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[Neuropsychological problems of cerebrovascular pathology in children].

Cerebrovascular pathology in infancy is, unlike in adults, infrequent. However, this must not lead us to think it is unimportant. There are a number of different vascular processes that exert an influence to varying degrees on the neurological and psychological future of our young patients. These sequelae can be of more or less importance and, on some occasions, can be lesions that will accompany them throughout the rest of their lives, in spite of the therapeutic methods we have available today. We basically differentiate vascular organic lesions that are pre-established or due to malformations from other causes acquired as a consequence of an anomalous situation inherent to other pathologies and that have an extravascular origin. The most striking of these, because of their frequency, gravity and cellular pathology, are peri/intraventricular haemorrhages (PIVH) in those born premature and those weighing very little at birth. The causes from malformations remain and are relatively rare with a stable frequency, while the number of cases of PIVH has risen sharply in recent years due to different causes, the most notable of which is the increase in preterm multiple births, at around 30-32 weeks of gestation. This group of the population requires early and continuous neuropaediatric monitoring. Some of the sequelae are detected and dealt with quickly; others may appear later and will need the joint, coordinated attention of neuropaediatricians, psychologists, educators and physiotherapists.

Cerebrovascular Disorders↗

Infertility treatment: implications for perinatology.

From 1975 to 1989 multiple birth rate in The Netherlands increased with almost 40%. Only a quarter of the increase can be related to births after in vitro fertilization. Evidence is presented that ovulation induction as an independent therapy or in combination with other forms of assisted reproduction is highly responsible for the rising number of multiplets. As a consequence, a heavy burden is placed on the units for specialized neonatological care as well as on the obstetrical wards in the tertiary centres for neonatology. Doctors should become aware of the facts and should inform the public properly about the risks of multiple pregnancy. An international approach is needed to get insight in the problems and to develop effective policies for the future.

Birth Weight↗

Patient-friendly ovarian stimulation.

The ultimate goal of successful IVF is the birth of a healthy child with no maternal complications. Advances in ovarian stimulation protocols using gonadotrophin-releasing hormone agonists (GnRHa) and high doses of gonadotrophins have resulted in increased oocyte numbers with improved pregnancy and birth rates. However, the efficacy of such therapy is controversial when measured against the potential side effects. These side effects include those arising from oestrogen deprivation during desensitization, complications associated with an increased risk of ovarian hyperstimulation syndrome (OHSS), and an increased possibility of multiple births. Additionally, the increased cost due to more frequent monitoring and increased drug dosage negatively impacts on patient care. Thus, refinements in drug regimens are needed not only to address these side effects, but also to target the quality, not the quantity, of oocytes. In studies comparing GnRH antagonist (GnRHnt) to GnRHa, patients receiving GnRHnt underwent a shorter induction using less gonadotrophin, the incidence of OHSS was reduced and they reported a better quality of life. While larger studies are needed to confirm these promising findings, it appears that milder stimulation protocols could represent an interesting option, at least for selected patients.

Estrogens↗

Neural tube defects in Victoria, Australia: potential contributing factors and public health implications.

OBJECTIVES: To measure population prevalence and determine potential predictors of neural tube defects. METHOD: Analysis of all births reported to a mandated collection of perinatal data, and terminations prior to 20 weeks' gestation that have been reported to a data collection of birth defects in Victoria from 1983 to 1997. Prevalence at birth and risk ratios of infant and maternal characteristics associated with neural tube defects were calculated. RESULTS: Prevalence of spina bifida has remained steady for 15 years and was 8.8/10,000 in 1997. Anencephaly increased to 7.9/10,000 in 1997. After exclusion of pregnancy terminations, the 1997 birth prevalence was 4.5/10,000 for spina bifida and 2.4/10,000 for anencephaly. Neural tube defects are identified in 1 in 1600 fetuses, the risk being significantly higher for epileptic women (Adjusted Odds Ratio (AOR) = 3.70, 95% CI 2.25-6.07), multiple births (AOR = 4.56, 95% CI 3.46-6.02), teenage mothers (AOR = 1.47, 95% CI 1.09-2.00) compared with those aged 25-29, and women with three or more previous pregnancies (AOR = 1.40, 95% CI 1.10-1.78). The risk was lower for women of East Asian (AOR = 0.70, 95% CI 0.49-1.00) and Middle Eastern origin (AOR = 0.60, 95% CI 0.35-1.02) and these differences were approaching statistical significance. CONCLUSION: Total prevalence of neural tube defects did not decline up to 1997. IMPLICATIONS: It is unlikely that targeting 'at risk' groups identified in this study would make a difference to neural tube defect incidence. However, consideration could be given to identifying larger 'at risk' groups such as those with homocysteine metabolism defects.

