Determination of gestational age and/or birth weight at which sacral ossification centers appear.... more Determination of gestational age and/or birth weight at which sacral ossification centers appear. Radiographs were reviewed of newborns admitted to Auckland City Hospital between January 2008 and December 2010. Infants were divided into weight clusters increasing in 100-g increments from 400 g to 3000 g and 500-g increments thereafter, for a total of 29 weight clusters. Adequate images were available for at least five newborns per cluster. Images of 163 newborns were reviewed. All but six newborns had five sacral ossification centers by 32 weeks' gestation and a birth weight of 1800 g. Five of the six infants had a congenital anomaly and associated growth restriction. Infants can be expected to have all five sacral ossification centers present by the time they reach a gestational age of 32 weeks and/or a birth weight of 1800 g. Variation from this can be associated with congenital anomalies and growth restriction.
American Journal of Obstetrics and Gynecology, 2015
The recently published monograph "neonatal encephalopathy and ne... more The recently published monograph "neonatal encephalopathy and neurologic outcome" from the American College of Obstetricians and Gynecologists calls for root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy, in order to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. National clinical review of these individual cases has not previously been undertaken. To undertake multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality; and to identify themes for quality improvement. National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at one minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011. Cases were included if they had abnormal gases as defined by any of pH<=7.2, Base Excess <=-10 or lactate >=6, or if there were no cord gases, an Apgar score at 1 minute of <=7. Clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality, and to identify themes to guide quality improvement. Eighty-three babies fulfilled the inclusion criteria for the review, 56 (67%) moderate and 27 (33%) severe, 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH<=7.0, base excess <=-12, or lactate >=6; and 42% (8/19) without cord gases had 5 minute Apgar scores <5. Excluding five babies who died within a day of birth, all but one baby were admitted to a neonatal unit within one day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable due to personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. Multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.
OBJECTIVE: This study was undertaken to compare the effects of exposure to repeated courses of an... more OBJECTIVE: This study was undertaken to compare the effects of exposure to repeated courses of antenatal steroids with those of a single course on hypothalamic-pituitary-adrenal axis function. STUDY DESIGN: Women at risk of premature delivery were assessed for entry into a randomized controlled trial of repeated courses of corticosteroids (ACTORDS). If a woman declined the randomized trial then consent was sought for collection of observational data. Baseline bloods for cortisol and adrenocorticotropic hormone levels were collected and in a subset of infants a metyrapone test performed.
There were two aims to the study: (1) to provide local outcome data that would be useful in couns... more There were two aims to the study: (1) to provide local outcome data that would be useful in counselling prospective parents of triplets; and (2) to address the deficit in accurate contemporary data on neurodevelopmental outcome and neonatal morbidity for those infants weighing less than 1500 g at birth. We reviewed the outcome of triplet pregnancies born at National Women's Hospital / Auckland City Hospital (Auckland, New Zealand) for 1995-2005 inclusive. For this study triplet pregnancy was defined as a pregnancy beyond 20 weeks leading to registration of at least one birth. For the study period, 55 triplet pregnancies were identified. Forty-five percent of the pregnancies were reported as spontaneously conceived and 60% had no major complications other than premature delivery. One pregnancy spontaneously aborted; three fetuses from one pregnancy were stillborn, and four infants died in delivery suite. The median gestational age at birth was 32 (23-37) weeks and birth weight 1620 (530-2780) g. The median (range) Apgar score, for liveborns, was 8 (2-10) and 10 (4-10) for 1 and 5 minutes respectively. There were five neonatal deaths. Fifty-three infants, <1500g at birth, underwent formal developmental assessment. Three had cerebral palsy (2 hemiplegia and 1 spastic diplegia); one had marked motor delay and one hearing impairment requiring aids. The median Bayley II MDI was 95 (71-105) and PDI 94 (65-110). Outcomes were categorised in surviving triplets <1500 g as normal in 66%, mild abnormality in 17%, moderate abnormality in 15% and severely abnormal in only 2%. Although triplets represent a significant burden on the regional NICUs the outcome, including those <1500 g at birth, compares favourably with that reported.
