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Juhantalo M, Hautakangas T, Palomäki O, Uotila J. Uterine contractile activity and neonatal outcome - A blind analysis of a randomized controlled trial cohort. Acta Obstet Gynecol Scand 2024; 103:1396-1407. [PMID: 38567650 PMCID: PMC11168260 DOI: 10.1111/aogs.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Sufficient contractions are necessary for a successful delivery but each contraction temporarily constricts the oxygenated blood flow to the fetus. Individual fetal or placental characteristics determine how the fetus can withstand this temporary low oxygen saturation. However, only a few studies have examined the impact of uterine activity on neonatal outcome and even less attention has been paid to parturients' individual characteristics. Our objective was therefore to find out whether fetuses compromised by maternal or intrapartum risk factors are more vulnerable to excessive uterine activity. MATERIAL AND METHODS Uterine contractile activity was assessed by intrauterine pressure catheters. Women (n = 625) with term singleton pregnancies and fetus in cephalic presentation were included in this secondary, blind analysis of a randomized controlled trial cohort. Intrauterine pressure as Montevideo units (MVU), contraction frequency/10 min and uterine baseline tone were calculated for 4 h prior to birth or the decision to perform cesarean section. Uterine activity in relation to umbilical artery pH linearly or ≤7.10 was used as the primary outcome. Need for operative delivery (either cesarean section or vacuum-assisted delivery) due to fetal distress was analyzed as a secondary outcome. In addition, belonging to vulnerable subgroups with, for example, chorioamnionitis, hypertensive or diabetic disorders, maternal smoking or neonatal birthweight <10th percentile were investigated as additional risk factors. RESULTS A linear decline in umbilical artery pH was seen with increasing intrauterine pressure in all deliveries (p < 0.001). Among parturients with suspected chorioamnionitis, every increasing 10 MVUs increased the likelihood of umbilical artery pH ≤7.10 (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.02-1.34, p = 0.023). The need for operative delivery due to fetal distress was increased among all laboring women by every increasing 10 MVUs (OR 1.05, 95% CI 1.01-1.09, p = 0.015). This association with operative deliveries was further increased among parturients with hypertensive disorders (OR 1.23, 95% CI 1.05-1.43, p = 0.009) and among those with diabetic disorders (OR 1.13, 95% CI 1.04-1.28, p = 0.003). CONCLUSIONS Increasing intrauterine pressure impairs umbilical artery pH especially among parturients with suspected chorioamnionitis. Fetuses in pregnancies affected by chorioamnionitis, hypertensive or diabetic disorders are more vulnerable to high intrauterine pressure.
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Affiliation(s)
- Milla Juhantalo
- Department of Obstetrics and GynecologyTampere University Hospital, Wellbeing Services County of PirkanmaaTampereFinland
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Tuija Hautakangas
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Obstetrics and Gynecology, Hospital NovaWellbeing Services County of Central FinlandJyväskyläFinland
| | - Outi Palomäki
- Department of Obstetrics and GynecologyTampere University Hospital, Wellbeing Services County of PirkanmaaTampereFinland
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Jukka Uotila
- Department of Obstetrics and GynecologyTampere University Hospital, Wellbeing Services County of PirkanmaaTampereFinland
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
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Roto S, Nupponen I, Kalliala I, Kaijomaa M. Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study. BMC Pregnancy Childbirth 2024; 24:421. [PMID: 38867160 PMCID: PMC11167761 DOI: 10.1186/s12884-024-06596-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/20/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia. METHODS We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013-2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated. RESULTS Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14-1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18-8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28-9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia. CONCLUSIONS Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.
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Affiliation(s)
- Suoma Roto
- Department of obstetrics and gynecology, Helsinki University Women's Hospital, Haartmaninkatu 2, Helsinki, 00029, Finland
| | - Irmeli Nupponen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Kalliala
- Department of obstetrics and gynecology, Helsinki University Women's Hospital, Haartmaninkatu 2, Helsinki, 00029, Finland
| | - Marja Kaijomaa
- Department of obstetrics and gynecology, Helsinki University Women's Hospital, Haartmaninkatu 2, Helsinki, 00029, Finland.
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Lv H, Liu F, Wang Q, Dong Z, Zhang H, Ren P, Li L. Correlation analysis between the amniotic fluid contamination and clinical grading of neonatal hypoxic-ischemic encephalopathy and biomarkers of brain damage. BMC Pediatr 2024; 24:178. [PMID: 38481189 PMCID: PMC10935862 DOI: 10.1186/s12887-024-04663-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Amniotic fluid contamination (AFC) is a risk factor for neonatal hypoxic ischemic encephalopathy (HIE); however, the correlation between AFC level and the incidence and clinical grading of HIE, in addition to relevant biomarkers of brain damage, have not been assessed. METHODS This single-center observational study included 75 neonates with moderate-to-severe HIE. The neonates with HIE were divided into four subgroups according to the AFC level: normal amniotic fluid with HIE group (NAF-HIE), I°AFC with HIE group (I°AFC-HIE), II°AFC with HIE group (II°AFC-HIE), and III°AFC with HIE group (III°AFC-HIE). The control groups consisted of 35 healthy neonates. The clinical grading of neonatal HIE was performed according to the criteria of Sarnat and Sarnat. Serum tau protein and S100B were detected by enzyme-linked immunosorbent assay kits. Correlations of serum tau protein and S100B were evaluated using the Pearson correlation analysis. RESULTS (1) The incidence of neonatal HIE in the NAF-HIE group was 20 cases (26. 7%), I°AFC-HIE was 13 cases (17.3%), II°AFC-HIE was 10 cases (13.3%), and III°AFC-HIE was 32 cases (42. 7%). The incidence of moderate-to-severe HIE in the I°-III°AFC-HIE groups was 73.3% (55/75). (2) In 44 cases with severe HIE, 26 cases (59.1%) occurred in the III°AFC-HIE group, which had a significantly higher incidence of severe HIE than moderate HIE (p < 0.05). In NAF-HIE and I°AFC-HIE groups, the incidence of moderate HIE was 45.2% and 29.0%, respectively, which was higher than that of severe HIE (X2 = 9.2425, p < 0.05; X2 = 5.0472, p < 0.05, respectively). (3) Serum tau protein and S100B levels in the HIE groups were significantly higher than in the control group (all p < 0.05), and were significantly higher in the III°AFC-HIE group than in the NAF-HIE and I°AFC-HIE groups (all p < 0.05). (4) Serum tau protein and S100B levels in the severe HIE group were significantly higher in the moderate HIE group (all p < 0.05). (5) Serum tau protein and S100B levels were significantly positively correlated (r = 0.7703, p < 0.0001). CONCLUSION Among children with severe HIE, the incidence of III°AFC was higher, and the levels of serum tau protein and S100B were increased. AFC level might be associated with HIE grading.
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Affiliation(s)
- Hongyan Lv
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China.
- Department of Neonatology and Neonatal Pathology, Handan Maternal and Child Health Care Hospital, No. 50, Li Ming Street, Hanshan District, Handan City, Hebei Province, 056001, China.
| | - Fang Liu
- Department of Pediatrics, NICU the 980th Hospital of the People's Liberation Army Joint Service Support Force (Bethune International Peace Hospital), Shijiazhuang, 050082, PR China
| | - Qiuli Wang
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China
| | - Zhiyong Dong
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China
| | - Huiming Zhang
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China
| | - Pengshun Ren
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China
| | - Liangxiang Li
- Department of Neonatal Pathology, Handan Maternal and Child Health Care Hospital, Handan, 056001, PR China
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Junior LCM, Pinto CN, Gerencer CS, Pro ECG, de Carvalho HB. Association of maternal, fetal and labor variables with a low Apgar score in the fifth minute in term pregnancy: a case-control study. Arch Gynecol Obstet 2023; 308:1473-1483. [PMID: 36374349 PMCID: PMC9662118 DOI: 10.1007/s00404-022-06832-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To search for maternal, labor-related and fetal variables associated with low Apgar in the fifth minute in term pregnancy. METHODS A retrospective case-control study with term births was conducted in a public teaching hospital from 2013 to 2020. Cases were term births with Apgar score less than 7 in the fifth minute, and controls, the next one or two births following a case, with Apgar of 7 or more. Non-cephalic presentations, multiples and malformations were excluded. We accessed 100 cases and 190 controls. We considered significant values of p < 0.05. RESULTS Were accessed 27 variables which could be risk factors, from which 12 were associated with the outcome. We found a protective effect of prelabor cesarean for the outcome, odds ratio (OR) 0.38, p = 0.013. Consequently, we conducted two sets of analyses: in the whole group and in the group of laboring women. The values of OR were in general greater in the group of laboring women, compared with the whole group. We conducted multivariate analysis within the group of women in labor. The variables which fitted best in the model were nulliparity, male sex of the fetus, less than six prenatal visits and abnormal cardiotocography; all remained significant. An association of rupture of membranes more than 360 min with the outcome, even after controlling fpr duration of labor, was found; adjusted OR 2.45, p = 0.023. CONCLUSION Twelve variables were associated with the outcome. Prelabor cesarean had a protective effect. The time of ruptured membranes was associated with low Apgar.
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Affiliation(s)
- Luís Carlos Machado Junior
- Universidade de São Paulo/Faculdade de Medicina/Centro de Saúde Escola Samuel Barnsley Pessoa, São Paulo, Brazil.
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil.
| | - Camila Nazareth Pinto
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
| | - Caroline Sangalan Gerencer
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
| | - Elisa Caroline Giacometti Pro
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
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Gallo DM, Romero R, Bosco M, Gotsch F, Jaiman S, Jung E, Suksai M, Ramón Y Cajal CL, Yoon BH, Chaiworapongsa T. Meconium-stained amniotic fluid. Am J Obstet Gynecol 2023; 228:S1158-S1178. [PMID: 37012128 PMCID: PMC10291742 DOI: 10.1016/j.ajog.2022.11.1283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 04/04/2023]
Abstract
Green-stained amniotic fluid, often referred to as meconium-stained amniotic fluid, is present in 5% to 20% of patients in labor and is considered an obstetric hazard. The condition has been attributed to the passage of fetal colonic content (meconium), intraamniotic bleeding with the presence of heme catabolic products, or both. The frequency of green-stained amniotic fluid increases as a function of gestational age, reaching approximately 27% in post-term gestation. Green-stained amniotic fluid during labor has been associated with fetal acidemia (umbilical artery pH <7.00), neonatal respiratory distress, and seizures as well as cerebral palsy. Hypoxia is widely considered a mechanism responsible for fetal defecation and meconium-stained amniotic fluid; however, most fetuses with meconium-stained amniotic fluid do not have fetal acidemia. Intraamniotic infection/inflammation has emerged as an important factor in meconium-stained amniotic fluid in term and preterm gestations, as patients with these conditions have a higher rate of clinical chorioamnionitis and neonatal sepsis. The precise mechanisms linking intraamniotic inflammation to green-stained amniotic fluid have not been determined, but the effects of oxidative stress in heme catabolism have been implicated. Two randomized clinical trials suggest that antibiotic administration decreases the rate of clinical chorioamnionitis in patients with meconium-stained amniotic fluid. A serious complication of meconium-stained amniotic fluid is meconium aspiration syndrome. This condition develops in 5% of cases presenting with meconium-stained amniotic fluid and is a severe complication typical of term newborns. Meconium aspiration syndrome is attributed to the mechanical and chemical effects of aspirated meconium coupled with local and systemic fetal inflammation. Routine naso/oropharyngeal suctioning and tracheal intubation in cases of meconium-stained amniotic fluid have not been shown to be beneficial and are no longer recommended in obstetrical practice. A systematic review of randomized controlled trials suggested that amnioinfusion may decrease the rate of meconium aspiration syndrome. Histologic examination of the fetal membranes for meconium has been invoked in medical legal litigation to time the occurrence of fetal injury. However, inferences have been largely based on the results of in vitro experiments, and extrapolation of such findings to the clinical setting warrants caution. Fetal defecation throughout gestation appears to be a physiologic phenomenon based on ultrasound as well as in observations in animals.
