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Vesoulis ZA, Diggs S, Brackett C, Sullivan B. Racial and geographic disparities in neonatal brain care. Semin Perinatol 2024:151925. [PMID: 38897830 DOI: 10.1016/j.semperi.2024.151925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
In this review, we explore race-based disparities in neonatology and their impact on brain injury and neurodevelopmental outcomes. We discuss the historical context of healthcare discrimination, focusing on the post-Civil War era and the segregation of healthcare facilities. We highlight the increasing disparity in infant mortality rates between Black and White infants, with premature birth being a major contributing factor, and emphasize the role of prenatal factors such as metabolic syndrome and toxic stress in affecting neonatal health. Furthermore, we examine the geographic and historical aspects of racial disparities, including the consequences of redlining and limited access to healthcare facilities or nutritious food options in Black communities. Finally, we delve into the higher incidence of brain injuries in Black neonates, as well as disparities in adverse neurodevelopmental outcome. This evidence underscores the need for comprehensive efforts to address systemic racism and provide equitable access to healthcare resources.
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Affiliation(s)
- Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Stephanie Diggs
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Cherise Brackett
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
| | - Brynne Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
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Minor KC, Liu J, Druzin ML, El-Sayed YY, Hintz SR, Bonifacio SL, Leonard SA, Lee HC, Profit J, Karakash SD. Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort. Am J Obstet Gynecol 2024:S0002-9378(24)00478-2. [PMID: 38580044 DOI: 10.1016/j.ajog.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy contributes to morbidity and mortality among neonates ≥36 weeks of gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic-ischemic encephalopathy, and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with preeclampsia with severe features. OBJECTIVE (1) Determine trends in the incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate, and hypoxic-ischemic encephalopathy; (2) evaluate the association between hypertensive disorders of pregnancy and hypoxic-ischemic encephalopathy; and (3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic-ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN We analyzed a prospective cohort of live births ≥36 weeks of gestation between 2012 and 2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic-ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic-ischemic encephalopathy. RESULTS Among 44,314 unique infants, the diagnosis of hypoxic-ischemic encephalopathy, maternal hypertensive disorders of pregnancy, and the use of magnesium sulfate increased over time. Compared with patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a high-risk population. They were more likely to be publicly insured, born between 36 and 38 weeks of gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, experience preterm labor and fetal distress, and undergo operative delivery (all P<.002). Hypertensive disorders of pregnancy were associated with hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.13-1.40]; P<.001) and specifically moderate/severe hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.42]; P<.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.71 [95% confidence interval, 0.52-0.97]; P=.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.63 [95% confidence interval, 0.42-0.94]; P=.03). CONCLUSION Hypertensive disorders of pregnancy are associated with hypoxic-ischemic encephalopathy and, specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with a significant reduction in the odds of hypoxic-ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to neonatal intensive care unit at ≥36 weeks of gestation. The findings of this observational study cannot prove causality and are intended to generate hypotheses for future clinical trials on magnesium sulfate in term infants.
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Affiliation(s)
- Kathleen C Minor
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA.
| | - Jessica Liu
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Maurice L Druzin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Yasser Y El-Sayed
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Susan R Hintz
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Sonia L Bonifacio
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Henry C Lee
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Scarlett D Karakash
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
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Jung E, Romero R, Suksai M, Gotsch F, Chaemsaithong P, Erez O, Conde-Agudelo A, Gomez-Lopez N, Berry SM, Meyyazhagan A, Yoon BH. Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment. Am J Obstet Gynecol 2024; 230:S807-S840. [PMID: 38233317 DOI: 10.1016/j.ajog.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 04/05/2023]
Abstract
Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.
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Affiliation(s)
- Eunjung Jung
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | - Manaphat Suksai
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Francesca Gotsch
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Offer Erez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Agustin Conde-Agudelo
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Stanley M Berry
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Bo Hyun Yoon
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
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Kodidhi A, Riley M, Vesoulis Z. The influence of late prematurity on the encephalopathy exam of infants with neonatal encephalopathy. J Neonatal Perinatal Med 2023; 16:693-700. [PMID: 38073399 PMCID: PMC10753960 DOI: 10.3233/npm-230041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Late preterm (LPT) infants are increasingly treated for hypoxic-ischemic encephalopathy (HIE). However, neurodevelopmental differences of LPT infants may independently influence the neurologic exam and confound care. METHODS Perinatal and outcome characteristics were extracted along with the worst autonomic and state/neuromuscular/reflex Sarnat components in a cross-section of infants with moderate/severe HIE. Infants were classified as late preterm (LPT, 34-36 weeks) or term (>36 weeks). RESULTS 250 infants were identified, 55 were late preterm. LPT infants had lower mean gestational age and birthweight and greater length of stay (LOS). LPT infants had higher median scores for the Moro and respiratory autonomic components, but no difference in total score. CONCLUSIONS LPT infants had increased LOS, worse Moro reflex, and respiratory status, but no clinically or statistically significant differences in total Sarnat scores. Although it is important to note the impact of immaturity on the exam, it is unlikely to independently alter management.
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Affiliation(s)
- A Kodidhi
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - M Riley
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Z Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Smith J, Solomons R, Vollmer L, Langenegger EJ, Lotz JW, Andronikou S, Anthony J, van Toorn R. Intrapartum Basal Ganglia-Thalamic Pattern Injury and Radiologically Termed "Acute Profound Hypoxic-Ischemic Brain Injury" Are Not Synonymous. Am J Perinatol 2022; 39:1124-1131. [PMID: 33321532 DOI: 10.1055/s-0040-1721692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Human cases of acute profound hypoxic-ischemic (HI) injury (HII), in which the insult duration timed with precision had been identified, remains rare, and there is often uncertainty of the prior state of fetal health. STUDY DESIGN A retrospective analysis of 10 medicolegal cases of neonatal encephalopathy-cerebral palsy survivors who sustained intrapartum HI basal ganglia-thalamic (BGT) pattern injury in the absence of an obstetric sentinel event. RESULTS Cardiotocography (CTG) admission status was reassuring in six and suspicious in four of the cases. The median time from assessment by admission CTG or auscultation to birth was 687.5 minutes (interquartile range [IQR]: 373.5-817.5 minutes), while the median time interval between first pathological CTG and delivery of the infant was 179 minutes (IQR: 137-199.25 minutes). The mode of delivery in the majority of infants (60%) was by unassisted vaginal birth; four were delivered by delayed caesarean section. The median (IQR) interval between the decision to perform a caesarean section and delivery was 169 minutes (range: 124-192.5 minutes). CONCLUSION The study shows that if a nonreassuring fetal status develops during labor and is prolonged, a BGT pattern HI injury may result, in the absence of a perinatal sentinel event. Intrapartum BGT pattern injury and radiologically termed "acute profound HI brain injury" are not necessarily synonymous. A visualized magnetic resonance imaging (MRI) pattern should preferably solely reflect the patterns description and severity, rather than a causative mechanism of injury. KEY POINTS · BGT HI injury pattern on MRI may develop in the absence of a perinatal sentinel event.. · BGT pattern injury may not be synonymous with "acute profound HI brain injury.". · MRI pattern and severity thereof should be described rather than a causative mechanism of injury..
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Affiliation(s)
- Johan Smith
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Lindi Vollmer
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Eduard J Langenegger
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jan W Lotz
- Division of Radiodiagnosis, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Savvas Andronikou
- Department of Radiology, the Children's Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Anthony
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Zhu Y, Mosko JJ, Chidekel A, Wolfson MR, Shaffer TH. Effects of xenon gas on human airway epithelial cells during hyperoxia and hypothermia. J Neonatal Perinatal Med 2020; 13:469-476. [PMID: 32444566 PMCID: PMC7836053 DOI: 10.3233/npm-190364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypothermia with xenon gas has been used to reduce brain injury and disability rate after perinatal hypoxia-ischemia. We evaluated xenon gas therapy effects in an in vitro model with or without hypothermia on cultured human airway epithelial cells (Calu-3). METHODS Calu-3 monolayers were grown at an air-liquid interface and exposed to one of the following conditions: 1) 21% FiO2 at 37°C (control); 2) 45% FiO2 and 50% xenon at 37°C; 3) 21% FiO2 and 50% xenon at 32°C; 4) 45% FiO2 and 50% xenon at 32°C for 24 hours. Transepithelial resistance (TER) measurements were performed and apical surface fluids were collected and assayed for total protein, IL-6, and IL-8. Three monolayers were used for immunofluorescence localization of zonula occludens-1 (ZO-1). The data were analyzed by one-way ANOVA. RESULTS TER decreased at 24 hours in all treatment groups. Xenon with hyperoxia and hypothermia resulted in greatest decrease in TER compared with other groups. Immunofluorescence localization of ZO-1 (XY) showed reduced density of ZO-1 rings and incomplete ring-like staining in the 45% FiO2- 50% xenon group at 32°C compared with other groups. Secretion of total protein was not different among groups. Secretion of IL-6 in 21% FiO2 with xenon group at 32°C was less than that of the control group. The secretion of IL-8 in 45% FiO2 with xenon at 32°C was greater than that of other groups. CONCLUSION Hyperoxia and hypothermia result in detrimental epithelial cell function and inflammation over 24-hour exposure. Xenon gas did not affect cell function or reduce inflammation.
