Congenital infections as contributors to the onset of diabetes in children: A longitudinal study in the United States, 2001-2017

BACKGROUND

Maternal infections during pregnancy, particularly with rubella virus, were reported to increase the risk of diabetes in children. Widespread vaccination has decreased the number of infants with congenital rubella syndrome in the United States, although it remains a problem in developing countries. Because vaccine hesitancy has recently increased, we investigated the association between congenital infections with subsequent diabetes risk in children in the United States.

METHODS

Using data from a nationwide private health insurer for years 2001-2017, 1 475 587 infants were followed for an average of 3.9 years (maximum 16.5 years). Information was obtained regarding congenital infections (rubella, cytomegalovirus, other congenital infections) and perinatal infections, as well as for the development of diabetes mellitus and diabetic ketoacidosis.

RESULTS

There were 781 infants with congenital infections and 73 974 with perinatal infections. Diabetes developed in 3334 children. The odds of developing diabetes for infants with congenital rubella infection were 12-fold greater (P = .013) and, for infants with congenital cytomegalovirus infection, were 4-fold greater (P = .011) than infants without congenital or perinatal infection. Infants with other congenital infections had 3-fold greater odds of developing diabetes (P = .044). Results were similar for diabetes ketoacidosis. Infants with other perinatal infections had 49% greater odds of developing diabetes during the follow-up period (P < .001).

CONCLUSION

Congenital and other perinatal infections are associated with elevated risks of developing diabetes mellitus during childhood. Vaccination for rubella remains an important preventive action to reduce the incidence of diabetes in children.

Perinatal and long-term outcomes in fetuses diagnosed with isolated unilateral ventriculomegaly: systematic review and meta-analysis

OBJECTIVES

The majority of studies on fetal ventriculomegaly have focused on the perinatal and long-term outcomes in fetuses with an antenatal diagnosis of bilateral ventriculomegaly. The aim of this study was to undertake a systematic review and meta-analysis to quantify the perinatal and long-term outcomes in fetuses diagnosed in the second or third trimester of pregnancy with isolated unilateral ventriculomegaly.

METHODS

MEDLINE, EMBASE and The Cochrane Library were searched electronically. Outcomes investigated included incidence of aneuploidy, congenital infection, progression of ventriculomegaly, associated brain and extracerebral abnormalities in the apparently isolated cases and neurodevelopmental delay in both apparently and truly isolated cases. Sensitivity analysis was performed according to whether the ventriculomegaly was mild/moderate (atrial width < 15 mm) or severe (atrial width ≥ 15 mm). Reference lists within relevant articles and reviews were hand-searched for additional reports. Cohort and case-control studies were included. Meta-analysis of proportions was used, and between-study heterogeneity was assessed using the I² test.

RESULTS

The search yielded 2053 citations. The full text was retrieved for 202, and 11 studies were included in the systematic review. In fetuses with apparently isolated unilateral ventriculomegaly, no chromosomal abnormalities were identified and the pooled prevalence of congenital infection was 8.2% (95% CI, 3.6-14.5%). The pooled prevalence of additional brain abnormalities detected prenatally and postnatally by magnetic resonance imaging was 5.1% (95% CI, 0.2-16.1%) and 6.4% (95% CI, 0.3-19.4%), respectively. The pooled prevalence of abnormal neurodevelopment was 5.9% (95% CI, 2.2-11.2%) in apparently isolated cases with an atrial width of < 15 mm, and it was 7.0% (95% CI, 3.2-12.2%) in fetuses with truly isolated unilateral ventriculomegaly. Most cases with apparently isolated ventriculomegaly were classified as mild/moderate (93.5%) and therefore the outcomes in this group were similar to those in the whole cohort of apparently isolated ventriculomegaly.

CONCLUSIONS

The prevalence of aneuploidy, congenital infection and neurodevelopmental delay in fetuses with a prenatal diagnosis of isolated unilateral ventriculomegaly is likely to be low. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[Vaccination of premature infants, a population at high risk of infection]

The incidence of prematurity has steadily increased in Belgium these last years, reaching 7,9 % in 2010. Infections remain for these infants an important cause of morbidity and mortality during their hospitalization in the neonatal intensive care units as well as during their first months of life in the community. Despite the immaturity of their immune system, their ability to develop a protective immune response to most vaccines has been established. Instable very low birth weight prematures are at risk cardio- respiratory incidents after vaccine administration, but these incidents are transient and without consequences if they are monitored during and after vaccination. This paper reviews the current recommendations on the immunization of the premature infants.

