Severe Hyaline Membrane Disease Research Articles

Outcomes of newborns to mothers with COVID-19

IntroductionCoronavirus disease 2019 (COVID-19) has spread rapidly across the world. Given the sharply increased infection rate, the number of pregnant women and children with COVID-19 is correspondingly on the rise. SARS-CoV-2 infection is transmitted through droplets; though hypothesized, other transmission routes have not been confirmed. As of now, it remains unclear whether and how SARS-CoV-2 can possibly be transmitted from the mother to the fetus. MethodThis study examines the medical records of 30 neonates born to women with COVID-19, the objective being to provide documented information on maternal-child transmission and infant outcomes. ResultsOut of the 30 newborns, 28 had negative PCR test results for SARS-CoV-2; among their mothers, fifteen had fever, nine had cough and twenty had delivered by cesarean section. The median birth term was 37wk2dy, and twenty of the neonates were male. Most of them were asymptomatic, except for the three who presented with shortness of breath. Two of them were intubated and both died, the first because of severe sepsis and the second due to severe hyaline membrane disease. As regards the two infected neonates, the first represents a probable case of congenital SARS-CoV-2 infection, which appears unlikely in the second case. The outcome for both of them was good, without any complications. ConclusionMaternal-fetal transmission of the SARS- CoV-2 virus was not detected in the majority of the reported cases, although two of 30 neonates had positive qRT-PCR test results. Our study supports the hypothesis that though it seldom actually occurs, in utero SARS-CoV-2 vertical transmission is possible.

Use of early nasal continuous positive airway pressure in preterm neonates with hyaline membrane disease (neonatal respiratory distress syndrome)

Background: In developing countries like ours, there is high burden of prematurity and sub-optimal use of antenatal steroid administration resulting infrequent hyaline membrane disease (HMD).Methods: A total 50 cases of clinically diagnosed HMD with gestational age between 28-34 weeks admitted to neonatal intensive care unit (ICU). 50 babies were treated with early nasal continuous positive airway pressure (CPAP) (within 6 hours of onset of respiratory distress).Results: Incidence of prematurity was 12.42%. Incidence of HMD observed between gestational ages of 28-34 weeks is 3.2%. Out of total 50 babies who were managed with early nasal CPAP, it proved effective in 40 babies (80%), remaining 10 babies (20%) had to be intubated and required ventilation. Out of 10 babies who required ventilation 90% of the babies were less than 32 weeks gestation age; remaining 10% were between 33-34 weeks. Analysis of these results showed that outcome is better with increased gestational age (p<0.005). Out of 10 babies who failed 80% were <1500 g and remaining 20% above 1500 g. We found significant improvement (p<0.005) in SA score after application of nasal CPAP. Babies on CPAP had significant improvement in oxygenation (p<0.05). A success rate of 93.1% observed in moderate grade HMD (p<0.005). Out of 10 babies who failed on nasal CPAP, 80% of them had severe grade HMD and 20% showed moderate HMD. A success rate of 92.86% was found in babies of mothers who had received antenatal steroids and 63.63% of babies whose mothers had not received antenatal steroids improved with early nasal CPAP (p<0.05).Conclusions: Nasal CPAP is found to be effective in babies of mothers who had received antenatal steroids. Nasal CPAP is safe, inexpensive and effective means of respiratory support in HMD. Use of early nasal CPAP which is simple, non-invasive, has low capital outlay and does not require expertise, is the option for us where most places cannot provide invasive ventilation.

Neonatal Ureaplasma urealyticum colonization increases pulmonary and cerebral morbidity despite treatment with macrolide antibiotics.