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Affiliation(s)
- Dahiana M Gallo
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Gynecology and Obstetrics, Universidad Del Valle, Cali, Colombia
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | - Mariachiara Bosco
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Francesca Gotsch
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Sunil Jaiman
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Carlos López Ramón Y Cajal
- Unit of Prenatal Diagnosis, Service of Obstetrics and Gynecology, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tinnakorn Chaiworapongsa
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
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Chen X, Chen H, Jiang D. Maternal and Fetal Risk Factors for Neonatal Hypoxic-Ischemic Encephalopathy: A Retrospective Study. Int J Gen Med 2023; 16:537-545. [PMID: 36818762 PMCID: PMC9936872 DOI: 10.2147/ijgm.s394202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023] Open
Abstract
Background Neonatal hypoxic-ischemic encephalopathy (HIE) leads to different degree of neurological sequelae. The incidence of HIE is relatively high, and the risk factors associated with HIE are still controversial. It is necessary to identify the risk factors associated with HIE. Methods A total of 258 neonates (110 HIE patients and 148 controls) were enrolled in this study. The characteristics of pregnant women and fetuses during pregnancy and delivery were compared between HIE patients and controls, and the risk factors of HIE were analyzed. Results The proportions of premature infants, low-birth-weight infants and the levels of 1-minute Apgar score, 5-minute Apgar score in HIE group were significantly lower than those in control group, while the proportion of amniotic fluid contamination in the HIE group was significantly higher than those of the controls. When HIE was taken as the end point of 1-minute Apgar score, and 5-minute Apgar score, the cut-off value of 1-minute Apgar score was 3, and 5-minute Apgar score was 7 by receiver operating characteristic (ROC) curve analysis. The results of multivariate logistic regression analysis showed that low birth weight (<2.5 kg) (OR 1.780, 95% CI: 0.124-25.463, P=0.016), amniotic fluid contamination (OR 3.223, 95% CI: 1.049-9.901, P=0.041), low 1-minute Apgar score (≤3) (OR 92.425, 95% CI: 15.522-550.343, P<0.001), and low 5-minute Apgar score (≤7) (OR 12.641, 95% CI: 2.894-55.227, P=0.001) may increase risk of HIE. In addition, amniotic fluid contamination, low 1-minute Apgar score (≤3), and low 5-minute Apgar score (≤7) may increase risk of HIE among newborns born to women without previous childbearing history, but not in newborns born to women with previous childbearing history. Conclusion Low birth weight (<2.5 kg), amniotic fluid contamination, low 1-minute Apgar score (≤3), and 5-minute Apgar score (≤7) may increase risk of HIE.
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Affiliation(s)
- Xuexin Chen
- Department of Neonatology, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Correspondence: Xuexin Chen, Department of Neonatology, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, No. 63 Huangtang Road, Meijiang District, Meizhou, People’s Republic of China, Tel +86 753-2131-230, Email
| | - Hongxiang Chen
- Department of Neonatology, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Dongchang Jiang
- Department of Neonatology, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
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Tarvonen MJ, Lear CA, Andersson S, Gunn AJ, Teramo KA. Increased variability of fetal heart rate during labour: a review of preclinical and clinical studies. BJOG 2022; 129:2070-2081. [PMID: 35596699 PMCID: PMC9796294 DOI: 10.1111/1471-0528.17234] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 01/01/2023]
Abstract
Increased fetal heart rate variability (FHRV) in intrapartum cardiotocographic recording has been variably defined and poorly understood, limiting its clinical utility. Both preclinical (animal) and clinical (human) evidence support that increased FHRV is observed in the early stage of intrapartum fetal hypoxaemia but can also be observed in a subset of fetuses during the preterminal stage of repeated hypoxaemia. This review of available evidence provides data and expert opinion on the pathophysiology of increased FHRV, its clinical significance and a stepwise approach regarding the management of this pattern, and propose recommendations for standardisation of related terminology.
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Affiliation(s)
- Mikko J. Tarvonen
- Department of Obstetrics and GynaecologyUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
| | - Christopher A. Lear
- Fetal Physiology and Neuroscience GroupDepartment of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Sture Andersson
- Children’s Hospital, Paediatric Research CentreUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
| | - Alistair J. Gunn
- Fetal Physiology and Neuroscience GroupDepartment of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Kari A. Teramo
- Department of Obstetrics and GynaecologyUniversity of Helsinki, and Helsinki University HospitalHelsinkiFinland
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Reynolds AJ, Murray ML, Geary MP, Ater SB, Hayes BC. Uterine activity in labour and the risk of neonatal encephalopathy: a case control study. Eur J Obstet Gynecol Reprod Biol 2022; 274:73-79. [PMID: 35605517 DOI: 10.1016/j.ejogrb.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/13/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the relationship between intrapartum contraction frequency, rest interval duration, and cervical dilation speed and the risk of neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This was a retrospective case-control study conducted in a maternity hospital in Dublin, Ireland. Babies born without major congenital anomalies between September 2006 and November 2017 at ≥ 35 + 0 weeks' gestational age were eligible. Cases were diagnosed with moderate-severe HIE. The controls were the first eligible baby born before and after each case with normal Apgar scores and not admitted to the neonatal unit. Intrapartum uterine activity was assessed by automated analysis of external tocography recordings. Cervical dilation was assessed by linear interpolation between vaginal examination measurements. The speed of cervical dilation was expressed as the times from 4 to 6 cm, >6 cm to the start of pushing, and from pushing to delivery. RESULTS Intrapartum tocographs results were available in 49 of 88 cases and 121 of 176 controls. The median contraction rate in cases was 7.7 (Interquartile range [IQR]: 6.6-9.0) compared to 7.0 in controls (IQR: 6.2-7.9) (p = 0.021). The median rest interval duration was 56 s (IQR: 38-76) in cases and 62 s (IQR: 50-79) in controls (p = 0.058). Cases took longer to progress from > 6 cm to the start of pushing (cases: 02:58 [01:14-04:49], controls: 01:48 [00:51-03:34], p = 0.020) and from pushing to delivery (cases: 00:34 [00:24-01:10], controls: 00:27 [00:13-00:56], p = 0.036). CONCLUSIONS Higher contraction frequencies and slower progress towards the end of labour are both independently associated with the risk of moderate-severe HIE. Inter-contraction rest interval duration as measured by external tocography does not provide additional accuracy.
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Affiliation(s)
| | | | - Michael P Geary
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland
| | | | - Breda C Hayes
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland
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Lorain P, Bower A, Gottardi E, Dommergues M, Foix L'Helias L, Guellec I, Kayem G. Risk factors for hypoxic-ischemic encephalopathy in cases of severe acidosis: A case-control study. Acta Obstet Gynecol Scand 2022; 101:471-478. [PMID: 35338480 DOI: 10.1111/aogs.14326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of the study was to identify the obstetric risk factors for hypoxic-ischemic encephalopathy (HIE) in infants with asphyxia at birth. MATERIAL AND METHODS This multicenter case-control study covered the 5-year period from 2014 through 2018 and included newborns ≥36 weeks of gestation with an umbilical pH at birth ≤7.0. Cases were newborns who developed moderate or severe HIE; they were matched with controls with pH ≤7.0 at birth over the same period without moderate or severe HIE. The factors studied were maternal, gestational, intrapartum, delivery-related, and neonatal characteristics. A multivariable analysis was performed to study the maternal, obstetric, and neonatal factors independently associated with moderate or severe HIE. RESULTS Our review of the records identified 41 cases and 98 controls. Compared with controls, children with moderate or severe HIE had a lower 5-min Apgar score, lower umbilical artery pH, and higher cord lactate levels at birth and at 1 h of life. Obstetric factors associated with moderate or severe HIE were the occurrence of an acute event (adjusted odds ratio [aOR] 6.4; 95% confidence interval [CI] 1.8-22.5), maternal fever (aOR 3.5; 95% CI 1.0-11.9), and thick meconium during labor (aOR 2.9; 95% CI 1.0-8.6). CONCLUSIONS HIE is associated with a lower 5-min Apgar score and with the severity of acidosis at birth and at 1 h of life. In newborns with a pH <7.0 at birth, the occurrence of an acute obstetric event, maternal fever, and thick meconium are independent factors associated with moderate or severe HIE.
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Affiliation(s)
- Perrine Lorain
- Department of Gynecology and Obstetrics, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France
| | - Alexandra Bower
- Department of Neonatology, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France
| | - Elsa Gottardi
- Department of Gynecology and Obstetrics, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France
| | - Marc Dommergues
- Department of Gynecology and Obstetrics, Pitié Salpétrière Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France
| | - Laurence Foix L'Helias
- Department of Neonatology, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France.,Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Research Center for Epidemiology and BioStatistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Isabelle Guellec
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Research Center for Epidemiology and BioStatistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France.,Neonatal Intensive Care Unit, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France
| | - Gilles Kayem
- Department of Gynecology and Obstetrics, Trousseau Hospital - Assistance Publique-Hopitaux de Paris, Sorbonne University, Paris, France.,Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Research Center for Epidemiology and BioStatistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
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10
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On the effect of irregular uterine activity during a vaginal delivery using an electro-chemo-mechanical constitutive model. J Mech Behav Biomed Mater 2022; 131:105250. [DOI: 10.1016/j.jmbbm.2022.105250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/08/2022] [Accepted: 04/17/2022] [Indexed: 11/21/2022]
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11
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Chavez-Valdez R, Miller S, Spahic H, Vaidya D, Parkinson C, Dietrick B, Brooks S, Gerner GJ, Tekes A, Graham EM, Northington FJ, Everett AD. Therapeutic Hypothermia Modulates the Relationships Between Indicators of Severity of Neonatal Hypoxic Ischemic Encephalopathy and Serum Biomarkers. Front Neurol 2021; 12:748150. [PMID: 34795631 PMCID: PMC8593186 DOI: 10.3389/fneur.2021.748150] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine the changes due to therapeutic hypothermia (TH) exposure in the strength of association between traditional clinical and biochemical indicators of severity of neonatal hypoxic-ischemic encephalopathy (HIE) and serum biomarkers. We hypothesized that culmination of TH changes the strength of the relationships between traditional indicators of severity of HIE and serum biomarkers. Methods: This was a single-center observational cohort study of 178 neonates with HIE treated with TH and followed with serum biomarkers: (i) brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) (neurotrophins); (ii) tau and glial fibrillary acidic protein (GFAP) (neural cell injury); and (iii) interleukin 6 (IL-6), IL-8, and IL-10 (cytokines), during their first week of life. Adjusted mixed-effect models tested associations with HIE indicators in relation to TH exposure. Results: At admission, lower Apgar scores and base excess (BE) and higher lactate and nucleated red blood cell (NRBC) count correlated with higher Sarnat scores. These indicators of worse HIE severity, including higher Sarnat score, correlated with lower VEGF and higher tau, GFAP, and IL-10 levels at different time points. Within the first 24 h of life, patients with a Sarnat score >2 had lower VEGF levels, whereas only those with score of 3 also had higher GFAP and IL-10 levels. Tau levels increased during TH in patients with Sarnat score of 3, whereas tau and GFAP increased after TH in those with scores of 2. After adjustments, lower VEGF levels during TH and higher tau, GFAP, and IL-10 levels during and after TH were associated with worse Sarnat scores. Tau and GFAP relationship with Sarnat score became stronger after TH. Conclusion: Therapeutic hypothermia exerts an independent modulatory effect in the relationships between traditional indicators of severity of HIE and serum biomarkers after adjustments. Thus, the timing of biomarker testing in relation to TH exposure must be carefully considered if biomarkers are proposed for patient stratification in novel clinical trials.