Advances in magnetic resonance technology have revolutionized our ability to obtain detailed imag... more Advances in magnetic resonance technology have revolutionized our ability to obtain detailed images of the neonatal brain without the use of ionizing radiation. Magnetic resonance imaging has now become the modality of choice for the in-vivo assessment of brain development, myelination and pathology.
BACKGROUND AND PURPOSE: MR imaging was performed in very preterm infants by using an MR imager in... more BACKGROUND AND PURPOSE: MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive care unit. The aims of this study were to assess the development of myelination in the preterm brain based on MR imaging findings and to compare the ability of T1-weighted conventional spin-echo, inversion recovery fast spin-echo, and T2-weighted fast spin-echo MR imaging to show myelination in these infants.
Background: Offspring born following maternal gestational diabetes are at risk of excessive child... more Background: Offspring born following maternal gestational diabetes are at risk of excessive childhood weight gain and Type 2 diabetes in childhood, which in turn is associated with an increased rate of hypertension. We aimed to determine the systolic and diastolic blood pressure at two years of age in a cohort of children exposed to gestational diabetes mellitus using data from the MiG trial of metformin use in gestational diabetes. The secondary aim was to analyze these data by randomization of treatment to insulin or metformin. Methods: The offspring of women who had gestational diabetes and had been assigned to either open treatment with metformin (with supplemental insulin if required) or insulin in the MiG trial were followed up at 2 years of age. Oscillometric measurement of BP in the right arm was performed by a researcher using an appropriately sized cuff.
Abstract Background: In multi-ethnic New Zealand the prevalence of obesity and diabetes is increa... more Abstract Background: In multi-ethnic New Zealand the prevalence of obesity and diabetes is increasing and varies by ethnic group. Aim: This study explored ethnic and gender differences in body composition in offspring of women treated for gestational diabetes in the metformin in gestational diabetes (MiG) trial. Sample and methods: Total and regional body composition measured by dual X-ray absorptiometry were investigated in European, Indian, Polynesian and "Other" children aged 2 years (48 boys; 56 girls). Results: By ethnicity, boys were not different by height or weight. Compared with European girls, Indian girls weighed less (2.3 ± 0.58 kg) and Polynesian (1.13 ± 0.53 kg) more, but percentage body fat was not different. Adjusted for age, height and weight boys had less total and appendicular fat and higher abdominal fat mass and total bone mineral density than girls (p < 0.001). Adjusted for age, weight and height Indian boys had more fat in the central and abdominal regions and less total lean mass than European boys (p < 0.05). Conclusion: These measurements provide early evidence for gender and ethnic differences in the distribution of fat and might help identify who is most likely to benefit from intervention in the first few years of life to reduce risk of chronic disease including diabetes.
MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive ... more MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive care unit. The aims of this study were to assess the development of myelination in the preterm brain based on MR imaging findings and to compare the ability of T1-weighted conventional spin-echo, inversion recovery fast spin-echo, and T2-weighted fast spin-echo MR imaging to show myelination in these infants. MR imaging was performed for 26 preterm infants with a median gestational age of 28 weeks who had normal neurodevelopmental outcomes at 2 years corrected age. Myelin was evident in the gracile and cuneate nuclei and fasciculi, vestibular nuclei, cerebellar vermis, inferior and superior cerebellar peduncles, dentate nucleus, medial longitudinal fasciculus, medial geniculate bodies, subthalamic nuclei, inferior olivary nuclei, ventrolateral nuclei of the thalamus, decussation of the superior cerebellar peduncles, medial lemnisci, lateral lemnisci, and inferior colliculi at < or = 2...
There were two aims to the study: (1) to provide local outcome data that would be useful in couns... more There were two aims to the study: (1) to provide local outcome data that would be useful in counselling prospective parents of triplets; and (2) to address the deficit in accurate contemporary data on neurodevelopmental outcome and neonatal morbidity for those infants weighing less than 1500 g at birth. We reviewed the outcome of triplet pregnancies born at National Women's Hospital / Auckland City Hospital (Auckland, New Zealand) for 1995-2005 inclusive. For this study triplet pregnancy was defined as a pregnancy beyond 20 weeks leading to registration of at least one birth. For the study period, 55 triplet pregnancies were identified. Forty-five percent of the pregnancies were reported as spontaneously conceived and 60% had no major complications other than premature delivery. One pregnancy spontaneously aborted; three fetuses from one pregnancy were stillborn, and four infants died in delivery suite. The median gestational age at birth was 32 (23-37) weeks and birth weight 16...
Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian ... more Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian cancer. Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the procedure was repeated after 4-6 weeks. If the findings disappeared, the study was repeated after 1 year. If the abnormality persisted, study was complemented with tumor markers, computed tomography and laparoscopic surgery. The findings were compared with a control group of women in whom ovarian transvaginal ultrasonography was formally indicated. Results: A total of 26007 transvaginal ultrasound were performed: 8813 (33.8%) belonged to the screening group and 17194 (66.2%) to the control group. In 14 patients of the screening group, a malignant tumor was diagnosed and histologically confirmed. The mean age of these patients was 45 years old (SD 12). Eleven of these tumors were stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were diagnosed in patients with a mean age of 48 years (SD 17). In this group, 11 tumors were in stage I, and six were borderline. Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data reveals that tumors detected in patients screened with transvaginal ultrasound are in earlier stages when compared with those diagnosed in the control group. No differences were found in age and number of borderline tumors between both groups. Additional studies are needed to support this preliminary findings.
To assess the safety of selective head cooling in birth-asphyxiated term newborn infants while ma... more To assess the safety of selective head cooling in birth-asphyxiated term newborn infants while maintaining the rectal temperature at 35.0 degrees C or 34.5 degrees C. Twenty-six term infants with Apgar &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=6 at 5 minutes or cord/first arterial pH &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7.1, plus evidence of encephalopathy, were studied. After parental consent had been obtained, 13 infants received selective head cooling with the rectal temperature maintained at 35.0 degrees C in 6 infants and at 34.5 degrees C in 7 infants. The remaining 13 infants were normothermic. Cooling was achieved by circulating water at 10 degrees C through a cap placed around the head. Rectal, fontanelle, and nasopharyngeal temperatures were monitored. One cooled infant died 2 days after rewarming, and 3 control infants died. Seizures occurred in 9 (69%)of 13 cooled infants and 5 (38%) of 13 control infants. Respiratory support within the first 72 hours of life was required in 10 of 13 infants in both the cooled and control groups. Three cooled infants and 1 control infant received nitric oxide for persistent pulmonary hypertension. During the same interval, 6 of the cooled infants and 4 of the control infants had episodes in which their blood pressure fell to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;40 mm Hg; in 2 infants in each group, the lowest blood pressure was below 35 mm Hg. No requirement for volume expansion or increased inotropic support was seen in any infant during stepwise rewarming. All of the cooled infants demonstrated a fall in heart rate during cooling, but the rate was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;80/min in only 2 cases and no infant had a rate &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;70/min. No infant demonstrated an abnormal rhythm or was clinically compromised by the change in heart rate. One infant cooled to a rectal temperature of 34.5 degrees C had a prolonged QT interval of 570 ms associated with a heart rate of 85/min on electrocardiogram aged 34 hours. This returned to normal after rewarming. Platelet counts below 150 x 10(9)/L, hypoglycemia below 2.6 mmol/L, and highest creatinine were not statistically different between cooled and control infants. Positive precooling blood cultures were found in 1 cooled and 1 control infant. The mean cap water input temperature used during cooling was 10 +/- 1 degrees C. During active cooling, the mean difference between rectal and nasopharyngeal temperature was 1.4 degrees C in the infants who were not receiving respiratory support, but this gradient could not be measured in those who were receiving respiratory support that involved delivery of warmed gases to the nasopharynx. This study suggests that selective head cooling combined with mild systemic hypothermia of 34.4 degrees C or 35.0 degrees C is a stable, well-tolerated method of reducing cerebral temperature in term newborn infants after perinatal asphyxia.
