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Abiramalatha T, Bandyopadhyay T, Ramaswamy VV, Shaik NB, Thanigainathan S, Pullattayil AK, Amboiram P. Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence. Pediatr Neurol 2021; 124:51-71. [PMID: 34537463 DOI: 10.1016/j.pediatrneurol.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/20/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity. METHODS Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL. CONCLUSION Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Prakash Amboiram
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Camfferman FA, de Goederen R, Govaert P, Dudink J, van Bel F, Pellicer A, Cools F. Diagnostic and predictive value of Doppler ultrasound for evaluation of the brain circulation in preterm infants: a systematic review. Pediatr Res 2020; 87:50-58. [PMID: 32218536 PMCID: PMC7098887 DOI: 10.1038/s41390-020-0777-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Very and extremely preterm infants frequently have brain injury-related long-term neurodevelopmental problems. Altered perfusion, for example, seen in the context of a hemodynamically significant patent ductus arteriosus (PDA), has been linked to injury of the immature brain. However, a direct relation with outcome has not been reviewed systematically. METHODS A systematic review was conducted to provide an overview of the value of different cerebral arterial blood flow parameters assessed by Doppler ultrasound, in relation to brain injury, to predict long-term neurodevelopmental outcome in preterm infants. RESULTS In total, 23 studies were included. Because of heterogeneity of studies, a meta-analysis of results was not possible. All included studies on resistance index (RI) showed significantly higher values in subjects with a hemodynamically significant PDA. However, absolute differences in RI values were small. Studies using Doppler parameters to predict brain injury and long-term neurodevelopmental outcome were inconsistent. DISCUSSION There is no clear evidence to support the routine determination of RI or other Doppler parameters in the cerebral arteries to predict brain injury and long-term neurodevelopmental outcome in the preterm infant. However, there is evidence that elevated RI can point to the presence of a hemodynamically significant PDA.
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Affiliation(s)
- Fleur A Camfferman
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Robbin de Goederen
- Dutch Craniofacial Centre Rotterdam, Department of Plastic and Reconstructive Surgery, Erasmus Medical Center University, Rotterdam, The Netherlands
| | - Paul Govaert
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, ZNA Middelheim, Antwerp, Belgium
- Department of Rehabilitation and Physical Therapy, Gent University Hospital, Gent, Belgium
| | - Jeroen Dudink
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Lu HY, Zhang Q, Wang QX, Lu JY. Contribution of Histologic Chorioamnionitis and Fetal Inflammatory Response Syndrome to Increased Risk of Brain Injury in Infants With Preterm Premature Rupture of Membranes. Pediatr Neurol 2016; 61:94-98.e1. [PMID: 27353694 DOI: 10.1016/j.pediatrneurol.2016.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To determine the association of histologic chorioamnionitis (HCA) and fetal inflammatory response syndrome (FIRS) with brain injuries in infants born to mothers with preterm premature rupture of membranes. METHODS A total of 103 singleton infants born to mothers with preterm premature rupture of membranes were enrolled. The placental inflammation was confirmed by HCA, and FIRS was defined in fetuses with preterm labor and an elevation of the fetal plasma interleukin-6 concentration. Examination of brain images was conducted to confirm the existence of brain injuries. Based on placental HCA and umbilical cord blood interleukin-6 level, all patients were divided into three groups: HCA(-)FIRS(+), HCA(+)FIRS(-), and HCA(+)FIRS(+). RESULTS Among all infants with preterm premature rupture of membranes, 53.40% were exposed to HCA, 20.38% experienced FIRS, and the overall incidence of brain injuries was 38.83%. The incidence of brain injury in HCA(-)FIRS(+), HCA(+)FIRS(-), and HCA(+)FIRS(+) groups were 20.83%, 41.18%, and 76.19%, respectively. HCA at the advanced grades and stages was associated with increased risk of brain injury. Umbilical cord blood levels of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), and granulocyte-colony stimulating factor (G-CSF) in premature infants with brain injuries were significantly higher than in those without brain injuries. Infants diagnosed with both HCA and FIRS showed significantly higher levels of IL-8, TNF-α, and G-CSF than those with HCA alone. CONCLUSIONS Preterm infants exposed to severe chorioamnionitis had an increased risk of brain injury. IL-6, IL-8, TNF-α, and G-CSF in cord blood were associated with brain injuries in preterm infants and may be used as extradiagnostic criteria.
