Effect of maternal low dose aspirin on neonatal platelet function

OBJECTIVE

To evaluate the effect of maternal low dose aspirin ingestion in platelet function of newborn.

DESIGN

Prospective randomized placebo controlled study.

METHODS

25 neonates born to mothers receiving low dose aspirin and 25 matched neonates with no maternal exposure to aspirin were studied. 2 ml of EDTA and 4.5 ml of citrate blood was collected from umbilical vein using double clamped umbilical stump for hemogram, coagulation profile and platelet functions.

RESULTS

The platelet counts (10(9)/l) of study and control groups were 186.4 +/- 22.76 (116-225) and 205.28 +/- 17.34 (176-225), respectively. There was no significant difference in coagulation parameters. Prothrombin time index (PTI) was 86.24 +/- 6.623 and 87 +/- 6.43, respectively in the study and control group while PTTK (sec) was 55.88 +/- 20.54 and 52.12 +/- 11.82 in study and control subjects, respectively. The platelet aggregation studies (platelet function) with various platelet agonists in study and control group did not show any significant difference. Clinically, none of the babies had bleeding.

CONCLUSIONS

Use of low dose aspirin in pregnant women was found to be safe and had no adverse effects on platelet functions of newborn.

Comparative ABR profile in high risk infants

Auditory brainstem responses (ABR) were studied in 52 children upto the age of 3 months, suffering from neonatal jaundice, prematurity, pyogenic meningitis and septicemia. Absolute latency of wave I and interpeak latency I-V were found to be significantly delayed in cases of jaundice and absolute latency of wave V and interpeak latency I-V were prolonged in cases with prematurity. In cases following pyogenic meningitis absolute latency of wave V and interpeak latency of I-III, I-V were significantly delayed compared to septicemia where absolute latency I, V and interpeak latency I-V were significantly delayed (P < 0.05). Maximum auditory insult was seen in cases with neonatal jaundice where 30.77% each had severe SN deafness and 30.77% had moderate degree of deafness compared to prematurity, meningitis and septicemia where 14.28, 7.69 and 25% were found to have severe SN deafness and 7.14, 38.46 and 25% had moderate deafness. Overall incidence of deafness of any kind in these factors was 44.23%.

Bone and joint infection in neonates

A retrospective study was done to review the clinical experience of septic arthritis and osteomyelitis in the newborns in our centre. Case records of all the neonates born from January 1989 to August 1994 and those admitted to outborn nursery from 1985 to 1993 were reviewed. Diagnosis of septic arthritis/osteomyelitis was made in the presence of relevant clinical signs and supported by positive culture from blood or joint fluid and abnormal X-ray or ultrasound findings. The incidence of septic arthritis and osteomyelitis among inborn babies was 1 in 1500. There were 25 neonates with mean gestational age 34.5 (range 27-40) weeks and mean birth weight 2269 (range 990-4750) gms. Limitation of movement (64%) and local swelling (60%) were commonest presentations. A total of 33 joints were involved in 25 babies. Eight babies (32%) had multiple joint involvement. Hip and knee were the most commonly involved joints (48% each). In 19 babies (76%) joint involvement occurred in association with a generalized septicemic illness while 6 babies (24%) had localised signs and symptoms. Joint aspirate was positive for gram stain or culture in 12 (48%) and 10 babies (40%) had positive blood culture. Klebsiella pneumoniae and Staphylococcus aureus were commonest isolates. Radiological changes were seen in 13 (52%) babies. All were treated with appropriate antibiotics and open surgical drainage was done in 5 (20%) cases. Bone and joint infections are important complications in sick septicemic neonates and need early diagnosis, appropriate management with antibiotics, surgical drainage in selected cases to prevent long term morbidity.

Epidemiology of systemic candidiasis in a tertiary care neonatal unit

143 neonates were diagnosed to have acquired systemic candidiasis out of a total 4530 admissions (3.2 per cent) to the neonatal intensive care unit (NICU) during a period of 6 1/2 years from January 1990 to June 1996. Mean age at onset was 10.4 days, mean birth weight 1454 g, and mean gestation was 31.7 weeks. Ninety-four per cent were premature, 95 per cent low birth weight (LBW), and all had undergone peripheral vein catheterization and had received broad spectrum antibiotics, except one, prior to the diagnosis. Fifty-eight per cent were ventilated and 15 per cent received parenteral nutrition. Persistent/recurrent pneumonia, apnoea, lethargy, high gastric aspirates, and abdominal distension were the common clinical manifestations. Candida tropicalis, C. albicans, and C. guillermondii were the most common isolates. Blood and urine were the predominant sites for isolation of Candida. Fluconazole was the most used antifungal agent, with 24 per cent resistance against it. Fifty per cent of babies died due to all causes. Of all the deaths, two-thirds were Candida related. Candida-attributable deaths occurred in 24 cases (17 per cent).

