Current evidence on the safety profile of NSAIDs for the treatment of PDA

Patent ductus arteriosus (PDA) complicates the clinical course of preterm infants. Nonsteroidal anti-inflammatory drugs, especially Indomethacin and Ibuprofen, have been widely used for both prevention and treatment of PDA. Short-term efficacy of Indomethacin or Ibuprofen is equivalent, while Ibuprofen results show a higher safety profile. Ibuprofen is associated with fewer clinical gastrointestinal and renal side effects with respect to Indomethacin even if subclinical potential effects are reported. When administered as prophylaxis, Ibuprofen has no effects on prevention of intraventricular haemorrhage unlike Indomethacin. Considering the potential adverse effects of both these drugs, a careful monitoring during and after the treatment period is highly recommended.

Neonatal outcome in hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders in pregnancy account for increased perinatal morbidity and mortality when compared to uneventful gestations.

AIMS

To analyze perinatal outcome of pregnancies complicated by different kinds of hypertension to uncomplicated pregnancies in a series of Italian women and to compare our data with series from other countries.

STUDY DESIGN

The sample was divided into four groups of hypertensive women: chronic hypertension (CH), gestational hypertension (GH), preeclampsia (PE), and chronic hypertension complicated by preeclampsia (CHPE). One thousand normal pregnancies served as controls.

SUBJECTS

Neonatal features of the offspring of 965 Italian women with hypertension in pregnancy were evaluated.

MEASURES

Gestational age, birthweight and the rate of small for gestational age were the outcomes. Perinatal asphyxia and mortality were also assessed.

RESULTS

Gestational age, the mean of birth weight and birth percentile were significantly lower in all groups with hypertensive complications when compared with controls. The rate of very early preterm delivery (<32 weeks) was 7.8% in CH, 5.9% in GH, 21.2% in PE and 37.2% in CHPE while it was to 1.2% in the control group. The rate of SGA was globally 16.2% in CH, 22.8% in GH, 50.7% in PE, 37.2% in CHPE and 5% in controls. The rate of SGA in PE was much higher than reported in series from other countries.

CONCLUSION

Comparing our data with those reported from other countries, it is evident that the rate of fetal growth restriction in PE we found in our center, is significantly higher even in the presence of a global lower incidence of PE.

Is the prophylaxis of patent ductus arteriosus useful in extremely premature infants?

This study was aimed to verify the efficacy and safety of ibuprofen prophylaxis of patent ductus arteriosus in very preterm infants, in order to select infants receiving higher benefits from this intervention. Two hundred neonates with gestational age (GA) < or = 28 weeks receiving ibuprofen within the first two hours of life were included. Ductus closure rate was 68%, and results were significantly dependent on GA (48.8% among neonates with GA < 26 weeks vs 73.2% among those with GA > or = 26 weeks, p < 0.01). Neonates with GA < 26 weeks showed a lower ductus closure after the primary course of therapy (20% vs 57.5%, p < 0.01), as well as higher reopening rate (16.2% vs 3.8%, p < 0.05) and need for surgical ligation (38.8% vs 5.8%, p < 0.01). During the prophylaxis period, 11 neonates (5.5%) showed pulmonary hypertension. Considering risks/benefits, we recommend prophylaxis only in infants with GA < 26 weeks.

Postoperative chylous ascites: increased scrotal volume as "alarm bell"

Chylous ascites has been reported only rarely as a possible consequence of congenital diaphragmatic hernia (CDH) surgical treatment. The present report regards a case of chylous ascites that developed after surgical treatment of CDH and was interestingly anticipated by increased scrotal volume. The aim was to alert neonatologists and pediatric surgeons about the potential usefulness of this clinical sign as a precocious "alarm bell" for chylous ascites development.

Peripheral blockade as treatment of arm ischaemia at birth

INTRODUCTION

Limbs ischaemia represents a rare event during the neonatal period. The present paper reports an unusual case of precocious arm ischemia that occurred immediately after birth and successfully treated with a peripheral nerve blockade.

CONCLUSIONS

Peripheral nerve blockade resulted in an effective and safe therapeutic approach able to allow the salvaging of the limbs.

