Showing papers in "American Journal of Perinatology in 2018"
TL;DR: In the long term, the aim for a new definition of BPD is to develop a classification based on the pathophysiology and objective lung function evaluation providing a more accurate assessment for individual patients.
Abstract: The advances in obstetric and neonatal care over the last half century have resulted in changes in pathophysiology and clinical presentation of bronchopulmonary dysplasia (BPD). In contrast to the original description of BPD by Northway et al as a severe lung injury in relatively mature preterm infants, the most common form of BPD currently is characterized by chronic respiratory insufficiency in extremely preterm infants. This evolution in the presentation of BPD, along with changes in respiratory support strategies such as increased use of nasal cannula oxygen, has presented a unique challenge to find a definition that describes the severity of lung damage and predict the long-term respiratory outcomes with some accuracy. The limitations of current definitions of BPD include inconsistent correlation with long-term respiratory outcomes, inability to classify infants dying from severe respiratory failure prior to 36 weeks' postmenstrual age, and potential inappropriate categorization of infants on nasal cannula oxygen or with extrapulmonary causes of respiratory failure. In the long term, the aim for a new definition of BPD is to develop a classification based on the pathophysiology and objective lung function evaluation providing a more accurate assessment for individual patients. Until then, a consensus definition that encompasses current clinical practices, provides reasonable prediction of later respiratory outcomes, and is relatively simple to use should be achieved.
48 citations
TL;DR: Following the 2014 RSVIP guidance change, RSV IP use declined and RSVH increased among infants born at 29 to 34 wGA and aged <3 months, respectively.
Abstract: Objective This article aims to compare respiratory syncytial virus (RSV) immunoprophylaxis (IP) use and RSV hospitalization rates (RSVH) in preterm and full-term infants without chronic lung disease of prematurity or congenital heart disease before and after the recommendation against RSV IP use in preterm infants born at 29 to 34 weeks' gestational age (wGA). Study Design Infants in commercial and Medicaid claims databases were followed from birth through first year to assess RSV IP and RSVH, as a function of infant's age and wGA. RSV IP was based on pharmacy or outpatient medical claims for palivizumab. RSVH was based on inpatient medical claims with a diagnosis of RSV. Results Commercial and Medicaid infants 29 to 34 wGA represented 2.9 to 3.5% of all births. RSV IP use in infants 29 to 34 wGA decreased 62 to 95% (p Conclusion Following the 2014 RSV IP guidance change, RSV IP use declined and RSVH increased among infants born at 29 to 34 wGA and aged
40 citations
TL;DR: The results indicate an association between high AUR and a composite outcome of death or adverse neurodevelopmental outcomes at 18 to 21 months' corrected age.
Abstract: Objective The objective is to evaluate the association between antibiotic utilization and neurodevelopmental outcomes at 18 to 21 months' corrected age among extremely low gestational age neonates without culture-proven sepsis or necrotizing enterocolitis (NEC). Study Design We conducted a retrospective cohort study of infants born between April 2009 and September 2011 at Result There were 1,373 infants who fulfilled our inclusion criteria. Compared with infants in the lowest AUR quartile (Q1), those in the highest quartile (Q4) had higher odds of death or sNDI (adjusted odds ratio [AOR] = 7.44; 95% confidence interval [CI]: 4.55, 12.2) and death (AOR = 39.3; 95% CI: 16.1, 95.9). Conclusion Our results indicate an association between high AUR and a composite outcome of death or adverse neurodevelopmental outcomes at 18 to 21 months' corrected age.
39 citations
TL;DR: Maternal microbiome biodiversity changes as pregnancy progresses and correlates with GWG, and those who gained above the median GWG had increased abundance of Bacteroidetes and other phyla.
Abstract: Objective To measure maternal gut microbiome biodiversity in pregnancy. Materials and Methods In phase 1, maternal fecal samples were collected by rectal swab in 20 healthy pregnant women (14–28 weeks gestation) to measure bacterial abundance. In phase 2, fecal samples were collected from 31 women at enrollment ( Results In phase 1, 16 of 20 samples yielded usable data. White women (n = 10) had greater abundance of Firmicutes (23 ± 0.15 vs. 16% ± 0.75, p = 0.007) and Bacteroidetes (24 ± 0.14 vs. 19% ± 0.68, p = 0.015) compared with non-White women (n = 6). In the 11 paired specimens, Bacteroidetes increased in abundance from baseline to follow-up. Compared with women who gained weight below the median gestational weight gain (GWG, Conclusion Maternal microbiome biodiversity changes as pregnancy progresses and correlates with GWG.
37 citations
TL;DR: Analysis of early HR‐SpO2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants.
