Risk factors for neonatal intraventricular haemorrhage in spontaneous prematurity at 32 weeks gestation or less

The histologic fetal inflammatory response and neonatal outcomes: systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the prognostic role of concomitant histological fetal inflammatory response with chorioamnionitis on neonatal outcomes through a systematic review and meta-analysis of existing literature.

DATA SOURCES

The primary search was conducted on October 17, 2021, and it was updated on May 26, 2023, across 4 separate databases (MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and Scopus) without using any filters.

STUDY ELIGIBILITY CRITERIA

Observational studies reporting obstetrical and neonatal outcomes of infant-mother dyads with histological chorioamnionitis and histological fetal inflammatory response vs infant-mother dyads with histological chorioamnionitis alone were eligible. Studies that enrolled only preterm neonates, studies on neonates born before 37 weeks of gestation, or studies on neonates with very low birthweight (birthweight <1500 g) were included. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42021283448).

METHODS

The records were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random-effect model-based pooled odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes.

RESULTS

Overall, 50 studies were identified. A quantitative analysis of 14 outcomes was performed. Subgroup analysis using the mean gestational age of the studies was performed, and a cutoff of 28 weeks of gestation was implemented. Among neonates with lower gestational ages, early-onset sepsis (pooled odds ratio, 2.23; 95% confidence interval, 1.76-2.84) and bronchopulmonary dysplasia (pooled odds ratio, 1.30; 95% confidence interval, 1.02-1.66) were associated with histological fetal inflammatory response. Our analysis showed that preterm neonates with a concomitant histological fetal inflammatory response are more likely to develop intraventricular hemorrhage (pooled odds ratio, 1.54; 95% confidence interval, 1.18-2.02) and retinopathy of prematurity (pooled odds ratio, 1.37; 95% confidence interval, 1.03-1.82). The odds of clinical chorioamnionitis were almost 3-fold higher among infant-mother dyads with histological fetal inflammatory response than among infant-mother dyads with histological chorioamnionitis alone (pooled odds ratio, 2.99; 95% confidence interval, 1.96-4.55).

CONCLUSION

This study investigated multiple neonatal outcomes and found association in the case of 4 major morbidities: early-onset sepsis, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity.

Previable preterm premature rupture of membranes: 117 cases with neonatal outcomes in light of current research

BACKGROUND

ppPROM <  24 + 0 weeks of gestation complicates <  1 % of all pregnancies but is responsible for significant maternal and neonatal morbidity. It is associated with 18-20% of perinatal deaths.

OBJECTIVE

To evaluate neonatal outcome after expectant management in ppPROM in order to obtain evidence-based information for purposes of future counselling.

METHODS

A single-centre, retrospective cohort study of 117 neonates born 1994 to 2012 after ppPROM <  24 weeks of gestation with a latency period >  24 hours and admission to the NICU of the Department of Neonatology, University of Bonn. Data of pregnancy characteristics and neonatal outcome were collected. The results were compared to those found in the literature.

RESULTS

The mean gestational age at ppPROM was 20.45±2,9 weeks (range 11 + 2 -22 + 6) with a mean latency period of 44.7±34.8 days (range 1-135). Mean gestational age at birth was 26.77±3.22 weeks (range 22 + 2-35 + 3). 117 newborns were admitted to the NICU, the overall survival rate at discharge was 72.6% (85/117). Non-survivors had a significantly lower gestational age and higher rates of intra-amniotic infections. The most common neonatal morbidities were RDS (76.1%), BPD (22.2%), pulmonary hypoplasia (PH) (14.5%), neonatal sepsis (37.6%), IVH (34.1% all grades, 17.9% grades III/IV), NEC (8.5%) and musculoskeletal deformities (13.7%). Mild growth restriction as a new complication of ppPROM was observed.

CONCLUSIONS

Neonatal morbidity after expectant management is similar to that described for infants without ppPROM, but carries a higher risk of pulmonary hypoplasia and mild growth restriction.

Establishment and evaluation of nomogram for predicting intraventricular hemorrhage in neonatal acute respiratory distress syndrome

BACKGROUND

Intraventricular hemorrhage (IVH) is the most common type of brain injury in newborns, especially in newborns with Neonatal acute respiratory distress syndrome (ARDS). IVH can cause brain parenchyma damage and long-term neurological sequelae in children. Early identification and prevention of sequelae are essential. This study aims to establish a predictive nomogram for the early prediction of IVH in newborns with ARDS.

METHODS

From 2019 to 2021, we collected data from 222 infants diagnosed with ARDS in the Department of Neonatology, First Affiliated Hospital of Xinjiang Medical University. Infants have been randomly assigned to the training set (n = 161) or the validation set (n = 61) at a ratio of 7:3. Variables were screened using the Least Absolute Contract and Selection Operator (LASSO) regression to create a risk model for IVH in infants with ARDS. The variables chosen in the LASSO regression model were used to establish the prediction model using multivariate logistic regression analysis.

RESULTS

We recognized 4 variables as independent risk factors for IVH in newborns with ARDS via LASSO analysis, consisting of premature rupture of membranes (PROM), pulmonary surfactant (PS) dosage, PH¹ and Arterial partial pressure of oxygen (PaO₂¹). The C-Index for this dataset is 0.868 (95% CI: 0.837-0.940) and the C index in bootstrap verification is 0.852 respectively. The analysis of the decision curve shows that the model can significantly improve clinical efficiency in predicting IVH. We also provide a website based on the model and open it to users for free, so that the model can be better applied to clinical practice.

CONCLUSION

In conclusion, the nomogram based on 4 factors shows good identification, calibration and clinical practicability. Our nomographs can help clinicians make clinical decisions, screen high-risk ARDS newborns, and facilitate early identification and management of IVH patients.

Placental pathology and intraventricular hemorrhage in preterm and small for gestational age infants

OBJECTIVE

The aim of this study was to examine the relationship between chorioamnionitis and vascular malperfusion on placental pathology and intraventricular hemorrhage (IVH) in premature and small for gestational age (SGA) infants.

STUDY DESIGN

A retrospective analysis of 263 infants ≤34 weeks gestation or ≤1800 g and their mothers was conducted by chart review for placental pathology and clinical data from 2014 to 2018. Unadjusted and adjusted odds ratios (OR) for the association of placental pathology with IVH were calculated.

RESULT

Unadjusted OR showed an association between acute chorioamnionitis and IVH, but logistic regression analysis showed a non-significant adjusted OR between acute or chronic chorioamnionitis with IVH. Maternal vascular malperfusion was significantly associated with increased IVH when controlling for confounders.

CONCLUSION

Placental maternal vascular malperfusion is associated with the development of IVH in premature and SGA infants when controlling for other confounders.

Pathological staging of chorioamnionitis contributes to complications in preterm infants

Objective

To investigate the effect of pathological staging of chorioamnionitis (CA) on complications in preterm infants;

Methods

A single-center, retrospective study was conducted to choose singleton preterm infants (gestational age < 37 weeks) from the Department of Obstetrics and Gynecology in our hospital from December 2016 to December 2017. The basic data and placental pathological results were retrospectively collected. According to the placental pathological results of whether inflammation infiltrating amnion, CA 0/I phase was classified into non-amnionitis group, CA II/III phase was classified into amnionitis group, the incidence of common complications in preterm infants was compared. Further, logistic regression was used to analyze the effects of amnionitis on complications after being adjusted to gestational age, birth weight and thrombocytopenia.

Results

A total of 221 preterm infants were enrolled, including 186 cases in non-amnionitis group and 35 cases in amnionitis group. The gestational age of amnionitis group (32.00 ± 2.71 weeks) was significantly lower than non-amnionitis group (34.14 ± 2.06 weeks), birth weight (1.93 ± 0.64 kg) was significantly lower than that of non-amnionitis group (2.26 ± 0.58 kg), and the hospital stay in amnionitis group was significantly longer (25.71 ± 19.23 days), all of the difference above was statistically significant(P < 0.05). The incidence of intraventricular hemorrhage (IVH) in amnionitis group (37.14%) was significantly higher than that in non-amnionitis group (13.98%) (P = 0.002), and the risk of IVH was significantly increased by amnionitis (OR = 3.636, 95%CI: 1.632–8.102); after correction of gestational age, birth weight and thrombocytopenia, the risk of IVH was still significantly increased (OR = 2.471, P = 0.046, 95% CI: 1.015–6.015). And the late-onset IVH was more common (P = 0.009).

Conclusion

Amnionitis leads to a significant reduction in gestational age and birth weight in preterm infants, and it is an independent risk factor for IVH.