[Congenital and perinatal infections in the Marche region (Italy): an epidemiological study and differences between ethnic groups]

The purpose of this study was to evaluate the epidemiological data regarding congenital and perinatal infections in the Marche region to verify the existence of differences in relation to maternal country of origin. This prospective study was conducted from May 2001 to April 2012, and it involved all the maternity units of the Marche region. A total of 10232 pregnant women were included, 25.1% of whom were of foreign nationality while the number of births totalled 10371. Estimated uptake of antenatal screening was 80.5% for CMV infection, 98.6% for HBV infection, 97.5% for HCV infection, 97.4% for HIV infection, 93.1% for syphilis and 98.5% for toxoplasmosis. For group B streptococcus vaginal and perianal swabs were performed in 81.2% of all women (78.4% in immigrant and 90.4% in Italian women; the difference was statistically significant [p 0.001]) and 13.6% were positive. The overall prevalence for CMV infection was 72.3% (91.9% in immigrant women) while for toxoplasmosis it was 27.5% (28.8% in immigrant women). The rate of seroconversion in pregnant women investigated for CMV infection was 0.28%, while that for toxoplasmosis was 0.09%. The overall prevalence for HBV infection was 0.79% (4.3% in immigrant and 0.4% in Italian pregnant women; the difference was statistically significant [p 0.001]), 0.4% for HCV infection (1% in immigrant and 0.48% in Italian pregnant women; the difference was not statistically significant [p 0.413]), 0.22% for syphilis (0.8% in immigrant and 0.08% in Italian pregnant women; the difference was not statistically significant [p 0.062]), 0.09% for HIV infection, and 0.03% for tuberculosis. The prevalence of congenital CMV infection was 0.04% and that of congenital toxoplasmosis 0.01%. The prevalence of early-onset infection from Group B streptococcus was 0.029%. No cases were observed of congenital syphilis, congenital tuberculosis or maternal and neonatal HSV infections. The study proves that in the Marche region there is a high percentage of women who undergo prenatal screening, including screening for infections, not offered by the National Health Service, such as CMV and HCV. The data also demonstrate that some infections, such as tuberculosis, HIV and HBV, almost exclusively affect immigrant women. Regarding neonatal infections, the data presented are in line with those in the literature, with the exception of congenital CMV infection, in which the low prevalence observed could be linked to the recent and massive migration of already immunized women.

Maternal plasma lipopolysaccharide binding protein (LBP) concentrations in pregnancy complicated by preterm premature rupture of membranes

OBJECTIVES

To compare maternal plasma LBP concentrations in pregnancies complicated by preterm premature rupture of membranes (pPROM), and PROM at term, with their levels in uncomplicated pregnancy, and to determine whether LBP concentrations are of value in the diagnosis of subclinical intra-amniotic infection (IAI) in the prediction of the length of the pPROM-to-delivery interval, and in the prediction of neonatal congenital infection.

STUDY DESIGN

Thirty-one patients with pPROM, 35 with PROM at term, 33 healthy women at preterm gestation and 35 healthy women at term were included. In the pPROM group, analysis of maternal plasma LBP concentrations with reference to leukocytosis, C-reactive protein, vaginal fluid culture, neonatal infection and pPROM-to-delivery interval was carried out.

RESULTS

LBP concentrations in the four studied groups were comparable. Although in 58.1% of pPROM cases at least one laboratory parameter of infection was observed, the only difference concerned the subgroup with CRP above 10mg/L, in which LBP concentrations were higher. Comparison of LBP concentrations in patients delivered within 24 and 72h of pPROM and after these times showed no differences, or between patients who gave birth to newborns with and without congenital infection. The predictive values of these measurements were poor.

CONCLUSION

The predictive value of maternal LBP determinations in the diagnostics of pPROM cases suspected of IAI is unsatisfactory. LBP measurements performed shortly after pPROM, are not of value either in the prediction of newborn's infection, or in the prognosis of latency period duration.

The contribution of laboratory investigations in diagnosis of congenital infections

Congenital diseases are an important indicator of the degree of development of primary health care, because primary prevention is paramount in diagnosing and diminishing the number of those types of cases. Syphilis is a sexually transmitted chronic infectious disease and with an evolution, often unpredictable. Primary prevention aims to prevent infection of the fetus, while secondary prevention aims for a reduction in the severity of sequels already installed.

Prognosis of isolated mild to moderate fetal cerebral ventriculomegaly: a systematic review

AIMS

To ascertain risk of aneuploidy, infection and neurological abnormality for the fetus diagnosed with isolated mild (10.1-12.0 mm) to moderate (12.1-15.0 mm) cerebral ventriculomegaly and to compare the neurological outcome between symmetrical vs. asymmetrical and stable vs. progressive ventriculomegaly.

METHODS

A systematic review was conducted. Literature was identified by searching two bibliographical databases between 1980 and 2009 without language restrictions. The data extracted were inspected for heterogeneity. Overall rates and confidence intervals (CIs) for each prognostic factor were calculated. When comparative data existed, the odds ratio (OR) was calculated.

