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The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites

The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites 314 Citations from the literature /InternationalJournal of Gynecology & Obstetrics 55 (1996) 313-321 a fetal loss within 30 days of the amniocentesis (2.2 vs. 0.2%) reduced neonatal mortality more among white than among than women undergoing genetic amniocentesis at 16-19 weeks’ blacks. Methods. We merged vital-statistics information for all gestation. Four of the seven patients (57%) with a fetal loss 1563 infants with very low birth weights (500 to 1500 g) born within 30 days of an early amniocentesis had procedure-re- from 1987 through 1989 or in 1991 and 1992 to residents of St. lated complications, such as amniotic fluid leakage, bleeding, Louis with clinical data from the four neonatal intensive care and infection, that caused the pregnancy to be lost. No dif- units in the St. Louis area; we then compared neonatal ferences were noted between the two groups in the number of mortality during two periods, one before and one after the preterm deliveries, later fetal deaths, neonatal deaths, or FDA’s approval of surfactant for clinical use (1987 through newborns weighing less than the tenth percentile for gestatio- 1989 and 1991 through 1992). Results. The use of surfactant nal age. Conclusion: Genetic amniocentesis at 11-14 weeks is increased by a factor of 10 between 1987 through 1989 and associated with more post-procedure complications and a 1991 through 1992. The neonatal mortality rate among all higher fetal loss rate within 30 days of the procedure than a very-low-birth-weight infants decreased 17%, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in genetic amniocentesis performed at 16-19 weeks’ gestation. 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41% reduction in the Decreased plasma tryptophan in pregnancy mortality rate among white newborns with very low birth Schrocksnadel H.; Baier-Bitterlich G.; Dapunt 0.; Wachter weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In H.; Fuchs D. contrast, among black infants, the mortality rate for very-low- AUT birth-weight infants did not change significantly (195.6 per OBSTET GYNECOL 1996 88/l (47-50) 1000 and 196.8 per 1000). The relative risk of death among Objective: To examine levels of serum tryptophan and its black newborns with very low birth weights as compared with degradation product kynurenine in uncomplicated pregnancy, white newborns with similar weights was 0.7 from 1987 through according to the week of pregnancy and the concentrations of 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differ- neopterin. Methods: Plasma was analyzed from 45 healthy ences in mortality were not explained by differences in access pregnant women (15 in each trimester), 15 healthy puerperas, to surfactant therapy, by differences in mortality between and 20 non-pregnant controls. Tryptophan and kynurenine black and white infants who received surfactant, or by differ- were measured by reverse-phase, high-performance liquid ences in the use of antenatal corticosteroid therapy. Conclu- chromatography, and neopterin by radioimmunoassay. Re- sions. After surfactant therapy for RDS became generally sults: In healthy pregnant women, tryptophan values de- available, neonatal mortality improved more for white than creased (median first trimester: 72 &Lpmol/l; second for black infants with very low birth weights. trimester: 51 p@mol/l; third trimester: 46 Pr@mol/l; P < 0.001) in a manner correlated with the duration of pregnancy (Spearman rank correlation coefficient r(s) = -0.771, P < UK collaborative randomised trial of neonatal extracorporeal 0.001) and normalized in the puerperium (median 60 membrane oxygenation &,Pmol/l). No change in kynurenine, a tryptophan degrada- Field D.J.; Davis C.; Elbourne D.; Grant A.; Johnson A.; tion product, was observed, but the ratio of kynurenine to Macrae D. tryptophan increased during pregnancy and correlated posi- GBR tively with gestational age (r(s) = 0.714, P < 0.001). In addi- LANCET 1996 348/9020 (75-82) tion, an inverse correlation existed between neopterin and Background: Extracorporeal membrane oxygenation (ECMO) tryptophan concentrations (r(s) = - 0.566, P < O.OOl), as well is a complex and expensive technology that can be used to as a positive one between neopterin and the kynurenine to provide temporary support during respiratory failure. Its value tryptophan ratio (r(s) = 0.660, P < 0.001). Conclusion: Tryp- for mature newborn infants is controversial because of varying tophan levels decrease during normal pregnancy and the de- interpretation of the available evidence. We undertook a crease may be related to immune activation phenomena. collaborative trial throughout the UK to assess whether a policy of referral for ECMO has a beneficial effect on survival The influence of the wider use of surfactant therapy on to 1 year without severe disability in comparison with conven- neonatal mortality among blacks and whites tional management. Methods: Between 1993 and 1995, 185 mature (gestational age at birth p < p 35 weeks, birthweight Hamvas A.; Wise P.H.; Yang R.K.; Wampler N.S.; Noguchi p I p 2 kg) newborn infants with severe respiratory failure A.; Maurer M.M.; Walentik C.A.; Schramm W.F.; Cole S.F. (oxygenation index p I p 40) were enrolled from 55 hospi- USA N ENGL J MED 1996 334/25 (1635-1640) tals in a random&d comparison of either referral to one of Background. Surfactant therapy reduces morbidity and mor- five specialist centres for consideration of ECMO or contin- tality among premature infants with the respiratory distress ued intensive conventional management at the original hospi- tal. The most common diagnoses were persistent pulmonary syndrome (RDS). Fetal pulmonary surfactant matures more hypertension due to meconium aspiration, congenital di- slowly in white than in black fetuses, and therefore RDS is aphragmatic hernia, isolated persistent fetal circulation, sep- more prevalent among whites than among blacks. We rea- soned that the increased use of surfactant after its approval by sis, and idiopathic respiratory distress syndrome. Of the in- the Food and Drug Administration (FDA) in 1990 might have fants allocated ECMO, 84% received this support. Recruit- http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Gynecology & Obstetrics Wiley