Perinatal prediction model for severe intraventricular hemorrhage and the effect of early postnatal acidosis

PURPOSE

Severe acidosis is one of the strongest predictors of neurologic outcomes in full-term infants with suspected hypoxic-ischemic encephalopathy. However, the relative importance of acidosis as a predictor of outcomes in preterm infants is much less clear. The goals of the present study were to examine the association between postnatal acidosis and severe intraventricular hemorrhage (IVH) and to establish a new score model including acid-base status after birth for predicting the risk of this morbidity.

METHODS

The study sample was very low birth weight (VLBW) infants in the Korean Neonatal Network (KNN) cohort registry, collected prospectively from January 2013 to December 2014. Infants with blood pH and base deficit (BD) values collected within the first hour after birth, and documentation of severe IVH, were included. Multivariate stepwise logistic regression analysis was used to determine the contribution of postnatal acidosis to predicting severe IVH in VLBW infants. In addition, a prediction model was developed.

RESULTS

Data from 2518 VLBW infants were analyzed. Infants with postnatal acidosis had a higher incidence of severe IVH. The clinical model plus blood BD values improved predictive performance, compared with models using only perinatal data or blood pH.

CONCLUSIONS

A prediction model for severe IVH was developed using the KNN registry of VLBW infants. Immediate postnatal acidosis, defined based on blood BD, was associated with a higher-risk-adjusted incidence of severe IVH.

[Epidemiology, risk factors and child prognosis: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of preterm premature rupture of membranes (PPROM). To describe the evolution of pregnancy, neonatal outcomes and the prognosis of infants born in a context of PPROM, according to the existence of an associated intrauterine infection and to the latency duration.

METHOD

Consultation of the Medline database, from 1980 to February 2018.

RESULTS

PPROM before 37 and before 34 weeks' gestation occur in 2-3% and <1% of pregnancies, respectively (LE2). Although many risk factors are identified, few are modifiable, and the vast majority of patients have no risk factors (LE2). Consequently, individual prediction of the risk of PPROM and primary prevention measures have not been shown to be effective and are not recommended in clinical practice (Grade B). Most women give birth within the week following PPROM (LE2). The main complications of PPROM are prematurity, intrauterine infection and obstetric and maternal complications (LE2). Latency duration and the frequency of complications decrease with increasing gestational age at PPROM (LE2). Neonatal prognosis is largely conditioned by gestational age at birth, with no apparent over-risk of poor outcomes linked to PPROM compared to other causes of preterm birth (LE2). In contrast, intrauterine infection is associated with an increased risk of in utero fetal death (LE3), necrotizing enterocolitis (LE1) and early-onset sepsis (LE2). The association of intrauterine infection with neurological morbidity remains controversial. Prolongation of latency, from gestational age at PPROM, is beneficial for the child (LE2).

CONCLUSION

PPROM is a major cause of prematurity and short- and long-term mortality and morbidity. Antenatal care is an important issue for obstetric and pediatric teams, aiming to reduce complications and adverse consequences for both mother and child.

Vascular placental pathology and the relationship between hypertensive disorders of pregnancy and neonatal outcomes in very low birth weight infants

OBJECTIVE

To investigate vascular placental pathology's effect on known associations between hypertensive disorders and four adverse neonatal outcomes-bronchopulmonary dysplasia, intraventricular hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, and death.

STUDY DESIGN

Retrospective cohort of very low birth weight neonates born at a single center (n = 911). Statistical analysis included χ², t test, modified Poisson regression with robust error variance to measure risk, and Wald test. Stratified models assessed the effect of maternal hypertension on neonatal outcomes in those exposed to placental pathology.

RESULTS

Neonates exposed to maternal hypertension and placental pathology had an increased risk of bronchopulmonary dysplasia (relative risk (RR) = 5.23, 95% confidence interval (CI): 2.07, 13.22) compared to those exposed to hypertension without placental pathology (RR = 1.63, 95% CI: 1.14, 2.34; Wald test p = 0.02). Similar, but non-significant, trends also emerged for necrotizing enterocolitis and death.

CONCLUSION

Vascular placental pathology may amplify the risk of adverse outcomes in neonates exposed to hypertension and may mark the extent to which hypertension affects neonates.

Histologic chorioamnionitis in preterm infants: correlation with brain magnetic resonance imaging at term equivalent age

BACKGROUND

To explore the associations between histologic chorioamnionitis with brain injury, maturation and size on magnetic resonance imaging (MRI) of preterm infants at term equivalent age.

METHODS

Preterm infants (23-36 weeks' gestational age) were recruited into two longitudinal cohort studies. Presence or absence of chorioamnionitis was obtained from placental histology and clinical data were recorded. MRI at term-equivalent age was assessed for brain injury (intraventricular haemorrhage, cysts, signal abnormalities), maturation (degree of myelination, gyral maturation) and size of cerebral structures (metrics and brain segmentation). Histologic chorioamnionitis was assessed as a predictor of MRI variables using linear and logistic regression, with adjustment for confounding perinatal variables.

RESULTS

Two hundred and twelve infants were included in this study, 47 (22%) of whom had histologic chorioamnionitis. Histologic chorioamnionitis was associated with higher odds of intraventricular haemorrhage (odds ratio [OR] (95% confidence interval [CI]) = 7.4 (2.4, 23.1)), less mature gyral maturation (OR (95% CI) = 2.0 (1.0, 3.8)) and larger brain volume (mean difference in cubic centimeter (95% CI) of 14.1 (1.9, 26.2)); but all relationships disappeared following adjustment for perinatal variables.

CONCLUSION

Histologic chorioamnionitis was not independently associated with IVH, less mature gyral maturation or brain volume at term-equivalent age in preterm infants.

The combined exposure to intra-amniotic inflammation and neonatal respiratory distress syndrome increases the risk of intraventricular hemorrhage in preterm neonates

OBJECTIVE

To evaluate the impact of combined exposure to intra-amniotic inflammation and neonatal respiratory distress syndrome (RDS) on the development of intraventricular hemorrhage (IVH) in preterm neonates.

METHODS

This retrospective cohort study includes 207 consecutive preterm births (24.0-33.0 weeks of gestation). Intra-amniotic inflammation was defined as an amniotic fluid matrix metalloproteinase-8 concentration >23 ng/mL. According to McMenamin's classification, IVH was defined as grade II or higher when detected by neurosonography within the first weeks of life.

RESULTS

(1) IVH was diagnosed in 6.8% (14/207) of neonates in the study population; (2) IVH was frequent among newborns exposed to intra-amniotic inflammation when followed by postnatal RDS [33% (6/18)]. The frequency of IVH was 7% (8/115) among neonates exposed to either of these conditions - intra-amniotic inflammation or RDS - and 0% (0/64) among those who were not exposed to these conditions; and (3) Neonates exposed to intra-amniotic inflammation and postnatal RDS had a significantly higher risk of IVH than those with only intra-amniotic inflammation [odds ratio (OR) 4.6, 95% confidence interval (CI) 1.1-19.3] and those with RDS alone (OR 5.6, 95% CI 1.0-30.9), after adjusting for gestational age.

CONCLUSION

The combined exposure to intra-amniotic inflammation and postnatal RDS markedly increased the risk of IVH in preterm neonates.

15-Hydroxyprostaglandin Dehydrogenase Protein Expression in Human Fetal Membranes With and Without Subclinical Inflammation

Prostaglandins play a central role in the stimulation and maintenance of both term and preterm labor. 15-Hydroxyprostaglandin dehydrogenase (PGDH), localized primarily to chorion trophoblasts, is the key enzyme responsible for the metabolism of prostaglandins. In preterm chorion, levels of PGDH protein and activity were lower when compared to term and were further reduced with the presence of infection, but effects of subclinical inflammation and membrane rupture on PGDH expression are not known. Our objectives were (1) to determine the relative expression of PGDH in amnion and chorion and (2) to determine the effect of preterm premature rupture of membranes (PPROM) and (3) subclinical inflammation on PGDH protein expression in preterm fetal membranes. Fetal membranes were collected from women with idiopathic preterm labor. Patients were divided into preterm birth (1) <32 weeks with PPROM (n = 6), (2) <32 weeks with intact membranes (n = 11), (3) >or=32 and <37 weeks with PPROM (n = 10), and (4) >or=32 and <37 weeks with intact membranes (n = 10). Different antibodies were used to detect protein expression and localization of PGDH in amnion and chorion from these patients using both Western blotting and immunohistochemistry. Antibody T (AbT) localized PGDH to chorion trophoblasts, whereas antibody C (AbC) detected immunoreactive (ir) PGDH predominantly in the amnion mesenchyme. By Western blot, AbT showed a stronger 29-kDa ir-PGDH band whereas with AbC, a stronger 55-kDa ir-PGDH signal was detected. 55-kDa ir-PGDH was significantly higher in PPROM amnion, specifically in the <32 weeks group (P < .05) and with PPROM >24 hours (P < .05). No change was detected in the 29-kDa ir-PGDH in either amnion or chorion with gestational age or the presence and absence of PPROM. In addition, neither form of ir-PGDH was altered significantly with or without subclinical inflammation. ir-PGDH is detectable in both chorion trophoblasts and amnion, especially in the mesenchyme; however, the predominant form of the enzyme differs in the 2 tissues. PPROM and subclinical inflammation do not appear to affect the levels of 29-kDa ir-PGDH protein in the fetal membranes. The differential expression of 55-kDa ir-PGDH in preterm amnion with and without PPROM supports the need for a better understanding of the different forms of PGDH.