RESULTS

The search strategy yielded 2150 relevant citations of which 28 studies were included in the review. The overall rate of infection and chromosomal abnormality was 1.5 and 5% (95% CI 3, 7), respectively. The risk of neurological abnormality regardless of karyotype or infection screen was 14% (95% CI 10, 18) and this reduced to 12% (95% CI 9, 15) when both chromosomes and infection screen were normal. The risk of neurological abnormality was significantly lower in stable compared to progressive ventriculomegaly [OR 0.29 (95% CI 0.15, 0.58)]. No significant differences were detected when symmetrical vs. asymmetrical ventriculomegaly were compared [OR 0.91 (95% CI 0.34, 2.41)].

CONCLUSION

This systematic review provides the physician with some estimates of prognosis in cases of isolated mild to moderate ventriculomegaly.

Effect of intrauterine infection and perinatal risk factors on serum concentrations of insulin like growth factor (IGF-I) in full-term and preterm newborns

OBJECTIVES

IGF-I is believed to be a key factor in fetal growth dynamics It is widely known, that serious early-onset infection in the newborn is a risk factor for further developmental disturbances in a child. However, effect of congenital infection as well as an influence of infectious and non-infectious perinatal risk factors on circulating IGF-I concentrations in newborns has not been examined, yet.

DESIGN

Thus, the aim of this study was: 1) evaluation of IGF-I venous blood serum concentration in full-term and premature infants considering their sex, occurrence of intrauterine infection and perinatal risk factors; 2) establishing the relationship between IGF-I serum concentrations and chosen anthropometric parameters values in infected and healthy newborns.

SETTING

The study involved 112 newborns appropriate for gestational age. Taking into consideration occurrence of early onset infection and gestational age we divided examined children into 4 groups: I group--infected, full-term newborns; II group--infected premature newborns; III group--healthy full-term newborns; IV group--healthy premature newborns. In all infants immediately after birth anthropometric measurements were performed (birth weight, body length, circumference of head and circumference of chest) and serum IGF-I concentration was determined.

RESULTS

We demonstrated that full-term infants with intrauterine infection have statistically significantly higher concentration of IGF-I in blood serum than infected premature infants and healthy full-term infants. Analysis of correlation revealed a significant positive linear correlations between IGF-I serum concentration and gestational age and anthropometric parameters values.

CONCLUSIONS

We conclude that intrauterine infection increases serum IGF-I concentration in full-term infants, but not in preterm infants, that may be a result of immaturity. We suggest serum IGF-I concentration may be considered an additional element of developmental and nutritional state assessment in infected newborn.

[Evaluation of the relationship between circulating nucleated red blood cells count and inborn infection in neonates]

OBJECTIVES

to determine the relationship between the initial nucleated red blood cells (nRBC) count during the first 12 hours after birth and inborn infection in neonates.

MATERIALS AND METHODS

The retrospective study comprised of 306 neonates born in the Department of Perinatology of the I Chair of Gynaecology and Obstetrics in Łódź, Poland, in the years 2002-2007, among whom the nucleated red blood cells count were calculated within the first 12 hours after birth. Two categories of nRBC count: the normal and the elevated value, were statistically elaborated by a Mann-Whitney test and a chi-square test with two clinical outcome categories: the presence and the absence of inborn infection in the analyzed neonates. Statistical significance was indicated by p value lower than 0,05.

RESULTS

Among 306 newborns, there were 127 mature neonates (41.5%) and 179 prematures (58.5%). The mean of the initial nRBC count in the analyzed newborn population was 40, 15. The mean of the nRBC count in the infected neonates was three times higher (52.56) than the mean of the nRBC count in newborns without inborn infection (16.76) - (p=0.00001). Inborn neonatal infection concerned a vast majority of cases with an elevated value of the nRBC count (86.4%), but in 13.6%, inborn infection was not observed. Among the cases with a normal nRBC count, the presence and the absence of inborn infection was diagnosed in about 50% of the analyzed babies (50.83% vs 49.17%). The elevated value of the nRBC count in infected neonates concerned mainly premature babies, rather than mature neonates, and similarly in neonates with a lower Apgar score than in babies born in good condition.

CONCLUSIONS

1. The positive association between elevated initial nucleated red blood cells count after birth and inborn infection in newborns has been revealed. 2. An elevated nucleated red blood cells count may be an auxiliary, early indicator for inborn infection in neonates. 3. Prematurity and perinatal asphyxia favour the elevation of a nucleated red blood cells count in cases with inborn infection.

Childhood infection and adult disease

In England and Wales there is a strong geographical relation between current mortality from chronic bronchitis and emphysema in adults and infant mortality from bronchitis and pneumonia 50 years ago. Follow-up studies of infants and children show that certain pulmonary infections cause persisting abnormalities of lung function. This suggests that infection of an organ system during a period of rapid growth may have permanent deleterious effects. Long-term consequences of infection may also depend on age-related differences in the host response. The relationship between age of infection with hepatitis B virus and the likelihood of becoming a chronic HBsAg carrier is an example of this. Evidence that the common communicable diseases of childhood tend to have occurred late in cases of multiple sclerosis hints at similar mechanisms in this disease. The current patterns of motor neuron disease mirror the epidemiology of poliovirus infection 40 years ago both in geographical distribution and in changes over time. The same neuronal populations are affected in both these conditions; is there a causal link?