Preterm small for gestational age infants are not at higher risk for parenteral nutrition-associated cholestasis

OBJECTIVE

To assess if being small for gestational age impacts parenteral nutrition-associated cholestasis (PNAC) development.

STUDY DESIGN

We reviewed all the very low-birth weight infants exposed to parenteral nutrition for >14 days from 1996 to 2006, comparing auxological and clinical data, as well as nutritional history, during the first 4 weeks of life of infants with cholestasis and control subjects.

RESULTS

Of 445 very low-birth weight infants, 55 had development of PNAC. Infants with cholestasis had lower birth weight and gestational age but similar birth weight z-score compared with infants without cholestasis, and they received a lower amount of enteral feeds (25.8 +/- 20.7 vs 67.9 +/- 33.0 mL/kg, P < .001), a greater amount of intravenous glucose (10.6 +/- 1.3 vs 7.5 +/- 2.5 g/kg, P < .0001), lipids (1.8 +/- 0.4 vs 1.3 +/- 0.5, P < .0001) and proteins (2.7 +/- 0.5 vs 1.9 +/- 0.7, P < .0001), and needed a higher number of days of fasting (13.2 +/- 6.7 vs 6.5 +/- 4.8, P < .001). Enteral intake between 0 and 21 days of life (OR 0.66; 95% CI 0.53, 0.81, P < .0001) and oxygen therapy (OR 1.05; 95% CI 1.01, 1.09; P = .030) were identified as the best independent predictors of PNAC.

CONCLUSIONS

Enteral feeding remains the main factor for the prevention of PNAC, whereas small for gestational age infants do not have a higher risk of PNAC.

Different fetal-neonatal outcomes in siblings born to a mother with Graves-Basedow disease after total thyroidectomy: a case series

Introduction

We describe three different fetal or neonatal outcomes in the offspring of a mother who had persistent circulating thyrotropin receptor antibodies despite having undergone a total thyroidectomy several years before.

Case presentation

The three different outcomes were an intrauterine death, a mild and transient fetal and neonatal hyperthyroidism and a severe fetal and neonatal hyperthyroidism that required specific therapy.

Conclusions

The three cases are interesting because of the different outcomes, the absence of a direct correlation between thyrotropin receptor antibody levels and clinical signs, and the persistence of thyrotropin receptor antibodies several years after a total thyroidectomy.

Hypertrabecular aspect of left ventricular myocardium: a possible complication of congenital hypothyroidism in a preterm infant

We report a case of hypertrabeculated left ventricular myocardium associated with congenital hypothyroidism in a preterm infant. The myocardical anomalies and long QT interval, absent at birth, appeared simultaneously to abnormal thyroid hormones and progressively improved until complete recovery during Levo-Thyroxine treatment. We speculate that thyroid dysfunction could be the potential cause of transient hypertrabecular aspect of the left ventricle.

Is neonatal antiretroviral therapy a risk factor for NEC occurrence?

An association between maternal human immunodeficiency virus (HIV) infection and increased necrotizing enterocolitis (NEC) risk has been reported. Viral exposure and maternal antiretroviral therapy have been described as mediators of this risk. We report a preterm patient with delayed meconium passage and subsequent NEC, in which both the above-mentioned mechanisms were excluded, suggesting that neonatal antiretroviral therapy could be the most relevant risk factor for NEC in a susceptible preterm gut.

Severe subdural hemorrhage due to minimal prenatal trauma

The authors report a case of minimal prenatal trauma producing a large subdural hematoma in the fetus, which was diagnosed in utero by MR imaging. The occurrence of such a complication is extremely rare in the absence of significant maternal trauma. Prenatally diagnosed intracranial hemorrhages, particularly those that are subdural in origin, have a poor prognosis in most cases. After birth, brain compression required a complex neurosurgical intervention because simple hematoma evacuation was not possible. The clinical and neurological outcome at 6 months was excellent, as confirmed by the neuroimaging findings.

Does Ibuprofen increase neonatal hyperbilirubinemia?

OBJECTIVE

The aim of this study was to investigate whether ibuprofen exposure was associated with increased hyperbilirubinemia in preterm infants.

METHODS

Since 2000, ibuprofen has been administered to all infants at <30 weeks of gestation who are admitted to our unit, to prevent patent ductus arteriosus. We retrospectively compared data for 418 infants subjected to ibuprofen prophylaxis (2000-2007) and 288 infants not exposed to ibuprofen (1993-1999).

