of time. Appropriate diagnosis and treatment improve the outcome. However dissociation often occurs between clinical manifestation, laboratory and microbiological findings. AIMS: To determine the incidence of neonatal bacteremia in our hospital, to identify the spectrum of organisms from positive blood cultures (BC), to analyze the correlation between clinical manifestation of EOS and/or laboratory abnormalities. PATIENTS AND METHODS: This study was carried out at the University Hospital of Obstetrics and Gynecology "Maichin dom"- Sofia for 2012. From all 4081 inborn babies 848 were at risk for maternal-fetal infection. In the first two hours after birth they were screened for EONS using a panel of microbiological probes and laboratory blood tests, followed up the next days. According the guidelines of the Neonatology clinic a standard antibiotic therapy was started. 43 of the screened infants (1.05% of all inborn babies) had positive BC and were enrolled in this study. RESULTS: Sixteen from the 43 babies with positive BC were with birthweight > 2500g (0.48% from all 3316 life born term infants), 27--with birthweight < 2500g (3.5% from all 765 low birthweight babies), 24 were patients of the NICU (3.8% of all 635 babies admitted at the NICU for 2012). No one died. The following groups of organisms in BC were isolated: 24 BC with coagulase-negative Staphylococci, Methicilline sensitive (MSCoNS)--11 of them without any clinical symptoms and laboratory abnormalities were interpreted as result of contamination, 1 BC with Staphylococcus aureus MS (MSSA), 8 with alpha-Streptococci, 5 with Enterococcus faecalis (1 in combination with MSCoNS), 2 with GBS, 2 with Aerococcus urinae and 2 BC with Listeria monocytogenes. Gram-negative organisms were not found in BC after birth. 30 from the infants with positive BC didn't show any clinical symptom of EONS. 20 of them were without laboratory criteria for infection and were discharged after negative BC control. 10 newborns were with transient elevation of CRP but without clinical symptoms. 13 babies showed clinical symptoms of EOS, 3 of them had transient respiratory failure, but negative laboratory criteria. 10 babies met the clinical and laboratory criteria for EONS; in 8 of them the CRP was significantly elevated. Most critically ill were 3 ELBW and ELGA babies: 2 twins with Listeria and 1 baby with MSSA-EONS. CONCLUSIONS: In our study, CoNS were found to be the most common cause of EONS or bacteremia, low incidence of GBS sepsis was established. Almost the half of the babies with positive BC were asymptomatic and without laboratory data for infection. Elevation of the CRP-value was the most frequent laboratory abnormality in symptomatic infants.

[Perforated neonatal appendicitis in a preterm newborn].

UNLABELLED: Abstract: Appendicitis is common in paediatric surgical praxis, but extremely rare in newborn infants. CASE REPORT: We report a premature male newborn from a twin pregnancy with gestational age of 31(+4) weeks, birth-weight 1580g, who underwent a laparotomy because of perforation. The baby was admitted to NICU after birth with transitory respiratory failure and early onset neonatal sepsis. MS-Staphylococcus epidermidis was isolated from blood culture, gastric contents and all peripheral specimens, C-reactive protein values were elevated after birth and significantly increased before surgery; thrombocytopenia and mild anemia were found. The control blood culture showed Candida albicans. At day 25 after birth life threatening deterioration occurred: feculent vomiting, progressing distension and palpable rigidity of the abdomen, absence of peristalsis, respiratory distress. Abdominal radiograph showed significantly distension of the intestines, air liquid levels, and discrete signs of pneumoperitoneum. The baby was transferred to the surgery with the diagnosis NEC with perforation. Appendicitis acuta gangrenosa perforativa and peritonitis fibrinopurulenta totalis were found intra-operatively but without signs of NEC. Appendectomy and sanitation of the abdominal cavity were carried out. The histological result confirmed gangrenous perforative appendicitis and purulent necrotic peritonitis. The postoperative course was unremarkable. The boy was transferred to the neonatology on day 33 of life and discharged home 12 days later. CONCLUSIONS: Despite of the low incidence of neonatal appendicitis, it should be taken into consideration if unclear abdominal symptoms occur in the neonatal period. Early surgical intervention contribute to a reduction of potential complications.