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Affiliation(s)
- Hong-Yan Lu
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China.
| | - Qiang Zhang
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Qiu-Xia Wang
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Jun-Ying Lu
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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Maxwell JR, Denson JL, Joste NE, Robinson S, Jantzie LL. Combined in utero hypoxia-ischemia and lipopolysaccharide administration in rats induces chorioamnionitis and a fetal inflammatory response syndrome. Placenta 2015; 36:1378-84. [PMID: 26601766 DOI: 10.1016/j.placenta.2015.10.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/16/2015] [Accepted: 10/12/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Preterm birth is a major cause of infant morbidity and long-term disability, and is associated with numerous central nervous system (CNS) deficits. Infants exposed to intrauterine inflammation, specifically chorioamnionitis, are at risk for very early preterm birth and neurological complications including cerebral palsy, epilepsy, and behavioral and cognitive deficits. However, placenta-brain axis abnormalities and their relationship to subsequent permanent CNS injury remain poorly defined. METHODS Intrauterine injury was induced in rats on embryonic day 18 (E18) by transient systemic hypoxia-ischemia (TSHI) and intra-amniotic lipopolysaccharide (LPS) injection. Placenta, brain and serum were collected from E19 to postnatal day 0 (P0). Histology, TUNEL staining, western blot and multiplex immunoassays were used to quantify placental and brain abnormalities, and fetal serum cytokine levels. RESULTS Prenatal TSHI + LPS caused acute and subacute placental injury hallmarked by inflammatory infiltrate, edema, hemorrhage and cell death along with placental increases in IL-1β and TNFα. TSHI + LPS increased a diverse array of circulating inflammatory proteins including IL-1β, TNFα, IL-6, IL-10, IL-4, IFNγ and CXCL1, both immediately after TSHI + LPS and in live born pups. CNS inflammation was characterized by increased CXCL1. DISCUSSION Prenatal TSHI + LPS in rats induces placental injury and inflammation histologically consistent with chorioamnionitis, concomitant with elevated serum and CNS pro-inflammatory cytokines. This model accurately recapitulates key pathophysiological processes observed in extremely preterm infants including placental, fetal, and CNS inflammation. Further investigation into the mechanism of CNS injury following chorioamnionitis and the placental-brain axis will guide the use of future interventions.
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Affiliation(s)
- Jessie R Maxwell
- Departments of Pediatrics and Neurosciences, University of New Mexico, Albuquerque, NM, USA
| | - Jesse L Denson
- Departments of Pediatrics and Neurosciences, University of New Mexico, Albuquerque, NM, USA
| | - Nancy E Joste
- Department of Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Shenandoah Robinson
- Departments of Neurosurgery and Neurology, Kirby Center for Neurobiology, Boston Children's Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren L Jantzie
- Departments of Pediatrics and Neurosciences, University of New Mexico, Albuquerque, NM, USA.