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Affiliation(s)
- Raul Chavez-Valdez
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sarah Miller
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harisa Spahic
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Dhananjay Vaidya
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Charlamaine Parkinson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Barbara Dietrick
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sandra Brooks
- Department of Pediatrics, Division of Neonatology, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States
| | - Gwendolyn J Gerner
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, United States.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aylin Tekes
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ernest M Graham
- Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Frances J Northington
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Neuroscience Intensive Care Nursery Program, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Allen D Everett
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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12
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Burgod C, Pant S, Morales MM, Montaldo P, Ivain P, Elangovan R, Bassett P, Thayyil S. Effect of intra-partum Oxytocin on neonatal encephalopathy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2021; 21:736. [PMID: 34717571 PMCID: PMC8556930 DOI: 10.1186/s12884-021-04216-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/15/2021] [Indexed: 11/15/2022] Open
Abstract
Background Oxytocin is widely used for induction and augmentation of labour, particularly in low- and middle-income countries (LMICs). In this systematic review and meta-analysis, we examined the effect of intra-partum Oxytocin use on neonatal encephalopathy. Methods The protocol for this study was registered with PROSPERO (ID: CRD42020165049). We searched Medline, Embase and Web of Science Core Collection databases for papers published between January 1970 and May 2021. We considered all studies involving term and near-term (≥36 weeks’ gestation) primigravidae and multiparous women. We included all randomised, quasi-randomised clinical trials, retrospective studies and non-randomised prospective studies reporting intra-partum Oxytocin administration for induction and/or augmentation of labour. Our primary outcome was neonatal encephalopathy. Risk of bias was assessed in non-randomised studies using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. The RoB 2.0 tool was used for randomised studies. A Mantel-Haenszel statistical method and random effects analysis model were used for meta-analysis. Odds ratios were used to determine effect measure and reported with 95% confidence intervals. Results We included data from seven studies (6 Case-control studies, 1 cluster-randomised trial) of which 3 took place in high-income countries (HICs) and 4 in LMICs. The pooled data included a total of 24,208 women giving birth at or after 36 weeks; 7642 had intra-partum Oxytocin for induction and/or augmentation of labour, and 16,566 did not receive intra-partum Oxytocin. Oxytocin use was associated with an increased prevalence of neonatal encephalopathy (Odds Ratio 2.19, 95% CI 1.58 to 3.04; p < 0.00001). Conclusions Intra-partum Oxytocin may increase the risk of neonatal encephalopathy. Future clinical trials of uterotonics should include neonatal encephalopathy as a key outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04216-3.
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Affiliation(s)
- Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK.
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Maria Moreno Morales
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK.,Neonatal Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Ramyia Elangovan
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Paul Bassett
- Statsconsultancy Ltd., Amersham, London, England
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, Du Cane Road, London, W12 0HS, UK
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13
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Chalak L, Redline RW, Goodman AM, Juul SE, Chang T, Yanowitz TD, Maitre N, Mayock DE, Lampland AL, Bendel-Stenzel E, Riley D, Mathur AM, Rao R, Van Meurs KP, Wu TW, Gonzalez FF, Flibotte J, Mietzsch U, Sokol GM, Ahmad KA, Baserga M, Weitkamp JH, Poindexter BB, Comstock BA, Wu YW. Acute and Chronic Placental Abnormalities in a Multicenter Cohort of Newborn Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2021; 237:190-196. [PMID: 34144032 DOI: 10.1016/j.jpeds.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the frequency of placental abnormalities in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) and to determine the association between acuity of placental abnormalities and clinical characteristics of HIE. STUDY DESIGN Infants born at ≥36 weeks of gestation (n = 500) with moderate or severe HIE were enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. A placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute and chronic placental abnormalities using a standard classification system. RESULTS Complete placental pathologic examination was available for 321 of 500 (64%) trial participants. Placental abnormalities were identified in 273 of 321 (85%) and were more common in infants ≥40 weeks of gestation (93% vs 81%, P = .01). A combination of acute and chronic placental abnormalities (43%) was more common than either acute (20%) or chronic (21%) abnormalities alone. Acute abnormalities included meconium staining of the placenta (41%) and histologic chorioamnionitis (39%). Chronic abnormalities included maternal vascular malperfusion (25%), villitis of unknown etiology (8%), and fetal vascular malperfusion (6%). Infants with chronic placental abnormalities exhibited a greater mean base deficit at birth (-15.9 vs -14.3, P = .049) than those without such abnormalities. Patients with HIE and acute placental lesions had older mean gestational ages (39.1 vs 38.0, P < .001) and greater rates of clinically diagnosed chorioamnionitis (25% vs 2%, P < .001) than those without acute abnormalities. CONCLUSIONS Combined acute and chronic placental abnormalities were common in this cohort of infants with HIE, underscoring the complex causal pathways of HIE. TRIAL REGISTRATION ClinicalTrials.gov: NCT02811263.
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Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amy M Goodman
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine, Washington, DC
| | - Toby D Yanowitz
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC and Magee Womens Hospital of UPMC, Pittsburgh, PA
| | - Nathalie Maitre
- Department of Pediatrics and Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Bendel-Stenzel
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX
| | - Amit M Mathur
- Department of Pediatrics/Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA
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14
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Sunny AK, Paudel P, Tiwari J, Bagale BB, Kukka A, Hong Z, Ewald U, Berkelhamer S, Ashish Kc. A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal. BMC Pediatr 2021; 21:394. [PMID: 34507527 PMCID: PMC8431921 DOI: 10.1186/s12887-021-02858-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/25/2021] [Indexed: 12/20/2022] Open
Abstract
Background Perinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings. Aim To determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition. Methods A nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis. Results The incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1–6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0–3.6), malposition (aOR:1.8, 95% CI, 1.0–3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3–2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3–3.3) and male gender (aOR:1.6, 95% CI, 1.2–2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2–56.3). Conclusion The incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.
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Affiliation(s)
| | | | | | | | - Antti Kukka
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Paediatrics, Länssjukhuset Gävle-Sandviken, Gävle, Sweden
| | - Zhou Hong
- Department of Maternal and Child Health, Peking University of Health Sciences, Peking, China
| | - Uwe Ewald
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sara Berkelhamer
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
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15
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Kitamura E, Koike M, Hirayama T, Sunabori T, Kameda H, Hioki H, Takeda S, Itakura A. Susceptibility of subregions of prefrontal cortex and corpus callosum to damage by high-dose oxytocin-induced labor in male neonatal mice. PLoS One 2021; 16:e0256693. [PMID: 34437622 PMCID: PMC8389436 DOI: 10.1371/journal.pone.0256693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022] Open
Abstract
Induction and augmentation of labor is one of the most common obstetrical interventions. However, this intervention is not free of risks and could cause adverse events, such as hyperactive uterine contraction, uterine rupture, and amniotic-fluid embolism. Our previous study using a new animal model showed that labor induced with high-dose oxytocin (OXT) in pregnant mice resulted in massive cell death in selective brain regions, specifically in male offspring. The affected brain regions included the prefrontal cortex (PFC), but a detailed study in the PFC subregions has not been performed. In this study, we induced labor in mice using high-dose OXT and investigated neonatal brain damage in detail in the PFC using light and electron microscopy. We found that TUNEL-positive or pyknotic nuclei and Iba-1-positive microglial cells were detected more abundantly in infralimbic (IL) and prelimbic (PL) cortex of the ventromedial PFC (vmPFC) in male pups delivered by OXT-induced labor than in the control male pups. These Iba-1-positive microglial cells were engulfing dying cells. Additionally, we also noticed that in the forceps minor (FMI) of the corpus callosum (CC), the number of TUNEL-positive or pyknotic nuclei and Iba-1-positive microglial cells were largely increased and Iba-1-positive microglial cells phagocytosed massive dying cells in male pups delivered by high-dose OXT-induced labor. In conclusion, IL and PL of the vmPFC and FMI of the CC, were susceptible to brain damage in male neonates after high-dose OXT-induced labor.
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Affiliation(s)
- Eri Kitamura
- Department of Cell Biology and Neuroscience, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masato Koike
- Department of Cell Biology and Neuroscience, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Advanced Research Institute for Health Science, Juntendo University, Tokyo, Japan
| | - Takashi Hirayama
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takehiko Sunabori
- Department of Cell Biology and Neuroscience, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Kameda
- Department of Cell Biology and Neuroscience, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Hioki
- Department of Cell Biology and Neuroscience, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Neuroanatomy, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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16
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Abstract
Perinatal asphyxia remains one of the major causes of morbidity and mortality for term newborns. Though access to health care and birth attendants have decreased the rate, Neonatal encephalopathy (NE) has not been eliminated. Worldwide, women at socioeconomic disadvantage have the highest risk of delivering a neonate with NE. Neonates that will experience perinatal asphyxia cannot be easily identified prospectively and the intrapartum testing available is not specific enough to clearly indicate the best course of action in most cases. Despite this, training programs that aim to decrease morbidity and mortality from all causes appear to be associated with fewer cases of perinatal asphyxia. The current best approach is to support education and communication for all people involved in the care of birthing women. Ideally, new technology will address identification of the fetus likely to be affected or the fetus who is beginning to experience injury in advance of delivery.
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Affiliation(s)
- Meghan G Hill
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
| | - Kathryn L Reed
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine Tucson, Tucson, USA.
| | - Richard N Brown
- Divisions of Obstetrics, Maternal Fetal Medicine and Ultrasound, Department of Obstetrics & Gynaecology, McGill University Health Centre, Montreal, Canada.
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17
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Wang J, Tao E, Mo M, Ding W, Yuan J, Wang M, Zheng C, Zheng H. Perinatal Risk Factors Influencing Neonatal Hypoxic Ischemic Encephalopathy in Southern China: A Case-Control Study. Am J Perinatol 2021; 38:e182-e186. [PMID: 32219797 DOI: 10.1055/s-0040-1708884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In this study, our objective was to explore the relevant influencing factors of neonatal hypoxic-ischemic encephalopathy (HIE) in Southern China and provide scientific basis for improving the quality of life for neonates. STUDY DESIGN A retrospective analysis of 306 cases with HIE neonates who were admitted during April 2015 to October 2017 was conducted. A total of 306 non-HIE patients admitted to the same hospital during the same period were also included as controls. The basic clinical characteristics were analyzed, and the risk factors for HIE were assessed by logistic regression analysis. RESULTS Univariate analysis showed that the differences in medicals during pregnancy, placenta previa, fetal distress during labor, cesarean section, amniotic fluid contamination, abnormal labor stage, and Apgar showed significantly different in the case group and the control group (p < 0.05). The multivariate logistic regression analysis revealed that the placenta previa, medicals during pregnancy, fetal distress, abnormal labor stage, Apgar's score, amniotic fluid contamination, and cesarean section were independent risk factors for HIE. CONCLUSION The placenta previa, medicals during pregnancy, fetal distress, and abnormal labor stage can increase the risk of HIE. Early detection, early diagnosis, and treatment might make great achievement in improving the life quality of HIE neonates.