[Socio-demographic characteristics and vitamin D status in women born before 32 weeks'].

UNLABELLED: Deficiency of vitamin D (25-OHD) is a health problem among prematurely born women and their newborns independently of the geographical location of the country. OBJECTIVES: To study serum levels of vitamin D in patients born before 32 weeks and their newborns at birth. To analyse the socio-demographic factors, complications of pregnancy and their relationship with vitamin D status of women. PATIENTS AND METHODS: The study has been carried out in the University hospital "Maichin dom" Sofia for the period August 2013-January 2014. 35 women who gave birth before 32 gestational week and their 41 newborns with birth weight < 1500g have been investigated. The serum level of vitamin D (25-OH D) in mother-infant pairs at birth and 8 weeks of age in infants has been investigated. The ECLIA method has been used. Serum levels of vit D (25-OHD) have been estimated as sufficient:(> 30 ng/ml), insufficient (21-29ng/ml) and deficient (< 20 ng/ml). RESULTS: At delivery according to their vit D (25- OHD) serum levels 63% of the mothers are defficient /12.61 ± 4.8 ng/ml/, 28.5% are insufficient/26.66 ± 2.59/and only 8.5%/40.4 ± 8.48/sufficient with normal levels of vitamin D. For newborns data are respectively 32%/ 20.08 ± 3.69/-deficient, 49%/27.39 ± 2.70/- insufficient and 19 %- sufficient/41.6 + 10/ There is a positive correlation between mother's and children's serum levels of vitamin D (25- OHD). Statistical significant differences are observed in the levels of vitamin D and the presence of infection and preeclampsia in the mothers. During the period of the study there were no seasonal variations in vit D (25-OHD) serum levels of mother-baby pairs. All newborns received Vit D3 1334 IU/daily from 20th day of age. At eight weeks of age sufficient levels of vitamin D have 70% of the children, but 30% of the newborns remains with inadequate supplementation/27.09 ng/ml/. CONCLUSION: 91.5% of mothers are with insufficient serum levels of vitamin D (25OHD) at birth, and a deficit is present in 63% of all women. Only in 8.5% of the women had normal values. This implies more effective monitoring and vitamin D prophylaxis during pregnancy.

[Fetal growth curve based on gestational age and fetal maturity].

Most of the fetal growth charts available in the literature were created too long ago, based on various populations and using various eligibility criteria. The purpose of our study was to develop a nomogram of fetal weights based on the gestational age and neonatal maturity. The study is prospective and retrospective in nature. 1,748 fetuses of 20 to 40 gestational weeks were assessed directly after birth, and all cases were classified based on the number of weeks of pregnancy completed, but fetuses were not classified based on their gender. The mean weekly weight gain of fetuses was 100 g until the 30 gestation week, and 200 g thereafter. The results we obtained for the 50th percentile for fetus weight were weights meanly 200 g lower than those per Babson's chart (Fenton's scale). The weights in the 10th percentile were also 50-100 g lower until the 31 gestation week, with increasing difference to 150 g thereafter. For 2011, the incidence of growth-retarded fetuses at Maichin Dom Hospital was 7.09% per Babson's chart, and 5.1% according to our data of the 10th percentile. The study demonstrated that nomograms for relevant populations should be used to assess normal growth of fetuses.

[Congenital cystic lung lesions--review of the literature with three clinical cases].