The steady states of microbial growth on mixtures of substitutable substrates in a chemostat

Microbes growing on mixtures of substrates in a chemostat exhibit different substrate utilization patterns, depending on the dilution rate and feed concentrations. For instance, when supplied with high feed concentrations of a binary mixture, both substrates are consumed at low dilution rates, but only one of the substrates is consumed at high dilution rates. The goal of this work is to explain the onset of such transitions, which play a very significant role in ecology and bioengineering. In previous work, we formulated a mathematical model of mixed-substrate growth in batch cultures. We use the extension of this model to continuous cultures as the framework for understanding substrate utilization patterns in continuous cultures. Our explanation rests upon the existence of two special types of dilution rates predicted by the model. The first is the so-called critical dilution rate at which the growth rate becomes zero, leading to cell washout. The existence of the critical dilution rate obtains from the simplest models of microbial growth, and is rooted in the fact that growth is inherently autocatalytic. The second type of special dilution rate, a unique feature of our model, stems from the recognition that synthesis of the enzymes catalysing the uptake of substrates is also autocatalytic. Hence, associated with each substrate is a transition dilution rate at which the synthesis rate of the transport enzyme becomes zero. We show that: (1) the substrate utilization patterns in continuous cultures are completely determined by the relative magnitudes of the critical and transition dilution rates; and (2) the critical and transition dilution rates are in turn determined by the feed concentrations. This allows us to construct an operating diagram, which yields the substrate utilization pattern for any given dilution rate and feed concentrations. The theory explains most of the mixed-substrate phenomena summarized in a recent review article by Egli (1995, Adv. Microbiol. Ecol. 14, 305-386).

Role of early postnatal dexamethasone in respiratory distress syndrome

OBJECTIVE

To study the effect of early postnatal dexamethasone therapy on severity of hyaline membrane disease.

DESIGN

Prospective, randomized, controlled, unblinded study.

SETTING

Neonatal Intensive Care Unit.

METHODS

19 babies who had hyaline membrane disease were included in this study. The inclusion criteria were clinical and radiographic diagnosis of RDS, requiring mechanical ventilation and FiO2 > 0.3. Ten babies received injection dexamethasone 0.5 mg/kg/dose 12 hourly for 3 days starting within 6 hours of birth. The control group did not receive any drug. Babies with active infection, bleeding tendency and congenital malformation were excluded. None of the babies received surfactant. The duration of ventilation and AaDO2 and FiO2 requirements from day one to five were calculated.

RESULTS

The initial AaDO2 were similar in both the groups but on day 3, 4, 5 AaDO2 were low in study group (201, 85, 70) compared to control group (236, 209, 162). The initial FiO2 were 0.66 and 0.63 in dexamethasone and control groups, respectively and remained high till day 2 and came down in study group on days 3, 4 and 5 (0.41, 0.27, 0.27) compared to control group (0.53, 0.34, 0.42). The mean duration of ventilation was shorter in dexamethasone group (87 hours) vs control group (120 hours).

CONCLUSION

Early use of postnatal dexamethasone reduces the disease severity and oxygen requirement in RDS and hence would be useful in the Indian context.

Anaerobes in neonatal septicaemia: a cause for concern

The purpose of this study was to determine the prevalence and vertical transmission of anaerobic infection in early onset neonatal septicaemia in babies born to mothers with adverse perinatal factors. One-hundred neonates born to mothers with one or more adverse perinatal factors were prospectively studied. Aerobic and anaerobic blood cultures were drawn in addition to rapid diagnostic tests. High vaginal swabs were also taken from all mothers prior to delivery. Anaerobic Clostridium species infection was found in 5 per cent babies and all of them were symptomatic. Fifteen babies had aerobic infection. There was one baby with concomitant aerobic and anaerobic infection. There was no significant difference in sex distribution, birth weight, or gestational age between babies with aerobic and anaerobic infection. Similarly, there were no symptoms unique to anaerobic infection. None of the rapid diagnostic tests had a good sensitivity for anaerobic infection. Fifty-two per cent of the mothers had anaerobic growth in their vaginal swabs, but none had transmitted to their babies. All five babies recovered within 24-72 h of commencing therapy. This study shows that anaerobes have a role in early onset neonatal septicaemia. They cause serious morbidity, but carry a good prognosis. For identification of such infection blood culture is mandatory.