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Affiliation(s)
- Junrong Wang
- Department of Laboratory Medicine, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Enfu Tao
- Department of Pediatrics, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Miaojun Mo
- Department of Pediatrics, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Weimin Ding
- Department of Obstetrics and Gynecology, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Junhui Yuan
- Department of Pediatrics, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Min Wang
- Department of Laboratory Medicine, Taizhou Women's and Children's Hospital, Zhejiang Province, China
| | - Changhua Zheng
- Department of Pediatrics, Wenling Maternal and Child Health Care Hospital, Zhejiang Province, China
| | - Haixiao Zheng
- Department of Laboratory Medicine, Taizhou Women's and Children's Hospital, Zhejiang Province, China
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18
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Evaluation of risk factors for neonatal hypoxic ischemic encephalopathy. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2021. [DOI: 10.21673/anadoluklin.951203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Yates N, Gunn AJ, Bennet L, Dhillon SK, Davidson JO. Preventing Brain Injury in the Preterm Infant-Current Controversies and Potential Therapies. Int J Mol Sci 2021; 22:ijms22041671. [PMID: 33562339 PMCID: PMC7915709 DOI: 10.3390/ijms22041671] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Preterm birth is associated with a high risk of morbidity and mortality including brain damage and cerebral palsy. The development of brain injury in the preterm infant may be influenced by many factors including perinatal asphyxia, infection/inflammation, chronic hypoxia and exposure to treatments such as mechanical ventilation and corticosteroids. There are currently very limited treatment options available. In clinical trials, magnesium sulfate has been associated with a small, significant reduction in the risk of cerebral palsy and gross motor dysfunction in early childhood but no effect on the combined outcome of death or disability, and longer-term follow up to date has not shown improved neurological outcomes in school-age children. Recombinant erythropoietin has shown neuroprotective potential in preclinical studies but two large randomized trials, in extremely preterm infants, of treatment started within 24 or 48 h of birth showed no effect on the risk of severe neurodevelopmental impairment or death at 2 years of age. Preclinical studies have highlighted a number of promising neuroprotective treatments, such as therapeutic hypothermia, melatonin, human amnion epithelial cells, umbilical cord blood and vitamin D supplementation, which may be useful at reducing brain damage in preterm infants. Moreover, refinements of clinical care of preterm infants have the potential to influence later neurological outcomes, including the administration of antenatal and postnatal corticosteroids and more accurate identification and targeted treatment of seizures.
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Affiliation(s)
- Nathanael Yates
- The Queensland Brain Institute, University of Queensland, St Lucia, QLD 4072, Australia;
- School of Human Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - Alistair J. Gunn
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Laura Bennet
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Simerdeep K. Dhillon
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Joanne O. Davidson
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
- Correspondence: ; Tel.: +64-9-373-7599 (ext. 89596)
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Placental origins of neonatal diseases: toward a precision medicine approach. Pediatr Res 2021; 89:377-383. [PMID: 33288874 DOI: 10.1038/s41390-020-01293-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 01/30/2023]
Abstract
The placenta is the single most reliable source for precise information on intrauterine environment, as well as maternal and fetal health. It mediates the physiology of two distinct yet highly interconnected individuals. The pathology that develops in the placenta, and the adaptations the placenta undergoes to mitigate this pathology, may influence the later life health of the mother and baby. Pathological placental examination provides a unique opportunity to explore and understand the intrauterine environment, as well as providing a record of events that may be associated with adverse pregnancy outcomes. A number of placental lesions have been described in association with various neonatal morbidities. The purpose of this review is to summarize the evidence for the association of placental pathologic lesions with neurodevelopmental outcomes infants with specific neonatal morbidities, including (1) neonatal encephalopathy, (2) bronchopulmonary dysplasia, (3) congenital heart diseases, and (4) autism spectrum disorders. For each of these disease processes, we will also propose specific research priorities in future studies. We conclude with a hospital-specific protocol for triaging which placentas should receive histological evaluation as a fundamental first step for the field of neuroplacentology to guide precision-based therapeutic approaches in the affected newborns. IMPACT: The purpose of this review is to summarize the evidence for placental origins of neonatal diseases. We propose specific research priorities in the field of neuroplacentology in future studies. We also present a targeted hospital-based approach for triaging which placentas should receive histological evaluation.
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Lv HY, Wang QL, Chen HY, You YJ, Ren PS, Li LX. Study on serum Tau protein level and neurodevelopmental outcome of placental abruption with neonatal hypoxic-ischemic encephalopathy. J Matern Fetal Neonatal Med 2020; 33:3887-3893. [PMID: 30821182 DOI: 10.1080/14767058.2019.1588878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The aim of this study was to explore differences in serum Tau protein levels and neurodevelopmental prognoses of placental abruption or umbilical cord around neck with hypoxic-ischemic encephalopathy (HIE).Methods: Forty neonates with moderate/severe HIE divided into placental abruption with HIE group (placental abruption with hypoxic-ischemic encephalopathy (PA-HIE) group) (n = 18) and umbilical cord around the neck with HIE group (umbilical cord around the neck with hypoxic-ischemic encephalopathy (UCAN-HIE) group) (n = 22). Healthy term newborns comprised the control group (n = 35). Serum Tau protein levels were measured using an enzyme-linked immunosorbent assay 24 hours (3.50 hours [1.00-24.00]) after birth. Neurodevelopment outcomes were assessed based on the Gesell Developmental Scale at 9 months of age.Results: Serum Tau protein levels were significantly higher in 40 cases (1013 pg/ml [538.04-1190.42]) than in the control group (106.41 pg/ml [64.55-154.71], p = .0001). Serum Tau protein levels in the PA-HIE group (1024.46 pg/ml [657.88-1190.42]) were significantly higher than those in the UCAN-HIE group (892.78 pg/ml [538.04-1179.50], p = .0149). The development quotient score in the PA-HIE group (67.0 [47.0-90.0]) was significantly lower than that in the UCAN-HIE group (81.5 [52.6-100.0]) (p = .0028). The component ratio of neurodevelopmental retardation in the PA-HIE group (44.45%) was significantly higher than that in the UCAN-HIE group (22.73%) (X2 = 13.3138, p = .0013).Conclusions: Compared with the UCAN-HIE group, the serum Tau protein level and the component ratio of neurodevelopmental retardation were significantly higher in the PA-HIE group.
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Affiliation(s)
- Hong-Yan Lv
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, PR China.,Department of Neonatal Pathology, Handan Maternal and Child Health Care Hospital of Handan, Handan, PR China
| | - Qiu-Li Wang
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, PR China
| | - Hui-Ying Chen
- Laboratory of Genetics, Handan Maternal and Child Health Care Hospital, Handan, PR China
| | - Yi-Jun You
- Laboratory of Genetics, Handan Maternal and Child Health Care Hospital, Handan, PR China
| | - Peng-Shun Ren
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, PR China
| | - Lian-Xiang Li
- Department of Neonatal Pathology, Handan Maternal and Child Health Care Hospital of Handan, Handan, PR China.,Department of Neural Development and Neural Pathology, Hebei University of Engineering School of Medicine, Handan, PR China
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Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis. Br J Anaesth 2020; 126:500-515. [PMID: 33218673 DOI: 10.1016/j.bja.2020.09.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Epidural analgesia is associated with intrapartum hyperthermia, and chorioamnionitis is associated with neonatal brain injury. However, it is not known if epidural hyperthermia is associated with neonatal brain injury. This systematic review and meta-analysis investigated three questions: (1) does epidural analgesia cause intrapartum hyperthermia, (2) is intrapartum hyperthermia associated with neonatal brain injury, and (3) is epidural-induced hyperthermia associated with neonatal brain injury? METHODS PubMed, ISI Web of Knowledge, The Cochrane Library, and Embase were searched from inception to January 2020 using Medical Subject Headings (MeSH) terms relating to epidural analgesia, hyperthermia, labour, and neonatal brain injury. Studies were reviewed independently for inclusion and quality by two authors (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach). Two meta-analyses were performed using the Mantel-Haenszel fixed effect method to generate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Forty-one studies were included for Question 1 (646 296 participants), 36 for Question 2 (11 866 021 participants), and two studies for Question 3 (297 113 participants). When the mode of analgesia was randomised, epidural analgesia was associated with intrapartum hyperthermia (OR: 4.21; 95% CI: 3.48-5.09). There was an association between intrapartum hyperthermia and neonatal brain injury (OR: 2.79; 95% CI: 2.54-2.3.06). It was not possible to quantify the association between epidural-induced hyperthermia and neonatal brain injury. CONCLUSIONS Epidural analgesia is a cause of intrapartum hyperthermia, and intrapartum hyperthermia of any cause is associated with neonatal brain injury. Further work is required to establish if epidural-induced hyperthermia is a cause of neonatal brain injury.
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Antepartum and intrapartum risk factors for neonatal hypoxic-ischemic encephalopathy: a systematic review with meta-analysis. Curr Opin Obstet Gynecol 2020; 31:410-417. [PMID: 31567446 DOI: 10.1097/gco.0000000000000581] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review literature about risk factors of neonatal hypoxic-ischemic encephalopathy (HIE). RECENT FINDINGS Search in PubMed, MEDLINE, Embase, Clinicaltrials.gov and reference lists from 1999 to 2018. INCLUSION CRITERIA study population composed of neonates who manifested HIE within 28 days from delivery, data reported as proportional rate. Studies were excluded if they included preterm pregnancies, postnatal conditions leading to HIE and/or fetal malformations, focused on a single risk factor, were not in English language. PRISMA guidelines were followed. Interstudies heterogeneity was assessed and a random/fixed models were generated as appropriate. Comparison between neonates with HIE vs. controls was performed by calculating odds ratio-95% confidence interval (OR-95% CI). Differences were significant if 95% CI did not encompass 1. Twelve articles were included. Fetuses with growth restriction (OR: 2.87; 95% CI: 1.77-4.67), nonreassuring cardiotocography (OR: 6.38; 95% CI: 2.56-15.93), emergency cesarean section (OR: 3.69; 95% CI: 2.75-4.96), meconium (OR: 3.76; 95% CI: 2.58-5.46) and chorioamnionitis (OR: 3.46: 95% CI: 2.07-5.79) were at higher risk of developing HIE. Nulliparity, gestational diabetes, hypertension, oligohydramnios, polyhydramnios, male sex, induction of labor, labor augmentation, premature rupture of membrane, and vacuum delivery were not significantly different. SUMMARY Neonatal HIE has multifactorial origin and its cause is often undetermined and not preventable.PROSPERO (Registration number: CRD42018106563).
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Reynolds AJ, Geary MP, Hayes BC. Intrapartum uterine activity and neonatal outcomes: a systematic review. BMC Pregnancy Childbirth 2020; 20:532. [PMID: 32919464 PMCID: PMC7488697 DOI: 10.1186/s12884-020-03219-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increased uterine activity (UA) may not allow adequate recovery time for foetal oxygenation. METHODS The aim of the study was to determine if increased UA during labour is associated with an increased risk of either short- or long-term neurological injury in term neonates, or with neonatal proxy measures of intrapartum hypoxia-ischemia. MEDLINE, CINAHL, and ClinicalTrials.gov were searched using the following terms: uterine activity, excessive uterine activity, XSUA, uterine hyperstimulation, and tachysystole. Any study that analysed the relationship between UA during term labour and neurological outcomes/selected proxy neurological outcomes was eligible for inclusion. Outcomes from individual studies were reported in tables and presented descriptively with odds ratios (OR) and 95% confidence intervals (CI) for dichotomous outcomes and means with standard deviations for continuous outcomes. Where group numbers were provided, ORs and their CIs were calculated according to Altman. MAIN RESULTS Twelve studies met the inclusion criteria. Seven studies featured umbilical artery pH as an individual outcome. Umbilical artery base excess and Apgar scores were both reported as individual outcomes in four studies. No study examined long term neurodevelopmental outcomes and only one study reported on encephalopathy as an outcome. The evidence for a relationship between UA and adverse infant outcomes was inconsistent. The reported estimated effect size varied from non-existent to clinically significant. CONCLUSIONS There is some evidence that increased UA may be a non-specific predictor of depressed neurological function in the newborn, but it is inconsistent and insufficient to support the conclusion that an association generally exists.