To evaluate the influence of Ureaplasma urealyticum (UU) colonization on neonatal pulmonary and cerebral morbidity. Single-center case-control study including all preterm infants with positive UU tracheal colonization between 1990 and 2012. Cases were matched with controls by birth year, gestational age, birth weight, and sex. All cases had received macrolide antibiotics for UU infection starting at the time of first positive culture results from tracheal aspirates. Main outcome parameters included presence and severity of hyaline membrane disease (IRDS), duration of ventilation, bronchopulmonary dysplasia at 36 postmenstrual age and neurological morbidities (seizures, intra-/periventricular hemorrhages-I/PVH, periventricular leukomalacia-PVL). Of 74 cases identified 8 died and 4 had to be excluded; thus, 62 preterm infants were compared to 62 matched controls. UU was significantly associated with IRDS (79 vs. 61%, p=0.015), BPD (24 vs. 6%, p=0.003), seizures (23 vs. 5%, p=0.002) and I/PVH (45 vs. 24%, p=0.028). Cases had longer duration of mechanical ventilation and total duration of invasive and non-invasive ventilation (median 11 vs. 6days p=0.006 and 25 vs. 16.5days p=0.019, respectively). UU was found to be significantly associated with pulmonary short- and long-term morbidity and mild cerebral impairment despite treatment with macrolide antibiotics.

Factores de risco de displasia broncopulmonar em cinco unidades portuguesas de cuidados intensivos neonatais

The pathogenesis of bronchopulmonary dysplasia (BPD) is clearly multifactorial. Specific pathogenic risk factors are prematurity, respiratory distress, oxygen supplementation, mechanical ventilation (MV), inflammation, patent ductus arteriosus (PDA), etc.Aim: To evaluate BPD prevalence and to identify risk factors for BPD in five Portuguese Neonatal Intensive Care Units in order to develop better practices the management of these newborns.Material and methods: 256 very low birth weight infants with gestational age (GA) <30 weeks and/or birthweight (BW) <1250g admitted in five Portuguese NICUs, between 2004 and 2006 were studied. A protocol was filled in based on clinical information registered in the hospital charts. BPD was defined as oxygen dependency at 36 weeks of postconceptional age.Results: BPD prevalence was 12.9% (33/256). BPD risk decreased 46% per GA week and of 39% per 100g BW. BPD risk was significantly higher among newborns with low BW (adj OR= 0.73, 95% CI=0.57-0.95), severe hyaline membrane disease (adj OR= 9.85, 95% CI=1.05-92.35), and those with sepsis (adj OR=6.22, 95% CI=1.68-23.02), those with longer duration on ventilatory support (42 vs 3 days, respectively in BPD and no BPD patients, p<0.001) and longer duration of FiO2>;0.30 (85 vs 5 days, respectively in BPD and no BPD patients, p<0.001).Comments: The most relevant risk factors were low birth weight, severe hyaline membrane disease, duration of respiratory support and oxygen therapy, and nosocomial sepsis. The implementation of potentially better practices to reduce lung injury in neonates must be addressed to improve practices to decrease these risk factors.Rev Port Pneumol 2010; XVI (3): 419-430

Factores de risco de displasia broncopulmonar em cinco unidades portuguesas de cuidados intensivos neonatais

The pathogenesis of bronchopulmonary dysplasia (BPD) is clearly multifactorial. Specific pathogenic risk factors are prematurity, respiratory distress, oxygen supplementation, mechanical ventilation (MV), inflammation, patent ductus arteriosus (PDA), etc. AimTo evaluate BPD prevalence and to identify risk factors for BPD in five Portuguese Neonatal Intensive Care Units in order to develop better practices the management of these newborns. Material and methods256 very low birth weight infants with gestational age (GA) <30 weeks and/or birthweight (BW) <1250g admitted in five Portuguese NICUs, between 2004 and 2006 were studied. A protocol was filled in based on clinical information regis- tered in the hospital charts. BPD was defined as oxygen dependency at 36 weeks of postconceptional age. ResultsBPD prevalence was 12.9% (33/256). BPD risk decreased 46% per GA week and of 39% per 100g BW. BPD risk was significantly higher among newborns with low BW (adj OR=0.73, 95% CI=0.57-0.95), severe hyaline membrane disease (adj OR=9.85, 95% CI=1.05-92.35), and those with sepsis (adj OR=6.22, 95% CI=1.68-23.02), those with longer duration on ventilatory support (42 vs 3 days, respectively in BPD and no BPD patients, p<0.001) and longer duration of FiO2>0.30 (85 vs 5 days, respectively in BPD and no BPD patients, p<0.001). CommentsThe most relevant risk factors were low birth weight, severe hyaline membrane disease, duration of respiratory support and oxygen therapy, and nosocomial sepsis. The implementation of potentially better practices to reduce lung injury in neonates must be addressed to improve practices to decrease these risk factors.