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Affiliation(s)
- Y Zhu
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - J J Mosko
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - A Chidekel
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.,Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - M R Wolfson
- Departments of Physiology and Pediatrics, Department of Thoracic Medicine and Surgery, CENTRe: Collaborative for Environmental and Neonatal Therapeutics Research, Center for Inflammation and Translational Clinical Lung Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - T H Shaffer
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.,Departments of Physiology and Pediatrics, Department of Thoracic Medicine and Surgery, CENTRe: Collaborative for Environmental and Neonatal Therapeutics Research, Center for Inflammation and Translational Clinical Lung Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Thigha R, Alzoani A, Almazkary MM, Khormi A, Albar R. Magnitude, short-term outcomes and risk factors for hypoxic ischemic encephalopathy at abha maternity and children hospital, Abha City, Saudi Arabia and literature review. J Clin Neonatol 2020. [DOI: 10.4103/jcn.jcn_12_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Liston R, Sawchuck D, Young D. No. 197b-Fetal Health Surveillance: Intrapartum Consensus Guideline. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e298-e322. [PMID: 29680084 DOI: 10.1016/j.jogc.2018.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada. OPTIONS Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: LABOUR SUPPORT DURING ACTIVE LABOUR: RECOMMENDATION 2: PROFESSIONAL ONE-TO ONE CARE AND INTRAPARTUM FETAL SURVEILLANCE: RECOMMENDATION 3: INTERMITTENT AUSCULTATION IN LABOUR: RECOMMENDATION 4: ADMISSION FETAL HEART TEST: RECOMMENDATION 5: INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME: When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). RECOMMENDATION 6: DIGITAL FETAL SCALP STIMULATION: RECOMMENDATION 7: FETAL SCALP BLOOD SAMPLING: RECOMMENDATION 8: UMBILICAL CORD BLOOD GASES: RECOMMENDATION 9: FETAL PULSE OXIMETRY: RECOMMENDATION 10: ST WAVEFORM ANALYSIS: RECOMMENDATION 11: INTRAPARTUM FETAL SCALP LACTATE TESTING.
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Liston R, Sawchuck D, Young D. N° 197b-Surveillance du bien-être fœtal : Directive consensus d'intrapartum. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e323-e352. [PMID: 29680085 DOI: 10.1016/j.jogc.2018.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yang W, Wang L, Tian T, Liu L, Jin L, Liu J, Ren A. Maternal hypertensive disorders in pregnancy and risk of hypoxic-ischemia encephalopathy. J Matern Fetal Neonatal Med 2019; 34:1754-1762. [PMID: 31331218 DOI: 10.1080/14767058.2019.1647529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) is one of the most serious birth complications for neonates. Few studies reported the relationship between maternal blood pressure disorders and risk of neonatal HIE. OBJECTIVE This study was conducted to examine whether maternal hypertensive disorders in pregnancy increase the risk of HIE. METHODS The analyses were performed using data from a large population-based cohort study aiming to prevent neural tube defects by supplementation with folic acid. The subjects comprised 183,981 women with singleton live births delivered at gestational ages of 32-42 weeks, who registered in two southern provinces in China. Blood pressure was measured by trained health care workers at each prenatal visit. Diagnosis information on HIE was recorded at the time of delivery. RESULTS Totally 19,298 women (10.49%) were diagnosed with maternal hypertensive disorders in pregnancy and 255 infants (1.4 per 1000) with HIE, respectively. Compared with the normotensive group, a great increment in the risk of HIE was observed in women with hypertensive disorders (adjusted RR = 2.40, 95% confidence interval [CI]: 1.79-3.22) after adjusting for maternal confounding factors. A greater association was presented among preterm (32-36 weeks) infants with an adjusted RR of 5.45 (95% CI: 2.79, 10.65) compared to a RR of 2.09 (95% CI: 1.49, 2.92) among full-term (37-42 weeks) infants (p for heterogeneity < .05). Further stratification analyses showed that no matter with or without small for gestational age (SGA), maternal hypertensive disorders were associated with the increased risk for HIE. Sensitivity analyses excluding infants with low or high birth weight did not appreciably change the findings. CONCLUSIONS Our present study demonstrated a positive association of maternal hypertensive disorders in pregnancy with the risk of neonatal HIE.
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Affiliation(s)
- Wenlei Yang
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Linlin Wang
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Tian Tian
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lijun Liu
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lei Jin
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Jianmeng Liu
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Aiguo Ren
- Institute of Reproductive and Child Health, NHC Key Laboratory of Reproductive Health, Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
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11
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Aslam S, Strickland T, Molloy EJ. Neonatal Encephalopathy: Need for Recognition of Multiple Etiologies for Optimal Management. Front Pediatr 2019; 7:142. [PMID: 31058120 PMCID: PMC6477286 DOI: 10.3389/fped.2019.00142] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
Neonatal encephalopathy (NE) is associated with high mortality and morbidity. Factors predisposing to NE can be antenatal, perinatal, or a combination of both. Antenatal maternal factors, familial factors, genetic predisposition, hypoxic ischemic encephalopathy, infections, placental abnormalities, thrombophilia, coagulation defects, and metabolic disorders all have been implicated in the pathogenesis of NE. At present, therapeutic hypothermia is the only treatment available, regardless of etiology. Recognizing the etiology of NE involved can also guide investigations such as metabolic and sepsis workups to ensure optimal management. Understanding the etiology of NE may allow the development of targeted adjunctive therapies related to the underlying mechanism and develop preventative strategies.
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Affiliation(s)
- Saima Aslam
- Paediatrics, National Maternity Hospital, Dublin, Ireland.,UCD School of Medicine & Medical Sciences, University College Dublin, Dublin, Ireland
| | - Tammy Strickland
- Paediatrics, National Maternity Hospital, Dublin, Ireland.,Trinity College Translational Medicine Institute, Academic Paediatrics, Trinity College Dublin, National Children's Hospital, Dublin, Ireland.,Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Eleanor J Molloy
- Paediatrics, National Maternity Hospital, Dublin, Ireland.,UCD School of Medicine & Medical Sciences, University College Dublin, Dublin, Ireland.,Trinity College Translational Medicine Institute, Academic Paediatrics, Trinity College Dublin, National Children's Hospital, Dublin, Ireland.,Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital, Drimnagh, Ireland
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12
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Odd D, Heep A, Luyt K, Draycott T. Hypoxic-ischemic brain injury: Planned delivery before intrapartum events. J Neonatal Perinatal Med 2018; 10:347-353. [PMID: 29286930 DOI: 10.3233/npm-16152] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mothers are increasingly given greater control over many of the choices around birth, although there is little robust evidence to inform these choices. After an infant is born with HIE the question of whether it was predictable, or preventable, is often raised. Intrapartum 'sentinel' events and antenatal predictors of HIE have been well described, however there is little evidence how antenatal and intrapartum factors interact. This is particularly important when elective delivery by lower segment caesarean section (LSCS) has been shown to be beneficial in high risk groups. AIM To develop a clinical risk score to identify women with a higher risk of having an infant with HIE. PATIENTS AND METHODS This study is based on the Avon Longitudinal Study of Parents and Children (ALSPAC). This dataset was split into two halves: with each infant being randomly allocated to either cohort one or two. The first cohort was used for the derivation of the model, while it was tested exclusively on the second. Logistic regression modelling was then performed to develop a predictive model. The final model was used to predict the outcome of infants in the second cohort and infants divided into four risk quartiles. To give some indication of possible avoidable disease, the proportion of infants with HIE, potentially avoided by earlier delivery, was estimated by assuming that medicalized delivery by elective LSCS at 37 weeks would remove intrapartum risk of HIE for those infants undelivered at this point. RESULTS In the final model seven covariates remained (parity, preeclampsia, polyhydramnios, prelabor rupture of membranes, gender, concerns over fetal growth and prematurity). When applied to the second cohort, a ROC curve for the prediction of developing HIE in the newborn period showed good evidence for association (AUC 0.68 (0.60 to 0.77)) and the risk score derived was strongly associated with the risk of HIE, resuscitation and stillbirth, and neonatal death (all p < 0.05). Elective delivery of high risk infants at 37 weeks gestation could prevent 14% of all HIE, with a NNT of 41. CONCLUSION It is possible to combine routine antenatal findings to identify infants at higher risk of neonatal HIE, thereby recognizing those infants who may benefit most from delivery by elective caesarean section. This work suggests a clinical risk score permits antenatal identification of high-risk infants whose outcome may be amenable to changes in clinical practice to potentially reduce HIE rates, and its devastating consequences.
