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Shepherd ES, Goldsmith S, Doyle LW, Middleton P, Marret S, Rouse DJ, Pryde P, Wolf HT, Crowther CA. Magnesium Sulfate Before Preterm Birth for Neuroprotection: An Updated Cochrane Systematic Review. Obstet Gynecol 2024; 144:161-170. [PMID: 38830233 PMCID: PMC11250087 DOI: 10.1097/aog.0000000000005644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE To systematically review the evidence for the effectiveness and safety of magnesium sulfate as a fetal neuroprotective agent when given to individuals at risk of preterm birth. DATA SOURCES We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov , the World Health Organization International Clinical Trials Registry Platform (through March 17, 2023), and reference lists of relevant studies. METHODS OF STUDY SELECTION Randomized controlled trials (RCTs) assessing magnesium sulfate for fetal neuroprotection in pregnant participants at risk of imminent preterm birth were eligible. Two authors assessed RCTs for inclusion, extracted data, and evaluated risk of bias, trustworthiness, and evidence certainty (GRADE [Grading of Recommendations Assessment, Development and Evaluation]). TABULATION, INTEGRATION, AND RESULTS We included six RCTs (5,917 pregnant participants and 6,759 fetuses at less than 34 weeks of gestation at randomization). They were conducted in high-income countries (two in the United States, two across Australia and New Zealand, and one each in Denmark and France) and commenced between 1995 and 2018. Primary outcomes: up to 2 years of corrected age, magnesium sulfate compared with placebo reduced the risk of cerebral palsy (risk ratio [RR] 0.71, 95% CI, 0.57-0.89; six RCTs, 6,107 children) and death or cerebral palsy (RR 0.87, 95% CI, 0.77-0.98; six RCTs, 6,481 children) (high-certainty evidence). Magnesium sulfate had little or no effect on death up to 2 years of corrected age (moderate-certainty evidence) or these outcomes at school age (low-certainty evidence). Although there was little or no effect on death or cardiac or respiratory arrest for pregnant individuals (low-certainty evidence), magnesium sulfate increased adverse effects severe enough to stop treatment (RR 3.21, 95% CI, 1.88-5.48; three RCTs, 4,736 participants; moderate-certainty evidence). Secondary outcome: magnesium sulfate reduced the risk of severe neonatal intraventricular hemorrhage (moderate-certainty evidence). CONCLUSION Magnesium sulfate for preterm fetal neuroprotection reduces cerebral palsy and death or cerebral palsy for children. Further research is required on longer-term benefits and harms for children, effect variation by participant and treatment characteristics, and the generalizability of findings to low- and middle-income countries. SYSTEMATIC REVIEW REGISTRATION The review protocol was based on a standard Cochrane Pregnancy and Childbirth template and our previous Cochrane Systematic Review (doi: 10.1002/14651858.CD004661.pub3 ; published before the introduction of PROSPERO).
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Affiliation(s)
- Emily S Shepherd
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute (SAHMRI), and Adelaide Medical School, University of Adelaide, Adelaide, the Cerebral Palsy Alliance Research Institute, Specialty of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, and the Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Australia; INSERM Unit 1245, Team 4, Rouen School of Medicine, Normandy University, and the Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, Rouen University Hospital, Rouen, France; Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; the Department of Gynaecology and Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark; and the Liggins Institute, University of Auckland, Auckland, New Zealand
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Shepherd ES, Goldsmith S, Doyle LW, Middleton P, Marret S, Rouse DJ, Pryde P, Wolf HT, Crowther CA. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev 2024; 5:CD004661. [PMID: 38726883 PMCID: PMC11082932 DOI: 10.1002/14651858.cd004661.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND Magnesium sulphate is a common therapy in perinatal care. Its benefits when given to women at risk of preterm birth for fetal neuroprotection (prevention of cerebral palsy for children) were shown in a 2009 Cochrane review. Internationally, use of magnesium sulphate for preterm cerebral palsy prevention is now recommended practice. As new randomised controlled trials (RCTs) and longer-term follow-up of prior RCTs have since been conducted, this review updates the previously published version. OBJECTIVES To assess the effectiveness and safety of magnesium sulphate as a fetal neuroprotective agent when given to women considered to be at risk of preterm birth. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 17 March 2023, as well as reference lists of retrieved studies. SELECTION CRITERIA We included RCTs and cluster-RCTs of women at risk of preterm birth that assessed prenatal magnesium sulphate for fetal neuroprotection compared with placebo or no treatment. All methods of administration (intravenous, intramuscular, and oral) were eligible. We did not include studies where magnesium sulphate was used with the primary aim of preterm labour tocolysis, or the prevention and/or treatment of eclampsia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed RCTs for inclusion, extracted data, and assessed risk of bias and trustworthiness. Dichotomous data were presented as summary risk ratios (RR) with 95% confidence intervals (CI), and continuous data were presented as mean differences with 95% CI. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included six RCTs (5917 women and their 6759 fetuses alive at randomisation). All RCTs were conducted in high-income countries. The RCTs compared magnesium sulphate with placebo in women at risk of preterm birth at less than 34 weeks' gestation; however, treatment regimens and inclusion/exclusion criteria varied. Though the RCTs were at an overall low risk of bias, the certainty of evidence ranged from high to very low, due to concerns regarding study limitations, imprecision, and inconsistency. Primary outcomes for infants/children: Up to two years' corrected age, magnesium sulphate compared with placebo reduced cerebral palsy (RR 0.71, 95% CI 0.57 to 0.89; 6 RCTs, 6107 children; number needed to treat for additional beneficial outcome (NNTB) 60, 95% CI 41 to 158) and death or cerebral palsy (RR 0.87, 95% CI 0.77 to 0.98; 6 RCTs, 6481 children; NNTB 56, 95% CI 32 to 363) (both high-certainty evidence). Magnesium sulphate probably resulted in little to no difference in death (fetal, neonatal, or later) (RR 0.96, 95% CI 0.82 to 1.13; 6 RCTs, 6759 children); major neurodevelopmental disability (RR 1.09, 95% CI 0.83 to 1.44; 1 RCT, 987 children); or death or major neurodevelopmental disability (RR 0.95, 95% CI 0.85 to 1.07; 3 RCTs, 4279 children) (all moderate-certainty evidence). At early school age, magnesium sulphate may have resulted in little to no difference in death (fetal, neonatal, or later) (RR 0.82, 95% CI 0.66 to 1.02; 2 RCTs, 1758 children); cerebral palsy (RR 0.99, 95% CI 0.69 to 1.41; 2 RCTs, 1038 children); death or cerebral palsy (RR 0.90, 95% CI 0.67 to 1.20; 1 RCT, 503 children); and death or major neurodevelopmental disability (RR 0.81, 95% CI 0.59 to 1.12; 1 RCT, 503 children) (all low-certainty evidence). Magnesium sulphate may also have resulted in little to no difference in major neurodevelopmental disability, but the evidence is very uncertain (average RR 0.92, 95% CI 0.53 to 1.62; 2 RCTs, 940 children; very low-certainty evidence). Secondary outcomes for infants/children: Magnesium sulphate probably reduced severe intraventricular haemorrhage (grade 3 or 4) (RR 0.76, 95% CI 0.60 to 0.98; 5 RCTs, 5885 infants; NNTB 92, 95% CI 55 to 1102; moderate-certainty evidence) and may have resulted in little to no difference in chronic lung disease/bronchopulmonary dysplasia (average RR 0.92, 95% CI 0.77 to 1.10; 5 RCTs, 6689 infants; low-certainty evidence). Primary outcomes for women: Magnesium sulphate may have resulted in little or no difference in severe maternal outcomes potentially related to treatment (death, cardiac arrest, respiratory arrest) (RR 0.32, 95% CI 0.01 to 7.92; 4 RCTs, 5300 women; low-certainty evidence). However, magnesium sulphate probably increased maternal adverse effects severe enough to stop treatment (average RR 3.21, 95% CI 1.88 to 5.48; 3 RCTs, 4736 women; moderate-certainty evidence). Secondary outcomes for women: Magnesium sulphate probably resulted in little to no difference in caesarean section (RR 0.96, 95% CI 0.91 to 1.02; 5 RCTs, 5861 women) and postpartum haemorrhage (RR 0.94, 95% CI 0.80 to 1.09; 2 RCTs, 2495 women) (both moderate-certainty evidence). Breastfeeding at hospital discharge and women's views of treatment were not reported. AUTHORS' CONCLUSIONS The currently available evidence indicates that magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus, compared with placebo, reduces cerebral palsy, and death or cerebral palsy, in children up to two years' corrected age, and probably reduces severe intraventricular haemorrhage for infants. Magnesium sulphate may result in little to no difference in outcomes in children at school age. While magnesium sulphate may result in little to no difference in severe maternal outcomes (death, cardiac arrest, respiratory arrest), it probably increases maternal adverse effects severe enough to stop treatment. Further research is needed on the longer-term benefits and harms for children, into adolescence and adulthood. Additional studies to determine variation in effects by characteristics of women treated and magnesium sulphate regimens used, along with the generalisability of findings to low- and middle-income countries, should be considered.