Intrauterine inflammation, cerebral oxygen consumption and susceptibility to early brain injury in very preterm newborns

BACKGROUND

In utero exposure to inflammation results in elevated cerebral oxygen consumption. This increased metabolic demand may contribute to the association between chorioamnionitis and intraventricular haemorrhage (P/IVH). We hypothesised that intrauterine inflammation imposes an elevated cerebral metabolic load and increased fractional oxygen extraction (cFTOE) with cFTOE further increased in the presence of early P/IVH.

METHODS

Eighty-three infants ≤30 weeks gestation were recruited. Exposure to intrauterine inflammation was determined by placental histology. Total internal carotid blood flow (Doppler ultrasound) and near infrared spectroscopy were measured and cerebral oxygen delivery (mcerbDO2), consumption (mcerbVO2) and cFTOE were calculated on days 1 and 3 of life. Primary outcome was defined as death or P/IVH >grade II (cranial sonograph) by day 3.

RESULTS

Infants exposed to intrauterine inflammation had higher total internal carotid blood flow (92 vs 63 mL/kg/min) and mcerbDO2 (13.7 vs 10.1 mL/kg/min) than those not exposed to inflammation. Newborns with P/IVH had both higher oxygen consumption and extraction compared with those without sonographic injury regardless of exposure to intrauterine inflammation. Further, in preterms exposed to inflammation, those with P/IVH had higher consumption (6.1 vs 4.8 mL/kg/min) and extraction than those without injury. These differences were observed only on day 1 of life.

CONCLUSIONS

Although P/IVH is multifactorial in preterm newborns, it is likely that cerebral hypoxic-ischaemia plays a central pathophysiological role. These data provide a mechanistic insight into this process and suggests that the increased cerebral metabolic load imposed by the presence of inflammation results in a higher risk of critical hypoxic ischaemia in the preterm with increased susceptibility to significant P/IVH.

Risk Factors for Intraventricular Hemorrhage in Preterm Infants Born at 34 Weeks of Gestation or Less Following Preterm Premature Rupture of Membranes

OBJECTIVE

The objective of this study is to identify possible perinatal risk factors related to intraventricular hemorrhage (IVH) in preterm infants born at 34 weeks of gestation or less following preterm premature rupture of membranes (pPROM).

METHODS

A total of 292 preterm infants born at 34 weeks of gestation or less following pPROM were enrolled in the study, while 155 newborns with incomplete data, especially those that lack histological examination of the placenta, maternal details, and neonatal characteristics, have been further excluded. Finally, data of 137 preterm infants were included in the analysis. All infants underwent ultrasonographic screening for IVH. Thirty-three infants with IVH were considered as cases and 104 infants without IVH were considered as controls. The association between risk factors and IVH was evaluated by univariate and multivariate logistic regression analyses.

RESULTS

The incidence of IVH in preterm infants born at 34 weeks of gestation or less following pPROM was 24.1%, while the incidence of maternal chorioamnionitis was 43.8%. By univariate analysis, gestational age, birth weight, asphyxia resuscitation, maternal chorioamnionitis, fetal distress, amniotic fluid index, and latency of the rupture of membranes to birth were found to be significantly different between the 2 groups. By logistic regression analysis, lower gestational age, low birth weight, asphyxia resuscitation, and maternal chorioamnionitis were found to be independent risk factors for IVH.

CONCLUSION

Lower gestational age, low birth weight, asphyxia resuscitation, and maternal chorioamnionitis are independent risk factors for IVH in preterm infants born at 34 weeks of gestation or less following pPROM.

Elevated plasma and cerebrospinal fluid interleukin-1 beta and tumor necrosis factor-alpha concentration and combined outcome of death or abnormal neuroimaging in preterm neonates with early-onset clinical sepsis

OBJECTIVE

Prematurity and sepsis are the major contributors of neonatal mortality and neurodevelopmental sequelae. The present study was conducted to measure the plasma and cerebrospinal fluid (CSF) concentration of interleukin (IL)-1β and tumor necrotic factor (TNF)-α in preterm neonates with early-onset clinical sepsis (EOCS), and to find out their association with combined outcome of death or abnormal neuroimaging.

STUDY DESIGN

Thirty-two preterm (⩽34 weeks) neonates with EOCS and 32 gestational age-matched, healthy neonates served as cases and controls, respectively. Samples were collected soon after birth. Neonates were followed up clinically and by serial cranial ultrasonography (CUS) until discharge and subsequently by magnetic resonance imaging (MRI) of brain until 1 year. Developmental screening was done by Denver Developmental Screening test-II.

RESULT

In EOCS group, no neonate had any clinical/microbiological evidence of meningitis. Blood culture was positive in 17 (53%). CUS was abnormal in 12 (37%) (intracranial hemorrhage-11, periventricular leukomalacia-1). Ten (31%) neonates expired. Significant elevation of plasma and CSF IL-1β and TNF-α was observed in the EOCS group. On follow-up, seven (22%) neonates showed evidence of white matter damage in MRI, two of them had developmental delay and microcephaly. Plasma and CSF IL-1β and TNF-α concentration were significantly elevated in deceased neonates and those with abnormal neuroimaging. Both biomarkers demonstrated high predictive accuracy for poor outcome in receiver-operating curve analysis.

CONCLUSION

Elevation of plasma and CSF IL-1β and TNF-α is associated with an increase in the combined outcome of death or abnormal neuroimaging in preterm neonates with EOCS in the absence of clinical/microbiological evidence of meningitis with high predictive accuracy.

Intraventricular Hemorrhage and Post Hemorrhagic Hydrocephalus among Very-Low-Birth-Weight Infants in Korea

Here, we aimed to evaluate the incidence and mortality of intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus (PHH) among very-low-birth-weight (VLBW) infants in Korea and assess the associated factors of PHH. This cohort study used prospectively collected data from the Korean Neonatal Network (KNN). Among 2,386 VLBW infants in the KNN database born between January 2013 and June 2014, 63 infants who died without brain ultrasonography results were excluded. Maternal demographics and neonatal clinical characteristics were assessed. The overall incidence of IVH in all the VLBW infants was 42.2% (987 of 2,323), while those of IVH grade 1, 2, 3, and 4 were 25.1%, 7.0%, 4.8%, and 5.5%, respectively. The incidence and severity of IVH showed a negatively correlating trend with gestational age and birth weight. PHH developed in 0%, 3.5%, 36.1%, and 63.8% of the surviving infants with IVH grades 1, 2, 3, and 4, respectively. Overall, in the VLBW infants, the IVH-associated mortality rate was 1.0% (24/2,323). Only IVH grade severity was proven to be an associated with PHH development in infants with IVH grades 3-4. This is the first Korean national report of IVH and PHH incidences in VLBW infants. Further risk factor analyses or quality improvement studies to reduce IVH are warranted.

