Congenital rubella syndrome in Western Australia

The birth prevalence of congenital rubella syndrome (CRS) in Western Australia has been around 20 per 10 000 live births with peaks up to 100 per 10 000 in rubella epidemic years. The rate appears to be falling but it is still too soon to know whether the rubella vaccination programme in Western Australia has made a significant impact. The cohorts of young women who would have received the schoolgirl vaccination programme are only now entering the child bearing age groups. Observed falls may be due also to delayed diagnosis particularly of cases of deafness only. The proportion of nonimmune young women who would have been eligible for the programme in one maternity hospital has fallen. This study needs to be repeated to ascertain whether further epidemics of rubella have resulted in peaks of CRS or whether the vaccination programme has started to have an effect.

Perinatal events and intraventricular/subependymal hemorrhage in the very low-birth weight infant

One hundred nineteen very low-birth weight infants were studied to see whether intrapartum fetal distress with or without acidosis correlated with the development of intraventricular and subependymal hemorrhage. Of 112 infants studied prospectively, 24% (27/112) had intraventricular/subependymal hemorrhage documented by real-time ultrasound studies shortly after birth; only 4.4 (5/112) had severe hemorrhage (grade 3/4). Ominous fetal heart rate patterns occurred in 50% of monitored infants with severe intraventricular/subependymal hemorrhage compared to 8% of matched controls (p less than 0.01). Reassuring fetal heart rate patterns were more predominant in infants without intraventricular/subependymal hemorrhage (p less than 0.05). Neonatal depression and the need for assisted ventilation beyond the immediate delivery period were more frequent in infants who developed intraventricular/subependymal hemorrhage. Antepartum and intrapartum complications, fetal presentation, cesarean section, duration of labor, hyaline membrane disease, and volume expansion appeared to play no role in the incidence of intraventricular/subependymal hemorrhage. Preliminary data presented here suggest that intrapartum fetal distress and acidosis may be significant factors in predicting which very low-birth weight infant will develop intraventricular/subependymal hemorrhage. The condition of the infant at birth may be more significant with respect to the extent of intraventricular/subependymal hemorrhage than a variety of obstetric variables. Aggressive management of appropriately selected patients and judicious resuscitation of the very low-birth weight infant may keep the incidence of severe intraventricular/subependymal hemorrhage at a minimum, thereby optimizing neurological outcome for this high-risk group.

Ultrasound signs in threatened abortion and their prognostic significance

During the first and early second trimesters of pregnancy in 244 consecutive patients with uterine bleeding, ultrasound studies were conducted to determine the cause of bleeding. In 165 of the patients the fetus was alive, and the outcome of pregnancy was successful in 143 (87%) despite the fact that ultrasound scanning revealed a total of 60 abnormalities. In the 22 patients whose pregnancy outcome was unfavorable, the number of abnormalities was significantly higher (P less than .05). The most common ultrasound abnormalities were placenta covering the internal os, fetal growth delay, multiple gestation, and intrauterine hematoma. At ultrasound examination, the presence of one or more abnormalities plus bleeding for three days or more significantly increased the risk to the pregnancy. When the duration of bleeding was less than three days and the ultrasound examination was normal, the risk to the pregnancy was lower (7%) than that of patients who had bled for three days or more and had at least one abnormality on ultrasound examination (24%) (P less than .05).

Brain injury and intrauterine death

Many of the stresses contributing to brain injury in the intrapartum or neonatal period may also exist prenatally. To define this problem, we reviewed the clinical features and neuropathologic findings in 433 consecutive stillbirth autopsies. Twenty-five had evidence of periventricular/intraventricular hemorrhage or gliosis. Twenty infants had died in utero before active labor and five during delivery. Nine stillbirths were infected. Ten cases had periventricular/intraventricular hemorrhage alone, five had the hemorrhage with parenchymal hemorrhage, five had parenchymal hemorrhage only, and five had gliosis. This group of 25 cases establishes that intrauterine brain injury is not rare. Separation of antepartum events occurring in utero from those imposed during labor, delivery, resuscitation, and the neonatal period is very important and has significant medical and legal implications.

