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Volume 2, No 2, April, 2001
DOES INTRAPARTUM ANTIOXIDANT STATUS RELATE TO PREMATURE LABOR ?
Azza A Ibrahim, Mohsen MM Mahgoub*, Amaal E Shehata** , Wafaa A Al-Nimr***
Departments of Obstetrics & Gynecology, Pediatrics*, Medical Biochemistry** and Community Medicine***, Faculty of Medicine - Zagazig University
Abstract
Preterm labor have very bad consequences for the newborn. Every method which maintain pregnancy till term deserves to be analysed. As oxygen-free radicals have been implicated in the pathogenesis of various diseases, the objective of this work was to study the relationship between intrapartum total antioxidant capacity (TAC) and premature labor of non-identifiable cause (s). Subjects included 60 primigravid primiparous women (40 with premature labor and 20 term deliveries), as well as their 60 neonates. Antioxidant capacity of intrapartum maternal blood and cord blood serum was determined by a manual assay measuring the relative inhibition of oxidation of 2,2` - azino – di – (3-ethylbenzthiazoline) – 6 sulfonic acid (ABTS). Possible correlations between antioxidant capacity and various perinatal factors were also tested. Results revealed a statistically significant relationship between maternal and neonatal serum TAC (r = 0.60 & P < 0.05), a strong positive statistically significant correlation between cord serum TAC and gestational age (r = 0.64), a statistically significant lower serum TAC in women with premature labor than in those with term deliveries, as well as a statistically significant lower gestational age, birth weight, Apgar score at one minute, and cord serum TAC in premature neonates than in term neonates. It is concluded that defective antioxidant capacity of pregnant women and/or oxidant stress may have a role in premature labor. So we recommend regular assay of TAC in maternal blood serum during pregnancy, as well as provision of vitamins, known with antioxidative activity, when required.
BIOPHYSICAL PROFILE AS A PREDICTOR OF LONG TERM DEVELOPMENTAL OUTCOME IN INFANTS OF HIGH RISK PREGNANCY
G.S. ALY*, S. BAHADER*, M.A. ABDEL-WAHED**, S. TL-TOHAMY***, R.A. HANNA****, and N. ALI****
Institute Of Postgraduate Childhood Studies*, Pediatric**, Obstetrics and Gynecology*** Departments, Ain Shams University and National Research Center****, Cairo.Abstract
The present study aimed at evaluation of the value of biophysical profile scoring (BPS) in assessing the fetal condition in 100 high-risk pregnant mothers of variable risk factors, and in prediction of the developmental outcome of these infants. Twenty cohort pregnant mothers, who were having normal uncomplicated pregnancy, constituted the control group. At the time of delivery, APGAR score and capillary blood gases were done for estimation of neonatal condition. Assessment of developmental status at 1 year was done by Denver Developmental Screen Test (DDST). The study showed a significant difference in BPS between the high risk and control groups. A positive statistical correlation was reported between the BPS, APGAR scores, and blood gases and pH of the high-risk neonates. A negative statistical correlation was found between BPS and the developmental score in the studied group indicating normal developmental status in case of high BPS. Similar correlation was observed between the developmental score and both APGAR score and neonatal arterial blood gases. There was no significant correlation between either BPS or the developmental score, and maternal age, parity, or neonatal weight.
