Rigid catheters reduced duration of less invasive surfactant therapy procedures in manikins

AIM

Different catheters can be used for less invasive surfactant therapy (LIST): feeding tubes inserted with or without Magill forceps, different angiocatheters and centre specific devices, such as umbilical catheters affixed to a stylet. This study compared the effectiveness of LIST devices and endotracheal tubes (ETT).

METHODS

Video recordings of 20 neonatologists simulating different LIST techniques on two manikin heads were analysed. Procedural effectiveness was evaluated by the duration of procedures and failure rates. Ease of use was scored.

RESULTS

The median procedure time for the Neonatal Intubation Trainer was significantly longer with feeding tubes without Magill forceps. For the more difficult ALS Baby Trainer, successful procedures lasted a median of 24 (17-32) seconds with ETT, 24 (15-36) seconds with stylet-guided catheters and 34 (27-46) seconds and 37 (29-42) seconds with 13-cm and 30-cm angiocatheters, respectively. Both methods using feeding tubes were statistically slower than ETT intubation, lasting 32 (25-44) seconds and 39 (27-95) seconds with or without Magill forceps. Failure rates (7-20%) were no different between the LIST methods. Techniques using feeding tubes were rated as more difficult.

CONCLUSION

Only rigid or stylet-guided catheters required tracheal catheterisation times similar to those of endotracheal intubation and neonatologists found them easier.

Two-year neonatal outcome following PPROM prior to 25 weeks with a prolonged period of oligohydramnios

BACKGROUND

Improved neonatal survival data have been reported following early preterm prelabour rupture of membranes (PPROM) prior to 25 weeks gestation with a prolonged latency to delivery and persistent oligohydramnios. However, data regarding long-term respiratory and neurological morbidity are lacking.

AIMS

To evaluate the respiratory and neurological outcome data at two years of age in a cohort of infants born following PPROM prior to 25 weeks with a prolonged latency (14 days) to delivery and compare the data to an aged matched group of infants.

METHODS

Retrospective case note analysis over a 43-month period at Saint Luc University Hospital, Brussels.

RESULTS

15 surviving infants born following PPROM were matched to a group of 30 control infants. Although there was no significant difference in the incidence of BPD between the groups (33% vs 27%, p=0.24), the length of hospitalisation, duration of respiratory support and number of hospital readmissions for respiratory indications were all significantly higher for infants born following a prolonged period of oligohydramnios. There were no major anomalies on cranial ultrasound in the PPROM group and Baileys developmental assessment at 20-24 months corrected gestational age showed no difference between the two groups (Mental development index 93.9 vs 94.4 and Psychomotor development index 95.5 vs 95.8 respectively p = ns).

CONCLUSION

Neurodevelopmental outcome appears encouraging in this cohort although these infants are at high risk of prolonged initial hospitalisation and significant respiratory morbidity in the first two-years of life.

Contemporary neonatal outcome following rupture of membranes prior to 25 weeks with prolonged oligohydramnios

BACKGROUND

Prolonged oligohydramnios following early preterm prelabour rupture of membranes (PPROM) is traditionally associated with high neonatal mortality and significant risk of pulmonary hypoplasia. However, recent evidence points to an apparent improvement in outcome.

AIMS

To document current neonatal outcomes following rupture of membranes prior to 25 weeks with severe persistent oligohydramnios and a latency to delivery of at least 14 days.

METHODS

A retrospective case note analysis over a 28-month period at Saint Luc University Hospital, Brussels.

RESULTS

From 23 pregnancies that were complicated by PPROM prior to 25 weeks, 15 infants were born after 24 weeks with a latency of more than 14 days and persistent oligohydramnios. Nine infants (60%) had severe respiratory failure and clinical signs compatible with pulmonary hypoplasia. Seven of these infants (78%) responded to high frequency ventilation and inhaled nitric oxide therapy with good clinical outcome but two died from severe respiratory failure. Five infants showed no clinical signs of pulmonary hypoplasia and responded to conventional neonatal management. One of these infants died at 77 days of age of necrotising enterocolitis. One infant was not resuscitated and died within minutes of birth, following prior discussion with the perinatal team and the parents. Survivors in this high-risk group (73%) had low morbidity at the time of discharge.

SUMMARY

The favourable neonatal survival and morbidity figures are in keeping with recent published evidence. This study confirms improved outcome even amongst the highest risk infants with documented persistent oligohydramnios.