Temporal trends of intraventricular hemorrhage of prematurity in Nova Scotia from 1993 to 2012

OBJECT Intraventicular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PHH) are common in premature newborns. The epidemiology of these conditions has been described, but selection bias remains a significant concern in many studies. The goal of this study was to review temporal trends in the incidence of IVH, PHH, and shunt surgery in a population-based cohort of very preterm infants with no selection bias. METHODS All very preterm infants (gestational age ≥ 20 and ≤ 30 weeks) born from 1993 onward to residents of Nova Scotia were evaluated by the IWK Health Centre's Perinatal Follow-Up Program, and were entered in a database. Infants born to residents of Nova Scotia from January 1, 1993, to December 31, 2012, were included in this study. The incidences of IVH, PHH, and shunt surgery were calculated, basic demographic information was described, and chi-square test for trends over time was determined. RESULTS Of 1334 successfully resuscitated very preterm infants who survived to their initial screening ultrasound, 407 (31%) had an IVH, and 149 (11%) had an IVH Grade 3 or 4. No patients with IVH Grade 1 or 2 developed PHH. The percentage of very preterm infants with IVH Grade 3 or 4 has significantly increased over time (p = 0.013), as have the incidence of PHH and shunt surgery (p = 0.001 and p = 0.011, respectively) in infants with Grade 3 or 4 IVH. The proportion of patients with PHH receiving a shunt has not changed over time (p = 0.813). CONCLUSIONS The increasing incidence of high-grade IVH-and PHH and shunt surgery in infants with high-grade IVH-over time is worrisome. This study identifies a number of associated factors, but further research to identify preventable and treatable causal factors is warranted.

Risk factors associated with germinal matrix-intraventricular hemorrhage in preterm neonates

Objective

The purpose of this study is to identify the risk factors associated with the development of germinal matrix-intraventricular hemorrhage (GM-IVH) and the relationship of the severity of disease and prematurity.

Methods

A total of 168 premature neonates whose birth weight ≤1500 g or gestational age ≤34 weeks were examined by cranial ultrasound (CUS) for detection of GM-IVH among the babies admitted between January 2011 and December 2012 in our medical center neonatal intensive care unit. The babies were divided into two groups : GM-IVH and non-IVH. Clinical presentations, precipitating factors of the patients and maternal factors were analyzed.

Results

In univariate analysis, gestational age, birth weight, delivery method, presence of premature rupture of membrane (PROM) and level of sodium and glucose were statistically meaningful factors (p<0.05). But only two factors, gestational age and presence of patent ductus arteriosus (PDA) were statistically meaningful in multivariate logistic regression (p<0.05). Delivery method [normal vaginal delivery (NVD) to Caeserean section] was borderline significant (p<0.10).

Conclusion

Presence of PDA and gestational age were the important risk factors associated with development of GM-IVH.

Chorioamnionitis in the pathogenesis of brain injury in preterm infants

Chorioamnionitis (or placental infection) is suspected to be a risk factor for brain injury in premature infants. The suggested association between chorioamnionitis and cystic periventricular leukomalacia and cerebral palsy is uncertain because of the variability of study designs and definitions of chorioamnionitis. Improvements in neonatal intensive care may have attenuated the impact of chorioamnionitis on brain health outcomes. Large multicenter studies using rigorous definitions of chorioamnionitis on placental pathologies and quantitative magnetic resonance techniques may offer the optimal way to clarify the complex role of chorioamnionitis in modifying brain health and long-term outcomes.

It is not the ride: inter-hospital transport is not an independent risk factor for intraventricular hemorrhage among very low birth weight infants

OBJECTIVE

The purpose of this study was to evaluate the relationship between intraventricular hemorrhage (IVH), inter-hospital transport and known potential risk factors for IVH.

STUDY DESIGN

Very low birth weight (VLBW <1500 g) infants admitted to a large regional neonatal intensive care unit within 48 h of life from 2005 to 2010 were identified. Logistic regression and proportional odds logistic regression models were used to compare inborn versus outborn patients with respect to IVH (any vs none) and IVH grade, respectively. Logistic regression was used to quantify the association between outborn status and mortality.

RESULT

A total of 758 infants were included in the study (inborn=568, outborn=190). Outborn infants were found to have greater IVH severity than inborn (odds ratio (OR): 1.52; P=0.012). After accounting for 20 clinical and demographic variables in a multivariable model, the association between outborn status and IVH lacked statistical significance (OR: 1.14; P=0.56). Significant predictors of IVH grade included vaginal delivery (OR: 2.16; P<0.001), patent ductus arteriosus (OR: 1.65; P=0.005), 5-min Apgar (OR: 0.85; P=0.005) and gestational age (OR: 0.98; P=0.012). Sixty-nine (9.1%) of the infants died. After adjusting for potential confounders, the relationship between mortality and outborn status was not significant (OR:1.26; P=0.516). Significant predictors of mortality included gestational age (OR: 1.03; P=0.04) and 5-min Apgar (OR:1.22; P=0.02).

CONCLUSION

Although VLBW infants transported during the first 2 days of life have higher rates of IVH than infants born at a tertiary care facility, this relationship may be explained by associations with underlying clinical variables rather than transport itself.

Incidence of brain injuries in premature infants with gestational age ≤ 34 weeks in ten urban hospitals in China

BACKGROUND

There is a large number (1.5 million per year) of premature births in China. It is necessary to obtain the authentic incidences of intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL), the common brain injuries, in Chinese premature infants. The present multicenter study aimed to investigate the incidence of brain injuries in premature infants in ten urban hospitals in China.

METHODS

The research proposal was designed by the Subspecialty Group of Neonatology of Pediatric Society of the Chinese Medical Association. Ten large-scale urban hospitals voluntarily joined the multicenter investigation. All premature infants with a gestational age ≤ 34 weeks in the ten hospitals were subjected to routine cranial ultrasound within three days after birth, and then to repeated ultrasound every 3-7 days till their discharge from the hospital from January 2005 to August 2006. A uniform data collection sheet was designed to record cases of brain injuries.

RESULTS

The incidences of overall IVH and severe IVH were 19.7% (305/1551) and 4.6% (72/1551), respectively with 18.4% (56/305) for grade 1, 58.0% (177/305) for grade 2, 17.7% (54/305) for grade 3 and 5.9% (18/305) for grade 4 in nine hospitals. The incidences of overall PVL and cystic PVL were 5.0% (89/1792) and 0.8% (14/1792) respectively, with 84.3% (75/89) for grade 1, 13.5% (12/89) for grade 2, and 2.2% (2/89) for grade 3 in the ten hospitals. The statistically significant risk factors that might aggravate the severity of IVH were vaginal delivery (OR=1.883, 95% CI: 1.099-3.228, P=0.020) and mechanical ventilation (OR=4.150, 95% CI: 2.384-7.223, P=0.000). The risk factors that might result in the development of cystic PVL was vaginal delivery (OR=21.094, 95% CI: 2.650-167.895, P=0.000).

CONCLUSIONS

The investigative report can basically reflect the incidence of brain injuries in premature infants in major big cities of China. Since more than 60% of the Chinese population live in the rural areas of China, it is expected to undertake a further multicenter investigation covering the rural areas in the future.

Proteomics/diagnosis of chorioamnionitis and of relationships with the fetal exposome

Proteomics, a relatively young science, originally emerged as a complement to genomics research. By definition, the goal of proteomics is to provide a snapshot of all the proteins within an organism, tissue or biological sample at a given moment. Proteomics has the ability to single out one or more proteins (biomarkers) that change consistently in affected subjects as compared to those disease-free. From a proteomics perspective, chorioamnionitis poses both challenges and opportunities. Challenges relate to the dynamic course of the inflammatory process, and compartmentalization of the gestational sac in relation to the maternal compartment. An inability to evaluate the amniotic fluid non-invasively and repeatedly for meaningful changes in its proteome, and lack of a true gold standard for diagnosis of inflammation and/or infection, represent additional challenges. On the other hand, the unbiased and holistic nature of proteomics offers a real opportunity to improve the current diagnostic and prognostic algorithms for chorioamnionitis. Even at this current stage there are reasons to believe that proteomic biomarkers will improve the understanding of how chorioamnionitis programs or affects the fetus in utero, thus defining its exposome (sum of interactions between genetic make-up of the fetus and the intrauterine environment) of pregnancies affected by infection and/or inflammation. This review summarizes the results of proteomics studies that have aimed or reached these goals.

Elevated interleukin-6 concentration and alterations of the coagulation system are associated with the development of intraventricular hemorrhage in extremely preterm infants

BACKGROUND

Pathogenesis of intraventricular hemorrhage (IVH) in premature infants is multifactorial. Little is known about the influence of pro-inflammatory cytokine activation on the coagulation system in extremely preterm infants and its impact on the development of IVH.

OBJECTIVE

To determine the interaction between serum interleukin-6 (IL-6) and the coagulation system in preterm infants predisposed to the development of IVH.

METHODS

Vitamin K-dependent coagulation factors were examined retrospectively in 132 extremely preterm infants prior to vitamin K administration at the first day of life. Patients were grouped according to the occurrence of IVH and serum concentration of IL-6 >/<100 pg/ml.