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Affiliation(s)
- David Odd
- Neonatal Unit, North Bristol NHS Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Axel Heep
- Neonatal Unit, North Bristol NHS Trust, Bristol, UK.,University of Bristol, Bristol, UK
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13
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Joyce NM, Tully E, Kirkham C, Dicker P, Breathnach FM. Perinatal mortality or severe neonatal encephalopathy among normally formed singleton pregnancies according to obstetric risk status:" is low risk the new high risk?" A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2018; 228:71-75. [PMID: 29909266 DOI: 10.1016/j.ejogrb.2018.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the capacity of the current system of obstetric risk stratification at the outset of pregnancy to predict severe adverse perinatal outcome. STUDY DESIGN This retrospective cohort study of singleton pregnancies over a five year period (2009-2013) was performed at the Rotunda Hospital, Dublin, Ireland. High-risk or low-risk status was assigned retrospectively to a large consecutive cohort of women with a normally-formed singleton pregnancy on the basis of factors analyzed at the first prenatal hospital visit. The incidence of severe perinatal morbidity and mortality were compared between high- and low-risk groups to determine the predictive utility of risk stratification at the outset of pregnancy for severe perinatal morbidity. RESULTS During the study period, 41,044 patients registered for prenatal care. 25,702;(63%) were deemed low-risk and 15,342;(37%) high-risk. Low-risk women were statistically more likely to be nulliparous (p < 0.0001) and to have a spontaneous or operative vaginal delivery (p < 0.0001). High-risk women were more likely to be multiparous and to undergo Caesarean delivery (p < 0.0001). The perinatal mortality rate was 3.8 per-1000 in low-risk pregnancies and 6.1 per-1000 in the a priori high-risk group (p = 0.012). The incidence of severe neonatal encephalopathy (NNE) was 1.8 and 0.65 per-1000 in the low and high-risk groups respectively (p = 0.0025). CONCLUSION Where low-risk status is assigned at registration, neonatal encephalopathy is more prevalent. This data is relevant for the design of prenatal care models and demonstrates that assignment of low obstetric risk on the basis of maternal or pre-pregnancy factors alone may erroneously be interpreted as conferring low-risk status to the fetus.
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Affiliation(s)
- Niamh M Joyce
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
| | - Elizabeth Tully
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Colin Kirkham
- The Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Patrick Dicker
- RCSI Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Lower Mercer Street, Dublin 2, Ireland
| | - Fionnuala M Breathnach
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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14
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Romero R, Gomez-Lopez N, Kusanovic JP, Pacora P, Panaitescu B, Erez O, Yoon BH. Clinical Chorioamnionitis at Term: New Insights into the Etiology, Microbiology, and the Fetal, Maternal and Amniotic Cavity Inflammatory Responses. NOGYOGYASZATI ES SZULESZETI TOVABBKEPZO SZEMLE 2018; 20:103-112. [PMID: 30320312 PMCID: PMC6177213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Clinical chorioamnionitis is the most common infection related diagnosis made in labor and delivery units worldwide. It is traditionally believed to be due to microbial invasion of the amniotic cavity, which elicits a maternal inflammatory response characterized by maternal fever, uterine tenderness, maternal tachycardia and leukocytosis. The condition is often associated with fetal tachycardia and a foul smelling amniotic fluid. Recent studies in which amniocentesis has been used to characterize the microbiologic state of the amniotic cavity and the inflammatory response show that only 60% of patients with the diagnosis of clinical chorioamnionitis have proven infection using culture or molecular microbiologic techniques. The remainder of the patients have intra-amniotic inflammation without demonstrable microorganisms or a maternal systemic inflammatory response (fever) in the absence of intra-amniotic inflammation. The latter cases often represent a systemic inflammatory response after epidural anesthesia/analgesia has been administered. The most common microorganisms are Ureaplasma species and Gardnerella vaginalis. In the presence of ruptured membranes, the frequency of infection is 70%, which is substantially higher than patients who have intact membranes (25%). The amniotic fluid inflammatory response is characterized by an infiltration of neutrophils and monocytes. Both cell types are activated in the presence of infection and can produce inflammatory cytokines. The white blood cells in the amniotic fluid can be of fetal or maternal origin. The maternal inflammatory response is characterized by an elevation in the concentration of pyrogenic cytokines. The cytokine plasma concentrations in the fetal circulation are elevated even if there is no evidence of an intra-amniotic inflammatory response suggesting that maternal plasma cytokines may cross the placental barrier and induce a mild fetal inflammatory response. Placental pathology is of limited value in the diagnosis of proven intra-amniotic infection. The clinical criteria traditionally used in clinical medicine have accuracy around 50% and therefore, they cannot distinguish between patients with a proven intra-amniotic infection and those with intra-amniotic inflammation alone. Analysis of amniotic fluid with a bedside test for MMP-8 can allow the rapid identification of the patient at risk for infection and may decrease the need for antibiotic administration to neonates. An important consideration is whether antibiotics effective against Ureaplasma species should be administered to patients with clinical chorioamnionitis, given that these genital mycoplasmas are the most common organisms found in the amniotic fluid. The emergent picture is that clinical chorioamnionitis is a heterogeneous syndrome, which requires further study to optimize maternal and neonatal outcomes.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Immunology, Microbiology and Biochemistry, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Department of Obstetrics and Gynecology, Sótero del Río Hospital, Santiago, Chile
- Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bogdan Panaitescu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bo Hyun Yoon
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U. S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
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15
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Bianco A, Moore G, Taylor S. Neonatal Encephalopathy in Calves Presented to a University Hospital. J Vet Intern Med 2017; 31:1892-1899. [PMID: 28865106 PMCID: PMC5697198 DOI: 10.1111/jvim.14821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/07/2017] [Accepted: 08/01/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND While studies have examined bovine dystocia in relation to calf survival, little has been published regarding perinatal morbidity and treatment of newborn calves beyond failure of transfer of passive immunity (FTPI). Neonatal encephalopathy (NE) is a clinical syndrome commonly diagnosed in infants and foals but is poorly described in calves. HYPOTHESIS/OBJECTIVES To identify risk factors for development of NE in calves and factors predictive of survival. ANIMALS Neonatal calves presented to a University hospital over a 10-year period. METHODS Retrospective cohort study (2005-2015). Medical records of all neonatal calves presented to the hospital were examined, and cases of NE were identified. Data pertaining to demographics, dam parity, labor, treatment, and outcome were collected and analyzed with univariate and multivariate statistics. RESULTS Of 200 calves in the final analysis, 58 (29%; 95% CI: 22.8-35.8%) were classified as NE and 142 calves as non-NE. In univariate analysis, factors significantly associated with diagnosis of NE included male sex, presence of dystocia, abnormal position in the birth canal, and prolonged labor. In the multivariate model, only orientation of the calf in the birth canal remained significant (OR 2.14; 95% CI: 1.02-4.49; P = 0.044). Overall survival of calves with NE was good (45/58; 77.6%; 95% CI: 64.7-87.5); dam parity and being a twin was significantly associated with nonsurvival. CONCLUSIONS Calves born after dystocia, especially if malpresented, should be closely monitored for nursing behavior within the first 24 hours of life. Prognosis for survival is good, but supportive care might be required for several days.
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Affiliation(s)
- A.W. Bianco
- Department of Veterinary Clinical SciencesCollege of Veterinary MedicinePurdue UniversityWest LafayetteIN
| | - G.E. Moore
- Department of Veterinary AdministrationCollege of Veterinary MedicinePurdue UniversityWest LafayetteIN
| | - S.D. Taylor
- Department of Veterinary Clinical SciencesCollege of Veterinary MedicinePurdue UniversityWest LafayetteIN
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16
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Howley MM, Fisher SC, Van Zutphen AR, Waller DK, Carmichael SL, Browne ML. Thyroid Medication Use and Birth Defects in the National Birth Defects Prevention Study. Birth Defects Res 2017; 109:1471-1481. [DOI: 10.1002/bdr2.1095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Meredith M. Howley
- Congenital Malformations Registry; New York State Department of Health; Albany New York
| | - Sarah C. Fisher
- Congenital Malformations Registry; New York State Department of Health; Albany New York
| | - Alissa R. Van Zutphen
- Congenital Malformations Registry; New York State Department of Health; Albany New York
- Department of Epidemiology and Biostatistics, School of Public Health; University at Albany; Rensselaer New York
| | - Dorothy K. Waller
- School of Public Health; University of Texas Health Science Center; Houston Texas
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics; Stanford University; Stanford California
| | - Marilyn L. Browne
- Congenital Malformations Registry; New York State Department of Health; Albany New York
- Department of Epidemiology and Biostatistics, School of Public Health; University at Albany; Rensselaer New York
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17
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Lavesson T, Källén K, Olofsson P. Fetal and maternal temperatures during labor and delivery: a prospective descriptive study. J Matern Fetal Neonatal Med 2017; 31:1533-1541. [PMID: 28412845 DOI: 10.1080/14767058.2017.1319928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study is to study the fetal scalp temperature (FST) and maternal axillary temperature (MAT) during vaginal delivery relative to progression of labor, uterine contractions (UC) and epidural analgesia (EDA), and to construct normal temperature reference ranges related to stage of labor. MATERIAL AND METHODS Temperatures were recorded continuously in labor of 132 women with a bi-metal temperature sensor attached to the axilla (MAT) and a similar sensor mounted in a scalp electrode (FST). The temperature data were stored electronically and analyzed offline at cervical dilatations of 2-3, 5, 7-8, and 10 cm, and at full retraction. The FST was read before, at increasing, at peak, at decreasing, and after UC. The MAT and FST curves were compared with mixed-effect models statistics for repeated measurements. A two-tailed p <.05 was considered significant. RESULTS The FST did not vary during UC (p = .24). Both FST and MAT increased linearly by progression of labor (both p < .001). The increases in temperatures were greater with EDA than without (p < .001). CONCLUSIONS During UC, the FST showed no alteration. Both FST and MAT increased significantly by progression of labor, and significantly more in the presence of EDA. The presented normal temperature reference ranges can be used for future research.