Abstract: Background We previously showed, in a single-center study, that early heart rate (HR) characteristics predicted later adverse outcomes in very low birth weight (VLBW) infants. We sought to improve predictive models by adding oxygenation data and testing in a second neonatal intensive care unit (NICU). Methods HR and oxygen saturation (SpO2) from the first 12 hours and first 7 days after birth were analyzed for 778 VLBW infants at two NICUs. Using multivariate logistic regression, clinical predictive scores were developed for death, severe intraventricular hemorrhage (sIVH), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (tROP), late-onset septicemia (LOS), and necrotizing enterocolitis (NEC). Ten HR-SpO2 measures were analyzed, with first 12 hours data used for predicting death or sIVH and first 7 days for the other outcomes. HR-SpO2 models were combined with clinical models to develop a pulse oximetry predictive score (POPS). Net reclassification improvement (NRI) compared performance of POPS with the clinical predictive score. Results Models using clinical or pulse oximetry variables alone performed well for each outcome. POPS performed better than clinical variables for predicting death, sIVH, and BPD (NRI > 0.5, p Conclusion Analysis of early HR-SpO2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants.
34 citations
TL;DR: An overview of the current diagnostic approaches available or under development for diagnosing neonatal sepsis is provided.
Abstract: Progress in neonatal care has decrease morbidity and mortality due to neonatal sepsis (NS). Although diagnosis of sepsis continues to rely on blood culture, this method is too slow and limited by false-negative results. There are numerous sepsis biomarkers that have been evaluated for the early diagnosis of NS, but, to date, there is no single ideal biomarker, though novel biomarkers are becoming more sophisticated and specific in their clinical applications. This review provides an overview of the current diagnostic approaches available or under development for diagnosing NS.
29 citations
TL;DR: The pathophysiology, evolution and the evidence, randomized control trials, observational studies, and translational research to support recommendations to prevent delay in resuscitation and minimize hypoxia‐ischemia often associated with MSAF are discussed.
Abstract: Meconium-stained amniotic fluid (MSAF) during delivery is a marker of fetal stress. Neonates born through MSAF often need resuscitation and are at risk of meconium aspiration syndrome (MAS), air leaks, hypoxic-ischemic encephalopathy, extracorporeal membrane oxygenation (ECMO), and death. The neonatal resuscitation approach to MSAF has evolved over the last three decades. Previously, nonvigorous neonates soon after delivery were suctioned under the vocal cords with direct visualization technique using a meconium aspirator. The recent neonatal resuscitation program (NRP) recommends against suctioning but favors resuscitation with positive pressure ventilation of nonvigorous neonates with MSAF. This recommendation is aimed to prevent delay in resuscitation and minimize hypoxia-ischemia often associated with MSAF. In this review, we discuss the pathophysiology, evolution and the evidence, randomized control trials, observational studies, and translational research to support these recommendations. The frequency of ECMO use for neonatal respiratory indication of MAS has declined over the years probably secondary to improvements in neonatal intensive care and reduction of postmaturity. Changes in resuscitation practices may have contributed to reduced incidence and severity of MAS. Larger randomized controlled studies are needed among nonvigorous infants with MSAF. However, ethical dilemmas and loss of equipoise pose a challenge to conduct such studies.
27 citations
TL;DR: The adjunctive use of glucose gel as a supplement to feedings in infants admitted to the newborn nursery at risk for neonatal hypoglycemia reduces the frequency of transfer to a higher level of care for intravenous dextrose treatment.
Abstract: Objective To evaluate whether glucose gel as a supplement to feedings in infants admitted to the newborn nursery at risk for neonatal hypoglycemia (NH) reduces the frequency of transfer to a higher level of care for intravenous dextrose treatment. Study Design We revised our newborn nursery protocol for management of infants at risk for NH to include use of 40% glucose gel (200 mg/kg). Study population included late preterm, small and large for gestational age infants, and infants of diabetic mothers. We compared outcomes before (4/1/14–3/31/15: Year 1) and after (4/1/15–3/31/16: Year 2) initiation of the revised protocol. Our prospective primary outcome was transfer to the neonatal intensive care unit (NICU) for treatment with a continuous infusion of dextrose. Results NICU transfer for management of NH fell from 8.1% in Year 1 (34 of 421 at-risk infants screened) to 3.7% in Year 2 (14 of 383 at-risk infants screened). Rate of exclusive breastfeeding increased from 6% in Year 1 to 19% in Year 2. Hospital charges for the study population decreased from 801,276 USD to 387,688 USD in Year 1 and Year 2, respectively. Conclusion Our study supports the adjunctive use of glucose gel to reduce NICU admissions and total hospitalization expense.
27 citations
TL;DR: In infants aged <6 months, the risk for RSVH for infants 29 to 34 wGA compared with term infants increased significantly after the RSV IP recommendations became more restrictive after the 2014 guidance changes for immunoprophylaxis.