RESULTS

The ibuprofen group had a significantly higher peak total serum bilirubin level (9.0 +/- 2.5 mg/dL vs 7.3 +/- 3.3 mg/dL), more need for phototherapy (398 infants [95%] vs 254 infants [87.6%]), and a longer phototherapy duration (94.3 +/- 43.6 hours vs 87.2 +/- 38.6 hours). Groups did not differ with respect to gestational age, birth weight, gender ratio, glucose-6-phosphate dehydrogenase deficiency incidence, or hypoalbuminemia (<2.5 g/dL) incidence. Hemolytic isoimmunization was diagnosed with similar incidences (no-ibuprofen group: 7 of 288 infants; ibuprofen group: 8 of 418 infants). The rates of exchange-transfusion also were similar between the groups (no-ibuprofen group: 14 infants [4.8%]; ibuprofen group: 19 infants [4.5%]).

CONCLUSIONS

Ibuprofen administration was associated with higher peak total serum bilirubin levels, and the more-pronounced hyperbilirubinemia led to longer phototherapy. The potential role of competition between ibuprofen and bilirubin in the hepatic glucuronidation pathway is discussed.

An unusual complication of umbilical catheterisation

We report the first case of perforated Meckel's diverticulum in a 1-day-old pre-term infant as a consequence of umbilical vein catheterisation. The clinical course consisted of abdominal distension and pneumoperitoneum that occurred after 12 h of life. Perforated Meckel's diverticulum was found at laparotomy. Neither inflammatory phenomena nor ectopic mucosa were found at microscopical examination. Perforation of the diverticulum was a complication of umbilical catheter insertion through a narrow lumen in the umbilical cord mistaken for an umbilical vein and connected to Meckel's diverticulum through a very short fibrous band. A search of the literature did not reveal any similar cases.

Atypical manifestations of congenital parvovirus B19 infection

Parvovirus B19 infection in pregnancy is associated with fetal anemia, hydrops and fetal death. We report two unusual manifestations of vertical parvovirus B19 infection. The first patient developed hydrops as consequence of myocarditis with involvement of sino-atrial node. The other had pleural effusion reactive to the hepatic localization of the virus.

Visual function at 35 and 40 weeks' postmenstrual age in low-risk preterm infants

OBJECTIVES

The objectives of this study were to (1) assess visual function in low-risk preterm infants at 35 and 40 weeks' postmenstrual age, (2) compare preterm visual abilities at term-equivalent age with term-born infants, and (3) evaluate effects of preterm extrauterine life on early visual function.

METHODS

Visual function was assessed by using a validated test battery at 35 and 40 weeks' postmenstrual age in 109 low-risk preterm infants who were born at <31 weeks' gestation. The preterm findings were compared with data from term-born infants collected by using the same test protocol.

RESULTS

All preterm infants completed both assessments. The 35-week responses were generally less mature than those at 40 weeks. Preterm infants at both ages were significantly more mature than term-born infants for ocular movements and vertical and arc tracking and at 40 weeks for stripe discrimination. In contrast, tracking a colored stimulus, attention at distance, and stripe discrimination were more mature at term age (in both term-born and preterm infants) than at 35 weeks.

CONCLUSIONS

Our findings provide data for visual function at 35 and 40 weeks' postmenstrual age in low-risk preterm infants. The results suggest that early extrauterine experience may accelerate the maturation of aspects of visual function related to ocular stability and tracking but does not seem to affect other aspects that may be more cortically mediated.

Severe hyperbilirubinemia in a glucose-6-phosphate dehydrogenase-deficient preterm neonate: could prematurity be the main responsible factor?

We report on a premature infant with glucose-6-phosphate dehydrogenase deficiency and severe hyperbilirubinemia. In this patient, all known potential hemolytic agents were excluded and no findings of hemolysis were observed. The crucial role of prematurity in the pathogenesis of this type of jaundice is discussed.

Cardiac complications in preterm infants with percutaneous long lines: the importance of early diagnosis

Percutaneous long lines, routinely used in preterm infants, can be associated with several cardiac complications such as pericardial effusion and consequent cardiac tamponade. We report three patients with pericardial effusion highlighting the importance of cardiac ultrasound monitoring to both early diagnosis and treatment.