[Anti-rubella IgM and IgG antibodies in congenital cardiopathy]

In utero infection by rubella virus is a well known cause of congenital heart disease. We look for prevalence of anti-rubella antibodies of IgM (primary response) or IgG (anamnestic response) classes in sera of 32 children with congenital heart disease and in 12 normal children of the same socioeconomic background. Only in a patient with a full congenital rubella syndrome we found high titers of IgG anti-rubella antibodies, there was no difference in prevalence of IgM nor IgG anti-rubella antibodies between normals and cardiac patients. There is no reason to look for anti-rubella antibodies in the isolated congenital heart disease.

Nonimmunologic fetal hydrops associated with hyperreactio luteinalis

A case of nonimmunologic fetal hydrops associated with maternal bilateral theca lutein cysts (hyperreactio luteinalis) is presented. It is proposed that the theca lutein cysts were caused by elevated human chorionic gonadotropin (hCG) production from the hydropic placenta. These cysts appeared to regress after the patient's delivery, while beta-hCG levels declined.

[Etiology and pathogenesis of congenital physical and mental handicaps]

Two to five percent of newborn infants present with congenital structural defects. This incidence contains mostly rare to extremely rare conditions. Aetiologically, these consist of defects secondary to genetic and environmental causes, with a third group of defects which are presumed to be due to an unfavorable combination of genetic and environmental factors. In many individual patients, however, allocation into one of these groups is difficult or even impossible. The following clinical and epidemiologic observations may help in some cases to arrive at a classification; pedigree, pregnancy history (infections, teratogens, bleeding, foetal movements etc.), clinical picture and various complementary investigations. Pathogenetically, we may classify congenital structural defects into primary defects (malformations) and secondary ones, if a primarily correctly formed structure has secondarily been deformed (deformation) or destroyed (disruption). In many cases, these clinical observations will then allow a classification into one of the groups. The importance of the determination of the aetiology and pathogenesis of structural defects for the individual family is in the subsequent implications for determination of the risk of recurrence.

The pathogenesis of prune belly

Three neonates were born with marked abdominal muscular laxity from three different conditions (posterior urethral valves, nonimmune ascites, and intestinal duplication); two had fetal abdominal distention by ascites documented in utero by obstetric ultrasonographic examination. Another fetus, whose abdominal distention was relieved at 21 weeks' gestation by in utero decompression of urinary obstruction, was born with only mild abdominal changes, which suggests that the "prune belly" phenotype can resolve if distention is relieved early enough. These observations suggest that the abdominal laxity in prune belly syndrome is a simple deformation secondary to abdominal stretching and distention during fetal development and is not an intrinsic generalized mesodermal abnormality.

Congenital hydrocephalus secondary to intra-uterine germinal matrix/intraventricular haemorrhage

An infant with hydrocephalus which had been diagnosed at birth died at one month of age. Subsequent neuropathological studies demonstrated old germinal matrix haemorrhage and complete occlusion of the aqueduct of Sylvius by fibroglial tissue, both of which appeared to be older than four weeks, indicating that they had occurred in utero. These observations are consistent with the occurrence of intra-uterine intraventricular haemorrhage secondary to haemorrhage of the subependymal germinal matrix, leading to occlusion of the aqueduct of Sylvius and hydrocephalus prior to birth.

[Fetal hydrops caused by cardiac failure in utero: description of 2 cases and pathogenetic considerations]

Two cases of congestive heart failure in utero with fetal hydrops are reported. The diagnosis was made during pregnancy by means of echography. Cardiac failure, derived from supraventricular tachycardia not associated with structural anomalies of the heart, was observed in one of the patients. By digoxin administration and vagal stimulation the rhythm reverted to sinus, one hour after birth. In the second case fetal echography showed a fetus with serious bradycardia (45/min.) and ascites. On the bases of a median located and symmetric liver and of a complex heart malformation a diagnosis of "isomeric syndrome" was supposed. One hour after vaginal delivery, the newborn dead and autopsy confirmed a left isomeric syndrome with polisplenia and complex congenital cardiopathy (left ventricle and mitral hypoplasy, double outlet right ventricle, pulmonary stenosis, anomalous systemic and pulmonary venous return).

