Acute Fetal Distress Research Articles

Emergency anaesthesia for the compromised fetus

Emergency anaesthesia for the compromised fetus encompasses anaesthesia for both acute fetal distress and the chronically hypoxic fetus. Fetal distress, a poorly defined term, is still used by clinicians today. Parer and Livingston defined fetal distress as “progressive fetal asphyxia, that if not corrected or circumvented, will result in decompensation of the physiologic responses (primarily redistribution of blood flow to preserve oxygenation of vital organs) and cause permanent central nervous system and other organ damage or death.” More recently the term “non-reassuring fetal status” has been adopted as a better descriptor than fetal distress.

Intracervical misoprostol as an effective method of labor induction at term

Objects: The purpose of this study was to evaluate the safety and effectiveness of intracervical misoprostol for the induction of labor at term. Methods: Eighty-nine term pregnancies requiring induction of labor were treated intracervically with 50 μg of misoprostol. The dose was repeated every 4 h until adequate uterine contraction and cervical dilatation were achieved. Status of cervical ripening, uterine contraction, cervical dilatation, labor course and side effects were recorded and analyzed. Results: Among the 89 patients, 58 had an unfavorable cervix (Bishop score ≤4) and 31 had a favorable cervix (Bishop score >4). Labor was successfully induced in all cases, most (93.3%) of which required a single dose of misoprostol. Seventy-two patients (81%) proceeded to spontaneous vaginal delivery, and 61 (85%) deliveries were achieved within 12 h. The other 17 cases received cesarean delivery with indications of fetopelvic disproportion (six cases), failure of induction (seven cases) and acute fetal distress (four cases). The mean duration from induction to regular uterine contraction and to delivery was 483±537 min and 79.2±38.2 min, respectively, with no significant difference between the two groups with differing status of cervical ripening. Complications of uterine contraction, including tachysystole (15 cases), hypertonus (one case) and hyperstimulation (10 cases) were more common in the group of unfavorable cervix (45%) than that of favorable cervix (23%) ( P<0.05). Conclusion: In addition to the oral and intravaginal routes of administration, intracervical misoprostol at a single dose of 50 μg appears to be an effective method for induction of labor at term, but caution should be taken with cases with unfavorable cervix.

Tratamiento y prevención de las hemorragias cerebrales en el recién nacido

The risk factors leading to the occurrence of intracranial hemorrhages in premature newborn babies are well known. However, in full-term babies this has not been so systematically studied. Although the incidence is lower it is not rare and they are more varied in the form of presentation than in premature babies. Thus, as well as the classical intraperiventricular hemorrhages, subarachnoid and intraparenchymatous hemorrhages also occur relatively often, particularly the subarachnoid kind. The aetiopathogenesis of the hemorrhages is different, so preventive measures are also different, based particularly on avoidance of perinatal asphyxia and traumatic manoevres during labour. A study by our Department, in which risk factors associated with 17 newborn babies of over 35 weeks gestation who had a history of intracranial hemorrhage in the early neonatal period showed that over half the cases (58%) had a history of acute foetal distress. A quarter had congenital cardiopathy (detected at birth) and the same number had a respiratory distress syndrome due to various causes, particularly pneumothorax and infections. Regarding treatment of the acute phase, it is essential to maintain cerebral perfusion and monitor both arterial hypertension and hypotension, control the intracranial pressure (avoiding increases) and avoid fluctuations of cerebral blood flow. Follow-up by means of serial echographs makes early detection of dilatation and hydrocephaly possible and permits suitable suitable treatment rapidly and with immediate monitoring of its efficacy.