RESULTS

Occurrence of IVH was associated with clinical diagnosis of chorioamnionitis, low gestational age, high CRIB score, air leak, catecholamine treatment, low initial hematocrit and increased serum concentration of IL-6. Infants developing IVH showed a diminished coagulation profile. Multivariable logistic regression analysis revealed decreased activity of coagulation factor VII, development of pneumothorax and low hematocrit as independent risk factors for the development of IVH. An increased IL-6 serum concentration was associated with a significantly decreased activity of coagulation factor VII and increased levels of fibrinogen.

CONCLUSIONS

The association of elevated IL-6 levels with alterations of the coagulation profile and development of IVH found in our study supports the assumption of a close pathophysiological relation between inflammation and IVH.

Proteomics mapping of cord blood identifies haptoglobin "switch-on" pattern as biomarker of early-onset neonatal sepsis in preterm newborns

Background

Intra-amniotic infection and/or inflammation (IAI) are important causes of preterm birth and early-onset neonatal sepsis (EONS). A prompt and accurate diagnosis of EONS is critical for improved neonatal outcomes. We sought to explore the cord blood proteome and identify biomarkers and functional protein networks characterizing EONS in preterm newborns.

Methodology/Principal Findings

We studied a prospective cohort of 180 premature newborns delivered May 2004-September 2009. A proteomics discovery phase employing two-dimensional differential gel electrophoresis (2D-DIGE) and mass spectrometry identified 19 differentially-expressed proteins in cord blood of newborns with culture-confirmed EONS (n = 3) versus GA-matched controls (n = 3). Ontological classifications of the proteins included transfer/carrier, immunity/defense, protease/extracellular matrix. The 1^st-level external validation conducted in the remaining 174 samples confirmed elevated haptoglobin and haptoglobin-related protein immunoreactivity (Hp&HpRP) in newborns with EONS (presumed and culture-confirmed) independent of GA at birth and birthweight (P<0.001). Western blot concurred in determining that EONS babies had conspicuous Hp&HpRP bands in cord blood (“switch-on pattern”) as opposed to non-EONS newborns who had near-absent “switch-off pattern” (P<0.001). Fetal Hp phenotype independently impacted Hp&HpRP. A Bayesian latent-class analysis (LCA) was further used for unbiased classification of all 180 cases based on probability of “antenatal IAI exposure” as latent variable. This was then subjected to 2^nd-level validation against indicators of adverse short-term neonatal outcome. The optimal LCA algorithm combined Hp&HpRP switch pattern (most input), interleukin-6 and neonatal hematological indices yielding two non-overlapping newborn clusters with low (≤20%) versus high (≥70%) probability of IAI exposure. This approach reclassified ∼30% of clinical EONS diagnoses lowering the number needed to harm and increasing the odds ratios for several adverse outcomes including intra-ventricular hemorrhage.

Conclusions/Significance

Antenatal exposure to IAI results in precocious switch-on of Hp&HpRP expression. As EONS biomarker, cord blood Hp&HpRP has potential to improve the selection of newborns for prompt and targeted treatment at birth.

Replication of genetic associations in the inflammation, complement, and coagulation pathways with intraventricular hemorrhage in LBW preterm neonates

Intraventricular hemorrhage (IVH) is a significant morbidity seen in very LBW infants. Genes related to the inflammation, infection, complement, or coagulation pathways have been implicated as risk factors for IVH. We examined 10 candidate genes for associations with IVH in 271 preterm infants (64 with IVH grades I-IV and 207 without IVH) weighing <1500 g. The heterozygous genotype OR = 8.1, CI = 2.5-26.0, p = 4 × 10(-4)) and the A allele (OR = 7.3, CI = 2.4-22.5, p = 1 × 10(-4)) of the coagulation factor V (FV) Leiden mutation (rs6025) were associated with an increased risk of developing IVH grade I or II but not grade III or IV after correction for multiple testing with Bonferroni. Lack of association in the severe grades of IVH may be a result of lack of power to detect an effect given the small sample size (n = 8). However, this result is consistent with previous research that demonstrates that the heterozygous genotype of the FV mutation is associated with increased risk for the development of IVH but a decreased risk for the progression or extension to more severe grades of IVH.

Correlation between placental histopathology and fetal/neonatal outcome: chorioamnionitis and funisitis are associated to intraventricular haemorrage and retinopathy of prematurity in preterm newborns

INTRODUCTION

Placental anatomopathologic lesions are usually associated with pregnancy complications and neonatal impaired outcome.

PATIENTS AND METHODS

We included in our study 122 patients with gestational age of 26-35 weeks. From the analysis of three pathological aspects (chorioamnionitis, funisitis and chronic hypoxia), a score was assigned to each lesion depending on the severity of the alteration, to establish a correlation with an impaired neonatal outcome in preterm newborns.

RESULTS

We found a correlation between chronic hypoxia and preeclampsia, intrauterine growth restriction and/or small-for-gestational age status at birth. Our results also showed the strong association of fetal placental inflammatory status (chorioamnionitis and funisitis) with premature rupture of membranes, very low birth weight, birth at/before 32 gestational weeks, late-onset sepsis, patent duct arteriosus, intraventricular haemorrhage (IVH) and retinopathy of prematurity (ROP).

CONCLUSIONS

We confirm that placental lesions are associated with impaired pregnancy and neonatal outcome. During pregnancy it may be useful to identify some markers of inflammatory status and chronic hypoxia for an early diagnosis and a detailed monitoring of pregnancy course. Placental pathological analysis is very important to predict the risk of developing serious complications of preterm birth as ROP and IVH.

Cord blood erythropoietin and interleukin-6 for prediction of intraventricular hemorrhage in the preterm neonate

OBJECTIVE

To evaluate cord blood erythropoietin (EPO) and interleukin-6 (IL-6) levels to predict preterm infants at risk of developing intraventricular hemorrhage (IVH).

METHODS

Levels of umbilical cord EPO, acid-base status and IL-6 were analyzed in 116 consecutive, preterm newborns (GA at delivery: 29 [23-34 ] weeks) born to mothers who had a clinically indicated amniocentesis to rule out infection. Early-onset neonatal sepsis (EONS) was diagnosed using symptoms, hematological criteria and blood cultures.

RESULTS

IVH was diagnosed by cranial ultrasounds. The prevalence of IVH in our population was 25% (29/116). There was a direct relationship between cord blood EPO and cord blood IL-6 concentration (r = 0.225, p = 0.014), independent of GA at birth. Elevated cord blood EPO levels (r = 0.182, p = 0.016) and GA at birth (r =  -0.236, p = 0.004) remained significant independent factors associated with the risk of IVH, when evaluated with stepwise logistic regression analyses. Cord blood IL-6, pH, and EONS were not associated with IVH. These relationships remained following correction for GA at birth (p = 0.027).

CONCLUSIONS

Our results suggest that elevation in cord blood EPO may predict newborns at risk for IVH, independent of fetal inflammatory status. Further studies are warranted to confirm this association.

Chemokine CCL18 predicts intraventricular hemorrhage in very preterm infants

BACKGROUND

Intraventricular hemorrhage (IVH) in very preterm infants is a common disease associated with long-term consequences. Risk factors of IVH remain to be further defined.

AIMS

To determine whether specific immunoproteins at birth predict the risk of IVH and whether their receptors are localized at the bleeding site.

METHODS

A prospective cohort consisted of 163 infants born before 32 weeks of gestation. Altogether 107 cord blood immunoproteins and 12 cytokines from peripheral blood obtained 1 and 7 days after birth were analyzed. Serial brain ultrasounds were assessed. Immunohistochemistry of a chemokine receptor from 14 autopsies was studied.

RESULTS

Low levels of cord chemokine CCL18 (chemokine (C-C motif) ligand 18) robustly predicted the risk of IVH grade II-IV when ante- and neonatal risk factors were considered. Cord CCL18 increased from 32 weeks to term. During the first week after very preterm birth CCL18 increased as the risk of new IVH cases decreased. CCL18 receptor, CCR3, was detectable in choroid plexus, periventricular capillary endothelium, ependymal cells, and in germinal matrix.

CONCLUSION

Low cord blood CCL18 is an independent risk factor of IVH. CCL18 may inhibit signal transduction of its receptor in periventricular cells. Defining the function and regulation of CCL18 may help to decrease the risk of IVH.

