Obstetric parameters and Doppler findings in cerebral circulation as predictors of 1 year neurodevelopmental outcome in asphyxiated infants

Umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes in children: a systematic review and meta-analysis

BACKGROUND

Umbilical cord blood acid-base sampling is routinely performed at many hospitals. Recent studies have questioned this practice and the association of acidosis with cerebral palsy.

OBJECTIVE

To investigate the associations between the results of umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes and mortality in children.

SEARCH STRATEGY

We searched six databases using the search strategy: umbilical cord AND outcomes.

SELECTION CRITERIA

Randomised controlled trials, cohorts and case-control studies from high-income countries that investigated the association between umbilical cord blood analysis and neurodevelopmental outcomes and mortality from 1 year after birth in children born at term.

DATA COLLECTION AND ANALYSIS

We critically assessed the included studies, extracted data and conducted meta-analyses comparing adverse outcomes between children with and without acidosis, and the mean proportions of adverse outcomes. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach.

MAIN RESULTS

We have very low confidence in the following findings: acidosis was associated with higher cognitive development scores compared with non-acidosis (mean difference 5.18, 95% CI 0.84-9.52; n = two studies). Children with acidosis also showed a tendency towards higher risk of death (relative risk [RR] 5.72, 95% CI 0.90-36.27; n = four studies) and CP (RR 3.40, 95% CI 0.86-13.39; n = four studies), although this was not statistically significant. The proportion of children with CP was 2.39/1000 across the studies, assessed as high certainty evidence.

CONCLUSION

Due to low certainty of evidence, the associations between umbilical cord blood gas analysis at delivery and long-term neurodevelopmental outcomes in children remains unclear.

A Scoping Review of Cerebral Doppler Arterial Waveforms in Infants

Cerebral Doppler ultrasound has been an important tool in pediatric diagnostics and prognostics for decades. Although the Doppler spectrum can provide detailed information on cerebral perfusion, the measured spectrum is often reduced to simple numerical parameters. To help pediatric clinicians recognize the visual characteristics of disease-associated Doppler spectra and identify possible areas for future research, a scoping review of primary studies on cerebral Doppler arterial waveforms in infants was performed. A systematic search in three online bibliographic databases yielded 4898 unique records. Among these, 179 studies included cerebral Doppler spectra for at least five infants below 1 y of age. The studies describe variations in the cerebral waveforms related to physiological changes (43%), pathology (62%) and medical interventions (40%). Characteristics were typically reported as resistance index (64%), peak systolic velocity (43%) or end-diastolic velocity (39%). Most studies focused on the anterior (59%) and middle (42%) cerebral arteries. Our review highlights the need for a more standardized terminology to describe cerebral velocity waveforms and for precise definitions of Doppler parameters. We provide a list of reporting variables that may facilitate unambiguous reports. Future studies may gain from combining multiple Doppler parameters to use more of the information encoded in the Doppler spectrum, investigating the full spectrum itself and using the possibilities for long-term monitoring with Doppler ultrasound.

Using Doppler sonography resistive index for the diagnosis of perinatal asphyxia: a multi-centered study

BACKGROUND AND OBJECTIVE

Inhere we evaluated the diagnostic utility of Doppler sonography (DS) of the anterior cerebral artery (ACA), middle cerebral artery (MCA) and the basilar arteries (BA) based on resistive index (RI) for the diagnosis of asphyxia.

METHODS

In this multi-centered cross-sectional study, neonates with clinical diagnosis of asphyxia, were considered for study. During the first 24 h, neonates underwent DS. MRI was done for each neonate during the first month, after discharge or during hospital admission, after obtaining clinical stability. Staging based on DS was compared with staging based on MRI.

RESULTS

Overall, 34 patients entered the study. DS of the ACA, MCA, BA all had significant correlation with MRI findings (regarding severity of asphyxia) (r > 0.8 and p < 0.001). In the receiver-operating-characteristic analysis, ideal cut-off point for diagnoses of asphyxia based on ACA and BA was RI ≤ 0.62 [area under the curve (AUC) = 0.957 and 95% CI: 0.819-0.997; sensitivity = 95.65; specificity = 100; positive predictive value (PPV) = 100; negative predictive value (NPV) = 90.9 and negative likelihood ratio (NLR) = 0.043]. Regarding MCA, similarly, a RI ≤ 0.62 was ideal for differentiating between normal and asphyxiated neonates (AUC = 0.990 and 95% CI: 0.873-1; sensitivity = 91.30; specificity = 100; PPV = 91.2; NPV = 100 and NLR = 0.087).

CONCLUSION

For evaluating neonates clinically suspected of asphyxia, especially in centers with limited facilities such as MRI, DS can be used as a first line diagnostic modality and RI of ≤ 0.62 is an appropriate cut-off for the diagnosis of perinatal asphyxia.

Sex differences in cerebral blood flow following chorioamnionitis in healthy term infants

OBJECTIVE

Sex is an important determinant of neonatal outcomes and may have a significant role in the physiologic response to maternal chorioamnionitis. Our goal was to determine cerebral blood flow (CBF) parameters by sex and subsequent neurodevelopment in healthy term infants exposed to chorioamnionitis.