The findings of this study can lead to the conclusion that routine biophysical profile scoring is valuable in anticipating the neonatal condition in high-risk pregnancies. Abnormal BPS increases the likelihood of subsequent fetal morbidity and/or mortality. Based on these data, it would be feasible to continue conservative management of some risky pregnancies if BPS is normal, to reduce neonatal hazards. Association of BPS with blood gases and pH of the neonates of high-risk pregnancies gives an idea about the long term developmental sequelae of these infants at one year of age.FOCAL INFECTIONS IN NEONATES RECOVERING FROM GENERALIZED SEPSIS: THE VALUE OF SERIAL CRP MEASUREMENTS
M.A. ABDEL-WAHED, H.A. AWADH, M.N. EL-BARBARY, W.ABBAAS
PEDIATRIC DEPARTMENT, FACULTY OF MEDICINE, AIN SHAMS UNIVERSITYAbstract
The rate of focal neonatal infections in neonates recovering from generalized septicemia was studied. Among 97 septic neonates whose serum CRP levels remain high after 2 weeks of adequate antibiotic therapy, despite partial clinical improvement, 33 neonates recovered upon continuation of antibiotics without identifying a focal infection. Nine neonates had minor cutaneous infection that also resolved with continuing the same antibiotic course. On the other hand, serious focal infections were diagnosed in the remaining 55 neonates. Forty-two neonates suffered septic osteoarticular infections that affected more than a joint in 7 neonates (i.e. 54 joints were infected in the 42 neonates). Hip joint was most commonly affected (43 cases), whereas knee and shoulder were affected in 6 & 5 cases respectively. Diagnosis was made by plain x-ray in only 21% of cases whereas joint sonographic examination was relatively more sensitive (70% of cases). Microbiological diagnosis was possible in slightly more than half of patients (26/47 neonates). Klebsiella pneumoniae was the commonest bacterial agent responsible for septic arthritis/osteomyelitis (14 cases), followed by Staph. aureus (9 cases), and coagulase negative Staph. (3 cases). Treatment consisted of drainage by needle aspiration of joint space or open synovectomy with intravenous (IV) antibiotics.
Intracranial suppuration was diagnosed in 6 neonates (by cranial sonography and/or brain computed tomography), 4 of them had multiple brain abscesses, one had solitary brain abscess, and the last one had infected subdural hematoma. The causative bacteria were; Enterobacter cloacae in 2 cases, Serratia marcescens in another 2, each of Proteus mirabilis and E.coli in one case. Cases with intracranial suppuration were treated either by open neurosurgical drainage or imaging guided aspiration together with massive IV antibiotics.
Finally, 2 neonates developed adrenal abscesses complicating adrenal hemorrhage for which percutaneous aspiration in one case and open drainage in the other, supportive measures and IV antibiotics were provided. E.coli was cultured from one case whereas no bacteria could be recovered from the other.
Accordingly it can be stated that serious localized neonatal infections are not uncommon, frequently heralded by a persistently high CRP values and less commonly neutrophil leucocytosis with bandemia. Clinical findings that may indicate a focus of infection, such as convulsions or joint swelling, are usually few. Therefore we conclude that serial estimations of CRP is valuable in predicting localized infection. In cases of persistently high CRP, meticulous effort should be done for early diagnosis of serious focal neonatal infection to avoid their damaging long-term sequelae.
Serum Prolactin and its Evolution in Neonatal Seizures
Souod I, Beshir M, Iskander I, Shaaban F, Salama I, Abou Ismail LAbstract
Prolactin is the most specific neurohormone that is elevated after seizures . To assess the effect of neonatal seizures on the hypothalamus , and to determine the clinical usefulness of plasma prolactin as a neonatal seizure marker, as well as its role in differentiating its etiology; we studied postictal and unstimulated serum prolactin levels in 34 full term newborns (21 males and 13 females) who had seizure activity.
Postictal prolactin levels were obtained within 30 min after seizure, and unstimulated levels were estimated 24 hours after the last convulsive activity .The ratio of postictal to recovery baseline prolactin level ( prolactin ratio) was used as indicator of postictal prolactin increase .
Postictal serum prolactin level was significantly higher for all patients as compared to the unstimulated level (P < 0.001). Regarding the analysis in relation to the type of seizure ,there was marked significance with tonic clonic convulsions.
Marked hyperprolactinemia (ratio> 2) was found in only 30% in all patients . The most common cause of seizures in our study was HIE (44.1% of cases) ,meningitis was the second followed by ICH and finally hydrocephalus . The mean postictal prolactin level was significantly higher than unstimulated recovery level in the HIE with ( P<0. 01) and meningitis ( P<0.05) as compared to other etiologies.