Risk factors for periventricular-intraventricular hemorrhage in premature infants

Periventricular-intraventricular hemorrhage (PV-IVH) is a major cause of neurological disabilities in preterm newborns. This study aimed to determine the perinatal factors associated with PV-IVH. We conducted a retrospective case-control study from preterm infants born at < or =34 weeks of gestation and admitted to Neonatal Intensive Care Units of Seoul National University Children's Hospital and Seoul National University Bundang Hospital between June 2003 and December 2007. Neonates with no cranial sonographic data or infants transferred from other centers after three days of age were excluded. Of 1,044 eligible subjects, 59 infants with PV-IVH grade 2, 3, and 4 were allocated to the case group. The control group consisted of 118 infants without PV-IVH who were matched for gestational age and birth weight to each case of PV-IVH. At the multivariate logistic regression model, metabolic acidosis (odds ratio [OR]: 6.94; 95% confidence interval [CI]: 1.12-43.23) and use of inotropes (OR: 3.70; 95% CI: 1.16-11.84) were associated with an increased risk of PV-IVH. Maternal use of antenatal corticosteroids decreases the risk of PV-IVH (OR: 0.36; 95% CI: 0.14-0.92).

Is an endothelial nitric oxide synthase gene mutation a risk factor in the origin of intraventricular hemorrhage?

OBJECT

Studies have shown decreased levels of nitric oxide (NO), the product of endothelial NO synthase (eNOS) gene activity, in infants with respiratory conditions and intraventricular hemorrhage (IVH). The authors evaluated the association of the eNOS gene promoter polymorphism T-786C with the cause of these conditions (respiratory conditions and IVH) in premature infants.

METHODS

Blood samples from 124 African American premature infants were studied. The DNA was isolated and microplate polymerase chain reaction-restriction fragment length polymorphism assay was performed. Genotypes were scored as: TT homozygotes with 140 bp and 40 bp; CC homozygotes with 90 bp, 50 bp, and 40 bp; and TC heterozygotes with 140 bp, 90 bp, 50 bp, and 40 bp. Genotypes were stratified according to ethnicity, preterm status, and prematurity conditions.

RESULTS

The mutant allele -786C was present in 15.3% of premature infants with respiratory distress syndrome, bronchopulmonary dysplasia, and IVH, compared with 7.25% in those premature infants without these conditions. A significant 2-fold increase of the mutant allele in patients compared with controls (p = 0.04, OR 2.3) reveals that the eNOS -786C allele could be a significant risk factor in the origin of respiratory conditions and IVH in premature infants.

CONCLUSIONS

These results suggest that the mutant eNOS -786C allele is a significant risk factor in the origin of respiratory and IVH diseases, probably mediating an insufficient supply of endogenous NO in premature infants.

The role of systemic hemodynamic disturbances in prematurity-related brain injury

Premature infants who experience cerebrovascular injury frequently have acute and long-term neurologic complications. In this article, we explore the relationship between systemic hemodynamic insults and brain injury in this patient population and the mechanisms that might be at play.

Brain imaging findings in very preterm infants throughout the neonatal period: part II. Relation with perinatal clinical data

This study describes the relation between frequent and clinically relevant brain imaging findings in very preterm infants (GA<32 weeks), assessed with sequential cranial ultrasonography throughout the neonatal period and MRI around term age, and several potential perinatal risk factors. For ultrasound findings during admission the following independent risk factors were identified: male gender for periventricular echodensities and intraventricular haemorrhage, postnatal corticosteroid treatment for cystic white matter lesions, and lower gestational age for post-haemorrhagic ventricular dilatation. For MRI findings around term age, including punctate white matter lesions, ventricular dilatation, decreased cortical complexity, and diffuse and excessive high signal intensity, no independent risk factors were found. In very preterm infants, the risk factors for frequently found changes on cranial ultrasound have largely remained unchanged over the last decades, while no risk factors could be identified for subtle and diffuse white matter injury as seen on MRI around term age.

Histological inflammatory responses in the placenta and early neonatal brain injury

We investigated the relationship between the severity of histological inflammatory responses in the placenta, chorionic plate, and umbilical cord in conjunction with the intraventricular hemorrhage (IVH) risk in premature infants. Clinical data were prospectively collected for 287 consecutive premature neonates born before 32 completed weeks of gestation and admitted to the level III neonatal intensive care unit of the Department of Pediatrics at Padua University from January 1999 to December 2004. Placental histology for histological chorioamnionitis (HCA) was graded and scored according to Redline and others. The diagnosis of IVH (grades I-IV) was graded according to Volpe's classification. Among the placentas of the 287 preterm examined infants, 68 (23.6%) were diagnosed with acute HCA. Overall incidence of IVH was 11.8%. Of 68 preterm neonates with HCA, 11 developed IVH (16.1%). Maternal HCA at the higher grades and stages increased the risk of IVH: 7 (64%) of the 11 preterm infants with maternal HCA grade 3 developed IVH (RR; 95% CI 2.05; 1.1-3.6) and 8 (73%) of the 11 preterm neonates with stage 3 developed IVH (RR; 95% CI 1.59; 1.0-2.5). Conversely, fetal inflammation was not associated with an increased risk of IVH. In conclusion, the IVH risk in preterm infants at less than 32 gestation weeks is significantly associated with severe grade and stage maternal HCA inflammatory scores.

Interleukin-6 polymorphism is associated with chorioamnionitis and neonatal infections in preterm infants

OBJECTIVES

To evaluate whether genotypes of interleukin (IL)-6 gene promoter positions -174 and -572 are associated with histologic chorioamnionitis and neonatal inflammatory disease in preterm infants.

STUDY DESIGN

DNA from very low birth weight or very preterm infants (n = 107) was genotyped for IL-6-174 and -572 polymorphisms (GG/GC/CC). The placentas were analyzed for histological inflammatory findings. Data on neonatal inflammatory diseases, including chronic lung disease (CLD), necrotizing enterocolitis (NEC), and septicemia, were collected using the definitions of the Vermont Oxford Network database.

RESULTS

In univariate analyses, the IL-6-174 GG genotype was associated with a higher incidence of histologic chorioamnionitis. In multivariate analyses, the -174 GG and -572 GC genotypes were correlated with histologic chorioamnionitis (P = .039 and .009, respectively). Gestational age was not associated with genotype polymorphisms. IL-6-174 genotypes were not associated with CLD and/or NEC, but the CC genotype was correlated with septicemia in both univariate and multivariate analyses (P = .027). IL-6-572 genotypes were not associated with neonatal inflammatory disease.

CONCLUSIONS

The IL-6-174 GG and -572 GC genotypes were associated with a higher incidence of histologic chorioamnionitis, and the IL-6-174 CC genotype was associated with septicemia in preterm infants. These findings suggest that the genetic composition of the IL-6 promoter area plays a significant role in the pathogenesis of chorioamnionitis and neonatal infections.

Does placental inflammation relate to brain lesions and volume in preterm infants?

OBJECTIVES

To evaluate the association between histologic inflammation of placenta and brain findings in ultrasound examinations and regional brain volumes in magnetic resonance imaging in very-low-birth-weight (VLBW) or in very preterm infants.

STUDY DESIGN

VLBW or very preterm infants (n = 121) were categorized into 3 groups according to the most pathologic brain finding on ultrasound examinations until term. The brain magnetic resonance imaging performed at term was analyzed for regional brain volumes. The placentas were analyzed for histologic inflammatory findings.

RESULTS

Histologic chorioamnionitis on the fetal side correlated to brain lesions in univariate but not in multivariate analyses. Low gestational age was the only significant risk factor for brain lesions in multivariate analysis (P < .0001). Histologic chorioamnionitis was not associated with brain volumes in multivariate analyses. Female sex, low gestational age, and low birth weight z score correlated to smaller volumes in total brain tissue (P = .001, P = .0002, P < .0001, respectively) and cerebellum (P = .047, P = .003, P = .001, respectively). In addition, low gestational age and low-birth-weight z score correlated to a smaller combined volume of basal ganglia and thalami (P = .0002).

CONCLUSIONS

Placental inflammation does not appear to correlate to brain lesions or smaller regional brain volumes in VLBW or in very preterm infants at term age.

Circulatory disturbances during the first postnatal 24 hours in extremely premature infants 25 weeks or less of gestation with histological fetal inflammation

AIM

To investigate the effect of pre-existing fetal inflammation on hemodynamics during the first postnatal 24 h in extremely premature infants <or= 25 weeks of gestation.

METHODS

We defined fetal inflammation as the infiltration of neutrophils into the chorionic plate vessels or umbilical cord vessels on histological examination. In 41 infants born between 22 and 25 weeks of gestation, 23 displayed fetal inflammation and 18 displayed no fetal inflammation. Circulatory indices including blood pressure, heart rate, average urine flow, catecholamine index, ejection fraction of the left ventricle, and volume load for 24 h were compared between the two groups, as well as the incidence of intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and death. The comparisons were made with repeated measure anova and with Fisher's exact test, or unpaired t-test. Probability values <0.05 were considered significant.