STUDY DESIGN

CBF by Doppler ultrasound in anterior and middle cerebral (ACA, MCA) and basilar arteries were analyzed for time-averaged maximum velocity (TAMX) and corrected resistive index in 52 term control and chorioamnionitis-exposed infants between 24 and 72 h after birth. Placental pathology confirmed histologic evidence of chorioamnionitis (HC). Bayley Scales of Infant Development-III were administered at 12 months.

RESULT

HC male infants had significantly greater TAMX in the MCA and lower mean MCA and ACA resistance than HC females. Abnormal CBF correlated negatively with neurodevelopmental outcome.

CONCLUSION

CBF is altered in term infants with histologically confirmed chorioamnionitis compared with control infants with sex-specific differences.

EEG, evoked potentials and pulsed Doppler in asphyxiated term infants

OBJECTIVE

To evaluate electroencephalograms (EEG), evoked potentials (EPs) and Doppler findings in the cerebral arteries as predictors of a 1-year outcome in asphyxiated newborn infants.

METHODS

EEG and EPs (brain stem auditory (BAEP), somatosensory (SEP), visual (VEP) evoked potentials) were assessed in 30 asphyxiated and 30 healthy term infants during the first days (range 1-8). Cerebral blood flow velocities (CBFV) were measured from the cerebral arteries using pulsed Doppler at ∼24h of age. EEG, EPs, Doppler findings, symptoms of hypoxic ischemic encephalopathy (HIE) and their combination were evaluated in predicting a 1-year outcome.

RESULTS

An abnormal EEG background predicted poor outcome in the asphyxia group with a sensitivity of 67% and 81% specificity, and an abnormal SEP with 75% and 79%, respectively. Combining increased systolic CBFV (mean+3SD) with abnormal EEG or SEP improved the specificity, but not the sensitivity. The predictive values of abnormal BAEP and VEP were poor. Normal EEG and SEP predicted good outcome in the asphyxia group with sensitivities from 79% to 81%. The combination of normal EEG, normal SEP and systolic CBFV<3SD predicted good outcome with a sensitivity of 74% and 100% specificity.

CONCLUSIONS

Combining abnormal EEG or EPs findings with increased systolic CBFV did not improve prediction of a poor 1-year outcome of asphyxiated infants. Normal EEG and normal SEP combined with systolic CBFV<3SD at about 24 h can be valuable in the prediction of normal 1-year outcome.

SIGNIFICANCE

Combining systolic CBFV at 24 h with EEG and SEP examinations can be of use in the prediction of normal 1-year outcome among asphyxiated infants.

Intrauterine inflammation alters cardiopulmonary but not cerebral hemodynamics during open endotracheal tube suction in preterm lambs

BACKGROUND

Intrauterine inflammation adversely affects cardiopulmonary, systemic, and cerebral hemodynamics in preterm neonates, but its impact on responses to endotracheal tube (ETT) suction, known to affect hemodynamics, is unknown. We hypothesized that intrauterine inflammation would alter the cardiopulmonary and cerebral hemodynamic response to open ETT suction in preterm lambs.

METHODS

Chronically instrumented fetuses received intra-amniotic lipopolysaccharide (LPS; to induce intrauterine inflammation) or saline at 118 d of gestation (term ~147 d). At 125 d of gestation, lambs were delivered and mechanically ventilated. Open ETT suction was performed 30 min after delivery. Pulmonary and cerebral arterial pressures and flows were recorded continuously.

RESULTS

Intrauterine inflammation reduced pulmonary blood flow (PBF) and increased pulmonary vascular resistance (PVR) after preterm birth. PBF and left-ventricular output (LVO) increased during and immediately after ETT suction in both groups, but the values were higher in LPS-exposed lambs. Preductal oxygenation significantly decreased during ETT suction but to a greater extent in LPS-exposed lambs. Cerebral blood flow and systemic arterial pressure were increased by open ETT suction similarly in the two groups.

CONCLUSION

Intrauterine inflammation exacerbates the neonatal hemodynamic response to open ETT suction.

Relationship of neonatal cerebral blood flow velocity asymmetry with early motor, cognitive and language development in term infants

The objective of this study was to examine the relationships of Doppler cerebral blood flow velocity (CBFV) asymmetry measures with developmental outcomes in term infants. Doppler CBFV parameters (peak systolic velocity [PSV] and mean velocity [MV]) of the bilateral middle cerebral arteries of 52 healthy term infants were prospectively examined on postnatal days 1-5, and then their motor, cognitive and language development was evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition, at 6, 12, 18 and 24 months of age. The left CBFV asymmetry measure (PSV or MV) was calculated by subtracting the right-side value from the left-side value. Left CBFV asymmetry measures were significantly positively related to motor scores at 6 (r = 0.3-0.32, p < 0.05) and 12 (r = 0.35, p < 0.05) months of age, but were not related to cognitive or language outcome. Thus, the leftward hemodynamic status of the middle cerebral arteries, as measured by cranial Doppler ultrasound in the neonatal period, predicts early motor outcome in term infants.