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Dhillon SK, Gunn AJ, Jung Y, Mathai S, Bennet L, Fraser M. Lipopolysaccharide-Induced Preconditioning Attenuates Apoptosis and Differentially Regulates TLR4 and TLR7 Gene Expression after Ischemia in the Preterm Ovine Fetal Brain. Dev Neurosci 2015; 37:497-514. [PMID: 26184807 DOI: 10.1159/000433422] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/13/2015] [Indexed: 11/19/2022] Open
Abstract
Acute exposure to subclinical infection modulates subsequent hypoxia-ischemia (HI) injury in a time-dependent manner, likely by cross-talk through Toll-like receptors (TLRs), but the specific pathways are unclear in the preterm-equivalent brain. In the present study, we tested the hypothesis that repeated low-dose exposure to lipopolysaccharide (LPS) before acute ischemia would be associated with induction of specific TLRs that are potentially neuroprotective. Fetal sheep at 0.65 gestation (term is ∼145 days) received intravenous boluses of low-dose LPS for 5 days (day 1, 50 ng/kg; days 2-5, 100 ng/kg) or the same volume of saline. Either 4 or 24 h after the last bolus of LPS, complete carotid occlusion was induced for 22 min. Five days after LPS, brains were collected. Pretreatment with LPS for 5 days decreased cellular apoptosis, microglial activation and reactive astrogliosis in response to HI injury induced 24 but not 4 h after the last dose of LPS. This was associated with upregulation of TLR4, TLR7 and IFN-β mRNA, and increased fetal plasma IFN-β concentrations. The association of reduced white matter apoptosis and astrogliosis after repeated low-dose LPS finishing 24 h but not 4 h before cerebral ischemia, with central and peripheral induction of IFN-β, suggests the possibility that IFN-β may be an important mediator of endogenous neuroprotection in the developing brain.
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Jantzie LL, Corbett CJ, Berglass J, Firl DJ, Flores J, Mannix R, Robinson S. Complex pattern of interaction between in utero hypoxia-ischemia and intra-amniotic inflammation disrupts brain development and motor function. J Neuroinflammation 2014; 11:131. [PMID: 25082427 PMCID: PMC4128546 DOI: 10.1186/1742-2094-11-131] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/15/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Infants born preterm commonly suffer from a combination of hypoxia-ischemia (HI) and infectious perinatal inflammatory insults that lead to cerebral palsy, cognitive delay, behavioral issues and epilepsy. Using a novel rat model of combined late gestation HI and lipopolysaccharide (LPS)-induced inflammation, we tested our hypothesis that inflammation from HI and LPS differentially affects gliosis, white matter development and motor impairment during the first postnatal month. METHODS Pregnant rats underwent laparotomy on embryonic day 18 and transient systemic HI (TSHI) and/or intra-amniotic LPS injection. Shams received laparotomy and anesthesia only. Pups were born at term. Immunohistochemistry with stereological estimates was performed to assess regional glial loads, and western blots were performed for protein expression. Erythropoietin ligand and receptor levels were quantified using quantitative PCR. Digigait analysis detected gait deficits. Statistical analysis was performed with one-way analysis of variance and post-hoc Bonferonni correction. RESULTS Microglial and astroglial immunolabeling are elevated in TSHI + LPS fimbria at postnatal day 2 compared to sham (both P < 0.03). At postnatal day 15, myelin basic protein expression is reduced by 31% in TSHI + LPS pups compared to shams (P < 0.05). By postnatal day 28, white matter injury shifts from the acute injury pattern to a chronic injury pattern in TSHI pups only. Both myelin basic protein expression (P < 0.01) and the phosphoneurofilament/neurofilament ratio, a marker of axonal dysfunction, are reduced in postnatal day 28 TSHI pups (P < 0.001). Erythropoietin ligand to receptor ratios differ between brains exposed to TSHI and LPS. Gait analyses reveal that all groups (TSHI, LPS and TSHI + LPS) are ataxic with deficits in stride, paw placement, gait consistency and coordination (all P < 0.001). CONCLUSIONS Prenatal TSHI and TSHI + LPS lead to different patterns of injury with respect to myelination, axon integrity and gait deficits. Dual injury leads to acute alterations in glial response and cellular inflammation, while TSHI alone causes more prominent chronic white matter and axonal injury. Both injuries cause significant gait deficits. Further study will contribute to stratification of injury mechanisms in preterm infants, and guide the use of promising therapeutic interventions.