Abstract: Objective The objective of this study was to compare risk for respiratory syncytial virus (RSV) hospitalizations (RSVH) for preterm infants 29 to 34 weeks gestational age (wGA) versus term infants before and after 2014 guidance changes for immunoprophylaxis (IP), using data from the 2012 to 2016 RSV seasons. Study Design Using commercial and Medicaid claims databases, infants born between July 1, 2011 and June 30, 2016 were categorized as preterm or term. RSVH during the RSV season (November–March) were identified for infants aged Results In all seasons, preterm infants had higher RSVH rates than term infants. Seasonal RRs prior to the guidance change for preterm wGA categories versus term infants ranged from 1.6 to 3.4. After the guidance change, the seasonal RRs ranged from 2.6 to 5.6. In 2014 to 2016, the risk associated with prematurity of 29 to 34 wGA versus term was significantly higher than in 2012 to 2014 (P Conclusion In infants aged
25 citations
TL;DR: The pilot study was unable to detect a beneficial effect by adding intravenous paracetamol to ibuprofen for the treatment of hsPDA, and larger prospective studies are needed to explore the positive tendency suggested by the results.
Abstract: Objective The objective of this study was to compare the closure rate of hemodynamically significant patent ductus arteriosus (hsPDA) of intravenous ibuprofen + paracetamol (acetaminophen) versus ibuprofen + placebo, in preterm infants of 24 to 316/7 weeks postmenstrual age. Study Design This is a single-center, double-blind, randomized controlled pilot study. Infants were assigned for treatment with either intravenous ibuprofen + paracetamol (n = 12) or ibuprofen + placebo (n = 12). Results There was no statistical difference in baseline characteristics of the two groups. Echocardiography parameters were comparable before treatment in both groups. There was a trend toward higher hsPDA closure rate in the paracetamol group in comparison to the placebo group (83 vs. 42%, p = 0.08). No adverse effects, clinical or laboratory, were associated with adding paracetamol. Conclusion Our pilot study was unable to detect a beneficial effect by adding intravenous paracetamol to ibuprofen for the treatment of hsPDA. Larger prospective studies are needed to explore the positive tendency suggested by our results and to assure safety.
24 citations
TL;DR: In all deliveries, QBL does not predict Hb drop more accurately than EBL, and the decision to perform QBL needs to balance accuracy with a resource intense measurement process.
Abstract: Objective The National Partnership for Maternal Safety released a postpartum hemorrhage bundle in 2015 recommending quantification of blood loss (QBL) for all deliveries. We sought to determine whether QBL more accurately predicts hemoglobin (Hb) drop than visually estimated blood loss (EBL). Study Design This is a prospective observational study. Preintervention data (PRE) were collected on all deliveries between October 15, 2013 and December 15, 2013. Deliveries were included if EBL, admission Hb, and 12-hour postpartum Hb (12hrCBC) were available. QBL was implemented in July 2015. Postintervention data (POST) were collected between October 20, 2015 and December 20, 2015. A total of 500 mL EBL was predicted to result in 1 g/dL Hb drop at 12hrCBC. Student's t-test was used to compare the means. Results A total of 592 of 626 (95%) PRE and 583 of 613 (95%) POST deliveries were included. Overall, 278 (48%) POST deliveries had QBL recorded. In both PRE and POST, actual Hb drop differed from predicted by 0.6 g/dL in both groups of deliveries. When evaluating deliveries with EBL > 1,000 mL, QBL in POST was slightly better at predicting Hb drop versus EBL in PRE, although not statistically significant (0.2 vs. 0.5 g/dL, p = 0.17). Conclusion In all deliveries, QBL does not predict Hb drop more accurately than EBL. The decision to perform QBL needs to balance accuracy with a resource intense measurement process.
TL;DR: The purpose of this article is to review the current understanding of changes in bowel perfusion in NEC, discuss the accuracy of abdominal US in detecting NEC, and explain how the use of CEUS and NIRS will enhance the precise and early detection of altered/pathological bowel wall perfusion of NEC.
Abstract: Despite extensive research and improvements in the field of neonatal care, the morbidity and mortality associated with necrotizing enterocolitis (NEC) have remained unchanged over the past three decades. Early detection of ischemia and necrotic bowel is vital in improving morbidity and mortality associated with NEC; however, strategies for predicting and preventing NEC are lacking. Contrast-enhanced ultrasound (CEUS) and near-infrared spectroscopy (NIRS) are novel techniques in pediatrics that have been proven as safe modalities. CEUS has benefits over conventional ultrasound (US) by its improved real-time evaluation of the micro- and macrovascularities of normally and abnormally perfused tissue. US has been implemented as a useful adjunct to X-ray for earlier evaluation of NEC. NIRS is another noninvasive technique that has shown promise in improving early detection of NEC. The purpose of this article is to review the current understanding of changes in bowel perfusion in NEC, discuss the accuracy of abdominal US in detecting NEC, and explain how the use of CEUS and NIRS will enhance the precise and early detection of altered/pathological bowel wall perfusion in the initial development and course of NEC.