To investigate preterm infants, we have installed in our neonatal intensive care unit a dedicated... more To investigate preterm infants, we have installed in our neonatal intensive care unit a dedicated magnetic resonance (MR) imaging system which was specifically designed for neonatal use. The aim of this study was to describe the MR appearances of the brain in preterm infants who were first scanned between 25 and 32 weeks gestational age (GA) and to outline changes to the brains of these infants between their first scan and term. Preterm infants of 25 to 32 weeks GA were imaged using the 1T neonatal MR system (Oxford Magnet Technology, Eyensham, Oxfordshire, England/Picker International, Cleveland, OH). The scanning protocol included T1-weighted conventional spin echo (repetition time [TR], 600; echo time, 20 ms), inversion recovery fast spin echo (TR, 3530; effective echo time, 30; inversion time, 950 ms), and T2-weighted fast spin echo (TR, 3500; effective echo time, 208 ms) sequences. Seventeen infants of median 28 weeks GA (range, 24 to 31 weeks) at birth were imaged a total of 53 times between birth and term. The median number of images per infant was two (range, 1 to 9). In infants of &lt; 30 weeks GA, the germinal matrix was visualized at the margins of the lateral ventricles. It had a short T1 and short T2 and the bulk of it involuted at between 30 and 32 weeks GA. The white matter had a relatively homogeneous low signal except for bands of altered signal (probably originating from regions containing radial glia and migrating cells) which were most apparent anterolateral and posterolateral to the lateral ventricles. Myelination was seen in the posterior brainstem, cerebellum, and region of the ventrolateral nuclei of the thalamus. Infants had very little cortical folding at 25 weeks GA but this developed later in an orderly fashion. The neonatal MR system allowed extremely preterm infants to be studied safely with MR imaging. The images acquired demonstrated the germinal matrix, early myelination, and early cortical folding. Evolution of these features was demonstrated with serial studies.
To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hy... more To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hypothermia after hypoxic-ischemic encephalopathy. Infants &gt;/=37 weeks&#39; gestation, who had an umbilical artery pH &lt;/=7.09 or Apgar score &lt;/=6 at 5 minutes, plus clinical encephalopathy. Infants with major congenital abnormalities were excluded. Infants were allocated to either no cooling (rectal temperature = 37.0 +/- 0.2 degrees C, n = 15), or, sequentially, to head cooling accompanied by different levels of systemic hypothermia, including minimal cooling, rectal temperature 36.5 degrees C to 36 degrees C (n = 6), and mild cooling, to either 35.9 degrees C to 35.5 degrees C (n = 6), 35 +/- 0.5 degrees C (n = 6) or 34.5 +/- 0.5 degrees C (n = 7). Head cooling was accomplished by circulating cooled water through a coil of tubing wrapped around the head for up to 72 hours. Survivors were followed up with regular neurologic examination by a neonatologist until 18 months of age, then with blinded developmental testing using the revised Bayley Scales. A total of 40 term infants were enrolled from 2 to 5 hours after birth. The control and the cooled groups were not significantly different for gestation, birth weight, Apgar score, and initial pH. There were 6 early neonatal deaths (3 normothermic and 3 cooled), and 1 death in infancy associated with severe spastic cerebral palsy in a normothermic infant. Six normothermic, 1 minimally cooled, and 4 mildly cooled infants had early stage 1 encephalopathy; all but 1 had a good outcome. Among infants with early stage 2 or 3 encephalopathy, an adverse outcome was found in 4 of 9 normothermic infants (44%) and 4 of 5 minimally cooled infants (80%), whereas in the combined mildly cooled groups, an adverse outcome was found in 4 of 15 infants (26%, odds ratio 0.46 [0.08, 2.56] vs normothermia). The present study supports the safety of hypothermia, with no evidence of late adverse effects in any infant. Among infants with moderate to severe encephalopathy at enrollment, there was a tendency toward better outcome. These results emphasize the relatively wide range of outcomes using purely clinical criteria for enrollment. Therapeutic hypothermia should not be used outside of stringent, multicenter trials.
Systematic meta-analysis suggests that induced hypothermia for neonatal encephalopathy is well to... more Systematic meta-analysis suggests that induced hypothermia for neonatal encephalopathy is well tolerated but that there is a statistically borderline increase in requirement for cardiovascular support. It is unclear whether this represents a genuine cardiovascular effect of hypothermia.