Etiology of sporadic acute and fulminant non-A, non-B viral hepatitis in north India

BACKGROUND

Viral hepatitis is a major public health problem in India.

AIM

To investigate the association of various hepatitis viruses in patients with acute liver diseases in north India.

METHODS

One hundred and thirteen patients with acute viral hepatitis (AVH; n = 70) or fulminant hepatic failure (FHF; N = 43) were evaluated for the presence of hepatitis A, B, C and E virus infection. Hepatitis C virus (HCV) testing was done using second-generation anti-HCV ELISA test and reverse transcriptase polymerase chain reaction (PCR) for the detection of HCV RNA in the serum of patients with non-A, non-B (NANB) hepatitis. Detection of IgM anti-HEV antibody was done in patients found negative for the above viruses (n = 53).

RESULTS

Hepatitis A and B viruses accounted for 3.5% and 42.5% of the 113 cases, respectively. HCV infection accounted for 12% of the NANB cases with AVH and 15.5% with FHF. PCR was more useful than serological tests for the detection of HCV infection. HEV infection accounted for 49% of the NANB, non-C cases with AVH and 25% with FHF; pregnant women with HEV infection had a fulminant course. No etiological agent could be established in 28.3% of cases.

CONCLUSION

HEV is the most important cause of NANB hepatitis; hepatitis B virus is still a major concern, while HCV is not an important cause of acute viral liver disease in India.

Evolution of neonatal and pediatric critical care in India

During the last decade, the disciplines of neonatal and pediatric critical care have rapidly progressed in India. The growth of Neonatal Intensive Care has paced the growth of Pediatric Critical Care. The substantial growth of discipline and the positive improvements in neonatal outcomes are the results of the concerted efforts of the National Neonatal Forum and commitment of expatriate physicians residing in the United States. This article provides the background information regarding perinatal, neonatal, and infant mortalities in India. It also describes the maternal child health care delivery system in the Indian subcontinent.

Simplified assessment of asphyxia at birth

A simplified clinical method of assessment of the baby soon after birth was evaluated and compared with the cord blood pH and 1 min Apgar score. The assessment recorded cry, respiration, colour, activity, reflex response, and cord pulsation. Sixty-two neonates born at term by normal vaginal delivery with 1 min Apgar score of 0-6 (n = 31) and 7-10 (n = 31) were studied. Linear correlation coefficient (r) and Goodman's correlation coefficient (gamma) were used for statistical comparison. A combination of cry, colour and activity showed the best correlation with cord blood pH (r = 0.3842, P < 0.01: gamma = 0.7138) and 1 min Apgar score (r = 0.7768, P < 0.01, gamma = 0.9393) and was as useful as the combination of all the six clinical parameters. Illiterate traditional birth attendants can be safely taught to use cry, colour, and activity for assessing baby's condition at birth.

Photooxidant injury to glucose-6-phosphate dehydrogenase-deficient erythrocytes with bilirubin as the sensitizer--an in vitro study

To evaluate the hypothesis that glucose-6-phosphate dehydrogenase (G6PD)-deficient erythrocytes are more prone to photooxidant injury with bilirubin as the sensitizer, we compared the malonyl dialdehyde (MDA) levels and haematocrit values in 11 G6PD-deficient samples with a bilirubin: albumin molar ratio of 1:2 (10 mg% bilirubin, 2.5 g % albumin) photoexposed at 6 microW cm-2 nm-2 (420-460 nm), with 11 of control samples. Twelve hours after photoexposure the incremental changes in MDA levels (OD units) were higher in G6PD-deficient samples [mean (SE) = 0.230 (0.171) vs 0.075 (0.043), p < 0.01]. Antioxidant drugs may have a protective role while G6PD-deficient neonates undergo phototherapy.