TL;DR: The management of fetuses with CHD will be discussed, along with summarizing the in utero and fetal echocardiographic findings used for risk stratification of newborns withCHD and reviewing the basic principles used for planning for neonatal resuscitation and initial transitional care of these complex newborns.
Abstract: Advances in prenatal imaging have improved the examination of the fetal cardiovascular system. Fetal echocardiography facilitates the prenatal diagnosis of congenital heart disease (CHD) and through sequential examination, allows assessment of fetal cardiac hemodynamics, predicting the evolution of anatomical and functional cardiovascular abnormalities in utero and during the transition to a postnatal circulation at delivery. This approach allows detailed diagnosis with prenatal counseling and enables planning to define perinatal management, selecting the fetuses at a risk of postnatal hemodynamic instability who are likely to require a specialized delivery plan. The prenatal diagnosis and management of critical neonatal CHD has been shown to play an important role in improving the outcome of newborns with these conditions, allowing timely stabilization of the circulation prior to cardiac intervention or surgery, thus reducing the risk of perioperative morbidity and mortality. Diagnostic protocols aimed at risk-stratifying severity and potential postnatal compromise in fetuses with CHD have been developed to identify those who may require special intervention at birth or within the first days of life. In addition, new methodologies are being studied to improve the accuracy of prediction of disease severity. Perinatal management of neonates with a prenatal diagnosis of CHD requires a close collaboration between obstetric, neonatal, and cardiology services. In this article, the management of fetuses with CHD will be discussed, along with summarizing the in utero and fetal echocardiographic findings used for risk stratification of newborns with CHD and reviewing the basic principles used for planning for neonatal resuscitation and initial transitional care of these complex newborns.
TL;DR: This study explored the differences in perceptions and practice variations among neonatologists and pediatric nephrologists in diagnostic criteria, management, and follow‐up of neonatal AKI.
Abstract: BACKGROUND Neonatal acute kidney injury (AKI) occurs in 40 to 70% of critically ill neonatal intensive care admissions. This study explored the differences in perceptions and practice variations among neonatologists and pediatric nephrologists in diagnostic criteria, management, and follow-up of neonatal AKI. METHODS A survey weblink was emailed to nephrologists and neonatologists in Australia, Canada, New Zealand, India, and the United States. Questions consisted of demographic and unit practices, three clinical scenarios assessing awareness of definitions of neonatal AKI, knowledge, management, and follow-up practices. RESULTS Many knowledge gaps among neonatologists, and to a lesser extent, pediatric nephrologists were identified. Neonatologists were less likely to use categorical definitions of neonatal AKI (p < 0.00001) or diagnose stage 1 AKI (p < 0.00001) than pediatric nephrologists. Guidelines for creatinine monitoring for nephrotoxic medications were reported by 34% (aminoglycosides) and 62% (indomethacin) of respondents. Nephrologists were more likely to consider follow-up after AKI than neonatologists (p < 0.00001). Also, 92 and 86% of neonatologists and nephrologists, respectively, reported no standardization or infrastructure for long-term renal follow-up. CONCLUSION Neonatal AKI is underappreciated, particularly among neonatologists. A lack of evidence on neonatal AKI contributes to this variation in response. Therefore, dissemination of current knowledge and areas for research should be the priority.
TL;DR: After 48 hours of cooling, a higher rcSO2 was associated with a severely abnormal outcome, adding to the predictive value of aEEG in cooled, asphyxiated infants.
Abstract: Objective To assess the predictive value of amplitude-integrated electroencephalography EEG (aEEG) and near-infrared spectroscopy (NIRS) during therapeutic hypothermia Patients and Methods We studied 39 cooled, asphyxiated infants We assessed aEEG and calculated mean regional cerebral oxygen saturation (rcSO2) during and after treatment At 30 months, we performed a neurological examination and administered the Bayley Scales of Infant and Toddler Development, 3rd edition We calculated the odds ratios (ORs) of abnormal aEEG and rcSO2 for severely abnormal outcome Results At 6 and 12 hours, severely abnormal aEEGs predicted severely abnormal outcomes (OR, 77 [95% confidence interval, CI, 139–426] and 244 [95% CI 42–143] respectively), as did epileptic activity (OR 289, 46–183) During the first 48 hours, rcSO2 was not associated with outcome, but at 72 hours after birth and after rewarming it was, with ORs for severely abnormal outcomes of 128 (131–124) and 216 (105–189), respectively In multivariate analyses, aEEG and rcSO2 remained independently predictive in the model at 48 hours and significantly from 72 hours after birth onward Conclusion aEEG was a strong predictor of adverse outcome After 48 hours of cooling, a higher rcSO2 was associated with a severely abnormal outcome, adding to the predictive value of aEEG in cooled, asphyxiated infants
TL;DR: Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival, while those with right‐sided CDH had lower rates.
