Pulmonary hypertension in the newborn

Serum pentraxin 3 levels in term neonates with persistent pulmonary hypertension

BACKGROUND

Persistent pulmonary hypertension of the neonate (PPHN) is a serious disorder. The long pentraxin 3 (PTX3) plays an important role in angiogenesis, cell proliferation, tissue repair and cell regulation. The present study aims to assess the diagnostic and clinical value of PTX3 in PPHN.

METHODS

The present case-control 60 full-term neonates diagnosed with PPHN by echocardiography within 72 hours of birth. In addition, there were 30 age and sex-matched healthy neonates who served as controls. All participants were subjected to careful history taking and complete clinical examination, Laboratory investigations included complete blood count, C-reactive protein (CRP), blood culture and PTX3 level. Radiological investigations included plain X- ray and two-dimensional transthoracic echocardiography (TTE).

RESULTS

Comparison between patients and controls revealed that patients had significantly higher CRP (6.12±2.18 versus 3.69±1.25 mg/dl, p < 0.001) and PTX3 levels (2.07±0.67 versus 0.96±0.21, p < 0.001) when compared with controls. Patients with associated PDA had significantly higher PTX3 levels when compared with patients without (2.58±0.5 versus 2.02±0.51 ng/ml, p = 0.002). Also, patients with associated PFO had significantly higher PTX3 levels when compared with patients without (2.12±1.05 versus 2.05±0.46, p = 0.002). ROC curve analysis identified good performance of CRP and PTX3 levels in diagnosis of PPHN with PTX3 showing better performance.

CONCLUSIONS

There is a significant association between serum PTX3 levels and PPHN particularly those with associated PDA or PFO.

Pulmonary hypertension among preterm infants born at 22 through 32 weeks gestation in France: Prevalence, survival, morbidity and management in the EPIPAGE-2 cohort study

OBJECTIVE

To determine the prevalence, short-term prognosis and pharmacologic management of pulmonary hypertension (PH) among very preterm infants born before 32 weeks gestation (WG).

STUDY DESIGN

In the EPIPAGE-2 French national prospective population-based cohort of preterm infants born in 2011, those presenting with PH were identified and prevalence was estimated using multiple imputation. The primary outcome was survival without severe morbidity at discharge and was compared between infants with or without PH after adjusting for confounders, using generalized estimating equations models. Subgroup analysis was performed according to gestational age (GA) groups.

RESULTS

Among 3383 eligible infants, 3222 were analyzed. The prevalence of PH was 6.0 % (95 % CI, 5.2-6.9), 14.5 % in infants born at 22-27+6 WG vs 2.7 % in infants born at 28-31+6 WG (P < .001). The primary outcome (survival without severe morbidity at discharge) occurred in 30.2 % of infants with PH vs 80.2 % of infants without PH (P < .001). Adjusted incidence rate ratios for survival without severe morbidity among infants with PH were 0.42 (0.32-0.57) and 0.52 (0.39-0.69) in infants born at 22-27+6 weeks gestation and those born at 28-31+6 weeks, respectively. Among infants with PH, 92.2 % (95 % CI, 87.7-95.2) received sedation and/or analgesia, 63.5 % (95 % CI, 56.6-69.9) received inhaled NO and 57.6 % (95 % CI, 50.9-64.0) received hemodynamic treatments.

CONCLUSION

In this population-based cohort of very preterm infants, the prevalence of PH was 6 %. PH was associated with a significant decrease of survival without severe morbidity in this population.

Large scale application of pulse oximeter and auscultation in screening of neonatal congenital heart disease

Purpose

To conduct a retrospective evaluation of a large clinical implementation of combined pulse oximeter (POX) and cardiac auscultation as a fast-screening device for congenital heart disease (CHD).

Methods

Every newborn in a large maternity healthcare center received auscultation and POX screening within 24 hours after delivery. When an abnormal heart murmur or SpO₂ level was detected, an echocardiogram was ordered to confirm the diagnosis of CHD.

Results

From January 1, 2018 to December 31, 2019, there were 44,147 livebirths at the studied hospital where 498 suspected CHD were identified: 27 newborns by POX screening and 471 by cardiac auscultation. The diagnosis was further confirmed in 458 neonates through echocardiogram. This result put forth an overall diagnosis rate of 92.0%. Cardiac auscultation detected the majority of CHD cases 438 (95.6%) while POX only screened 20 (4.4%) cases. Interestingly, no CHD case was detected by both auscultation examination and POX screening. Auscultation detected most of the common types of CHD, but POX excelled in identifying rare and critical cases. POX screening alone had a very low accuracy of 74.07% in positive predict value (PPV). On the other hand, auscultation functioned well in terms of PPV and negative predict value (NPV) (92.99 and 99.95%, respectively), but the addition of POX improved the overall screening performance resulting in 100% NPV. We also validate the finding with the data 6 months after the study period.

Conclusion

Our study demonstrated that addition of pulse oximetry to routine cardiac auscultation could be used as an accurate and feasible screening for early screening of CHD in newborns in large-scale clinical practice.

Pulmonary hypertension in congenital diaphragmatic hernia: ANTENATAL PREDICTION AND IMPACT ON NEONATAL MORTALITY

OBJECTIVE

To determine the prevalence of pulmonary hypertension(PAH) in left-sided congenital diaphragmatic hernia(CDH); how we could predict it; and how PAH contributed to the model for mortality prediction.

STUDY DESIGN

Retrospective analysis in three European centers. The primary outcome was the presence of PAH on postnatal day(d)1,7, and at discharge. Studied predictors of PAH were: observed/expected-lung/head-ratio(o/e LHR), liver-herniation, FETO, and gestational age(GA) at delivery. The combined effect of pre-and postnatal variables on mortality was modeled by Cox regression.

RESULTS

Of the 197 neonates, 56(28.4%) died. At d1, 67.5%(133/197) had PAH and 61.9% (101/163) by d7. Overall, 6.4% (9/141) had PAH at discharge.At d1, o/eLHR(OR 0.96) and FETO(OR 2.99) independently correlated to PAH(AUC:0.74). At d7, PAH significantly correlated only with the use of FETO (OR 3.9;AUC:0.65). None were significant for PAH at discharge.Combining the occurrence of PAH with antenatal biomarkers improved mortality prediction(p=0.02), in a model including o/eLHR(HR:0.94), FETO(HR:0.35), liver herniation(HR:16.78), and PAH(HR:15.95).