Congenital cystic lung lesions are rare. Mainly affects the lower respiratory patishta.i are congenital cystic malformation and adematozna bronchopulmonary sequestration (BPS). The pathogenesis of the occurrence of these malformations is not clear but they have a common clinical course. In most cases, the anomaly is asymptomatic and occurs with infections of the lung during the first year of life. Currently congenital lung lesions were classified into five types and is considered by most authors. The anomaly is due to the abnormal proliferation of terminal bronchioles accompanied by inhibition of alveolar development between 7-17 weeks, obstructed airway dysplasia and metaplasia of normal lung tissue. Early diagnosis is vital in making a medical decision on how to treat CCAM. Associated with abnormalities of the urinary tract, cardiovascular system, gastrointestinal atresia, diaphragmatic hernia skeletal abnormalities. In pregnancies in which prenatal lung lesions weighs registered necessary series of ultrasound examinations to track finding and using the Doppler to assess how the blood supply of the fault. The clinical presentation of malformations is respiratory distress, respiratory infection, and dyspnea. The use of CT and MRA allows better visualization of the pulmonary lesions. With its combination with arteriography and bronchoscopy are used to differentiate CCAM and pulmonary sequestration. We present three cases with lung lesions were born in Neonatologia clinic at the University Hospital of Obstetrics and Gynecology "Maternity" Sofia for the period 2010-2012 three cases CCAMs type 1, operated by 5 meters after birth with a good final outcome without complications in the postoperative period and lack of pulmonary symptoms up to 1 year after birth.

[Frequency, severity and risk factors for bronchopulmonary dysplasia among very low birth weight premature infants admitted in the NICU of the University Obstetrics and Gynecology Hospital, Sofia].

BACKGROUND: The progress in the perinatology improved the survival rate of the infants with extremely low birth weight and gestational age. Among the most immature of them the frequency of bronchopulmonary dysplasia (BPD) remains high.. The use of different diagnostic criteria for BPD makes comparing the results difficult. AIM: To evaluate the frequency of BPD by birth weight and gestational age according to the new diagnostic criteria, and to identify the risk factors for development the disease. METHODS: 563 very low birth weight infants (<1500 g) were admitted to NICU from 01.01.2008 to 30.06.2010. 485 survived more than 28 days and were included in this study. BPD was diagnosed if supplemental 02 for the first 28 days was necessary. 02-requirements at 36 gestational weeks (gw) determine the severity level. RESULTS: 26,8% from the infants were with supplemental 02 in the first 28 d of life, but only the half of them 13,6% were with 02 > 21% at 36 gw (the classical diagnostic criteria for BPD). 10,9% were with moderate BPD, 2,7% - with severe BPD. The frequency of BPD decreased progressively from almost 100% at 23 gw or birth weight < 600 g to single cases after the 31 gw and birth weight > 1200 g. Mild or moderate BPD was more likely if gestational age was > 27 gw. The need for ventilatory support increased from 1,5 (+2,8) days (no-BPD group) to 50,2 (+/-20,1) days (severe BPD), p<0.05. Significant postnatal risk factors for developing BPD were patent ductus arteriosus - diagnosed in 25,4%; pneumothorax - in 3% of the BPD infants, compared with 1,7% and 0,5% among the infants without BPD respectively, p<0. 05. Sepsis and pulmonary hemorrhage were found slightly more frequently in the BPD group too (p>0, 05). The use of antenatal steroids was found to be a protective factor - 45% of the BPD infants had received antenatal steroids compared with 55% of those without BPD (p=0.05). CONCLUSION: According to the new diagnostic criteria, the frequency of BPD was about 2 times higher compared to the classical definition. Main risk factors were found to be ELBW, ELGA; additional risk carried the need for prolonged ventilatory support, patent ductus arteriosus and air leak syndrome.

[Problems and neonatal outcome of very low birth weight newborn infants after in vitro fertilization].