Fatores prognósticos para o parto transvaginal em pacientes com cesárea anterior

Objectives: to determine prognostic factors for vaginal delivery in pregnant women after previous cesarean section admitted to CAM-IMIP in labor.Patients and Methods: a case-control study was performed, analyzing all deliveries of patients with previous cesarean section admitted to CAM-IMIP between January 1991 and December 1994. Patients who had a cesarean section (n=156) were considered cases while patients with a vaginal birth were the controls (n=338). Inclusion criteria were: gestational age > 36 weeks, previous cesarean section at least 1 year before, alive fetus, spontaneous labor and vertex presentation. Patients with high-risk pregnancies, acute fetal distress and a previous vaginal delivery after cesarean section were excluded. Statistical analysis was performed with in Epi-Info 6.0 and Epi-Soft, using c2 test, Fisher's exact test and Student's t test. Odds ratio and its 95% confidence interval was calculated and multiple logistic regression analysis was performed for the control of confounding factors. Results: overall rate of cesarean section was 31.6%. Maternal factors significantly associated with vaginal delivery were age 35 years (OR = 0.54, 95% CI = 0.36-0.82), history of vaginal delivery (OR = 1.6, 95% CI = 1.01-2.55) and complications of pregnancy as indication for previous cesarean section (OR = 3.67, 95% CI =1.19-12.02). A significant association with vaginal delivery could not be detected for other variables: interval between previous cesarean section and present delivery, other indications for cesarean section and type of uterine suture. In a multiple logistic regression model the variables that remained associated with vaginal delivery were maternal age and previous vaginal delivery. Conclusions: maternal age below 20 years, previous cesarean section indicated due to gestational complications and previous vaginal delivery were favorably associated with vaginal delivery in patients with prior cesarean section. Risk of repeated cesarean section is increased in pregnant women aged 35 years or above. These factors should be contemplated when obstetrical evaluation of the delivery route is performed.

Impact of reverse end‐diastolic flow velocity in umbilical artery on pregnancy outcome after the 28th gestational week

The aim of this study was to discuss pregnancy outcome in chromosomally and structurally normal fetuses having reverse end-diastolic flow velocity (REDFV) on Doppler umbilical artery velocimetry (DUAV) in the third trimester. DUAV was performed in the high risk pregnancy antepartum fetal surveillance. We excluded gestational age less than 28 weeks, multiple pregnancies, and chromosomal or congenital anomalies. Thirty cases were categorized as having REDFV The pregnancy outcome was investigated in these cases. There were three stillbirths and 12 neonatal deaths, resulting in a perinatal mortality rate of 50%. Twenty-eight patients (93.3%) had complications with preeclampsia (20 of severe degree and eight moderate). Cesarean section was performed on 24 patients (80%) due to acute fetal distress. The mean gestational age at delivery was 31.8+/-3.2 weeks. The mean diagnosis-to-delivery interval was 10+/-8.2 hours. The average birth weight was 970+/-270 gm, 28 (93.3%) were found to be below the 10th percentile of ideal birth weight. An umbilical artery pH less than 7.2 at delivery was found in 12 of 18 examined cases (66.7%). Twelve out of 15 placentae (80%) showed significant infarcts on pathological examination. All newborns (100%) needed admission to the neonatal intensive care unit. REDFV on DUAV represents an ominous and severe fetal condition with an adverse pregnancy outcome, especially in conditions associated with preeclampsia and/or intrauterine growth retardation. Intensive and frequent surveillance and aggressive management at the appropriate time would improve perinatal outcome.

Fetal cerebral and umbilical artery blood flow changes during pregnancy complicated by malaria.

The objectives of our study were to quantify the fetal cerebral artery and umbilical artery blood flow changes daily during a malaria crisis in a pregnant patient and evaluate the sensitivity and the specificity of Doppler indices for the prediction of acute fetal distress at the end of the pregnancy. The study, designed as a prospective and observational one, was carried out in the obstetric department of a government hospital in French Guiana, on 23 women with pregnancies complicated by malaria (age range, 23 +/- 5 years; primiparas, 30%); crisis date: 30.8 +/- 2.5 weeks of gestation; start of treatment: 3.7 +/- 1.3 days after crisis started). The main measures of outcome consisted of daily determinations of fetal Doppler indices during the crisis, evidence of fetal distress (fetal heart rate decelerations) during labor, Apgar scores after birth, gestational age at birth, mode of delivery, and birth weight. During the crisis umbilical artery resistance index increased by 5 to 20% (P < 0.05), cerebral artery resistance index decreased by 5 to 20% (P < 0.05), and CURR decreased by 10 to 35% (P < 0.01), indicating flow redistribution toward the brain. No relationship was found between the CURR value and the following data: parasitemia grade, parity, gestational age of the crisis, date and mode of delivery, and fetal weight. A change in the hypoxia index (% change in CURR during the crisis x number of days of crisis) greater than 150 was associated with abnormal fetal heart rate in 75% of the cases, and a hypoxia index lower than 150 was associated with normal fetal heart rate in 90% of the cases (sensitivity, 89%; specificity, 77%). Lastly, the combination (hypoxia index > 150 and CURR < 1) was associated with abnormal fetal heart rate in 80% of the cases, and one or two of these normal parameters were associated with normal fetal heart rate in 84.6% of the cases (sensitivity, 80%; specificity, 84%). The CURR and the hypoxia index during the malaria crisis can be used to predict acute fetal distress at delivery.