Small for gestational age babies: Indian scene

Intrauterine growth retardation (IUGR) is an important determinant of neonatal mortality, morbidity and poor neurologic outcome. The study was aimed to evaluate the magnitude of perinatal risk factors in causation and the neonatal outcome of small for gestational age (SGA) babies. One hundred and three SGA babies born over a period of one year were retrospectively analysed during their hospital stay. 3.53 per cent of the babies were SGA with mean birth weight of 1657 +/- SD 354 gm (range 600-2200 gm). 68.9 per cent were term babies and 51.5 per cent were females. Toxemia of pregnancy (30.09%), hypertensive diseases of pregnancy (HDP) excluding toxemia (5.8%), diabetes mellitus (1.94%), medical disorders including renal and cardiac (3.88%), anemia (Hb < 8 gm%) and IU infection (0.97%) were the main conditions responsible for SGA. In 56.3% pregnancies, no cause could be ascertained. The common perinatal problems were infections in 27 (26.2%), birth asphyxia in 22 (21.36%), polycythemia in 25 (24.3%), jaundice in 22 (21.36%) and hypoglycemia in 7 (6.8%). Congenital malformations in 2 (1.94%) and Hyaline membrane disease in 1 (0.97%) were uncommon problems. 5.8 per cent babies died due to various perinatal problems. Based on these findings it was concluded that idiopathic (? Constitutional) intrauterine growth retardation was the commonest cause of SGA in Indian babies. 58.3 per cent babies had neonatal problems and they had a better survival compared to their western counterparts.

Fluconazole

Incidence of systemic candidiasis is increasing with improvement in the survival of high risk neonates who undergo multiple interventions. Therapies available to treat systemic fungal infection are few and have several drawbacks. Fluconazole, a new triazole derivative may be a useful anti-fungal agent in view of its excellent oral absorption, easy administration, low plasma protein affinity, long half-life, high concentrations in urine and CSF, minimal adverse reactions, wide spectrum of anti-fungal activity and high specificity for fungal cytochrome P450 system. Its utility in neonates and children with candidiasis has already been documented by few case reports and studies.

Fluconazole in the management of neonatal systemic candidiasis

OBJECTIVE

To evaluate the role of Fluconazole in the management of neonatal systemic candidiasis.

DESIGN

Descriptive, retrospective analysis.

SUBJECTS

23 neonates diagnosed as systemic candidiasis based on clinical suspicion with blood and/or urine culture positive for candida were treated with Fluconazole (5 mg/kg/day) for > 7 days.

RESULTS

Babies had mean birth weight 1590 + 533 g, mean gestation 32.3 + 3.1 wks and fungal sepsis was diagnosed at a mean age of 14.3 + 7.9 days. Candida albicans (43.5%), C. tropicalis (21.7%), C. guillermondii (13%), C. parapsillosis (13%) and C. krusei (8.7%) were the species isolated. Fluconazole was effective in 82.3% cases with no side effects. Four resistant cases were C. parapsillosis (n = 2), C. albicans (n = 1) and C. guillermondii (n = 1) and there were three deaths, all in resistant cases though one death was unrelated to candidemia.

CONCLUSION

Fluconazole is a safe and effective drug for neonatal systemic candidiasis.

A prospective study of delta infection in fulminant hepatic failure

Thirty one patients of HBV related Fulminant Hepatic Failure (FHF) were studied for the presence of delta infection and subsequently the clinical features, course and outcome of the delta infected cases was compared with those of delta uninfected cases. Out of 31 patients studied, 11 patients (35.8%) were reactive for anti-delta antibodies. There was no significant difference in age in delta reactive and non-reactive group. Hepatic encephalopathy was seen in all of the patients. The mean SGOT and SGPT were 378 +/- 88.74 U and 454 +/- 70.44 U respectively in anti-delta reactive group as compared to 239 +/- 74.94 U and 274.1 +/- 100.34 U respectively in anti-delta non reactive group (p < 0.05). During follow up, 10/11 patients (91%) died in anti-delta reactive group as compared to 13/20 patients (65%) in anti-delta non reactive group. So this study suggests that delta virus infection is quite common in India and it lead to excerbation of illness and carries a relatively poor prognosis for FHF.

Kinetics of theophylline in apnea of prematurity in small for gestational age babies

OBJECTIVES

To study the pharmacokinetics of theophylline and its correlations to pharmacodynamic effects in apnea of prematurity in small for gestational age babies.

DESIGN

Prospective case control study.