UNLABELLED: The use of assisted reproduction technologies is undoubtedly successful in the treatment of sterility. However it sets up numerous of issues for the obstetricians and neonatologists. AIMS: To evaluate the incidence, the specific problems and the neonatal outcome of newborns with very low birth weight (VLBW) <1500 g born from pregnancies after in vitro fertilization (IVF). METHODS: The study enrolled all 563 VLBW infants admitted in the NICU of the "Maichin Dom" hospital from 01.01.2008 to 30.06.2010. 119 (21.1%) of them were conceived with assisted reproduction technology (IVF- group), and 444 (78.9%) were conceived naturally (control group). All infants were followed up till their discharge home or death. Poor outcome measures were in hospital neonatal death or morbidities with long term sequels: severe congenital malformations, bronchopulmonary dysplasia, severe brain injuries (intraventricular haemorrhages gr. Ill-IV periventricular leucomalacia), retinopathy of prematurity gr. Ill-V. RESULTS: There were no significant differences in terms of mean birth weight (BW) and gestational age (GA) between the groups (1170 g and 1173 g, 29,8 and 30,0 weeks of gestation respectively). Intrauterine growth retardation (BW of <10 percentile for GA) was observed in 42% in the IVF-group, versus 38.5% (NS) The frequency of the babies from multiple pregnancies was significantly higher in the IVF-group: 88.2% versus 27.5%, and the triplets were 48% versus only 0.9% in the control group. In the IVF-babies more active obstetric approach was carried out: caesarean section in 85% versus 57%, and completed antenatal corticosteroid course in 80% versus 41% in the control group. There were no significant differences of in hospital neonatal mortality rate - 14.3% in the IVF-group versus 14.9%; congenital malformations or severe morbidities at discharge - 22.7% versus 27.5%, discharged in good health - 63% versus 57.6%. CONCLUSIONS: The major problems of VLBW-newborns after IVF result from the higher incidence of multiple pregnancies with their corresponding risks. Nevertheless, strict pregnancy follow-up, more frequently use of antenatal steroids, cesarean delivery such as intensive neonatal resuscitation ensure a clinical outcome and prognosis which do not differ from the naturally conceived VLBW-newborns.

[Newaspects of neonatal resuscitation guidelines and their practical application].

In this article we discuss the changes in the guidelines for newborn resuscitation, 2010, the International Liaison Committee on Resuscitation and their practical application at national level. The Resuscitation algorithm is simplified, the assessment of the need for resuscitation and progression to the next stage are based on heart rate and respiration only, that makes it easy for routine use and staff training. Routine suctioning of airways is not more recommended, even if meconium stained amniotic fluid is available endotracheal aspiration remains controversial. The most important changes concern the use of oxygen - there are clear recommendations to start resuscitation with air in term and low oxygen concentrations in preterm infants, monitoring the SpO2, so that the targeted SpO2 values for the first minutes of life are not exceeded. Some other aspects of newborn resuscitation and their practical application on local basis are discussed too: delayed cord clamping, therapeutic hypothermia, staff training. Controversial remain questions concerning initial resuscitation of extremely low gestational age newborns, such as some ethical issues.

["In vitro" babies--dreams, that turned real, but a lot of questions and unknown items].

UNLABELLED: In vitro babies bring happiness to a lot of families. Their development, health and social problems are being studied in details. OBJECTIVES: To establish the well being of babies, born at the University Maternity Hospital "Maichin dom" following assisted reproduction (AR), probable risk factors immediately after birth and afterwards. Aims of the study are to look for a correlation between AR and the incidence and importance of medical problems, arising during the neonatal period: multiple pregnancy; prematurity; intrauterine growth retardation; neonatal mortality; inborn malformations and chromosomal diseases; CNS impairment; duration of hospitalization. STUDY DESIGN: This is a retrospective study including all 440 babies born thanks to AR (according to the available medical records) during the period 2008-2010 at the University Maternity Hospital "Maichin dom". A correlation between the main items observed and the number of babies in each pregnancy was investigated for the period 01.01.2010-31.12.2010. RESULTS: During the period 2008-2010 there are 99 babies from single pregnancy, 15 (15%) admitted to the NICU; 384 twin pregnancies (186 of them after AR)--733 babies and 15 foetus mortus. 114 IVF couplets (31%) or 221 babies (7 foetus mortus) are admitted to physiological neonatal ward, while 72 (63%) couplets or 137 babies (7 foetus mortus) are admitted to the NICU. There are 48 triplet pregnancies or 141 babies (3 f. mortus), 40 being IVF (83%) or 117 babies, all 40 AR triplets are admitted to the NICU. 269 babies (61% of all AR babies) need intensive treatment--mostly (94%) babies from multiple pregnancies. Mean birth weight was established to be 2060 g; with babies, requiring intensive treatment is 1408 g. Gestational age at birth is from 25 to 39 g.w.; with NICU patients mean gestational age is 32 g.w. Mean maternal age is relatively high--34 years with a wide range (24-50 years). A high incidence of operative deliveries is established--mostly with couplets and triplets. CONCLUSIONS: Rules of good clinical practice should be introduced with AR, aiming at reducing the number of multiple pregnancies. This should be priority for all national programs for assisted reproduction.