Abstract: Objective The objective of this study was to examine laterality as a predictor of outcomes among fetuses with prenatally diagnosed congenital diaphragmatic hernia (CDH). Methods This is a retrospective cohort study of pregnancies with CDH evaluated at our center from 2008 to 2016 compared cases with right-sided CDH (RCDH) versus left-sided CDH (LCDH). The primary outcome was survival to discharge. Secondary outcomes included ultrasound predictors of poor prognosis (liver herniation, stomach herniation, lung area-to-head circumference ratio [LHR]), concurrent anomalies, hydrops, stillbirth, preterm birth, mode of delivery, small for gestational age, use of extracorporeal membrane oxygenation, and length of stay. Terminations and stillbirths were excluded from analyses of neonatal outcomes. Results In this study, 157 (83%) LCDH and 32 (17%) RCDH cases were identified. Survival to discharge was similar (64 vs. 66.4%, p = 0.49) with regard to laterality. RCDH had higher rates of liver herniation (90.6 vs. 72%, p = 0.03), hydrops fetalis (15.6 vs. 1.3%, p Conclusion Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival.
TL;DR: This review summarizes the current evidence regarding lactoferrin and discusses the areas in need of further guidance prior to the adoption of strategies that include a routine use of lact oferrin in neonates and young children.
Abstract: Lactoferrin is one of the most represented and important bioactive proteins in human and mammal milk. In humans, lactoferrin is responsible for several actions targeting anti-infective, immunological, and gastrointestinal domains in neonates, infants, and young children. Evidence-based data vouch for the ability of supplemented lactoferrin to prevent sepsis and necrotizing enterocolitis in preterm infants and to reduce the burden of morbidity related to gastrointestinal and respiratory pathogens in young children. However, several issues remain pending regarding answers and clarification related to quality control, correct intakes, optimal schedules and schemes of supplementations, interactions with probiotics, and different types of milk and formulas. This review summarizes the current evidence regarding lactoferrin and discusses the areas in need of further guidance prior to the adoption of strategies that include a routine use of lactoferrin in neonates and young children.
TL;DR: LU may be used to confirm antenatally diagnosed CPAM and to suspect CPAM in infants with respiratory distress if cystic lung lesions are revealed, and further studies are necessary to define the place of LU in the management of CPAM.
Abstract: Background and Objective Congenital pulmonary airway malformation (CPAM) is a group of rare congenital malformations of the lung and airways. Lung ultrasound (LU) is increasingly used to diagnose neonatal respiratory diseases since it is quick, easy to learn, and radiation-free, but no formal data exist for congenital lung malformations. We aimed to describe LU findings in CPAM neonates needing neonatal intensive care unit (NICU) admission and to compare them with a control population. Methods A retrospective review of CPAM cases from three tertiary academic NICUs over 3 years (2014–2016) identified five patients with CPAM who had undergone LU examination. LU was compared with chest radiograms and computed tomography (CT) scans that were used as references. Results CPAM lesions were easily identified and corresponded well with CT scans; they varied from a single large cystic lesion, multiple hypoechoic lesions, and/or consolidation. The first two LU findings have not been described in other respiratory conditions and were not found in controls. Conclusion We provide the first description of LU findings in neonates with CPAM. LU may be used to confirm antenatally diagnosed CPAM and to suspect CPAM in infants with respiratory distress if cystic lung lesions are revealed. Further studies are necessary to define the place of LU in the management of CPAM.
TL;DR: Both the El‐Khuffash and Shaare Zedek scores are predictive of PDA‐associated morbidities and both scores positively predicted chronic lung disease/death in this population of preterm infants.
Abstract: Introduction Several echocardiographic scoring systems have been developed to assess the severity of patent ductus arteriosus (PDA) shunting in preterm infants. Objective The objective of this study was to compare the ability of two different scoring systems to evaluate the hemodynamic significance of the PDA and to predict long-term PDA-associated morbidities. Subjects El-Khuffash cohort (previously described) was derived from a multicenter, prospective, observational study conducted in tertiary neonatal intensive care units in Ireland, Canada, and Australia. Results A total of 141 infants with a mean gestational age of 26 ± 1.4 weeks and a mean birth weight of 952 ± 235 g were evaluated on day 2 of life. The two scores were well correlated with each other and both scores positively predicted chronic lung disease/death in this population. Conclusion There appears to be an overall stepwise progression in the incidence of poor outcome parameters from “closed” to “borderline” to “hemodynamically significant” PDA. Both the El-Khuffash and Shaare Zedek scores are predictive of PDA-associated morbidities.
TL;DR: It is hypothesized that utilization of a twin‐specific nomograms, when compared with one based on singleton data, is less likely to classify twins as having abnormal growth and more likely to identify perinatal morbidity and mortality.