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Affiliation(s)
- Emily S Shepherd
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Shona Goldsmith
- Cerebral Palsy Alliance Research Institute, Specialty of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Lex W Doyle
- Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Australia
| | - Philippa Middleton
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Stéphane Marret
- INSERM Unit 1245, Team 4, Rouen School of Medicine, Normandy University, Rouen, France
- Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, Rouen University Hospital, Rouen, France
| | - Dwight J Rouse
- Women & Infants Hospital of Rhode Island, The Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Peter Pryde
- Department of Anesthesiology, The University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Hanne T Wolf
- Department of Gynaecology and Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
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Zhou L, Liu X, Yan X, Liu Y, Xie Y, Sun C. Long-term effects of prenatal magnesium sulfate exposure on nervous system development in preterm-born children. Food Sci Nutr 2023; 11:7061-7069. [PMID: 37970388 PMCID: PMC10630835 DOI: 10.1002/fsn3.3630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 11/17/2023] Open
Abstract
This study used structural magnetic resonance imaging to analyze changes in the gray matter volume (GMV) of preterm-born (PTB) and term-born (TB) children to help elucidate the influence of magnesium sulfate treatment on the nervous system development. A total of 51 subjects were recruited, including 28 PTB and 23 TB children. The intelligence scale and MRI scan were completed at the corrected age of 10 to 16 years. A whole-brain voxel-wise analysis tested the main effect of the status (PTB without magnesium, PTB with magnesium, and TB) using a factorial design in SPM8. The mean volumes of the regions that showed significant group effects on the GMV after the FDR correction were extracted in the common space for each subject. Verbal and full-scale intelligence quotient scores were significantly lower for PTB children without magnesium than for TB children; however, the scores of PTB children with magnesium and TB children were almost identical. Compared with TB children, PTB children had significantly reduced left straight gyrus and left inferior frontal gyrus GMVs; however, the volumes of PTB children with magnesium were closer to those of TB children. Changes in the GMV of the left inferior frontal gyrus were significantly correlated with full-scale and verbal intelligence quotient scores, whereas the lower gestational age at the time of mgsou4 treatment led to a larger GMV of the left inferior frontal gyrus. Brain structural abnormalities could exist in PTB children. The GMVs of the left straight gyrus and left inferior frontal gyrus were significantly reduced in these children. The influence of magnesium sulfate treatment was not significant, but the cognitive levels of these children were significantly increased and almost identical to those of TB children. Initiation of magnesium sulfate treatment during gestation is negatively correlated with the left inferior frontal gyrus GMV.
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Affiliation(s)
- Le Zhou
- Obstetrics and Gynecology Department, West China Second University HospitalSichuan UniversityChengduChina
| | - Xinghui Liu
- Obstetrics and Gynecology Department, West China Second University HospitalSichuan UniversityChengduChina
| | - Xiaoli Yan
- Obstetrics and Gynecology DepartmentThe Southwest Hospital of the Army Medical UniversityChongqingChina
| | - Yingwei Liu
- Obstetrics and Gynecology DepartmentThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Yao Xie
- Obstetrics and Gynecology DepartmentSichuan Academy of Medical Sciences – Sichuan Provincial People's HospitalChengduChina
| | - Chuntang Sun
- Obstetrics and Gynecology Department, West China Second University HospitalSichuan UniversityChengduChina
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Kobayashi A, Ito M, Ota E, Namba F. School-Age Outcomes of Antenatal Magnesium Sulphate in Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1324. [PMID: 37628323 PMCID: PMC10453514 DOI: 10.3390/children10081324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Antenatal magnesium sulphate (MgSO4) therapy given to women at risk of preterm birth reduced the risk of cerebral palsy in early childhood. However, its effect on longer-term neurological outcomes remains uncertain. This study aimed to assess the effects of antenatal MgSO4 therapy on school-age outcomes of preterm infants. METHODS We conducted a systematic review and meta-analysis. We searched MEDLINE, EMBASE, CENTRAL, and CINAHL for randomized controlled trials (RCTs). Two reviewers independently evaluated the eligibility for inclusion and extracted data. RESULTS Ten RCTs were included. Only two of them were on school-age outcomes. Antenatal MgSO4 therapy had no impact on cerebral palsy, hearing impairment, neurosensory disability, and death at school-age. Meta-analysis on mental retardation and visual impairment was not able to be performed due to different methods of evaluation. In the analysis of short-term outcomes conducted as secondary outcomes, antenatal MgSO4 therapy increased the risk of maternal adverse events with any symptom (3 RCTs; risk ratio 2.79; 95% confidence interval 1.10 to 7.05, low certainty of evidence) but was not associated with any neonatal symptoms. CONCLUSIONS The number of cases was insufficient to determine the impact of antenatal MgSO4 therapy on school-age outcomes. Further accumulation of long-term data is required.
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Affiliation(s)
- Akira Kobayashi
- General Center for Perinatal, Maternal and Neonatal Medicine, Niigata University Medical and Dental Hospital, Niigata 951-8520, Japan
| | - Masato Ito
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita 010-8543, Japan;
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke’s International University, Chuo-ku, Tokyo 104-0044, Japan;
- Tokyo Foundation for Policy Research, Minato-ku, Tokyo 106-0032, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama 350-8550, Japan
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Perlman JM. Periventricular- intraventricular hemorrhage in the premature infant- A historical perspective. Semin Perinatol 2022; 46:151591. [PMID: 35422351 DOI: 10.1016/j.semperi.2022.151591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this chapter is to trace the evolution of intraventricular hemorrhage in the premature infant highlighting the importance of the germinal matrix, a critical role for cerebral blood flow changes in the genesis of hemorrhage, clinical factors that increase the bleeding risk, and potential preventative strategies. In 1976, neuropathological studies demonstrated capillary rupture within the germinal matrix as the precursor of hemorrhage. In 1980, introduction of cranial ultrasound facilitated diagnosis of intraventricular hemorrhage. In 1979, loss of cerebral autoregulation in sick newborn infants was demonstrated. In the 1980's, studies demonstrated the importance of intravascular factors in provoking hemorrhage. In 1983, the association of cerebral blood flow velocity fluctuations and subsequent hemorrhage was demonstrated. In 1994, antenatal steroids use to accelerate lung development was recommended. This was associated with an unanticipated reduction in hemorrhage. In the mid 1990's early indomethacin administration was associated with a reduction of severe hemorrhage.
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Affiliation(s)
- Jeffrey M Perlman
- Department of Pediatrics, Weill Cornell Medicine, Division Chief of Newborn Medicine, New York Presbyterian Hospital, 1283 York Avenue 15(th) Floor, New York, NY, 10065.
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Abstract
Despite improvements in the mortality rates of preterm infants, rates of germinal matrix intraventricular hemorrhage (IVH) have remained static with an overall incidence of 25% in infants less than 32 weeks. The importance of the lesion relates primarily to the underlying injury to the developing brain and the associated long-term neurodevelopmental consequences. This clinical-orientated review focuses on the pathogenesis of IVH and discusses the evidence behind proposed prevention strategies.
