Advances in the field of neonatal-perinatal medicine and interventions of the 1960's have resulted in decreased mortality rates for infants suffering a variety of perinatal insults. However, it has been estimated that 25% of the survivors of high risk births will go on to have serious lifetime diabilities (Behrman, 1977). Resulting neurological morbidity may be expressed in major cognitive disabilities (i.e., cerebral palsy, mental retardation, learning disorders and the like). Early identification of these children seems Parmalee, Sigman, & Beckwith, 1982). However, the prediction of neurological outcomes remains problematic.Recognizing the psychometric concerns associated with. perinatal risk measures currently used (Crawford, 1965: Bobbin, 1963: Wenar, 1963), the Transition Scale was created as a potentially reliable measure of perinatal risks observed at the time of birth. With a sample of 116 newborn subjects, the present investigation evaluated the stability and underlying constructs of the newly created measure. In addition, comparisons were made with information obtained critical to prevention and early intervention (Cohen, from the medical chart (i.e., Apgar Score).The percentage of agreement between the two independent raters for individual items of the Transition Scale ranged from .95 to 1.00, with the overall interrater agreement calculated as .98. Similarly, an examination of the agreement between each individual rater's responses and the medical chart information revealed percentages ranging from .90 to 1.00, with overall percentages of .96 and .97. Furthermore, the results of a factor analysis indicated that the Transition Scale offers substantial construct validity.Overall, the present investigation recommends the Transition Scale as a reliable research instrument with potential clinical utility. In addition, an examination of the underlying constructs of the measure point to the potential of the Transition Scale as a valid predictor of neurological morbidity. Further research using a high risk sample of infants is recommended. / Department of Educational Psychology

The present study was an effort to empirically subtype children's learning disabilities. A review of the literature was presented with a focus on current and historical subtyping attempts. A cluster analysis was performed on 1144 school-age learning disabled children who had completed extensive neuropsychological, intellectual, and achievement measures. Four interpretable clusters emerged which were seen as (1) Verbal-Sequential-Arithmetic Deficits, (2) Motor Speed and Cognitive Flexibility Deficits, (3) Mixed Language/Perceptual Deficits, and a (4) No Deficit Subtype. Not only did these clusters indicate unique profiles for each subtype across the sample, but developmental differences were also apparent between all four clusters. The current investigation suggested the utility of an empirical-neuropsychological approach to subtyping children's learning disabilities, while also portraying the importance of neurodevelopmental considerations of subtypes. Future directions in research were discussed. / Department of Educational Psychology

Due to rapid growth in computing power, the collection of high dimensional and complex datasets is increasingly feasible. To reap their full benefit, novel analytic strategies may be required. Application of such methods remains limited in certain epidemiologic research areas. The overarching aim of this dissertation was to apply novel analytic strategies with close ties to causal inference and statistical learning theory to gain new insights into well-studied areas of perinatal epidemiology. In Study 1, we explored whether the association between short interpregnancy intervals (i.e., the end of one pregnancy to the start of the next) and increased risk of preterm birth may be due to residual confounding in three populations (n=693 American Indian and n=728 white women from the Northern Plains, U.S., and n=783 mixed ancestry women from the Western Cape, South Africa). Using data from the prospective Safe Passage cohort (2007-2015), we applied propensity score methods to control for a variety of sociodemographic and reproductive factors. A third-to-half of women with <6 months intervals had propensity scores that largely did not overlap with those of women with 18-23 months intervals. Since the propensity score models included factors related to both interpregnancy interval and preterm birth, these findings suggest the possibility of strong confounding in all three populations. The pooled associational estimate with preterm birth was attenuated in the propensity score trimmed and weighted data (risk ratio 1.4, 95% CI 0.75-2.6) compared with the crude results (risk ratio 1.7, 95% CI 1.1-2.7). However, the sample size and precision were reduced after propensity score trimming, and several covariates remained