Multiple congenital malformations in two sibs reminiscent of hydrolethalus and pseudotrisomy 13 syndromes

We report on two sibs, born to consanguineous parents, with defects of the midline including cleft lip and palate, flat nose, hypotelorism, and dysgenesis of corpus callosum, in addition to short limbs, radiolucent tibial notch, digital anomalies, ambiguous genitalia, and hypopituitarism. In spite of the similarities between this condition and the hydrolethalus and pseudotrisomy 13 syndromes, our patients had neither preaxial nor postaxial polydactyly, but had previously undescribed bilateral radiolucent tibial notch, which is not known to be part of those two syndromes. The cases presented here may very well represent a new autosomal recessive syndrome.

Intracranial hemorrhage in hypothermic low-birth-weight neonates

We studied periventricular/intraventricular type intracranial hemorrhage (ICH) by cranial ultrasonography in 82 low-birth-weight (LBW) newborn infants with admission hypothermia against the gestational-age-matched 82 normothermic neonates. The incidence of ICH was higher in the hypothermic infants during the 1st week of life (34/82 vs 20/82, P less than 0.02). Although the distribution of individual grades of ICH was not significantly different between the groups, the first ultrasound scan showed higher incidence of major ICH (grades 3 and 4) in the hypothermic infants. Most of the minor ICH (grades 1 and 2) after the first ultrasound appeared in infants who were small for their gestational age. Our data do not support the contention that admission hypothermia can precipitate the development of IVH in LBW infants. However, the detection of admission hypothermia in a LBW neonate should make one suspect the possibility of ICH and regard it as a manifestation of the severity of ICH rather than the cause. Most likely, this close relationship between hypothermia and neonatal ICH originates from perinatal asphyxia and the cumulative adverse effects of asphyxia-related events.

Intracranial hemorrhage in small-for-gestational-age neonates: comparison with weight-matched appropriate-for-gestational-age infants

In a comparative study of 93 small-for-gestational-age (SGA) infants against 93 weight-matched, appropriate-for-gestational-age (AGA) neonates, the SGA group exhibited a significantly lower incidence of periventricular-intraventricular type intracranial hemorrhage (ICH) at the first ultrasound scan than did the AGA neonates (9/93 vs 21/93; p less than 0.02). This apparent advantage was no longer maintained in later scans of the first week (16/93 vs 27/93; NS), despite the fact that the SGA group were 4 weeks advanced in gestational age and had fewer respiratory problems than the AGA controls. It is prudent, therefore, to follow SGA infants closely for ICH by repeat ultrasound examinations even if the first scan is negative. Evaluation of the subgroup of SGA infants with ICH against the total SGA population revealed lower admission body temperature and Apgar scores, and higher incidence of asphyxia, resuscitation, and mortality. The above observations in SGA infants with ICH and the lack of a similar trend between the AGA infants with ICH and the total AGA population suggest that SGA status, hypothermia, and ICH are interrelated. Hypothermia, therefore, can be used as a convenient marker for the possibility of ICH in low birth weight SGA infants. The authors' data is consistent with the view that hypothermia and ICH are both the consequences of perinatal asphyxia in SGA infants and probably reflect the magnitude of stormy perinatal events.

Intracranial hemorrhage in low-birth-weight twins during neonatal period

Since twins have a higher incidence of premature birth, fetal distress, asphyxia and other pre- and intrapartum high-risk factors, it is reasonable to expect that they may be vulnerable to intracranial hemorrhage. Forty-seven pairs of low-birth-weight twins were studied during the newborn period by serial cranial ultrasound. The comparisons of groups, based on birth order, relative size of the neonates, and the mode of delivery, showed no significant differences in the incidence of intracranial hemorrhage between first and second twins, smaller and larger twins, or vaginal and cesarean delivery. However, the comparison based on the presentation of the infant revealed a significantly higher number of intracranial hemorrhages within the first week of life in the breech group than in the cephalic presentation group. The adverse effect of breech presentation on intracranial hemorrhage did not appear to be mediated by the well recognized risk factors such as lower gestational age, lower Apgar scores, and higher incidence of respiratory distress syndrome and assisted ventilation. Since most of the twins with ICH had breech presentation and were delivered by cesarean section, this mode of delivery does not seem to protect the twins with breech presentation from intracranial hemorrhage.

Serum calcitonin response to administration of calcium in newborn infants during exchange blood transfusion

In 25 newborn infants, 30 "exchange" transfusions were performed. Pre-exchange serum calcitonin concentrations of newborn infants were higher than those of normal adults and of donor blood used for exchange transfusion. A gradual decline of serum calcitonin concentrations was observed with increasing postnatal age. Serum calcium and magnesium concentrations were inversely related to serum calcitonin concentrations. Newborn infants had significant elevations of serum calcitonin values within a few minutes after the administration of calcium. Gestationally younger infants (less than or equal to 33 weeks) had significantly more pronounced and swifter elevations of serum calcitonin concentrations after calcium administration than gestationally more mature infants (less than 33 weeks). We speculate that calcitonin may be an important "fetal hormone" and that increased calcitonin concentrations may relate to the pathogenesis of neonatal hypocalcemia.

The role of postnatal age and magnesium on parathyroid hormone responses during "exchange" blood transfusion in the newborn period

One hundred and eight "exchange" blood transfusions were done on 61 newborn infants. Baseline serum PTH concentrations and the PTH rise in response to citrate-induced hypocalcemia were studied. Baseline PTH values increased with postnatal age, particularly after the first three days of life. The acute response of PTH to citrate-induced hypocalcemia appears within ten minutes following the initiation of exchange transfusion and was shortlived in spite of further decline of serum ionized calcium. The dominant effect of postnatal age over gestational age was demonstrated: postnatally older but gestationally less mature infants exhibited greater responsiveness than postnatally younger, but gestationally more mature, infants. The PTH response during exchange transfusion was blunted in hypomagnesemic infants. Since lower serum magnesium concentrations were also present during the first three days of life, a separate effect of serum magnesium concentrations on parathyroid responsiveness cannot be ruled out in this study.

Tuberculosis in pregnancy with fatal congenital infection

An unusual case of miliary tuberculosis which presented as fever and a tubo-ovarian abscess in a postpartum patient is described. Fatal congenital tuberculosis was also diagnosed in the mother's premature infant. The difficulties encountered in diagnosing the tuberculosis in these patients are summarized, and the need for early recognition and therapy is emphasized. Epidemiologic follow-up of the premature infant's exposed contacts was thorough and revealed no new cases of tuberculosis among the infants or the personnel who were exposed to the infected baby.