Vitrification of human blastocysts with the Hemi-Straw carrier: application of assisted hatching after thawing

BACKGROUND

The present study was undertaken to examine the usefulness of both vitrification and assisted hatching (AH) on blastocysts that originate from embryos showing different qualities during their cleavage stage.

METHODS

A total of 281 blastocysts were vitrified (93 vitrification-warming cycles) in a mixture of ethylene glycol-dimethylsulphoxide-Ficoll and sucrose using the Hemi-Straw (HS) carrier system. After warming, AH using the partial dissection technique was performed in 36 cycles.

RESULTS

After warming and culture for 24 h, a total of 168 blastocysts (60%) was suitable for embryo transfers and a total of 25 ongoing pregnancies (27%) was obtained. Forty-nine transfers of 96 no-AH blastocysts and 36 transfers of 72 AH blastocysts resulted in an implantation rate of 13 and 22% respectively (P < 0.05). The percentage of transfers with at least one hatching blastocyst was significantly higher after application of AH (69 versus 33%) (P < 0.001). In all, 73 and 38% of blastocysts showing respectively optimal and non-optimal embryo development during the early stage were available for transfer (P < 0.001). Consequently, implantation rates of 19 and 6% were obtained after transfers of blastocysts showing respectively optimal and poor embryo development.

CONCLUSIONS

Artificial opening of the zona pellucida after warming of vitrified blastocysts significantly improved the rate of transfers with hatched blastocysts and the implantation and pregnancy rates. The percentage of blastocysts that survived the HS vitrification procedure and were available for embryo transfer is related to their previous developmental quality.

Births after vitrification at morula and blastocyst stages: effect of artificial reduction of the blastocoelic cavity before vitrification

BACKGROUND

In 1996, with the introduction of sequential media, we set up a programme of cryopreservation of supernumerary morulae (day 4) and blastocysts (day 5) using a vitrification procedure. Our results showed that the efficiency of the vitrification method was dependent on the stage of embryo development and was negatively correlated with the expansion of the blastocoele. We postulated that a large blastocoele might disturb cryopreservative potential due to ice crystal formation during the cooling step. We analysed therefore the effectiveness of reducing before vitrification the volume of the blastocoelic cavity.

METHOD

Day 4 and day 5 embryos were vitrified in 40% ethylene glycol-18% Ficoll and 0.3 mol/l sucrose before plunging the straws directly into liquid nitrogen. Artificial shrinkage of the blastocyst was achieved after pushing a needle into the blastocoele cavity until it contracted.

RESULTS

The survival rate post-thawing of day 4 and intact day 5 embryos was correlated with the volume of the blastocoele. In the control group only 20.3% blastocysts or expanded blastocysts survived as compared with 54.5 and 58.5% with morulae and early blastocyst respectively. After puncturing the blastocoelic cavity, an increase in the survival rate of up to 70.6% was noted. The pregnancy rates were improved after the artificial shrinkage procedure (20.5%) compared with the control intact blastocyst group (4.5%) (not significant). After reduction of the blastocoelic cavity, a significant increase in the implantation rate per vitrified blastocyst was observed (12.0 versus 1.4% P < 0.01).

CONCLUSIONS

Our results showed that survival rates in cryopreserved expanded blastocysts could be improved by reducing the fluid content. This was presumably because mechanical damage caused by ice crystal formation was avoided. These observations should be considered when establishing a strategy and a protocol for cryopreservation of day 5 embryos.

[Choanal atresia: a retrospective study of 39 cases]

The purpose of this study was to investigate the clinical characteristics and the surgical management in patients with choanal atresia. We performed a retrospective study at the Saint-Luc University hospital, Brussels, between January 1988 and June 2000. Surgical corrections were performed using different approach (transnasal endoscopic, transpalatal) and different instrumentations (urethral sounds, laser nd-YAG, laser CO2, microdebrider). Portex endotracheal tubes were inserted as nasal stents in the vast majority of the patients with bilateral choanal atresia. Thirty-nine children with choanal atresia (22 unilateral and 17 bilateral) (9: M, 30: F) were studied. 38 of them were surgically managed. Based on clinical inspection and On CT-Scan, choanal atresia was defined as membranous for 4 patients, osseous for 6 and mixte for 29. Associated congenital anomalies were found in 22.7% of unilateral and in 70.5% of bilateral choanal atresia (Total: 43.5%). Of those children with bilateral choanal atresia, 75% were asymptomatic after four surgical procedures. In children with unilateral choanal atresia, 45% were asymptomatic after one surgical correction and 100% after three surgical corrections. Four patients were managed using an endoscopic endonasal approach with the microdebrider and showed no evidence of recurrence. Outcome analyses of factors that may influence the results of surgery are difficult to establish since many different surgical options were taken during this period. However, it seems that bilateral choanal atresia is associated with more surgical corrections before achieving a normal nasal breathing than unilateral choanal atresia. After this review, our current strategy regarding the choanal atresia will be to begin with the endoscopic endonasal approach using the microdebrider (stents if bilateral) and to propose the transpalatal approach in case of recurrence.