imbalanced. The data demonstrated the complexity of the processes leading to interpregnancy interval length. These issues may have been difficult to identify without comprehensive confounder data and with other methods, such as traditional regression adjustment. In Study 2, we examined the relative importance of timing (first trimester versus second/third trimesters) and degree of gestational weight gain in relation to infant size at birth (small-and-large-for-gestational age) among women with obesity using data from a medical records-based case-cohort study (Pittsburgh, PA, 1998-2010). We operationalized serial antenatal weight measurements as above, below, or within the current recommended ranges for U.S. pregnancies, i.e., 0.2-2.0 kg total gain in the first trimester and 0.17-0.27 kg per week in the second and third trimesters (based on group based trajectory modeling). Data were analyzed by obesity class (n=1290 in the class I subcohort, n=1247 class II, n=1198 class III). Our findings supported the current clinical guidelines, except for women with class III obesity. Among women with class III obesity, lower than recommended gain in the second and third trimesters was associated with decreased risk of having a large-for-gestational age infant (adjusted risk ratio 0.76, 95% CI 0.51-1.1), while not increasing small-for-gestational age (SGA) risk (adjusted risk ratio 1.0, 95% CI 0.63-1.7). Our results were in agreement with findings from several other studies of women with obesity using other methodologies to operationalize gestational weight gain. In Study 3, we used hierarchical clustering to explore latent groups of placental pathology features. We also investigated whether the placental clusters, in addition to birthweight percentiles, were beneficial to explain the variability of select adverse pregnancy outcomes. Data were from the Safe Passage Study (same as Study 1, n=2005). We identified one cluster with low prevalence of abnormalities (60.9%) and three clusters that mapped well to the expert consensus-based Amsterdam criteria: severe maternal vascular malperfusion (5.8%), fetal vascular malperfusion (11.1%), and inflammation (22.1%). The clusters were weakly-to-moderately associated with certain antenatal risk factors, pregnancy complications, and neonatal outcomes. Birthweight percentiles plus the placental clusters was better able to explain the variance of select adverse outcomes, compared with using small-for-gestational age only. This study serves as proof-of-concept that machine learning methods, and placental data, may aid in the identification and etiologic study of certain adverse pregnancy outcomes. In sum, all three studies support that the application of novel analytic methods to high-dimensional datasets may expand our understanding of certain causal questions, even ones that have been broached before, although, as seen in Study 2, such research may not always yield novel insights.

Perinatal hypoxia-ischaemia is a major cause of disability, including cerebral palsy, yet a neuroprotectant which fully protects the brain remains elusive. Following a hypoxic-ischaemic insult, striatal medium-spiny neurons and hippocampal CA1 neurons are vulnerable to a complex cascade of neurotoxic events. This cascade includes energy failure, a massive release of glutamate, the formation of free radicals and caspase activation. The overall aim of this thesis was to assess the efficacy of three potential neuroprotective strategies that target this cascade from different directions. Short-term, and where appropriate, long-term, neuroprotection was investigated. The first treatment strategy aimed to suppress the generation of free radicals through treatment with the potent free radical spin trap, N-tertbutyl-(2-sulphophenyl)-nitrone (S-PBN). The second compound tested was the caspase-3 inhibitor, minocycline. Finally, the third treatment strategy combined a series of S-PBN injections with 6 hours of moderate hypothermia immediately after hypoxia-ischaemia. Hypothermia is suggested to slow the rate of the neurotoxic cascade, thus potentially allowing other neuroprotective agents greater efficacy. Using an adaptation of the Rice et al. (1981) model, hypoxia-ischaemia was induced on postnatal day (PN) 8 in the right cerebral hemisphere. For the short-term studies, the rats were perfused at 14 days-of-age. The brains were dissected out and embedded in Technovit. Forty [mu]m serial sections were cut through the right striatum and hippocampus. The total number of medium-spiny neurons in the striatum and where appropriate, the total number of neurons in the hippocampal CA1 pyramidal layer, were stereologically determined using the optical disector/Cavalieri method. For the long-term study, fine motor control was assessed in half of the animals through the staircase test from 9-11 weeks-of-age. Neuroprotection was assessed