Confidence Intervals↗

Low-birthweight children at early school-age: a longitudinal study.

Eighty-seven per cent of a cohort of 299 low-birthweight (LBW) infants (less than or equal to 2000 g) were examined at age 6 years 8 months, together with 111 control children. All the controls and 248 of the LBW children were individually assessed in school. Information about another 13 LBW children was obtained by questionnaire. Problems in primary school were related to social grade, evidence of early intra-uterine insult, sex, postnatal complications and neurological and developmental status in the first year of life. Multiple birth, gestation and intra-uterine growth were not clearly related to problems in school. The incidence of major handicap, as compared with LBW infants born between 1953 and 1955, showed little change when earlier-born infants who had been subjected to severe restriction of fluid and calorie intake were excluded. Ninety-two per cent of LBW children traced were attending normal schools. Those who showed no evidence of early intra-uterine insult and who were neurologically normal in the first year of life were largely indistinguishable from control children reared in similar homes.

Child↗

Sextuplet pregnancy after human menopausal gonadotropin superovulation and intrauterine insemination. A case report.

Sextuplet pregnancy occurred after human menopausal gonadotropin ovulation induction, intrauterine insemination and human chorionic gonadotropin support in the luteal phase. The patient's peak serum estradiol concentration was 861 pg/mL, and ultrasound monitoring demonstrated only one follicle greater than 11 mm in diameter. The possibility of high-order multiple birth exists despite intensive monitoring efforts for this therapy.

Adult↗

IVF results: optimize not maximize.

The desire to improve in vitro fertilization (IVF) results has led clinicians to replace more than 1 embryo in the uterus. As a result, multiple births have increased over the last 2 decades to epidemic proportions, exposing the field of assisted conception to justified criticism. This review aims to ensure that physicians involved in the field of fertility treatment are aware of the risks and complications related to multiple pregnancies, and to explore possible strategies such as blastocyst culture, preimplantation genetic screening, and embryo cryopreservation, which can help to control and reverse the tide of multiple pregnancies without reducing the good success rate that modern IVF treatment enjoys. A brief overview of the respective UK legislative system is also presented.

Cryopreservation↗

Mother's age and daughter's fecundity. An epidemiological analysis of late 19th to early 20th century family reconstitutions.

BACKGROUND: At both ends of the female reproductive span, the risk of reproductive problems is increased. We hypothesize that this is partly explained by inadequate maturation of oocytes ('pre-ovulatory overripeness'). As this phenomenon has been shown to lead to gonadal anomalies in the offspring of animals, we tested the prediction that daughters of older and very young mothers more often suffer reproductive problems due to ovarian maldevelopment. METHODS: We analysed family reconstitutions of 1907 women born in Rotterdam, the Netherlands, between 1873 and 1902. We defined several measures of fecundity based on numbers, birth rates and fates of offspring. We made use of general estimating equations (GEE), a statistical technique that allowed simultaneous analysis of different births per woman while controlling for various time-dependent or time-independent co-variables. RESULTS: The results indicated an increased risk of childlessness (adjusted odds ratio (aOR = 2.6, 95% CI : 1.1-7.4), stillbirth (aOR = 2.5, 95% CI : 1.1-5.6) and multiple birth (aOR = 2.1, 95% CI : 0.8-5.4) for daughters of mothers of >or=40 years as compared to daughters born to mothers of intermediate age (24-30 years). Daughters of mothers of <or=20 years, on the other hand, did not appear to have reduced fecundity. CONCLUSION: The results point to a decreased fecundity of daughters of older mothers, but not of daughters of younger mothers. The inconsistency of the results with respect to the oocytal-maturation hypothesis points to the action of other causal or non-causal mechanisms.