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Affiliation(s)
- Tony Lavesson
- a Department of Obstetrics and Gynecology, Helsingborg Hospital , Institution of Clinical Sciences Malmö, Lund University , Helsingborg , Sweden
| | - Karin Källén
- b Institution of Clinical Sciences Lund, Center for Reproductive Epidemiology , Lund , Sweden.,c Tornblad Institute, Lund University , Lund , Sweden
| | - Per Olofsson
- d Department of Obstetrics and Gynecology , Institution of Clinical Sciences Malmö, Skåne University Hospital, Lund University , Malmö , Sweden
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18
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Lee YK, Penn A, Patel M, Pandit R, Song D, Ha BY. Hypothermia-treated neonates with hypoxic-ischemic encephalopathy: Optimal timing of quantitative ADC measurement to predict disease severity. Neuroradiol J 2016; 30:28-35. [PMID: 27881816 DOI: 10.1177/1971400916678229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
To determine the optimal time window for MR imaging with quantitative ADC measurement in neonatal HIE after hypothermia treatment, a retrospective review was performed on consecutive hypothermia-treated term neonates with HIE, with an initial and follow-up MR imaging within the first two weeks of life. Three neuroradiologists categorized each set of MR imaging as normal, mild, moderate or severe HIE based on a consensus review of the serial imaging. The lowest ADC values from the white matter, corpus callosum, and basal ganglia/thalamus were measured. The ADC values between mild-moderate and severe HIE were compared using a Student's t-test over a range of different time windows. A total of 33 MR imaging examinations were performed on 16 neonates that included three normal, four mild, five moderate, and four severe HIE. The time window of 3-10 days showed a statistically significant decrease in ADC value in severe HIE compared to mild-moderate HIE in all three locations, respectively: white matter 0.5 ± 0.22 versus 0.83 ± 0.27 ( p value 0.01), corpus callosum 0.69 ± 0.19 versus 0.91 ± 0.17 ( p value 0.01), and basal ganglia/thalamus 0.63 ± 0.16 versus 0.98 ± 0.06 ( p value <0.01). The range of 3-10 days is the optimal time window for MR imaging with quantitative ADC after hypothermia treatment.
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Affiliation(s)
- Yauk K Lee
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Alex Penn
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Mahesh Patel
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Rajul Pandit
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Dongli Song
- 2 Department of Pediatrics, Santa Clara Valley Medical Center, USA
| | - Bo Yoon Ha
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
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19
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Dior UP, Kogan L, Eventov-Friedman S, Gil M, Bahar R, Ergaz Z, Porat S, Calderon-Margalit R. Very High Intrapartum Fever in Term Pregnancies and Adverse Obstetric and Neonatal Outcomes. Neonatology 2016; 109:62-8. [PMID: 26536344 DOI: 10.1159/000440938] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/07/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intrapartum fever is a well-known risk factor for adverse perinatal outcomes. Maternal intrapartum fever ≥39.0°C at term is a rare event during labor, and there is scarce evidence regarding its implications. OBJECTIVES To investigate the association between very high intrapartum maternal fever and perinatal outcomes in term pregnancies. METHODS A retrospective cohort analysis including 43,560 term, singleton live births in two medical centers between the years 2003 and 2011 was performed. We compared parturients who experienced a maximal intrapartum fever of <38.0°C with two subgroups of parturients who experienced respective maximal fevers of 38.0-38.9°C and ≥39°C. Adjusted risks for adverse perinatal outcomes were calculated by using multiple logistic regression models to control for confounders. RESULTS Compared with normal intrapartum temperature, intrapartum fever ≥39.0°C was associated with an extremely elevated risk for neonatal sepsis 16.08 (95% CI: 2.15, 120.3) as well as with low Apgar scores and neonatal intensive care unit admissions (p < 0.001). Additionally, very high intrapartum fever was related to significantly higher risk for operative delivery (p < 0.001). CONCLUSIONS Extremely elevated intrapartum fever is an important indicator of severe neonatal morbidity and operative delivery.
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Affiliation(s)
- Uri P Dior
- Department of Obstetrics and Gynecology, Hadassah Medical Center and Hebrew University-Hadassah Medical School, Jerusalem, Israel
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20
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Romero R, Chaemsaithong P, Docheva N, Korzeniewski SJ, Tarca AL, Bhatti G, Xu Z, Kusanovic JP, Dong Z, Yoon BH, Hassan SS, Chaiworapongsa T, Yeo L, Kim YM, Kim YM. Clinical chorioamnionitis at term V: umbilical cord plasma cytokine profile in the context of a systemic maternal inflammatory response. J Perinat Med 2016; 44:53-76. [PMID: 26360486 PMCID: PMC5625297 DOI: 10.1515/jpm-2015-0121] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Microbial invasion of the fetus due to intra-amniotic infection can lead to a systemic inflammatory response characterized by elevated concentrations of cytokines in the umbilical cord plasma/serum. Clinical chorioamnionitis represents the maternal syndrome often associated with intra-amniotic infection, although other causes of this syndrome have been recently described. The objective of this study was to characterize the umbilical cord plasma cytokine profile in neonates born to mothers with clinical chorioamnionitis at term, according to the presence or absence of bacteria and/or intra-amniotic inflammation. MATERIALS AND METHODS A cross-sectional study was conducted, including patients with clinical chorioamnionitis at term (n=38; cases) and those with spontaneous term labor without clinical chorioamnionitis (n=77; controls). Women with clinical chorioamnionitis were classified according to the results of amniotic fluid culture, broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) and amniotic fluid interleukin (IL)-6 concentration into three groups: 1) no intra-amniotic inflammation; 2) intra-amniotic inflammation without detectable microorganisms; or 3) microbial-associated intra-amniotic inflammation. A fetal inflammatory response syndrome (FIRS) was defined as an umbilical cord plasma IL-6 concentration >11 pg/mL. The umbilical cord plasma concentrations of 29 cytokines were determined with sensitive and specific V-PLEX immunoassays. Nonparametric statistical methods were used for analysis, adjusting for a false discovery rate of 5%. RESULTS 1) Neonates born to mothers with clinical chorioamnionitis at term (considered in toto) had significantly higher median umbilical cord plasma concentrations of IL-6, IL-12p70, IL-16, IL-13, IL-4, IL-10 and IL-8, but significantly lower interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF)-α concentrations than neonates born to mothers with spontaneous term labor without clinical chorioamnionitis; 2) neonates born to mothers with clinical chorioamnionitis at term but without intra-amniotic inflammation had higher concentrations of IL-6, IL-12p70, IL-13, IL-4, IL-5, and IL-8, but lower IFN-γ, than neonates not exposed to clinical chorioamnionitis, suggesting that maternal fever in the absence of intra-amniotic inflammation leads to a change in the fetal cytokine network; 3) there were significant, positive correlations between maternal and umbilical cord plasma IL-6 and IL-8 concentrations (IL-6: Spearman correlation=0.53; P<0.001; IL-8: Spearman correlation=0.42; P<0.001), consistent with placental transfer of cytokines; 4) an elevated fetal plasma IL-6 (>11 pg/mL), the diagnostic criterion for FIRS, was present in 21% of cases (8/38), and all these neonates were born to mothers with proven intra-amniotic infection; and 5) FIRS was associated with a high concentration of umbilical cord plasma IL-8, IL-10 and monocyte chemoattractant protein (MCP)-1. CONCLUSIONS Neonates born to mothers with clinical chorioamnionitis at term had higher concentrations of umbilical cord plasma cytokines than those born to mothers without clinical chorioamnionitis. Even neonates exposed to clinical chorioamnionitis but not to intra-amniotic inflammation had elevated concentrations of multiple cytokines, suggesting that intrapartum fever alters the fetal immune response.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA,Department of Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nikolina Docheva
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Adi L. Tarca
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gaurav Bhatti
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zhonghui Xu
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Juan P. Kusanovic
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF). Department of Obstetrics and Gynecology, Sótero del Río Hospital, Santiago, Chile,Department of Obstetrics and Gynecology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Zhong Dong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Sonia S. Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yeon Mee Kim
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA,Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan Korea
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Hassanein SMA, Deifalla SM, El-Houssinie M, Mokbel SA. Safety and Efficacy of Cerebrolysin in Infants with Communication Defects due to Severe Perinatal Brain Insult: A Randomized Controlled Clinical Trial. J Clin Neurol 2015; 12:79-84. [PMID: 26365023 PMCID: PMC4712290 DOI: 10.3988/jcn.2016.12.1.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 11/27/2022] Open
Abstract
Background and Purpose The neuroregenerative drug Cerebrolysin has demonstrated efficacy in improving cognition in adults with stroke and Alzheimer's disease. The aim of this study was to determine the efficacy and safety of Cerebrolysin in the treatment of communication defects in infants with severe perinatal brain insult. Methods A randomized placebo-controlled clinical trial was conducted in which 158 infants (age 6-21 months) with communication defects due to severe perinatal brain insult were enrolled; 120 infants completed the study. The Cerebrolysin group (n=60) received twice-weekly Cerebrolysin injections of 0.1 mL/kg body weight for 5 weeks (total of ten injections). The placebo group (n=60) received the same amount and number of normal saline injections. Results The baseline Communication and Symbolic-Behavior-Scale-Developmental Profile scores were comparable between the two groups. After 3 months, the placebo group exhibited improvements in the social (p<0.01) and speech composite (p=0.02) scores, with 10% and 1.5% increases from baseline, respectively. The scores of the Cerebrolysin group changed from concern to no concern, with increases of 65.44%, 45.54%, 358.06%, and 96.00% from baseline in the social (p<0.001), speech (p<0.001), symbolic (p<0.001), and total (p<0.001) scores. Conclusions Cerebrolysin dramatically improved infants' communication especially symbolic behavior which positively affected social interaction. These findings suggest that cerebrolysin may be an effective and feasible way equivalent to stem cell therapy.