[CRIB II score and method of delivery for very low and extremely low birth weight infants].

UNLABELLED: The purpose of this study is to determine the influence of method of delivery on CRIB II score in preterm infants born in vertex presentation < or = 32 weeks of gestation. MATERIAL AND METHODS: Prospective study over five years period (2006-2010) that includes 162 cases. 115 (71%) of patients are delivered vaginally and 47 (29%) with cesarean section. CRIB II score is used as a tool for measuring the risk of neonatal dead and severe morbidity in neonatal period. It's predictive value is based on the birth weight, gestation weeks, gender, the lowest values of BE (base excess) in the first hour of life and the temperature at acceptance in neonatal intensive care unit. There is a reciprocal dependence between CRIB II, duration of pregnancy and birth weight. This requires a comparison of vaginal birth and Cesarean section in the following subgroups: 25-26 weeks, 27-28 weeks, 29-30 weeks and 31-32 weeks and weight 500-750 g., 751-900 g., 901-1000 g., 1001-1250 g. and 1251-1500 g. RESULTS: Mean score values for vaginal births are 14.08 p. (points) at 25-26 weeks, 10.54 p. at 27-28 weeks, 6.90 p. at 29-30 weeks and 5 p. at 31-32 weeks. In the same periods of pregnancy mean CRIB II in Cesarean section deliveries are 13, 6 p., 10, 58 p., 7, 85 p. and 5 p. Significant statistical difference is not found between groups. Results remained almost unchanged after adjusting for birth weight in vaginal and cesarean births. CONCLUSION: The risk of poor perinatal outcome assessed by CRIB II is independent of the method of delivery but strongly influenced by the duration of pregnancy and birth weight.

[Osteopenia of prematurity--prophylaxis, diagnostics and treatment].

UNLABELLED: Osteopenia of prematurity is a metabolic bone disease of premature infants with birth weight < 1500 g and gestational age < 32 weeks. Sub-optimal bone matrix, poor skeletal support and an increased risk of fractures characterized the disease. Its importance is determined by relatively high frequency--between 30-70% of infants at risk, multifactorial etiology and impact on early and late morbidity of the newborns. The prevention and treatment of bone disorders are important aspects of the care of preterm babies. OBJECTIVE: To identify of the risk factors, to determine early diagnostic criteria and to create a prevention program for osteopenia in infants with very low and extremely low birth weight. MATERIALS AND METHODS: The prospective study includes 39 preterm babies with birth weight below 1500 gr. and < 32 g. w who were admitted to the NICU from September 2011-January 2012. Bone metabolism was monitored by calcium, phosphate and alkaline phosphatise at 2-weeks intervals. Vitamin D levels of the neonates were registered at birth, and at 8th week. PTH was measured at the second and the 8th weeks. RESULTS: The following biochemical abnormalities were found. Hypophosphatemia in two weeks (P < 1,6 mmol/l), a gradual increase in phosphorus levels and normalization at eight weeks of age. There was a significant positive correlation between 25OHD/phosphorus at eight weeks/r = 0.353/. Significantly elevated levels of parathyroid hormone in eight weeks, correlating with low levels of vitamin D (negative correlation between 25OHD/parathormone r = -0.581). Blood levels of calcium and alkaline phosphatase were in normal limits. IN CONCLUSION: Risk factors for osteopenia are: the low gestational age and low levels of vitamin D at birth. Biochemical markers of osteopenia are: changes in levels of parathyroid hormone, phosphorus and vitamin D at eight weeks of age. Prevention includes: early supplementation of vitamin D in the risk neonates with individual dose adjustment. Upon biochemical evidence of osteopenia treatment should begin in the second week of life with supplementation of phosphorus, and vitamin D 1320 IU/daily and appropriate physiotherapy.