Determination of gestational age and/or birth weight at which sacral ossification centers appear.... more Determination of gestational age and/or birth weight at which sacral ossification centers appear. Radiographs were reviewed of newborns admitted to Auckland City Hospital between January 2008 and December 2010. Infants were divided into weight clusters increasing in 100-g increments from 400 g to 3000 g and 500-g increments thereafter, for a total of 29 weight clusters. Adequate images were available for at least five newborns per cluster. Images of 163 newborns were reviewed. All but six newborns had five sacral ossification centers by 32 weeks&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; gestation and a birth weight of 1800 g. Five of the six infants had a congenital anomaly and associated growth restriction. Infants can be expected to have all five sacral ossification centers present by the time they reach a gestational age of 32 weeks and/or a birth weight of 1800 g. Variation from this can be associated with congenital anomalies and growth restriction.
American Journal of Obstetrics and Gynecology, 2015
The recently published monograph &amp;amp;amp;amp;amp;amp;quot;neonatal encephalopathy and ne... more The recently published monograph &amp;amp;amp;amp;amp;amp;quot;neonatal encephalopathy and neurologic outcome&amp;amp;amp;amp;amp;amp;quot; from the American College of Obstetricians and Gynecologists calls for root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy, in order to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. National clinical review of these individual cases has not previously been undertaken. To undertake multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality; and to identify themes for quality improvement. National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at one minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011. Cases were included if they had abnormal gases as defined by any of pH&amp;amp;amp;amp;amp;amp;lt;=7.2, Base Excess &amp;amp;amp;amp;amp;amp;lt;=-10 or lactate &amp;amp;amp;amp;amp;amp;gt;=6, or if there were no cord gases, an Apgar score at 1 minute of &amp;amp;amp;amp;amp;amp;lt;=7. Clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality, and to identify themes to guide quality improvement. Eighty-three babies fulfilled the inclusion criteria for the review, 56 (67%) moderate and 27 (33%) severe, 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH&amp;amp;amp;amp;amp;amp;lt;=7.0, base excess &amp;amp;amp;amp;amp;amp;lt;=-12, or lactate &amp;amp;amp;amp;amp;amp;gt;=6; and 42% (8/19) without cord gases had 5 minute Apgar scores &amp;amp;amp;amp;amp;amp;lt;5. Excluding five babies who died within a day of birth, all but one baby were admitted to a neonatal unit within one day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable due to personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. Multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.
OBJECTIVE: This study was undertaken to compare the effects of exposure to repeated courses of an... more OBJECTIVE: This study was undertaken to compare the effects of exposure to repeated courses of antenatal steroids with those of a single course on hypothalamic-pituitary-adrenal axis function. STUDY DESIGN: Women at risk of premature delivery were assessed for entry into a randomized controlled trial of repeated courses of corticosteroids (ACTORDS). If a woman declined the randomized trial then consent was sought for collection of observational data. Baseline bloods for cortisol and adrenocorticotropic hormone levels were collected and in a subset of infants a metyrapone test performed.
There were two aims to the study: (1) to provide local outcome data that would be useful in couns... more There were two aims to the study: (1) to provide local outcome data that would be useful in counselling prospective parents of triplets; and (2) to address the deficit in accurate contemporary data on neurodevelopmental outcome and neonatal morbidity for those infants weighing less than 1500 g at birth. We reviewed the outcome of triplet pregnancies born at National Women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital / Auckland City Hospital (Auckland, New Zealand) for 1995-2005 inclusive. For this study triplet pregnancy was defined as a pregnancy beyond 20 weeks leading to registration of at least one birth. For the study period, 55 triplet pregnancies were identified. Forty-five percent of the pregnancies were reported as spontaneously conceived and 60% had no major complications other than premature delivery. One pregnancy spontaneously aborted; three fetuses from one pregnancy were stillborn, and four infants died in delivery suite. The median gestational age at birth was 32 (23-37) weeks and birth weight 1620 (530-2780) g. The median (range) Apgar score, for liveborns, was 8 (2-10) and 10 (4-10) for 1 and 5 minutes respectively. There were five neonatal deaths. Fifty-three infants, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1500g at birth, underwent formal developmental assessment. Three had cerebral palsy (2 hemiplegia and 1 spastic diplegia); one had marked motor delay and one hearing impairment requiring aids. The median Bayley II MDI was 95 (71-105) and PDI 94 (65-110). Outcomes were categorised in surviving triplets &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1500 g as normal in 66%, mild abnormality in 17%, moderate abnormality in 15% and severely abnormal in only 2%. Although triplets represent a significant burden on the regional NICUs the outcome, including those &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1500 g at birth, compares favourably with that reported.