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Affiliation(s)
- Aisling A Garvey
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Bansal V, Desai A. Efficacy of Antenatal Magnesium Sulfate for Neuroprotection in Extreme Prematurity: A Comparative Observational Study. J Obstet Gynaecol India 2022; 72:36-47. [PMID: 34393393 PMCID: PMC8349599 DOI: 10.1007/s13224-021-01531-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Survival of preterm infants has improved drastically. In addition to significant contribution to neonatal mortality, impact of prematurity among survivors may continue through life impairing long-term physical life through neuro-disability and increased risk of cerebral palsy. Maternal administration of magnesium sulfate prior to impending preterm birth is an effective strategy to reduce neuromorbidity. Aim To investigate the effectiveness of antenatal magnesium sulfate for neuroprotection in preterm infants between 26 and 34 weeks in preventing early neonatal morbidity and mortality. Secondary objective was to assess any adverse events with the use of magnesium sulfate on the mother and neonate. Method This was a prospective observational comparative study for 2 years at our tertiary care hospital of 100 pregnant women who gave preterm births. Fifty infants each were born to mothers who were either not given MgSO4 (Group 1) or given 4gm intravenous loading dose MgSO4 (Group 2), preferably 4 h prior to preterm birth. Results Among all the preterm in our study, 81% delivered between 30 and 34 weeks. There was no significant difference in terms of maternal mortality or serious morbidity including postpartum hemorrhage, caesarian section rates or length of hospital stay among women receiving MgSO4 versus no MgSO4. Mild maternal side effects secondary to magnesium sulfate were experienced in 8% cases. There were no significant differences between both groups for low 5 min APGAR, need for NICU admission, neonatal convulsions, hyperbilirubinemia, necrotizing enterocolitis, periventricular leukomalacia and septicemia. There was a trend toward reduced risk in the magnesium sulfate group for need for mechanical ventilation and ongoing respiratory support, intraventricular hemorrhage, neonatal hypotension, hypothermia, length of NICU stay. IVH was less frequent and less severe in babies exposed to antenatal MgSO4 (8%) as compared to non-MgSO4 group (16%). Neonatal morbidities were more when antenatal MgSO4 was given less than 4 h from delivery. Conclusion MgSO4 is a safe drug to use in antenatal women at risk for impending preterm. Antenatal magnesium sulfate given to women in established preterm labor conferred significant neuroprotective advantage to the neonate. MgSO4 also has protective effect on the need of invasive ventilatory support in preterm infants. Given the breadth of evidence in its favor, it is time for us to start using MgSO4 in clinical practice for neuroprotective intent in all our extreme preterm births.
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Affiliation(s)
- Vandana Bansal
- Department of Obstetrics and Gynaecology, Nowrosjee Wadia Maternity Hospital, Seth G.S. Medical College, Parel, Mumbai, Maharashtra India
| | - Avinash Desai
- Department of Neonatology, Nowrosjee Wadia Maternity Hospital, Parel, Mumbai, Maharashtra India
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Jin MC, Parker JJ, Rodrigues AJ, Ruiz Colón GD, Garcia CA, Mahaney KB, Grant GA, Prolo LM. Development of an integrated risk scale for prediction of shunt placement after neonatal intraventricular hemorrhage. J Neurosurg Pediatr 2022; 29:444-453. [PMID: 35090135 DOI: 10.3171/2021.11.peds21390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neonatal intraventricular hemorrhage (IVH) is a major cause of mortality and morbidity, particularly following premature birth. Even after the acute phase, posthemorrhagic hydrocephalus is a long-term complication, frequently requiring permanent ventriculoperitoneal shunt (VPS) placement. Currently, there are no risk classification methods integrating the constellation of clinical data to predict short- and long-term prognosis in neonatal IVH. To address this need, the authors developed a two-part machine learning approach for predicting short- and long-term outcomes after diagnosis of neonatal IVH. Integrating both maternal and neonatal characteristics, they developed a binary classifier to predict short-term mortality risk and a clinical scale to predict the long-term risk of VPS placement. METHODS Neonates with IVH were identified from the Optum Clinformatics Data Mart administrative claims database. Matched maternal and childbirth characteristics were obtained for all patients. The primary endpoints of interest were short-term (30 day) mortality and long-term VPS placement. Classification of short-term mortality risk was evaluated using 5 different machine learning approaches and the best-performing method was validated using a withheld validation subset. Prediction of long-term shunt risk was performed using a multivariable Cox regression model with stepwise variable selection, which was subsequently converted to an easily applied integer risk scale. RESULTS A total of 5926 neonates with IVH were identified. Most patients were born before 32 weeks' gestation (67.2%) and with low birth weight (81.2%). Empirical 30-day mortality risk was 10.9% across all IVH grades and highest among grade IV IVH (34.3%). Among the neonates who survived > 30 days, actuarial 12-month postdiagnosis risk of shunt placement was 5.4% across all IVH grades and 31.3% for grade IV IVH. The optimal short-term risk classifier was a random forest model achieving an area under the receiver operating characteristic curve of 0.882 with important predictors ranging from gestational age to diverse comorbid medical conditions. Selected features for long-term shunt risk stratification were IVH grade, respiratory distress syndrome, disseminated intravascular coagulation, and maternal preeclampsia or eclampsia. An integer risk scale, termed the Shunt Prediction After IVH in Neonates (SPAIN) scale, was developed from these 4 features, which, evaluated on withheld cases, demonstrated improved risk stratification compared with IVH grade alone (Harrell's concordance index 0.869 vs 0.852). CONCLUSIONS In a large cohort of neonates with IVH, the authors developed a two-pronged, integrated, risk classification approach to anticipate short-term mortality and long-term shunt risk. The application of such approaches may improve the prognostication of outcomes and identification of higher-risk individuals who warrant careful surveillance and early intervention.
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Affiliation(s)
- Michael C Jin
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Jonathon J Parker
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Adrian J Rodrigues
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Gabriela D Ruiz Colón
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Cesar A Garcia
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Kelly B Mahaney
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
| | - Gerald A Grant
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
| | - Laura M Prolo
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
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Molony CL, Hiscock R, Kaufman J, Keenan E, Hastie R, Brownfoot FC. Growth trajectory of preterm small-for-gestational-age neonates. J Matern Fetal Neonatal Med 2021; 35:8400-8406. [PMID: 34503371 DOI: 10.1080/14767058.2021.1974835] [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: 10/20/2022]
Abstract
AIM To assess the growth trajectory of preterm small-for-gestational-age (SGA) neonates compared to preterm non-small-for-gestational age neonates in the neonatal intensive care unit and special care nursery. METHODS We conducted a retrospective cohort study at a large tertiary hospital in Victoria, Australia, examining neonates ≤34 weeks' gestation admitted to the neonatal intensive care unit or special care nursery between 2013 and 2017. We categorized neonates according to their birth weight centile: <10th centile (small-for-gestational age) and ≥10th centile (non-small-for-gestational age). Growth trajectory was tracked based on serial weights obtained in the neonatal intensive care unit and special care nursery, using z-scores derived from Fenton preterm growth charts. Our primary outcome was the change in weight z-score from birth to discharge from neonatal intensive care unit or special care nursery. RESULTS Of the 910 babies included, 88 were small-for-gestational age and 822 were appropriate-for gestational age. Both groups had a reduction in their weight z-score; however, SGA babies had a significantly smaller reduction (-0.62 SD compared to -0.85 SD, p < .0001). Small-for-gestational-age neonates were four times more likely to experience an increase in their weight z-score across their admission compared to neonates who were not small-for-gestational age (OR 4.04, 95% CI 2.23-7.48, p < .0001). Small-for-gestational-age neonates had an increased median length of stay, increased incidence of necrotizing enterocolitis but a reduced incidence of intraventricular hemorrhage. CONCLUSIONS Preterm SGA babies experience a smaller reduction in their weight trajectory compared to their appropriately grown counterparts in the neonatal intensive care unit or special care nursery.