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Affiliation(s)
- Adam J Reynolds
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
| | - Michael P Geary
- Department of Obstetrics and Gynaecology, The Rotunda Hospital, Dublin, Ireland
| | - Breda C Hayes
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
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Ravichandran L, Allen VM, Allen AC, Vincer M, Baskett TF, Woolcott CG. Incidence, Intrapartum Risk Factors, and Prognosis of Neonatal Hypoxic-Ischemic Encephalopathy Among Infants Born at 35 Weeks Gestation or More. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1489-1497. [PMID: 33039315 DOI: 10.1016/j.jogc.2020.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Neonatal hypoxic-ischemic encephalopathy (HIE) is associated with neonatal mortality, acute neurological injury, and long-term neurodevelopmental disabilities; however, the association between intrapartum factors and HIE remains unclear. METHODS This population-based cohort study used linked obstetrical and newborn data derived from the Nova Scotia Atlee Perinatal Database (NSAPD, 1988-2015) and the AC Allen Perinatal Follow-Up Program Database (2006-2015) for all pregnancies with live, non-anomalous newborns ≥35 weeks gestation, not delivered by pre-labour cesarean section. Temporal trends in HIE incidence were described, and logistic regression estimated odds ratios (OR) with 95% confidence intervals (CI) for the association of intrapartum factors with HIE. RESULTS The NSAPD identified 227 HIE cases in the population of 226 711 deliveries from 1988 to 2015. Women with clinical chorioamnionitis in labour (OR 8.0; 95% CI 3.9-16), emergency cesarean delivery (OR 10; 95% CI 7.6-14), shoulder dystocia (OR 3.5; 95% CI 2.1-5.7), placental abruption (OR 18; 95% CI 11-29), and cord prolapse (OR 30; 95% CI 15-61) were more likely to have newborns with HIE. Two-thirds of newborns with HIE had an abnormal intrapartum fetal heart rate tracing. The mortality rate among infants with HIE was 27% by 3 years of age. Neurodevelopmental outcomes in the surviving infants were normal in 43% and showed severe developmental delay in 40%. CONCLUSION Overall, the rate of HIE was low in infants born at ≥35 weeks gestation. The identification of associated intrapartum factors should promote increased surveillance in these clinical situations and emphasize the importance of careful management to optimize newborn outcomes.
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Affiliation(s)
| | - Victoria M Allen
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, NS.
| | - Alexander C Allen
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, NS; Department of Pediatrics, Dalhousie University, Halifax, NS
| | - Michael Vincer
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, NS; Department of Pediatrics, Dalhousie University, Halifax, NS
| | - Thomas F Baskett
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, NS
| | - Christy G Woolcott
- Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, NS; Department of Pediatrics, Dalhousie University, Halifax, NS
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Placental pathology and neonatal brain MRI in a randomized trial of erythropoietin for hypoxic-ischemic encephalopathy. Pediatr Res 2020; 87:879-884. [PMID: 31261373 DOI: 10.1038/s41390-019-0493-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Newborns with hypoxic-ischemic encephalopathy (HIE) may exhibit abnormalities on placental histology. In this phase II clinical trial ancillary study, we hypothesized that placental abnormalities correlate with MRI brain injury and with response to treatment. METHODS Fifty newborns with moderate/severe encephalopathy who received hypothermia were enrolled in a double-blind, placebo-controlled trial of erythropoietin for HIE. A study pathologist reviewed all available clinical pathology reports to determine the presence of chronic abnormalities and acute chorioamnionitis. Neonatal brain MRIs were scored using a validated HIE scoring system. RESULTS Placental abnormalities in 19 of the 35 (54%) patients with available pathology reports included chronic changes (N = 13), acute chorioamnionitis (N = 9), or both (N = 3). MRI subcortical brain injury was less common in infants with a placental abnormality (26 vs. 69%, P = 0.02). Erythropoietin treatment was associated with a lower global brain injury score (median 2.0 vs. 11.5, P = 0.003) and lower rate of subcortical brain injury (33 vs. 90%, P = 0.01) among patients with no chronic placental abnormality but not in patients whose placentas harbored a chronic abnormality. CONCLUSION Erythropoietin treatment was associated with less brain injury only in patients whose placentas exhibited no chronic histologic changes. Placentas may provide clues to treatment response in HIE.
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Locatelli A, Lambicchi L, Incerti M, Bonati F, Ferdico M, Malguzzi S, Torcasio F, Calzi P, Varisco T, Paterlini G. Is perinatal asphyxia predictable? BMC Pregnancy Childbirth 2020; 20:186. [PMID: 32228514 PMCID: PMC7106720 DOI: 10.1186/s12884-020-02876-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of our study was to evaluate the association between perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) with the presence of ante and intrapartum risk factors and/or abnormal fetal heart rate (FHR) findings, in order to improve maternal and neonatal management. METHODS We did a prospective observational cohort study from a network of four hospitals (one Hub center with neonatal intensive care unit and three level I Spoke centers) between 2014 and 2016. Neonates of gestational age ≥ 35 weeks, birthweight ≥1800 g, without lethal malformations were included if diagnosed with perinatal asphyxia, defined as pH ≤7.0 or Base Excess (BE) ≤ - 12 mMol/L in Umbical Artery (UA) or within 1 h, 10 min Apgar < 5, or need for resuscitation > 10 min. FHR monitoring was classified in three categories according to the American College of Obstetricians and Gynecologists (ACOG). Pregnancies were divided into four classes: 1) low risk; 2) antepartum risk; 3) intrapartum risk; 4) and both ante and intrapartum risk. In the first six hours of life asphyxiated neonates were evaluated using the Thomson score (TS): if TS ≥ 5 neonates were transferred to Hub for further assessment; if TS ≥ 7 hypothermia was indicated. RESULTS Perinatal asphyxia occurred in 21.5‰ cases (321/14,896) and HIE in 1.1‰ (16/14,896). The total study population was composed of 281 asphyxiated neonates: 68/5152 (1.3%) born at Hub and 213/9744 (2.2%) at Spokes (p < 0.001, OR 0.59, 95% CI 0.45-0.79). 32/213 (15%) neonates were transferred from Spokes to Hub. Overall, 12/281 were treated with hypothermia. HIE occurred in 16/281 (5.7%) neonates: four grade I, eight grade II and four grade III. Incidence of HIE was not different between Hub and Spokes. Pregnancies resulting in asphyxiated neonates were classified as class 1) 1.1%, 2) 52.3%, 3) 3.2%, and 4) 43.4%. Sentinel events occurred in 23.5% of the cases and FHR was category II or III in 50.5% of the cases. 40.2% cases of asphyxia and 18.8% cases of HIE were not preceded by sentinel events or abnormal FHR. CONCLUSIONS We identified at least one risk factor associated with all cases of HIE and with most cases of perinatal asphyxia. In absence of risk factors, the probability of developing perinatal asphyxia resulted extremely low. FHR monitoring alone is not a reliable tool for detecting the probability of eventual asphyxia.
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Affiliation(s)
- Anna Locatelli
- Department of Obstetrics and Gynecology, ASST Vimercate, Carate B.za Hospital, University of Milano-Bicocca, Monza, Italy.
| | - Laura Lambicchi
- Department of Obstetrics and Gynecology, Fondazione MBBM, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Maddalena Incerti
- Department of Obstetrics and Gynecology, Fondazione MBBM, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Francesca Bonati
- Department of Obstetrics and Gynecology, ASST Vimercate, Carate B.za Hospital, University of Milano-Bicocca, Monza, Italy
| | - Massimo Ferdico
- Department of Obstetrics and Gynecology, ASST Vimercate, Vimercate Hospital, Vimercate, Italy
| | - Silvia Malguzzi
- Neonatal Intensive Care Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Ferruccio Torcasio
- Department of Pediatrics, ASST Vimercate, Carate B.za Hospital, Vimercate, Italy
| | - Patrizia Calzi
- Department of Pediatrics, ASST Vimercate, Vimercate Hospital, Vimercate, Italy
| | - Tiziana Varisco
- Department of Pediatrics, ASST Monza, Desio Hospital, Desio, Italy
| | - Giuseppe Paterlini
- Neonatal Intensive Care Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
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Antenatal and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy. J Perinatol 2020; 40:63-69. [PMID: 31611618 DOI: 10.1038/s41372-019-0531-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/09/2019] [Accepted: 08/27/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify antenatal and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy (HIE). STUDY DESIGN A single center, retrospective cohort study was conducted for 25,494 singleton births ≥36 weeks' gestation born between 2009 and 2016. Univariate and multivariate analyses were performed to identify risk factors for HIE. RESULTS Thirty-seven infants met HIE inclusion criteria. Independent antenatal risk factors included primigravida, previous fetal death/stillbirth, antidepressant use, illicit drug use, Rh sensitization, and adjusted gestational weight gain >13.6 kg. Independent intrapartum risk factors identified were placental abruption, ruptured uterus, moderate-to-heavy meconium stained amniotic fluid, and delivery by cesarean-section. An intrapartum risk factor was present in 70.3% of the HIE group compared with 29.6% of the non-HIE group. CONCLUSION Intrapartum period risk factors appear to be important for the development of HIE. Gestational weight gain may serve as an important modifiable factor to reduce the risk of HIE.
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Thornton PD, Campbell RT, Mogos MF, Klima CS, Parsson J, Strid M. Meconium aspiration syndrome: Incidence and outcomes using discharge data. Early Hum Dev 2019; 136:21-26. [PMID: 31295648 DOI: 10.1016/j.earlhumdev.2019.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Meconium aspiration syndrome (MAS) is a leading cause of morbidity and mortality among term, otherwise healthy newborns, yet population studies are rare. Definitions, outcomes and International Classification of Diseases (ICD) codes are heterogenous, complicating estimates of incidence, outcomes and risks. AIMS To measure population incidence, risks and outcomes of MAS by ICD codes. STUDY DESIGN Retrospective population study. SUBJECTS Kids Inpatient Database (KID) 2012, a nationally representative weighted sample of newborn discharges in the United States. OUTCOME MEASURES Incidence, demographic distribution, and comorbidity associated with MAS. RESULTS In 2012 there were 9295 weighted discharges diagnosed MAS with symptoms (2.49/1000) and 4304 cases without symptoms (1.15/1000). Newborns with symptoms had nearly twice the length of stay (LOS) (6.68 vs 3.65 days, p 0.001) and nearly 3 times the total charges ($44,473 versus $15,461, p < 0.001) as those without symptoms. Incidence of death was over four times higher (7.7/1000 vs 1.7/1000, p < 0.001), persistent pulmonary hypertension 3 times higher (57.6/1000 vs 15.8/1000, p < 0.001), and hypoxic ischemic encephalopathy 5 times higher (6.2/1000 vs 1.2/1000, p < 0.001) among MAS cases with respiratory symptoms than MAS cases without respiratory symptoms. Odds ratio of MAS with symptoms was 1.54 (95% CI 1.39-1.73) for black newborns compared to whites. CONCLUSIONS Discharge data are useful for providing population estimates of MAS incidence. Prior studies have used consolidated ICD codes for MAS (with and without respiratory symptoms), yet these represent very different disease severities. Combining MAS diagnoses with and without respiratory symptoms misrepresents incidence and disease severity, complicating comparisons of outcomes and prevention strategies.
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Affiliation(s)
- Patrick D Thornton
- University of Illinois, Chicago, 845 S. Damen Ave MC 802, Chicago, IL 60612, United States of America.
| | | | - Mulubrhan F Mogos
- University of Illinois, Chicago, 845 S. Damen Ave MC 802, Chicago, IL 60612, United States of America.
| | - Carrie S Klima
- University of Illinois, Chicago, 845 S. Damen Ave MC 802, Chicago, IL 60612, United States of America.