Lymphatic malformations of the head and neck: a retrospective review and a support for staging

BACKGROUND

Lymphatic malformations (LM) are rare benign congenital tumors appearing mainly in the head and neck with a considerably variable outcome. A need exists to validate a staging system, taking into account the prognosis of the malformation, including preoperative and postoperative complications, long-term sequelae, and persistence of the disease to improve parental counseling and evaluate the outcome of a surgical treatment of such tumors.

METHODS

Twenty-two patients treated for LM were selected from a series of 129 patients operated on for congenital malformations of the head and neck between 1986 and 1997 at St-Luc University Hospital, Brussels, Belgium. Their charts were reviewed retrospectively, with a special focus on the anatomic location of the lesions and all the complications reported. According to de Serres et al, LM up to now have been divided into six possible categories according to their unilateral or bilateral infrahyoid and/or suprahyoid locations.

RESULTS

Stage I (unilateral infrahyoid): nine patients, 11% of complications (without mediastinal extension: 0%, with mediastinal extension: 50%); stage II (unilateral suprahyoid): three patients, 33% of complications; stage III (unilateral suprahyoid and infrahyoid): eight patients, 75% of complications; stage V (bilateral suprahyoid and infrahyoid): two patients, 100% of complications. None of the children was initially seen with stage IV (bilateral suprahyoid) or stage VI (bilateral infrahyoid) LM. Overall complications, preoperative complications, postoperative com- plications, and long-term morbidity showed a significant in- crease from stage I to V (p <.01, p =.002, p =.02, and p =.03, respectively).

CONCLUSIONS

A staging system of cervicofacial LM based on the anatomic location can be reliably used for prognostic purposes, allowing a more accurate assessment of the global risk of complications and determination of surgical outcome. Mediastinal extension in stage I patients seems to be associated with a higher rate of complications. Such information can be used to inform parents more appropriately regarding the management and long-term prognosis of their children's malformation.

[Perinatal thrombocytopenia of maternal origin]

Maternal causes of perinatal thrombocytopenia include neonatal alloimmune thrombocytopenia, autoimmune disorders, intrauterine infections and hypertensive diseases. The diagnosis of these pathologies is difficult because they can occur in sick neonates, but also in healthy babies without a history suggesting illness. The treatment has to be quickly established in order to decrease eventual hemorrhagic complications. These latter can be amplified by several clinical circumstances and especially by the platelet immaturity of this time of life. The risk of recurrence for the next pregnancies has to be determined and can lead to diagnostic or therapeutic measures during the antenatal period.

Severe exacerbation of liver disease during pregnancy in a thalassemic GBV-C/HGV-positive patient and neonatal hepatitis in offspring

The case of a young woman with GB virus C/hepatitis G virus (GBV-C/HGV) infection and with a severe exacerbation of chronic hepatitis of unknown etiology during pregnancy is described. In the offspring, severe neonatal hepatitis with subsequent mild chronic liver disease of at least 16-month duration was followed by the development of antibodies to the envelope protein (E2) of GBV-C/HGV, suggesting that the child was recovering from GBV-C/HGV infection. There was an improvement in clinical and biochemical parameters in the mother following delivery and alpha-interferon therapy was associated with a transient biochemical response.

Recurrence of neonatal haemochromatosis in half sibs born of unaffected mothers

We report two families in which neonatal haemochromatosis was observed in half sibs. In the first family, two successive girls were born of different fathers. In the second family, an affected brother and sister were followed by an affected half brother born after donor insemination. These observations, as well as a previous abstract describing two affected half sisters, revive the debate over the inheritance of neonatal haemochromatosis. Incomplete penetrance or gonadal mosaicism for a dominant disorder, a maternal "environmental factor", or mitochondrial defect may be more suitable explanations than autosomal recessive inheritance in this condition. Alternative modes of fertilisation, such as donor insemination or in vitro fertilisation with donor eggs, should be considered with caution.