Abstract: Objective We hypothesized that utilization of a twin-specific nomograms, when compared with one based on singleton data, is less likely to classify twins as having abnormal growth and more likely to identify perinatal morbidity and mortality. Materials and Methods Data were culled from seven Maternal-Fetal Medicine Units (MFMU) studies, the included twin gestations in their study population. Each newborn twin's birth weight percentile was categorized using Alexander et al (singleton data) and Ananth et al (twin data) nomogram. Logistic regression models were adjusted for maternal race and body mass index, neonatal sex, study, and twin correlation. Results More twins were categorized as small for gestational age (SGA) when singleton nomogram was used (33%) compared with twin nomogram (4%). The use of singleton nomogram revealed a higher composite neonatal morbidity (CNM) and stillbirth rates among SGA twins but a similar neonatal mortality rate when compared with appropriate for gestational age. Correspondingly, when twin-specific nomogram was utilized, the CNM, odds of stillbirth, and neonatal mortality were higher among SGA twins. The rate of large for gestational age among twins was increased with the use of twin-specific nomograms. Conclusion Utilization of twin-specific nomogram is less likely to categorize twins as SGA and more likely to identify those at risk for stillbirth and neonatal mortality.
TL;DR: Maternal hyperoxygenation during fetal ultrasound can characterize fetal pulmonary vasoreactivity (PVr) and its associations with postnatal physiology and may help identify fetuses with CHD at risk for perinatal compromise.
Abstract: Background Maternal hyperoxygenation (MH) during fetal ultrasound can characterize fetal pulmonary vasoreactivity (PVr) and its associations with postnatal physiology. Objective We explored MH testing to facilitate perinatal risk stratification for fetuses with congenital heart disease (CHD). Methods MH was performed in 12 fetuses: 2 with Ebstein anomaly, 2 with total anomalous pulmonary venous connection (TAPVC), 4 with hypoplastic left heart syndrome (HLHS) with (a) restrictive atrial septum (RAS) or (b) intact atrial septum (IAS) with decompressing vertical vein (VV), and 4 with D-loop transposition of the great arteries (TGA). PVr and physiologic and anatomic changes with MH and outcomes were recorded. Results Among Ebstein fetuses, pulmonary blood flow with MH mirrored postnatal findings. Among TAPVC fetuses, MH VV gradients correlated with postnatal gradients. One HLHS/IAS/VV fetus had no PVr and decreased pulmonary vein forward to reverse velocity time integral ratio with MH. Shortly after delivery, the infant experienced severe low cardiac output and required urgent atrial septoplasty. The remaining HLHS fetuses had PVr and underwent routine Stage 1 Norwood. Among TGA fetuses, septum primum position, foramen ovale flow, and the presence or absence of PVr with MH reflected postnatal findings. Conclusion MH may help identify fetuses with CHD at risk for perinatal compromise. Additional study may yield insights into fetal PVr and elucidate predictors of perinatal outcomes.
TL;DR: The findings highlight the need to identify interventions and guide research efforts to mitigate the rate of SMM and its economic burden and show the hospital cost with any SMM was 2.1 times higher than those without anySMM.
Abstract: Objective The objective of this study was to estimate the contemporary national rate of severe maternal morbidity (SMM) and its associated hospital cost during delivery hospitalization. Study Design We conducted a retrospective study identifying all delivery hospitalizations in the United States between 2011 and 2012. We used data from the National (Nationwide) Inpatient sample of the Healthcare Cost and Utilization Project. The delivery hospitalizations with SMM were identified by having at least one of the 25 previously established list of diagnosis and procedure codes. Aggregate and mean hospital costs were estimated. A generalized linear regression model was used to examine the association between SMM and hospital costs. Results Of 7,438,946 delivery hospitalizations identified, the rate of SMM was 154 per 10,000 delivery hospitalizations. Without any SMM, the mean hospital cost was $4,300 and with any SMM, the mean hospital cost was $11,000. After adjustment, comparing to those without any SMM, the mean cost of delivery hospitalizations with any SMM was 2.1 (95% confidence interval: 2.1–2.2) times higher, and this ratio increases from 1.7-fold in those with only one SMM to 10.3-fold in those with five or more concurrent SMM. Conclusion The hospital cost with any SMM was 2.1 times higher than those without any SMM. Our findings highlight the need to identify interventions and guide research efforts to mitigate the rate of SMM and its economic burden.
TL;DR: Variation exists in recommendations on the timing and need for consent prior to routine antenatal anti‐D immune globulin administration, prophylaxis for unique circumstances (e.g., threatened abortion < 12 weeks, complete molar pregnancy), and the use of cell‐free fetal DNA testing for fetal RhD genotype.