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Scheidegger S, Held U, Grass B, Latal B, Hagmann C, Brotschi B. Association of perinatal risk factors with neurological outcome in neonates with hypoxic ischemic encephalopathy. J Matern Fetal Neonatal Med 2019; 34:1020-1027. [PMID: 31117854 DOI: 10.1080/14767058.2019.1623196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Neonates exposed to perinatal insults typically present with hypoxic ischemic encephalopathy (HIE). The aim of our study was to analyze the association between known risk factors for HIE and the severity of encephalopathy after birth and neurological outcome in neonates during the first 4 d of life. METHODS Retrospective cohort study including 174 neonates registered between 2011 and 2013 in the National Asphyxia and Cooling Register of Switzerland. RESULTS None of the studied perinatal risk factors is associated with the severity of encephalopathy after birth. Fetal distress during labor (OR, 2.06; 95% CI, 1.02-4.25, p = .049) and neonatal head circumference (HC) above 10th percentile (p10) at birth (OR, 1.33; 95% CI, 1.05-1.69, p = .02) were associated with neurological benefit in the univariate analysis. Fetal distress on maternal admission for delivery was the only risk factor for neurological harm in the univariate (OR, 0.26; 95% CI, 0.12-0.57, p < .01) and the multivariate analysis (OR, 0.15; 95% CI, 0.04-0.67, p = .013). We identified two different patient scenarios: the probability for neurological benefit during the first 4 d of life was only 20% in neonates with the combination of all the following risk factors (gestational age >41 weeks, chorioamnionitis, fetal distress on maternal admission for delivery, fetal distress during labor, sentinel events during labor, HC below 10th percentile), whereas in the absence of these risk factors the probability for neurological benefit increased to 80%. CONCLUSIONS We identified a constellation of risk factors that influence neurological outcome in neonates with HIE during the first 4 d of life. These findings may help clinicians to counsel parents during the early neonatal period. (ClinicalTrials.gov NCT02800018).
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Affiliation(s)
- S Scheidegger
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | - U Held
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | - B Grass
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | - B Latal
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | - C Hagmann
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | - B Brotschi
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
| | -
- Department of Pediatric and Neonatal Intensive Care, University Childrens' Hospital Zurich, Zurich, Switzerland
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Parker SJ, Kuzniewicz M, Niki H, Wu YW. Antenatal and Intrapartum Risk Factors for Hypoxic-Ischemic Encephalopathy in a US Birth Cohort. J Pediatr 2018; 203:163-169. [PMID: 30270166 DOI: 10.1016/j.jpeds.2018.08.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/12/2018] [Accepted: 08/13/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify risk factors for hypoxic-ischemic encephalopathy (HIE) within a recent US birth cohort. STUDY DESIGN In a retrospective cohort study of 44 572 singleton infants ≥36 weeks of gestation born at Kaiser Permanente Northern California in 2008-2015, we identified all infants with HIE based on the presence of 3 inclusion criteria: clinical signs of neonatal encephalopathy, NICU admission, and either a 10-minute Apgar of ≤5 or a base excess of ≤-15 mmol/L. Neonatal acidemia was defined as a base excess of ≤-12 mmol/L. We ascertained antenatal and intrapartum complications from electronic records. Multivariable analysis was performed using logistic regression. RESULTS There were 45 infants (1.0 per 1000) with HIE and 197 (4.4 per 1000) with neonatal acidemia. Of the infants with HIE, 64% had an intrapartum complication consisting of a sentinel event (36%), clinical chorioamnionitis (40%), or both (11%). Risk factors for HIE on multivariable analysis were sentinel event (relative risk [RR], 16.1; 95% CI, 8.4-33) and clinical chorioamnionitis (RR, 5.2; 95% CI, 2.7-9.9). After removing the 16 infants with HIE who were exposed to a sentinel event from multivariate analysis, maternal age of ≥35 years (RR, 2.5; 95% CI, 1.1-5.6) and a urinary tract infection during pregnancy (RR, 2.6; 95% CI, 1.0-6.5) emerged as potential antenatal risk factors for HIE. CONCLUSIONS A significant proportion of HIE is preceded by a sentinel event, emphasizing the importance of developing improved methodologies to predict and prevent this perinatal complication. Strategies focused on reducing other complications such as clinical chorioamnionitis and/or maternal pyrexia may also improve our ability to prevent HIE.
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Affiliation(s)
- Sarah-Jane Parker
- Perinatal Research Unit, Division of Research, Kaiser Permanente, Oakland, CA
| | - Michael Kuzniewicz
- Perinatal Research Unit, Division of Research, Kaiser Permanente, Oakland, CA; Department of Pediatrics, University of California, San Francisco, CA
| | - Hamid Niki
- Perinatal Research Unit, Division of Research, Kaiser Permanente, Oakland, CA
| | - Yvonne W Wu
- Department of Pediatrics, University of California, San Francisco, CA; Department of Neurology, University of California, San Francisco, CA.
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Murray ML. Optimizing a Woman’s Capacity to Give Birth. INTERNATIONAL JOURNAL OF CHILDBIRTH 2018. [DOI: 10.1891/2156-5287.8.2.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dhillon SK, Lear CA, Galinsky R, Wassink G, Davidson JO, Juul S, Robertson NJ, Gunn AJ, Bennet L. The fetus at the tipping point: modifying the outcome of fetal asphyxia. J Physiol 2018; 596:5571-5592. [PMID: 29774532 DOI: 10.1113/jp274949] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022] Open
Abstract
Brain injury around birth is associated with nearly half of all cases of cerebral palsy. Although brain injury is multifactorial, particularly after preterm birth, acute hypoxia-ischaemia is a major contributor to injury. It is now well established that the severity of injury after hypoxia-ischaemia is determined by a dynamic balance between injurious and protective processes. In addition, mothers who are at risk of premature delivery have high rates of diabetes and antepartum infection/inflammation and are almost universally given treatments such as antenatal glucocorticoids and magnesium sulphate to reduce the risk of death and complications after preterm birth. We review evidence that these common factors affect responses to fetal asphyxia, often in unexpected ways. For example, glucocorticoid exposure dramatically increases delayed cell loss after acute hypoxia-ischaemia, largely through secondary hyperglycaemia. This critical new information is important to understand the effects of clinical treatments of women whose fetuses are at risk of perinatal asphyxia.
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Affiliation(s)
| | - Christopher A Lear
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Department of Physiology, University of Auckland, Auckland, New Zealand.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Guido Wassink
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Alistair J Gunn
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Department of Physiology, University of Auckland, Auckland, New Zealand
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Hayes BC, Doherty E, Grehan A, Madigan C, McGarvey C, Mulvany S, Matthews TG, King MD. Neurodevelopmental outcome in survivors of hypoxic ischemic encephalopathy without cerebral palsy. Eur J Pediatr 2018; 177:19-32. [PMID: 29063960 DOI: 10.1007/s00431-017-3028-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED To access outcome following hypoxic ischemic encephalopathy (HIE), survivors without cerebral palsy were invited for formal developmental assessment. Children aged ≥ 42 months were assessed using the NEPSY-2, Movement Assessment Battery for Children 2 (Movement ABC-2), Behavior Rating Inventory of Executive Function, and the Child Behavior Checklist. Children aged < 42 months were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition (BSITD-3). One hundred forty-six children attended for assessments [Grade 1 (112), Grade 2 (33), and Grade 3 (1)]. BSITD-3 did not identify significant rates of impairment on cognitive, motor, or language subtests. A significant proportion of children scored < 3rd percentile on the adaptive behavior scale. In older age groups, difficulties were seen in 16/24 NEPSY-2 subtests and on timed assessments using Movement ABC-2. Difficulties arose especially in the "control" aspects of cognition and behavior. Behavioral difficulties were common with internalizing problems predominating. There was a graded effect with grade 2 cases differing significantly from grade 1 cases. CONCLUSION Following HIE, children may experience attention, memory, and behavior difficulties which are not always evident at a young age. The adaptive behavior questionnaire may be a useful tool to select children requiring developmental surveillance beyond 2 years of age. What is known: • Diversity of outcome across grades of HIE is reported and few studies have looked at the milder consequences of HIE at school age. What is new: • Following HIE children may experience attention, memory, and behavior difficulties which are not always evident at a young age. • The adaptive behavior questionnaire may be a useful tool to select children requiring developmental surveillance beyond 2 years of age.
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Affiliation(s)
| | - Elaine Doherty
- The Children's University Hospital, Temple St, Dublin 1, Ireland
| | | | | | - Cliona McGarvey
- The Children's University Hospital, Temple St, Dublin 1, Ireland
| | | | | | - Mary D King
- The Children's University Hospital, Temple St, Dublin 1, Ireland.,UCD School of Medicine and Medical Science, Dublin, Ireland
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Torbenson VE, Tolcher MC, Nesbitt KM, Colby CE, El-Nashar SA, Gostout BS, Weaver AL, Mc Gree ME, Famuyide AO. Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: a case-controlled study. BMC Pregnancy Childbirth 2017; 17:415. [PMID: 29228911 PMCID: PMC5725836 DOI: 10.1186/s12884-017-1610-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/30/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Neonatal encephalopathy (NE) affects 2-4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE. METHODS Hospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case. RESULTS Twenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1-144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0-135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p < 0.001) were significantly associated with hypoxic ischemic encephalopathy. The presence of a category 3 fetal heart rate tracing in any of the four 15-min segments during the hour prior to delivery (28.0% versus 4.0%, p = 0.002) was more common among hypoxic ischemic encephalopathy cases. CONCLUSION Prolonged second stage of labor and the presence of meconium-stained amniotic fluid are risk factors for the development of HIE. Close scrutiny should be paid to labors that develop these features especially in the presence of an abnormal fetal heart tracing. Acute events also account for a substantial number of HIE cases and health systems should develop programs that can optimize the response to these emergencies.
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Affiliation(s)
- Vanessa E Torbenson
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mary Catherine Tolcher
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kate M Nesbitt
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher E Colby
- Department of Pediatric and Adolescent Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Sherif A El-Nashar
- Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland, OH, USA
| | - Bobbie S Gostout
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, MN, USA
| | - Michaela E Mc Gree
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, MN, USA
| | - Abimbola O Famuyide
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA.
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[Risk factors associated with the development of perinatal asphyxia in neonates at the Hospital Universitario del Valle, Cali, Colombia, 2010-2011]. BIOMEDICA 2017; 37:51-56. [PMID: 28527266 DOI: 10.7705/biomedica.v37i1.2844] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/01/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Perinatal asphyxia is one of the main causes of perinatal mortality and morbidity worldwide and it generates high costs for health systems; however, it has modifiable risk factors. OBJECTIVE To identify the risk factors associated with the development of perinatal asphyxia in newborns at Hospital Universitario del Valle, Cali, Colombia. MATERIALS AND METHODS Incident cases and concurrent controls were examined. Cases were defined as newborns with moderate to severe perinatal asphyxia who were older than or equal to 36 weeks of gestational age, needed advanced resuscitation and presented one of the following: early neurological disorders, multi-organ commitment or a sentinel event. The controls were newborns without asphyxia who were born one week apart from the case at the most and had a comparable gestational age. Patients with major congenital malformations and syndromes were excluded. RESULTS Fifty-six cases and 168 controls were examined. Premature placental abruption (OR=41.09; 95%CI: 4.61-366.56), labor with a prolonged expulsive phase (OR=31.76; 95%CI: 8.33-121.19), lack of oxytocin use (OR=2.57; 95% CI: 1.08 - 6.13) and mothers without a partner (OR=2.56; 95% CI: 1.21-5.41) were risk factors for the development of perinatal asphyxia in the study population. Social difficulties were found in a greater proportion among the mothers of cases. CONCLUSIONS Proper control and monitoring of labor, development of a thorough partograph, and active searches are recommended to ensure that all pregnant women have adequate prenatal care with the provision of social support to reduce the frequency and negative impact of perinatal asphyxia.