CONCLUSIONS

Antenatal prediction of PAH was only moderate. The postnatal occurrence of PAH further increases the risk of death. Whereas this may be used to counsel parents in the postnatal period, our study demonstrates there is a need to find more accurate antenatal predictors for PAH. This article is protected by copyright. All rights reserved.

Intrapulmonary artery Doppler to predict mortality and morbidity in fetuses with mild or moderate left-sided congenital diaphragmatic hernia

OBJECTIVES

In fetuses with isolated left-sided congenital diaphragmatic hernia (LCDH), prenatal detection of severe pulmonary hypoplasia is important, as fetal therapy can improve survival. Cases with mild or moderate lung hypoplasia still carry a considerable risk of mortality and morbidity, but there has been less interest in the accurate prediction of outcome in these cases. In this study of fetuses with mild or moderate isolated LCDH, we aimed to investigate: (1) the association between intrapulmonary artery (IPA) Doppler findings and mortality at discharge; (2) whether adding IPA Doppler findings improves the prediction of mortality based on lung size and liver herniation; and (3) the association between IPA Doppler findings and early neonatal morbidity.

METHODS

This was a retrospective study of all consecutive fetuses assessed at the BCNatal and UZ Leuven hospitals between 2008 and 2020 with a prenatal diagnosis of isolated, non-severe LCDH, defined as observed-to-expected lung-to-head ratio (o/e-LHR) > 25%, that were managed expectantly during pregnancy followed by standardized neonatal management. An additional inclusion criterion was the availability of IPA Doppler measurements. The primary outcome was the association between IPA Doppler findings and mortality at discharge. Other predictors included o/e-LHR, liver herniation and gestational age at birth. Secondary outcomes were the association between IPA Doppler findings and the presence of pulmonary hypertension (PHT), need for supplemental oxygen at discharge and need for extracorporeal membrane oxygenation. IPA pulsatility index (PI) values were converted into Z-scores. Logistic regression analysis was performed to investigate the associations between predictor variables and outcome, and the best model was chosen based on the Nagelkerke R² .

RESULTS

Observations for 70 non-severe LCDH cases were available. Fifty-four (77%) fetuses survived until discharge. On logistic regression analysis, higher IPA-PI was associated with an increased risk of mortality (odds ratio (OR), 3.96 (95% CI, 1.62-9.70)), independently of o/e-LHR (OR, 0.87 (95% CI, 0.79-0.97)). An IPA-PI Z-score cut-off of 1.8 predicted mortality with a detection rate of 69% and specificity of 93%. Adding IPA-PI to o/e-LHR improved significantly the model's performance (Nagelkerke R² , 46% for o/e-LHR + IPA-PI vs 28% for o/e-LHR (P < 0.002)), with a detection rate of 81% at a 10% false-positive rate. IPA-PI was associated with PHT (OR, 2.20 (95% CI, 1.01-4.59)) and need for oxygen supplementation at discharge (OR, 1.90 (95% CI, 1.10-3.40)), independently of lung size.

CONCLUSIONS

In fetuses with mild or moderate LCDH, IPA-PI was associated with mortality and morbidity, independently of lung size. A model combining o/e-LHR with IPA-PI identified up to four in five cases that eventually died, despite being considered to have non-severe pulmonary hypoplasia. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia

OBJECTIVES

(1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO).

METHODS

Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension.

RESULTS

The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04).

CONCLUSION

Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.

Echocardiographic Parameters Predictive of Poor Outcome in Persistent Pulmonary Hypertension of the Newborn (PPHN): Preliminary Results

The aim is to conduct a pilot study to prospectively describe echocardiographic parameters in neonates with pulmonary hypertension (PH) managed according to current recommendations and to identify those parameters that could predict worsening of short-term outcomes. All neonates less than 28 days old with a diagnosis of PH were prospectively enrolled in a tertiary care center for 1 year. Two echocardiograms were performed by a trained neonatologist. The first echocardiogram was performed at the time of diagnosis, whereas the second was performed just after basic therapeutic optimization. The cohort included 27 neonates. Mean gestational age at birth was 36.1 weeks gestational age (WGA) (SD: 4) and mean birth weight was 2658 g (SD: 907). Six neonates (22%) died before day 28, with a median age at death of 48 h (IQR [33; 89]). Although the first echocardiogram showed no difference, the second highlighted a strong link between the persistence of right-to left-shunt and death (p = 0.002). We showed a link between right-to-left shunt and a poor outcome (death or morbidity) after therapeutic optimization among premature and full-term neonates suffering from PH. We recommend repeating echocardiography after basic therapeutic optimization and for prognostic purposes, taking into account only the second examination. Larger cohorts are needed to confirm these results.

Early surgical complications after congenital diaphragmatic hernia repair by thoracotomy vs. laparotomy: A bicentric comparison

PURPOSE

The surgical strategy for congenital diaphragmatic hernia (CDH) repair remains debated and mainly depends on the training and preference of the surgeon. Our aim was to evaluate the occurrence and nature of surgical reinterventions within the first year of life, following repair through thoracotomy as compared to laparotomy.

METHODS

This is a retrospective bi-centric cohort study comparing postero-lateral thoracotomy (n = 55) versus subcostal laparotomy (n = 62) for CDH repair (IRB: MP001882). We included neonates with isolated, left-sided, Bochdalek-type CDH who were operated on between 2000 and 2017, and had a minimum follow-up of 1 year. Excluded were patients treated prenatally and/or had extra-corporeal membrane oxygenation. Outcomes were occurrence and nature of surgical reinterventions and mortality by 1 year of life.

RESULTS

Both groups had comparable neonatal severity risk profiles. The overall surgical reintervention rate by 1 year of age was higher in the thoracotomy group (29.1% vs. 6.5%; p = 0.001), mainly because of a higher prevalence of acute bowel complications (18.1% vs. 3.2%; p = 0.012) requiring surgery, such as perforation, obstruction and volvulus. At 1 year of follow-up, groups were similar in terms of recurrence (5.5% vs. 1.6%; p = 0.341), surgical interventions related to severe gastroesophageal reflux disease (3.6% vs. 1.6%; p = 0.600) and mortality (5.5% vs. 6.6%; p = 1.000).

CONCLUSION

Postnatal CDH repair through thoracotomy was associated with a higher rate of surgical reinterventions within the first year of life, especially for severe acute gastro-intestinal complications. There seemed to be no difference in recurrence and mortality rate.

TYPE OF STUDY

Retrospective Comparative Cohort Study.

LEVEL OF EVIDENCE

Level III.

