Early perinatal diagnosis of mothers at risk of developing post-partum depression--a concise guide for obstetricians, midwives, neonatologists and paediatricians

OBJECTIVE

In this article, we tried to provide all those involved in perinatal medicine with a concise guide to detect mothers at risk of developing post-partum depression. Motherhood is a critical situation characterized by role conflicts because conflicts among the role of mother, worker and wife are the norm in the post-partum period and may jeopardize the mother's existence.

METHODS

We have described a kind of personality that is at great risk of developing post-partum depression because of the incapacity to creatively manage situations of role conflict. This personality structure is called typus melancholicus, and we operationally defined its main features: orderliness, conscientiousness, hypernomia/heteronomia and intolerance of ambiguity.

RESULTS

We have shown how these mothers may typically behave during pregnancy and early motherhood: they cannot avoid behaving with feverish perfectionism, developing an exaggerated preoccupation towards the unborn child and hostility towards persons and events that are experienced as an obstacle to their search for perfection. They ultra-carefully follow all the steps concerning paediatric check-ups and feel all the responsibility relating to the care of the child, without being able to delegate to someone else or share their feelings.

CONCLUSION

We hope to provide those clinicians who are engaged in the care of pregnant women and their children with a valuable and user-friendly instrument for understanding and making a timely diagnoses of at-risk psychopathological phenomena.

Phenobarbital for neonatal seizures in hypoxic ischemic encephalopathy: a pharmacokinetic study during whole body hypothermia

PURPOSE

Therapeutic hypothermia has recently been introduced to treat term newborns with hypoxic-ischemic encephalopathy, of whom more than half have seizures. Phenobarbital is widely used to treat neonatal seizures, but it is unknown whether its pharmacokinetics is affected by hypothermia. We evaluated the influence of hypothermia on phenobarbital pharmacokinetics in asphyxiated newborns.

METHODS

Nineteen term asphyxiated newborns treated with mild whole body hypothermia, started within 6 h after birth and protracted for 72 h, received phenobarbital for clinical seizures. Treatment schedule consisted of a loading dose of 20 mg/kg, titrated to response, up to a maximum dose of 40 mg/kg, followed by a maintenance dose of 2.5 or 1.5 mg/kg every 12 h. Phenobarbital concentrations were measured on 28 dried blood spots in each newborn.

KEY FINDINGS

Eighteen newborns showed plasma concentrations within the reference range after receiving a loading dose of 20 mg/kg. In the remaining newborn, who had received a loading dose of 35 mg/kg, phenobarbital concentrations exceeded the upper reference limit. Phenobarbital concentrations reached a virtual steady state in all newborns. Pharmacokinetic parameters were then calculated. Minimum and maximum concentration (24.7 ± 8.8 and 30.63 ± 10.3 mg/L), average plasma concentration (27.37 ± 9.4 mg/L), and half-life (173.9 ± 62.5 h) were considerably higher than reported in literature for normothermic newborns. Pharmacokinetic parameters did not differ significantly between infants receiving different maintenance doses.

SIGNIFICANCE

Phenobarbital administered to newborns under whole body hypothermia results in higher plasma concentrations and longer half-lives than expected in normothermic newborns.

Study protocol: safety and efficacy of propranolol in newborns with Retinopathy of Prematurity (PROP-ROP): ISRCTN18523491

Background

Despite new therapeutic approaches have improved the prognosis of newborns with retinopathy of prematurity (ROP), an unfavourable structural and functional outcome still remains high. There is high pressure to develop new drugs to prevent and treat ROP. There is increasing enthusiasm for anti-VEGF drugs, but angiogenic inhibitors selective for abnormal blood vessels would be considered as an optimal treatment.

In an animal experimental model of proliferative retinopathy, we have recently demonstrated that the pharmacological blockade of beta-adrenoreceptors improves retinal neovascularization and blood retinal barrier breakdown consequent to hypoxia. The purpose of this study is to evaluate the propranolol administration in preterm newborns suffering from a precocious phase of ROP in terms of safety and efficacy in counteracting the progression of retinopathy.

Methods/Design

Preterm newborns (gestational age at birth lower than 32 weeks) with stage 2 ROP (zone II-III without plus) will be randomized, according to their gestational age, to receive propranolol added to standard treatment (treatment adopted by the ETROP Cooperative Group) or standard treatment alone. Propranolol will be administered until retinal vascularization will be completely developed, but not more than 90 days. Forty-four participants will be recruited into the study. To evaluate the safety of propranolol administration, cardiac and respiratory parameters will be continuously monitored. Blood samplings will be performed to check renal, liver and metabolic balance. To evaluate the efficacy of propranolol, the progression of the disease, the number of laser treatments or vitrectomies, the incidence of retinal detachment or blindness, will be evaluated by serial ophthalmologic examinations. Visual function will be evaluated by means of behavioural standardized tests.