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Diaz J, Abiola S, Kim N, Avaritt O, Flock D, Yu J, Northington FJ, Chavez-Valdez R. Therapeutic Hypothermia Provides Variable Protection against Behavioral Deficits after Neonatal Hypoxia-Ischemia: A Potential Role for Brain-Derived Neurotrophic Factor. Dev Neurosci 2017; 39:257-272. [PMID: 28196356 DOI: 10.1159/000454949] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite treatment with therapeutic hypothermia (TH), infants who survive hypoxic ischemic (HI) encephalopathy (HIE) have persistent neurological abnormalities at school age. Protection by TH against HI brain injury is variable in both humans and animal models. Our current preclinical model of hypoxia-ischemia (HI) and TH displays this variability of outcomes in neuropathological and neuroimaging end points with some sexual dimorphism. The detailed behavioral phenotype of this model is unknown. Whether there is sexual dimorphism in certain behavioral domains is also not known. Brain-derived neurotrophic factor (BDNF) supports neuronal cell survival and repair but may also be a marker of injury. Here, we characterize the behavioral deficits after HI and TH stratified by sex, as well as late changes in BDNF and its correlation with memory impairment. METHODS HI was induced in C57BL6 mice on postnatal day 10 (p10) (modified Vannucci model). Mice were randomized to TH (31°C) or normothermia (NT, 36°C) for 4 h after HI. Controls were anesthesia-exposed, age- and sex-matched littermates. Between p16 and p39, growth was followed, and behavioral testing was performed including reflexes (air righting, forelimb grasp and negative geotaxis) and sensorimotor, learning, and memory skills (open field, balance beam, adhesive removal, Y-maze tests, and object location task [OLT]). Correlations between mature BDNF levels in the forebrain and p42 memory outcomes were studied. RESULTS Both male and female HI mice had an approximately 8-12% lower growth rate (g/day) than shams (p ≤ 0.01) by p39. TH ameliorated this growth failure in females but not in males. In female mice, HI injury prolonged the time spent at the periphery (open field) at p36 (p = 0.004), regardless of treatment. TH prevented motor impairments in the balance beam and adhesive removal tests in male and female mice, respectively (p ≤ 0.05). Male and female HI mice visited the new arm of the Y-maze 12.5% (p = 0.05) and 10% (p = 0.03) less often than shams, respectively. Male HI mice also had 35% lower exploratory preference score than sham (p ≤ 0.001) in the OLT. TH did not prevent memory impairments found with Y-maze testing or OLT in either sex (p ≤ 0.01) at p26. At p42, BDNF levels in the forebrain ipsilateral to the HI insult were 1.7- to 2-fold higher than BDNF levels in the sham forebrain, and TH did not prevent this increase. Higher BDNF levels in the forebrain ipsilateral to the insult correlated with worse performance in the Y-maze in both sexes and in OLT in male mice (p = 0.01). CONCLUSIONS TH provides benefit in specific domains of behavior following neonatal HI. In general, these benefits accrued to both males and females, but not in all areas. In some domains, such as memory, no benefit of TH was found. Late differences in individual BDNF levels may explain some of these findings.
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Affiliation(s)
- Johana Diaz
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Mehrabadi A, Lisonkova S, Joseph KS. Heterogeneity of respiratory distress syndrome: risk factors and morbidity associated with early and late gestation disease. BMC Pregnancy Childbirth 2016; 16:281. [PMID: 27678336 PMCID: PMC5039795 DOI: 10.1186/s12884-016-1085-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 09/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although respiratory distress syndrome (RDS) is considered a disease of prematurity, there is evidence to suggest heterogeneity between early and late gestation RDS. We examined the epidemiologic features of RDS occurring at early and late gestation. METHODS We conducted a retrospective cohort study including live births in the United States in 2005-06, with information obtained from the National Center for Health Statistics. Early (<32 weeks) and late gestation RDS (≥39 weeks) were contrasted in terms of risk factors and associations with pregnancy complications, obstetric intervention and co-morbidity. Logistic regression was used to quantify the effects of risk factors, while other associations were quantified descriptively. RESULTS There were 27,971 RDS cases, yielding an incidence of 6.4 per 1000 live births. Early and late gestation RDS differed in terms of risk factors, with factors such as multi-fetal gestation more strongly associated with early (adjusted odds ratio [aOR] 11.6, 95 % confidence interval 11.0-12.2) compared with late gestation RDS (aOR 3.66, 95 % confidence interval 2.68-4.98). The morbidity correlates of early and late gestation RDS also differed substantially; neonatal seizures were less strongly associated with early (OR 5.90, 95 % confidence interval 3.67-9.47) compared with late gestation RDS (OR 33.1, 95 % confidence interval 27.2-40.2), while meconium aspiration syndrome was not significantly associated with early gestation RDS (OR 1.87, 95 % confidence interval 0.94-3.72) and very strongly associated with late gestation RDS (OR 39.8, 95 % confidence interval 34.7-45.6). CONCLUSIONS Differences in risk factors and morbidity correlates of early and late gestation RDS suggest that these entities represent two distinct diseases.
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Affiliation(s)
- Azar Mehrabadi
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada. .,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave. West, Montreal, QC, H3A 1A2, Canada.
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Lee J, Romero R, Lee KA, Kim EN, Korzeniewski SJ, Chaemsaithong P, Yoon BH. Meconium aspiration syndrome: a role for fetal systemic inflammation. Am J Obstet Gynecol 2016; 214:366.e1-9. [PMID: 26484777 PMCID: PMC5625352 DOI: 10.1016/j.ajog.2015.10.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/26/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Meconium aspiration syndrome (MAS) is a leading cause of morbidity and mortality in term infants. Meconium-stained amniotic fluid (MSAF) occurs in approximately 1 of every 7 pregnancies, but only 5% of neonates exposed to MSAF develop MAS. Why some infants exposed to meconium develop MAS while others do not is a fundamental question. Patients with MSAF have a higher frequency of intraamniotic inflammation/infection than those with clear fluid. We propose that fetal systemic inflammation is a risk factor for the development of MAS in patients with MSAF. OBJECTIVE We sought to investigate whether intraamniotic inflammation and funisitis, the histopathologic landmark of a fetal inflammatory response, predispose to MAS. STUDY DESIGN A prospective cohort study was conducted from 1995 through 2009. Amniotic fluid (AF) samples (n = 1281) were collected at the time of cesarean delivery from women who delivered singleton newborns at term (gestational age ≥38 weeks). Intraamniotic inflammation was diagnosed if the AF concentration of matrix metalloproteinase-8 was >23 ng/mL. Funisitis was diagnosed by histologic examination if inflammation was present in the umbilical cord. RESULTS The prevalence of MSAF was 9.2% (118/1281), and 10.2% (12/118) of neonates exposed to MSAF developed MAS. There were no significant differences in the median gestational age or umbilical cord arterial pH at birth between neonates who developed MAS and those who did not (each P > .1). Mothers whose newborns developed MAS had a higher median of AF matrix metalloproteinase-8 (456.8 vs 157.2 ng/mL, P < .05). Newborns exposed to intraamniotic inflammation had a higher rate of MAS than those who were not exposed to intraamniotic inflammation [13.0% (10/77) vs 0% (0/32), P = .03], as did those exposed to funisitis [31.3% (5/16) vs 7.3% (6/82); relative risk, 4.3; 95% confidence interval, 1.5-12.3]. Among the 89 newborns for whom both AF and placental histology were available, MAS was more common in patients with both intraamniotic inflammation and funisitis than in those without intraamniotic inflammation and funisitis [28.6% (4/14) vs 0% (0/28), P = .009], while the rate of MAS did not show a significant difference between patients with intraamniotic inflammation alone (without funisitis) and those without intraamniotic inflammation and funisitis [10.9% (5/46) vs 0% (0/28)]. CONCLUSION The combination of intraamniotic inflammation with fetal systemic inflammation is an important antecedent of MAS. This concept has implications for the understanding of the mechanisms of disease responsible for MAS and for the development of prognostic models and therapeutic interventions for this disorder.
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Affiliation(s)
- JoonHo Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Kyung A Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Na Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Steven J Korzeniewski
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Ragusa A, Gizzo S, Noventa M, Ferrazzi E, Deiana S, Svelato A. Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term. Arch Gynecol Obstet 2016; 294:753-61. [PMID: 26924640 DOI: 10.1007/s00404-016-4046-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 02/09/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor. METHODS Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the "action line" in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention. RESULTS Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns). CONCLUSION Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.
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Affiliation(s)
- Antonio Ragusa
- Dipartimento Materno Infantile, U.O.C. di Ginecologia e Ostetricia, Massa Carrara Hospital, Via Enrico Mattei 21, 54100, Massa Carrara, Italy.
| | - Salvatore Gizzo
- Dipartimento di Salute della Donna e del Bambino, U.O.C. di Ginecologia e Ostetricia, University of Padua, Via Giustiniani 3, 35128, Padua, Italy
| | - Marco Noventa
- Dipartimento di Salute della Donna e del Bambino, U.O.C. di Ginecologia e Ostetricia, University of Padua, Via Giustiniani 3, 35128, Padua, Italy
| | - Enrico Ferrazzi
- Department of Woman, Mother and Newborn, School of Medicine, Ospedale "V. Buzzi", Milan, Italy
| | - Sara Deiana
- Department of Obstetrics and Gynaecology, San Giovanni di Dio General Hospital, University of Cagliari, Cagliari, Italy
| | - Alessandro Svelato
- Department of Obstetrics and Gynaecology, Carlo Poma General Hospital, Mantua, Italy
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Hayes BC, Ryan S, McGarvey C, Mulvany S, Doherty E, Grehan A, Madigan C, Matthews T, King MD. Brain magnetic resonance imaging and outcome after hypoxic ischaemic encephalopathy. J Matern Fetal Neonatal Med 2015; 29:777-82. [PMID: 25754207 DOI: 10.3109/14767058.2015.1018167] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To correlate pattern of injury on neonatal brain magnetic resonance imaging (MRI) with outcome in infants ≥36 + 0 weeks gestation with hypoxic ischaemic encephalopathy. METHODS Prospective cohort study. Images were blindly reviewed. Children were assessed using a variety of standardised assessments. RESULTS MRI brain was performed on 88 infants. Follow up was available in 73(83%) infants. Eight of 25(32%) children with normal imaging had below normal assessment scores. Eight infants (12%) had isolated punctate white matter lesions and five of these had abnormal assessment scores. Death and cerebral palsy were seen only in children with imaging scores ≥3 on basal ganglia/thalami (BGT) score or ≥4 on watershed score. No developmental concerns were raised in 3/7(43%) infants with isolated watershed injury. Ten of 13(77%) infants with isolated BGT injury died or developed cerebral palsy. All 23 children with posterior limb of the internal capsule (PLIC) injury displayed developmental difficulties. CONCLUSIONS Almost one-third of infants with a normal MRI brain may be at risk of developmental problems. Punctate foci of white matter injury are common and not always benign. PLIC involvement is usually associated with neurological sequelae including isolated cognitive deficits. Worst outcomes are associated with basal ganglia injury.
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Affiliation(s)
| | - Stephanie Ryan
- b The Children's University Hospital , Dublin , Ireland , and
| | - Cliona McGarvey
- b The Children's University Hospital , Dublin , Ireland , and
| | | | - Elaine Doherty
- b The Children's University Hospital , Dublin , Ireland , and
| | | | - Cathy Madigan
- b The Children's University Hospital , Dublin , Ireland , and
| | | | - Mary D King
- b The Children's University Hospital , Dublin , Ireland , and.,c School of Medicine and Medical Science, University College , Dublin , Ireland
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Schifrin BS, Soliman M, Koos B. Litigation related to intrapartum fetal surveillance. Best Pract Res Clin Obstet Gynaecol 2015; 30:87-97. [PMID: 26227999 DOI: 10.1016/j.bpobgyn.2015.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022]
Abstract
The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention ("rescue") predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of "rescue", but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.