Adolescent↗

[Current percentile curves for body weight, body length and head circumference of newborn infants after the 25th week of pregnancy].

Up-to-date regional standard curves of birth weight, body length and head circumference have been derived from a survey of perinatal data (Perinatalerhebung) including 96.3% of all neonates born in 1988/89 in an area of northern Germany (westfalian districts of Münster, Detmold and Arnsberg). After exclusion of nongerman neonates, multiple births and those with doubtful date, complete data of 129,858 neonates (including 410 prematures of 25-28 gestational weeks) were evaluated. Mathematical analysis resulted in standard curves reliable between the 25 and 42 gestational weeks and between the 3rd and 97th percentile. Mean male birth weight at 40 weeks was 3612 g versus 3469 g in females. The normal range for boys was 2800-4500 g, and 2650-4350 g for girls. Irrespective of sex, mean body length of term neonates was 52.3 cm (48-57), mean head circumference was 35.2 cm (33-38). We suggest the use of these standard curves for newborns in northern Germany.

Birth Weight↗

The Nordic contribution to the English language twin literature.

This project was inspired by the extensive contribution of Nordic researchers to the English language twin literature. The purpose of the study was to compile a source bibliography of twin literature written at Nordic institutions. The bibliography compiled as a supplement for this paper provides as complete a survey as is possible to obtain in the United States. Our search began with a Medline Computer data base. To make our survey more complete, we cross-referenced and added to this using the Index Medicus, the National Institute of Mental Health Bibliography, Excerpta Medica, specific article references, references provided by Nordic university libraries and Gedda's Estudio dei Gemelli. The full bibliography of 313 references is available at no cost from the Center for the study of multiple Birth, Rm. 476, 333 E. Superior, Chicago, Ill. 60611, U.S.A.

Bibliographies as Topic↗

In vitro fertilization in Sweden: child morbidity including cancer risk.

OBJECTIVE: To study long-term morbidity among children conceived by IVF. DESIGN: A register study in Sweden of IVF infants compared with all infants born. SETTING: National health registers. PATIENT(S): More than 16,000 children born after IVF (30% of them after intracytoplasmic sperm injection) were studied with national health registers. MAIN OUTCOME MEASURE(S): Total number of days in hospital care at different ages, hospitalization for specific diagnoses, childhood cancer. RESULT(S): An overuse of hospital care was found among IVF children up to 6 years of age, which was partly explained by maternal characteristics. Discharge diagnoses indicating brain damage (mental retardation, cerebral palsy, epilepsy, behavioral problems) occurred in excess and seemed to be completely explained by preterm births. In addition, other discharge diagnoses were overrepresented, some of them linked to preterm birth. There were 29 children with cancer (21 expected); 5 of them had Langerhan's histiocytosis. CONCLUSION(S): Long-term morbidity among children conceived by IVF is higher than among naturally conceived infants. This was partly explained by an excess of preterm and multiple births but might also mirror different parental attitudes toward medical care for their children. No general increase in cancer risk was seen, but unexpectedly many children with histiocytosis were noted.

Adolescent↗

Obstetric risk factors for stress urinary incontinence: a population-based study.