in the remaining animals. All animals were sacrificed at 12 weeks-of-age. The total number of striatal medium-spiny neurons was stereologically determined in the non-behavioural animals as described above. A series of seven injections of S-PBN (100mg/kg) did not offer statistically significant neuroprotection to the striatum at one week after perinatal hypoxia-ischaemia. Similarly, a single injection of minocycline (45mg/kg) immediately after the insult did not offer significant neuroprotection to the striatum nor the CA1 region of the hippocampus at this early time-point. In contrast, when the series of S-PBN injections was combined with 6 hours of moderate hypothermia post-hypoxia-ischaemia, sterelogical analysis revealed significant neuroprotection of the striatal medium-spiny neurons to normal levels at one week after the injury. No significant neuroprotection was seen in the CA1 region of the same animals. To assess whether this impressive striatal neuroprotection was long-lasting and whether it represented functional rescue, the final experiment in this thesis investigated rat pups at 12 weeks-of-age after exposure to hypoxia-ischaemia at PN8. Treatment with S-PBN/hypothermia offered persistent neuroprotection of striatal medium-spiny neurons and preservation of fine motor skills compared to diluent-normothermia-treated controls. The long-term behavioural outcomes were compared with normal, uninjured controls and the total number of medium-spiny neurons was compared with normal numbers from the literature. These comparisons revealed that the histological and functional integrity of the striatum was rescued to normal levels. This is the first study to identify a treatment strategy that offers complete and long-lasting preservation of striatal neuronal numbers, by accurate and unbiased stereological methods, paired with persistent preservation of fine motor control following perinatal hypoxia-ischaemia.

The purpose of this integrative literature review was to provide a compilation and review of literature related to perinatal outcomes of clients with antepartum or intrapartum oligohydramnios and management decisions applied to these clients. This paper is intended to synthesize and summarize the most current knowledge retrieved in these topics between the years of 1990- 2000. A general search using key terms was conducted, and yielded 63 prospective articles comprised of full articles, abstracts, and literature reviews. Seventeen articles on oligohydramnios, amniotic fluid volume measurements, and perinatal outcomes were retained out of the 35 that were found. The search for the literature discussing management of oligohydramnios produced 9 articles, of which 3 were found to be pertinent to this project. Twelve of the total 39 articles retained were literature reviews and were used for citation and identification of additional information material to this topic. Seven of the 39 articles were retained for the sole purpose of enabling the author to provide a descriptive, thorough review on the relevant concepts of this review. Studies reviewing amniotic fluid volume/oligohydramnios and perinatal outcomes suggest great variance among likelihood of adverse perinatal outcomes. Studies reviewing management of oligohydramnios suggest amnioinfusion may have obstetrical and perinatal benefits for the client with oligohydramnios. Aggressive management including indication for cesarean section related to fetal distress and labor induction were implied with minimal discussion on conservative management for these clients.

Diploma thesis deals with historical formation of neonatal intensive care in the Czech Republic. Its aim is to map the evolution of intensive care, from the very beginning up to the contemporary period, and provide a concise overview of events leading to Czech Republic being one of the countries where level of neonatal care is considered to be most advanced. Theoretical nature of the thesis required a study of historical and contemporary literature, particurarly artticles and books. As an extra supplement, authentic information have been gathered from the pathfinders. In the introduction to the thesis, reason for choosing the topic is described, then current status of knowledge in this area is summarized. Following that, process of creating of the historical analysis is described. Chapter on neonatology introduces and explains terms that are crucial for comprehending the context stated in the historical part of the thesis. Chapter which maps the historical evolution itself is divided into seven sub chapters which describe course of events in the particular periods. Evolution of perinatal care abroad is also shortly described. Thesis reviews an extraordinary evolution of neonatal intensive care which has occurred in very short period of time. During this period pioneers had to overcome many hurdles,...