Abstract: Objective The objective of this study was to compare national guidelines on the prevention of RhD alloimmunization. Study Design We performed a review of four national guidelines on prevention of alloimmunization from the American Congress of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynaecologists, Society of Obstetricians and Gynaecologists of Canada, and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. We compared the indications/contraindications, timing, dosing, formulation and route of anti-D immune globulin, and management of unique circumstances. The references were compared with regard to the number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. Results Variation exists in recommendations on the timing and need for consent prior to routine antenatal anti-D immune globulin administration, prophylaxis for unique circumstances (e.g., threatened abortion Conclusion These variations in recommendations reflect the heterogeneity of the literature on the prevention of alloimmunization and highlight the need for synthesis of evidence to create an international guideline on prevention of alloimmunization. This may improve safety, quality, optimize outcomes, and stimulate future trials.
TL;DR: Hypotension was common in asphyxiated newborns treated with hypothermia and was associated with an increased risk of (severe) brain injury in these newborns.
Abstract: Objective This study aimed to assess the incidence of hypotension in asphyxiated newborns treated with hypothermia, the variability in treatments for hypotension, and the impact of hypotension on the pattern of brain injury. Study Design We conducted a retrospective cohort study of asphyxiated newborns treated with hypothermia. Mean blood pressures, lactate levels, and inotropic support medications were recorded during the hospitalization. Presence and severity of brain injury were scored using the brain magnetic resonance imaging (MRI) obtained after the hypothermia treatment was completed. Results One hundred and ninety term asphyxiated newborns were treated with hypothermia. Eighty-one percent developed hypotension. Fifty-five percent of the newborns in the hypotensive group developed brain injury compared with 35% of the newborns in the normotensive group (p = 0.04). Twenty-nine percent of the newborns in the hypotensive group developed severe brain injury, compared with only 15% in the normotensive group. Nineteen percent of the newborns presenting with volume- and/or catecholamine-resistant hypotension had near-total injury, compared with 6% in the normotensive group and 8% in the group responding to volume and/or catecholamines. Conclusion Hypotension was common in asphyxiated newborns treated with hypothermia and was associated with an increased risk of (severe) brain injury in these newborns.
TL;DR: Institution of a clinical practice algorithm to instruct clinicians on sodium supplementation in preterm infants may improve growth outcomes.
Abstract: Objective To implement and evaluate a clinical practice algorithm to identify preterm infants with sodium deficiency and guide sodium supplementation based on urine sodium concentrations. Study Design Urine sodium concentration was measured in infants born at 260/7 to 296/7 weeks' gestation at 2-week intervals. Sodium supplementation was based on the urine sodium algorithm. Growth and respiratory outcomes in this cohort were compared with a matched cohort cared for in our neonatal intensive care unit prior to algorithm implementation (2014–2015 cohort). Results Data were compared for 50 infants in the 2014–2015 cohort and 40 infants in the 2016 cohort. Urine sodium concentration met criteria for supplementation in 75% of the 2016 cohort infants within the first 4 weeks after birth. Average daily sodium intake was greater in the 2016 cohort compared with the 2014–2015 cohort (p Conclusion Institution of a clinical practice algorithm to instruct clinicians on sodium supplementation in preterm infants may improve growth outcomes.
TL;DR: Longitudinal changes in cardiac output were noted in neonates with HIE during TH and rewarming, and echocardiography evidence of pulmonary hypertension (PH) was identified in five neonates.
Abstract: Objective This article compares hemodynamic characteristics of neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH) with normal versus abnormal brain magnetic resonance imaging (MRI). Methods Serial echocardiography (echo) was performed within 24 hours, after 48 to 72 hours of cooling, within 24 hours of normothermia, and after starting feeds. Pulmonary hemodynamics, cardiac output, and ventricular function were evaluated. All neonates underwent brain MRI (day 4–5), per clinical standard of care. Clinical cardiovascular and echocardiography characteristics were compared between patients with normal versus abnormal MRI. Cardiovascular changes during TH and after rewarming were identified. Results Twenty neonates at median gestation and birth weight of 40 weeks (interquartile range [IQR]: 39, 41) and 3,410 g (IQR: 2,885, 4,093), respectively, were enrolled. Increased median left ventricular output (LVO) (106–159 mL/kg/min, p Conclusion Longitudinal changes in cardiac output were noted in neonates with HIE during TH and rewarming. Echocardiography evidence of PH, however, was associated with abnormal MRI brain. The prognostic relevance of these physiologic changes requires more comprehensive delineation.
TL;DR: Examination of the causes of death provides insights into areas in which clinical improvements may further improve the outlook for children with complex congenital heart disease.