We conclude that the postictal serum prolactin level may be a helpful marker in the differentiation of neonatal seizures , specially in units where EEG video monitoring is unavailable , and more with tonic clonic fits . A reliable comparative basal prolactin neonatal level in relation to the different gestational ages is mandatory now to overcome the inconvinience to await recovery basal unstimulated serum level.
Sodium Homeostasis in Septicemic NeonatesEl-Rasheidy, O.F. and Yousef, M.F.*
Departments of Pediatrics and Clinical Pathology*Faculty of Medicine, Ain Shams University
Abstract
This study was conducted to evaluate sodium (Na+) homeostasis in neonatal septicemia as well as its correlation with gestation and birth weight. The study comprised 80 neonates who were classified clinically and laboratory into: septic group (40 neonates) and controls (40 neonates). Subjects were further subdivided equally according to gestational age into terms and preterms subgroups.
All neonates were subjected to full history taking, thorough clinical examination, assessment of gestational age and sepsis score, laboratory tests including complete blood count, estimation of C-reactive protein (C-RP), serum sodium (Na+), serum aldosterone and plasma atrial natriuretic peptide (ANP).
Statistical analysis of our results showed that there was a statistically significant decrease in the mean serum (Na+) level and an increase in the aldosterone and plasma ANP in preterm neonates compared to term ones whether in septic or non-septic control groups (p<0.01). Similarly, septic neonates showed a statistically significant lower mean (Na+) level and higher mean serum aldosterone and plasma ANP as compared to the controls (p<0.01). Statistical regression analysis of our data revealed that serum (Na+) level was significantly positively correlated with gestational age and birth weight, and negatively correlated with serum aldosterone and plasma ANP (p<0.05). Meanwhile, septic parameters (sepsis score and C-RP) were significantly negatively correlated with serum (Na+) and positively correlated with serum aldosterone and plasma ANP.
So, we come to the conclusion that preterm infants and septic ones are more vulnerable to develop hyponatremia. Therefore, septic preterm infants are at a greater risk to have the hazardous sequelae of hyponatremia, a condition which necessitates careful look and management.
Urinary Uric Acid/Creatinine Ratio and Simkin’s Index as Markers for Perinatal Asphyxia
Lotfy M. El-Sayed, Nahed M. Khater, Sahar A. El-Sharawy, Magdy M. Ibraheeem* and El-Shaymaa A. Ali
Departments of Pediatrics and Medical Biochemistry* Faculty of Medicine, Zagazig UniversityAbstract
To study the value of urinary uric acid/creatinine (UA/Cr) ratio and Simkin’s index (uric acid excretion in mg/dl of glomerular filtrate) in identification of perinatal asphyxia, 30 asphyxiated neonates were studied versus 30 non-asphyxiated normal newborns. They were subjected to full history taking and thorough clinical examination including assessment of gestational age, Apgar scores at 1, 5 and 10 minutes and severity of hypoxic-ischemic encephalopathy (HIE). Laboratory investigations included arterial blood gasses and acid base balance, serum creatinine (Cr), urinary uric acid (UA) and creatinine (Cr) in early spot urine sample. Apgar scores were significantly lower in cases than controls, but non significant difference were detected between the three stages of HIE or in relating the scores to the short and long term outcome. Arterial pH was significantly lower in cases than controls and recorded significant difference among different stages of HIE and also in short and long term outcome. Both urinary UA/Cr ratio and Simkin’s index were significantly higher in asphyxiated cases than controls and in preterm of asphyxiated and control groups than full term groups. Moreover, there were significant difference in urinary UA/Cr ratio and Simkin’s index between different stages of HIE and in the short-term outcome and also both had significantly positive correlation with the poor prognostic scores. Urinary UA/Cr ratio and Simkin’s index were found to be accurate by 80% and 85% respectively, sensitive (76.6%, 80%), specific (83%, 90%), with a positive predictive value of 82.1% and 88.8% and negative predictive value of 78.1 and 81.8%. Thus urinary UA/Cr ratio and Simkin’s index allow for rapid recognition of asphyxia and assessment of its severity and potential for short-term morbidity or death as well as the prediction of the long-term outcome.