Use of Treprostinil in Pediatric Pulmonary Hypertension: Case Reports and Review of the Literature

BACKGROUND

Add-on therapy with prostacyclin in pediatric refractory pulmonary hypertension (PH) poses a challenge, especially when considering continuous intravenous administration in younger children. A search for alternate routes of drug delivery has led to the clinical investigation of stable and long-acting prostacyclin analogues, such as subcutaneous treprostinil. We reported 2 pediatric cases of PH treated with subcutaneous treprostinil and reviewed the literature on treprostinil use in children.

METHOD

The literature review used 3 electronic databases and a combination of terms (treprostinil, pediatric, PH, prostanoid, etc). We also searched for pediatric clinical trials on treprostinil registered on international clinical trial registries.

RESULTS

The reported cases highlighted the multifactorial nature of PH in pediatrics: a female child with a giant omphalocele, and intracardiac and extracardiac shunts; and a male premature child with a congenital diaphragmatic hernia and long-term PH. The literature review identified 19 studies reporting treprostinil use in 421 children with various types of PH (groups 1 and 3). Subcutaneous treprostinil was the most administered formulation, at a mean dose of 40 ng/kg/min. Overall, 12 clinical trials on treprostinil for children with PH were registered on the clinical trial registries. Most authors concluded that subcutaneous treprostinil was effective, well tolerated, and represented an alternative to intravenous epoprostenol.

CONCLUSIONS

Subcutaneous treprostinil may be a useful adjunct in the therapeutic algorithm for children with severe PH, refractory to oral drugs, and after a complete check-up for all PH etiologies.

Pentraxin 3: A Potential Novel Predictor for Neonatal Pulmonary Hypertension

BACKGROUND:

Persistent pulmonary hypertension of the newborn (PPHN) is a serious neonatal problem which has a high mortality rate even with advanced modes of mechanical ventilation. Pentraxin 3 is one of the long pentraxins, which plays an essential role in regulation of cell proliferation and angiogenesis.

AIM:

This study aims to assess serum pentraxin 3 levels in neonates with pulmonary arterial hypertension and compare them in those who have other congenital heart diseases and healthy neonates. Also, we intended to evaluate serum levels of CRP as a mediator of inflammation in the studied groups.

METHODS:

The study is a case-control study. Cases were recruited from El Galaa Teaching Hospital, classified into three groups; each group had thirty cases. The first one: cases with pulmonary hypertension (PHT), the second one: cases with congenital heart diseases (CHD) without pulmonary hypertension and the third group included healthy neonates. All participants were subjected to full history taking and full clinical examination. Diagnosis of congenital heart disease and pulmonary hypertension was made according to echocardiographic findings by pediatric cardiologist using echocardiography machine. Laboratory investigations included measurement of serum pentraxin 3, Routine CBC, CRP.

RESULTS:

This study found that the mean serum pentraxin 3 in PHT neonates was significantly higher than that of the control and CHD neonates (p ≤ 0.001, p = 0.02 respectively). Also, the mean Pentraxin3 of the CHD neonates was significantly higher than that of the control (p = 0.06). Also, the mean CRP of the PHT neonates was significantly higher than that of the control (p = 0.01). Regression analysis showed that Pentraxin3 was the main predictor of PAP (P = 0.01).

CONCLUSION:

Serum pentraxin 3 is significantly elevated in neonates with pulmonary hypertension, so measurement of pentraxin 3 levels in neonates may be valuable as a predictor for pulmonary hypertension in neonates.

Effect of bosentan therapy in persistent pulmonary hypertension of the newborn

BACKGROUND

Persistent pulmonary hypertension of the newborn (PPHN) contributes to neonatal hypoxemia and is associated with a high mortality. Some PPHN patients are unresponsive to inhaled nitric oxide (iNO). Bosentan, an oral endothelin-1 receptor antagonist, reduces pulmonary vascular resistance and hence may play a role in the treatment of PPHN.

METHODS

A retrospective medical records review was performed in newborns who received oral bosentan as an adjunctive therapy for treatment of PPHN between January 2013 and February 2016 at the neonatal intensive care unit of Songklanagarind Hospital. The main outcomes were the effect of bosentan on oxygenation and hemodynamic status after commencement of treatment and the safety of bosentan.

RESULTS

Forty neonates at a median (IQR) gestation of 38 (36.8-40) weeks and an initial median (IQR) oxygen index (OI) of 29.2 (13.4-40.1) received bosentan therapy. Oral bosentan was commenced at a median (IQR) age of 27 (14.5-40.2) hours and the mean (SD) duration of treatment was 6.2 (3.1) days. The OI, alveolar-arterial oxygen difference (AaDO₂) and oxygen saturation (SpO₂) improved significantly at 2 h after treatment (p = 0.002, p = 0.01 and p < 0.001, respectively). In 21 (52.5%) neonates who received iNO and bosentan, the median OI (IQR) was 34.2 (29.0-42.6) with a significant decrease of OI at 6 h (p = 0.005) after treatment. In 19 (47.5%) neonates who received bosentan alone, the median OI (IQR) was 13.0 (9.8-30.9) with a significant decrease of OI in 2 h (p = 0.01) after treatment. The blood pressures before and after bosentan treatment were not statistically significantly different. The mortality rate was 12.5% (5/40).

CONCLUSION

Oral bosentan may be a safe and effective treatment to improve oxygenation in neonates with PPHN. Bosentan can be used as an adjuvant therapy with iNO and can be an alternative therapy option in mild-to-moderate PPHN.

Treprostinil for persistent pulmonary hypertension of the newborn, with early onset sepsis in preterm infant: 2 Case reports

RATIONALE

Persistent pulmonary hypertension of the newborn (PPHN) is a syndrome of failed circulatory adaptation at birth with persisting increased pulmonary vascular resistance that is associated with high mortality rates especially in preterm infants.

PATIENT CONCERNS

We reported 2 cases of PPHN in preterm infants with respiratory distress syndrome and early onset sepsis refractory to therapy with vasopressors, inotropes, and inhaled nitric oxide (iNO), in whom treatment with treprostinil was successful.

DIAGNOSES

Infants showed a difference of more than 10% between pre- and postductal saturation of peripheral oxygen by pulse oximetry. Echocardiogram showed flattened ventricular septum, right to left shunting through the patent ductus arteriosus, and tricuspid regurgitation velocity above 2.9 m/s.

INTERVENTIONS

The patients received treprostinil through central venous line because iNO therapy was not effective.

OUTCOMES

Within 6 to 12 hours after treatment with treprostinil, the patients showed dramatic clinical improvement, and no systemic side effects were observed, including intraventricular hemorrhage (≥grade II).