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Affiliation(s)
- Claire L Molony
- Department of Obstetrics and Gynaecology, Mercy Perinatal, University of Melbourne, Mercy Hospital for Women, Heidelberg, Australia.,Mercy Hospital for Women, Heidelberg, Australia
| | | | - Jonathan Kaufman
- Department of Paediatrics, Sunshine Hospital, St Albans, Australia
| | - Emerson Keenan
- Department of Obstetrics and Gynaecology, Mercy Perinatal, University of Melbourne, Mercy Hospital for Women, Heidelberg, Australia
| | - Roxanne Hastie
- Department of Obstetrics and Gynaecology, Mercy Perinatal, University of Melbourne, Mercy Hospital for Women, Heidelberg, Australia
| | - Fiona C Brownfoot
- Department of Obstetrics and Gynaecology, Mercy Perinatal, University of Melbourne, Mercy Hospital for Women, Heidelberg, Australia.,Mercy Hospital for Women, Heidelberg, Australia
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Ozer Bekmez B, Oğuz Y, Kutman HGK, Uygur D, Canpolat FE, Oğuz SS, Tayman C. The Effect of Antenatal Neuroprotective Magnesium Sulfate Treatment on Cerebral Oxygenation in Preterm Infants. Am J Perinatol 2021; 38:e64-e70. [PMID: 32143226 DOI: 10.1055/s-0040-1705148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Antenatal magnesium sulfate (MgSO4) treatment is associated with reduced risk of cerebral palsy in preterm infants. We aimed to investigate whether this treatment leads to any alterations on cerebral hemodynamics which could be detected by near-infrared spectroscopy (NIRS) readings in early postnatal life. STUDY DESIGN Infants with gestational ages (GAs) ≤ 32 weeks were divided into two groups regarding their exposure to antenatal neuroprotective MgSO4 treatment or not. NIRS monitoring was performed to all infants, and readings were recorded for 2 hours each day during the first 3 days of life. The primary aim was to compare regional cerebral oxygen saturation (rcSO2) and cerebral fractional tissue oxygen extraction (cFTOE) between the groups. RESULTS Sixty-six infants were exposed to antenatal MgSO4, while 64 of them did not. GA and birth weight were significantly lower in the treatment group (p < 0.01). No difference was observed in rcSO2 and cFTOE levels in the first, second, and the third days of life (p > 0.05). An insignificant reduction in severe intraventricular hemorrhage rates was observed (8 vs. 15%, p = 0.24). CONCLUSION We could not demonstrate any effect on cerebral oxygenation of preterm infants in early postnatal life that could be attributed to antenatal neuroprotective MgSO4 treatment. Future studies are warranted to clarify the exact underlying mechanisms of neuroprotection.
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Affiliation(s)
- Buse Ozer Bekmez
- Division of Neonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Yüksel Oğuz
- Division of Perinatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Hayriye Gözde Kanmaz Kutman
- Division of Neonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Dilek Uygur
- Division of Perinatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Fuat Emre Canpolat
- Division of Neonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Serife Suna Oğuz
- Division of Neonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
| | - Cüneyt Tayman
- Division of Neonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Altındağ, Ankara, Turkey
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Emeruwa UN, Krenitsky NM, Sheen JJ. Advances in Management for Preterm Fetuses at Risk of Delivery. Clin Perinatol 2020; 47:685-703. [PMID: 33153655 DOI: 10.1016/j.clp.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.
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Affiliation(s)
- Ukachi N Emeruwa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 East 168th Street PH 16-66, New York, NY 10032, USA. https://twitter.com/MissUkachi
| | - Nicole M Krenitsky
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 East 168th Street PH 16-66, New York, NY 10032, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 East 168th Street PH 16-66, New York, NY 10032, USA.
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12
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Abstract
OBJECTIVE The objective is to provide guidelines for the use of antenatal magnesium sulphate for fetal neuroprotection of the preterm infant. OPTIONS Antenatal magnesium sulphate administration should be considered for fetal neuroprotection when women present at ≤33 + 6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. OUTCOMES The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. EVIDENCE Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in December 2017, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of "death or CP" (relative risk [RR] 0.85; 95% confidence interval [CI] 0.74-0.98; 4 trials, 4446 infants), "death or moderate-severe CP" (RR 0.85; 95% CI 0.73-0.99; 3 trials, 4250 infants), "any CP" (RR 0.71; 95% CI 0.55-0.91; 4, trials, 4446 infants), "moderate-to-severe CP" (RR 0.60; 95% CI 0.43-0.84; 3 trials, 4250 infants), and "substantial gross motor dysfunction" (inability to walk without assistance) (RR 0.60; 95% CI 0.43-0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs because women eligible to receive antenatal magnesium sulphate will be judged to have imminent preterm birth. VALIDATION Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium sulphate was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, magnesium sulphate was recommended only at <30 weeks gestation, based on 2 considerations. First, no single gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. In March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on magnesium sulphate for fetal neuroprotection. It stated that "the available evidence suggests that magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants." No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with 1 of the larger trials. Similarly, the World Health Organization also strongly recommends use of magnesium sulphate for fetal neuroprotection in its 2015 recommendations on interventions to improve preterm birth outcomes but cites further researching on dosing regimen and re-treatment. SPONSORS Canadian Institutes of Health Research (CIHR). SUMMARY STATEMENT RECOMMENDATIONS.
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13
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Shepherd E, Salam RA, Manhas D, Synnes A, Middleton P, Makrides M, Crowther CA. Antenatal magnesium sulphate and adverse neonatal outcomes: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002988. [PMID: 31809499 PMCID: PMC6897495 DOI: 10.1371/journal.pmed.1002988] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/06/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes. METHODS AND FINDINGS CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only. CONCLUSIONS Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.
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Affiliation(s)
- Emily Shepherd
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Rehana A. Salam
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Deepak Manhas
- University of British Columbia, Vancouver, British Columbia,
Canada
| | - Anne Synnes
- University of British Columbia, Vancouver, British Columbia,
Canada
| | - Philippa Middleton
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Maria Makrides
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Caroline A. Crowther
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- Liggins Institute, University of Auckland, Auckland, New
Zealand
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14
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Sloane AJ, Flannery DD, Lafferty M, Jensen EA, Dysart K, Cook A, Greenspan J, Aghai ZH. Hypertensive disorders during pregnancy are associated with reduced severe intraventricular hemorrhage in very-low-birth-weight infants. J Perinatol 2019; 39:1125-1130. [PMID: 31263202 DOI: 10.1038/s41372-019-0413-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/12/2019] [Accepted: 05/10/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine differences in severe intraventricular hemorrhage (IVH) between very-low-birth-weight (≤1500 g, VLBW) infants born to mothers with and without hypertensive disorders (HD). DESIGN/METHODS Retrospective analysis from the Optum Neonatal Database. The primary outcome of interest was severe IVH (grade 3 or 4). Secondary outcomes included other neonatal morbidities, mortality, and length of hospitalization. Outcomes were compared between VLBW infants born to mothers with and without HD. RESULTS A total of 5456 infants met inclusion criteria. After multivariable regression analysis, risks of severe IVH and bronchopulmonary dysplasia (BPD) were lower ([OR 0.42, 95% CI 0.33-0.89, p = 0.01] and [OR 0.75, 95% CI 0.58-0.97, p = 0.03], respectively) and median length of hospitalization was decreased in the HD group (49 versus 61 days, p < 0.001). CONCLUSIONS VLBW infants born to mothers with HD have a decreased risk of severe IVH, BPD, and a shorter duration of hospitalization.
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Affiliation(s)
- Amy J Sloane
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Dustin D Flannery
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Margaret Lafferty
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Erik A Jensen
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Dysart
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jay Greenspan
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Zubair H Aghai
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA.
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15
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Koning G, Leverin AL, Nair S, Schwendimann L, Ek J, Carlsson Y, Gressens P, Thornton C, Wang X, Mallard C, Hagberg H. Magnesium induces preconditioning of the neonatal brain via profound mitochondrial protection. J Cereb Blood Flow Metab 2019; 39:1038-1055. [PMID: 29206066 PMCID: PMC6547197 DOI: 10.1177/0271678x17746132] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/12/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Magnesium sulphate (MgSO4) given to women in preterm labor reduces cerebral palsy in their offspring but the mechanism behind this protection is unclear, limiting its effective, safe clinical implementation. Previous studies suggest that MgSO4 is not neuroprotective if administered during or after the insult, so we hypothesised that MgSO4 induces preconditioning in the immature brain. Therefore, we administered MgSO4 at various time-points before/after unilateral hypoxia-ischemia (HI) in seven-day-old rats. We found that MgSO4 treatment administered as a bolus between 6 days and 12 h prior to HI markedly reduced the brain injury, with maximal protection achieved by 1.1 mg/g MgSO4 administered 24 h before HI. As serum magnesium levels returned to baseline before the induction of HI, we ascribed this reduction in brain injury to preconditioning. Cerebral blood flow was unaffected, but mRNAs/miRNAs involved in mitochondrial function and metabolism were modulated by MgSO4. Metabolomic analysis (H+-NMR) disclosed that MgSO4 attenuated HI-induced increases in succinate and prevented depletion of high-energy phosphates. MgSO4 pretreatment preserved mitochondrial respiration, reducing ROS production and inflammation after HI. Therefore, we propose that MgSO4 evokes preconditioning via induction of mitochondrial resistance and attenuation of inflammation.