THE VALUE OF NEUTROPHIL CD11b EXPRESSION, INTERLEUKIN-6, AND SOLUBLE RECEPTORS OF TUMOR NECROSIS FACTOR IN EARLY DIAGNOSIS OF NEONATAL SEPSIS.
TAHANI A. EL-KERDANI*, M.A. ABDEL-WAHED**, G.S. ALI**, FATEMA Z. ABDEL-BASSET**, M.N. EL-BARBARY**
CLINICAL PATHOLOGY*, PEDIATRIC** DEPARTMENTS, FACULTY OF MEDICINE & INSTITUTE OF CHILDHOOD STUDIES, AIN-SHAMS UNIVERSITYAbstract
The value of neutrophil CD11b expression, plasma interleukin-6 (IL-6), and soluble tumor necrosis factor receptors (sTNF-R) 55 and 75 in early detection of neonatal infection was studied in 288 neonates. The studied newborns were classified into 4 groups: group 0 (not infected), group 1 (possibly infected), group 2a (culture +ve infection), and group 2b (probably infected, culture –ve). We looked for the optimal cutoff points of these parameters using the receiver operating characteristics (ROC) curve.
The neutrophil CD11b expression was >100 median FU in all neonates with confirmed infection, >60 FU in all but one neonate of those with suspected infection, and <60 FU in non-infected group. A cutoff value of 60 FU or greater gave a 96% sensitivity, 100% specificity, and a negative predictive value of 99%.
The median levels of plasma IL-6 in groups 2a, 2b,1, and 0 were 260 pg/ml, 700 pg/ml, 160 pg/ml, and 0 pg/ml respectively. A cutoff value of 100 pg/ml was 83.3% sensitive and 90.3% specific in diagnosing neonatal infection. For newborns sampled at birth or within the 1st postnatal hour, sensitivity was 100% and specificity 92.3%. This high sensitivity persisted until the 12th hour of life.
The sTNF-R 55 levels were significantly higher in groups 2a (median 12 ng/ml), 2b (median 7 ng/ml), and 1 (median 7 ng/ml) than group 0 (median 3.9 ng/ml). The sensitivity and specificity of a cutoff level of 6 ng/ml were 75% and 69% respectively. Similarly, sTNF-R 75 levels in groups 2a (median 7ng/ml), 2b (median 11.2 ng/ml), and 1 (median 10.6 ng/ml) than group 0 ( median 7 ng/ml). With a cutoff value of 9 ng/ml, sensitivity and specificity were 80% and 67% respectively. On the other hand, sensitivity of CRP was low initially but improved with progress of infection.
It is concluded that neutrophil CD11b is a promising test for ruling out early onset neonatal sepsis. If validated prospectively, such assay may reduce hospital stay and antibiotic use in newborns at risk of sepsis. High plasma IL-6 alone before 12th hour of life, and combined with high CRP thereafter, provides a useful marker for identifying the majority of early infected neonates. The sTNF-R seems less useful in this context because of their smaller magnitude of variation.
NEONATAL ADRENAL HEMORRHAGE: CLINCAL AND RADIOLOGICAL ASPECTS
ABDEL-WAHED M A*, AIDA EL-SHIBINY**, HASSAN A T***
DEPARTMENTS OF PEDIATRICS*, DIAGNOSTIC RADIOLOGY**, AND SURGERY***, FACULTY OF MEDICINE, AIN SHAMS UNIVERSITYAbstract
Neonatal adrenal hemorrhage (NAH) is not uncommon, often clinically subtle condition that may associate perinatal hypoxia, birth trauma, and neonatal sepsis. We investigated the rate, and diagnostic characteristics of NAH among 280 sick neonates at NICU, Maternity Hospital, Ain Shams University. Twelve neonates (4.28%) were diagnosed as having NAH. There was a male predominance (7:5). The mean birth weight of neonates with NAH was 3.16 kg, mean gestational age was 38.67 weeks. The major predisposing factors were; perinatal hypoxia, traumatic delivery because of large birth weight or breech presentation, as well as neonatal septicemia. The condition was unilateral in the majority of cases (11/12), the right gland being affected mostly (10 cases), whereas the left gland was affected only once. The only bilateral case developed adrenocortical insufficiency with shock and prerenal failure that required blood transfusion, fluid adjustment, steroid treatment, and inotropic measures. Later, the condition was complicated by bilateral adrenal suppuration that justified sonography guided aspiration. The sole presentation in one case was right sided inguinoscrotal hematoma. Five cases (about 42%) within this study were asymptomatic. On the other hand, common symptoms were poor feeding and vomiting, anemia, abdominal mass, and jaundice.