[Vitamin D levels in maternal--VLBW infants pairs].

UNLABELLED: Normal foetal growth depends on sufficient mother's vit D intake. Premature birth interrupts vit D and mineral mother-to-foetus transfer and leads to vit D deficiency and disturbs newborn mineral bone metabolism. OBJECTIVES: To determine vit. D plasma levels in mothers and their very low birth weight- (VLBW) newborns and the prevalence of vit D deficiency in this population, to investigate seasonal variation and analyse babies' vit D levels from birth to the 8 postnatal week. PATIENTS AND METHODS: The study has been carried out in the University hospital "Maichin dom" Sofia for the period 09.2011-01.2012 and there have been investigated 32 women and their 39 VLBW infants as a target group. 25-OHD level has been measured in maternal and newborn cord blood samples. The ECLIA method has been used. 25-OHD level has been tested second time at eight weeks of age in 34 infants. According to the maternal vit D levels the patients have been divided into 3 groups: Group. 1--vit D reference range level (> 30 ng/ml); Group. 2--vit D insufficiency (21-29 ng/ml), Group. 3--vit D deficiency (< 20 ng/ml). RESULTS: Low Vit. D levels have been estimated in 62.5% of mothers' group. Nevertheless, only 38.6% of all babies have been Vit. D deficient. In 61.4% of them vit D has been in normal range (32.4-35.7 ng/ml). A significant positive correlation between maternal and infants' vit D level at birth has been established (r = 0.516; p = 0.002). There have been found a significant seasonal dependence of vit D level at birth in the group too: vit D plasma levels have been estimated higher in September-October group compared to those in November-January group. Most of the blood samples in winter months showed lower vit. D levels than the autumn group. At 8 weeks of age 67.6% of the babies have been with vit D insufficiency. There has been a significant positive correlation between 25-OHD levels at birth and at weeks (r = 0.425; p = 0.012). CONCLUSION: Vit. D insufficiency has been found in 62.5% of the mothers at birth. Maternal vit. D deficiency is a significant risk factor for neonatal vit D deficiency. There is a clear seasonal dependency with a significantly lower 25-OHD level in the mothers and their VLBW babies in winter months.

[The very low birth weight and very low gestational age neonates--survival, prognosis and perspectives].

The advances in perinatal medicine during the last decades lead to a reduction in neonatal mortality rates in risk newborns and a gradual lowering of the gestational age when survival is possible to 22 weeks of gestation. In the present survey we are making a review of the studies about the survival and the prognosis in neonates with very low birth weight and gestational age (VLBW, VLGA). Infants weighting more than 1000 g and with gestational age above 28 g.w. are with a good prognosis: low neonatal mortality and morbidity rates. In newborns with gestational age between 26 and 28 g.w. the neonatal mortality rates are relatively low, however the trend of further lowering has not changed during the last 15 years; morbidity rates varies between different centers and are relatively high. The greatest medical, social and ethical dilemmas represent the newborns with gestational age less than 25 g.w. In this group with an overall high neonatal mortality (with big variations between different centers), there is a significant high morbidity rate among survived babies. These are the infants at the border of perinatal viability, the "grey zone" of the neonatology, where further discussions are going on about the activity of the obstetric management, the intensity and the amount of neonatal resuscitation.