LESSONS

IV treprostinil might be given to preterm infants with severe PPHN, who did not respond to conservative therapies, including iNO.

Common respiratory conditions of the newborn

KEY POINTS

Respiratory distress is a common presenting feature among newborn infants.Prompt investigation to ascertain the underlying diagnosis and appropriate subsequent management is important to improve outcomes.Many of the underlying causes of respiratory distress in a newborn are unique to this age group.A chest radiograph is crucial to assist in diagnosis of an underlying cause.

EDUCATIONAL AIMS

To inform readers of the common respiratory problems encountered in neonatology and the evidence-based management of these conditions.To enable readers to develop a framework for diagnosis of an infant with respiratory distress. The first hours and days of life are of crucial importance for the newborn infant as the infant adapts to the extra-uterine environment. The newborn infant is vulnerable to a range of respiratory diseases, many unique to this period of early life as the developing fluid-filled fetal lungs adapt to the extrauterine environment. The clinical signs of respiratory distress are important to recognise and further investigate, to identify the underlying cause. The epidemiology, diagnostic features and management of common neonatal respiratory conditions are covered in this review article aimed at all healthcare professionals who come into contact with newborn infants.

Evaluation of the maternal and fetal risk factors associated with neonatal care unit hospitalization time

OBJECTIVE

To evaluate maternal and neonatal risk factors associated with the length of hospital stay in the neonatal intensive care unit (NICU).

MATERIAL AND METHOD

This retrospective observational study was based on 3607 newborns who were admitted to the NICU of a tertiary teaching hospital from January 2012 through December 2014. Known obstetric risk factors associated with duration of hospitalization in NICUs were assessed including intrauterine growth restriction, maternal diabetes, oligohydramnios, chorioamnionitis, premeture rupture of membranes, preeclampsia, congenital malformations, neonatal sepsis, premature retinopathy, intracranial bleeding, necrotizing enterocolitis, meconium aspiration, maternal hypertension, fetal congenital cardiac malformations, congenital metabolic diseases, congenital hypothyroidism, pneumonia, pulmonary hypertension, bronchopulmonary dysplasia, pneumothorax and respiratory distress syndrome.

RESULTS

Gestational age (beta coefficient: -0.244, p<0.001) and birth weight (beta coefficient: -0.237, p<0.001) were significant confounders for duration of hospitalization in newborns.

CONCLUSION

Gestational age and the birth weight were the most important confounders for duration of hospitalization. Neonate care in developing countries would further benefit from additional large population-based long-term studies with broad parameters.

Dynamic Changes of Pulmonary Arterial Pressure and Ductus Arteriosus in Human Newborns From Birth to 72 Hours of Age

Normal pulmonary artery pressure and pulmonary hypertension assessment of newborns is rarely reported. The aim of the study is to explore dynamic changes of pulmonary arterial pressure and ductus arteriosus in human newborns from birth to 72 h of age with echocardiography.A total of 76 cases of normal newborns were prospectively detected by echocardiography after birth of 2 h, 6 h, 12 h, 24 h, 48 h, and 72 h, respectively. Ductus arteriosus diameter, blood shunt direction, blood flow velocity, and pressure gradient were recorded. The brachial artery blood pressure were measured to estimate the pulmonary artery systolic pressure (PASP) and pulmonary artery diastolic pressure (PADP) using patent ductus arteriosus pressure gradient method. The mean pulmonary artery pressure (PAMP) were calculated by equation of PAMP = PADP + 1/3(PASP-PADP).(1) There were 76 cases of normal newborns. Among them, 29 cases (38%) ductus arteriosus closed within 24 h, 59 cases (78%) closed within 48 h, 72 cases (95%) closed within 72 h, and 4 cases (5%) ductus arteriosus not closed within 72 h. (2) The ductus arteriosus diameter of 2 h, 6 h, 12 h, 24 h, 48 h, and 72 h after birth was 4.60 ± 0.59 mm, 3.37 ± 0.59 mm, 2.47 ± 0.49 mm, 1.89 ± 0.41 mm, 1.61 ± 0.35 mm, and 1.20 ± 0.24 mm, respectively. Compared all of the ductus arteriosus diameter of the above time periods, there were statistically differences with P < 0.05, respectively. (3) The mean PASP in 2 h, 6 h, 12 h, 24 h, 48 h, 72 h after birth were 76.58 ± 7.28 mm Hg, 65.53 ± 9.25mm Hg, 52.51 ± 9.07 mm Hg, 43.83 ± 7.90 mm Hg, 38.07 ± 8.26 mm Hg, and 36 ± 6.48 mm Hg, respectively. The PADP of the above time period were 37.88 ± 5.56 mm Hg, 29.93 ± 7.91 mm Hg, 23.43 ± 7.37 mm Hg, 19.70 ± 8.51 mm Hg, 13.85 ± 5.58 mm Hg, 13.25 ± 6.18 mm Hg, respectively. The PAMP of the above time period were 63.41 ± 7.03 mm Hg, 51.78 ± 9.82 mm Hg, 40.94 ± 9.32 mm Hg, 34.39 ± 9.89 mm Hg, 26.23 ± 7.49 mm Hg, 25.25 ± 8.29 mm Hg, respectively. There were statistically differences with P < 0.05 between each time periods of PASP, PADP, and PAMP. (4) The upper 95% limit reference range of PASP of normal newborns of 72 h after birth were 39.97 mm Hg.(1) Normal newborns ductus arteriosus diameter gradually decreased after birth, and 95% of them spontaneous closed within 24 to 72 h. (2) Normal newborns pulmonary artery pressure showed a gradually decline after birth, the upper 95% limit reference range for PASP measured in normal newborns <72 h of age was 39.97 mm Hg. Therefore, the diagnostic criteria of newborns pulmonary hypertension may be >40.00 mm Hg according to our limited study.