A correlative study on the changes of blood gas, plasma fibrinogen and D-dimmer in neonates with hya-line membrane disease

Objective To explore the changes of blood gas, plasma fibrinogen and D-dimmer levels in neonates with severe hyaline membrane disease (HMD). Methods Forty - three neonates with severe HMD(treated by mechanical ventilation) ,26 neonates with mild HMD( without treated by mechanical venti-lation) and 31 controls were studied. The blood gas,plasma fibrinogen and D-dimmer levels were measured. Results Compared with other two groups, the levels of blood pH, PaO2 and FBG decreased significantly in neonates with severe HMD (P<0.01). The levels of PaCO2 and D-dimmer increased significantly (P<0.01). The blood pH was negatively correlated with plasma D-dimmer level,but it was positively correlated with plasma FBG level in neonates with severe HMD. Conclusion There are coagulation abnormalities in neonates with severe HMD. Hypoxemia and acidosis have close relationship with the coagulation abnormali-ties. Key words: Hyaline membrane disease; Blood gas analysis; Fibrinogen; D-dimmer

Addressing Hemolysis in an Infant Due to Mother–Infant ABO Blood Incompatibility

This issue of the Journal of the Medical Library Association (JMLA) honors the life of and contributions to medical librarianship of Estelle Brodman, PhD. Dr. Brodman's interests in medical bibliography, automation, international collaboration, education, the history of medicine, and the profession were far reaching, and her ideas reflected innovation and a strong desire to grow the profession and skills of medical librarians [1, 2]. Since that time, medical librarianship has continued to evolve, realizing many of the ideas Dr. Brodman and others advocated. For example, the availability of medical databases and widespread use of computers in libraries have improved library processes and the ability to quickly locate information. With her strong advocacy of lifelong learning, Dr. Brodman also serves as an important role model as a librarian/educator, and she would likely have been pleased to see the profession's emphasis on continuing education and research [3, 4]. As McClure noted in her discussion of Dr. Brodman as a historian, Dr. Brodman found that the study of history “often illuminates the meaning of the present and indicates logical possibilities for the future” [5]. The history of the development of neonatal critical care, like that of medical librarianship, has doubtless been influenced and evolved by pioneering thinkers. One such thinker and contemporary of Dr. Brodman, Mildred T. Stahlman, MD, was also a leader in education, practice, and research in her chosen field, neonatal critical care medicine. In 1961, Dr. Stahlman, known as the pioneer of modern neonatal intensive care, led a National Institutes of Health research project to explore the physiological aspects of the developing fetus and changes that occur at birth [6, 7]. At a critical point in her research, Dr. Stahlman made the groundbreaking decision to adapt a scaled-down respirator, a breathing machine originally developed for polio patients, to assist breathing in an infant born with severe hyaline membrane disease, a lung disease seen in premature infants whose lungs have not yet fully developed. The infant, who previously faced certain death, was able to survive with this first-ever respiratory therapy that gave a viable treatment option for preterm babies with underdeveloped lungs [6, 8]. This groundbreaking research led Dr. Stahlman to develop the first modern neonatal intensive care unit (NICU) at Vanderbilt University Medical Center [6]. Today, NICUs have become an essential part of health care in the United States for critically ill infants and their families, providing constant observation and care for these babies. Premature babies, infants born earlier than thirty-seven weeks gestation (the typical threshold for defining normal gestation) [9], represent a high percentage of those cared for by a NICU. These babies often have a variety of developmental issues requiring intensive treatment. Given the constantly evolving state of clinical research, NICU teams frequently encounter information needs requiring consultation of the medical literature.