Outcome in infants with birth weight 500 to 999 gm: a regional study of 1979 and 1980 births

During 1979 and 1980, 351 infants weighing 500 to 999 gm were born in the State of Victoria, Australia; 89 (25.4%) survived to 2 years of age. Survival was better for tertiary center births (29%) than for those born elsewhere (17%). Multidisciplinary teams reviewed 83 of the survivors at 2 years of age postterm; some data were available for the other six children. Overall, 22.5% of infants had severe functional handicap, 29.2% had either moderate or mild handicap, and 48.3% had no handicap. Severe functional handicap was present in 50% of outborn infants; this was significantly more common than in those born in tertiary centers (15.5%), and the Bayley Mental Developmental Index was also significantly lower in outborn infants. The prevalence of cerebral palsy (13.5%), bilateral blindness (3.4%), and severe sensorineural deafness (3.4%) did not differ significantly in the inborn and outborn infants. Singleton inborn infants of appropriate weight for gestational age had significantly less severe functional handicap (9.1%), compared with 37.5% for the group of infants who were either small for gestational age or one of multiple births. Six of the 18 outborn infants could have been transferred in utero, and improvements in immediate neonatal care were possible in seven other infants.

Behavior troubles in nursery school children and their possible relationship to pregnancy or delivery difficulties

Thirty four children, 3-5 year old, of 3 nursery schools, with emotional inhibition or temper tantrums detected by the nursery staff, were investigated on difficulties in pregnancy or delivery, by specifically asking their mothers. Compared to a matched control group, the mothers of probands reported more anxious pregnancies (.025), more somatic disturbed pregnancies (.005), experienced more foetal hypermotivity (.05), and their deliveries were more anomalous (.005). The vital conditions of their new-borns were affected by more distress (.025). Since there is an increasing amount of literature stressing on one hand on relationships between pregnancy and delivery difficulties and future biopsychological and social maladjustment, and on the other hand on childhood antecedents of adult mental diseases, an early detection and a correct causality are the first steps to right therapeutic interventions.

Intrauterine infections with group B beta-haemolytic streptococci

The case records of 15 infants with intrauterine infections due to group B beta-haemolytic streptococci were traced from the records of two geographically separate centres over a 4-year period (1979-1982). Six infants were stillborn and the other nine died within the first 6 h. All the infants weighed less than 1000 g and were less than 28 weeks gestation. Placental examination in 14 of the 15 infants showed the presence of chorioamnionitis and funisitis. The infants also showed evidence of pneumonitis. Four infants had evidence of otitis media, two had evidence of an early meningitis. A history of antepartum bleeding was present in six infants and abundant retroplacental clot was noted in four of them. The membranes had been ruptured for greater than 24 h in only three infants. In six of the infants the membranes were intact at the time of delivery. A history of intact membranes at the time of delivery does not exclude a diagnosis of an intrauterine infection with this organism, and this series of infants highlights the importance of routine bacteriologic studies of all perinatal deaths.

Fetal polyuria and hydramnios associated with Bartter's syndrome

The case of a woman with recurrent hydramnios in three pregnancies, from which the only surviving infant was later found to have Bartter's syndrome, is described. Analysis of electrolytes, renin activity, and aldosterone levels in amniotic fluid from this pregnancy are presented. The finding of maternal hydramnios in the present and 12 other reported cases of Bartter's syndrome suggests that increased fetal voiding is the most likely causative factor in the development of increased amniotic fluid volume. Early onset hydramnios might signify Bartter's syndrome in the offspring in families with an index case. In cases of hydramnios of unknown etiology, appropriate investigations might lead to early diagnosis and treatment of Bartter's syndrome.