Fetal liver hemangioma and chorioangioma: two unusual cases of severe fetal anemia detected by ultrasonography and its perinatal management

Severe anemia was diagnosed by cordocentesis in two fetuses, one with a large chorioangioma, the other with a liver hemangioma. Despite the presence of a chronic fetotumoral shunt, both cases were partly treated by a fetal intravascular transfusion, followed by an elective Cesarean section. This 'predelivery' management of anemia should improve neonatal morbidity associated with severe hematological and acid-base balance disorders.

Sonographic evaluation of traumatic spinal cord lesions in the newborn infant

We present a case of spinal cord injury due to birth trauma and assess the value of sonography for diagnosis, lesion characterization, and follow-up. Sonography is a non-invasive and easily reproducible imaging method for examining a ventilated child, and its initial sensitivity is comparable to that of MRI. Sonography is the method of choice for guiding diagnosis in this type of traumatic lesion to the newborn.

[Congenital paralysis due to compression. Apropos of 4 cases]

Four cases of congenital dysfunction of major peripheral nerves are reported and discussed. The first patient was a girl born by spontaneous delivery with an area of skin and muscle necrosis on the dorsal aspect of the forearm and a palsy of the three major nerves of the upper limb. The second patient was a boy born by caesarean section with the same necrotic lesions and a palsy of the ulnar and median nerve. The third patient was a boy born uneventfully with a truncal lesion of the sciatic nerve at the thigh. The fourth who was delivered by caesarean section for alteration of the monitoring presented a severe strangulation of the arm by the umbilical cord with palsy of the radial and ulnar nerve. The palsies recovered spontaneously and the sequelae are mostly due to the muscle necrosis. Congenital dysfunction of major peripheral nerves have been described as a complication of congenital constriction band syndrome, in association with subcutaneous fat necrosis, neonatal gangrene or aplasia cutis congenita. Intrauterine compression of a limb may be favoured by decreased foetal activity, by spontaneous rupture of the amniotic sac, particularly if there is a delay in delivery and by abnormal uterine activity during labour. Our three first cases confirm that the compression may arise before the labour. The fourth demonstrates that umbilical cord strangulation may lead to anoxia of the foetus together with compression of the limb.

Sperm morphology and IVF pregnancy rate: comparison between Percoll gradient centrifugation and swim-up procedures

Many groups currently use two methods for the separation of motile spermatozoa, swim-up (S-up) and centrifugation on discontinuous Percoll gradient (PGC), and comparison of results indicates that PGC is superior. In this study we have attempted to identify the factors explaining this difference. This laboratory has long-standing expertise in seminology, thus the parameters of sperm morphology were the obvious first choice for detailed study. First, the respective effects of S-up and PGC on sperm morphology were analysed in different types of ejaculates: 62 semen samples with normal parameters and 41 with poor parameters. Both separation techniques resulted in improved morphology in the final preparation but only the increase of morphologically normal spermatozoa in the final Percoll suspension was significant. Second, application of these techniques in our in-vitro fertilization (IVF) programme revealed that, together with the improvement of sperm morphology, a higher pregnancy rate was obtained after PGC. The ongoing pregnancy rates per oocyte retrieval were 21.1% for the S-up technique and 33.3% for the PGC technique. These data show that spermatozoa selected by PGC present an improved morphology which we believe to be linked to improvement of the quality of the in-vitro fertilized embryos and ultimately the percentage of successful IVF results.

Techniques of sperm selection, improvement and separation in an in vitro fertilization program

The Authors present a review of the various techniques used for improving the fertility potential of sperm within the context of an in vitro fertilization (IVF) program. After a brief description of the mechanisms leading to normal in vivo fertilization, they discuss the different methods of selecting and improving sperm for IVF. They conclude that centrifugation on discontinuous Percoll gradients would seem to be the most efficient separation method from all points of view, while the addition of pharmacological agents to improve sperm quality and motility lead to extremely unsatisfactory results.

Within-subject variations of sperm parameters and their importance in an in vitro fertilization program

Spermiograms of 150 males were assessed, in view of studying them before an in vitro fertilization attempt. Within subject variations were determined with regard to sperm count and spermatozoal motility pattern. Ultimately these results were compared to the seminological parameters studied at the time of the in vitro-fertilization attempt. Overall results showed a clear drop in semen parameters at the time of egg retrieval. This drop was more marked when semen parameters were amongst the higher values at the start.