Diagnosis was feasible in most cases with conventional sonography. Doppler and/or CT examinations were required in cases with abdominal mass as conventional sonography was inconclusive in ruling out the possibility of neonatal neuroblastoma.
In conclusion, NAH can be detected early by abdominal sonography in vulnerable neonates and most cases recover with conservative measures. Thus, unnecessary surgery and life threatening sequelae because of late recognition are preventable.
BONE-MINERAL DENSITY IN CHILDREN WITH SPASTIC CEREBRAL PALSY
Abdel Wahed M.A.*, El-Barbary M.N.*, El-Sawi A.M.**, El-Serafy A. ***
Pediatrics departments, Ain-Shams University*, Cairo University**, Department Of Diagnostic Radiology, Seuz-Canal University***Abstract
Bone-mineral density of the lumbar spine was assessed in 19 children with spastic cerebral palsy (CP). Their mean age was 5.7 years (range was 3 to 11 years). The evaluation included measurement of serum osteocalcin and calcium as well as urinary calcium excretion. The bone-mineral density was measured by dual-energy x-ray absorptiometry, then was normalized for age and weight using the mean SD values of healthy control children. All the children demonstrated severe reduction in bone-mineral density, being consistently less than one standard deviation below the age-matched normal means. The pattern of involvement, ambulatory status, and the use of anticonvulsant medications were the factors that best correlated with bone-mineral density. Prolonged periods of immobilization correlated, also with low bone density, but history of previous fractures and biochemical markers of bone turnover did not.
In conclusion, the degree of mechanical handicap is the major determinant of bone-mineral density in children with CP, while serum levels of osteocalcin, calcium and urinary calcium excretion are not reliable indicators of metabolic bone disease in this group of patients.
INTRAPARTUM BLOOD LEAD STATUS IN AREAS WITH HIGH AND LOW POLLUTION, OF SHARKIA GOVERNORATE-EGYPT
Azza A Ibrahim, Fatma Y Farahat*, Alaa Z Ibrahim**, Mohsen MM Mahgoub**, Zainab I D El-Darawany**, Adel M El-Shiekh**, El-Sayed H Abdel-Hameed ***
Departments of Obstetrics and Gynecology, Forensic and Clinical Toxicology*, Pediatrics**,and Community Medicine***, Faculty of Medicine – Zagazig UniversityAbstract
The objective of this study was to monitor blood lead (B Pb) and blood zinc protoporphyrin (B ZPP) levels in mothers and children during pregnancy and at birth, and to assess the influence of the strongly polluted environment on the content of Pb in pregnant women and their neonates. Methods: The B Pb and B ZPP concentrations in maternal and umbilical cord blood were determined in 50 parturient women at delivery. Twenty-five lived in agricultural rural area with low air pollution and 25 lived in urban area with high air pollution. Results: The mean B Pb concentrations ( + SD) in maternal and umbilical cord blood and the correlation coefficient, of all subjects, were 13.4 + 5.6 ug/dL, 9.1 + 1.81 ug/dL, and r = 0.68 respectively. Meanwhile, that of B ZPP were 128 + 14.7 ug/dL, 109 + 20.4 ug/dL, and r = 0.85 respectively. The obtained statistically highly significant elevation of B Pb and B ZPP concentrations, among women/neonates, living in the city, in comparison to those living in agricultural rural area, may be related to increased exposure via occupation, smoking, using lead-glazed ciramic, as well as traffic roads. We concluded that the concentrations of blood Pb & ZPP in neonates are proportionately related to that of pregnant women, the placenta is not a good barrier to the transfer of Pb from mother’s blood to the fetus, and that a large scale study and periodic surveillance of B Pb and/or B ZPP levels in pregnancy, particularly for women who have an urban residance, is advocated. Meanwhile adverse efforts aimed at lowering environmental lead exposure should be implemented.