OBJECTIVE: To evaluate obstetric and maternal risk factors for stress urinary incontinence. METHODS: We linked three national, Swedish, population-based registries with the use of unique personal identification numbers. All women born between 1932 and 1977 and operated on for stress urinary incontinence between 1987 and 1996 were identified from the Hospital Discharge Registry. This information was linked with the Medical Birth Registry (for the years 1973-1995), containing information on antenatal care, delivery, and the newborn, and the Fertility Registry (for the years 1932-1997), containing information on the number of children delivered by each Swedish woman. For determination of odds ratios (ORs) and approximate 95% confidence intervals (CIs), we used the Mantel-Haenszel method and a test-based method after suitable stratifications and exclusions. RESULTS: Diabetes mellitus, body mass index (BMI), age at first delivery, parity, birth weight, and epidural analgesia were positively associated with incontinence surgery. In contrast, cesarean delivery, forceps/vacuum extraction, and episiotomy were negatively associated with incontinence surgery. No association was found between surgery for stress incontinence and age at last delivery, smoking during pregnancy, level of education, multiple birth, large perineal tear, or breech presentation at any vaginal delivery. The OR for incontinence surgery was similarly decreased for nulliparous women and for uniparous women delivered by elective cesarean. CONCLUSION: Vaginal delivery, notably the first, is strongly associated with later surgery for stress incontinence, but the association is modified by maternal conditions and interventions during delivery. No association was found between surgery for stress incontinence and pregnancy per se.

Adult↗

Pharyngeal lecithin/sphingomyelin ratios in newborn infants.

Lecithin/sphingomyelin ratios were measured on hypopharyngeal secretions from newborn infants within 6 h of birth. L/S ratios of 1.8 or less correlated with the development of the idiopathic respiratory-distress syndrome. Low L/S ratios were more common in the shorter gestation infants, and there was a predominance of L/S ratios of more than 1.8 above 32 weeks' gestation. In multiple births, the first-born of triplets and quadruplets had higher L/S ratios than those subsequently born. This may indicate a link between fetal lung maturation and the onset of labour.

Birth Order↗

Starting, spacing and stopping in the reproductive histories of outer Hebridean families.

Maternal ages at the first maternity (starting), at the last maternity (stopping) and the lengths of intervals between maternities (spacing) have been studied in the Outer Hebridean islands of Harris and Barra for births between the years of 1855 and 1990, a period during which a considerable 'fertility transition' occurred. There was a tendency in each island for increases with time in the ages at starting among less-fecund women (although after 1936 starting ages declined), and highly significant heterogeneity of covariance: adjusted means dependent on the total numbers of maternities experienced. The same result was seen for the ages at stopping. Lengths of reproductive life (the difference between ages at starting and stopping) rose to 1876-1895, and then fell, apart from a short-lived rise in Barra during 1956-1975, possibly due to the papal encyclical Humaneae Vitae. Intervals between marriage and first maternity and between successive maternities were studied by hazard function survival analysis. The marriage first birth interval remained very constant, unaffected by total maternities. The father's occupation and the mother's age at first maternity showed no significant relationships. In Barra there was a weak negative relationship with the date of the marriage. For intervals between maternities in both islands, total maternities and the death of a previous infant were associated with shorter, and birth order with longer intervals. In Harris, there were tendencies for intervals to be consistently long or short in families, and for the age of the mother and date at first maternity to be negatively related to the length of the interval. In Barra, a previous multiple birth was followed by a longer interval. The date of the previous maternity, father's occupation, maternal age at the previous maternity, the sex of the previous child, and the duration of the marriage appeared to have no influence on maternity intervals. Evidence for an effect of economic deprivation during the 19th century on the variables considered was equivocal. During the 20th century, it is suggested that economic depression during the inter-war years, the spread of contraception, and improvements in health care may have acted 'synergistically' to produce the lower ages of childbearing and the shortening of maternity intervals and reproductive lives.

Adolescent↗

Risk factors for perinatal and postnatal mortality in lambs.