Prediction of Neonatal Respiratory Function and Pulmonary Hypertension in Fetuses with Isolated Congenital Diaphragmatic Hernia in the Fetal Endoscopic Tracleal Occlusion Era: A Single-Center Study

Objective: To correlate prenatal indicators of pulmonary hypoplasia with neonatal lung function and pulmonary hypertension (PHT) in isolated congenital diaphragmatic hernia (iCDH). Materials and Methods: Prospective single-center study on 40 fetuses with iCDH either expectantly managed (n = 13) or undergoing tracheal occlusion (n = 27). Prenatal predictors included observed/expected lung-head ratio (O/E LHR), observed/expected total fetal lung volume, fetal pulmonary reactivity to maternal O2 administration (Δpulsatility index, ΔPI) and liver-to-thorax ratio (LiTR) as measured in the second and third trimesters. Postnatal outcome measures included survival until discharge, best oxygenation index (OI) and alveolar-arterial oxygen gradient [D(A-a)O2] in the first 24 h of life and the occurrence of PHT in the first 28 days of life. Results: Median gestational age (GA) at evaluations was 27.2 and 34.3 weeks. GA at delivery was 36.0 weeks, and overall survival was 55%. In the second trimester, measurement of lung size, LiTR and pulmonary reactivity were significantly related to survival and the best OI and D(A-a)O2.The occurrence of PHT was better predicted by ΔPI and LiTR. Conclusions: O/E LHR, LiTR and vascular reactivity correlate with ventilatory parameters in the first 24 h of life. Occurrence of PHT at ≥28 days was best predicted by LiTR and ΔPI, but not by lung size.

Expression of hypoxia-inducible factor-1α, endothelin-1 and adrenomedullin in newborn rats with hypoxia-induced pulmonary hypertension

Hypoxia-inducible factor (HIF)-1α is associated with hypoxia-induced pulmonary hypertension (HPH) in adults. In the present study, the expression levels of HIF-1α, endothelin (ET)-1 and adrenomedullin (ADM) were analyzed during HPH in neonates. In total, 96 newborn rats were subjected to hypoxia or normoxia for 3, 5, 7, 10, 14 or 21 days (n=8 per subgroup). HIF-1α, ET-1 and ADM expression levels were measured by quantitative polymerase chain reaction. In addition, the intima-media thickness/external diameter ratio (MT%) and medial wall cross-sectional area/vessel total cross-sectional area ratio (MA%) were calculated to evaluate pulmonary vascular remodeling. The mean pulmonary arterial pressure (mPAP) increased with exposure to hypoxia. Furthermore, the expression levels of HIF-1α, ET-1 and ADM in the lungs were shown to increase after three and five days of hypoxia, while the MT% and MA% increased after seven days of hypoxia, as compared with the controls (P<0.05). Therefore, the expression of HIF-1α, ET-1 and ADM is upregulated in the lungs of newborn rats during early HPH. At later stages, the mPAP increases, vascular remodeling occurs and HIF-1α, ET-1 and ADM expression levels restore to normal levels.

Vasotrophic regulation of age-dependent hypoxic cerebrovascular remodeling

Hypoxia can induce functional and structural vascular remodeling by changing the expression of trophic factors to promote homeostasis. While most experimental approaches have been focused on functional remodeling, structural remodeling can reflect changes in the abundance and organization of vascular proteins that determine functional remodeling. Better understanding of age-dependent hypoxic macrovascular remodeling processes of the cerebral vasculature and its clinical implications require knowledge of the vasotrophic factors that influence arterial structure and function. Hypoxia can affect the expression of transcription factors, classical receptor tyrosine kinase factors, non-classical G-protein coupled factors, catecholamines, and purines. Hypoxia's remodeling effects can be mediated by Hypoxia Inducible Factor (HIF) upregulation in most vascular beds, but alterations in the expression of growth factors can also be independent of HIF. PPARγ is another transcription factor involved in hypoxic remodeling. Expression of classical receptor tyrosine kinase ligands, including vascular endothelial growth factor, platelet derived growth factor, fibroblast growth factor and angiopoietins, can be altered by hypoxia which can act simultaneously to affect remodeling. Tyrosine kinase-independent factors, such as transforming growth factor, nitric oxide, endothelin, angiotensin II, catecholamines, and purines also participate in the remodeling process. This adaptation to hypoxic stress can fundamentally change with age, resulting in different responses between fetuses and adults. Overall, these mechanisms integrate to assure that blood flow and metabolic demand are closely matched in all vascular beds and emphasize the view that the vascular wall is a highly dynamic and heterogeneous tissue with multiple cell types undergoing regular phenotypic transformation.

Risk factors and outcomes of persistent pulmonary hypertension of the newborn in neonatal intensive care unit of Al-minya university hospital in egypt

Background:

Persistent pulmonary hypertension of the newborn (PPHN) result from the failure of the normal fetal-to-neonatal circulatory transition is associated with substantial infant mortality and morbidity.

Objective:

To estimate the possible risk factors and assess the outcome of these cases.

Materials and Methods:

Prospective study was performed enrolling all full-term and post-term newborn admitted to the NICU from January 2009 to April 2012, All neonates were subjected to complete history and physical examination, laboratory data including a complete blood count, arterial blood gases, blood glucose, serum electrolytes, and blood culture to exclude sepsis. Cases with PPHN had a continuous pulse oximeter, blood pressure and electrocardiography monitoring. Chest X-ray and echocardiogarphy were carried out to verify shunt and exclude structural congenital heart disease.

Results:

Out of the studied 640 infants, 32 infants (5%) developed PPHN, Meconium aspiration, birth asphyxia, hyaline membrane diseases, neonatal septicemia, post-term birth being large for gestational age, cesarean section, maternal overweight, and diabetes mellitus were associated with an elevated risk for PPHN. All neonates treated with O₂, 10 neonates with Mg sulphate, 16 with oral sildenafil and 12 with mechanical ventilation. After 6 months follow-up, 12 (37.54%) improved and followed-up without sequelae, 4 (12.5%) developed some neurodevelopmental impairment, 8 (25%) died, 3 (9.3%) developed chronic lungs diseases, 2 (6.2%) developed hearing defects and another 3 (9.3%) missed follow-up.

Conclusion:

PPHN was found in 5% of the studied population. Meconium aspiration, birth asphyxia, neonatal septicemia, post-term were associated with an elevated risk for PPHN. As this is a unit based study, a comprehensive countrywide survey on PPHN in Egypt is recommended to determine any regional differences in disease incidence.

Effectiveness and safety of intravenous iloprost for severe persistent pulmonary hypertension of the newborn

OBJECTIVE

The aims of this study were to determine the effectiveness (oxygenation), safety (hemodynamic status) and short term outcomes of intravenous iloprost (IVI) administration as a rescue therapy in severe persistent pulmonary hypertension of the newborn (PPHN).

DESIGN

Retrospective medical records review.

SETTING

Tertiary neonatal intensive care unit at Songklanagarind Hospital, Songkhla Province, Hat Yai, Thailand.

PARTICIPANTS

Newborns who received IVI as an adjunctive therapy for treatment of severe PPHN, as defined by an oxygen index (OI) of >20 and without response to conventional therapies.