Discussion

This pilot study is the first research that explores the possible therapeutic role of beta blockers in ROP. The objective of this research is highly ambitious: to find a treatment simple, inexpensive, well tolerated and with few adverse effects, able to counteract one of the major complications of the prematurity. Any favourable results of this research could open new perspectives and original scenarios about the treatment or the prevention of this and other proliferative retinopathies.

Trial Registration

Current Controlled Trials ISRCTN18523491; ClinicalTrials.gov Identifier NCT01079715; EudraCT Number 2010-018737-21

Ethical dimensions of periviability

The birth of neonates at the limits of viability, or periviability, poses numerous challenges to health care providers and to systems of care, and the care of these pregnancies and neonates is fraught with ethical controversies. This statement summarizes the ethical principles involved in the care of periviable pregnancies and neonates, and provides expert clinical opinion about the numerous challenges posed by this problem around the world. Topics addressed include a summary of the published experience, an ethical framework, translating neonatal outcome data to the obstetric arena, management as a trial of intervention, referral to tertiary centers, neonatal resuscitation, cesarean delivery for fetal indication, and limits on life-sustaining neonatal treatment.

Oral topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia: a safety study

OBJECTIVE

To investigate whether topiramate associated with mild or deep hypothermia in asphyxiated term infants is safe in relation to the short-term outcome.

STUDY DESIGN

We report on 27 consecutive asphyxiated newborns who were treated with whole body hypothermia and 27 additional consecutive newborns with hypothermia who were co-treated with oral topiramate, once a day for 3 consecutive days, at 2 different doses.

RESULTS

Newborns were divided in 6 groups according to the depth of hypothermia and the association with higher or lower topiramate dosage. A statistical comparison of the groups identified some differences in biochemical and hemodynamic variables, but no adverse effects attributable to topiramate were detected. There were no statistically significant differences in the groups in short-term outcomes, survival rate at discharge, or incidence of pathologic brain magnetic resonance imaging.

CONCLUSION

Although the number of newborns in this study was limited, the short-term outcome and the safety data appear to support the evaluation of topiramate in clinical trials to explore its possible additive neuroprotective action.

Insulin-resistant hyperglycaemia complicating neonatal onset of methylmalonic and propionic acidaemias

BACKGROUND

Insulin-resistant hyperglycaemia may occasionally complicate the clinical course of organic acidaemias.

STUDY DESIGN

Clinical observation.

RESULTS

Two term infants, one suffering from acute early-onset methylmalonic acidaemia, the other suffering from acute early-onset propionic acidaemia, presented acutely with dehydration, ketoacidosis, and hyperammonaemia. Urinary organic acid, plasma amino acids, and blood and plasma acylcarnitine analysis allowed the diagnosis of methylmalonic and propionic acidaemias. The detection of the novel c.481G>A (p.Gly161Arg) and the known c.655A>T (p.Asn219Tyr) MUT gene mutations identified the first patient as affected by methylmalonic acidaemia mut type. The high increase of propionylcarnitine after carnitine administration in both patients suggested a greatly elevated metabolic intoxication. Both newborns showed insulin-resistant hyperglycaemia. Patient 1 died, but patient 2, after a strong reduction of glucose administration, survived. To our knowledge, this is the only patient with this complication who survived.

CONCLUSION

Insulin-resistant hyperglycaemia complicating neonatal onset of methylmalonic and propionic acidaemias is probably a marker of a serious disease. One patient with this complication survived after a strong reduction of glucose administration. Even if this is probably only a partial intervention, we hypothesize that in this situation a reduction of glucose administration can reduce almost the risk of persistent hyperglycaemia. Further studies are required to confirm our hypothesis.

Anti-oxidant enzymes and related elements in term and preterm newborns

BACKGROUND

Although oxidative stress-related diseases mostly affect neonates with extremely low birthweight, healthy preterm newborns might also be at risk of oxidative damages. The aim of the present study was to verify this possibility.