The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites

International Journal of Gynecology & Obstetrics , Volume 55 (3) – Dec 1, 1996
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Publisher
Wiley
Copyright
© International Federation of Gynecology and Obstetrics
ISSN
0020-7292
eISSN
1879-3479
DOI
10.1016/S0020-7292(97)82732-4
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Abstract

314 Citations from the literature /InternationalJournal of Gynecology & Obstetrics 55 (1996) 313-321 a fetal loss within 30 days of the amniocentesis (2.2 vs. 0.2%) reduced neonatal mortality more among white than among than women undergoing genetic amniocentesis at 16-19 weeks’ blacks. Methods. We merged vital-statistics information for all gestation. Four of the seven patients (57%) with a fetal loss 1563 infants with very low birth weights (500 to 1500 g) born within 30 days of an early amniocentesis had procedure-re- from 1987 through 1989 or in 1991 and 1992 to residents of St. lated complications, such as amniotic fluid leakage, bleeding, Louis with clinical data from the four neonatal intensive care and infection, that caused the pregnancy to be lost. No dif- units in the St. Louis area; we then compared neonatal ferences were noted between the two groups in the number of mortality during two periods, one before and one after the preterm deliveries, later fetal deaths, neonatal deaths, or FDA’s approval of surfactant for clinical use (1987 through newborns weighing less than the tenth percentile for gestatio- 1989 and 1991 through 1992). Results. The use of surfactant nal age. Conclusion: Genetic amniocentesis at 11-14 weeks is increased by a factor of 10 between 1987 through 1989 and associated with more post-procedure complications and a 1991 through 1992. The neonatal mortality rate among all higher fetal loss rate within 30 days of the procedure than a very-low-birth-weight infants decreased 17%, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in genetic amniocentesis performed at 16-19 weeks’ gestation. 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41% reduction in the Decreased plasma tryptophan in pregnancy mortality rate among white newborns with very low birth Schrocksnadel H.; Baier-Bitterlich G.; Dapunt 0.; Wachter weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In H.; Fuchs D. contrast, among black infants, the mortality rate for very-low- AUT birth-weight infants did not change significantly (195.6 per OBSTET GYNECOL 1996 88/l (47-50) 1000 and 196.8 per 1000). The relative risk of death among Objective: To examine levels of serum tryptophan and its black newborns with very low birth weights as compared with degradation product kynurenine in uncomplicated pregnancy, white newborns with similar weights was 0.7 from 1987 through according to the week of pregnancy and the concentrations of 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differ- neopterin. Methods: Plasma was analyzed from 45 healthy ences in mortality were not explained by differences in access pregnant women (15 in each trimester), 15 healthy puerperas, to surfactant therapy, by differences in mortality between and 20 non-pregnant controls. Tryptophan and kynurenine black and white infants who received surfactant, or by differ- were measured by reverse-phase, high-performance liquid ences in the use of antenatal corticosteroid