SETTING

Level III Neonatal Intensive Care Unit.

SUBJECTS

Ten small for gestational age (SGA) babies and 10 gestation matched appropriate for gestational age (AGA) babies with recurrent apnea of prematurity.

METHODS

All babies were investigated to exclude secondary causes of apnea. 5 mg/kg of aminophylline loading dose followed by 2 mg/kg as maintenance dose every 8 hourly intravenously was used. The trough and peak levels of theophylline were assessed on different days of therapy. Clinical monitoring was done for the efficacy and toxicity of the drug. Analysis was done using unpaired Student's 't' test and the correlation between plasma theophylline levels of different days was performed by using ANOVA.

RESULTS

The therapeutic drug levels were achieved within 24 hours in all babies. The SGA babies showed 25% higher drug levels as compared to AGA babies. The mean trough plasma theophylline levels ranged from 8.15 +/- 1.59 to 12.37 +/- 1.54 micrograms/ml in SGA babies while in AGA babies they ranged from 6.26 +/- 1.93 to 9.96 +/- 1.96 micrograms/ml in first 8 days of therapy. The mean peak levels in SGA babies ranged from 11.91 +/- 1.84 to 17.13 +/- 1.63 micrograms/ml and in AGA babies ranged from 8.17 +/- 1.84 to 13.02 +/- 1.48 micrograms/ml. Twenty per cent SGA and AGA babies each developed clinical toxicity though toxic drug levels were found in 50% SGA and 30% AGA babies.

CONCLUSION

There is a need to modify dosage schedule for these babies.

Neurotoxicity among pesticide applicators exposed to organophosphates

OBJECTIVES

An epidemiological study of 90 male pesticide applicators licensed in New York was conducted to investigate the effect of exposure to organophosphate pesticides on the peripheral nervous system.

METHODS

A cohort of farmers and pesticide applicators from New York State were questioned off season (November 1988-February 1989) and again during the spraying season (April 1989-August 1989) about the presence of several acute signs and symptoms. Short term exposure was validated by measuring the concentration of dimethylthiophosphate (DMTP), a metabolite of guthion, in urine. Chronic signs of subtle peripheral nerve damage were determined by vibration threshold sensitivity of the farmers and applicators tested during November 1988-February 1989 and compared with controls drawn from the general population who were tested during the same time period the next year (November 1989-February 1990). Vibration threshold sensitivity was determined for both the hands and feet. Long term exposure to pesticides was determined by questionnaire.

RESULTS

Paired t tests show that mean vibration threshold scores were significantly higher for the dominant (P < 0.00) and non-dominant (P < 0.04) hands among pesticide applicators when compared with scores for population based controls individually matched on age, sex, and county of residence.

CONCLUSIONS

A significant increase in mean vibration threshold sensitivity for the dominant and non-dominant hand suggests previous organophosphate exposure among pesticide applicators was associated with a loss of peripheral nerve function.

The incidence of retinopathy of prematurity in a neonatal care unit

In India, with advancement in neonatal care units, a large number of low-birth weight premature babies are now surviving and are at risk of developing retinopathy of prematurity (ROP). However, there are not enough reports on the incidence of ROP in this country. To determine the incidence of ROP in a prospective manner, 165 babies weighing < or = 1700 gm over a period of one year were examined. An incidence of 47.27% of ROP at the mean age of 7.21 +/- 0.3 weeks of life was detected. The maximum stage reached was stage 1 in 28 (16.97%), stage 2 in 29 (17.58%), stage 3 in 19 (11.52%) and stage 4b in 2 (1.21%) babies. Plus disease was present in 17 (10.3%) babies. Babies with lower birth weights and lower gestation age at birth had a significantly higher (p = < 0.05) incidence of ROP. However, the difference in mean birth weight and gestation age at birth for various stages of ROP was not significant (p = > 0.05). Thus, we recommend screening for all babies weighing < or = 1700 gm.