Congenital infections associated with international travel during pregnancy

With the overall increase in international travel, there is likely to be an increase in travel during pregnancy as well. In developing countries, pregnant women face exposures that can add significant risk for neonatal morbidity and mortality. Infections that can occur in utero or in the early neonatal period include malaria, yellow fever, tuberculosis, hepatitis, human immunodeficiency virus, leishmaniasis, toxoplasmosis, filariasis, Japanese encephalitis, rubella, typhoid fever, leptospirosis, dengue fever, Helicobacter pylori, and trypanosomiasis. When travel and potential exposure cannot be avoided, preventive measures are usually effective. Pretravel consultation should include careful discussion of length of travel, antimalarial prophylaxis, insect avoidance, food and water hygiene, vaccination, and body fluid precautions.

Echocardiographic assessment of early circulatory status in preterm infants with suspected intrauterine infection

OBJECTIVE

To assess early circulatory status in very low birthweight (VLBW) infants with suspected intrauterine infections.

PATIENTS

Thirteen VLBW infants who were diagnosed with prenatal infections because of raised serum IgM at birth (infectious group), and 39 infants matched for gestational age and birth weight (control group).

METHODS

Echocardiographic assessments were performed consecutively from birth to day 28 in all VLBW infants. Left ventricular output (LVO) and left ventricular stroke volume (LVSV) were measured using Doppler echocardiography. Pulsed Doppler assessment of pulmonary artery pressure (PAP) was performed using the corrected ratio of the pulmonary artery acceleration time to the right ventricular ejection time (AT/RVET(c)). Blood flow in the superior mesenteric artery (SMA) was also evaluated by Doppler ultrasound.

RESULTS

Mean LVO and LVSV were both significantly higher in the infectious group than in the control group at 12 hours (LVO; 188 v 154 ml/kg/min) and 72 hours (LVO; 216 v 173 ml/kg/min) of life. Pulsed Doppler assessment of PAP showed that mean AT/RVET(c) values were significantly lower in the infectious group than in the control group at 48 hours, 96 hours, day 14, and day 28. In the analysis of SMA flow velocities, both peak systolic velocities and time averaged velocities had decreased significantly in the infectious group compared with the control group at 24 hours, 36 hours, 96 hours, and day 28.

CONCLUSIONS

VLBW infants with suspected prenatal infection showed a unique circulation status, namely high cardiac output, latency of high PAP, and low organ flow.

Are complete blood cell counts useful in the evaluation of asymptomatic neonates exposed to suspected chorioamnionitis?

OBJECTIVE

Chorioamnionitis complicates 1% to 10% of pregnancies and increases the risk of neonatal infection. Women with chorioamnionitis receive intrapartum antibiotics, often resulting in inconclusive neonatal blood cultures. Peripheral neutrophil values are used frequently to assist in the diagnosis of neonatal infection and to determine duration of antibiotics; we sought to determine the utility of this approach.

METHODS

A prospective observational study was performed in 856 near-term/term neonates who were exposed to suspected chorioamnionitis. Each received antibiotics for 48 hours unless clinical infection or positive blood cultures occurred. Peripheral neutrophils were measured serially and analyzed using the reference ranges of Manroe et al; an additional analysis of only the initial neutrophil values used the normal ranges of Schelonka et al. Results of neutrophil analyses were not used to determine duration of therapy. Fifty percent of asymptomatic neonates were seen postdischarge to ascertain recurrent infection. Local patient charges were examined.

RESULTS

Ninety-six percent of neonates were asymptomatic and had negative cultures, and antibiotics were discontinued at 48 hours. A total of 2427 neutrophil counts were analyzed. Although abnormal neutrophil values were more frequent in infected or symptomatic neonates, 99% of asymptomatic neonates had > or = 1 abnormal value. The specificity and negative predictive values for abnormal neutrophil values ranged between 0.12 and 0.95 and 0.91 and 0.97, respectively; sensitivity was 0.27 to 0.76. Significant differences in interpretation of the initial neutrophil values were noted, depending on the normal values used. Follow-up was performed for 373 asymptomatic neonates until 3 weeks' postnatal age. Eight required rehospitalization; none had evidence of bacterial infection. If neutrophil values had been used to determine duration of antibiotics, then local costs would have increased by 76,000 dollars to 425,000 dollars per year.

CONCLUSIONS

Single or serial neutrophil values do not assist in the diagnosis of early-onset infection or determination of duration of antibiotic therapy in asymptomatic, culture-negative neonates who are > or = 35 weeks' gestation and are delivered of women with suspected chorioamnionitis.

Diagnosis of fetal infections

PURPOSE OF REVIEW

The purpose of this review is to present recent developments in the prenatal diagnosis of the most clinically relevant congenital infections.