RESULTS

Infants with and without fetal inflammation had similar birthweights and gestational age. There was no significant difference in incidence of PVL and death. However, infants with fetal inflammation had a significantly higher incidence of IVH >or= 3 than infants with no fetal inflammation (49% vs 17%) (P=0.04). Infants with fetal inflammation had significantly higher heart rate (P=0.005), catecholamine index (P=0.019) and volume load (P=0.021).

CONCLUSION

Histological evidence of fetal inflammation in extremely premature infants is associated with circulatory disturbances over the first 24 h of life and increases in the incidence of IVH >or= 3.

Isolated parenchymal lesions on cranial ultrasound in very preterm infants in the context of maternal infection

AIM

To explore the associations between a clinical diagnosis of maternal infection (CDMI) and findings on the initial cranial ultrasound scan in very preterm infants.

METHODS

Among infants born at less than 32 weeks gestation, cases of CDMI and controls were identified on the basis of routinely available obstetric data. Neonatal cranial ultrasound scans carried out soon after birth were retrospectively reviewed for evidence of parenchymal echodensity (PED), intraventricular haemorrhage (IVH) or PED contiguous with IVH.

RESULTS

Any PED was identified in 20/40 (50%) cases of CDMI and 9/30 (30%) of controls. Logistic regression was used to adjust for differences between the two study groups. When compared with normal scans, isolated PED was more likely with CDMI odds ratio, OR (95% confidence interval, CI), 41.8 (2.64, 662) and lower Apgar score at 5 min 2.89 (1.05, 7.98). IVH was more likely with lower gestational age, OR for each completed week of gestation 0.64 (0.46, 0.88) and a protective effect of female sex, OR 0.25 (0.063, 0.98), PED contiguous with IVH was more likely with lower gestational age OR 0.59 (0.336, 1.04).

CONCLUSIONS

CDMI may be associated with isolated PED in very preterm infants. We speculate that isolated PED (including "flares") identify infants who have sustained early brain injury because of intrauterine infection. Isolated PED may be a useful intermediate outcome in perinatal cohort studies.

The occurrence of obstructive vs absorptive hydrocephalus in newborns and infants: relevance to treatment choices

BACKGROUND AND OBJECTIVE

The classification of hydrocephalus in newborns and in infants is different from the classification in adulthood. This difference exists due to disparity in the source pathologies that produce the hydrocephalus, and the practical distinctions in prognosis and treatment choices. The objective of this paper is to present the spectrum of obstructive-communicating hydrocephalus, which is more complex in the pediatric group, and to propose the relevance of this particular classification to treatment options.

MATERIALS AND METHODS

The authors categorized infants with active hydrocephalus at time of presentation into the following four groups along the spectrum of communicating vs obstructive HCP. Group 1: patients with a purely absorptive (communicating) HCP. In these patients, tetraventricular dilatation is usually observed with occasional extraaxial fluid accumulation. An extracranial CSF diversion (shunt) is the treatment of choice. Group 2: patients with an obstructive component together with a persistent absorptive component. In these patients, a technically successful endoscopic procedure will not prevent progression of clinical symptoms of HCP. An extracranial CSF diversion (shunt) should be the treatment of choice even though some of these patients are currently treated by endoscopy. Group 3: patients with an obstructive component together with a temporary absorptive component. In these patients, a technically successful ETV should be followed by temporary CSF drainage [via LP, continuous spinal drainage (CLD), or ventriculostomy] with or without supplemental medical treatment (i.e., Diamox) for several days. Such temporary drainage may decrease failure rate in this subgroup. Group 4: patients with a purely obstructive HCP. In these patients, an endoscopic procedure (ETV) is the treatment of choice. According to this spectrum classification, the authors classify different entities with representative cases and discuss relevancy to treatment options and prognosis.

RESULTS

The data suggest that obstructive hydrocephalus in the very young population may be rather a combination of obstructive and absorptive problem. The outcome of the patient depends mainly not only on the basic pathology causing the hydrocephalus but also on the treatment that is chosen and its complications. While bleeding and infection represent the major causes for communicating hydrocephalus, patients with complex pathologies of congenital type and intra- or interventricular obstructions may reflect obstructive hydrocephalus. Treatment of these patients may be successful by shuntless procedures if the absorptive problem is not the major component. In transient absorptive hydrocephalus, temporary measures were effective in many cases leading to successful procedures of ETV and/or posterior-fossa decompression in selected cases.

CONCLUSIONS

Shuntless procedures are the dream of a pediatric neurosurgeon provided it solves the problem and does not imply unacceptable risk. However, the benefit has to be evaluated years after the procedure is performed, as only prospective multicenter studies will truly show which procedure may have the best overall results in the developing child. Until such studies are available, understanding the basic pathology or the combination of pathologies leading to hydrocephalus in a given child may open the window of opportunities for other than shunt surgery in many hydrocephalic children with major obstructive component.

Intrauterine Inflammation and the Onset of Peri-Intraventricular Hemorrhage in Premature Infants

BACKGROUND

Peri-intraventricular hemorrhage (P/IVH) is a common neonatal morbidity among premature infants. The aim of the study was to examine the association between placental and/or fetal inflammation and the onset of P/IVH in premature infants.

METHODS

A prospective study included 125 infants with gestational age 23-29 weeks. Placentas were examined for the presence of chorioamnionitis and funisitis, cord blood was sampled for the measurement of cytokines (IL-6 and IL-8). Fetal inflammation was defined as levels of IL-6 higher than 7.6 pg/ml. P/IVH was defined as early if diagnosed within the 1st day after birth; thereafter P/IVH was defined as late.

RESULTS

Adjusted for the influence of gestational age, early-onset sepsis (OR 3.2, p = 0.045) and no or incomplete antenatal steroid course (OR 6.0, p = 0.001) significantly predicted early P/IVH. Funisitis (OR 1.6, p = 0.06) and fetal inflammation (OR 2.6, p = 0.06) were only partially associated with early hemorrhage. Contrary to that, respiratory distress syndrome (OR 3.4, p = 0.04), mechanical ventilation (OR 5.9, p = 0.008), low blood pressure (OR 3.5, p = 0.02), and vasopressors (OR 5.7, p = 0.002) were associated with late P/IVH. In multivariate analysis no or incomplete steroid course remained independent predictors for early and use of vasopressors for late P/IVH. The interaction of fetal inflammation and vaginal delivery with no or incomplete steroid course increased the risk of early P/IVH.

CONCLUSIONS

These results indicate different risk factors for early and late P/IVH. Neither funisitis nor fetal inflammation independently predicts the onset of P/IVH. However, the interaction of fetal inflammation and vaginal delivery with no or incomplete antenatal steroid course increase the risk of early but not also late P/IVH.

Neonatal brain damage following prolonged latency after preterm premature rupture of membranes

This study evaluated the risk of brain damage in neonates delivered at < 34 weeks following a prolonged latency after preterm premature rupture of membranes (pPROM). The medical records of 77 singletons delivered at < 34 weeks with pPROM and 66 singletons delivered at < 34 weeks with preterm labor and intact membranes were reviewed. Latency was divided into four intervals: < or = 24, > 24-< or = 72, > 72- < or = 168 hr, and > 1 week. Outcomes in the longer three intervals were compared with those in neonates delivered at < or = 24 hr after pPROM. The documented outcomes were placental (histologic chorioamnionitis, vasculitis, funnisitis) and neonatal (intraventricular hemorrhage, ventriculomegaly, germinal matrix hemorrhage, periventricular leukomalacia). Odds ratios and 95% CI for the risk of histologic chorioamnionitis according to the respective latency intervals were 4.8 (1.0-22.9), 7.0 (1.1-43.1), 7.4 (2.1-42.3) in patients with pPROM. The risks of intracranial ultrasonic abnormalities, however, did not increased with prolonged latency. In the patients with preterm labor and intact membranes, the both risks did not increased with increasing latency. Therefore, this study was suggested that the risk of histologic chorioamnionitis increased with increasing latency, but there was no relationship between neonatal brain damage and latency interval after pPROM.

Prevention of intraventricular haemorrhage: a role for recombinant activated factor VII?

As the survival from extreme prematurity continues to improve, focus on the quality of this survival becomes increasingly important. Prevention of intraventricular haemorrhage (IVH) and its potential long-term sequelae remains one of the major challenges in the early management of these infants. Recombinant activated factor VII (rVIIa), a novel haemostatic agent with an ever-expanding list of potential applications, warrants consideration for use in this setting. This review examines the pathogenesis and prevention of IVH, current concepts of haemostasis both in adults and neonates, and the postulated mechanism of action and various uses of rVIIa. Published data specifically relating to use of rVIIa in neonates is summarised. The hypothesis that early (prophylactic) administration of rVIIa to extremely preterm infants (<28 weeks) would reduce the incidence of severe IVH is explored.