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Affiliation(s)
- Sahar M A Hassanein
- Pediatric Department, Children's Hospital, Faculty of Medicine, Ain Shams University, Abassia square, Cairo, Egypt.
| | - Shaymaa M Deifalla
- Pediatric Department, Children's Hospital, Faculty of Medicine, Ain Shams University, Abassia square, Cairo, Egypt
| | - Moustafa El-Houssinie
- Community Medicine Department, Faculty of Medicine, Ain Shams University, Abassia square, Cairo, Egypt
| | - Somaia A Mokbel
- Clinical Pharmacology Department, Faculty of Medicine, Mansoura University, Dakahlia, Egypt
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Jonsson M, Ågren J, Nordén-Lindeberg S, Ohlin A, Hanson U. Suboptimal care and metabolic acidemia is associated with neonatal encephalopathy but not with neonatal seizures alone: a population-based clinical audit. Acta Obstet Gynecol Scand 2014; 93:477-82. [DOI: 10.1111/aogs.12381] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Maria Jonsson
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Johan Ågren
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | | | - Andreas Ohlin
- Department of Pediatrics; Örebro University Hospital; Örebro Sweden
| | - Ulf Hanson
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
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Martinez-Biarge M, Diez-Sebastian J, Wusthoff CJ, Mercuri E, Cowan FM. Antepartum and intrapartum factors preceding neonatal hypoxic-ischemic encephalopathy. Pediatrics 2013; 132:e952-9. [PMID: 24019409 DOI: 10.1542/peds.2013-0511] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine whether antepartum factors alone, intrapartum factors alone, or both in combination, are associated with term neonatal hypoxic-ischemic encephalopathy (HIE). METHODS A total of 405 infants ≥ 35 weeks' gestation with early encephalopathy, born between 1992 and 2007, were compared with 239 neurologically normal infants born between 1996 and 1997. All cases met criteria for perinatal asphyxia, had neuroimaging findings consistent with acute hypoxia-ischemia, and had no evidence for a non-hypoxic-ischemic cause of their encephalopathy. RESULTS Both antepartum and intrapartum factors were associated with the development of HIE on univariate analysis. Case infants were more often delivered by emergency cesarean delivery (CD; 50% vs 11%, P < .001) and none was delivered by elective CD (vs 10% of controls). On logistic regression analysis only 1 antepartum factor (gestation ≥ 41 weeks) and 7 intrapartum factors (prolonged membrane rupture, abnormal cardiotocography, thick meconium, sentinel event, shoulder dystocia, tight nuchal cord, failed vacuum) remained independently associated with HIE (area under the curve 0.88; confidence interval 0.85-0.91; P < .001). Overall, 6.7% of cases and 43.5% of controls had only antepartum factors; 20% of cases and 5.8% of controls had only intrapartum factors; 69.5% of cases and 31% of controls had antepartum and intrapartum factors; and 3.7% of cases and 19.7% of controls had no identifiable risk factors (P < .001). CONCLUSIONS Our results do not support the hypothesis that HIE is attributable to antepartum factors alone, but they strongly point to the intrapartum period as the necessary factor in the development of this condition.
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Affiliation(s)
- Miriam Martinez-Biarge
- MRCPCH, Department of Paediatrics, 5 Floor, Hammersmith House, Hammersmith Hospital, DuCane Rd, London W12 OHS, United Kingdom.
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Leviton A. Why the term neonatal encephalopathy should be preferred over neonatal hypoxic-ischemic encephalopathy. Am J Obstet Gynecol 2013; 208:176-80. [PMID: 22901708 DOI: 10.1016/j.ajog.2012.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 07/13/2012] [Accepted: 07/19/2012] [Indexed: 02/05/2023]
Abstract
The unresponsiveness of the full-term newborn is sometimes attributed to asphyxia, even when no severe physiologic disturbance occurred during labor and delivery. The controversy about whether to use the name "hypoxic-ischemic encephalopathy" or "newborn encephalopathy" has recently flared in publications directed toward pediatricians and neurologists. In this clinic opinion piece, I discuss the importance to obstetricians of this decision and explain why "newborn encephalopathy" should be the default term.
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Ellenberg JH, Nelson KB. The association of cerebral palsy with birth asphyxia: a definitional quagmire. Dev Med Child Neurol 2013; 55:210-6. [PMID: 23121164 DOI: 10.1111/dmcn.12016] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to investigate whether current literature provides a useful body of evidence reflecting the proportion of cerebral palsy (CP) that is attributable to birth asphyxia. METHOD We identified 23 studies conducted between 1986 and 2010 that provided data on intrapartum risks of CP. RESULTS The proportion of CP with birth asphyxia as a precursor (case exposure rate) varied from less than 3% to over 50% in the 23 studies reviewed. The studies were heterogeneous in many regards, including the definitions for birth asphyxia and the outcome of CP. INTERPRETATIONS Current data do not support the belief, widely held in the medical and legal communities, that birth asphyxia can be recognized reliably and specifically, or that much of CP is due to birth asphyxia. The very high case exposure rates linking birth asphyxia to CP can probably be attributed to several factors: the fact that the clinical picture at birth cannot specifically identify birth asphyxia; the definition of CP employed; and confusion of proximal effects - results - with causes. Further research is needed.
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Affiliation(s)
- Jonas H Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Lavesson T, Åkerman F, Källén K, Olofsson P. Effects on fetal and maternal temperatures of paracetamol administration during labour: a case-control study. Eur J Obstet Gynecol Reprod Biol 2013; 168:138-44. [PMID: 23375211 DOI: 10.1016/j.ejogrb.2012.12.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 12/14/2012] [Accepted: 12/30/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To study the effect of paracetamol (acetaminophen) on maternal and fetal temperatures in labour. STUDY DESIGN From a cohort of 185 women with continuous maternal axillary and fetal scalp temperature recordings in labour, 18 women treated with 1000mg paracetamol orally for pyrexia and 36 untreated controls matched for parity, cervical dilatation, and epidural analgesia were selected. Electronically stored temperature data were analysed offline post hoc. The dual temperatures recorded every 30min from 60min before (T-60) paracetamol administration (T0) until delivery, were noted. Longitudinal data were compared with Wilcoxon matched-pairs signed-ranks test and cross-sectional data with Mann-Whitney U test. Shapes of the temperature curves were compared with mixed-effect models statistics for repeated measurements. The main outcome measures were temperature changes after paracetamol. A two-tailed P<0.05 was considered significant. RESULTS Prior to T0 maternal and fetal temperatures increased in the paracetamol group, but after T0 no significant changes (P≥0.1) were seen when compared with Wilcoxon signed-ranks test. In the control group, both temperatures increased from T-60 and onwards. Delta-temperatures (fetal minus maternal temperature) remained unchanged in both groups. Analyses of the mixed-effect models showed a significant difference (P=0.01) in the shape of fetal temperature curves between the paracetamol and control groups, but no significant difference (P=0.4) in maternal temperature curve shapes. CONCLUSION In febrile parturients, neither maternal nor fetal temperatures dropped after paracetamol, but paracetamol halted an increasing trend and stabilised the fetal temperature. The effect of paracetamol on maternal temperature was inconclusive.
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Affiliation(s)
- Tony Lavesson
- Institution of Clinical Sciences, Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden.