RECENT FINDINGS

Immunoglobin G avidity testing can help to differentiate between recent or prior infection. A combination of tests, including serology, avidity and polymerase chain reaction, may be necessary to improve accuracy of diagnosis. The interval between exposure to an infectious agent and prenatal testing can be critical to the interpretation of the test result.

SUMMARY

This review reinforces the need for accurate testing to guide appropriate counseling and individual fetal risk assessment. The findings of viral-specific antibodies or sonographic abnormalities do not accurately predict the severity or outcome of fetal infection. Further research is necessary to determine the pathogenesis of transplacental viral transmission and thereby allow us to target prevention strategies.

[Intranatal asphyxia, prematurity and congenital infection--their role for brain damage in very low birth weight newborns]

The authors examined 273 newborns weighing less than 1500 g. Their birth weight was very low (1001-1500 g) in 179 but extremely low (< 1000 g) in 94 newborns. Neurological damage was proved in 101 cases (36.99%). The probable reasons for intra- (peri-) ventricular and cerebral hemorrhages in these newborns were the following: respiratory distress syndrome (in 11 cases or 10.89%), mother-fetal infection (in 16 cases or 15.84%), and combination of asphyxia and infection (in 10 cases or 9.9%). The severe degree of prematurity (and immaturity) remained the only causative factor in the rest 64 premature newborns (63.37% of the cases). The results from the distribution of the neurological lesions according to the gestational age were also considered. Usage of monofactorial regression models detected statistically significant differences between asphyxia, infection and brain damage in the newborns of different gestational age.

Nongenetic causes of hearing loss

Nongenetic as well as genetic etiologies must be explored in the child with identified hearing loss. Graduates of the neonatal intensive care unit are at increased risk for developing hearing loss due to hypoxia, hyperbilirubinemia, very low birth weight, and ototoxic medications. Although meningitis has decreased in frequency, it is still a risk factor for hearing loss. Cytomegalovirus remains the most common congenital infection and a relatively common etiology of hearing loss, which can be progressive. Preventable causes of hearing loss include those caused by head trauma, noise, and ototoxic medications. Identification of the etiology of hearing loss can facilitate the development of a treatment and management plan.

Perinatal infections and brain injury: current treatment options

Antimicrobial therapy can ameliorate infection and prevent long-term morbidity caused by several pathogens that infect the fetus and neonate. Ultimately, however, preventive strategies need to be developed and incorporated into routine preconceptional care. The future of prevention lies in immunizations, and if past and current successes with smallpox, polio, rubella, and measles vaccination programs are any indication, the future is bright for the developing fetus.

Congenital infections and preconception counseling

Given the risks of congenital infections, the frequent occurrence of unintended pregnancy, and the lack of prenatal care in the first trimester, physicians should seek opportunities to discuss immunizations and disease prevention with women of childbearing age. Discussions of the following topics would be beneficial: 1. Encourage women to seek medical care at the first missed period. 2. Discuss safe sex and abstinence for prevention of sexually transmitted diseases. (See "Clinical Prevention Guidelines" in the CDC's 1998 Guidelines for Treatment of Sexually Transmitted Diseases.) 3. Encourage early medical care for vaginal discharge, pelvic pain, or possible exposure to sexually transmitted diseases. 4. Encourage good handwashing, especially before and after handling food or changing diapers. 5. Encourage the use of universal precautions when exposed to body fluids or blood. 6. Educate the patient on the importance of cooking food thoroughly and avoiding raw meat and unpasteurized dairy products. 7. Ensure vaccination against hepatitis B, rubella, and varicella.

Value of autopsy in nonimmune hydrops fetalis: series of 51 stillborn fetuses

Nonimmune hydrops fetalis (NIHF) is used to describe fetuses and newborns with generalized edema and cavity effusions. It is helpful to alert physicians about the presence of anemia, heart failure, and/or hypoproteinemia, but this diagnosis is frequently overlooked. We reviewed the autopsy files from 1990 to 2000, selected all cases with NIHF including clinical information (with maternal laboratory tests and ultrasound), and classified patients by etiology. Among 840 stillborn autopsies during the 11-year period, we found 51 with NIHF (6.07%). The clinical summary had mentioned hydrops in 14 patients and the etiology in another 7 by fetal ultrasonography, but without addressing the possibility of hydrops. In the remaining 30 cases neither hydrops nor an etiology was mentioned. Other pertinent diagnoses were maternal diabetes mellitus (4), congenital heart disease (3), and cystic hygroma (2). The following diagnoses were made in one instance each: cardiac tumor, twin transfusion syndrome, congenital adenomatoid malformation, syphilis, Turner syndrome, and cerebral arteriovenous malformation. Postmortem and placental examination confirmed the following etiologies: congenital infections (17); placental pathology significant enough to explain NIHF (10); cardiovascular diseases (8) (further classified as congenital heart disease [3], rhabdomyoma [1], and vascular malformations [4]); chromosomal abnormalities (6); uncontrolled maternal diabetes (4); intrathoracic lesions (2); prune-belly syndrome (2); and idiopathic NIHF (2). Only 3.9% of the cases studied had no identifiable etiology. The cause of hydrops was confirmed by autopsy in 47 fetuses (92%), which further supports the importance of performing an autopsy. Thirty-two cases (62.74%) had placental abnormalities helpful to the etiology (parvovirus, syphilis, Turner's syndrome, etc.). In 20 instances, the clinical summary had no mention of either hydrops or any of the diseases leading to it. The autopsy in conjunction with placental examination and fetal ultrasound represent the best combination to determine the etiology of NIHF among stillborn fetuses.

