The ductus arteriosus in the preterm infant: Histologic and clinical observations

In order to elucidate some of the unexplained phenomena in prolonged patency of the ductus arteriosus in preterm infants, the histology of the ductus was studied in 27 cases. Some of the infants had been treated with indomethacin. Four morphologic maturation stages are distinguinguished. There was no strict relation between gestational age or birth weight and histologic maturation. Therefore, one cannot predict whether a ductus is likely to be mature at the time of birth. In all infants with clinically diagnosed prolonged patency of the ductus beyond the first week, the immature maturation stage or the permanent patent type was observed. In both stages, reopening after initial closure with indomethacin occurred

Fetal distress due to placental insufficiency at 26 through 31 weeks: a comparison between an active and a more conservative management

OBJECTIVE: To compare perinatal mortality and short-term morbidity in extremely preterm infants with fetal distress due to placental insufficiency in two centers with different management attitude. DESIGN: Retrospective cohort study in two university hospitals of all infants with fetal growth retardation due to placental insufficiency resulting in signs of fetal distress at 26 through 31 weeks gestational age, during the years 1984 through 1989. Center A followed a conservative management: in some cases the risk of major handicaps or mortality was estimated so high, based on antenatally estimated fetal weight and gestational age, that the decision was taken to abstain from treatment. In all other cases cesarean section took place, but only if fetal distress was obvious. Center B used a more active management: cesarean section was performed in all cases, sometimes with only minor changes in fetal heart rate variability. RESULTS: Overall survival differed significantly: 55% (center A) versus 72% (center B), largely due to antenatal mortality in center A. Discharge survival rate of liveborn infants was 81% in center A and 72% in center B. More than half of the postnatal mortality was attributed to respiratory causes in both centres. An active management showed a tendency to a higher incidence of short-term morbidity. CONCLUSION: Selection by antenatal prediction of postnatal mortality using estimated fetal weight fails. Even in the group with the lowest birthweight postnatal mortality did not surpass 50%. Early intervention may be associated with higher short-term morbidity. Long-term follow-up of these children is needed to discriminate between both policies with regard to further development of surviving infant

School performance and behaviour in extremely preterm growth-retarded infants

OBJECTIVE: To describe school performance and behaviour of extremely preterm, growth-retarded infants. DESIGN: Cohort study at two tertiary care centres. Included were all surviving, singleton infants (N= 127) with fetal growth retardation due to placental insufficiency. All were delivered by caesarean section because of signs of fetal distress before the beginning of labour at a gestational age of 26 to 32 weeks during the years 1984-1989. Main outcome measures were special education, mainstream education below the appropriate age level and behaviour according to attention-deficit hyperactivity criteria at school age (4 1/2-10 1/2 yrs). The children were divided into two subgroups according to age at follow-up (> or =7 1/2 and <7 1/2 yr). A logistic regression analysis was performed with special school or repeating a grade and behavioural disturbance as dependent variables and gestational age, birth weight, sex of the infant, neonatal complications (intra cerebral haemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia or sepsis), age category at follow-up and sociodemographic factors as independent variables. RESULTS: 114 (90%) had a complete follow-up. Special education was found in 14% of the assessed children. More children in the older age group than in the younger age group were placed in special school (20% versus 10%). Behavioural problems were scored in 39% of the assessed children attending mainstream education. Special education was related to neonatal complications (bronchopulmonary dysplasia), behavioural problems to the absence of either parent. CONCLUSION: This specific group of growth-retarded children is at serious disadvantage for adequate performance in school, although the incidence of special education and behavioural problems was comparable to other preterm infants. Both special education and behavioural problems were not related to obstetric variables as gestational age and/or birth weigh

Influence of obstetric management on outcome of extremely preterm growth retarded infants

Aim - To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events. Methods - A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/4 to 10 1/4 years). Results - One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age. Conclusions - Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants

Effects of antenatal corticosteroid administration on mortality and long-term morbidity in early preterm, growth-restricted infants

OBJECTIVE: To evaluate the effect of antenatal corticosteroids on mortality, morbidity, and disability or handicap rate in early preterm, growth-restricted infants. METHODS: This case-control study in two tertiary care centers included all live-born singleton infants with growth-restriction due to placental insufficiency, who were delivered by cesarean because of cardiotocographic signs of fetal distress before the beginning of labor at a gestational age of 26-32 weeks during the years 1984-1991. Infants who had been treated antenatally with corticosteroids more than 24 hours and less than 7 days before birth were matched by birth weight, sex, and year of birth with infants whose mothers had been admitted more than 24 hours before delivery but were not treated antenatally with steroids. The main outcome measure was survival without disability or handicap at 2 years corrected age. A sample of 60 case-control pairs would give 81% power to demonstrate 50% increase of this outcome [odds ratio (OR) 3.0] by corticosteroid treatment. Behavior and physical growth were evaluated at school age by questionnaire. RESULTS: The study group and control group consisted of 62 infants each. Survival without disability or handicap at 2 years' corrected age was more frequent in the corticosteroid group [OR 3.2, confidence interval (CI) 1.1, 11.2]. In the long-term follow-up at school age there was a statistically significant negative effect on physical growth (OR 5.1, CI 1.4, 23.8), but no differences in behavior were detected. CONCLUSION: Benefits from antenatal corticosteroids for early preterm, growth-restricted infants appear to outweigh possible adverse effect

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome

OBJECTIVE: To determine the optimum mode of delivery of the early preterm fetus in breech presentation. DESIGN: Retrospective comparison of two cohorts of preterm breech fetus. SETTING: Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section. POPULATION: All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded. MAIN OUTCOME MEASURES: Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis. RESULTS: There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6-3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation. CONCLUSION: A policy of caesarean section for early preterm (26-31 weeks) breech delivery is not associated with increased survival without disability or handica