Effect of oral water soluble vitamin K on PIVKA-II levels in newborns

Intramuscular administration of vitamin K for prophylaxis against hemorrhagic disease of the newborn has the disadvantage of increased cost, pain, anxiety to parents and risk of transmission of infection. Oral route is a better alternative. Oral absorption of vitamin K has been shown to be equally good using special oral preparations. However, this preparation is not available in India. A prospective study was carried out on 51 full term, healthy breastfed newborns to evaluate if the injectable water soluble preparation of vitamin K (menadione sodium bisulphite) could be as effective. Fourteen babies received 1 mg vitamin K intramuscularly, 24 received 2 mg vitamin K orally while 13 controls did not receive vitamin K at birth. PIVKA-II levels were measured in cord blood and at 72-78 hours of age in all babies as a marker of vitamin K deficiency. The overall PIVKA-II prevalence in cord blood was 64.7%. At 72-78 hours, PIVKA-II was present in 50% of babies in IM group, 58.3% of babies in oral group and in 76.9% of babies in 'no vitamin K' group (p > 0.05). The PIVKA-II levels decreased or did not change at 72-78 hours in 91.6% of babies in oral group versus 92.8% of babies in IM group (p > 0.05). On the other hand, PIVKA-II levels increased in 30.7% of babies who did not receive vitamin K as against in 7.8% of babies receiving vitamin K in either form (p < 0.05). Hence, vitamin K prophylaxis is required for all newborns at birth and injectable vitamin K (menadione sodium bisulphite) given orally to term healthy babies is effective in preventing vitamin K deficiency state.

Role of routine lumbar puncture in neonatal sepsis

OBJECTIVE

To evaluate the utility of lumbar puncture done routinely as part of complete workup in neonatal sepsis.

METHODOLOGY

Two hundred and nine consecutive lumbar punctures performed in 169 neonates were prospectively evaluated for the diagnosis of meningitis over a 6 month period in a tertiary care referral neonatal unit.

RESULTS

Among babies with 'suspected clinical sepsis', five (3.3%) were diagnosed to have meningitis. None of the clinically normal babies with high risk obstetric factors alone had meningitis. The lumbar puncture was traumatic in 22.9%, and in 26.3% the fluid obtained was inadequate for complete analysis. The results were inconclusive in 37% of the cases.

CONCLUSION

Based on this study, routine lumbar puncture may not be required in clinically normal newborns with adverse obstetric factors. In babies with clinical sepsis, though the yield is not very high; there are no reliable clinical or laboratory markers to predict which babies will have meningitis and hence these babies would warrant a lumbar puncture.

Predictive perinatal score in the diagnosis of neonatal sepsis

A scoring system for prediction of neonatal sepsis was evolved after determining the interdependence of perinatal risk factors for infection. Records of 100 babies with a history of one or more perinatal risk factors were analysed for incidence of infection within 4 hours of birth and followed for 1 week thereafter for appearance of any clinical or laboratory signs of infection. The incidence of sepsis was compared amongst various risk factors. Since majority of perinatal risk factors occur in combinations interdependence of factors was determined using actuarial analysis and score assignment was done whether the factor was dependent or independent. No definite infection was seen in the control group of 100 babies having no history of high risk factors. The scoring system thus elucidated is recommended as a screening procedure for selecting of neonates for laboratory evaluation.

Cortisol response in acute foetal distress

Thirty neonates born after having acute intrapartum distress (study group) and 30 neonates matched for gestation, born without any clinical evidence of acute foetal distress (control group) were studied. Neonates with congenital malformation were excluded. Samples for cortisol estimation were taken from cord artery, cord vein at birth and from peripheral vein at 6 h of age. At birth maternal venous blood was also taken for cortisol estimation. Cortisol level was estimated by radioimmunoassay. Cord blood pH was measured immediately at birth in all neonates whereas base deficits were estimated in 20 neonates in the study group and 23 neonates in control group. Cortisol levels did not differ significantly in the groups with or without foetal distress. There was no significant correlation between cord blood pH and cord arterial cortisol levels. Significant positive correlation was found between cord arterial cortisol and maternal cortisol levels. We failed to find any significant cortisol response in acute foetal distress.

Preterm breech delivery in a developing country

OBJECTIVES

To determine if cesarean section offers any advantage over vaginal delivery for a preterm breech fetus in a developing country.

METHODS

A retrospective analysis from hospital records was done at a tertiary care center in North India. Two hundred and twenty-four preterm breech deliveries (28-36 completed weeks) between January 1988 and December 1991 from a total of 13,149 deliveries at the hospital during this period formed the study group. Fetal death and lethal congenital malformations diagnosed antepartum were excluded. Intrapartum and neonatal morbidity and mortality in vaginal versus cesarean deliveries were the main outcome measures.