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Affiliation(s)
- Gabriella Koning
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Anna-Lena Leverin
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Syam Nair
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Leslie Schwendimann
- PROTECT, INSERM, Université Paris
Diderot, Sorbonne Paris Cité, Paris, France
| | - Joakim Ek
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Ylva Carlsson
- Perinatal Center, Department of Clinical
Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Pierre Gressens
- PROTECT, INSERM, Université Paris
Diderot, Sorbonne Paris Cité, Paris, France
- Centre for the Developing Brain,
Department of Perinatal Imaging and Health, King's College London, London, UK
| | - Claire Thornton
- Centre for the Developing Brain,
Department of Perinatal Imaging and Health, King's College London, London, UK
| | - Xiaoyang Wang
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Carina Mallard
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
| | - Henrik Hagberg
- Perinatal Center, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg,
Sweden
- Perinatal Center, Department of Clinical
Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Centre for the Developing Brain,
Department of Perinatal Imaging and Health, King's College London, London, UK
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16
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Magee LA, De Silva DA, Sawchuck D, Synnes A, von Dadelszen P. No 376 - Recours au sulfate de magnésium aux fins de neuroprotection fœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:523-542. [DOI: 10.1016/j.jogc.2018.11.033] [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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17
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Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of periventricular-intraventricular hemorrhage. J Perinatol 2019; 39:54-62. [PMID: 30348960 DOI: 10.1038/s41372-018-0261-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/19/2018] [Accepted: 10/05/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Changes in cerebrovascular hemodynamics associated with head position may be important in the pathogenesis of periventricular-intraventricular hemorrhage (PIVH) in premature infants. This study evaluated the effect of elevated midline head positioning on cardiopulmonary function and the incidence of PIVH. STUDY DESIGN ELBW infants were randomized to FLAT (flat, supine) or ELEV (supine, bed elevated 30 degrees) for 96 h. Cardiopulmonary function, complications of prematurity, and the occurrence of PIVH were documented. RESULTS Infants were randomized into FLAT (n = 90) and ELEV groups (n = 90). No significant differences were seen in the incidence of BPD or other respiratory complications. The ELEV group developed significantly fewer grade 4 hemorrhages (p = 0.036) and survival to discharge was significantly higher in the ELEV group (p = 0.037). CONCLUSIONS Managing ELBW infants in an elevated midline head position for the first 4 days of life appears safe and may decrease the likelihood of severe PIVH and improve survival.
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18
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Yap V, Perlman JM. Intraventricular Hemorrhage and White Matter Injury in the Preterm Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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19
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Reduced inflammatory response by incorporating magnesium into porous TiO2 coating on titanium substrate. Colloids Surf B Biointerfaces 2018; 171:276-284. [DOI: 10.1016/j.colsurfb.2018.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/18/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
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20
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Korzeniewski SJ, Slaughter J, Lenski M, Haak P, Paneth N. The complex aetiology of cerebral palsy. Nat Rev Neurol 2018; 14:528-543. [PMID: 30104744 DOI: 10.1038/s41582-018-0043-6] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.
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Affiliation(s)
- Steven J Korzeniewski
- Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Jaime Slaughter
- Department of Health Systems and Sciences Research and Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
| | - Madeleine Lenski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Peterson Haak
- Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Nigel Paneth
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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21
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Magnesium sulphate induces preconditioning in preterm rodent models of cerebral hypoxia-ischemia. Int J Dev Neurosci 2018; 70:56-66. [PMID: 29355709 DOI: 10.1016/j.ijdevneu.2018.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/12/2018] [Accepted: 01/12/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Brain injury in preterm infants represents a substantial clinical problem associated with development of motor impairment, cognitive deficits and psychiatric problems. According to clinical studies, magnesium sulphate (MgSO4) given to women in preterm labor reduces the risk of cerebral palsy in the offspring but the mechanisms behind its neuroprotective effects are still unclear. Our aim was to explore whether MgSO4 induces tolerance (preconditioning) in the preterm rodent brain. For this purpose we established a model of perinatal hypoxia-ischemia (HI) in postnatal day 4 rats and also applied a recently developed postnatal day 5 mouse model of perinatal brain injury. METHODS Postnatal day 4 Wistar rats were exposed to unilateral carotid artery ligation followed by 60, 70 or 80 min of hypoxia (8% O2). On postnatal day 11, brains were collected and macroscopically visible damage as well as white and grey matter injury was examined using immunohistochemical staining. Once the model had been established, a possible preconditioning protection induced by a bolus MgSO4 injection prior to 80 min HI was examined 7 days after the insult. Next, a MgSO4 bolus was injected in C57Bl6 mice on PND 4 followed by exposure to unilateral carotid artery ligation and hypoxia, (10% O2) for 70 min on PND 5. Brains were collected 7 days after the insult and examined with immunohistochemistry for grey and white matter injury. RESULTS In rats, a 60 min period of hypoxia resulted in very few animals with brain injury and although 70 min of hypoxia resulted in a higher percentage of injured animals, the brains were marginally damaged. An 80 min exposure of hypoxia caused cortical tissue damage combined with hippocampal atrophy and neuronal loss in the C3 hippocampal layer. In the rat model, MgSO4 (1.1 mg/g administered i.p. 24 h prior to the induction of HI, resulting in a transient serum Mg2+ concentration elevation to 4.1 ± 0.2 mmol/l at 3 h post i.p. injection) reduced brain injury by 74% in grey matter and 64% in white matter. In the mouse model, MgSO4 (0.92 mg/g) i.p. injection given 24 h prior to the HI insult resulted in a Mg2+ serum concentration increase reaching 2.7 ± 0.3 mmol/l at 3 h post injection, which conferred a 40% reduction in grey matter injury. CONCLUSIONS We have established a postnatal day 4 rat model of HI for the study of preterm brain injury. MgSO4 provides a marked preconditioning protection both in postnatal day 4 rats and in postnatal day 5 mice.
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22
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Garg BD. Antenatal magnesium sulfate is beneficial or harmful in very preterm and extremely preterm neonates: a new insight. J Matern Fetal Neonatal Med 2018; 32:2084-2090. [PMID: 29301419 DOI: 10.1080/14767058.2018.1424823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS To evaluate whether antenatal MgSO4 is beneficial or harmful in very preterm and extremely preterm neonates. MATERIALS AND METHODS We retrieved published literature through searches of PubMed or Medline, CINAHL, and the Cochrane Library. Results were restricted to systematic reviews, meta-analysis, randomized controlled trials (RCTs), and relevant observational studies. RESULTS Evidence revealed that antenatal MgSO4 has neuroprotective role in preterm neonates and it decreased the risk of cerebral palsy and gross motor dysfunction. Evidences regarding association of antenatal MgSO4 with feed intolerance, NEC and SIP were from cohort studies and controversial. CONCLUSIONS We should continue use antenatal MgSO4 to all eligible patients according to protocol till the more robust evidence will suggest association with gastrointestinal complications. In the meantime, we should have a high index of suspicion of gastrointestinal complications in extremely preterms particularly <26 weeks of gestation.