Advances in magnetic resonance technology have revolutionized our ability to obtain detailed imag... more Advances in magnetic resonance technology have revolutionized our ability to obtain detailed images of the neonatal brain without the use of ionizing radiation. Magnetic resonance imaging has now become the modality of choice for the in-vivo assessment of brain development, myelination and pathology.
BACKGROUND AND PURPOSE: MR imaging was performed in very preterm infants by using an MR imager in... more BACKGROUND AND PURPOSE: MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive care unit. The aims of this study were to assess the development of myelination in the preterm brain based on MR imaging findings and to compare the ability of T1-weighted conventional spin-echo, inversion recovery fast spin-echo, and T2-weighted fast spin-echo MR imaging to show myelination in these infants.
Background: Offspring born following maternal gestational diabetes are at risk of excessive child... more Background: Offspring born following maternal gestational diabetes are at risk of excessive childhood weight gain and Type 2 diabetes in childhood, which in turn is associated with an increased rate of hypertension. We aimed to determine the systolic and diastolic blood pressure at two years of age in a cohort of children exposed to gestational diabetes mellitus using data from the MiG trial of metformin use in gestational diabetes. The secondary aim was to analyze these data by randomization of treatment to insulin or metformin. Methods: The offspring of women who had gestational diabetes and had been assigned to either open treatment with metformin (with supplemental insulin if required) or insulin in the MiG trial were followed up at 2 years of age. Oscillometric measurement of BP in the right arm was performed by a researcher using an appropriately sized cuff.
Abstract Background: In multi-ethnic New Zealand the prevalence of obesity and diabetes is increa... more Abstract Background: In multi-ethnic New Zealand the prevalence of obesity and diabetes is increasing and varies by ethnic group. Aim: This study explored ethnic and gender differences in body composition in offspring of women treated for gestational diabetes in the metformin in gestational diabetes (MiG) trial. Sample and methods: Total and regional body composition measured by dual X-ray absorptiometry were investigated in European, Indian, Polynesian and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Other&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; children aged 2 years (48 boys; 56 girls). Results: By ethnicity, boys were not different by height or weight. Compared with European girls, Indian girls weighed less (2.3 ± 0.58 kg) and Polynesian (1.13 ± 0.53 kg) more, but percentage body fat was not different. Adjusted for age, height and weight boys had less total and appendicular fat and higher abdominal fat mass and total bone mineral density than girls (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Adjusted for age, weight and height Indian boys had more fat in the central and abdominal regions and less total lean mass than European boys (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Conclusion: These measurements provide early evidence for gender and ethnic differences in the distribution of fat and might help identify who is most likely to benefit from intervention in the first few years of life to reduce risk of chronic disease including diabetes.
MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive ... more MR imaging was performed in very preterm infants by using an MR imager in the neonatal intensive care unit. The aims of this study were to assess the development of myelination in the preterm brain based on MR imaging findings and to compare the ability of T1-weighted conventional spin-echo, inversion recovery fast spin-echo, and T2-weighted fast spin-echo MR imaging to show myelination in these infants. MR imaging was performed for 26 preterm infants with a median gestational age of 28 weeks who had normal neurodevelopmental outcomes at 2 years corrected age. Myelin was evident in the gracile and cuneate nuclei and fasciculi, vestibular nuclei, cerebellar vermis, inferior and superior cerebellar peduncles, dentate nucleus, medial longitudinal fasciculus, medial geniculate bodies, subthalamic nuclei, inferior olivary nuclei, ventrolateral nuclei of the thalamus, decussation of the superior cerebellar peduncles, medial lemnisci, lateral lemnisci, and inferior colliculi at < or = 2...
