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OBJECTIVE: General anesthesia may be required for placenta accreta cesarean delivery. Intrauterine fetal anesthetic exposure should be minimized to avoid neonatal respiratory depression; opioids are often delayed until post-delivery. METHODS: In this observational study, we compared neonatal outcome using pre-delivery remifentanil versus post-delivery (deferred) opioids for placenta accreta cesarean delivery. Choice of anesthesia was discretionary. The primary outcome was Apgar score at 5 min comparing women who received pre-delivery remifentanil versus deferred opioid administration. We recorded maternal/obstetric characteristics, surgical characteristics, maternal hemodynamic data, neonatal outcomes: Apgar scores, umbilical vein pH and respiratory interventions at birth. RESULTS: Between February 2007 and April 2014 we identified 40 general anesthesia placenta accreta cesarean deliveries. The remifentanil dose rate ranged from 0.06 to 0.46 mcg kg(-1 )min(-1). Obstetric and maternal characteristics were similar. Neonatal Apgar, umbilical pH and respiratory intervention outcomes were similar in both groups; Apgar scores median (interquartile range IQR [range]) at 5 min were 9 (8-10) for pre-delivery remifentanil versus 9 (9-10) for deferred opioid administration, p = 0.18. CONCLUSIONS: We did not observe a significant effect on neonatal Apgar scores at 1 and 5 min, or respiratory interventions at birth when remifentanil infusion was administered pre-delivery.

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Fetal distress represents a pathophysiological condition in which oxygen is not available to the fetus in sufficient quantities. In cases of glucose 6-phosphate dehydrogenase (G6PD) deficiency, under conditions of oxidative stress, the residual G6PD and complimentary antioxidant mechanisms may become insufficient to neutralize the large amounts of ROS and to prevent severe hemolysis. Alteration in the oxidant-antioxidant profile is also known to occur in neonatal jaundice. The study group included 22 neonates presented with fetal distress during labor and 24 neonates with no evidence of fetal distress (control group). Umbilical cord blood samples were taken immediately after delivery, and the following blood tests were carried out after birth and at discharge from the hospital: erythrocyte count, total bilirubin, G6PD activity, and parameters presenting oxidative status [thiobarbituric acid reactive substances (TBARS), NO, O2 (-), H2O2, SOD, CAT, O2 (-)/SOD, and H2O2/CAT]. There were no significant differences in TBARS and NO values among neonates with or without fetal distress. However, the values of O2 (-), H2O2, SOD, O2 (-)/SOD, and H2O2/CAT among neonates born after fetal distress were significantly higher than in neonates without fetal distress (p < 0.01). In neonates with fetal distress, the total number of RBCs at delivery was significantly lower, accompanied with higher bilirubin content. Also neonates with fetal distress had lower activity of G6PD and lower CAT activity. Higher values of oxidative stress parameters in newborns delivered after fetal distress do not indicate strictly what occurred first-oxidative stress or basic lower G6PD activity.

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AIM: To evaluate an intervention to enhance parents' use of car safety seats (CSSs) for their newborn baby's first journey home from the hospital in a population not usually exposed to television, internet and mainstream printed media. METHODS: Parents of newborn babies who did not bring a CSS to the hospital before their baby was discharged were lent a CSS to use in a 'safe taxi' service. All taxi drivers were trained to install the CSS safely. The intervention was evaluated using preprogramme questionnaires and follow-up interviews 4-8 weeks after discharge. RESULTS: Twelve parents participated in the intervention during the study period (January to April 2011) and in the evaluation process. Eleven couples were Jewish and one was Muslim. Most (75%) reported that they had not previously used CSS routinely and the reason was not financial. Following the 'safe taxi' intervention, 83% reported the use of CSS when travelling in all vehicles (excluding buses). On follow-up, most participants reported that the intervention increased their awareness and the use of CSS. CONCLUSION: The intervention, targeted at this specific population, was well received by the parents, increased awareness, changed practices and assured that more newborns travelled home safely in a CSS.

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OBJECTIVE: To determine the correlation between specific fetal heart rate (FHR) abnormalities and the incidence of death, severe (grade 3-4) intraventricular hemorrhage (IVH) and periventricular echogenicity (PVE) in extremely low birth weight infants (ELBW) within the first 4 days after birth. METHODS: The study included live-born ELBW infants ≤ 30 weeks' gestation who were born in 2000-2007 at Kaplan Medical Center, Rehovot, Israel, and, who had FHR monitoring during the 24 h before delivery and cranial ultrasound during the first 4 days of life. FHR pattern was analyzed for the presence of baseline rate, reactivity, variability and decelerations. RESULTS: 96 infants with mean birth weight 757 ± 150 g and mean gestational age 25.8 ± 1.5 weeks were included. By 4 days of life, 23/96 (24%) died, 17/96 (18%) developed severe IVH and 31/96 (32%) had PVE. Absence of reactivity was significantly associated with increase in both death (p = 0.02, OR 3.45, 95% CI: 1.22-9.47 and severe IVH (p = 0.029, OR 3.33, 95% CI: 1.25-10) but not with PVE. Other FHR parameters were not associated with adverse outcome. CONCLUSION: These results suggest that FHR reactivity may be of value in predicting short-term outcome in ELBW infants. This may be helpful in counseling parents with imminent extremely preterm birth.

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The inability to appropriately ventilate neonates shortly after their birth could be related in rare cases to chest-wall rigidity caused by the placental transfer of fentanyl. Although this adverse effect is recognized when fentanyl is administered to neonates after their birth, the prenatal phenomenon is less known. Treatment with either naloxone or muscle relaxants reverses the fentanyl effect and may prevent unnecessary excessive ventilatory settings.

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Perinatal corticosteroids are like a double-edged sword. On the one hand, they reduce risk for major morbidity and even mortality; on the other hand, they modify growth and development of body systems, with short- and long-term consequences. The relationship between corticosteroids and neurodevelopmental outcome has been extensively studied in randomized controlled trials, cohort and case-control studies and meta-analyses. In this article we attempt accurately to reflect current clinical equipoise on this issue by reviewing the most recent literature and adding a new meta-analysis on the relationship between postnatal dexamethasone and cerebral palsy and neurodevelopmental impairment.

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Outcomes, both short and long term, differ between singletons and multiplets. Recently, a number of large, well-designed studies have clarified these differences, particularly in light of major changes in perinatal and neonatal care that have influenced changing outcomes. Accordingly, this article will review risks for singletons, twins and higher-order multiples as whole groups and also after correction for gestational age and other potential confounding variables that differ markedly between the groups. In addition, we will focus on the effects of certain factors such as antenatal steroid therapy and gender. Finally, we will detail the specific long-term risks for multiples in terms of growth and neurodevelopmental disabilities.

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UNLABELLED: Few therapies in perinatal medicine have created as much controversy as corticosteroids. Despite five decades of extensive research and practice, major areas of uncertainty remain. In this article, we review the most current evidence on both antenatal and postnatal therapy. CONCLUSION: Overall, it is clear that we must continue to investigate the most appropriate doses of the ideal preparation in the most appropriate target populations before we can let the steroid issues rest.

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