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Nelson KB, Bingham P, Edwards EM, Horbar JD, Kenny MJ, Inder T, Pfister RH, Raju T, Soll RF. Antecedents of neonatal encephalopathy in the Vermont Oxford Network Encephalopathy Registry. Pediatrics 2012; 130:878-86. [PMID: 23071210 PMCID: PMC4074646 DOI: 10.1542/peds.2012-0714] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Neonatal encephalopathy (NE) is a major predictor of death and long-term neurologic disability, but there are few studies of antecedents of NE. OBJECTIVES To identify antecedents in a large registry of infants who had NE. METHODS This was a maternal and infant record review of 4165 singleton neonates, gestational age of ≥ 36 weeks, meeting criteria for inclusion in the Vermont Oxford Network Neonatal Encephalopathy Registry. RESULTS Clinically recognized seizures were the most prevalent condition (60%); 49% had a 5-minute Apgar score of ≤ 3 and 18% had a reduced level of consciousness. An abnormal maternal or fetal condition predated labor in 46%; maternal hypertension (16%) or small for gestational age (16%) were the most frequent risk factors. In 8%, birth defects were identified. The most prevalent birth complication was elevated maternal temperature in labor of ≥ 37.5 °C in 27% of mothers with documented temperatures compared with 2% to 3.2% in controls in population-based studies. Clinical chorioamnionitis, prolonged membrane rupture, and maternal hypothyroidism exceeded rates in published controls. Acute asphyxial indicators were reported in 15% (in 35% if fetal bradycardia included) and inflammatory indicators in 24%. Almost one-half had neither asphyxial nor inflammatory indicators. Although most infants with NE were observably ill since the first minutes of life, only 54% of placentas were submitted for examination. CONCLUSIONS Clinically recognized asphyxial birth events, indicators of intrauterine exposure to inflammation, fetal growth restriction, and birth defects were each observed in term infants with NE, but much of NE in this large registry remained unexplained.
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Affiliation(s)
- Karin B. Nelson
- Children's Hospital National Medical Center, Washington, District of Columbia;,National Institute of Neurologic Disorders and Stroke, Bethesda, Maryland
| | | | | | - Jeffrey D. Horbar
- Departments of Pediatrics,,Vermont Oxford Network, Burlington, Vermont
| | - Michael J. Kenny
- Medical Biostatistics, University of Vermont, Burlington, Vermont;,Vermont Oxford Network, Burlington, Vermont
| | - Terrie Inder
- Department of Pediatrics, Washington University, St Louis, Missouri; and
| | - Robert H. Pfister
- Departments of Pediatrics,,Vermont Oxford Network, Burlington, Vermont
| | - Tonse Raju
- National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Roger F. Soll
- Departments of Pediatrics,,Vermont Oxford Network, Burlington, Vermont
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Spalice A, Del Balzo F, Papetti L, Nicita F, Ursitti F, Salvatori G, Iannetti P. Bilateral middle cerebral artery thromboembolic occlusion. Could maternal hyperthermia be a detrimental factor? Med Hypotheses 2011; 77:250-2. [PMID: 21565450 DOI: 10.1016/j.mehy.2011.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 04/11/2011] [Indexed: 10/18/2022]
Abstract
We describe a six-month-old girl with microcephaly, developmental delay, truncal hypotonia, left pyramidal signs, partial seizures and myoclonic spasms, born to a feverish mother. MRI showed bilateral vascular lesions in the territory of the middle cerebral arteries, prevalent in the right hemisphere, together with hypoplasia of the posterior part of the corpus callosum and Wallerian degeneration of the cerebral peduncle. There may be many reasons for these lesions. In the reported patient the presence of maternal hyperthermia could have exacerbated cerebral thromboembolic occlusion.
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Affiliation(s)
- Alberto Spalice
- Pediatric Neurology Division, Department of Pediatrics, La Sapienza University 1, Rome, Italy.
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Elkamil AI, Andersen GL, Salvesen KÅ, Skranes J, Irgens LM, Vik T. Induction of labor and cerebral palsy: a population-based study in Norway. Acta Obstet Gynecol Scand 2010; 90:83-91. [PMID: 21275920 DOI: 10.1111/j.1600-0412.2010.01022.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the association between labor induction and later development of cerebral palsy (CP). DESIGN Registry-based cohort study. SETTING Perinatal data on all children born in Norway 1996-1998 were obtained from the Medical Birth Registry of Norway (MBRN). Neurodevelopmental data were collected from the Norwegian Cerebral Palsy Registry (CPRN). POPULATION A total of 176,591 children surviving the neonatal period. Of 373 children with CP, detailed data were available on 241. METHODS Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated as estimates of the relative risk that a child with CP was born after labor induction. MAIN OUTCOME MEASURES Total CP and spastic CP subtypes. RESULTS Bilateral cerebral palsy was more frequently observed after induced labor (OR: 3.1; 95% CI 2.1-4.5). For children born at term the association between bilateral CP and labor induction was stronger (OR: 4.4; 95% CI 2.3-8.6). The association persisted after adjustment for maternal disease, gestational age, standard deviation score for birthweight (z-score) and prelabor rupture of membranes (PROM) (adjusted OR: 3.7; 95%CI 1.8-7.5). Among children with CP born at term, four-limb involvement (quadriplegia) was significantly more frequent after induced (45.5%) compared with non-induced labor (8.0%). There was no significant association between labor induction and unilateral CP subtype or CP in preterm born children. CONCLUSIONS In this study population, we found that labor induction at term was associated with excess risk of bilateral spastic CP and in particular CP with four-limb involvement.
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Affiliation(s)
- Areej I Elkamil
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Kesselheim AS, November MT, Lifford KL, McElrath TF, Puopolo AL, Orav EJ, Studdert DM. Using malpractice claims to identify risk factors for neurological impairment among infants following non-reassuring fetal heart rate patterns during labour. J Eval Clin Pract 2010; 16:476-83. [PMID: 20482746 DOI: 10.1111/j.1365-2753.2009.01148.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We sought to use a novel case-selection methodology to identify antenatal or intrapartum risk factors associated with neonatal neurological impairment following non-reassuring fetal heart rate patterns during labour. METHOD We used a retrospective case-control design with bivariate and multivariate conditional logistic regression. Cases were births in which electronic fetal monitoring (EFM) showed non-reassuring patterns and the infant had neurological disability. Controls were births in which EFM was non-reassuring but the infant was born healthy. We identified 36 cases from among malpractice claims filed with a liability insurer in Massachusetts between 1985 and 2001 and randomly selected 70 controls, matching them to cases by hospital, birth date and gestational age. RESULTS More cases had maternal antenatal vaginal bleeding (P = 0.004), a prolonged latent phase or protracted dilation during the first stage of labour (P = 0.03), and protracted descent or prolonged second stage (P = 0.01). More cases also had minimal variability on EFM on admission (P = 0.02) and during the second stage (P = 0.02). Multivariate analysis highlighted three significant predictors of neurological injury following complicated labour: antenatal vaginal bleeding (OR = 27.1), prolonged latent phase or protracted dilation in the first stage (OR = 4.0) and EFM showing minimal variability in the first stage (OR = 4.3). CONCLUSION These promising initial findings suggest that future research into outcomes from complicated labour with non-reassuring heart rate patterns should focus on maternal history of vaginal bleeding, slow labour and minimal variability on EFM.
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Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA02120, USA.
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[Cerebral palsy and perinatal asphyxia (I--diagnosis)]. ACTA ACUST UNITED AC 2010; 38:261-77. [PMID: 20378389 DOI: 10.1016/j.gyobfe.2010.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Accepted: 02/12/2010] [Indexed: 11/23/2022]
Abstract
Cerebral palsy (CP) is a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to nonprogressing disturbances that occurred in the developing fetal or infant brain. The motor abnormalies are often accompanied by disturbances of sensation, perception, cognition, behavior and/or by a seizure disorder. The prevalence of CP has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5- to 6-fold increase in the cesarean delivery rate. In the term newborn, CP may be attributed to perinatal asphyxia in case of metabolic acidosis in the cord blood (pH<7,00 and base deficit>12 mmol/L), followed by a moderate or severe neonatal encephalopathy within 24 hours and a further neurological impairement characterized by spastic quadriplegia and dyskinesia/dystonia. Dating the time of fetal asphyxia during delivery is possible when there are acute catastrophic complications during labor and unexpected acute or progressive fetal heart rate anomalies after a normal admission test, when there is a need for intensive neonatal resuscitation, a multi-organ failure within 72 hours of birth and visualization of acute non focal cerebral abnormalities, mainly by early magnetic resonance imaging (MRI). MRI sequences show either a brain-damaged pattern of the central basal ganglia, thalami and posterior limbs of internal capsules with relative cortical sparing, in acute, near-total asphyxial insults manifested by a continuous bradycardia or a pattern of cortical injury in the watershed zones and relative sparing of the central grey matter, in prolonged partial asphyxia, manifested by late or atypical variable decelerations with progressive fetal tachycardia, loss of reactivity and absent fluctuation. Prolongation of either type of asphyxial insult results in more global brain damage. In order to differentiate a CP occurring after perinatal asphyxia from other neurological sequelae in relation with infection, hemorrhage, stroke, malformations, genetic or metabolic diseases, it is essential that a definitive information from the brain by MRI and an extensive histological examination of the placenta are at disposal.