Prognosis of hypoxic-ischaemic encephalopathy in full-term newborns--value of neonatal electroencephalography.

This study was performed to assess the predictive value of EEG in HIE following acute fetal distress. For 38 full-term neonates, EEG was recorded at least before 48 hours of life and between 2 and 7 days. Neurological outcome was evaluated at a minimum age of one year. Normal or slightly abnormal early EEGs (14 cases) were observed with normal outcome (13 cases) or minor sequelae (1 case). Extremely abnormal early EEGs were associated with death (5 cases), severe sequelae (4 cases) or normal outcome (1 case); among the "intermediate" group (14 cases), improvement of background activity before 7 days indicated a good prognosis (4/5), whereas identical or worsened activity was noted in all cases with a poor outcome. Of neonates 90% with very abnormal EEGs and 64.3% with "intermediate" EEG presented a significantly unfavourable outcome compared with neonates having normal recordings (p < 0.0001). The EEG before 48 hours has an excellent sensitivity rate (94.7%) but a less satisfactory specificity rate (68.4%).

Does combined spinal-epidural analgesia with subarachnoid sufentanil increase the incidence of emergency cesarean delivery?

The purpose of this review was to determine if patients who receive combined spinal-epidural (CSE) analgesia with subarachnoid sufentanil have an increased incidence of emergency cesarean delivery for fetal distress when compared with patients who receive systemic or no medication (S/NM) for labor analgesia. A retrospective computerized analysis of data on all 2,560 deliveries at Bellevue Woman's Hospital for 14 months summarized practice parameters for 1,240 patients who received regional analgesia (98% CSE analgesia), identified 1,140 patients who received S/NM, and classified the urgency of 479 cesarean deliveries. In the CSE group there were 168 cesarean deliveries (emergency 16, urgent 58, semiurgent 70, and nonurgent 24) as compared with a total of 128 (emergency 16, urgent 43, semiurgent 69, nonurgent 0) in the S/NM group. Scheduled cesarean sections (180) were excluded from the study. The incidence of emergency cesarean delivery in 1,217 patients who received CSE analgesia with subarachnoid sufentanil (10-15 micrograms) compared with 1,140 patients who received S/NM for labor analgesia was 1.3% versus 1.4%, respectively. More importantly, there was no case in which emergency cesarean delivery was required for acute fetal distress in the absence of obstetric factors during the 90 minutes following administration of subarachnoid sufentanil. General anesthesia was required for emergency cesarean delivery in only one patient (6%) in the CSE group, as against eight patients (50%) in the S/NM group who required general anesthesia for emergency cesarean section (P < .05). This experience indicates that patients who receive CSE analgesia do not have a higher incidence of emergency cesarean delivery than patients who have S/NM for labor analgesia. Emergency cesarean section for fetal distress within 90 minutes of the administration of intrathecal sufentanil only occurred in association with obstetric factors. However, caution should be exercised in extrapolating these results to other practice settings, particularly high-risk referral centers.

Intravenous nitroglycerin for intrapartum internal podalic version of the second non-vertex twin

Objective: Authors report their experience of intravenous nitroglycerin as uterine relaxing agent for managing successfully internal podalic version of the second twin. Methods: From a retrospective study including nine observations of internal podalic version of the second non vertex twin performed with administration of intravenous nitroglycerin, between August 1994 and February 1996, authors compare their results with those reported elsewhere. Results: Two failures of internal podalic version with nitroglycerin have been observed. But one failure is not considered to be due to the NTG: it was a patient, who had a panic attack necessitating a general anesthesia for sedative purpose. The internal podalic version succeeded. The true failure of NTG needed an emergency cesarean due to acute fetal distress and a non relaxing uterus. One internal podalic version was complicated by hemorrhage. The intravenous NTG used to induce uterine atonia associated with epidural-analgesia to relief pain avoiding general anesthesia makes internal podalic version easier. Conclusion: Our results confirmed those already reported. That intravenous nitroglycerin (NTG) injection induces a transient and prompt uterine relaxation required for internal podalic version without affecting maternal and fetal prognosis.

Should a Moratorium Be Placed on Sublingual Nifedipine Capsules Given for Hypertensive Emergencies and Pseudoemergencies?