The relationship among inflammatory lesions of the umbilical cord (funisitis), umbilical cord plasma interleukin 6 concentration, amniotic fluid infection, and neonatal sepsis

OBJECTIVE

The purpose of this study was to determine whether funisitis (inflammation of the umbilical cord detected by histologic examination of the placenta) is associated with changes in the umbilical cord plasma concentration of interleukin 6, microbial invasion of the amniotic cavity, and neonatal sepsis.

STUDY DESIGN

The relationship among the presence of funisitis, interleukin 6 concentrations in umbilical cord plasma at birth, the results of amniotic fluid culture performed within 3 days of birth, and the occurrence of congenital neonatal sepsis was examined in 315 consecutive singleton preterm births (20-35 weeks' gestation). Funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton jelly. The interleukin 6 concentration was measured with a specific immunoassay. Amniocentesis was performed in 106 patients within 3 days of birth. Amniotic fluid was cultured for aerobic and anaerobic bacteria and for mycoplasmas.

RESULTS

(1) Funisitis was present in 25% of patients (78/315). (2) Patients with funisitis had a significantly higher median cord plasma interleukin 6 and a lower gestational age at birth than did those without funisitis (cord interleukin 6: median, 52.4 pg/mL; range, 0.9-19,230 pg/mL; vs median, 4.6 pg/mL; range, 0-18,108 pg/mL; gestational age: median, 31.1 weeks' gestation; range, 21.0-35.0 weeks' gestation; vs median, 32.9 weeks' gestation; range, 21.4-35.0 weeks' gestation; P<.001 for each comparison). (3) A cord plasma interleukin 6 of > or =17.5 pg/mL had a sensitivity of 70% and a specificity of 78% in the identification of funisitis. (4) Microbial invasion of the amniotic cavity and clinical chorioamnionitis were more common among patients with funisitis than among those without funisitis (positive amniotic fluid culture: 53% [20/38]; vs. 12% [8/68]; clinical chorioamnionitis: 18% [14/78]; vs. 4% [9/237]; P<.001 for each comparison). (5) Neonates with funisitis had a significantly higher rate of congenital sepsis than did those without this lesion (12% [8/66] vs. 1% [3/216]; P<.001); this difference remained significant after adjustment for gestational age at birth (odds ratio, 7.2; 95% confidence interval, 1.8-29.0).

CONCLUSION

(1) Umbilical cord plasma interleukin 6 concentrations were higher in neonates born with funisitis than in those without this lesion. (2) Funisitis is associated with amniotic fluid infection, congenital neonatal sepsis, and the fetal inflammatory response syndrome.

Update on diagnosis of congenital infection

Congenial infection is one of the greatest diagnostic challenges facing clinicians. The list pathogens related to intrauterine infections continues to grow with the identification of new etiologies and resurgence of others. Identification of a congenital infection as early as possible has both diagnostic and therapeutic advantages. This article will give an overview on common clinical findings in infants with congenital infection and a recommended clinical investigational approach for suspected congenital infection

Complex consanguinity associated with short rib-polydactyly syndrome III and congenital infection-like syndrome: a diagnostic problem in dysmorphic syndromes

Short rib-polydactyly syndromes (SRPS) are a heterogeneous group of recessively inherited lethal skeletal dysplasias. Four types have been recognised. However, overlap in the clinical and radiological features of the four types has led to difficulties in distinguishing between them. The congenital infection-like syndrome is an autosomal recessive syndrome characterised by mental retardation, microcephaly, seizures, and intracranial calcifications. We report a complex consanguineous family of Baluchi origin in whom short rib-polydactyly type III and congenital infection-like syndrome are segregating. Four children inherited SRPS III, one inherited congenital infection-like syndrome, and one inherited both. Although the radiological features in all the children with SRPS in this report were typical of type III, there was overlap in the clinical features with the other types of SRP syndromes. Furthermore, the child who inherited both SRPS III and congenital infection-like syndrome had CNS malformations in addition to periventricular calcification. CNS malformations have been described in SRPS types II and IV but not type III. This report further highlights the overlap between the different types of SRP syndrome. Moreover, it draws attention to the importance of considering the possibility of two recessive syndromes in the same child in complex consanguineous families when features overlap two syndromes.