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Affiliation(s)
- Bhawan Deep Garg
- a Surya Mother and Child Care Super Speciality Hospital , Mumbai , India
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23
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Crowther CA, Middleton PF, Voysey M, Askie L, Duley L, Pryde PG, Marret S, Doyle LW. Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant data meta-analysis. PLoS Med 2017; 14:e1002398. [PMID: 28976987 PMCID: PMC5627896 DOI: 10.1371/journal.pmed.1002398] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/31/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Babies born preterm are at an increased risk of dying in the first weeks of life, and those who survive have a higher rate of cerebral palsy (CP) compared with babies born at term. The aim of this individual participant data (IPD) meta-analysis (MA) was to assess the effects of antenatal magnesium sulphate, compared with no magnesium treatment, given to women at risk of preterm birth on important maternal and fetal outcomes, including survival free of CP, and whether effects differed by participant or treatment characteristics such as the reason the woman was at risk of preterm birth, why treatment was given, the gestational age at which magnesium sulphate treatment was received, or the dose and timing of the administration of magnesium sulphate. METHODS AND FINDINGS Trials in which women considered at risk of preterm birth (<37 weeks' gestation) were randomised to magnesium sulphate or control treatment and where neurologic outcomes for the baby were reported were eligible for inclusion. The primary outcomes were infant death or CP and severe maternal outcome potentially related to treatment. Studies were identified based on the Cochrane Pregnancy and Childbirth search strategy using the terms [antenatal or prenatal] and [magnesium] and [preterm or premature or neuroprotection or 'cerebral palsy']. The date of the last search was 28 February 2017. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. For each prespecified outcome, IPD were analysed using a 1-stage approach. All 5 trials identified were included, with 5,493 women and 6,131 babies. Overall, there was no clear effect of magnesium sulphate treatment compared with no treatment on the primary infant composite outcome of death or CP (relative risk [RR] 0.94, 95% confidence interval (CI) 0.85 to 1.05, 6,131 babies, 5 trials, p = 0.07 for heterogeneity of treatment effect across trials). In the prespecified sensitivity analysis restricted to data from the 4 trials in which the intent of treatment was fetal neuroprotection, there was a significant reduction in the risk of death or CP with magnesium sulphate treatment compared with no treatment (RR 0.86, 95% CI 0.75 to 0.99, 4,448 babies, 4 trials), with no significant heterogeneity (p = 0.28). The number needed to treat (NNT) to benefit was 41 women/babies to prevent 1 baby from either dying or having CP. For the primary outcome of severe maternal outcome potentially related to magnesium sulphate treatment, no events were recorded from the 2 trials providing data. When the individual components of the composite infant outcome were assessed, no effect was seen for death overall (RR 1.03, 95% CI 0.91 to 1.17, 6,131 babies, 5 trials) or in the analysis of death using only data from trials with the intent of fetal neuroprotection (RR 0.95, 95% CI 0.80 to 1.13, 4,448 babies, 4 trials). For cerebral palsy in survivors, magnesium sulphate treatment had a strong protective effect in both the overall analysis (RR 0.68, 95% CI 0.54 to 0.87, 4,601 babies, 5 trials, NNT to benefit 46) and the neuroprotective intent analysis (RR 0.68, 95% CI 0.53 to 0.87, 3,988 babies, 4 trials, NNT to benefit 42). No statistically significant differences were seen for any of the other secondary outcomes. The treatment effect varied little by the reason the woman was at risk of preterm birth, the gestational age at which magnesium sulphate treatment was given, the total dose received, or whether maintenance therapy was used. A limitation of the study was that not all trials could provide the data required for the planned analyses so that combined with low event rates for some important clinical events, the power to find a difference was limited. CONCLUSIONS Antenatal magnesium sulphate given prior to preterm birth for fetal neuroprotection prevents CP and reduces the combined risk of fetal/infant death or CP. Benefit is seen regardless of the reason for preterm birth, with similar effects across a range of preterm gestational ages and different treatment regimens. Widespread adoption worldwide of this relatively inexpensive, easy-to-administer treatment would lead to important global health benefits for infants born preterm.
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Affiliation(s)
- Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
- * E-mail:
| | - Philippa F. Middleton
- Australian Research Centre for Health of Women and Babies (ARCH), The Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
- Healthy Mothers Babies and Children, South Australian, Health and Medical Research Institute, Adelaide, Australia
| | - Merryn Voysey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queens Medical Centre, Nottingham, United Kingdom
| | - Peter G. Pryde
- The University of Wisconsin Medical School, Madison, Wisconsin, United States of America
| | - Stéphane Marret
- Department of Neonatal Medicine and Neuropediatrics, Rouen University Hospital, Rouen, France
- INSERM U 1245, Neovasc team, Perinatal neurological handicap and Neuroprotection IRIB, School of Medicine, Normandy University, Rouen, France
| | - Lex W. Doyle
- Department of Obstetrics and Gynaecology, The Royal Women’s’ Hospital, University of Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Abstract
Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.
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Affiliation(s)
- Angie C. Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kirsten Salmeen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Dawn Gano
- Departments of Neurology & Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mari-Paule Thiet
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Quiroz DL. PREVENCIÓN PRENATAL DE DAÑO NEUROLÓGICO EN PREMATURO EXTREMO. REVISTA MÉDICA CLÍNICA LAS CONDES 2016. [DOI: 10.1016/j.rmclc.2016.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Zeng X, Xue Y, Tian Q, Sun R, An R. Effects and Safety of Magnesium Sulfate on Neuroprotection: A Meta-analysis Based on PRISMA Guidelines. Medicine (Baltimore) 2016; 95:e2451. [PMID: 26735551 PMCID: PMC4706271 DOI: 10.1097/md.0000000000002451] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 11/26/2022] Open
Abstract
To evaluate the evidence of effects and safety of magnesium sulfate on neuroprotection for preterm infants who had exposure in uteri. We searched electronic databases and bibliographies of relevant papers to identify studies comparing magnesium sulfate (MgSO4) with placebo or other treatments in patients at high risk of preterm labor and reporting effects and safety of MgSO4 for antenatal infants. Then, we did this meta-analysis based on PRISMA guideline. The primary outcomes included fatal death, cerebral palsy (CP), intraventricular hemorrhage, and periventricular leukomalacia. Secondary outcomes included various neonatal and maternal outcomes. Ten studies including 6 randomized controlled trials and 5 cohort studies, and involving 18,655 preterm infants were analyzed. For the rate of moderate to severe CP, MgSO4 showed the ability to reduce the risk and achieved statistically significant difference (odd ratio [OR] 0.61, 95% confidence interval [CI] 0.42-0.89, P = 0.01). The comparison of mortality rate between the MgSO4 group and the placebo group only presented small difference clinically, but reached no statistical significance (OR 0.92, 95% CI 0.77-1.11, P = 0.39). Summarily, the analysis of adverse effects on babies showed no margin (P > 0.05). Yet for mothers, MgSO4 exhibited obvious side-effects, such as respiratory depression, nausea and so forth, but there exited great heterogeneity. MgSO4 administered to women at high risk of preterm labor could reduce the risk of moderate to severe CP, without obvious adverse effects on babies. Although there exit many unfavorable effects on mothers, yet they may be lessened through reduction of the dose of MgSO4 and could be tolerable for mothers. So MgSO4 is both beneficial and safety to be used as a neuroprotective agent for premature infants before a valid alternative was discovered.
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Affiliation(s)
- Xianling Zeng
- From the Department of Obstetrics and Gynecology, the First Affiliated Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi, China
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Hirtz DG, Weiner SJ, Bulas D, DiPietro M, Seibert J, Rouse DJ, Mercer BM, Varner MW, Reddy UM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter MW, O'Sullivan MJ, Peaceman AM, Hankins GDV, Dudley D, Caritis SN. Antenatal Magnesium and Cerebral Palsy in Preterm Infants. J Pediatr 2015; 167:834-839.e3. [PMID: 26254839 PMCID: PMC4587284 DOI: 10.1016/j.jpeds.2015.06.067] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 05/14/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the relationship of maternal antenatal magnesium sulfate (MgSO4) with neonatal cranial ultrasound abnormalities and cerebral palsy (CP). STUDY DESIGN In a randomized trial of MgSO4 or placebo in women at high risk of preterm delivery, up to 3 cranial ultrasounds were obtained in the neonatal period. Images were reviewed by at least 2 pediatric radiologists masked to treatment and other clinical conditions. Diagnoses were predefined for intraventricular hemorrhage, periventricular leukomalacia, intracerebral echolucency or echodensity, and ventriculomegaly. CP was diagnosed at 2 years of age by standardized neurologic examination. RESULTS Intraventricular hemorrhage, periventricular leukomalacia, intracerebral echolucency or echodensity, and ventriculomegaly were all strongly associated with an increased risk of CP. MgSO4 administration did not affect the risk of cranial ultrasound abnormality observed at 35 weeks postmenstrual age or later. However, for the 82% of infants born at <32 weeks gestation, MgSO4 was associated with a reduction in risk of echolucency or echodensity. The reduction in risk for echolucency explained 21% of the effect of MgSO4 on CP (P = .04), and for echodensity explained 20% of the effect (P = .02). CONCLUSIONS MgSO4 given prior to preterm delivery was associated with decreased risk of developing echodensities and echolucencies at <32 weeks gestation. However, this effect can only partially explain the effect of MgSO4 on CP at 2 years of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT00014989.