RESULTS

Although the combined intrapartum and neonatal mortality was significantly higher for vaginal delivery (35.9% vs. 17.7%), there was no significant difference when the data was correlated with birthweight or gestational age. The neonatal morbidity was also similar in both these groups. In women with a poor obstetric history, the neonatal survival was better in the cesarean group (93% vs. 43%; P = 0.0004).

CONCLUSION

Even with optimum neonatal care facilities, cesarean section does not offer any advantage over vaginal delivery for a preterm breech fetus in a developing country. The present study does not advocate the routine use of cesarean section for this group of fetuses. However, it is the preferred route of delivery for women with a poor obstetric history.

Acute intravascular haemolysis following exchange transfusion with G-6-PD deficient blood

A neonate with hyperbilirubinaemia who developed massive intravascular haemolysis following exchange transfusion with glucose-6-phosphate dehydrogenase deficient blood is described. It is recommended that in areas endemic for this enzyme deficiency the donor blood should be screened before being used for exchange transfusion.

Neonatal necrotizing enterocolitis: a clinical study

Necrotizing enterocolitis was found in 77 infants over a 5 year period. Diagnosis of NEC was established on 4.9 + 4.8 days in babies with birth weight of 1667 + 577 grams and the gestational age of 33.3 + 2.6 weeks. Definite disease occurred in 33 (42.9%) babies while there was strong suspicion in another 44 (57.1%) babies. Prefeed gastric residue (98.7%), abdominal distension (97.3%), lethargy (78.7%), hypotonia (60%) and jaundice (48%) were the main presenting features. However, blood in stools and abdominal wall erythema were found in 38.7% babies. About one third of infants had a positive blood culture. Pneumatosis intestinalis was present in 83.9% of babies and pneumoperitoneum was seen in 35.5% of neonates with NEC. Ileo-ceco-colic region was the commonest site of involvement. Overall survival was 61% and survival with Stage III was only 13%. Birth weight less than 1500 g, gestational age less than 32 weeks, erythema of the abdominal wall, intra-abdominal mass, portal venous gas in abdominal X-ray and Gram negative septicemia were associated with higher mortality.

Mode of delivery in deep transverse arrest

OBJECTIVES

To determine the trends in the mode of delivery in deep transverse arrest (DTA) over two decades and their impact on maternal morbidity and neonatal outcome.

METHODS

Obstetric and neonatal records of women with DTA who delivered at Nehru Hospital, PGIMER, Chandigarh in the years 1970, 1980 and 1990 were analyzed.

RESULTS

Although Kielland's forceps was used very frequently in 1970 (44.4%) it had disappeared by 1990 because of increased morbidity associated with it. Instead, use of vacuum extractor and cesarean section has increased over the years. Manual rotation forceps extraction was the most commonly used vaginal method of delivery over two decades (49.5%). Perinatal outcome was better with manual rotation forceps extraction or vacuum extraction as compared to Kielland's forceps. Cesarean section was associated with a high incidence of birth asphyxia (30%).

CONCLUSIONS

Manual rotation forceps extraction and vacuum extraction are safe methods of delivery in DTA. Cesarean section as an alternative does not improve the perinatal outcome.

Neonatal necrotizing enterocolitis an epidemiological study

Necrotizing enterocolitis (NEC) was diagnosed in 77 infants among 2200 admissions to the NICU during the period January 1986 to September 1990. The incidence was 0.5% of all live births and 3.5% of NICU admissions. Majority (57.1%) had Stage I of the disease while 23.4% had Stage II and 19.5% had Stage III of the disease. The average birth weight of the babies was 1650 +/- 577 g and gestational age 33.3 +/- 2.6 weeks. Majority (53.2%) were very low birth weight (VLBW) babies. Incidence was significantly more (5.7% vs 0.25%, p < 0.001) in VLBW infants and in preterm infants of gestational age less than 32 weeks (5.2% vs 0.09%, p < 0.001). Multiple risk factors were present in these babies while 8 babies did not have any risk factor. Risk of developing NEC was significantly more if infants had any of these risk factor (p < 0.001). Incidence of severe birth asphyxia was more in Stage I cases (35.7% vs 10.3%, p < 0.05). The age at presentation was 4.9 +/- 4.8 days and majority (96%) presented during the first 14 days. The overall survival was 61% and was 70.5, 77.8 and 13.3% in Stages I, II and III, respectively. VLBW and preterm infants had a higher mortality.