MAIN OUTCOME MEASURES

The change of OI and alveolar-arterial oxygen difference before and after commencement of IVI.

RESULTS

33 neonates with severe PPHN at a median gestation of 39 weeks and a baseline OI of 40 (range, 21-101) received IVI. The median OI and alveolar-arterial oxygen difference had a statistically significant decrease after 2 hours of treatment and continued to decline thereafter (P<0.05). All infants received one or more inotropic medications and volume expanders to provide blood pressure support with no statistically significant difference of blood pressure and heart rate before and after IVI treatment. The mortality rate was 15.2%, all of them had initially severe hypoxemia with a median OI of 53.6.

CONCLUSION

Triglyceride and non-high-density lipoprotein cholesterol are better than low-density lipoprotein cholesterol as predictors of cardiovascular disease risk factors in Chinese Han children and adolescents.

Hydralazine in infants with persistent hypoxemic respiratory failure

BACKGROUND

Most deaths of infants with chronic lung disease (CLD) are caused by respiratory failure, unremitting pulmonary artery hypertension (PAH) with cor pulmonale, or infection. Although the exact prevalence of PAH in infants with CLD is unknown, infants with CLD and severe PAH have a high mortality rate. Except for oxygen supplementation, no specific interventions have been established as effective in the treatment for PAH in premature infants with CLD. Little has been proven regarding the clinical efficacy of vasodilators and concerns remain regarding adverse effects.

OBJECTIVES

To review current evidence for the benefits and harms of hydralazine therapy to infants with persistent hypoxemic respiratory failure.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE via PubMed and EMBASE, and other clinical trials registries through November 2011 using the standard search strategy of the Cochrane Neonatal Review Group. We searched these databases using a strategy combining a variation of the Cochrane highly sensitive search strategy for identifying randomised trials in MEDLINE; sensitivity-maximising version with selected MeSH and free-text terms: hydralazine, vasodilator agent, antihypertensive agent, heart diseases, lung diseases, respiratory tract diseases, infant, and randomised controlled trial.

SELECTION CRITERIA

We considered only randomised controlled trials and quasi-randomised trials for inclusion. We included low birth weight (LBW) infants with persistent hypoxemic respiratory failure who were treated with any type of hydralazine therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality according to pre-specified criteria.

MAIN RESULTS

We found no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the safety and efficacy of hydralazine in LBW infants with persistent hypoxemic respiratory failure. Since hydralazine is inexpensive and potentially beneficial, randomised controlled trials are recommended. Such trials are particularly needed in settings where other medications such as sildenafil, inhaled nitric oxide (iNO), or extracorporeal membrane oxygenation (ECMO) are not available.

Antidepressant use in pregnancy: a critical review focused on risks and controversies

OBJECTIVE

Conflicting data have led to controversy regarding antidepressant use during pregnancy. The objectives of this study are to i) review the risks of untreated depression and anxiety, ii) review the literature on risks of exposure to antidepressants during pregnancy, iii) discuss the strengths and weaknesses of the different study designs used to evaluate those risks, and iv) provide clinical recommendations.

METHOD

MEDLINE/PubMed was searched for reports and studies on the risk of first-trimester teratogenicity, postnatal adaptation syndrome (PNAS), and persistent pulmonary hypertension (PPHN) with in utero antidepressant exposure.

RESULTS

While some individual studies suggest associations between some specific major malformations, the findings are inconsistent. Therefore, the absolute risks appear small. PNAS occurs in up to 30% of neonates exposed to antidepressants. In some studies, PPHN has been weakly associated with in utero antidepressant exposure, while in other studies, there has been no association.

CONCLUSION

Exposures of concern include that of untreated maternal illness as well as medication exposure. It is vital to have a careful discussion, tailored to each patient, which incorporates the evidence to date and considers methodological and statistical limitations. Past medication trials, previous success with symptom remission, and women's preference should guide treatment decisions.

A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia

OBJECTIVE

Severe pulmonary hypoplasia and pulmonary arterial hypertension are associated with reduced survival in congenital diaphragmatic hernia (CDH). We aimed to determine whether fetal endoscopic tracheal occlusion (FETO) improves survival in cases of severe isolated CDH.

METHODS

Between May 2008 and July 2010, patients whose fetuses had severe isolated CDH (lung-to-head ratio < 1.0, liver herniation into the thoracic cavity and no other detectable anomalies) were assigned randomly to FETO or to no fetal intervention (controls). FETO was performed under maternal epidural anesthesia supplemented with fetal intramuscular anesthesia. Tracheal balloon placement was achieved with ultrasound guidance and fetoscopy between 26 and 30 weeks of gestation. All cases that underwent FETO were delivered by the EXIT procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was survival to 6 months of age. Other maternal and neonatal outcomes were also evaluated.

RESULTS

Twenty patients were enrolled randomly to FETO and 21 patients to standard postnatal management. The mean gestational age at randomization was similar in both groups (P = 0.83). Delivery occurred at 35.6 ± 2.4 weeks in the FETO group and at 37.4 ± 1.9 weeks in the controls (P < 0.01). In the intention-to-treat analysis, 10/20 (50.0%) infants in the FETO group survived, while 1/21 (4.8%) controls survived (relative risk (RR), 10.5 (95% CI, 1.5-74.7), P < 0.01). In the received-treatment analysis, 10/19 (52.6%) infants in the FETO group and 1/19 (5.3%) controls survived (RR, 10.0 (95% CI, 1.4-70.6) P < 0.01).

CONCLUSION

FETO improves neonatal survival in cases with isolated severe CDH.

Inhaled nitric oxide improves systemic microcirculation in infants with hypoxemic respiratory failure

OBJECTIVES

To investigate the effect of inhaled nitric oxide on the systemic microcirculation. We hypothesized that inhaled nitric oxide improves the systemic microcirculation. Inhaled nitric oxide improves outcome in infants with persistent pulmonary hypertension of the newborn diagnosed by improving pulmonary blood flow and oxygenation. It reduces pulmonary vascular resistance without decline in systemic blood pressure. Inhaled nitric oxide is also utilized in the treatment of acute hypoxemic respiratory failure in children and adults. It is thought to improve regional ventilation perfusion by regional selective pulmonary vasodilation.

DESIGN

Pilot study.

SETTING

Intensive care unit of a level III university children's hospital.