Increasing Prevalence of Cerebral Palsy Among Very Preterm Infants: A Population-Based Study

It is unclear whether declines in neonatal and infant mortality have led to changes in the occurrence of cerebral palsy. We conducted a study to examine and investigate recent temporal changes in the prevalence of cerebral palsy in a population-based cohort of very preterm infants who were 24 to 30 weeks of gestational age. A population-based cohort of very preterm infants who were born between January 1, 1993, and December 31, 2002, was evaluated by the Perinatal Follow-up Program of Nova Scotia. Follow-up extended to age 2 years to ascertain the presence or absence of cerebral palsy and for overall survival. Infant survival and cerebral palsy rates were compared by year and also in two 5-year periods, 1993-1997 and 1998-2002. Logistic regression analyses were used to identify factors that potentially were responsible for temporal changes in cerebral palsy rates. A total of 672 liveborn very preterm infants were born to mothers who resided in Nova Scotia between 1993 and 2002. Infant mortality among very preterm infants decreased from 256 per 1000 live births in 1993 to 114 per 1000 live births in 2002, whereas the cerebral palsy rates increased from 44.4 per 1000 live births in 1993 to 100.0 per 1000 live births in 2002. Low gestational age, postnatal dexamethasone use, patent ductus arteriosus, severe hyaline membrane disease, resuscitation in the delivery room, and intraventricular hemorrhage were associated with higher rates of cerebral palsy, whereas antenatal corticosteroid use was associated with a lower rate. Cerebral palsy has increased substantially among very preterm infants in association with and possibly as a consequence of large declines in infant mortality.

Transient Hyperammonemia in Preterm Infants With Hypoxia.

Purpose of study– Transient hyperammonemia of the newborn can lead to an overwhelming and potentially fatal illness. The etiology of this condition is obscure although hypoxia, immature urea cycle and inadequate hepatic blood flow have all been implicated. We hypothesized that preterm infants with hypoxia would have elevated ammonia levels after birth that normalize within 3–4 weeks. The study aim was to measure serial plasma ammonia levels in preterm infants with hyaline membrane disease (HMD) or perinatal asphyxia to elucidate the role of hypoxia in the pathogenesis of hyperammonemia. Methods– Infants 24–37 weeks gestation with severe HMD or perinatal asphyxia who had indwelling umbilical catheters and parental consent were enrolled. Hyperalimentation with 10% trophamine was initiated at 24–48 hours of life. Blood samples were drawn at 24 hours, 48 hours and weekly until ammonia levels normalized. Plasma ammonia was analyzed using Vitros AMON Slide Analyzer. A level ≥ 50 umol/l was considered elevated. Pregnancy and neonatal data were collected. Repeated measures ANOVA was employed to examine mean differences in serial plasma levels in each group. All analyses were conducted using SPSS Version 11.5. Results– The study sample consisted of 20 neonates in the HMD and 6 in the asphyxia group. Infants with asphyxia had significantly lower apgar scores, cord pH and higher ALT levels. In the HMD group, mean plasma ammonia level decreased from 100.68±28.35 umol/l at 24 hours to 88.42±23.61umol/l at 48 hours (p=0.003) and 56.84±18.42 umol/l at week 2 (p<0.001). In the perinatal asphyxia group, mean ammonia levels decreased from 97.67±10.78 umol/l at 24 hours to 88.67±9.02 umol/l at 48 hours (p=0.003) and 56.83±7.12 umol/l at week 2 (p<0.001). No significant between group differences were seen in mean plasma ammonia. Ammonia levels correlated significantly with pH (neg), pO2(neg) and FiO2 (pos). Multiple regression analyses revealed that both pO2 and pH accounted for ∼73% variance of plasma ammonia levels (p<0.001) and pO2 alone accounted for ∼52% variance. Conclusions– Ammonia levels decreased significantly from 24 hours to week 2 in both groups. No significant correlation of plasma ammonia levels was seen with birth weight, gestational age, apgar scores, glucose, calcium, bilirubin, ALT levels and total caloric and protein intake. Hyperammonemia was not associated with neurologic dysfunction. PO2 and pH significantly predicted ammonia levels. Thus, hypoxic state associated with HMD and perinatal asphyxia is associated with transient hyperammonemia that lasts for 2–3 weeks.

High-frequency Oscillatory Ventilation

Preliminary results with high-frequency oscillatory ventilation (HFOV) applied in neonates with severe hyaline membrane disease have been promising. Experimental data in surfactant-deficient animals have clearly demonstrated the advantages of HFOV, when compared with conventional mechanical ventilation, in improving gas exchange and pulmonary mechanics and in preventing barotrauma without impairing haemodynamics. Combination of HFOV and surfactant therapy appears to be very effective particularly if a high-volume strategy is used. There are only four prospective randomized trials reported in the literature. The beneficial effects of HFOV on oxygenation and ventilation are convincing, but the precise effects on cerebral circulation and on surfactant remain to be evaluated.