Severe sepsis in a premature neonate: protein C replacement therapy

Treatment with activated protein C has been shown to reduce mortality in adult patients with severe sepsis but also to increase risk of bleeding. In patients with predisposition to bleeding, as in preterm infants, the inactivated form of protein C could serve as a safe therapeutic option. We report the case of a preterm neonate who developed severe sepsis on the 28th day of life, who was successfully treated with the inactivated form of protein C for a period of 96 hours.

Hepatic hematoma in a neonate with a high level of alpha-fetoprotein

Hepatic hematomas in neonates are uncommon lesions. When they are large or subcapsular in location, they can rupture with clinical signs of hemoperitoneum. We report a case of subcapsular hepatic hematoma (SHH) associated with a high level of alpha-fetoprotein (AFP), for which diagnosis was made with conservative management, following up with the reduction in size at ultrasound examination and the reduction of the level of AFP.

Tracheal agenesis without esophageal fistula: genetic, resuscitative, and pathological issues

An exceptional case of tracheal agenesis with no communication with the esophagus is described. This malformation needs surgical airway approach and is hardly classifiable. We analyzed the literature and our institutional data: this resulted to be the first case of such anatomical variant. Genetic and pathological issues are reviewed: recent genetic data seem to explain this malformation. We also reviewed the available literature about prenatal presentation. Because prenatal diagnosis is difficult to achieve and current guidelines for neonatal resuscitation do not provide any recommendation, the resuscitative team may not be prepared for managing such a case. Usefulness of uncommon resuscitative maneuvers is discussed: a promptly performed surgical tracheotomy is the only mean to ventilate such a baby.

Successful removal of catheter fragment from right atrium in a premature infant

A premature infant with rupture of percutaneous central catheter and subsequent migration of the fragment in the right atrium was reported. Umbilical venous catheterization was safely used to remove the fragment.

Efficacy of a single dose of antenatal corticosteroids on morbidity and mortality of preterm infants

OBJECTIVE

To assess the effectiveness of an incomplete course of antenatal corticosteroids (ACS) on neonatal morbidity and mortality of preterm infants.

METHODS

Preterm infants born at 25-34 weeks' gestational age between January 1, 1998 and December 31, 2003 were included in this study. Studied infants were divided in two groups: the ACS group included those infants who had been exposed to a single 12-mg dose of betamethasone before delivery while the control group included those infants who had been delivered without any antenatal corticosteroids treatment. The most important neonatal outcomes were compared between the two groups.

RESULTS

One hundred and seventy neonates (41.4%) were exposed to one 12-mg dose of betamethasone before delivery, while 241 neonates (58.6%) did not receive any antenatal corticosteroids treatment. Mean gestational age at delivery (30.4+/-2.4 weeks versus 31.2+/-2.9 weeks, p=0.004) and mean birth weight (1375+/-454 g versus 1625+/-580 g, p<0.001) were lower in the ACS group. The univariate analysis showed that delivery room intubation and respiratory distress syndrome were more frequent in the ACS group and that the length of stay was also significantly longer in this group. No differences were found concerning survival, neonatal morbidity, need for and duration of mechanical ventilation and oxygen therapy. The incidence of major outcomes in survivors was also similar. Logistic regression adjusted for gestational age showed that the exposure to a single dose of betamethasone before delivery was not associated with a significant reduction in the rate of any neonatal outcome. We also compared the outcomes in function of gestational age subclasses. In the 25-27 weeks subgroup, delivery room intubation, surfactant treatment and patent ductus arteriosus (PDA) were less frequent in ACS infants; they had also shorter ventilation and oxygen duration. In the 30-31 weeks subgroup, ACS infants had a lower incidence of mechanical ventilation and a shorter duration of oxygen therapy. Finally, no differences were found in the 28-29 weeks subgroup and in the 32-34 weeks subgroup.

CONCLUSION

Effects of incomplete antenatal corticosteroids are variable: they give some benefits to infants of 25-27 weeks gestational age, fail to show any difference in outcomes in the 32-34 weeks subgroup and are doubtful between these extremes.