BONE-MINERAL DENSITY IN CHILDREN WITH SPASTIC CEREBRAL PALSY
ABDEL WAHED M.A.*, EL-BARBARY M.N.*, EL-SAWI A.M.**.,EL-SERAFY A.***
Departments of pediatrics, Ain-Shams University*, Cairo University**, Department of Diagnostic Radiology, Seuz-Canal University***Abstract
Bone-mineral density of the lumbar spine was assessed in 19 children with spastic cerebral palsy (CP). Their mean age was 5.7 years (range was 3 to 11 years). The evaluation included measurement of serum osteocalcin and calcium as well as urinary calcium excretion. The bone-mineral density was measured by dual-energy x-ray absorptiometry, then was normalized for age and weight using the mean SD values of healthy control children. All the children demonstrated severe reduction in bone-mineral density, being consistently less than one standard deviation below the age-matched normal means.
The pattern of involvement, ambulatory status, and the use of anticonvulsant medications were the factors that best correlated with bone-mineral density. Prolonged periods of immobilization correlated, also with low bone density, but history of previous fractures and biochemical markers of bone turnover did not.
In conclusion, the degree of mechanical handicap is the major determinant of bone-mineral density in children with CP, while serum levels of osteocalcin, calcium and urinary calcium excretion are not reliable indicators of metabolic bone disease in this group of patients.
PREMATURITY AND PHOTOTHERAPY-ASSOCIATED CHANGES IN MESENTERIC BLOOD FLOW IN RESPONSE TO FEEDING USING THE ULTRASOUND PULSED DOPPLER
Ismail S. Ismail, Hanan M. Eisa*, Ibrahim S. Abu-Seif and Myra W. Erian.
Departments of Pediatrics and *Radiodiagnosis, Faculty of Medicine, Ain Shams University.Abstract
Intestinal disturbances such as abdominal distension and increased passage of loose watery stools are commonly observed in neonates receiving phototherapy for hyperbilirubinemia. A suggestion of a compensatory peripheral vasoconstriction as a mechanism to redistribute blood flow to the gut to accommodate increased intestinal metabolic demand was done. They also noted that infants receiving phototherapy have an increase of peripheral blood flow. In preterm infants, there is increased incidence of cerebral hemorrhage and NEC (Necrotizing enterocolitis) due to difference in postnatal circulatory adaptation and circulatory response to feeding as compared with full term. Twenty two (22) patients, admitted in the NICU of the Pediatric Department, Ain Shams University, were included in this study, they were categorized into tow groups .12 of them were full term infants suffering from neonatal jaundice and receiving phototherapy, 2 of them were females and 10 males. The remaining 10 were preterm infants; with average gestational age 33.8 + 1.3 weeks, 4 of them were males and the other 6 females. A third group of healthy full term infants not subjected to phototherapy was studied. It included 10 infants, 3 of them were males and 7 females. The three groups were subjected to prenatal, natal, and postnatal history taking, thorough clinical examination was done laying stress on the infants heart rate and mean blood pressure both pre and postprandially. Laboratory investigations were done for all infants in the form of: Complete Blood Picture, C Reactive Protein, and estimation of the serum total and direct bilirubin. The three groups were subjected to Ultrasonic measurement of the following: Superior Mesenteric Artery Mean Velocity and Superior Mesenteric Artery End Diastolic Flow Velocity, Superior Mesenteric Artery Relative Vascular Resistance, All these findings are measured both pre and post feeding. It is concluded that phototherapy blunted the postprandial mesenteric blood flow response to feeding in term infants, leading to the phototherapy related intestinal disturbances observed in the newborn infant. Preterm infants have increase in SMA Mean Velocity postprandially like the full term infant, however; in the preterm infant, there was a feeding associated systemic hemodynamic compensation for the increased blood flow to the gut.
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