Natural conception, ‟In vitro” and ‟NaPro”

Infertility has been a big problem since the beginning of human existence. Some causes of infertility have always been present, other called ‟civilization causes” appeared recently, causing an increased need for treatment, hence the assisted reproductive technologies (ART), including “in-vitro”, have been introduced. Most children conceived with this method are healthy, but there is no doubt that it is a group of increased risk of various diseases. These methods are not accepted by the Catholic church, mainly because they involve killing or freezing of embryos regarded as human beings, but also for other reasons.Infertility has been a big problem since the beginning of human existence. Some causes of infertility have always been present, other called ‟civilization causes” ap peared recently, causing an increased need for treatment, hence the assisted reproductive technologies (ART), including “in-vitro”, have been introduced. Most children conceived with this method are healthy, but there is no doubt that it is a group of increased risk of various diseases. These methods are not accepted by the Catholic church, mainly because they involve killing or freezing of embryos regarded as human beings, but also for other reasons. An alternative to ‟in vitro” are procreation methods defi ned as naprotechnology, free from the negative impact on the health of the newborn and mother, accepted by the Catholic church.In the author’s opinion, in the current situation, married couples who want to be treated for infertility should receive reliable and honest medical information about ART (“in vitro”) –assisted reproductive methods and ‟NaPro” – assisted procreation methods. Believers should advise the priest. Ultimately, the decision which procedure they will choose belongs to them

Are in-utero interventions justified? – perspective of neonatologists. – Part III. Twin to Twin Transfusion Syndrome and Congenital Heart Defects

Abstract Introduction: TTTS complicates from 10 to 15% of monochorionic diamniotic pregnancies. Expectant management is associated with 80 – 100% mortality. First in-utero intervention in the fetus with CHD was performed in 1991. However, only recently have they attained wider acceptance of cardiologists and perinatologists. Objective: Our main objective was to analyze the studies evaluating prenatal interventions in pregnancies complicated by TTTS or CHD, and to determine whether, given the available data, those interventions are justified. Methods: Pubmed and Cochrane database were searched for all studies related to in-utero interventions in fetuses with TTTS or CHD. Emphasis was placed on randomized controlled trials. Results: Meta-analysis published in Cochrane database concludes that laser photocoagulation of communicating vessels improves outcome in all stages of TTTS. Additional studies are required to elucidate the role of amnioreduction. For interventions in fetuses with CHD published data is limited to the case series. Potentially, selected patients with CHD would benefit from in-utero intervention, but additional studies are required. Conclusions: Prenatal interventions in TTTS improve the outcome. Further studies are required to define their role in patients with CHD. For all procedures selection criteria and indications for interventions need to be clarified. More precise prenatal diagnosis and improvements in the area of fetal monitoring during the procedure might positively impact survival. Preterm birth and premature rapture of membranes remain significant adverse outcomes. Complications associated with prematurity might counteract the positive effect of fetal intervention. Most cases of in-utero interventions should only be performed in specialized centers as a part of a clinical trial protocol

Are in-utero interventions justified? – perspective of neonatologists. – Part II. Spina Bifida, Obstructive Uropathy, Pleural Effusion

Abstract Introduction: Spina bifida, obstructive uropathy, and congenital pleural effusion (PE) belong to the group of congenital defects in which attempts of in-utero treatment were undertaken. Objective: Main objective of our study was to search for scientific evidence that would justify offering, and performing, in utero interventions in fetuses with spina bifida, obstructive uropathy and PE. Methods: Using Pubmed as the main source, all publications relevant to the subject of in-utero interventions in fetuses with spina bifida, obstructive uropathy, and PE were sought and carefully reviewed. An extra effort was made to identify all randomized controlled trials and meta-analyses. Results: Up to date, none of the aforementioned in-utero interventions was evaluated in the randomized controlled trial. Two ongoing studies, one for patients with spina bifida, and one for patients with obstructive uropathy, are still actively recruiting the subjects. As suggested by the results of meta-analysis, vesico-amniotic shunt might be recommended for selected group of fetuses with obstructive uropathy. For fetuses with unilateral or bilateral PE, in-utero drainage seems to improve the outcome only in cases complicated by hydrops fetalis. However, only case series are available. Conclusions: Because of insufficient scientific evidence, offering in utero intervention to women with pregnancy complicated by spina bifida, obstructive uropathy, and fetal PE on the routine basis is not justified. Until more data, preferably from randomized controlled trials are available, these procedures should only be performed in specialized centers as a part of carefully designed clinical trial

Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy

Hypoxia-ischemia in the perinatal period is a serious condition affecting infants, which can result in death and cerebral palsy and associated disabilities. There has been significant research progress in hypoxic-ischemic encephalopathy over the last 2 decades. Many new molecular mechanisms of asphyxia have been identified. Despite all these advances, therapeutic interventions in HIE remain to be limited. Recently it has been revealed that mild therapeutic hypothermia is the only modality shown to improve neurologic outcome. The authors present a summary of pathogenesis of HIE, animal studies of cooling for hypoxic and ischemic models, and first publications on human therapeutic hypothermia trials. The diagnosis of encephalopathy in full-term neonates and enrollment criteria for hypothermia are also discussed. The current data from randomized control trials of hypothermia as neuroprotection for full and near-term infants are presented along with the results of metaanalyses of these trials. Finally, the status of ongoing neonatal hypothermia trials as well as status of therapeutic hypothermia in Poland is summarized