O modelo de assistência ao parto em ambientes extra ou peri-hospitalares foi implantado no Brasil há dez anos. Conduzido por enfermeiras obstétricas e obstetrizes, constitui uma política do Ministério da Saúde direcionada a mulheres com gestação de baixo risco. Os estudos mostram que este modelo pode promover o parto fisiológico e reduzir o uso de intervenções desnecessárias, com bons resultados maternos e perinatais. O objetivo deste estudo foi comparar os resultados maternos e perinatais em mulheres de baixo risco atendidas em um centro de parto normal peri-hospitalar e hospital, considerando: 1. características sociodemográficas e obstétricas das mulheres; 2. utilização de intervenções durante o parto e nascimento entre mulheres e recém-nascidos; 3. condições maternas e perinatais no parto e no pós-parto. Trata-se de um estudo comparativo, observacional, analítico, de tipo transversal, sobre os resultados maternos e perinatais de mulheres de baixo risco, realizado no Centro de Parto Normal Casa de Maria (CPN-CM) e no Hospital Geral do Itaim Paulista (HGIP), na cidade de São Paulo. A população do estudo foi composta pelas 18.488 mulheres atendidas por estes serviços, entre 2003 e 2006. O cálculo do tamanho da amostra foi realizado com a intenção de se detectar uma diferença de, no mínimo, 10% na taxa de mulheres com episiotomia entre o HGIP (35%) e CPNCM (25%) com =0,05 e poder do teste de 90%. Foram incluídas na amostra 991 mulheres que tiveram o parto no CPN-CM e 325 que deram à luz no HGIP e que atendiam aos mesmos critérios estabelecidos para o parto no CPN-CM. As fontes de dados foram os registros dos prontuários das mulheres e seus respectivos recém-nascidos. A análise inferencial foi realizada pelos testes t-Student, Qui-quadrado e exato de Fisher, sendo considerados estatisticamente significantes os valores de p<0,05. Os dados indicaram que 45,4% eram nulíparas e 54,6% tinham um ou mais partos anteriores, sem diferença estatisticamente significante entre os locais de parto. Não houve caso de morte materna ou perinatal. Os resultados mostraram diferença estatisticamente significante entre as características sociodemográficas situação conjugal e realização de consulta de pré-natal e entre as condições na admissão dilatação cervical, estado das membranas e realização de monitorização eletrônica fetal. Quanto às intervenções obstétricas, as mulheres do hospital receberam mais restrição de dieta, amniotomia e ocitocina durante o primeiro período do parto e mais ergometrina e analgésico no pós-parto. Os resultados relacionados com os recém-nascidos mostraram diferenças estatisticamente significantes nas seguintes variáveis: Apgar no primeiro minuto, bossa serossanguínea; fratura de clavícula; desconforto respiratório; aspiração de vias aéreas superiores e gástrica; lavagem gástrica; administração de oxigênio nasal e com pressão positiva; entubação orotraqueal; internação em unidade neonatal. Os resultados maternos e neonatais da assistência no CPN são seguros em comparação com os do hospital. A assistência no CPN foi realizada com menos intervenções e com resultados maternos e neonatais semelhantes aos do hospital. Estes resultados podem subsidiar a ampliação deste modelo com a finalidade de melhorar os índices de morbidade materna e perinatal, além de promover o parto fisiológico / The model of childbirth care in free-standing and alongside birth centres was implemented in Brazil ten years ago. Led by obstetric nurse-midwives and midwives, it is a policy of the Ministry of Health proposed to assist low-risk pregnant women. Studies show that this model promotes natural birth, reducing the use of unnecessary interventions, and that maternal and perinatal outcomes are favourable. The objective of this study was to compare maternal and perinatal outcomes among low-risk women attended to at an alongside birth centre versus a hospital maternity ward, considering: 1. the sociodemographic and obstetric characteristics of the women; 2. the use of interventions during labour and birth in women and in their newborns; 3. the maternal and perinatal conditions during labour and postpartum. This is a comparative, observational, analytical cross-sectional study of maternal and perinatal outcomes for low-risk