therapy. Conclu- chromatography, and neopterin by radioimmunoassay. Re- sions. After surfactant therapy for RDS became generally sults: In healthy pregnant women, tryptophan values de- available, neonatal mortality improved more for white than creased (median first trimester: 72 &Lpmol/l; second for black infants with very low birth weights. trimester: 51 p@mol/l; third trimester: 46 Pr@mol/l; P < 0.001) in a manner correlated with the duration of pregnancy (Spearman rank correlation coefficient r(s) = -0.771, P < UK collaborative randomised trial of neonatal extracorporeal 0.001) and normalized in the puerperium (median 60 membrane oxygenation &,Pmol/l). No change in kynurenine, a tryptophan degrada- Field D.J.; Davis C.; Elbourne D.; Grant A.; Johnson A.; tion product, was observed, but the ratio of kynurenine to Macrae D. tryptophan increased during pregnancy and correlated posi- GBR tively with gestational age (r(s) = 0.714, P < 0.001). In addi- LANCET 1996 348/9020 (75-82) tion, an inverse correlation existed between neopterin and Background: Extracorporeal membrane oxygenation (ECMO) tryptophan concentrations (r(s) = - 0.566, P < O.OOl), as well is a complex and expensive technology that can be used to as a positive one between neopterin and the kynurenine to provide temporary support during respiratory failure. Its value tryptophan ratio (r(s) = 0.660, P < 0.001). Conclusion: Tryp- for mature newborn infants is controversial because of varying tophan levels decrease during normal pregnancy and the de- interpretation of the available evidence. We undertook a crease may be related to immune activation phenomena. collaborative trial throughout the UK to assess whether a policy of referral for ECMO has a beneficial effect on survival The influence of the wider use of surfactant therapy on to 1 year without severe disability in comparison with conven- neonatal mortality among blacks and whites tional management. Methods: Between 1993 and 1995, 185 mature (gestational age at birth p < p 35 weeks, birthweight Hamvas A.; Wise P.H.; Yang R.K.; Wampler N.S.; Noguchi p I p 2 kg) newborn infants with severe respiratory failure A.; Maurer M.M.; Walentik C.A.; Schramm W.F.; Cole S.F. (oxygenation index p I p 40) were enrolled from 55 hospi- USA N ENGL J MED 1996 334/25 (1635-1640) tals in a random&d comparison of either referral to one of Background. Surfactant therapy reduces morbidity and mor- five specialist centres for consideration of ECMO or contin- tality among premature infants with the respiratory distress ued intensive conventional management at the original hospi- tal. The most common diagnoses were persistent pulmonary syndrome (RDS). Fetal pulmonary surfactant matures more hypertension due to meconium aspiration, congenital di- slowly in white than in black fetuses, and therefore RDS is aphragmatic hernia, isolated persistent fetal circulation, sep- more prevalent among whites than among blacks. We rea- soned that the increased use of surfactant after its approval by sis, and idiopathic respiratory distress syndrome. Of the in- the Food and Drug Administration (FDA) in 1990 might have fants allocated ECMO, 84% received this support. Recruit-

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International Journal of Gynecology & Obstetrics – Wiley

Published: Dec 1, 1996

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