There were two aims to the study: (1) to provide local outcome data that would be useful in couns... more There were two aims to the study: (1) to provide local outcome data that would be useful in counselling prospective parents of triplets; and (2) to address the deficit in accurate contemporary data on neurodevelopmental outcome and neonatal morbidity for those infants weighing less than 1500 g at birth. We reviewed the outcome of triplet pregnancies born at National Women's Hospital / Auckland City Hospital (Auckland, New Zealand) for 1995-2005 inclusive. For this study triplet pregnancy was defined as a pregnancy beyond 20 weeks leading to registration of at least one birth. For the study period, 55 triplet pregnancies were identified. Forty-five percent of the pregnancies were reported as spontaneously conceived and 60% had no major complications other than premature delivery. One pregnancy spontaneously aborted; three fetuses from one pregnancy were stillborn, and four infants died in delivery suite. The median gestational age at birth was 32 (23-37) weeks and birth weight 16...
Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian ... more Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian cancer. Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the procedure was repeated after 4-6 weeks. If the findings disappeared, the study was repeated after 1 year. If the abnormality persisted, study was complemented with tumor markers, computed tomography and laparoscopic surgery. The findings were compared with a control group of women in whom ovarian transvaginal ultrasonography was formally indicated. Results: A total of 26007 transvaginal ultrasound were performed: 8813 (33.8%) belonged to the screening group and 17194 (66.2%) to the control group. In 14 patients of the screening group, a malignant tumor was diagnosed and histologically confirmed. The mean age of these patients was 45 years old (SD 12). Eleven of these tumors were stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were diagnosed in patients with a mean age of 48 years (SD 17). In this group, 11 tumors were in stage I, and six were borderline. Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data reveals that tumors detected in patients screened with transvaginal ultrasound are in earlier stages when compared with those diagnosed in the control group. No differences were found in age and number of borderline tumors between both groups. Additional studies are needed to support this preliminary findings.
To assess the safety of selective head cooling in birth-asphyxiated term newborn infants while ma... more To assess the safety of selective head cooling in birth-asphyxiated term newborn infants while maintaining the rectal temperature at 35.0 degrees C or 34.5 degrees C. Twenty-six term infants with Apgar &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=6 at 5 minutes or cord/first arterial pH &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7.1, plus evidence of encephalopathy, were studied. After parental consent had been obtained, 13 infants received selective head cooling with the rectal temperature maintained at 35.0 degrees C in 6 infants and at 34.5 degrees C in 7 infants. The remaining 13 infants were normothermic. Cooling was achieved by circulating water at 10 degrees C through a cap placed around the head. Rectal, fontanelle, and nasopharyngeal temperatures were monitored. One cooled infant died 2 days after rewarming, and 3 control infants died. Seizures occurred in 9 (69%)of 13 cooled infants and 5 (38%) of 13 control infants. Respiratory support within the first 72 hours of life was required in 10 of 13 infants in both the cooled and control groups. Three cooled infants and 1 control infant received nitric oxide for persistent pulmonary hypertension. During the same interval, 6 of the cooled infants and 4 of the control infants had episodes in which their blood pressure fell to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;40 mm Hg; in 2 infants in each group, the lowest blood pressure was below 35 mm Hg. No requirement for volume expansion or increased inotropic support was seen in any infant during stepwise rewarming. All of the cooled infants demonstrated a fall in heart rate during cooling, but the rate was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;80/min in only 2 cases and no infant had a rate &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;70/min. No infant demonstrated an abnormal rhythm or was clinically compromised by the change in heart rate. One infant cooled to a rectal temperature of 34.5 degrees C had a prolonged QT interval of 570 ms associated with a heart rate of 85/min on electrocardiogram aged 34 hours. This returned to normal after rewarming. Platelet counts below 150 x 10(9)/L, hypoglycemia below 2.6 mmol/L, and highest creatinine were not statistically different between cooled and control infants. Positive precooling blood cultures were found in 1 cooled and 1 control infant. The mean cap water input temperature used during cooling was 10 +/- 1 degrees C. During active cooling, the mean difference between rectal and nasopharyngeal temperature was 1.4 degrees C in the infants who were not receiving respiratory support, but this gradient could not be measured in those who were receiving respiratory support that involved delivery of warmed gases to the nasopharynx. This study suggests that selective head cooling combined with mild systemic hypothermia of 34.4 degrees C or 35.0 degrees C is a stable, well-tolerated method of reducing cerebral temperature in term newborn infants after perinatal asphyxia.