Over the past 2 decades, nifedipine in the form of capsules has become widely popular in the treatment of hypertensive emergencies. Unlike other agents, such as sodium nitroprusside, nicardipine hydrochloride, diazoxide, and nitroglycerin--which require intravenous administration and monitoring of blood pressure--nifedipine can be given orally, and close monitoring is said not to be necessary. Although administration of nifedipine capsules has been reported to be expedient and safe, it has not been approved by the Food and Drug Administration for labeling for treatment of hypertensive emergencies or of any other form of hypertension because of lack of outcome data. A review of the literature revealed reports of serious adverse effects such as cerebrovascular ischemia, stroke, numerous instances of severe hypotension, acute myocardial infarction, conduction disturbances, fetal distress, and death. Sublingual absorption of nifedipine has been found to be poor; most of the drug is absorbed by the intestinal mucosa. Given the seriousness of the reported adverse events and the lack of any clinical documentation attesting to a benefit, the use of nifedipine capsules for hypertensive emergencies and pseudoemergencies should be abandoned.

Linear disruption of umbilical cord: A rare anomaly of the cord associated with acute fetal distress and perinatal death/profound psychomotor retardation

We report on a non-malformed child with severe microcephaly and profound psychomotor delay. Review of the delivery/birth records documented descriptions consistent with linear disruption of the umbilical cord. This rare anomaly typically leads to acute fetal distress and perinatal death. Severe microcephaly and psychomotor delay without other anomalies should prompt a careful review of the delivery/birth records to search for umbilical cord descriptions consistent with this diagnosis. © 1996 Wiley-Liss, Inc.

Prise en charge des nouveau-nés maternité par un service de réanimation néonatale

Background. — Although in utero transfer seems actually the safest option when risk factors are identified, specialized transport teams remain important to consider for the neonatal overall management. Subjects. — From January 1988 through December 1992,692 transports of 838 neonates were prospectively studies to determine effectiveness and safety of the Hospital Lenval's neonatal transport team. Results. — Neonatal transport were required respectively for prematurity (46.4%), acute fetal distress (13.8%), respiratory distress (10.1%), intrauterine growth retardation (7.8%), multiple pregnancies (5.2%), perinatal asphyxia (3.1%) and life-threatening congenital abnormalities (2%). Pediatric assistance was unplanned in most of the cases (80%). Assistance with a pediatrician before delivery was performed more frequently (70%) for premature babies (mean gestational age 34.1 ± 3.1 wk) delivered by cesarean section in 66.4% of the cases: in this group, delivery room resuscitation was less aggressive. Assistance was performed after delivery less frequently (30%), approximately in one-half of the cases for neonatal distress: respiratory (33.9%) or neurologic (17.1%); in this group, delivery room resuscitation was more aggressive. In transit, ventilation support via endotracheal intubation was given to 17.9% of the babies. Neither death nor heavy complication occurred during transport. On arrival in the neonatal intensive care unit, hypothermia was noted in 9.6% of the cases, hypotension in 4.3%, hypoglycemia in 13.1% and metabolic acidosis in 10.4%. In our series, the overall mortality rate was 6%, and incidence of neurologic damage 3.3%. Conclusion. — A skilled person in neonatal resuscitation available at every referring maternity and regional high-risk obstetric/neonatal combined centre are two recommendations which could provide improved neonatal management.

Interleukin-6, interleukin-8, and granulocyte elastase in newborns with fetal distress.

Our purpose was to investigate the participation of cytokines and neutrophils in fetal distress. Umbilical cord serum interleukin-6 (IL-6), interleukin-8 (IL-8), and plasma granulocyte elastase (GEL) were measured in 30 normally grown newborns without fetal distress (Group A), 10 growth-retarded newborns without acute fetal distress (Group B), 5 normally grown newborns with fetal distress (Group C), and 5 growth-retarded newborns with fetal distress (Group D). Umbilical arterial blood pH and PO2 were also measured. Umbilical arterial blood pH and PO2 in either Group C or Group D were significantly lower than those in either Group A or Group B. The concentration of IL-6 in Group D was significantly higher than that in either Group A, B, or C. The level of IL-8 in either Group C or Group D was significantly higher than that in either Group A or Group B. The concentrations of GEL in Group D was significantly higher than that in either Group A or Group B. This study suggests that fetal distress in utero causes an elevation of immune factors such as IL-6, IL-8 and GEL.