Factors associated with preweaning mortality in lambs were identified by developing risk profiles with logistic regressions for perinatal and postnatal mortality. Compared with heavy lambs, lambs of low birth weight had almost twice the risk of perinatal mortality (odds ratio [OR] = 1.9) and lambs of average weight had a slightly lower risk (OR = 0.7). Two of four lambing location categories affected perinatal mortality, with lambs born at unmonitored areas at greatest risk (OR = 2.7). Multiple births increased the risk of perinatal mortality (OR = 1.5), especially among Targhee lambs (OR = 4.0). Breed variations in perinatal mortality were significant in Suffolk lambs (OR = 1.9) and Booroola Rambouillet lambs (OR = 2.1). Lambs born weak had an increased risk of postnatal mortality while strong lambs had a decreased risk (OR = 3.7 and 0.6, respectively) if the dam had an adequate milk supply. Poor milk supply increased the risk of postnatal mortality for lambs of average vigour (OR = 3.3), but did not change the risk for weak or strong lambs. Male lambs castrated at 30 days of age were at less risk of postnatal mortality (OR = 0.3) than females. There were slight increases in the risk of postnatal mortality for intact males (OR = 1.3), low birth weight lambs (OR = 1.6), and lambs born in sheds (OR = 1.3). Suffolk lambs (OR = 1.8) and Targhee lambs (OR = 1.6) had a higher risk of postweaning mortality.

Animals↗

[Guidance for the obstetrician encountering a multiple pregnancy].

A retrospective review of multiple birth of higher order delivered at the Obstetric Clinic of University of Rome "La Sapienza" from 1982-1991 was performed. Comparison was made between this group (study group) and other published data. Since 1982 there has been more liberal use of abdominal delivery. Of the 25 multiple pregnancies, 17 were delivered by cesarean section (CS) and 8 by vaginal delivery. The corrected mortality rate in the study group was 19.2% (5/26) for vaginal delivery and 17.5% (10/57) for CS. Indication for CS was: elective (35%), fetal (18%) and maternal (47%). The main neonatal complications resulted from prematurity, and maternal noted complication were post-partum hemorrhage necessitating hysterectomy in one patient. The preferable mode of delivery cannot be stated dogmatically.

Adult↗

Annual summary of vital statistics--1995.

Recent trends in the vital statistics of the United States continued in 1995, including decreases in the number of births, the birth rate, the age-adjusted death rate, and the infant mortality rate; life expectancy at birth increased to a level equal to the record high of 75.8 years in 1992. Marriages and divorces both decreased. An estimated 3,900,089 infants were born during 1995, a decline of 1% from 1994. The preliminary birth rate for 1995 was 14.8 live births per 1000 total population, a 3% decline, and the lowest recorded in nearly two decades. The fertility rate, which relates births to women in the childbearing ages, declined to 65.6 live births per 1000 women 15 to 44 years old, the lowest rate since 1986. According to preliminary data for 1995, fertility rates declined for all racial groups with the gap narrowing between black and white rates. The fertility rate for black women declined 7% to a historic low level (71.7); the preliminary rate for white women (64.5) dropped just 1%. Fertility rates continue to be highest for Hispanic, especially Mexican-American, women. Preliminary data for 1995 suggest a 2% decline in the rate for Hispanic women to 103.7. The birth rate for teenagers has now decreased for four consecutive years, from a high of 62.1 per 1000 women 15 to 19 years old in 1991 to 56.9 in 1995, an overall decline of 8%. The rate of childbearing by unmarried mothers dropped 4% from 1994 to 1995, from 46.9 births per 1000 unmarried women 15 to 44 years old to 44.9, the first decline in the rate in nearly two decades. The proportion of all births occurring to unmarried women dropped as well in 1995, to 32.0% from 32.6% in 1994. Smoking during pregnancy dropped steadily from 1989 (19.5%) to 1994 (14.6%), a decline of about 25%. Prenatal care utilization continued to improve in 1995 with 81.2% of all mothers receiving care in the first trimester compared with 78.9% in 1993. Preliminary data for 1995 suggests continued improvement to 81.2%. The percent of infants delivered by cesarean delivery declined slightly to 20.8% in 1995. The percent of low birth weight (LBW) infants continued to climb in 1994 rising to 7.3%, from 7.2% in 1993. The proportion of LBW improved slightly among black infants, declining from 13.3% to 13.2% between 1993 and 1994. Preliminary figures for 1995 suggest continued decline in LBW for black infants (13.0%). The multiple birth ratio rose to 25.7 per 1000 births for 1994, an increase of 2% over 1993 and 33% since 1980. Age-adjusted death rates in 1995 were lower for heart disease, malignant neoplasms, accidents, and homicide. Although the total number of human immunodeficiency virus (HIV) infection deaths increased slightly from 42,114 in 1994 to an estimated 42,506 in 1995, the age-adjusted death rate for HIV infection did not increase, which may indicate a leveling off of the steep upward trend in mortality from HIV infection since 1987. Nearly 15,000 children between the ages of 1-14 years died in the United States (US) in 1995. The death rate for children 1 to 4 years old in 1995 was 40.4 per 100,000 population aged 1 to 4 years, 6% lower than the rate of 42.9 in 1994. The 1995 death rate for 5- to 14-year-olds was 22.1, 2% lower than the rate of 22.5 in 1994. Since 1979, death rates have declined by 37% for children 1 to 4 years old, and by 30% for children 5 to 14 years old. For children 1 to 4 years old, the leading cause of death was injuries, which accounted for for an estimated 2277 deaths in 1995, 36% of all deaths in this age group. Injuries were the leading cause of death for 5- to 14-year-olds as well, accounting for an ever higher percentage (41%) of all deaths. In 1995, the preliminary infant mortality rate was 7.5 per 1000live births, 6% lower than 1994, and the lowest ever recorded in the US. The decline occurred for neonatal as well as postneonatal mortality rates, and among white and black infants alike.