To investigate preterm infants, we have installed in our neonatal intensive care unit a dedicated... more To investigate preterm infants, we have installed in our neonatal intensive care unit a dedicated magnetic resonance (MR) imaging system which was specifically designed for neonatal use. The aim of this study was to describe the MR appearances of the brain in preterm infants who were first scanned between 25 and 32 weeks gestational age (GA) and to outline changes to the brains of these infants between their first scan and term. Preterm infants of 25 to 32 weeks GA were imaged using the 1T neonatal MR system (Oxford Magnet Technology, Eyensham, Oxfordshire, England/Picker International, Cleveland, OH). The scanning protocol included T1-weighted conventional spin echo (repetition time [TR], 600; echo time, 20 ms), inversion recovery fast spin echo (TR, 3530; effective echo time, 30; inversion time, 950 ms), and T2-weighted fast spin echo (TR, 3500; effective echo time, 208 ms) sequences. Seventeen infants of median 28 weeks GA (range, 24 to 31 weeks) at birth were imaged a total of 53 times between birth and term. The median number of images per infant was two (range, 1 to 9). In infants of &lt; 30 weeks GA, the germinal matrix was visualized at the margins of the lateral ventricles. It had a short T1 and short T2 and the bulk of it involuted at between 30 and 32 weeks GA. The white matter had a relatively homogeneous low signal except for bands of altered signal (probably originating from regions containing radial glia and migrating cells) which were most apparent anterolateral and posterolateral to the lateral ventricles. Myelination was seen in the posterior brainstem, cerebellum, and region of the ventrolateral nuclei of the thalamus. Infants had very little cortical folding at 25 weeks GA but this developed later in an orderly fashion. The neonatal MR system allowed extremely preterm infants to be studied safely with MR imaging. The images acquired demonstrated the germinal matrix, early myelination, and early cortical folding. Evolution of these features was demonstrated with serial studies.
To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hy... more To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hypothermia after hypoxic-ischemic encephalopathy. Infants &gt;/=37 weeks&#39; gestation, who had an umbilical artery pH &lt;/=7.09 or Apgar score &lt;/=6 at 5 minutes, plus clinical encephalopathy. Infants with major congenital abnormalities were excluded. Infants were allocated to either no cooling (rectal temperature = 37.0 +/- 0.2 degrees C, n = 15), or, sequentially, to head cooling accompanied by different levels of systemic hypothermia, including minimal cooling, rectal temperature 36.5 degrees C to 36 degrees C (n = 6), and mild cooling, to either 35.9 degrees C to 35.5 degrees C (n = 6), 35 +/- 0.5 degrees C (n = 6) or 34.5 +/- 0.5 degrees C (n = 7). Head cooling was accomplished by circulating cooled water through a coil of tubing wrapped around the head for up to 72 hours. Survivors were followed up with regular neurologic examination by a neonatologist until 18 months of age, then with blinded developmental testing using the revised Bayley Scales. A total of 40 term infants were enrolled from 2 to 5 hours after birth. The control and the cooled groups were not significantly different for gestation, birth weight, Apgar score, and initial pH. There were 6 early neonatal deaths (3 normothermic and 3 cooled), and 1 death in infancy associated with severe spastic cerebral palsy in a normothermic infant. Six normothermic, 1 minimally cooled, and 4 mildly cooled infants had early stage 1 encephalopathy; all but 1 had a good outcome. Among infants with early stage 2 or 3 encephalopathy, an adverse outcome was found in 4 of 9 normothermic infants (44%) and 4 of 5 minimally cooled infants (80%), whereas in the combined mildly cooled groups, an adverse outcome was found in 4 of 15 infants (26%, odds ratio 0.46 [0.08, 2.56] vs normothermia). The present study supports the safety of hypothermia, with no evidence of late adverse effects in any infant. Among infants with moderate to severe encephalopathy at enrollment, there was a tendency toward better outcome. These results emphasize the relatively wide range of outcomes using purely clinical criteria for enrollment. Therapeutic hypothermia should not be used outside of stringent, multicenter trials.
Systematic meta-analysis suggests that induced hypothermia for neonatal encephalopathy is well to... more Systematic meta-analysis suggests that induced hypothermia for neonatal encephalopathy is well tolerated but that there is a statistically borderline increase in requirement for cardiovascular support. It is unclear whether this represents a genuine cardiovascular effect of hypothermia.
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