women, which was conducted at the Casa de Maria alongside Birth Centre (CPN-CM) and at the Itaim Paulista General Hospital (HGIP), in the city of Sao Paulo. The study population was composed of 18,488 women who were assisted in these services during childbirth between 2003 and 2006. The sample size was calculated with the intent to detect at least a 10% difference in the rate of women with episiotomy among the HGIP (35%) and the CPN-CM (25%) with an =0.05 and test power=90%. The sampling included 991 women who had given birth at the CPN-CM, and 325 who had given birth at the HGIP and who met the same labour criteria as the CPN-CM. The data source was the collection of the womens and their respective newborns medical records. Students t-test, chi-square test and Fishers exact test were used for the inferential analysis, with the threshold p-value for statistical significance being p<0.05. The data showed that 45.4% were nulliparous and 54.6% had had one or more previous births, without any statistically significant difference between the birth places. There were no cases of maternal or perinatal death. In terms of the women, the sociodemographic outcomes that presented statistically significant differences were marital status and number of pre-natal medical appointments; while the outcomes related to conditions at the time of hospital entry statistically significant were: cervical dilation; status of ovular membrane; electronic foetal monitoring (EFM). In terms of obstetric interventions, women in the hospital received a more restricted diet, performance of amniotomy and administration of oxytocin during the first stage of labour; and administration of higher doses of ergometrine and pain relievers postpartum. In terms of the newborn, the outcomes that presented statistically significant differences were: Apgar score at the first minute; caput succedaneum; clavicle fracture; respiratory discomfort; airways and gastric aspiration; gastric lavage; administering supplemental oxygen through a nasal cannula with pressure transducer; orotracheal intubation; admittance to the neonatal care. Maternal and neonatal outcomes in CPN-CM demonstrate safety when compared to those of the hospital. Care provided in CPN-CM entailed fewer interventions and demonstrated similar maternal and neonatal outcomes to those in the hospital. These outcomes support expansion of this model in order to lower maternal and perinatal morbidity rates and to promote natural birth

O objetivo deste estudo foi comparar a morbidade e a mortalidade entre prematuros tardios (34 a 36 semanas e 6 dias de idade gestacional ao nascimento) com e sem restrição do crescimento fetal (RCF). O estudo foi desenvolvido longitudinalmente, envolvendo gestantes que apresentaram parto prematuro, sendo 50 com RCF (Grupo I) e 36, sem RCF (Grupo II), no período de outubro de 2004 a outubro de 2006. Foram avaliados os seguintes resultados pós-natais: peso e idade gestacional (IG) ao nascimento, cesárea, Apgar de quinto minuto, pH do sangue da artéria umbilical ao nascimento, necessidade e tempo de intubação orotraqueal (IOT) e de internação na unidade de terapia intensiva neonatal (UTI). Foram também avaliados: síndrome do desconforto respiratório (SDR), sepse, plaquetopenia, hipoglicemia, hemorragia intracraniana (HIC), icterícia e necessidade de fototerapia, tempo de internação e ocorrência de óbito. Para análise estatística foram utilizados os testes de Qui-Quadrado, exato de Fisher e teste não paramétrico de Kruskal Wallis, adotado nível de significância de 5%. As idades gestacionais avaliadas foram semelhantes nos dois grupos, com média de 35,5 semanas. Observou-se, no grupo I, maior freqüência dos seguintes resultados pós-natais adversos: menor peso ao nascimento (p<0,001), maior incidência de cesárea (92% versus 25% do grupo II; p<0,0001), maior necessidade de internação em UTI (58% versus 33%; p=0,041), maior tempo de internação (p<0,001) e de internação em UTI neonatal (p<0,001), maior ocorrência de HIC (12% versus 0; p=0,037), maior ocorrência de hipoglicemia (p= 24% versus 6%; 0,047) e maior tempo de fototerapia (p=0,005). Os grupos não apresentaram diferenças nos índices de Apgar, pH de cordão, IOT, SDR, plaquetopenia, sepse e icterícia. Não houve casos