Historical Perspectives

“The experimental hypothesis, in short, must always be based on prior observation.”—Claude Bernard (1) Modern adult intensive care started in Denmark in 1952 in response to the high mortality from the respiratory complications seen with a devastating epidemic of poliomyelitis. Anesthetists and physiologists created a new discipline when they collaborated to make sequential measurements of cardiorespiratory variables, then aggressively corrected abnormal conditions. (2) When modern neonatal intensive care emerged a decade later, it followed the same philosophy. The start of modern neonatology was stimulated in large part by an expanding understanding of: 1) the circulatory and respiratory physiology of adaptation to extrauterine life, 2) how those adjustments could fail, and 3) the pathophysiology of hyaline membrane disease. (3)(4)(5)(6)(7)(8)(9)(10) (The monograph by Dawes (3) gives an excellent overview of the relevant animal research). This research had reached a point where it could be applied to clinical care if the necessary physiologic measurements could be made in newborns. To this end, investigators began to catheterize the umbilical arteries of newborns to measure blood gas tensions and pH, with several investigators also measuring aortic pressures. (9)(11)(12)(13) Such invasive techniques were highly controversial initially, but they gradually became the accepted methodology for monitoring the sick neonate. (12) The use of oxygen in preterm infants who had cardiorespiratory distress was an important component of this change in approach to the sick infant. The standard had been to use no more than 40% oxygen to prevent retrolental fibroplasia (retinopathy of prematurity). However, it was obvious that this approach would be insufficient to relieve hypoxia in some infants and would produce hyperoxia in others. Avery and Oppenheimer (13) observed an increase in deaths due to …

Results of mechanical ventilation in premature infants with respiratory distress syndrome

This paper reveals the results of synchronized intermittent mandatory ventilation in premature babies over a period of 8 years. Out of 1532 mechanical ventilated newborns 438 were prematures with severe hyaline membrane disease. The incidence of barotraumatic complications (Pneumothorax 1.2%, pulmonary interstitial emphysema 3% and bronchopulmonary dysplasia 3.4%) was relatively low. We discuss this as an effect of using low respirator frequencies guaranteering sufficient emptying time of the lungs.

Delivery of patients with early onset, severe pre-eclampsia

Objectives: To compare the effects of induction/labor to delivery before labor in early onset, severe pre-eclampsia. Methods: Five-year prospective case series. Delivery course and neonatal outcome were examined for 335 women with viable singletons. Results: Induction was successful in 45% of attempts. Women exposed to labor had longer (5.5 days, P<0.0001) admissions to delivery periods and were more often delivered for maternal indications (RR=2.87, 95% CI=1.98–4.16). Their babies were born 1.6 weeks older ( P<0.0001) and 352 g heavier ( P<0.0001) than those delivered before labor. Babies exposed to labor needed intensive care less often (RR=0.4, 95% CI=0.27–0.58), had lower rates of severe hyaline membrane disease (RR=0.26, 95% CI=0.11–0.59) and sepsis (RR=0.56, 95% CI=0.33–0.93), and were discharged earlier ( P<0.0001). Conclusions: Exposure to induction/labor in selected patients is not detrimental to neonatal outcome in early, severe pre-eclampsia.

Early administration of the second dose of surfactant (beractant) in the treatment of severe hyaline membrane disease

Early administration of the second dose of surfactant (beractant) in the treatment of severe hyaline membrane disease

Early administration of the second dose of surfactant (beractant) in the treatment of severe hyaline membrane disease