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Affiliation(s)
- Barry S Schifrin
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Mohamed Soliman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Brian Koos
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Mcintyre S, Badawi N, Blair E, Nelson KB. Does aetiology of neonatal encephalopathy and hypoxic-ischaemic encephalopathy influence the outcome of treatment? Dev Med Child Neurol 2015; 57 Suppl 3:2-7. [PMID: 25800486 DOI: 10.1111/dmcn.12725] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2014] [Indexed: 12/21/2022]
Abstract
Neonatal encephalopathy, a clinical syndrome affecting term-born and late preterm newborn infants, increases the risk of perinatal death and long-term neurological morbidity, especially cerebral palsy. With the advent of therapeutic hypothermia, a treatment designed for hypoxic or ischaemic injury, associated mortality and morbidity rates have decreased. Unfortunately, only about one in eight neonates (95% confidence interval) who meet eligibility criteria for therapeutic cooling apparently benefit from the treatment. Studies of infants in representative populations indicate that neonatal encephalopathy is a potential result of a variety of antecedents and that asphyxial complications at birth account for only a small percentage of neonatal encephalopathy. In contrast, clinical case series suggest that a large proportion of neonatal encephalopathy is hypoxic or ischaemic, and trials of therapeutic hypothermia are specifically designed to include only infants exposed to hypoxia or ischaemia. This review addresses the differences, definitional and methodological, between infants studied and investigations undertaken, in population studies compared with cooling trials. It raises the question if there may be subgroups of infants with a clinical diagnosis of hypoxic-ischaemic encephalopathy (HIE) in whom the pathobiology of neonatal neurological depression is not fundamentally hypoxic or ischaemic and, therefore, for whom cooling may not be beneficial. In addition, it suggests approaches to future trials of cooling plus adjuvant therapy that may contribute to further improvement of care for these vulnerable neonates.
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Affiliation(s)
- Sarah Mcintyre
- Cerebral Palsy Alliance, University of Notre Dame, Darlinghurst, NSW, Australia
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Wayock CP, Meserole RL, Saria S, Jennings JM, Huisman TAGM, Northington FJ, Graham EM. Perinatal risk factors for severe injury in neonates treated with whole-body hypothermia for encephalopathy. Am J Obstet Gynecol 2014; 211:41.e1-8. [PMID: 24657795 PMCID: PMC4809753 DOI: 10.1016/j.ajog.2014.03.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/21/2014] [Accepted: 03/14/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Our objective was to identify perinatal risk factors that are available within 1 hour of birth that are associated with severe brain injury after hypothermia treatment for suspected hypoxic-ischemic encephalopathy. STUDY DESIGN One hundred nine neonates at ≥35 weeks' gestation who were admitted from January 2007 to September 2012 with suspected hypoxic-ischemic encephalopathy were treated with whole-body hypothermia; 98 of them (90%) underwent brain magnetic resonance imaging (MRI) at 7-10 days of life. Eight neonates died before brain imaging. Neonates who had severe brain injury, which was defined as death or abnormal MRI results (cases), were compared with surviving neonates with normal MRI (control subjects). Logistic regression models were used to identify risk factors that were predictive of severe injury. RESULTS Cases and control subjects did not differ with regard to gestational age, birthweight, mode of delivery, or diagnosis of nonreassuring fetal heart rate before delivery. Cases were significantly (P < .05) more likely to have had an abruption, a cord and neonatal arterial gas level that showed metabolic acidosis, lower platelet counts, lower glucose level, longer time to spontaneous respirations, intubation, chest compressions in the delivery room, and seizures. In multivariable logistic regression, lower initial neonatal arterial pH (P = .004), spontaneous respiration at >30 minutes of life (P = .002), and absence of exposure to oxytocin (P = .033) were associated independently with severe injury with 74.3% sensitivity and 74.4% specificity. CONCLUSION Worsening metabolic acidosis at birth, longer time to spontaneous respirations, and lack of exposure to oxytocin correlated with severe brain injury in neonates who were treated with whole-body hypothermia. These risk factors may help quickly identify neonatal candidates for time-sensitive investigational therapies for brain neuroprotection.
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Affiliation(s)
- Christopher P Wayock
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachel L Meserole
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Suchi Saria
- Departments of Computer Science and Health Policy and Management, Institute of Computational Medicine, Armstrong Institute for Patient Safety and Quality, Center for Population Health Information Technology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jacky M Jennings
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD; Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thierry A G M Huisman
- Neurosciences Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics; and Division of Pediatric Radiology, Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances J Northington
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD; Neurosciences Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ernest M Graham
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD; Neurosciences Intensive Care Nursery, Johns Hopkins University School of Medicine, Baltimore, MD
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Hayakawa M, Ito Y, Saito S, Mitsuda N, Hosono S, Yoda H, Cho K, Otsuki K, Ibara S, Terui K, Masumoto K, Murakoshi T, Nakai A, Tanaka M, Nakamura T. Incidence and prediction of outcome in hypoxic-ischemic encephalopathy in Japan. Pediatr Int 2014; 56:215-21. [PMID: 24127879 PMCID: PMC4491348 DOI: 10.1111/ped.12233] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 09/27/2013] [Accepted: 10/04/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) is one of the most critical pathologic conditions in neonatal medicine due to the potential for neurological deficits in later life. We investigated the incidence of term infants with moderate or severe HIE in Japan and identified prognostic risk factors for poor outcome in HIE. METHODS Data on 227 infants diagnosed with moderate or severe HIE and born between January and December 2008 were collected via nationwide surveys from 263 responding hospitals. Using logistic regression, we examined the relationship between maternal, antepartum, intrapartum, and neonatal risk factors and clinical outcome at 18 months following birth. RESULTS In Japan, the incidence of moderate or severe HIE was 0.37 per 1000 term live births. Outborn births, low Apgar score at 5 min, use of epinephrine, and low cord blood pH were intrapartum factors significantly associated with neurodevelopmental delay and death at 18 months. Serum lactate, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase (all, P < 0.001) and creatine kinase (P = 0.002) were significantly higher in infants with poor outcome compared to those with favorable outcomes. Abnormal brain magnetic resonance imaging (MRI), an important prognostic factor, was significantly associated with poor outcome (odds ratio, 11.57; 95% confidence interval: 5.66-23.64; P < 0.001). CONCLUSIONS Risk factors predicting poor outcome in HIE include outborn birth, low Apgar score at 5 min, use of epinephrine, laboratory abnormalities, and abnormal MRI findings.
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Affiliation(s)
- Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
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Romero R, Yoon BH, Chaemsaithong P, Cortez J, Park CW, Gonzalez R, Behnke E, Hassan SS, Gotsch F, Yeo L, Chaiworapongsa T. Secreted phospholipase A2 is increased in meconium-stained amniotic fluid of term gestations: potential implications for the genesis of meconium aspiration syndrome. J Matern Fetal Neonatal Med 2014; 27:975-83. [PMID: 24063538 DOI: 10.3109/14767058.2013.847918] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Meconium-stained amniotic fluid (MSAF) represents the passage of fetal colonic content into the amniotic cavity. Meconium aspiration syndrome (MAS) is a complication that occurs in a subset of infants with MSAF. Secreted phospholipase A2 (sPLA2) is detected in meconium and is implicated in the development of MAS. The purpose of this study was to determine if sPLA2 concentrations are increased in the amniotic fluid of women in spontaneous labor at term with MSAF. MATERIALS AND METHODS This was a cross-sectional study of patients in spontaneous term labor who underwent amniocentesis (n = 101). The patients were divided into two study groups: (1) MSAF (n = 61) and (2) clear fluid (n = 40). The presence of bacteria and endotoxin as well as interleukin-6 (IL-6) and sPLA2 concentrations in the amniotic fluid were determined. Statistical analyses were performed to test for normality and bivariate analysis. The Spearman correlation coefficient was used to study the relationship between sPLA2 and IL-6 concentrations in the amniotic fluid. RESULTS Patients with MSAF have a higher median sPLA2 concentration (ng/mL) in amniotic fluid than those with clear fluid [1.7 (0.98-2.89) versus 0.3 (0-0.6), p < 0.001]. Among patients with MSAF, those with either microbial invasion of the amniotic cavity (MIAC, defined as presence of bacteria in the amniotic cavity), or bacterial endotoxin had a significantly higher median sPLA2 concentration (ng/mL) in amniotic fluid than those without MIAC or endotoxin [2.4 (1.7-6.0) versus 1.7 (1.3-2.5), p < 0.05]. There was a positive correlation between sPLA2 and IL-6 concentrations in the amniotic fluid (Spearman Rho = 0.3, p < 0.05). CONCLUSION MSAF that contains bacteria or endotoxin has a higher concentration of sPLA2, and this may contribute to induce lung inflammation when meconium is aspirated before birth.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS , Bethesda, MD and Detroit, MI , USA
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Romero R, Yoon BH, Chaemsaithong P, Cortez J, Park CW, Gonzalez R, Behnke E, Hassan SS, Chaiworapongsa T, Yeo L. Bacteria and endotoxin in meconium-stained amniotic fluid at term: could intra-amniotic infection cause meconium passage? J Matern Fetal Neonatal Med 2013; 27:775-88. [PMID: 24028637 DOI: 10.3109/14767058.2013.844124] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Meconium-stained amniotic fluid (MSAF) is a common occurrence among women in spontaneous labor at term, and has been associated with adverse outcomes in both mother and neonate. MSAF is a risk factor for microbial invasion of the amniotic cavity (MIAC) and preterm birth among women with preterm labor and intact membranes. We now report the frequency of MIAC and the presence of bacterial endotoxin in the amniotic fluid of patients with MSAF at term. MATERIALS AND METHODS We conducted a cross-sectional study including women in presumed preterm labor because of uncertain dates who underwent amniocentesis, and were later determined to be at term (n = 108). Patients were allocated into two groups: (1) MSAF (n = 66) and (2) clear amniotic fluid (n = 42). The presence of bacteria was determined by microbiologic techniques, and endotoxin was detected using the Limulus amebocyte lysate (LAL) gel clot assay. Statistical analyses were performed to test for normality and bivariate comparisons. RESULTS Bacteria were more frequently present in patients with MSAF compared to those with clear amniotic fluid [19.6% (13/66) versus 4.7% (2/42); p < 0.05]. The microorganisms were Gram-negative rods (n = 7), Ureaplasma urealyticum (n = 4), Gram-positive rods (n = 2) and Mycoplasma hominis (n = 1). The LAL gel clot assay was positive in 46.9% (31/66) of patients with MSAF, and in 4.7% (2/42) of those with clear amniotic fluid (p < 0.001). After heat treatment, the frequency of a positive LAL gel clot assay remained higher in the MSAF group [18.1% (12/66) versus 2.3% (1/42), p < 0.05]. Median amniotic fluid IL-6 concentration (ng/mL) was higher [1.3 (0.7-1.9) versus 0.6 (0.3-1.2), p = 0.04], and median amniotic fluid glucose concentration (mg/dL) was lower [6 (0-8.9) versus 9 (7.4-12.6), p < 0.001] in the MSAF group, than in those with clear amniotic fluid. CONCLUSION MSAF at term was associated with an increased incidence of MIAC. The index of suspicion for an infection-related process in postpartum women and their neonates should be increased in the presence of MSAF.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS , Bethesda, MD and Detroit, MI , USA
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