Wentylacja mechaniczna z zastosowaniem helioxu w leczeniu wcześniaków z zespołem zaburzeń oddychania

Objective: The aim of the study was to assess the influence of mechanical ventilation with helium-oxygen mixture (heliox) on basic vital signs, oxygenation, acid-base balance and respiratory mechanics in newborns with respiratory distress syndrome (RDS), previously treated with surfactant. Material and methods: The study was carried out in preterm newborns with respiratory failure requiring mechanical ventilation due to RDS, requiring FiO2≥0.4 after a single dose of surfactant. Patients were ventilated using PCSIMV. Parameters of mechanical ventilation, respiratory function, oxygenation, acid-base balance and vital signs were recorded at baseline, one hour during and one hour after heliox ventilation. Results: Ten newborns with RDS were enrolled in the study. Mechanical ventilation with heliox did not affect vital signs and patient general condition remained stable during and after ventilation with heliox. Mechanical ventilation with heliox was associated with a statistically significant increase in tidal volume (mean 5.48 vs 6.55 ml/kg). There were no significant changes in minute ventilation and peak expiratory flow rate. Mechanical ventilation with heliox allowed the use of significantly lower fractions of inspired oxygen (mean 0.55 vs 0.35), with a significant decrease in the oxygenation index (mean 8.77 vs 5.02) and alveolar-arterial oxygen tension difference (mean 63.81vs113.28 mm Hg). After ventilation with this gas mixture was stopped, the patients required higher FiO2, OI and AaDO2 levels increased. Conclusions: Mechanical ventilation with heliox was safe, improved oxygenation and caused an increase in tidal volume in newborns with RDS previously treated with surfactant.Cel pracy: Ocena wpływu wentylacji mechanicznej z zastosowaniem helioxu (mieszaniny tlenu i helu) na postawowe parametry życiowe, utlenowanie, równowagę kwasowo-zasadową oraz wybrane elementy mechaniki oddychania u wcześniaków z ZZO leczonych uprzednio surfaktantem. Materiał i metody: Badanie przeprowadzono u wcześniaków z niewydolnością oddechową w przebiegu zespołu zaburzeń oddychania (ZZO), u których pomimo podania 1 dawki surfaktantu utrzymywało się podwyższone zapotrzebowanie na tlen (stężenie tlenu w mieszaninie oddechowej (FiO2 ) ≥0.4). Pacjenci byli wentylowani mechanicznie z wykorzystaniem trybu PC-SIMV. Parametry wentylacji, funkcji płuc, utlenowania, równowagi kwasowo-zasadowej i podstawowe parametry życiowe były rejestrowane na początku badania, następnie w ciągu godziny wentylacji helioxem oraz 1 godzinę po jej zakończeniu. Wyniki: Do badania włączono 10 noworodków z ZZO. Wentylacja helioxem nie miała wpływu na podstawowe parametry życiowe i stan ogólny pacjentów, który podczas stosowania helioxu oraz po jego zakończeniu pozostawał stabilny. Wentylacja mechaniczna z zastosowaniem helioxu wiązała się ze statystycznie istotnym zwiększeniem objętości oddechowych (5.48 vs 6.55 ml/kg; wartości średnie). Nie wystąpiły istotne zmiany w zakresie wentylacji minutowej i szczytowego przepływu końcowo-wydechowego. Wentylacja helioxem umożliwiła użycie istotnie niższych stężeń tlenu w mieszaninie oddechowej (0.55 vs 0.35), z jednoczesnym obniżeniem wskaźnika utlenowania (8.77 vs 5.02) i pęcherzykowo-tętniczej różnicy prężności tlenu (263.81 vs 113.28 mm Hg). Po zakończeniu wentylacji tą mieszaniną gazów pacjenci wymagali wyższego FiO2, a wartości OI i AaDO2 wzrosły. Wnioski: Wentylacja mechaniczna helioxem była bezpieczna, spowodowała poprawę utlenowania oraz zwiększenie objętości oddechowych u noworodków z ZZO leczonych surfaktantem

Aspekty diagnostyczne i kliniczne torbieli oskrzelowopochodnej w grupie 4 pacjentów z Kliniki Neonatologii ICZMP (1991-2005)