Global Health↗

Head circumference in ELBW babies is associated with learning difficulties and cognition but not ADHD in the school-aged child.

This study examines whether a small head circumference (HC) and low head-circumference growth velocity (HGV) during the first year of life predict consequences at school age in learning, cognition, and concentration. A total of 124 extremely-low-birthweight (ELBW) infants (birthweight 500 to 999 g) born between 1977 and 1986 were eligible for follow-up at the corrected ages of 4, 8, and 12 months and 2, 4, and 6 years. Infants were categorized as having a small HC (< 3% or 3 to 10%) on the basis of the 1990 British growth data which allowed standardized z-scores to be calculated for HC, independent of gestation and corrected age. HGV measurements were calculated using differences in the HC z-scores. In 1995, parents of 87 children agreed to participate in a study of learning and attention at school age. Attention-deficit-hyperactivity disorder (ADHD) was assessed using the Du Paul Rating Scale. Academic performances were based on a teacher questionnaire dealing with aspects of reading, writing, mathematics, and spelling. A child was considered to have a learning difficulty if academic problems were present in at least one of these four areas. Intellectual ability was assessed using the McCarthy Scale at 6 years. HC < 3% and 3 to 10% at 8 months' corrected age was strongly associated with school-aged learning problems (P=0.004), with a moderate specificity (70%), positive predictive value (PPV) (67%), and sensitivity (67%). HGV < or = 10% from birth to 4 months was also associated with learning problems at school age (P=0.01) with a higher specificity (98%) and PPV (88%) but lower sensitivity (20%). A logistic regression analysis was performed with the risk for learning difficulties at 8 months as the dependent variable. Sex, gestation, birthweight, multiple births, and a history of intraventricular hemorrhage did not substantially alter the unadjusted odds ratio (4.7; 95% CI 1.9 to 13.6). Maternal age and education did not confound the relation. No association was found between HC or HGV and ADHD. HC < 3% at 4 months (P<0.02), 8 months (P=0.02), and 12 months (P=0.04), and HGV between birth and 4 months (P<0.01) were significantly associated with low cognitive ability at 6 years.

Attention Deficit Disorder with Hyperactivity↗