Mononuclear cell subpopulations in preterm and full-term neonates: independent effects of gestational age, neonatal infection, maternal pre-eclampsia, maternal betamethason therapy, and mode of delivery

Blood samples from 29 preterm (24-32 weeks of gestation) and 21 full-term (37-42 weeks of gestation) neonates were analysed for surface markers of lymphocyte subtypes and macrophages, and the effects of gestational age, neonatal infection, maternal pre-eclampsia, maternal betamethason therapy and mode of delivery were assessed with multiple regression analysis. Gestational age alone had few independent effects (increase in CD3+, CD8+CD45RA+, and CD11alpha+ cells, and decrease in CD14+, HLA-DR- cells) during the third trimester on the proportions of the immune cell subtypes studied. Neonatal infection and mother's pre-eclampsia had the broadest and very opposite kinds of effects on the profile of immune cells in the blood. Infection of the neonate increased the proportions of several 'immature' cells (CD11alpha-CD20+, CD40+CD19-, and CD14+HLA-DR-), whereas mother's pre-eclampsia decreased the proportions of naive cell types (CD4+CD8+, CD5+CD19+). In addition, neonatal infection increased the proportion of T cells (CD3+, CD3+CD25+, and CD4+/CD8+ ratio, and CD45RA+ cells), while maternal pre-eclampsia had a decreasing effect on the proportion of CD4+ cells, CD4+/CD8+ ratio, and proportions of CD11alpha+, CD14+ and CD14+HLA-DR+ cells. Maternal betamethason therapy increased the proportion of T cells (CD3+) and macrophages (CD14+, CD14+HLA-DR+), but decreased the proportion of natural killer (NK) cells. Caesarean section was associated with a decrease in the proportion of CD14+ cells. We conclude that the 'normal range' of proportions of different mononuclear cells is wide during the last trimester; further, the effect of gestational age on these proportions is more limited than the effects of other neonatal and even maternal factors.

Fetal blood sampling--indication-related losses

The aim of this study, was to determine the fetal loss rate after fetal blood sampling (FBS) in relation to the indication. In total, 1981 FBS procedures (1878 pregnancies) were included, of which 117 were performed for the detection of congenital infection (group 1), 1437 for the detection of haemoglobinopathy (group 2), 233 for prenatal diagnosis with normal ultrasound findings (group 3), 121 for rapid karyotyping in cases with abnormal sonographic findings (group 4) and 73 for severe growth retardation (group 5). All the procedures were performed with a free-hand technique under continuous ultrasound guidance. Pregnancy losses occurring within two weeks of FBS were considered procedure-related losses. 343 pregnancies were terminated. Of the remaining 1535 continuing pregnancies, 73 (4.8 per cent) were lost, of which 39 (2.5 per cent) were lost within two weeks of the procedure. The procedure-related losses were 3 in 103 (2.9 per cent), 17 in 1090 (1.6 per cent), 2 in 191 (1 per cent), 11 in 84 (13.1 per cent) and 6 in 67 (8.9 per cent) in groups 1, 2, 3, 4 and 5, respectively. The differences in procedural loss between the five groups were highly significant, suggesting that the method entails a much higher risk when the fetus is structurally abnormal, or severely growth retarded. Patients should therefore be counselled before the procedure accordingly.

Stillbirth evaluation: what tests are needed?

OBJECTIVE

We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated.

STUDY DESIGN

A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions.

RESULTS

We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases.

CONCLUSION

The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial.

The autosomal recessive congenital intrauterine infection-like syndrome of microcephaly, intracranial calcification, and CNS disease: report of another Bedouin family

We describe a Bedouin family with the rare autosomal recessive infection-like syndrome of microcephaly, intracranial calcification and CNS disease that has so far been documented in only eight families including one from Kuwait. In the present family, the female proband had congenital microbrachycephaly, hypertonia, early-onset tonic-clonic seizures, a palpable liver and mild pulmonary stenosis. Follow-up examination of the girl identified delayed developmental milestones while head CT scan revealed partial agenesis of the corpus callosum, brain atrophy, dilated ventricles and scattered calcific foci in the caudate nuclei, the thalami, and the periventricular white matter. The possibility of intrauterine TORCH infection was excluded by the negative results of repeated immunovirology study and by the failure to recover viral inclusions in urine cultures. The proband had three apparently affected cousins with spasticity and CT findings of microcephaly and intracranial calcification. Other previously documented cases with the congenital intrauterine infection-like syndrome are reviewed.

The diagnosis of congenital infections: contemporary strategies

Congenital infections remain an important source of neurologic, ophthalmologic, and audiologic disability for thousands of children throughout the world. This review summarizes the clinical features and describes contemporary approaches to the microbiologic diagnosis of congenital infections. In particular, this review emphasizes the important roles that molecular methods, especially the polymerase chain reaction, have in detecting the many infectious agents capable of damaging the developing nervous system.