Background: Congenital bronchogenic cyst is a well-known but rare congenital malformation of the respiratory system. The origin of isolated cysts relates to the pseudoglandular phase of lung development (7th-16th week of gestation). This malformation can be diagnosed in radiological examinations in neonate as a single cyst in lungs situated peripherally or in mediastinum projection. The goal of our study was to establish diagnostic and clinical criteria for congenital bronchogenic cyst in neonates and children, based on postnatal diagnostics in our center. Material/Methods: We analyzed 4 cases of patients with congenital bronchogenic cyst, who were diagnosed and/or treated in the Department of Neonatology at the Polish Mother's Memorial Hospital Research Institute from 1 January 1991 do 31 March 2005. The diagnosis was established based on the clinical picture of the malformation, a chest x-ray, computed tomography of the lungs of the neonate, and pathological examination. After discharge from the Department, the neonates remained under the care of many specialists from our Institute in order to maintain follow-up. Results: In years 1991-2005 the diagnosis of congenital bronchogenic cyst was established in 4 patients treated in our Department. In these 4 cases, the diagnosis was established based on radiological diagnostics (chest x-ray and computed tomography of the lungs) and three of the four were confirmed by pathological exam. The differential diagnosis covered congenital cystic adenomatoid malformation of lungs (CCAM), enterogenic cysts, bronchopulmonary sequestration, congenital lobar emphysema, diaphragmatic hernia, and pneumothorax. Conclusions: Radiological diagnosis in neonates with congenital bronchogenic cyst is essential, because it allows us to obtain genuine data regarding this malformation in the population. Neonates diagnosed with congenital bronchogenic cyst should be monitored in a tertiary referral center. Our patients with a diagnosis of congenital bronchogenic cyst after successful surgery show normal psycho-physical development in follow-up, and none showed any disturbances in the circulatory system

Epigenetic influences in the development of bronchopulmonary dysplasia

Abstract Lung development is orchestrated by highly integrated morphogenic programs of interrelated patterns of gene and protein expression. Both genetic and epigenetic influences may alter the developing lung in the canalicular and saccular phase of lung development that lead to the development of bronchopulmonary dysplasia (BPD). Maternal exposures to toxins, and especially tobacco smoke associated nicotine nitrosamine ketones, fetal and neonatal infections (with or without chorioamnionitis) and techniques of neonatal ventilator management including surfactant therapy in concert with innate genetic susceptibility have life-long consequences for the infant afflicted with BPD. Exposure to supplemental oxygen poses another threat to the prematurely newborn and increases the risk for BPD and retinopathy of prematurity, but other effects in later life have been note among infants given oxygen as newborns. Thus a greater focus on these epigenetic influences and novel strategies to care for the preterm infant will hopefully reduce the worldwide burden of BPD and increase awareness regarding epigenetic mechanisms that determine long term health and well-being

The first application of therapeutic hypothermia in Poland – selective head cooling (Cool-Cap) with whole-body moderate hypothermia in a newborn with features of hypoxic ischemic encephalopathy

The authors present the first application of therapeutic hypothermia in a newborn in Poland. The female newborn, born with severe asphyxia, was transported to a referral perinatal center where the method of brain cooling was possible. Severe hypoxic ischemic encephalopathy was confirmed by an integrated EEG. During the cooling procedure (which lasted 72 hours), no important side effects were noticed. The neurodevelopmental outcome of the baby assessed during the first 2 years of her life is normal

Radiological diagnostics in neonates with different types of congenital cystic adenomatoid malformation of the lungs (CCAM) treated in Polish Mother's Memorial Hospital Research Institute (PMMHRI) in 1991-2005

Background: Congenital cystic adenomatoid malformation of the lungs (CCAM) is a rare congenital malformation of the respiratory tract. Authors present possibilities of the diagnostics of neonates with presumed CCAM based on radiological and morphological assessment of the respiratory tract. Clinical course of the CCAM may vary from uneventful to serious with different stage of the respiratory distress. The aim of the study was to establish diagnostic and clinical criteria of CCAM for neonates based on postnatal diagnostics in the reference centre. Material/Methods: We studied 27 cases of neonates with different types of CCAM (type I, II, III) who had been diagnosed and/or treated in the Neonatal Department of PMMHRI in 01.01.1991-31.03.2005. The diagnosis was established based on clinical course of the malformation, chest x-ray and CT of the neonate's lungs, autopsy and/or histopathology. Results: In the Neonatal Department of PMMHRI in 01.01.1991-31.03.2005 we observed 8 cases of CCAM type I (29,7%), 10 cases of CCAM type II (37%) and 9 cases of CCAM type III (33,3%). Diagnostic criteria were established based on radiological diagnostics of 17 cases and were confirmed by pathology. In 10 remaining cases of CCAM diagnosis was established by authopsy. Differential diagnosis included diaphragmatic hernia, bronchogenic cyst, enterogenic cyst, lung sequestrqtion, congenital lobar emphysema, hypoplasia or agenesis of the lungs, pneumonia/RDS. The guideline was established. Conclusions: 1. In case of CCAM suspicion monitoring in reference center is required 2. Surgical treatment should be applied based on the postnatal radiological diagnosis. 3. In case of CCAM in neonate complete differential diagnosis is required. 4. Asymptomatic course of CCAM or with a very few signs from respiratory tract can be difficult for identification both clinical and radiological

Fetal and neonatal alloimmune thrombocytopenia

Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is defined as a platelet coun