L'hématome spontané du cordon: une cause rare de souffrance fœtale aiguë

Background. - Spontaneous umbilical cord hematoma is a rare life-threatening gestational accident. Case report. - A 26 year-old primipara was examined at 38 weeks of gestation for fetal monitoring. There were a number of fetal decelerations with loss of baseline variability. Cesarean section performed for acute fetal distress resulted in a male infant with an Apgar score of 3 at 1 minute and 7 at 5 minutes and neonatal anemia (Hb: 11.6 g/l). Four umbilical cord hematomas were observed. Microscopic examination revealed a ruptured umbilical vein without other abnormality. Post natal evolution was marked by hypoxic-ischemic encephalopathy and death. Conclusion. - Spontaneous umbilical cord hematoma is rare ( 1 5,500 births) and often due to rupture of the umbilical vein. Risk factors are shortness or traction of the cord, post-maturity and infection. Umbilical cord hematomas are usually responsible for severe fetal distress or death.

Uterine rupture in association with alkaloidal (“crack”) cocaine abuse

The use of alkaloidal (“crack”) cocaine in pregnancy can result in systemic and focal vasoconstriction and abnormal uterine contractions forceful enough to cause the complete rupture of a gravid uterus along a previous vertical cesarean section scar. A 43-year-old woman was admitted to the emergency department with acute abdominal pain at 34 weeks' gestation. She had had a low vertical cesarean section 3 years previously for breech presentation with acute fetal distress at 28 weeks' gestation. The patient had a history of heavy “crack” abuse and admitted to inhaling “crack” throughout the day until 4 hours before admission. Within 15 minutes after presentation a laparotomy was performed, revealing an infant floating in the abdominal cavity. A live baby was promptly delivered, and the ruptured uterus was repaired. The patient was discharged 4 days post partum. “Crack” cocaine, through its known effects on the vasculature and contractility of the myometrium, likely facilitated the uterine rupture in this patient. The edges of the rupture wound were surprisingly clean, with little bleeding, perhaps owing to the drug's vasoconstrictive effects. It was therefore feasible to repair the uterus as an alternative approach to hysterectomy.

Relationship between acute fetal distress and maternal-placental-fetal circulations in severe preeclampsia.

Hypoxic complications are thought to be the result of vascular lesions in the maternal-placental or fetal-placental circulation, with a resultant decrease in blood flow. This study was designed 1) to explore what kind of pathophysiological changes occur in the maternal-placental-fetal circulations associated with acute fetal distress, and 2) to determine whether umbilical velocimetry can be used as a predictor of acute hypoxia in severe preeclampsia. Eighty-nine cases of severe preeclampsia, who had Doppler ultrasonography, maternal blood chemistry and hematogram examinations all performed within two days of delivery or fetal death, were studied. According to the absence or presence of acute fetal distress as determined by the fetal heart rate pattern, patients were divided into two groups: distress group and non-distress group. There was no significant difference between the two groups in maternal general status. However, patients in the distress group had a significantly shorter gestation age on admission and at delivery (p < 0.00001). In the distress group, the perinatal outcome was poor. Newborns in the distress group had, significantly, a lower birthweight, and a higher incidence of SGA, 1-min Apgar scores of less than 7, and fetal acidosis (pH < 7.2) (p < 0.001). Doppler ultrasonography also showed a significantly higher incidence of abnormal umbilical artery Doppler waveforms in the distress group (p < 0.05). However, there was no difference between the two groups in the uterine artery Doppler velocimetry. Maternal blood chemistry and hematogram examinations revealed significantly higher blood levels of hemoglobin, hematocrit, blood urea nitrogen, and creatinine but lower levels of total protein and albumin in the distress group. An abnormal umbilical artery SD ratio (> 95th centile) as a predictor of acute fetal compromise, judged by the incidence of abnormal fetal heart tracing mandating emergency delivery, 1-minute Apgar scores of less than 7, 5-minute Apgar scores of less than 7, and a pH value for the umbilical arterial blood of less than 7.2, had a sensitivity of 40.5-75%, specificity of 71.8-80%, positive predictive value of 12.5-75%, and negative predictive value of 64.5-98.4%. In severe preeclampsia, early onset of disease superimposed with maternal hemoconcentration might initiate an acute insult and predispose the fetus to acute hypoxia.