Timely diagnosis of congenital infections

The acronym TORCH has served to increase awareness of congenital infections; however, this collective term suggests that the clinical manifestations of congenital infections are not distinguishable by pathogen. Although some clinical features may be common to several of these infections, a congenital infection caused by one pathogen generally can be distinguished from infection caused by another pathogen on a clinical basis. Pediatricians need to be aware of the prominent features of each congenital infection rather than to consider them collectively. This article focuses on the prominent features of the more common congenital infections, suggests a specific diagnostic approach, and reviews the available therapeutic strategies.

Management strategies for congenital infections

Information on congenital infection is continuously expanding. New diagnostic techniques are making significant contributions to the prenatal diagnosis of several fetal infections. In this review we highlight some of the most recent advances in the diagnosis and management of the most common fetal infections, those caused by cytomegalovirus, human immunodeficiency virus 1, Toxoplasma, varicella-zoster virus, and parvovirus B19.

Epidemiology of neonatal infections

Neonatal infections can be considered in three groups, those acquired antenatally, perinatally and nosocomially. For many years it has been recognized that antenatal infections may cause death or serious fetal damage, but only recently have the more subtle features of antenatal infection been recognized. These include particularly the ability of some (such as toxoplasmosis) to produce disease many years later. Perinatal infection is often the result of maternal carriage of organisms, usually asymptomatically, and a variety of treatment approaches including immunotherapy (for hepatitis B) and antibacterial prophylaxis (for chlamydia) are being used to reduce the short- and long-term morbidity associated with this route of neonatal infection. Nosocomial infection in the neonatal nursery, and particularly in the neonatal intensive care unit may again lead to longer term problems in the infant, and organisms such as staphylococci or salmonella acquired during neonatal life may cause invasive disease weeks or even months later. The prevention of nosocomial infection will depend on the synthesis of a variety of approaches to reduce the number and spread of organisms in the environment of the vulnerable neonate.

Can expression of CD45RO, a T-cell surface molecule, be used to detect congenital infection?

Exclusion or confirmation of congenital infection can be difficult in newborn infants. The presence of an infective organism in a fetus leads to activation of fetal T lymphocytes. We have examined expression of isoforms of a T-cell surface molecule, CD45RO, in 119 infants, 8 of whom had an intrauterine infection diagnosed antenatally. CD45RO was expressed on fewer than 10% of T cells in control infants and on more than 17% of T cells from infants with known infection (p < 0.006). This method allows screening of infants for infection by a range of organisms as a cause of their infection.

Problems with serum IgM as a screening test for congenital infection

The purpose of this study was to determine the usefulness of the total serum IgM level as a screening test for congenital infection in asymptomatic or mildly symptomatic infants. A retrospective medical record review was performed on 168 infants in whom the serum IgM was measured as a screen for congenital infection. The indications for testing, the yield of testing, and the adequacy of follow-up of abnormal values were examined. Only one infant was diagnosed with a congenital infection which was not specifically suspected prior to screening; this was a case of congenital cytomegalovirus (CMV). Inappropriate screening was frequently performed in infants in whom indications for specific evaluation were present. Appropriate follow-up testing was performed in only 30% (seven of 23) of the infants with elevated serum IgM who received their pediatric care at our institution. Because of the low yield (< 1%) and lack of follow-up shown in this study, as well as poor sensitivity, serum IgM was not a useful screening test for congenital infection in our institution.

What can be learned from cordocentesis?

Cordocentesis is a well-accepted procedure that is widely practiced by experienced perinatologists. Its facile and safe access to the fetal circulation has broadened the spectrum of congenital disorders diagnosed prenatally. Some fetal disease states can now be identified and treated earlier, directly, more quickly, and more effectively than before, resulting in improved patient care. Although cordocentesis has been embraced by the perinatal community, it is, by definition, a technique of obtaining a fetal blood sample. A prerequisite for the procedure to exert its full impact on perinatal care is a highly capable clinical laboratory. The facility must be aware of the commonly requested fetal serologic, hematologic, and serum chemistry studies, as well as their normal values. Efforts must be made to perform fetal blood studies rapidly and reliably on small specimens. Laboratory personnel should be familiar with the indications and pitfalls of these tests and those that are best referred to a specialty laboratory. A general understanding of the perinatologist's needs and concerns will lead to a cooperative working relationship between clinician and laboratory. In this manner, we will truly discover what can be learned from cordocentesis.

[Pre- and perinatal infections with sexually transmissible microorganisms]

The sexually transmissible pathogenic microorganisms, which are also capable of initiating pre- or perinatal infections, include Neisseria gonorrhoeae, Treponema pallidum, Chlamydia trachomatis serovars D through K, group B streptococci, urogenital mycoplasmas, herpes simplex viruses types I and II, cytomegalovirus, hepatitis B virus, human immunodeficiency viruses, human papillomaviruses, Candida spp. and Trichomonas vaginalis. With special emphasis on paediatric and neonatological aspects, brief discussions of the following topics are presented: the epidemiology of these agents, the diseases they can induce in pregnancy, the mode of infection of and the diseases in the fetus and neonate, the preventive measures, the diagnosis and therapy.