Diagnostic considerations in arthrogryposis syndromes in South Africa

Congenital rigidity of multiple joints poses a difficult diagnostic and therapeutic problem. There are also semantic difficulties as the non-specific term "arthrogryposis" is often used for any individual with congenital limitation of joint movement. Many distinct syndromes present in this way and as they differ in their course, prognosis and genetic implications, diagnostic precision is crucial. A diagnostic analysis is given of 247 South African patients in whom "arthrogryposis" had been recorded, and the pathogenesis and nosology of congenital contractures are discussed in this paper. Three of these stiff joint conditions were originally described in South African patients, i.e. Liebenberg synostosis syndrome, digitotalar dysmorphism, and the Gordon syndrome of autosomal dominant cleft palate, camptodactyly and club feet.

Sinusoidal rhythm caused by fetal hemorrhage during fetoscopy

The sinusoidal fetal heart rate pattern has been reported to be associated with fetal anemia, hypoxia, administration of alphaprodine while, in other cases, it has been followed by good fetal outcome. In this case study fetoscopy was performed in a patient with thalassemia trait for prenatal diagnosis of thalassemia. Following the insertion of the trocar, bloodstained amniotic fluid was aspirated which resulted to be all fetal in origin. Estimation of feto-maternal hemorrhage was 5.7 ml while the amount of intra-amniotic bleeding could not be assessed. Fetal heart rate, which was recorded throughout fetoscopy, showed a sinusoidal pattern starting two minutes after the fetal hemorrhage which lasted more than ten minutes. Two hours later the fetal heart rate was normal. The pregnancy continued uneventfully and a healthy female baby weighing 3100 g was delivered at 38 weeks' gestation. Review of the literature suggests that a sinusoidal pattern may be caused either by a hemodynamic disturbance or fetal acidosis. In any case it does not always indicate impending fetal death.

Severe neonatal anemia possibly caused by spontaneous cephalic version, with excellent outcome--a case report

A 29-year-old primipara with breech presentation had a spontaneous cephalic version a few days before her admission. She was hospitalised because of a sudden decrease in fetal movements perceived. During labour a sinusoidal fetal heart rate pattern was observed. The mother gave birth to a strikingly pale 3250 g weighing boy. His APGAR score was 1/5/6. Cord hemoglobin was 2.9 g/dl and an acid elution test showed the presence of 9.1% fetal red cells in the maternal circulation. Following a transfusion of packed cells and total blood, the babies hemoglobin rose to above 10 g/dl. On the second day of life he developed an acute functional renal failure which responded well to fluid restriction and furosemide administration. Upon discharge, 10 days after birth, the physical and neurological examination were normal. At present time the child is two years old and thriving well. Anemia in the newborn due to occult blood loss may be the result of bleeding of the fetus into the maternal circulation. The incidence of a massive transplacental blood loss is increased by traumatic amniocentesis, by external cephalic version and during cesarian section. As illustrated by the present case, spontaneous cephalic version may possibly account for another cause of feto-maternal transfusion resulting in severe neonatal anemia. Severe anemia at birth secondary to an acute and massive feto-maternal hemorrhage is commonly associated with a poor prognosis. Under such conditions immediate re-expansion of the blood volume proved to be life saving.

[Rubella embryopathy with meningoencephalitis and demonstration of oligoclonal IgG in the cerebrospinal fluid]

A first case of congenital rubella with evidence of oligoclonal IgG in serum and cerebrospinal fluid during early manifestation is reported. The mother contracted the rubella infection during the first month of gestation. In addition to the more frequent symptoms of rubella embryopathy there were signs of active meningoencephalitis in the newborn. As a rare eye defect, bilateral congenital glaucoma was observed. Cranial computed tomography gave evidence predominantly for white matter involvement. Elevated IgG levels and oligoclonal IgG were found in both cerebrospinal fluid and serum. By means of quantitative estimation, a local synthesis of IgG in the central nervous system could be demonstrated.