PATIENTS

Consecutive ventilated patients who were treated with inhaled nitric oxide (20 ppm) were enrolled in this study. Eight patients (five boys, three girls) were included; five had congenital diaphragmatic hernia diagnosed, one had persistent pulmonary hypertension of the newborn diagnosed, one had acute respiratory distress syndrome diagnosed, and one had bronchiolitis diagnosed. The median age was 0 months (range, 0-38 months).

INTERVENTIONS

Inhaled nitric oxide administration.

MEASUREMENTS AND MAIN RESULTS

The microcirculation was assessed in the buccal mucosa within 1 hr before and within 1 hr after the start of inhaled nitric oxide using orthogonal polarization spectral imaging. The median functional capillary density before the inhaled nitric oxide was started was 4.0 cm/cm (range, 1.8-5.6 cm/cm) and improved to 4.9 cm/cm (range, 2.8-6.6 cm/cm; p = .017) after the start of inhaled nitric oxide.

CONCLUSIONS

Inhaled nitric oxide improves the systemic microcirculation in children with hypoxemic respiratory failure.

Vascular abnormalities in human newborns with pulmonary hypertension

Pulmonary vascular disease embodies all congenital or acquired pathologies that affect the pulmonary vasculature. One of them is pulmonary hypertension of the newborn (PHN), which is clinically characterized by a persistent high pulmonary vascular resistance postnatally and an abnormal vascular response. Morphologically, the vascular walls of the small pulmonary arteries become thickened, leading to increased resistance of these vessels and thus a worsening of gas exchange. PHN occurs as a primary disease or in association with abnormal lung development, for example as in congenital diaphragmatic hernia, and is a critical determinant of morbidity and mortality. Here we review the current knowledge about vascular abnormalities in PHN and discuss the vascular abnormalities in different conditions associated with pulmonary hypertension in human newborns in relation to recent findings from molecular biology.

A comparison of magnesium sulphate and sildenafil in the treatment of the newborns with persistent pulmonary hypertension: a randomized controlled trial

The aim of this prospective, randomized and controlled study was to compare the clinical efficacy of intravenous magnesium sulfate (MgSO₄) and oral sildenafil therapies with persistent pulmonary hypertension of the newborn. A total of 34 infants in the MgSO₄ group and 31 infants in the sildenafil group completed the study. The time to reach the adequate clinical response [defined as oxygen index (OI) level of <15, a pulmonary artery pressure of < 20 mmHg) was significantly shorter in the sildenafil group (p = 0.002). Duration of mechanical ventilation was longer and the number of the patients requiring inotropic support was higher in the MgSO₄ group (p = 0.001 and p = 0.002, respectively). Although among two groups the difference in OI > 5 as speculated in our hypothesis could only be found at 36 h of the treatment, sildenafil was more effective than MgSO₄ in the treatment of persistent pulmonary hypertension of the newborns with regard to time to adequate clinical response, duration of mechanical ventilation and support requirement with inotropic agents.

Predicting mortality in infants with persistent pulmonary hypertension of the newborn with the Score for Neonatal Acute Physiology-Version II (SNAP-II) in Thai neonates

AIM

To evaluate the ability of the Score for Neonatal Acute Physiology-Version II (SNAP-II) to predict mortality in infants with persistent pulmonary hypertension of the newborn (PPHN).

METHODS

A prospective cohort study of 41 infants with PPHN admitted to our neonatal intensive care unit between June 2008 and March 2010, who underwent a SNAP-II test within 12 h of admission.

RESULTS

Of the 41 infants, 14 died (34.1%) and 27 survived (65.9%). The SNAP-II scores were significantly higher in infants who died (50.1 ± 18.5 vs. 35.7 ± 16.8, P=0.02). Each point increase in the SNAP score increased the odds of mortality by 1.04 [95% confidence interval (CI) 1.01-1.07, P<0.01]. Infants who had a SNAP-II score of ≥ 43 had the greatest mortality risk with an odds ratio (OR) of 10.00 (95% CI 1.03-97.50). The SNAP-II model showed moderate discrimination in predicting mortality with a result of 0.72 (95% CI 0.56-0.88) under the receiver operating characteristic curve. The lowest blood pressure, lowest PaO(2)/FIO(2) ratio, and urine output within the first 12 h of admission were also independently found to be good predictors of an increased risk for death.

CONCLUSION

The SNAP-II scoring system significantly predicted mortality. PPHN infants with a SNAP-II score of ≥ 43 had the greatest mortality risk.

Regulation of the Pulmonary Circulation in the Fetus and Newborn

During the development of the pulmonary vasculature in the fetus, many structural and functional changes occur to prepare the lung for the transition to air breathing. The development of the pulmonary circulation is genetically controlled by an array of mitogenic factors in a temporo-spatial order. With advancing gestation, pulmonary vessels acquire increased vasoreactivity. The fetal pulmonary vasculature is exposed to a low oxygen tension environment that promotes high intrinsic myogenic tone and high vasocontractility. At birth, a dramatic reduction in pulmonary arterial pressure and resistance occurs with an increase in oxygen tension and blood flow. The striking hemodynamic differences in the pulmonary circulation of the fetus and newborn are regulated by various factors and vasoactive agents. Among them, nitric oxide, endothelin-1, and prostaglandin I2 are mainly derived from endothelial cells and exert their effects via cGMP, cAMP, and Rho kinase signaling pathways. Alterations in these signaling pathways may lead to vascular remodeling, high vasocontractility, and persistent pulmonary hypertension of the newborn.

The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists

OBJECTIVE

To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management.

METHOD

Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved.

RESULTS

Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment.

CONCLUSIONS

Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

Use of the myocardial performance index to assess right ventricular function in infants with pulmonary hypertension

BACKGROUND

This study aimed to measure and compare right ventricular (RV) function in normal infants and those with pulmonary hypertension (PHT) using the myocardial performance index (RVMPI) and to investigate the relationship between RV function and pulmonary artery pressure.

METHODS

A case-control study measured RVMPI in 16 infants with PHT (9 of whom had congenital diaphragmatic hernia) and 28 normal control infants. For the PHT infants, 43 paired measures of RVMPI and pulmonary artery pressure (estimated from tricuspid regurgitation jet velocity) were taken to allow investigation of the relationship between RVMPI and pulmonary artery pressure.

RESULTS

The mean RVMPI for the control infants was 0.24+/-0.09. The RVMPI was significantly elevated in the PHT group (0.55+/-0.17; p<0.0001), including a subgroup of infants with PHT secondary to congenital diaphragmatic hernia (0.58+/-0.18; p<0.0001). The correlation between RVMPI and pulmonary artery pressure in the infants with PHT (R2=0.05; p=0.17) was poor.