Factors predicting labour onset in patients treated with prostaglandin E 2 for cervical ripening

The aim of this study is the evaluation of predictive factors in the onset of labour after pre-induction cervical ripening with prostaglandins. We enrolled 112 consecutive singleton term pregnancies (37–42.3 weeks) with unfavourable cervix and intact membranes, requiring induction of labour because prolonged pregnancy (59%) or maternal/fetal complications (41%). Treatment consisted of the cervical application (once or twice, 12 h apart) of prostaglandin E 2 gel (Upjohn, Italy). Uterine activity was monitored by external cardio-tocography before and during the next 2 h. Two patients showed uterine hyperstimulation and acute fetal distress requiring caesarean section. Sixty percent of patients went to labour and delivered without further stimulations. In this group the rate of caesarean section (9.1%) was lower than in patients failing to onset labour (68.2%). According to the logistic regression three factors positively predicted the onset of labour: first-hour uterine contractility, basal uterine activity and gestational age. The first-hour contractility in particular, represents the myometrial sensitivity to prostaglandin E 2 and may become a practical marker of spontaneous onset of labour in patients undergoing cervical ripening.

Terbutaline Tocolysis Prior to Cesarean Section for Fetal Distress

Two hypotheses are examined: l) side effects of terbutaline tocolysis are limited to maternal tachycardia and 2) terbutaline tocolysis at the diagnosis of fetal distress will facilitate intrauterine resuscitation while preparation for cesarean delivery is underway. This is a 10-year chart review of terbutaline tocolysis as part of the management of acute fetal distress prior to cesarean delivery. All charts were reviewed for side effects of terbutaline use. During the final 27 months, efficacy of terbutaline resuscitation was studied by comparing the scalp-pH-to-cord-pH difference of individual fetuses in the terbutaline group with those where terbutaline was not used. The mean maternal pulse after terbutaline was 113 ± 20 (SD) beats per minute (bpm). A pulse of ≥140 bpm occurred in 11.7% of the terbutaline group (n = 368). A pulse of ≥140 bpm was more common (51.0%) when preoperative vagolytic medication (n = 119) was also administered. A pulse of ≥140 bpm occurred in 1.9% of the control group (n = 215)....

Distinct Features of Upper Gastrointestinal Endoscopy in the Newborn

Between January 1987 and December 1990, 293 upper GI endoscopic procedures were performed in 219 neonates &lt;1 month of age. No lesion was found in 57 cases (26%; group 1), whereas esophagitis was present in 158 cases, alone in 45 cases (20.6%; group 2) and associated with gastritis in 113 cases (51.8%; group 3). The association of esophagitis with gastritis seems to be a specific feature of neonates and not older children. The presence of gastritis with esophagitis suggests that a primary peptic mechanism is unlikely to explain all endoscopic findings, although the presence of such a mechanism secondary to esophagitis could contribute to the esophageal lesions. Acute fetal distress was more frequent in group 3 than in the other groups. Symptoms associated with endoscopic lesions in groups 2 and 3 were, respectively, malaise (38 and 42%), hematemesis (4 and 35%), frequent regurgitation (45 and 26%), and difficult feeding and/or failure to thrive (26 and 24%). In Group 3, minor symptoms often led to the diagnosis of severe mucosal lesions, and antireflux therapy elicited prompt relief of clinical symptoms. The causes of neonatal esophagogastritis remain unknown. Wide use of en‐doscopy in the presence of discrete clinical abnormalities is likely to considerably improve the clinical condition of some children in their first days of life.

Distinct Features of Upper Gastrointestinal Endoscopy in the Newborn

Between January 1987 and December 1990, 293 upper GI endoscopic procedures were performed in 219 neonates < 1 month of age. No lesion was found in 57 cases (26%; group 1), whereas esophagitis was present in 158 cases, alone in 45 cases (20.6%; group 2) and associated with gastritis in 113 cases (51.8%; group 3). The association of esophagitis with gastritis seems to be a specific feature of neonates and not older children. The presence of gastritis with esophagitis suggests that a primary peptic mechanism is unlikely to explain all endoscopic findings, although the presence of such a mechanism secondary to esophagitis could contribute to the esophageal lesions. Acute fetal distress was more frequent in group 3 than in the other groups. Symptoms associated with endoscopic lesions in groups 2 and 3 were, respectively, malaise (38 and 42%), hematemesis (4 and 35%), frequent regurgitation (45 and 26%), and difficult feeding and/or failure to thrive (26 and 24%). In Group 3, minor symptoms often led to the diagnosis of severe mucosal lesions, and antireflux therapy elicited prompt relief of clinical symptoms. The causes of neonatal esophagogastritis remain unknown. Wide use of endoscopy in the presence of discrete clinical abnormalities is likely to considerably improve the clinical condition of some children in their first days of life.