Histological chorioamnionitis and the risk of early intraventricular hemorrhage in infants born < or =28 weeks gestation

OBJECTIVE

To test the hypothesis that histological chorioamnionitis (CA) is not associated with increased risk of early onset intraventricular hemorrhage (IVH).

STUDY DESIGN

Clinical data were prospectively collected for 62 consecutive neonates born before 28 weeks of gestation. Placental histology for CA was performed by a pathologist unaware of the head ultrasound scan (HUS) results. The first HUS was obtained by 30 minutes of life. Follow-up HUS were performed before 24 hours and again at 48 to 72 postnatal hours of life. An IVH (grade I to IV) at less than 72 hours of life was deemed an early hemorrhage.

RESULTS

Nine of the 62 (14.5%) infants had early onset IVH. In all, 29 infants were born to women with histological evidence of CA; 33 infants did not have CA. Infants did not differ in birth weight, gestational age, sex, cord blood pH, 5-minute Apgar score of <7, cesarean delivery, prenatal use of steroids, administration of tocolytics, need for resuscitation, presence of pneumothorax, platelet count at birth, or use of surfactant. Early IVH rates (3/29 in CA vs 6/33 in non-CA) were similar (p=0.48). Two infants in each group with early IVH died before 2 weeks of age. Five additional infants from the CA group developed IVH at more than 72 postnatal hours of life (late onset IVH), and two of those infants progressed to develop periventricular leukomalacia (PVL). In contrast, only three non-CA infants had late IVH and none developed PVL. Logistic regression confirmed that no perinatal variables including CA were associated with early onset IVH.

CONCLUSION

Chorioamnionitis is not associated with increased risk of early IVH.

[Ultrasonic findings of intracranial hemorrhage in preterm neonates]

Intracranial hemorrhage ICH is one of the most common neurological events in pre-term newborn ICH is associated with low birth weight (< 1500 g) and gestational age (GA) at delivery (< 32 weeks). The most common site affected is the germinal matrix. Papile et al. classifies it at four grades. We analyzed, prospectively, 50 newborns (27 boys) with ultrasound diagnostic of ICH; all of them were pre-term (GA < 37 weeks). They were classified according to sex, gestational age, birth weight and degree of ICH. The children were divided into two groups: A--GA < or = 33 weeks and B--34-37 weeks. In group A there were 34 children (25 boys) with mean GA of 31 weeks and birth weights average of 1308 g. In group B there were 16 children (2 boys), mean GA 34 weeks and birth weight average of 1951 g. The grades of ICH were: Group A--I-14, II-14, III-4 and IV-2; Group B--I-12, II-3 and III-1. The complications were more common in group A with 12 than group B with 4 children. The lesions happen in greatest number and most severity in children with low birth weight and younger (low gestational age). Ultrasound has shown to be effective for diagnostic and follow up of those children.

Intraventricular Hemorrhage and Periventricular Leukomalacia in Preterm Infants

OBJECTIVE

To evaluate whether intraventricular hemorrhage and periventricular leukomalacia are characterized by different risk factors.

METHODS

In a cohort of 653 consecutive singleton neonates born after preterm membrane rupture, spontaneous preterm labor, or indicated preterm delivery at 24 to 33 weeks of gestation from January 1, 1993, to December 31, 2002, we evaluated the obstetric and histopathologic placental variables in reference to the development of intraventricular hemorrhage (n = 44), periventricular leukomalacia (n = 19), or no ultrasonographic cerebral lesion (n = 589). Excluded were stillbirths and congenital anomalies. Statistical analysis included Fisher exact test, Student t test, and stepwise logistic regression analysis with a 2-tailed P <.05 considered significant.

RESULTS

Multivariate analysis showed that occurrence of neonatal intraventricular hemorrhage and periventricular leukomalacia were associated only with spontaneous prematurity (odds ratio = 1.9; 95% confidence interval 1.1-3.4) and gestational age at delivery in weeks (odds ratio = 0.8; 95% confidence interval 0.7-0.9). Neonates with intraventricular hemorrhage did not differ from those with periventricular leukomalacia in any obstetric or neonatal variable, but there was a higher risk of neurodevelopmental delay associated with periventricular leukomalacia.

CONCLUSION

Among premature infants born at less than 34.0 weeks of gestation, intraventricular hemorrhage and periventricular leukomalacia share common clinical characteristics, with spontaneous preterm delivery and gestational age at delivery as the only independent antenatal predictors.

Lung and Brain Damage in Preterm Newborns

The relationships among bronchopulmonary dysplasia (BPD), brain white matter damage (WMD) and cerebral palsy (CP) are far from simple. Apparently, BPD and WMD are not associated, while BPD and CP are. The most likely explanation for this paradox is that ultrasound imaging does not identify all the WMD that might lead to CP ('tip-of-the-iceberg effect'). We discuss further methodological inconsistencies, etiological peculiarities related to antenatal infection/inflammation, and intervention-related issues. In particular, we expand on the multiple-hit scenario in the etiology of BPD and offer support for the hypothesis that it is not lung disease, but factors associated with lung disease (e.g. postnatal steroid exposure) that increase the risk for developmental disability in childhood.

Intraventricular administration of recombinant tissue plasminogen activator for intraventricular hemorrhage in the newborn

Intraventricular hemorrhage remains associated with high mortality and morbidity. Its most serious complication is posthemorrhagic hydrocephalus caused by multiple small blood clots obstructing the arachnoid villi. We treated three newborn infants (one term, two preterm) with posthemorrhagic hydrocephalus using recombinant tissue plasminogen activator, a thrombolytic agent, injected into the ventricles with a spinal needle. Sufficient fibrinolysis was achieved in these preterm patients. They all survived, and shunt surgery was only required in one. No adverse reactions or side effects have occurred. Intraventricular fibrinolysis with tissue plasminogen activator seems to be safe and effective for the treatment of intraventricular hemorrhage. However, controlled studies are needed for assessing treatment efficiency.

Risk factors for intraventricular hemorrhage in very low birth weight premature infants: a retrospective case-control study

OBJECTIVE

High-grade intraventricular hemorrhage (IVH) is an important cause of severe cognitive and motor neurologic impairment in very low birth weight infants and is associated with a high mortality rate. The risk of IVH is inversely related to gestational age and birth weight. Previous studies have proposed a number of risk factors for IVH; however, lack of adequate matching for gestational age and birth weight may have confounded the results. The purpose of this study was to identify variables that affect the risk of high-grade IVH, using a retrospective and case-control clinical study.

METHODS

From a cohort of 641 consecutive preterm infants with a birth weight of <1500 g, 36 infants with IVH grade 3 and/or 4 were identified. A control group of 69 infants, closely matched for gestational age and birth weight, was selected. Maternal factors, labor and delivery characteristics, and neonatal parameters were collected in both groups. Results of cranial ultrasound examinations, whether routine or performed in presence of clinical suspicion, were also collected. Univariate analysis and multivariate logistic regression analysis were performed.

RESULTS

High fraction of inspired oxygen in the first 24 hours, pneumothorax, fertility treatment (mostly IVF), and early sepsis were associated with an increased risk of IVH. A higher number of suctioning procedures, a higher first hematocrit, and a relatively low arterial pressure of carbon dioxide during the first 24 hours of life were associated with a lower occurrence. In the multivariate logistic regression model, early sepsis (odds ratio [OR]: 8.19; 95% confidence interval [CI]: 1.55-43.1) and fertility treatment (OR: 4.34; 95% CI: 1.42-13.3) were associated with a greater risk of high-grade IVH, whereas for every dose of antenatal steroid treatment there was a lower risk of high-grade IVH (OR: 0.52; 95% CI: 0.30-0.90) and each decrease in a mmHg unit of arterial pressure of carbon dioxide during the first 24 hours was associated with a lower risk of IVH (OR: 0.91; 95% CI: 0.83-0.98). This multivariate model had a sensitivity of 77%, a specificity of 75%, and a positive predictive value of 76%. The area under the curve derived from the receiver operator characteristic plots is 0.82.

CONCLUSIONS

Our results confirm that the development of IVH is associated with early sepsis and failure to give antenatal steroid treatment. We propose that fertility treatment (and especially IVF) may be a new risk factor, and more research is needed to assess its role.