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Brissaud O, Amirault M, Villega F, Periot O, Chateil JF, Allard M. Efficiency of fractional anisotropy and apparent diffusion coefficient on diffusion tensor imaging in prognosis of neonates with hypoxic-ischemic encephalopathy: a methodologic prospective pilot study. AJNR Am J Neuroradiol 2010; 31:282-7. [PMID: 19959775 DOI: 10.3174/ajnr.a1805] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The DTI parameters (FA and ADC) reflect the properties of the brain microstructure. Decreased anisotropy is a common feature of cerebral tissue abnormalities. Our study investigates the neurologic prognostic efficiency of these parameters in white (PLIC, CP) and gray matter (PP) in the first days of life in term neonates with HIE. We hypothesize that lesions in related brain areas could be part of a physiopathologic substratum supporting neurologic deficiencies in this population. MATERIALS AND METHODS A total of 22 neonates (13 girls and 9 boys; mean gestational age, 40 weeks +/- 9 days; birth weight, 3203 +/- 584 g) underwent brain MR imaging between day 1 and day 6 after birth; 6-noncollinear direction DTI was performed. FA and ADC were measured on specific brain areas. Amiel-Tison score was performed on day 8.5 +/- 4 (group A, favorable outcome [n = 16]; group B, unfavorable outcome [n = 6]). RESULTS Intraobserver and interobserver comparison in DTI parameter measurements showed a coefficient of variability of less than 5%. In PLIC and PP, the ADC values were lower in group B compared with group A (P = .000027), whereas in PLIC and CP, the FA values were lower in group B compared with group A (P < .02). CONCLUSIONS These findings indicate that a poor early neurologic outcome in neonates with HIE is associated with lower FA or ADC values in specific areas of white or gray matter. The difference in ADC/FA changes in the different brain areas explored may support possibly different pathologic processes.
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Affiliation(s)
- O Brissaud
- Université de Bordeaux, Bordeaux, France.
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Iwasaki S, Morokuma S, Yumoto Y, Hiwatashi A, Tsukimori K, Wake N. Acute onset antenatal fetal neurological injury suspected prenatally based on abnormalities in antenatal testing: a case report. J Matern Fetal Neonatal Med 2009; 22:1207-10. [PMID: 19916720 DOI: 10.3109/14767050903019619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This report discusses the case of a fetus with previously normal findings of cardiotocograph that experienced an acute neurologic insult antenatally. The fetus presented with abnormalities of its heart rate tracing and its movement patterns on ultrasound. Following delivery, the infant was diagnosed with hypoxic ischemic encephalopathy by DWI in the first 24 h after birth, despite having a normal postnatal brain ultrasound.
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Affiliation(s)
- Satomi Iwasaki
- Department of Gynecology and Obstetrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Chauhan SP, Hendrix NW, Magann EF, Sanderson M, Bofill JA, Briery CM, Morrison JC. Neonatal organ dysfunction among newborns at gestational age ⩾ 34 weeks and umbilical arterial pH < 7.00. J Matern Fetal Neonatal Med 2009; 17:261-8. [PMID: 16147835 DOI: 10.1080/14767050500073134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Among newborns at 34 weeks or more with umbilical arterial pH<7.00, we endeavoured to determine the pH threshold and risk factors for neonatal organ injury within 72 hours of birth. STUDY DESIGN Retrospectively, all non-anomalous newborns delivered over 6 years near term with a low pH were identified. Each case of a newborn with injury was compared with the next four neonates with a pH below 7.00 and no injury. A receiver-operating characteristic (ROC) curve and unconditional logistic regression was used. RESULTS Of the 87 newborns with pathologic acidosis, 16% had neonatal organ system injury. Inspection of the ROC curve indicates that a pH of 6.92 is the threshold that identifies newborns who will have damage to organs. Unconditional logistic regression analysis indicates that the significant risk factors for morbidity were an Apgar score <or=7 at 5 minutes, an UA pH <or=6.92, a sentinel event, and a history of maternal seizures among those at 37 weeks or more. CONCLUSIONS Among newborns at >or=37 weeks, pH <or=6.92 is the threshold linked with neonatal organ dysfunction.
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Affiliation(s)
- Suneet P Chauhan
- Spartanburg Regional Medical Center, Spartanburg, South Carolina 29303, USA.
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James DK, Telfer FM, Keating NA, Blair ME, Wilcox MA, Chilvers C. Reduced fetal movements and maternal medication - new pregnancy risk factors for neurodevelopmental disability in childhood. J OBSTET GYNAECOL 2009; 20:226-34. [PMID: 15512540 DOI: 10.1080/01443610050009494] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A case-control study was undertaken of 471 children on the Nottingham Special Needs Register (SNR) who were born in one of the two maternity units in the city between 1987 and 1993 (inclusive). Controls were selected as the next infant born at the same hospital following each index case. The aim of the study was to identify risk factors on the Nottingham Obstetric Database for a baby subsequently appearing on the SNR. Disability was analysed by both ICD-9 coding and functional assessment. Factors which independently and significantly predicted a child's likelihood of being on the SNR were breech presentation (adjusted odds ratio (OR) = 4.0), congenital abnormality (OR=4.9), intrapartum fetal distress (OR=1.7), fetal growth restriction (OR=2.0), socioeconomic deprivation (OR=1.8), prematurity (OR=2.2), reduced fetal movements (OR=2.5) and medication in pregnancy (OR=10.4). To our knowledge the last two factors have not previously been reported as risk predictors for neurodevelopmental disability.
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Affiliation(s)
- D K James
- Department of Obstetrics and Gynaecology, Child Health, Public, Health Medicine, and Epidemiology, University of Nottingham, UK.
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Scher MS. Neonatal Hypertonia: II. differential diagnosis and proposed neuroprotection. Pediatr Neurol 2008; 39:373-80. [PMID: 19027581 DOI: 10.1016/j.pediatrneurol.2008.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 08/29/2008] [Accepted: 09/03/2008] [Indexed: 01/08/2023]
Abstract
More accurate documentation of a neonate's specific hypertonic state could be helpful as part of serial neurologic examinations. The clinician would then be in a more advantageous position to choose the appropriate neuroprotective drug or the procedure that best fits with the etiology, localization, and timing of injury. Ideally, choices for neuroprotection will integrate history, examination, and diagnostic findings before considering options for prophylaxis, neurorescue, or neurorepair. Measuring the efficacy of a neuroprotection protocol should include a complete list of life-course challenges, including motor, epileptic, cognitive, and behavioral outcomes as expressed at successively older ages.
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Affiliation(s)
- Mark S Scher
- Program in Fetal and Neonatal Neurology, Division of Pediatric Neurology, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106-6090, USA.
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Neonatal hypertonia: I. Classification and structural-functional correlates. Pediatr Neurol 2008; 39:301-6. [PMID: 18940552 DOI: 10.1016/j.pediatrneurol.2008.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 08/29/2008] [Indexed: 11/22/2022]
Abstract
Neonatal hypertonic states can be encountered as expressions of abnormal tone and posture. It would be useful for the neonatal neurointensivist to more precisely describe the various presentations of neonatal hypertonia, taking into consideration a classification scheme adopted for hypertonia in children at older ages. An understanding of the ontogeny of muscle tone and posture during fetal and postnatal preterm time periods with maturation to full-term ages will help conceptualize the developmental structural-functional correlates that subserve the evolving expression of this abnormal clinical sign. In the future, a more accurate description of neonatal hypertonic states should be part of the complete clinical examination to help integrate etiology, timing of injury, and neurologic localization before choosing the appropriate therapeutic intervention.
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Abstract
One hundred ninety-three neonates with seizures were available on a neonatal seizure database, which included intrapartum and neonatal factors such as labor duration, fetal heart rate abnormalities, cord blood gas values, Apgar scores and clinical signs of encephalopathy. Regression analyses (analysis of variance) were performed on the entire cohort as well as specific subsets of neonates (eg, neonatal encephalopathy vs no encephalopathy) to assess the relationship between seizure timing and intrapartum/neonatal factors. Seizures were noted earlier for the encephalopathic group than for the nonencephalopathic group. No significant differences were noted for any intrapartum or neonatal factors. Timing of neonatal seizures, with or without an encephalopathy occurs within the first 2 days after birth and is independent of selected intrapartum and neonatal factors, underscoring recent task force recommendations concerning neonatal encephalopathy. Factors other than intrapartum events more likely contribute to the encephalopathic repertoire of the newborn, including seizures.
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Affiliation(s)
- Mark S Scher
- Rainbow Babies and Children's Hospital, Cleveland, Ohio 44106-6090, USA.