The aim of this study was to demonstrate that administration of the second dose of beractant 2 h after the first one is more effective than 6 h after the initial dose. The inclusion criteria for the recruitment of newborn infants were: age < or = 8 h, birthweight 600-2000 g, gestational age 23-36 wk, need for mechanical ventilation with inspiratory oxygen fraction (FiO2) > or = 0.4 and mean airway pressure (MAP) > or = 7 cmH2O to obtain arterial oxygen tension (PaO2) values between 70 and 80 mmHg, and thoracic X-ray compatible with hyaline membrane disease (HMD). Newborns with major congenital malformations, hydrops fetalis or severe pulmonary hypoplasia, or being treated with high-frequency oscillatory ventilation were excluded. In total, 57 premature newborns were studied, 20 of them below 1000 g, who received 100 mg kg-1 of beractant in 2 aliquots and showed an inadequate response, i.e. after 2 h of the first dose the newborn still needed a FiO2 > or = 0.4 and a MAP > or = 7 cmH2O to achieve a PaO2 > 70 mmHg. The second dose was randomly administered 2 or 6 h from the first one. The 2 study groups were comparable except for a higher need of dopamine and seroalbumin in 2-h group. Evolution and complications were similar. Twelve hours after the first dose, the percentage improvement in the arteriolar/alveolar ratio (a/ADO2) in the 2-h group was similar to that in the 6-h group. However, in newborns below 1000 g, 12 h after the first dose the a/ADO2 percentage improvement in the 2-h group was greater than in 6-h group (median of 103.6% vs 16.3%; p = 0.035). In premature infants below 1000 g, it seems reasonable to advance the second dose of beractant if needed.

Early administration of the second dose of surfactant (beractant) in the treatment of severe hyaline membrane disease

The aim of this study was to demonstrate that administration of the second dose of beractant 2 h after the first one is more effective than 6 h after the initial dose. The inclusion criteria for the recruitment of newborn infants were: age ≪8 h, birthweight 600–2000 g, gestational age 23–36 wk, need for mechanical ventilation with inspiratory oxygen fraction (F io2) ≫0.4 and mean airway pressure (MAP) ≪7cmH2O to obtain arterial oxygen tension (P ao2) values between 70 and 80mmHg, and thoracic X‐ray compatible with hyaline membrane disease (HMD). Newborns with major congenital malformations, hydrops fetalis or severe pulmonary hypoplasia, or being treated with high‐frequency oscillatory ventilation were excluded. In total, 57 premature newborns were studied, 20 of them below 1000 g, who received 100mgkg‐1 of beractant in 2 aliquots and showed an inadequate response, i.e. after 2 h of the first dose the newborn still needed a F io2≫ 0.4 and a MAP ≪ 7 cmH2O to achieve a P ao2 &gt; 70 mmHg. The second dose was randomly administered 2 or 6 h from the first one. Conclusion: The 2 study groups were comparable except for a higher need of dopamine and seroalbumin in 2‐h group. Evolution and complications were similar. Twelve hours after the first dose, the percentage improvement in the arteriolar/alveolar ratio (a/ADO2) in the 2‐h group was similar to that in the 6‐h group. However, in newborns below 1000 g, 12 h after the first dose the a/ADO2 percentage improvement in the 2‐h group was greater than in 6‐h group (median of 103.6% vs 16.3%; p= 0.035). In premature infants below 1000 g, it seems reasonable to advance the second dose of beractant if needed.

Congenital Afibrinogenemia

Congenital Afibrinogenemia

Efficacité et limites de la ventilation par oscillations à haute fréquence après échec de la ventilation conventionnelle chez des prématurés atteints de maladie des membranes hyalines sévère

Conflicting reports of high-frequency oscillatory ventilation (HFOV) use as an alternative to conventional mechanical ventilation have been published. This retrospective study has evaluated the efficacy and safety of rescue HFOV in preterm infants with severe hyaline membrane disease (HMD) after the failure of conventional mechanical ventilation (CMV). All newborns hospitalized in our neonatal intensive care unit (NICU) from 10.1.1993 to 15.4.1995 with CMV failure, defined as the need for more than 55% FiO2 without any improvement for at least six hours, have been retrospectively studied. The infants were shared according to the absence (Gr I) or the presence (Gr II) of persistent pulmonary hypertension of neonate (PPHN) in addition to HMD before HFOV. Gestational age (GA) was 29.2 +/- 3.7 weeks (mean +/- SD) in Gr I and 30.3 +/- 2.8 in Gr II. Birth weight was 1379 +/- 750 g and 1471 +/- 612 g, respectively. As soon as three hours after the onset of HFOV in both groups, a dramatic improvement was observed with a FiO2 drop from 82 +/- 20% to 64.8 +/- 25.5% (P < 0.01). Among the infants, 62% survived without any major disability and 28% died (46% in Gr II vs 12% in Gr I, P < 0.01). A trend towards a worsening of pre-existing brain lesions has been noticed. An increased risk of mortality was observed when a secondary worsening in O2 requirements occurred 24 hours after the onset of HFOV, despite an initial significant improvement. SGA was also associated with a poor prognosis (46% of the deaths vs 29% for AGA infants, P < 0.05). HFOV has been successfully used in premature infants with severe respiratory disease and failure of CMV. Criteria of poor prognosis were PPHN and SGA, or a secondary worsening in oxygen requirements after initial improvement. A trend towards aggravation of pre-existing brain lesions has been noticed after HFOV. This aggravation is more frequent when PPHN is associated with HMD. This observation suggests caution for HFOV use when these conditions are present in premature infants.

