- Sean C Blackwell, Jerrie S Refuerzo, et al (Detroit, Michigan)
The relationship between nucleated red blood cell counts and early-onset neonatal seizures.
Am J Obstet Gynceol. Vol.182; June 2000, p.1452-7)
Objective: this study was undertaken to better define the timing of neurologic insult in neonates with early-onset seizures through evaluation of neonatal nucleated red blood cell levels.
Study Design: Medical records and the International Classification of Diseases, Ninth Revision codes were used to identify all term neonates with neonatal convulsions who were delivered was matched to the next 3 neonates who met he following criteria : gestational age ³37 weeks, no early onset seizures, birthweight ³2800 g, umbilical artery pH ³7.25, and a 5-minute Apgar score <7. Demographic characteristics, clinical factors, and mean initial nucleated red blood cell counts were compared between groups.
Results: During the 6-year study period, there were a total of 36,490 singleton term deliveries of infants who were alive at birth. Forty-five (0.1%) of these neonates had early-onset seizures. Thirty neonates with early-onset seizures met the inclusion criteria. Mean nucleated red blood cell counts (number of nucleated red blood cells per 100 white blood cells) for neonates with early-onset seizures were significantly increased compared with those of control neonates.
Comment: This suggests that the timing of the hypoxicischemic insult occurred from 48 hours to 7 days before delivery.
The possibility also remains that the etiologic insult may be related not to asphyxia but to another mechanism such as a maternal or intrauterine infectious process.
In conclusion, the finding of an increased nucleated red blood cell count in a neonate with development of early-onset seizures suggests a hypoxicischemic insult before the intrapartum period. This finding may aid in the defense of claims that suggest that suboptimal intrapartum care was given and that intervention would have prevented neurologic injury.
Conclusion : Our findings are suggestive of the hypothesis that neurologic injury leading to early-onset seizures often occurs before the intrapartum period.
Expert comments: This article could be useful for defence in medical negligence law-suit.
- H Y How, B Jo Harris, et al (Cincinnati, Ohio and Louisvill,e Kentucky)
Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?
Am J Obstet Gynecol, vol.182, June 2000, p.1527-34.
Objective : The authors sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect.
Study Design: They performed a retrospective chart review.
Results : Between 1989 and 1999, they identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except than one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Lousiville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than imphalocele (gastroschisis, n=71; omphalocele, n=31). After they controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25,63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P=.16), for days to enteral feeding. After they controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1.69), but this was not statistically significant.
There was no statistically significant difference in the rates of neonatal death (2[3%] vs 2[6%]; P= .61) and neonatal sepsis (2[3%] vs 4[11%]; P=.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery (vaginal, 2(2,2) days; cesarean, 3(2,3) days; P=.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P=.16).
Conclusion: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.