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Hobbs C, Thoresen M, Tucker A, Aquilina K, Chakkarapani E, Dingley J. Xenon and hypothermia combine additively, offering long-term functional and histopathologic neuroprotection after neonatal hypoxia/ischemia. Stroke 2008; 39:1307-13. [PMID: 18309163 DOI: 10.1161/strokeaha.107.499822] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hypoxic/ischemic (HI) brain injury affects 1 to 6 per 1000 live human births, with a mortality of 15% to 20%. A quarter of survivors have permanent disabilities. Hypothermia is the only intervention that improves outcome; however, further improvements might be obtained by combining hypothermia with additional treatments. Xenon is a noble anesthetic gas with an excellent safety profile, showing great promise in vitro and in vivo as a neuroprotectant. We investigated combinations of 50% xenon (Xe(50%)) and hypothermia of 32 degrees C (HT(32 degrees C)) as a post-HI therapy. METHODS An established neonatal rat HI model was used. Serial functional neurologic testing into adulthood 10 weeks after injury was performed, followed by global and regional brain histopathology evaluation. RESULTS In the combination Xe(50%)HT(32 degrees C) group, complete restoration of long-term functional outcomes was seen. Hypothermia produced improvement on short- (P<0.001) and long- (P<0.001) term functional testing, whereas Xe(50%) alone predominantly improved long-term function (P<0.05), suggesting that short-term testing does not always predict eventual outcome. Similarly, the Xe(50%)HT(32 degrees C) combination produced the greatest (71%) improvement in global histopathology scores, a pattern mirrored in the regional scores, whereas Xe(50%) and HT(32 degrees C) individually produced smaller improvements (P<0.05 and P<0.001, respectively). The interaction between the 2 treatments was additive. CONCLUSIONS The xenon/hypothermia combination additively confers greater protection after HI than either treatment alone. The functional improvement is almost complete, is sustained long term, and is accompanied by greatly improved histopathology. The unique safety profile differentiates xenon as an attractive combination therapy with hypothermia to improve the otherwise bleak outcome from neonatal HI.
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Affiliation(s)
- Catherine Hobbs
- Department of Clinical Sciences at South Bristol, University of Bristol, Bristol, UK
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Houfflin-Debarge V, Closset E, Deruelle P. Surveillance du travail dans les situations à risque. ACTA ACUST UNITED AC 2008; 37 Suppl 1:S81-92. [DOI: 10.1016/j.jgyn.2007.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Martin A. [Fetal heart rate during labour: definitions and interpretation]. ACTA ACUST UNITED AC 2008; 37 Suppl 1:S34-45. [PMID: 18191915 DOI: 10.1016/j.jgyn.2007.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Continuous fetal heart rate monitoring is widely used during labor even in low risk pregnancies. Consensus is necessary to define and interpret accurately the different FHR patterns. The normal FHR tracing include baseline rate between 110-160 beats per minute (bpm), moderate variability (6-25 bpm), presence of accelerations and no decelerations. Uterine activity is monitored simultaneously: contractions frequency, duration, amplitude and relaxation time must be also normal. Abnormal baseline heart rate during 10 minutes or more is termed tachycardia above 160 bpm (except for FIGO above 150) and bradycardia below 110 bpm. Variability is minimal below 6 bpm and absent when non visible. Decelerations are classified as early, variable, late, and prolonged. Early and late decelerations have an onset gradual decrease of FHR, in contrast variable decelerations have an abrupt onset. Early deceleration is coincident in timing with uterine contraction. Variable deceleration is variable in onset, duration and timing, and may be described as typical or non reassuring. Late deceleration is associated with uterine contraction; the onset, nadir, and recovery occur after onset, peak and end of the contraction. Prolonged deceleration is lasting more than two but less 10 minutes, with almost onset abrupt and no repetition. Electronic fetal monitoring is a method to detect risk of fetal asphyxia; analysis and interpretation of FHR patterns are difficult with a high false positive rate, increasing operative deliveries. The patterns who are predictive of severe fetal acidosis include recurrent late or variable or prolonged decelerations or bradycardia, with absent FHR variability, and sudden severe bradycardia. The other FHR patterns are not conclusive and defined as non reassuring; obstetrical risk factors must be considered and other method (like scalp sampling for pH) utilised to evaluate fetal state.
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Affiliation(s)
- A Martin
- Service de Gynécologie-Obstétrique, Hôpital Saint-Jacques, CHRU de Besançon, Besançon Cedex, France.
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Girard N, Confort-Gouny S, Schneider J, Chapon F, Viola A, Pineau S, Combaz X, Cozzone P. Neuroimaging of neonatal encephalopathies. J Neuroradiol 2007; 34:167-82. [PMID: 17590440 DOI: 10.1016/j.neurad.2007.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neonatal brain disorders consist of a wide chapter including brain malformations, hypoxic-ischemic encephalopathy (HIE), intracranial infections, perinatal trauma and metabolic encephalopathy. We will focus here on HIE, intracranial infections (especially materno-fetal infection with or without prolonged and/or premature rupture of membranes) and metabolic encephalopathy, those three conditions being the most frequent so far in our experience. Neonatal stroke is also analyzed. Moreover minor perinatal events might be superimposed on an already damaged (infective, edematous, metabolically abnormal or maldeveloped) brain, highlighting the main role and potential benefits of neuroimaging during the neonatal period. The different methods of brain imaging are thus reported with their advantages and disadvantages.
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Affiliation(s)
- N Girard
- Department of Neuroradiology Diagnostique and Interventionnelle, hôpital Timone, université de la Méditerranée, 264 rue Saint-Pierre, 13005 Marseille, France.
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Abstract
Autism is a brain disorder characterized by abnormalities in how a person relates and communicates to others. Both post-mortem and neuroimaging studies indicate the presence of increased brain volume and, in some cases, an altered gray/white matter ratio. Contrary to established gross findings there is no recognized microscopic pathology to autism. Early studies provided multiple leads none of which have been validated. Clinicopathological associations have been difficult to sustain when considering possible variables such as use of medications, seizures, mental retardation and agonal/pre-agonal conditions. Research findings suggest widespread cortical abnormalities, lack of a vascular component and an intact blood-brain barrier. Many of the previously mentioned findings can be explained in terms of a mini-columnopathy. The significance of future controlled studies should be judged based on their explanatory powers; that is, how well do they relate to brain growth abnormalities and/or provide useful clinicopathological correlates.
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Affiliation(s)
- Manuel F Casanova
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY 40292, USA.
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References. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007. [DOI: 10.1016/s1701-2163(16)32622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Karin B Nelson
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland 20892, USA.
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Ellman LM, Huttunen M, Lönnqvist J, Cannon TD. The effects of genetic liability for schizophrenia and maternal smoking during pregnancy on obstetric complications. Schizophr Res 2007; 93:229-36. [PMID: 17475446 DOI: 10.1016/j.schres.2007.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Revised: 03/11/2007] [Accepted: 03/14/2007] [Indexed: 11/22/2022]
Abstract
UNLABELLED The purpose of this study was to determine whether a genetic vulnerability for schizophrenia and/or health-risk behaviors among schizophrenic pregnant women were associated with an increased incidence of obstetric complications (OCs). METHOD A high-risk birth cohort was formed by searching the Finnish Perinatal Register for all births from 1991-2000 with arterial cord pH values below 7.20, an indication of fetal asphyxia. This database was merged with national hospital discharge registries to determine psychiatric morbidity of the mothers and the mothers' first-degree relatives. Mothers were divided into 3 groups: women diagnosed with schizophrenia/schizoaffective disorder (n=53), mothers with a first-degree relative with schizophrenia/schizoaffective disorder (n=590) and healthy controls (n=36,895). RESULT Schizophrenic women had significantly more OCs than mothers with a first-degree schizophrenic relative and controls. These women had significantly increased rates of eclampsia, premature delivery, prenatal hospitalizations, and marginally significant increases in high blood pressure. Offspring of schizophrenic mothers had significantly decreased APGAR scores and birth weight and increased medical complications after birth. In contrast, women with a schizophrenic first-degree relative had no significant increases in OCs compared to controls. Schizophrenic mothers also smoked more than the other groups and smoking was found to mediate the relationship between maternal schizophrenic status and decreased birth weight among offspring. CONCLUSIONS Maternal schizophrenia during pregnancy leads to an increased risk of OCs, possibly due to engagement in health-risk behaviors during pregnancy, such as smoking, whereas genetic susceptibility to schizophrenia, by itself, does not appear to be related to incidence of OCs.
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Affiliation(s)
- Lauren M Ellman
- UCLA Psychology Department, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, United States.
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Wayenberg JL. Threshold of metabolic acidosis associated with neonatal encephalopathy in the term newborn. J Matern Fetal Neonatal Med 2007; 18:381-5. [PMID: 16390803 DOI: 10.1080/14767050500249916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the threshold of metabolic acidosis associated with neonatal encephalopathy (NE) in the term newborn. METHODS Term patients were included on the basis of abnormal hemodynamic, respiratory or neurological signs still persisting 30 min after birth. Base deficit (BD30) was measured in arterial blood between the 30th and the 45th min of life and correlated with the occurrence of NE during the first days of life using receiver operating characteristics (ROC) methodology. RESULTS Moderate or severe NE occurred in 26% of patients whose BD30 was higher than 10 mmol/L and in 79% of patients whose BD30 was higher than 18 mmol/L. No infants developed moderate or severe NE when BD30 was less than 10 mmol/L. The apex of ROC curve related to moderate or severe NE corresponds to a BD30 of 14 mmol/L. At this threshold, the sensitivity of BD30 is 73.2% and the specificity 82%. CONCLUSION The threshold of metabolic acidosis that provides the best combination of sensitivity and specificity in relation to the occurrence of moderate or severe NE was a BD30 higher than 14 mmol/L. Significant birth asphyxia should be considered if BD30 exceeds 10 mmol/L.
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Affiliation(s)
- Jean-Louis Wayenberg
- Department of Paediatrics, Hôpital Français - César de Paepe, Université Libre de Bruxelles, Brussels, Belgium.
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