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MESH Headings
- Animals
- Animals, Newborn
- Axons/pathology
- Brain/embryology
- Brain/growth & development
- Brain/metabolism
- Calcium-Binding Proteins/metabolism
- Disease Models, Animal
- Embryo, Mammalian
- Erythropoietin/genetics
- Erythropoietin/metabolism
- Female
- Gene Expression Regulation, Developmental/drug effects
- Gene Expression Regulation, Developmental/physiology
- Glial Fibrillary Acidic Protein/metabolism
- Hypoxia-Ischemia, Brain/pathology
- Hypoxia-Ischemia, Brain/physiopathology
- Inflammation/chemically induced
- Inflammation/pathology
- Leukoencephalopathies/etiology
- Lipopolysaccharides/toxicity
- Microfilament Proteins/metabolism
- Myelin Basic Protein/metabolism
- Pregnancy
- Prenatal Exposure Delayed Effects
- Rats
- Rats, Sprague-Dawley
- Receptors, Erythropoietin/genetics
- Receptors, Erythropoietin/metabolism
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Affiliation(s)
- Lauren L Jantzie
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
- Current address: Department of Pediatrics, UNM, Office of Pediatric Research, MSC10 5590, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Christopher J Corbett
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jacqueline Berglass
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Daniel J Firl
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Julian Flores
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Rebekah Mannix
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Shenandoah Robinson
- Departments of Neurology and Neurosurgery, F.M. Kirby Center for Neurobiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Zhao J, Chen Y, Xu Y, Pi G. Effect of intrauterine infection on brain development and injury. Int J Dev Neurosci 2013; 31:543-9. [DOI: 10.1016/j.ijdevneu.2013.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 06/23/2013] [Accepted: 06/23/2013] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jing Zhao
- Department of NeonatologyAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
- Department of PediatricsAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
| | - Yurong Chen
- Department of NeonatologyAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
- Department of PediatricsAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
| | - Yuxia Xu
- Department of PediatricsAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
| | - Guanghuan Pi
- Department of PediatricsAffiliated Hospital of North Sichuan Medical CollegeNanchong637000China
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Shahnazi M, Tagavi S, Hajizadeh K, Farshbaf Khalili A. The Effects of Intravenous Hydration on Amniotic Fluid Index in Pregnant Women with Preterm premature Rupture of Membranes: A Randomized Clinical Trial. J Caring Sci 2013; 2:47-52. [PMID: 25276709 DOI: 10.5681/jcs.2013.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 02/26/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Preterm premature rupture of membranes (PPROM) can result in fetal complications such as oligohydramnios. This study aimed to determine the effects of intravenous (IV) fluid bolus on amniotic fluid index (AFI) in pregnant women with PPROM. METHODS 24 women with PPROM during singleton live pregnancy of 28 to 34 weeks whose baseline AFI was ≤ 5cm were randomized into two groups. The study group received one liter intravenous fluid bolus of isotonic Ringer serum during 30-minute period. Reevaluations of amniotic fluid index in both groups were made 90 minutes and 48 hours after baseline measurement. Independent t-test and paired t-test were used to compare the two groups and mean amniotic fluid index before and after treatment, respectively. RESULTS The results of this study demonstrate that AFI decreased statistically significant in both the control and study groups. AFI decreased in both groups at 48 hours later. This decrease was not statistically significant in any group. The mean change in AFI (90 minutes and baseline) and (48 hours and baseline) between the two groups were not significant. The time between mean baseline measurements and delivery were 196.41 and 140.58 hours in the study and control groups, respectively. This difference was not statistically significant. CONCLUSION This study did not find significant impact of hydration On AFI as a prophylactic method on oligohydramnios in pregnant women with PPROM.
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Affiliation(s)
- Mahnaz Shahnazi
- Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Simin Tagavi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khadije Hajizadeh
- Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Azize Farshbaf Khalili
- Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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