METHODS

Urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG), erythrocyte glutathione peroxidase (GSHPx) and superoxide dismutase (SOD), plasma and erythrocyte concentrations of selenium, zinc and copper were measured until 100 days of life in 30 preterm infants with mean +/- SD birthweight and gestational age of 1605 +/- 122 g and 34.5 +/- 0.5 weeks. The control group included 30 term infants with birthweight 3123 158 g and gestational age 39.6 0.7 weeks.

RESULTS

Throughout the study period urinary 8-OHdG, taken as a marker of oxidative stress, was significantly higher in the preterm than in the term group. Up until 20 days of life, GSHPx activity was significantly lower in the preterm than in the term infants but this was not associated with any apparent selenium deficiency. Conversely, up until 100 days, preterm infants had significantly reduced SOD levels that appeared to reflect a shortage of the elements needed for this enzyme's activity, notably copper, the plasma concentrations of which were constantly and significantly below the control values.

CONCLUSION

The nutritional status of the elements related to the anti-oxidant enzymes, especially zinc and copper, should be carefully assessed in preterm infants, even if their birthweight is not extremely low.

Periviable babies: Italian suggestions for the ethical debate

With the advancement of medical technology, the outcomes for high-risk infants have greatly improved. However, hand and hand with the more positive result of saving neonates, modern neonatal intensive care has also brought to light several issues regarding the ethical grounds in infant care. One of the greatest problems concerns newborns at the threshold of viability. Treatment guidelines have been formulated for these babies in different countries all around the world and there is the general consensus to withhold resuscitation in neonates when gestational age in less than, or equal to 23 weeks, with intensive care ensured for infants at 25 weeks' gestational age. In order to provide helpful suggestions during the initial management of the threatened birth of an infant with a gestational age of 25 completed weeks or less, we conducted a study for reviewing international studies on survival and morbidity rates, international guidelines and practice recommendations. This gave rise to the creation of a consensus document subsequently submitted to the Italian Scientific Societies for approval. The 'Carta di Firenze' does not attempt to deal with the problems related to pediatric euthanasia or eugenetics: its aim is to protect the infant and the mother from undue suffering although addressing recommendations for the work of clinicians.

Curcumin protects cardiac cells against ischemia-reperfusion injury: effects on oxidative stress, NF-kappaB, and JNK pathways

In this study we explored the effects of curcumin in cardiac cells subjected to a protocol simulating ischemia-reperfusion (IR). Curcumin (10 microM) was administered before ischemia (pretreatment) or at the moment of reperfusion (posttreatment) and its effects were compared to those produced by a reference antioxidant (Trolox) with an equal antioxidant capacity. IR cardiac cells showed clear signs of oxidative stress, impaired mitochondrial activity, and a marked development of both necrotic and apoptotic processes; at the same time, increases in NF-kappaB nuclear translocation and JNK phosphorylation were observed. Curcumin pretreatment was revealed to be the most effective in attenuating all these modifications and, in particular, in reducing the death of IR cells. This confirms that the protective effect of curcumin is not related simply to its antioxidant properties but involves other mechanisms, notably interactions in the NF-kappaB and JNK pathways. These findings suggest that curcumin administration, in particular before the hypoxic challenge, represents a promising approach to protecting cardiac cells against IR injury. In this scenario our results point out the importance of the chronology for the outcome of the treatment and provide a differential valuation of the degree of protection that curcumin can exert by its antioxidant activity or by other mechanisms.

Comparison between pulse oximetry and transthoracic impedance alarm traces during home monitoring

OBJECTIVE

To compare transthoracic impedance (TTI/ECG) and pulse oximetry alarm traces detected during home monitoring in infants at risk of apnoea, bradycardia and hypoxaemia.

STUDY DESIGN

A retrospective evaluation of the monitor downloads of 67 infants who had undergone either TTI/ECG or pulse oximetry home monitoring using a device which can detect both parameters.

METHODS

The patients were categorised as: apparent life-threatening events (n = 39), preterm infants (n = 21) and miscellaneous (n = 7). TTI/ECG and pulse oximetry alarm traces were scored as either true or false alarms. Classification criteria were based on visual analysis of the impedance and plethysmographic waveforms captured by the memory monitor every time alarm thresholds were violated.

RESULTS

5242 alarms occurred over 3452 days of monitoring: 4562 (87%) were false and 680 (13%) true. The mean duration of monitoring was 51 days (range 5-220 days). There were 2982 TTI/ECG false alarms (65% of the total) and 1580 pulse oximetry false alarms (35%) (p = 0.0042). Of the 680 true alarms, 507 (74%) were desaturations not attributable to central apnoea and 173 (26%) were true TTI/ECG alarms (p = 0.0013).