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Affiliation(s)
- Deborah G Hirtz
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Steven J Weiner
- Biostatistics Center, The George Washington University, Washington, DC
| | - Dorothy Bulas
- Department of Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, DC
| | - Michael DiPietro
- Section of Pediatric Radiology, University of Michigan, Ann Arbor, MI
| | - Joanna Seibert
- Division of Radiology, Arkansas Children's Hospital, Little Rock, AR
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, and University of Tennessee, Memphis, TN
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson University and Drexel University, Philadelphia, PA
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Fergal D Malone
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | | | - Mary J O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, FL
| | - Alan M Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Donald Dudley
- Department of Obstetrics and Gynecology, University of Texas at San Antonio, San Antonio, TX
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA
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Stark MJ, Hodyl NA, Andersen CC. Effects of antenatal magnesium sulfate treatment for neonatal neuro-protection on cerebral oxygen kinetics. Pediatr Res 2015; 78:310-4. [PMID: 25985294 DOI: 10.1038/pr.2015.96] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 02/13/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The underlying neuro-protective mechanisms of antenatal magnesium sulfate (MgSO(4)) in infants born preterm remain poorly understood. Early neonatal brain injury may be preceded by low cerebral blood flow (CBF) and elevated cerebral fractional tissue oxygen extraction (cFTOE). This study investigated the effect of antenatal MgSO(4) on cerebral oxygen delivery, consumption, and cFTOE in preterm infants. METHODS CBF and tissue oxygenation index were measured, and oxygen delivery, consumption, and cFTOE calculated within 24 h of birth and at 48 and 72 h of life in 36 infants ≤ 30 wk gestation exposed to MgSO(4) and 29 unexposed infants. RESULTS Total internal carotid blood flow and cerebral oxygen delivery did not differ between the groups at the three study time-points. Cerebral oxygen consumption and cFTOE were lower in infants exposed to antenatal MgSO(4) (P = 0.012) compared to unexposed infants within 24 h of delivery. This difference was not evident by 48 h of age. Fewer infants in the MgSO(4) group developed P/IVH by 72 h of age (P = 0.03). CONCLUSION Infants exposed to MgSO(4) had similar systemic and cerebral hemodynamics but lower cFTOE compared to nonexposed. These findings suggest reduced cerebral metabolism maybe a component of the neuro-protective actions of antenatal MgSO(4).
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Affiliation(s)
- Michael J Stark
- 1] Robinson Research Institute & School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia [2] Department of Neonatology, Women's & Children's Hospital, North Adelaide, South Australia, Australia
| | - Nicolette A Hodyl
- Robinson Research Institute & School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia
| | - Chad C Andersen
- 1] Robinson Research Institute & School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia [2] Department of Neonatology, Women's & Children's Hospital, North Adelaide, South Australia, Australia
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Bousleiman SZ, Rice MM, Moss J, Todd A, Rincon M, Mallett G, Milluzzi C, Allard D, Dorman K, Ortiz F, Johnson F, Reed P, Tolivaisa S. Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals. Am J Obstet Gynecol 2015; 213:398.e1-11. [PMID: 25957021 PMCID: PMC4556564 DOI: 10.1016/j.ajog.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/08/2015] [Accepted: 05/02/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection. STUDY DESIGN A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011. RESULTS A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.
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Affiliation(s)
- Sabine Zoghbi Bousleiman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Madeline Murguia Rice
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, DC
| | - Joan Moss
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Allison Todd
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Cynthia Milluzzi
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH
| | - Donna Allard
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Karen Dorman
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Felecia Ortiz
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Francee Johnson
- Department of Obstetrics and Gynecology, The Ohio State University School of Medicine, Columbus, OH
| | - Peggy Reed
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Susan Tolivaisa
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Bordbar A, Farjadnia M. Maternal Morbidities and Occurrence of Intraventricular Hemorrhage in Preterm Infants. J Pediatr Intensive Care 2015; 4:156-161. [PMID: 31110865 DOI: 10.1055/s-0035-1559825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/24/2015] [Indexed: 01/18/2023] Open
Abstract
Intraventricular hemorrhage (IVH) is one of the most serious neurological morbidities in preterm infants. Several prenatal, intrapartum, and neonatal risk factors have been detected in different studies. However, maternal conditions that may render the neonates to IVH have been the subject of very few studies. Preterm infants with and without IVH were included in the study, and maternal obstetrics and general health clinical files were reviewed for any kind of morbidity. Data were then analyzed with statistical software to assess the association between maternal conditions and IVH. A total of 115 neonates with IVH and 120 infants without IVH were recruited. Among all maternal conditions, prolonged rupture of membrane (p = 0.00), laparoscopic surgery for infertility (p = 0.001), and in vitro fertilization (IVF) (p = 0.00) increased the risk of IVH in neonates significantly. IVF remained strongly associated with IVH even after controlling for confounding variables (odds ratio: 9.75; confidence interval: 2.66-35.75; p = 0.001). Based on our findings, prolonged rupture of membrane and IVF were maternal conditions that increased the risk of IVH. Laparoscopic surgery for infertility was also associated with an increased risk of IVH.
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Affiliation(s)
- Arash Bordbar
- Department of Neonatology, Akbarabadi Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahgol Farjadnia
- Department of Neonatology, Akbarabadi Hospital, Iran University of Medical Sciences, Tehran, Iran
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31
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Oh YL. Antenatal Magnesium Sulfate for Neuroprotective Effects In Preterm Infants. KOSIN MEDICAL JOURNAL 2014. [DOI: 10.7180/kmj.2014.29.2.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
<title>Abstract Fetal or neonatal brain injury can result in lifelong neurologic disability. Although survival rates for preterm infants have increased dramatically with the advent of modern perinatal and neonatal intensive care, but the rates of neurologic abnormalities in survivors, particularly motor disorders such as cerebral palsy, have not diminished. Antenatal magnesium sulfate may reduce the rates of cerebral palsy in survivors of preterm birth. There are five randomized controlled trials of magnesium sulfate administered to women at risk of preterm delivery before 34 weeks of gestation which have reported neurological outcomes for the child. From meta-analysis of these randomized trials, the rate of cerebral palsy was reduced by magnesium sulfate (RR, ᄋ·69; 95% CI, ᄋ·54-ᄋ·87; five trials; 6,145 infants) as did the moderate/severe cerebral palsy incidence (RR, 0.64; 95% CI, ᄋ·44-ᄋ·92; three trials; 4387 infants). There was no statistically significant difference between the rates of neonatal adverse outcomes of the magnesium administration group and the control group. In most prospective randomized studies, no significant difference in the severe mother-side side effects between the magnesium sul- fate administration group and the control group.</p><p>Antenataᅵ magnesium sulfate therapy is neuroprotective against motor dysfunction in offspring for the preterm infant; however the possibility of an increase in the fetal or neonatal death rate was not completely excluded.</p>
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Abad C, Vargas FR, Zoltan T, Proverbio T, Piñero S, Proverbio F, Marín R. Magnesium sulfate affords protection against oxidative damage during severe preeclampsia. Placenta 2014; 36:179-85. [PMID: 25486968 DOI: 10.1016/j.placenta.2014.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 10/12/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION MgSO4 is the drug of choice to prevent seizures in preeclamptic pregnant women, but its mechanism of action at the molecular level remains an enigma. In previous works, we found that treating preeclamptic women with MgSO4 reduces the lipid peroxidation of their red blood cell membranes to normal levels and leads to a significant reduction in the osmotic fragility of the red blood cells that is increased during preeclampsia. In addition, the increase in lipid peroxidation of red cell membranes induced by the Fenton reaction does not occur when MgSO4 is present. METHODS The antioxidant protection of MgSO4 was evaluated in UV-C-treated red blood cell ghosts and syncytiotrophoblast plasma membranes by measuring their level of lipid peroxidation. The interaction of MgSO4 with free radicals was assessed for its association with the galvinoxyl radical, the quenching of H2O2-induced chemiluminescence and its effect on sensitized peroxidation of linoleic acid. RESULTS a) MgSO4 protected red blood cell ghosts and the syncytiotrophoblast plasma membranes of normotensive pregnant women against lipid peroxidation induced by UV-C irradiation. b) MgSO4 does not seem to scavenge the galvinoxyl free radical. c) The quenching of the H2O2-enhanced luminol chemiluminescence is increased by the presence of MgSO4. d) The peroxidation of linoleic acid is significantly blocked by MgSO4. DISCUSSION MgSO4 may provide protection against oxidative damage of plasma membranes through interactions with alkyl radicals.
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Affiliation(s)
- C Abad
- Laboratorio de Bioenergética Celular, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - F R Vargas
- Laboratorio de Fotoquímica, Centro de Química, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - T Zoltan
- Laboratorio de Fotoquímica, Centro de Química, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - T Proverbio
- Laboratorio de Bioenergética Celular, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - S Piñero
- Laboratorio de Bioenergética Celular, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - F Proverbio
- Laboratorio de Bioenergética Celular, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
| | - R Marín
- Laboratorio de Bioenergética Celular, Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela.