Hospital admissions in the first year of life in very preterm infants.

To analyse hospital readmissions to 1 year in infants < 33 weeks' gestation. Cohort of very preterm infants born in Western Australia. Parental social class, history of asthma, race, gestational age, birthweight, sex, severity of respiratory disease and oxygen requirement at 28 days chronic lung disease (CLD), 36 weeks and term, maternal smoking, cohabitation with siblings, breast-feeding duration and hospital readmissions were recorded prospectively. Data were available for 538 of 560 (96%) infants discharged. Eight died in the first year. Two hundred and twenty-five infants (42%) had 443 readmissions, of which 370 were medical and 73 surgical. Risk factors for medical readmission were Aboriginal race, male sex and CLD. Breast-feeding was protective. Risk factors for surgical admission were male sex, lower gestation, severe hyaline membrane disease, severe CLD and birthweight < 10th centile. Readmission is common after very preterm birth. Risk factors for medical and surgical admission differ with CLD being the only perinatal factor associated with both medical and surgical admission.

Obstetrical outcome of pregnancy in patients with systemic Lupus Erythematosus. A study of 60 cases

Objective: To analyze the course of maternal diseases and the outcome of pregnancy in patients with systemic Lupus Erythematosus (SLE). Study design: During a period of 11 years we prospectively followed 60 pregnancies in 46 SLE patients in a tertiary care center in Barcelona (Spain). The management protocol included: (1) planning of conception when disease was inactive; (2) frequent follow-up visits by an internist–obstetrician team; (3) use of sequential ultrasonographic, Doppler and fetal echocardiographic examinations; (4) serial evaluations of maternal immunological condition; and (5) low dose aspirin from 1 month before attempting conception and throughout pregnancy was added in women with antiphospholipid antibodies. From 1985 until 1994 prednisone prophylaxis was used in all lupus patients during the last month of pregnancy and during the first month of the puerperium; from 1995 onwards this regime was abandoned. Results: The mean (S.D.) age of patients was 28.6 (4.8) years (range 20 to 42) and the mean (S.D.) previous duration of SLE was 6.25 (4.8) years (range 0 to 17). SLE was diagnosed during the pregnancy in two cases (3.3%) and the disease was active at conception in four cases (6.7%); at that time nine patients (15%) were taking prednisone. Antiphospholipid antibodies were positive in 16 patients (30.4%) and there were 10 (16.7%) pregnancies in patients having lupus nephropathy. There were three first-trimester miscarriages (5%) and four (6.7%) voluntary abortions. Obstetric complications in the remaining 53 pregnancies included: preterm delivery, 11 cases (20.8%); intrauterine growth retardation, five cases (9.4%); hypertension, 10 patients (18.9%), five of them fulfilling the criteria of preeclampsia; premature rupture of membranes, four patients (7.5%); finally, 13 neonates had a birthweight lower than 2500 g. There were 15 lupus flares (28.3%), giving a flare rate of 0.044 per patient/month. There were five neonatal deaths (perinatal mortality rate, 94‰): one because of complete heart block, three due to severe hyaline membrane disease resulting from extreme prematurity and one intrauterine death in a patient having the Leiden mutation. Conclusion: Pregnancy in patients with SLE should not be regarded as an unacceptable high-risk condition for the mother or her baby provided that conception is accurately planned and patients are managed according to a careful multidisciplinary treatment schedule.