CONCLUSIONS

Comparison of pulse oximetry and TTI/ECG alarm traces shows that true events were mostly attributable to desaturations, while false alarms were mainly provoked by TTI/ECG. The total number of false alarms is lower than reported in other studies using TTI/ECG only, thus indicating that monitoring using both pulse oximetry and TTI/ECG is suitable for home use. When the combination of both techniques is not feasible or not required, we recommend the use of motion resistant pulse oximetry alone.

Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births

Over the last 2 decades, the survival rate of infants born at < or = 25 weeks of gestation has increased; however, significant morbidity and disability persist. The commitment for their care gives rise to a variety of complex medical, social, and ethical aspects. Decision-making is a crucial issue that involves the infant, the family, health care providers, and society. In a review of the existing guidelines, we investigated the different approaches in the care of extremely preterm births in various countries. We found that many scientific societies and professional organizations have issued guidelines that address the recommendations for the care of these fetuses/neonates although to varying degrees. In this article we compare different approaches and assess the scientific grounds of the specific recommendations. With current standards, intensive care is generally considered justifiable at > or = 25 weeks, compassionate care at < or = 22 weeks, and an individual approach at 23 to 24 weeks, consistent with the parents' wishes and the infant's clinical conditions at birth.

[Intensive care at extremely low gestational age: ethical issues and treatment choices]

With the continuing progress of obstetrical and neonatal care, the limit of human viability has continued to shift towards younger gestational ages. The survival rate as well as the survival without disability increases with each additional week of gestation but, for infants born from 22 to 25 w GA, it is still really low, and the threshold of human viability appears to be limited to the physiological development of the lungs, which take place around the 23rd-24th w GA. At present, the care of such infants, born at the threshold of human viability, presents a variety of complex medical, social, and economical decisions assuming the characteristics of ethical decisions in that the limits between benefits and disadvantages is not so clearcut. What is the true infant's best interest is far to be understood and concern about the ethical basis of providing such intensive care is arising in the scientific community. In this paper the authors provide a review of the ethical basis of decisions related to the care of such infants: to treat, not to treat, intensive or compassionate care, withhold or withdraw treatment.

A 4-year survey on palivizumab respiratory syncytial virus (RSV)-prophylaxis: how can compliance be improved?

OBJECTIVE

To identify compliance-influencing factors and to suggest strategies for overcoming barriers in a preventive medicine program.

METHODS

A survey was conducted to evaluate compliance in children receiving palivizumab prophylaxis for respiratory syncytial virus (RSV) infections. Demographics, neonatal variables, and parental attitudes capable of influencing the outcome of prophylaxis were studied in 216 children over a four-year period.

RESULTS

The overall compliance rate with all recommended doses of palivizumab was 87%. Among the neonatal characteristics, low birth weight and a younger age at the beginning of the program were significantly associated with good compliance (p < 0.05). The strongest factor influencing poor compliance was being foreign-born or a non-native speaker (p < 0.01).

CONCLUSIONS

Compliance to RSV infection prophylaxis is reduced in infants born to foreign-born or non-native speakers. In order to enhance compliance, parents should be provided with adequate information in their own language explaining the advantages of the palivizumab prophylaxis program for RSV infections.

Bilateral consolidation of the lungs in a preterm infant: an unusual central venous catheter complication

We describe a case of bilateral parenchymal consolidation with sudden respiratory distress in a preterm baby as a complication of peripherally inserted central catheter (PICC) dislocation. The X-rays showed bilateral pulmonary consolidation with the catheter tip initially located in the right, and later in the left pulmonary artery. The catheter was withdrawn. As soon as the catheter was repositioned all clinical signs and symptoms disappeared. Neonatologists should consider the possibility of dramatic respiratory distress deriving from PICC dislocation. Careful tip catheter placement and conscientious monitoring may reduce morbidity.

Thoracentesis in pericardial and pleural effusion caused by central venous catheterization: a less invasive neonatal approach

An 840 g infant developed a rapid onset of shock-like symptoms. Pericardial and pleural effusions from an indwelling central catheter were diagnosed via echocardiography. A thoracentesis was promptly performed with immediate clinical improvement. The fluid withdrawn from the pleural space was analysed as hyperalimentation. The infant survived because of early diagnosis and aggressive therapeutic intervention. A pericardial effusion should be drained if there is cardiovascular compromise and because pericardiocentesis represents a high risk technique, attempts should be made to rectify the extravasation via thoracentesis.