CONCLUSIONS

In infants, RVMPI allows quantification of right ventricular function and detection of RV dysfunction in PHT. No linear relationship exists between RVMPI pulmonary artery pressure. Use of RVMPI in the clinical setting must take into account the global and load-dependent nature of this measure.

The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists

OBJECTIVE

To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management.

METHOD

Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved.

RESULTS

Both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestations, but the majority of studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder. Short-term neonatal irritability and neurobehavioral changes are also linked with maternal depression and antidepressant treatment. Several studies report fetal malformations in association with first trimester antidepressant exposure but there is no specific pattern of defects for individual medications or class of agents. The association between paroxetine and cardiac defects is more often found in studies that included all malformations rather than clinically significant malformations. Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and a low risk for persistent pulmonary hypertension in the newborn. Psychotherapy alone is an appropriate treatment for some pregnant women; however, others prefer pharmacotherapy or may require pharmacological treatment.

CONCLUSIONS

Antidepressant use in pregnancy is well studied, but available research has not yet adequately controlled for other factors that may influence birth outcomes including maternal illness or problematic health behaviors that can adversely affect pregnancy.

Pharmacotherapy for meconium aspiration

In this article we have attempted to review the current pharmacological treatment options for infants with meconium aspiration syndrome with or without persistent pulmonary hypertension. These treatments include ventilatory support, surfactant treatment and inhaled nitric oxide (INO), in addition to older and newer pharmacological treatments. These include sedatives, muscle relaxants, alkali infusion, antibiotics and the newer vasodilators. Many aspects of treatment, including ventilatory care, surfactant treatment and the use of INO, are reviewed in great detail in this issue. On the other hand, many newer pharmacological modalities of treatment described here have not been evaluated with randomized control trials. We have given an overview of these emerging therapies.

Predicting perinatal outcome in isolated congenital diaphragmatic hernia using fetal pulmonary artery diameters

OBJECTIVE

The aim of the study was to evaluate the potential of fetal pulmonary artery (PA) diameters to predict perinatal death and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH).

STUDY DESIGN

In this prospective observational study, observed PA (main, right, and left) diameters were measured at the level of the 3 vessels in 21 fetuses with isolated CDH and in 85 controls at 22 to 36 weeks. The observed/expected (o/e) diameters of the main, contralateral, and ipsilateral PAs were calculated by comparing these measurements with reference values obtained in our previous study and correlated with perinatal death and postnatal PAH.

RESULTS

The o/e PA diameters were significantly reduced in fetuses with CDH compared to controls (P < .001) and in fetuses with CDH who died (P < .050). However, there was no significant association between PA diameters and PAH (P >or= .050).

CONCLUSIONS

The PA diameters might be useful to predict perinatal death in isolated CDH but not postnatal PAH, suggesting that PA diameters are probably related to the severity of pulmonary hypoplasia.

Therapeutic Applications of Sildenafil Citrate in the Management of Paediatric Pulmonary Hypertension

Pulmonary hypertension is characterised by a progressive increase in pulmonary vascular resistance and a poor prognosis. The exact underlying mechanisms are still poorly understood; however, it is hypothesised that pulmonary medial hypertrophy and endothelial dysfunction lead to impaired production of vasodilators such as nitric oxide (NO) and prostacyclin, and increased expression of vasoconstrictors such as endothelin-1. The current treatment modalities for pulmonary hypertension include conventional supportive therapies and more specific pharmacological therapies that are targeted at abnormalities of endothelial function. NO and phosphodiesterase type 5 (PDE5) inhibitors induce pulmonary vasodilation by increasing intracellular cyclic guanosine monophosphate (cGMP) concentrations. Sildenafil citrate is a highly selective inhibitor of PDE5. Investigations in animal models and recent clinical case reports with some studies in the paediatric population suggest that sildenafil may be a promising agent in treating pulmonary hypertension. The effect of sildenafil on pulmonary vasculature appears to be independent of the underlying cause, thereby providing a role in idiopathic pulmonary arterial hypertension (PAH), PAH associated with congenital heart disease, pulmonary hypertension secondary to lung disease or persistent pulmonary hypertension of the newborn. It may also be beneficial in postoperative pulmonary hypertension and in neonates who are difficult to wean from inhaled NO. It is easily administered and effective, and has minimal systemic adverse effects. Although the reported results in children with pulmonary hypertension are promising, it is an experimental drug and large-scale randomised controlled studies are required to validate the safety, efficacy and dosage in the paediatric population.

Quantitative analysis of fetal pulmonary vasculature by 3-dimensional power Doppler ultrasonography in isolated congenital diaphragmatic hernia

OBJECTIVE

The purpose of this study was to evaluate the potential of 3-dimensional (3D) power Doppler imaging to predict neonatal outcome and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH).

STUDY DESIGN

In this prospective observational study, 3D-power Doppler ultrasonography was performed in 21 cases with isolated CDH between 23 and 33 weeks of gestation and in 58 controls between 20 and 40 weeks. Using the same preestablished settings for all cases, power Doppler was applied to each lung, and fetal lung volumes (FLV) were estimated using the rotational technique. The 3D power Doppler histogram was used to determine the vascular indices, which were plotted against gestational age and compared with neonatal outcome, PAH, gestational age, and FLV.

RESULTS

Fetal pulmonary vascular indices showed a constant distribution throughout gestation, being significantly lower in cases with CDH than in controls (P < .001). Among CDH cases, the vascular indices were significantly lower in fetuses who died (P < .05), and in fetuses with neonatal PAH (P < .05). The severity of neonatal PAH was also associated with a progressive reduction in prenatal vascular indices (P < .05). All vascular indices correlated with o/e-FLV, but not with gestational age.

CONCLUSION

All vascular indices seem to be constant throughout gestation. In isolated CDH, perinatal outcome and postnatal PAH can be predicted using the vascular indices assessed by 3D power Doppler histogram.

Persistent pulmonary hypertension of the newborn

In utero, fetal pulmonary vascular resistance (PVR) is high, but rapidly falls after birth. Expansion of the lungs, increase in oxygenation, release of vasoactive mediators, growth factors and remodeling of the vascular wall, all contribute to the reduction in PVR. Persistent pulmonary hypertension of the newborn (PPHN) is defined as a failure of the pulmonary vasculature to relax at birth, resulting in hypoxemia. PPHN is in fact a variety of disorders that have a common presentation. Some of the pathophysiological mechanisms and the therapeutic approaches are discussed below.