Diagnosis and Conditions

This is the common term given to most neonates who need some type of help breathing shortly after birth. Strictly speaking, RDS results from the absence or malfunction of the substance inside the lung, called surfactant, that helps humans to breathe. Surfactant is made by cells inside the lung, starting about 35 weeks post-menstrual age (PMA). This slippery, soap-like chemical, reduces the water surface-tension between the inside surfaces of the lung as it expands and collapses, allowing the lung to easily inhale oxygen and exhale carbon dioxide. Premature babies may not be able to make their own surfactant, causing difficulty breathing. Term babies with pneumonia, or those who pass meconium (the first stool) before they are born, may have surfactant that is not working properly, causing difficulty breathing. The discovery of surfactant and the ability to administer it into the lung of a newborn baby is one of the single most important advances in the care of newborn infants of the 20th century! History buffs may recall that President John F. Kennedy’s son, Patrick, was born at 33 weeks’ gestation and died two days later from surfactant deficiency/RDS. RDS is a short-lived condition and usually resolves without any long-term effects. Occasionally, however, it evolves into chronic lung disease (see below).

Also known as “preterm eye disease” or, historically, “retrolental fibroplasia,” this condition occurs in extremely preterm infants, and is worsened by prolonged exposure to excessive levels of supplemental oxygen. This becomes complicated when your baby needs the extra oxygen for severe lung disease, knowing there may be negative effects on the eyes. The American Academy of Pediatrics (AAP) has established guidelines for ROP exams (see http://pediatrics.aappublications.org/content/117/2/572.full), and your baby born at less than 32 weeks EGA and/or 1500 grams (3# 5oz) should receive serial eye examinations by a pediatric ophthalmologist for the condition. (Some older and/or bigger babies who are particularly sick may also receive eye exams.) Undiagnosed/untreated ROP can lead to blindness, so it’s important to keep your baby’s out-patient eye appointments after discharge.

This is the medical term for infection in the bloodstream that causes overall sickness. Most older children and adults have functioning immune systems that can isolate an infection and prevent it from spreading. Neonates – especially premature babies – do not have functioning immune systems and so are especially vulnerable to infection. Infection in the womb is the most common reason for premature birth, and sepsis is included in the list of possible diagnoses for most babies admitted to NICUs. Cultures of blood, urine, and possibly spinal fluid will be collected to look for bacterial growth. However, many factors can prevent the cultures from growing and your doctors may presume infection, and treat for it with antibiotics, even if it cannot be conclusively proven. Risk factors for infection acquired during labor and delivery include: 1) onset of labor before 37 weeks EGA; 2) rupture of membranes before 37 weeks EGA; 3) rupture of membranes more than 18 hours before delivery; 4) maternal fever during labor; 5) fetal HR > 180 during labor; 6) presence of Group B Streptococcus (GBS) bacteria on mother’s prenatal vaginal swab. The CDC, along with the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AMFP), and the American College of Obstetrics and Gynecology (ACOG), have collaborated on recommendations for screening and treatment of mothers and babies related to GBS colonization (http://www.cdc.gov/groupbstrep/guidelines/guidelines.html) that apply to your obstetrician and neonatologist. During NICU hospitalization, babies are prone to develop infections due to the need for invasive devices and frequent blood draws. Many hospitals now publically report their rates of infections and you may find this information on their websites or in various consumer and insurance publications.

Normally formed umbilical cords contain one vein and two arteries. The vein delivers oxygenated blood to the developing baby from the placenta; the arteries take the de-oxygenated blood from the fetus back to the placenta to be filtered by the mother. Occasionally, the umbilical cord has only two of these three vessels, a condition known as a “two-vessel cord” or “single umbilical artery” (SUA). This condition occurs in approximately 1 percent of singleton pregnancies and about 5 percent of multiple pregnancies (i.e., twins, triplets), and can be identified during prenatal ultrasound.

Most of the time, the condition does not result in any harm either during pregnancy or after birth; in fact, many cases of two-vessel cord / SUA are not identified until time of delivery. In the past, any baby born with a two-vessel cord had a renal ultrasound to assess kidney, ureter, and bladder anatomy. We now know, however, that there is only a very small likelihood of finding an additional problem when a two-vessel cord is the only apparent abnormality (a condition called “isolated SUA”); for this reason, current accepted practice does not recommend additional evaluation in these cases. Some practitioners, however, do not follow this guideline, and may suggest your baby undergo unnecessary and anxiety-provoking tests (either in utero or after delivery), such as echocardiogram, genetic counseling, or renal ultrasound.

Occasionally, a two-vessel cord can occur concurrently with other, more concerning problems that can impact healthy growth and development. SUA is a marker for these potential problems, rather than their cause. The most common problems are chromosomal abnormalities and complications with the skeletal, cardiovascular, genitourinary (GU) (i.e., kidneys, bladder, genitalia), and cardiovascular systems. Among babies with SUA, approximately 10 percent have an abnormal number of chromosomes, and 4 percent have a GU condition called vesicoureteric reflux (VUR).

For this reason, it’s important that a two-vessel cord be identified. Your neonatologist will then closely examine your baby for other signs of a possible abnormality and may order additional testing.

SOURCES

Beall MH, Isaacs C, “Umbilical Cord Complications,” Medscape, September 9, 2015. Available online at: http://emedicine.medscape.com/article/262470-overview#a3.

Bernstein PS, Van Eerden P, “Vessel Abnormalities in the Fetal Umbilical Cord,” Medscape Ob/Gyn, Ask the Experts, Obstetrics and Maternal-Fetal Medicine, May 15, 2003. Available online at: http://www.medscape.com/viewarticle/453593

Gornall AS, Kurinczuk JJ, Konje JC., “Antenatal detection of a single umbilical artery: does it matter?” Prenat Diagn. 2003 Feb;23(2):117-23.

Kari JA, El-Desoky SM, Basnawi F, Bahrawi O, “Vesicoureteric reflux in children,” Urol Ann. 2013 Oct-Dec; 5(4): 232–236. doi: 10.4103/0974-7796.120292. Prucka S, Clemens M, Catherine Craven C, McPherson, E, “Single umbilical artery: What does it mean for the fetus? A case-control analysis of pathologically ascertained cases,” Genetics in Medicine 2004; 6:54–57. doi:10.1097/01.GIM.0000105743.91723.B0 Mandujano A, Wilkins I, “MFM Consult: Single umbilical artery: What you need to know,” Contemporary OB/GYN, Obstetrics-Gynecology & Women's Health: October 1, 2010. Available online at: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-medicine-cases/mfm-consult-single-umbilical-artery-wha?page=full