Abstract: Cardiac surgery for congenital heart disease has changed dramatically since the first surgery in 1938. During the early era, children underwent surgery at older ages often with palliative procedures before their corrective operation. Not surprisingly, in the early era, there was considerably higher early and late mortality, including the additive risks of having more than one procedure and a long period of living with an unphysiological palliated circulation. Over time with advances in noninvasive diagnosis, surgical approach, cardiopulmonary bypass techniques, and team-based care, outcomes have improved. Children now undergo corrective surgery at a younger age and have fewer palliative procedures. Short-term outcome as measured by the commonly used metric “procedural early mortality” (i.e., death before hospital discharge or less than 30 days following a surgical procedure) is now as low as 1 or 2% for many low-to-moderate complexity procedures. Late outcomes have also improved with long-term survival of hospital survivors for simple lesions being close to population controls. Late outcomes for more complex defects still show diminishing survival relative to a control population. Examination of the causes of death provides insights into areas in which clinical improvements may further improve the outlook for children with complex congenital heart disease.
TL;DR: The development and implementation of this protocol is described to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.
Abstract: Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Many institutions use continuous insulin and glucose infusions during the intrapartum period, although practices are widely variable. At Northwestern Memorial Hospital, the "Management of the Perinatal Patient with Diabetes" policy and protocol was developed to improve consistency of management while also allowing individualization appropriate for the patient's specific diabetic needs. This protocol introduced standardized algorithms based on maternal insulin requirements to drive real-time maternal glucose control during labor as well as provided guidelines for postpartum glycemic control. This manuscript describes the development and implementation of this protocol to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.
TL;DR: It is speculated that antenatal 1,25‐(OH)2 D3 treatment preserves placental function in experimental CA and that these effects may be mediated by increased vascular growth.
Abstract: Background Chorioamnionitis (CA) is associated with a high risk for the development of bronchopulmonary dysplasia (BPD) after preterm birth, but mechanisms that increase susceptibility for BPD and strategies to prevent BPD are uncertain. As a model of CA, antenatal intra-amniotic (IA) endotoxin (ETX) exposure alters placental structure, causes fetal growth restriction, increases perinatal mortality, and causes sustained cardiorespiratory abnormalities throughout infancy. Vitamin D (Vit D) has been shown to have both anti-inflammatory and proangiogenic properties. Antenatal IA treatment with Vit D (1,25-(OH)2D3) during IA ETX exposure improves survival and increases vascular and alveolar growth in infant rats. Whether IA ETX causes decreased placental vascular development and if the protective effects of prenatal Vit D treatment are due to direct effects on the fetus or to improved placental vascular development remain unknown. Objective The objective of this study was to determine if IA ETX impairs placental vascular development and Vit D metabolism, and whether 1,25-(OH)2D3 treatment improves placental vascularity after IA ETX exposure during late gestation in pregnant rats. Design/Methods Fetal rats were exposed to ETX (10 mg), ETX + 1,25-(OH)2D3 (1 ng/mL), 1,25-(OH)2D3 (1 ng/mL), or saline (control) via IA injection at E20 and delivered 2 days later. To assess placental vascular development, histologic sections from the placenta were stained for CD31 and vessel density per high power field (HPF) was determined and analyzed using Matlab software. To determine the effects of ETX on placental Vit D metabolism, Vit D receptor (VDR) and activity of the Vit D conversion enzyme, CYP27B1, were assayed from placental homogenates. Angiogenic mediators were measured by reverse transcription polymerase chain reaction by RNA extracted from placental tissue. Results IA ETX reduced placenta and newborn birth weights by 22 and 20%, respectively, when compared with controls (placental weight: 0.60 vs. 0.47 g; p Conclusion IA ETX decreases placental growth and vessel density and decreases placental VDR and CYP27B1 protein expression, and that antenatal 1,25-(OH)2D3 restores placental weight and vessel density, as well as birth weight. We speculate that 1,25-(OH)2D3 treatment preserves placental function in experimental CA and that these effects may be mediated by increased vascular growth.
TL;DR: Oxygenation instability instability is a very common problem in the premature infant that manifests as intermittent hypoxemia episodes (HEs), which increase in frequency with postnatal age and are more common in infants with chronic lung disease.
Abstract: Oxygenation instability is a very common problem in the premature infant that manifests as intermittent hypoxemia episodes (HEs). These are particularly frequent in premature infants who are on mechanical ventilation beyond the first weeks after birth. However, they can also occur in spontaneously breathing infants. Some of these episodes are due to central apnea, but in ventilated infants, they are frequently due to contractions of the abdominal musculature that can splint the respiratory pump, resulting in periods of decreased lung volume and hypoventilation. HEs are often followed by periods of hyperoxemia that results from excessive oxygen supplementation given to correct the hypoxemia. These episodes increase in frequency with postnatal age and are more common in infants with chronic lung disease. Although the evidence is not conclusive, their detrimental effects on the infant's neurologic, ocular, and respiratory system may be significant. There is no specific treatment for HEs, but several interventions are available to ameliorate the severity and duration of the episodes. Further research is needed to define the impact of HEs on the preterm infant's developing central nervous system and other organ systems and to develop effective strategies to prevent these episodes.