de doença de membrana hialina, displasia broncopulmonar, hemorragia pulmonar ou óbito neonatal. Pode-se concluir que o grupo de prematuros tardios com RCF apresentou mais complicações neonatais do que o grupo sem RCF / The objective of this study was to compare neonatal morbidity and mortality between late-preterm infants (gestational age at birth: 34 to 36 weeks and 6 days) with and without fetal growth restriction (FGR). A longitudinal study was conducted between October 2004 and October 2006 involving 50 pregnant women with pre-term delivery associated with FGR (group I) and 36 women with spontaneous preterm delivery not associated with FGR (group II). The following postnatal outcomes were evaluated: weight and gestational age at birth, cesarean section rate, 5-minute Apgar score, umbilical artery pH at birth, and need for and duration of orotracheal intubation and hospitalization in the neonatal intensive care unit (NICU), as well as the presence of respiratory distress syndrome (RDS), sepsis, thrombocytopenia, hypoglycemia, intracranial hemorrhage (ICH) and jaundice, need for phototherapy, length of hospital stay, and occurrence of death. The chi-square test, Fishers exact test and nonparametric Kruskal-Wallis test were used for statistical analysis, adopting a level of significance of 5%. Gestational age was similar in groups I and II, with a mean of 35.5 weeks in both groups. A higher frequency of the following adverse postnatal outcomes was observed in group I: lower birth weight (p<0.001), higher incidence of cesarean section (92% versus 25% in group II; p<0.0001), greater need for NICU treatment (58% versus 33%; p=0.041), longer hospital (p<0.001) and NICU stay (p<0.001), higher frequency of ICH (12% versus 0; p=0.037) and hypoglycemia (24% versus 6%; p=0.047), and longer duration of phototherapy (p=0.005). No differences in Apgar scores, cord pH, orotracheal intubation, RDS, thrombocytopenia, sepsis, or jaundice were observed between groups. There were no cases of hyaline membrane disease, bronchopulmonary dysplasia, pulmonary hemorrhage, or neonatal death. In conclusion, the group of late-preterm infants with FGR presented more neonatal complications than the group without FGR

Abstract not available

A prospective study was conducted on a group of 160 students from 9 to 14 years of age with learning disabilities to predict neuropsychological outcome using perinatal information as predictors. Perinatal information was obtained from the Maternal Perinatal Scale (MPS) (Dean & Gray, 1985). Subjects' neuropsychological functioning was assessed by the Short Neuropsychological Screening Device (SNSD) (Reitan & Herring, 1985). Information concerning subjects' intelligence was obtained from the Wechsler Intelligence Scale for Children-III (WISC-III) administered within the past two years. Hollingshead's Four Factor Index of Social Status was employed to determine subjects' socioeconomic status. A stepwise multiple regression analysis yielded a regression model that contained a subset of 7 perinatal risk factors, involving: (1) Obstetric History; (2) Gestational Age; (3) Psychosocial Events; (4) Delivery; (5) Intrauterine Stress; (6) Teratogenic Stress; and (7) Fetal Oxygenation. A hierarchical regression analysis was further performed to examine if adding socioeconomic and intellectual information to the regression model could increase the prediction of neuropsychological outcome. Results showed that up to 82% of the variability in the neuropsychological outcome was explained by the linear composite of the 7 risk factors. When socioeconomic and intellectual information were added to the regression model, the prediction of neuropsychological outcome was significantly improved. About 201 of the students with learning disabilities in the present study were found to display symptoms similar to minimal brain damage (MBD) relating to poor visual-motor integration, underdeveloped language skills, and aphasic conditions. The results support the theory of a "continuum of reproductive casualty" proposed by Pasamanick et al. (1956). The importance of detecting early indicators of neuropsychological deficits in at risk children was further suggested by the present study. / Department of Educational Psychology