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A moving line in the sand: a review of obstetric management surrounding periviability. Obstet Gynecol Surv 2014; 69:359-68. [PMID: 25101845 DOI: 10.1097/ogx.0000000000000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Periviable birth poses numerous clinical and ethical challenges for the practicing clinician. We review the data surrounding the administration of corticosteroids for fetal lung maturity, antibiotics in the case of preterm premature rupture of membranes, magnesium sulfate for cerebral palsy prophylaxis, fetal monitoring, and cesarean delivery. The ethical complexities of patient counseling are also reviewed with a recommendation toward shared decision making between patient and physician.
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Regev RH, Arnon S, Litmanovitz I, Bauer-Rusek S, Boyko V, Lerner-Geva L, Reichman B. Outcome of singleton preterm small for gestational age infants born to mothers with pregnancy-induced hypertension. A population-based study. J Matern Fetal Neonatal Med 2014; 28:666-73. [DOI: 10.3109/14767058.2014.928851] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Effects of antenatal magnesium sulfate treatment on cerebral blood flow velocities in preterm neonates. J Perinatol 2014; 34:192-6. [PMID: 24480905 DOI: 10.1038/jp.2013.182] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/15/2013] [Accepted: 12/04/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study is to investigate the effects of antenatal magnesium sulfate (MgSO4) on cerebral blood flow (CBF) velocities in preterm neonates. STUDY DESIGN In this prospective case-control study, we included 53 neonates born between 26 and 34 weeks of gestation. Twenty neonates were exposed to MgSO4 antenatally and 33 were not. Serial daily Doppler flow measurements of middle cerebral artery (MCA) were performed. RESULT Significantly increased MCA mean velocities were found in the MgSO4 group. A progressive increase in serial Doppler measurements of MCA mean velocity from day 1 to day 5 of life was detected in both groups. CONCLUSION There is significant increase in MCA mean velocities in preterm neonates receiving antenatal MgSO4. This increment in CBF velocities might explain the protective role of MgSO4 in ischemic events and hypoxic brain damage.
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Bain ES, Middleton PF, Yelland LN, Ashwood PJ, Crowther CA. Maternal adverse effects with different loading infusion rates of antenatal magnesium sulphate for preterm fetal neuroprotection: the IRIS randomised trial. BJOG 2014; 121:595-603. [PMID: 24387624 DOI: 10.1111/1471-0528.12535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate a slower (compared with a standard) infusion rate of the loading dose of magnesium sulphate for preterm fetal neuroprotection as a strategy to reduce maternal adverse effects. DESIGN Randomised controlled trial. SETTING South Australian maternity hospital. POPULATION Fifty-one women at <30 weeks of gestation, where birth was planned or expected within 24 hours. METHODS Women received a loading infusion of 4 g of magnesium sulphate over either 60 or 20 minutes (followed by maintenance of 1 g/hour until birth, or for up to 24 hours). MAIN OUTCOME MEASURES Any maternal adverse effects associated with the infusion. RESULTS Overall, 71% of women experienced adverse effects during the first hour of their infusion; the difference between groups was not significant [15/25 (60%) 60-minute loading; 21/26 (81%) 20-minute loading; risk ratio (RR) 0.74; 95% confidence interval (95% CI) 0.51-1.08]. Although no serious maternal complications occurred, adverse effects led to three women ceasing the loading treatment (1/25 in the 60-minute loading group; 2/26 in the 20-minute loading group; RR 0.52; 95% CI 0.05-5.38). Women in the 60-minute loading group experienced significantly less warmth and flushing at 20 minutes into the infusion (7/25 in the 60-minute loading group; 15/26 in the 20-minute loading group; RR 0.49; 95% CI 0.24-0.99). No other differences between groups for maternally reported and clinical adverse effects were shown. CONCLUSIONS A slower rate of administering the loading dose of magnesium sulphate did not reduce the occurrence of maternal adverse effects overall. Flushing and warmth at 20 minutes into the infusion was reduced with a slower infusion.
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Affiliation(s)
- E S Bain
- Australian Research Centre for Health of Women and Babies, Robinson Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, Adelaide, Australia
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Abstract
Fetal or neonatal brain injury can result in lifelong neurologic disability. The most significant risk factor for perinatal brain injury is prematurity; however, in absolute numbers, full-term infants represent the majority of affected children. Research on strategies to prevent or mitigate the impact of perinatal brain injury ("perinatal neuroprotection") has established the mitigating roles of magnesium sulfate administration for preterm infants and therapeutic hypothermia for term infants with suspected perinatal brain injury. Banked umbilical cord blood, erythropoietin, and a number of other agents that may improve neuronal repair show promise for improving outcomes following perinatal brain injury in animal models. Other preventative strategies include delayed umbilical cord clamping in preterm infants and progesterone in women with prior preterm birth or short cervix and avoidance of infections. Despite these advances, we have not successfully decreased the rate of preterm birth, nor are we able to predict term infants at risk of hypoxic brain injury in order to intervene prior to the hypoxic event. Further, we lack the ability to modulate the sequelae of neuronal cell insults or the ability to repair brain injury after it has been sustained. As a consequence, despite exciting advances in the field of perinatal neuroprotection, perinatal brain injury still impacts thousands of newborns each year with significant long-term morbidity and mortality.
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Affiliation(s)
- Kirsten E. Salmeen
- 513 Parnassus Avenue, Room HSE-1634, Box 0556, San Francisco, CA 94143-0556USA
| | - Angie C. Jelin
- 106 Irving Street, NW, Room POB 108, Washington, DC 20010USA
| | - Mari-Paule Thiet
- 505 Parnassus Avenue, Moffitt 1478, Box 0132, San Francisco, CA 94143-0132USA
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Bachnas MA, Mose JC, Effendi JS, Andonotopo W. Influence of antenatal magnesium sulfate application on cord blood levels of brain-derived neurotrophic factor in premature infants. J Perinat Med 2014; 42:129-34. [PMID: 24062546 DOI: 10.1515/jpm-2013-0137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/14/2013] [Indexed: 11/15/2022]
Abstract
AIM To investigate the influence of antenatal magnesium sulfate (MgSO4) application on cord blood brain-derived neurotrophic factor (BDNF) levels - the first-line neuroprotection for preventing cerebral palsy in prematurely born infants. SUBJECTS AND METHODS A randomized controlled trial was conducted by observing 72 pregnant women who were divided into three groups: group I (preterm pregnancy with MgSO4), group II (preterm pregnancy without MgSO4), and group III (full-term pregnancy as control group). Groups I and II were selected by block permutation randomization on subjects. Inclusion criteria consisted of preterm pregnancy at 34 weeks of gestation or less who were in labor or having planned terminations and receiving antenatal corticosteroids. Exclusion criteria consisted of previous complications caused by MgSO4, previous history of antenatal MgSO4 application in the current pregnancy infant was born before 4 h administration of MgSO4 or unborn more than 72 h after maximum course of antenatal MgSO4 of 24 h, prolonged antenatal MgSO4 treatment (>24 h), refusal to participate, and emergent adverse events during the study. Group I was given intravenous MgSO4; initial dose was 4 g, which was maintained at 1 g/h up to maximum of 24 h. Meanwhile, groups II and III were not given any special treatment. BDNF was examined by ELISA by taking 5 mL cord blood sample shortly after birth. The result was statistically measured by ANOVA. RESULTS The cord blood BDNF levels in premature infants with antenatal MgSO4 was significantly higher than in premature infants without antenatal MgSO4 (11,568 vs. 5027 pg/mL, P=0.000). Moreover, the result was statistically comparable to full-term infants (11,568 vs. 13,300 pg/mL, P=0.085). CONCLUSION The application of antenatal MgSO4 in preterm delivery increased cord blood BDNF levels, which could have a potential role on fetal neuroprotection. Further investigation is needed.
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Suzuki-Kakisaka H, Sugimoto J, Tetarbe M, Romani AM, Ramirez Kitchen CM, Bernstein HB. Magnesium Sulfate Increases Intracellular Magnesium Reducing Inflammatory Cytokine Release in Neonates. Am J Reprod Immunol 2013; 70:213-20. [DOI: 10.1111/aji.12118] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 03/01/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
- Haruka Suzuki-Kakisaka
- Department of Reproductive Biology; Case Western Reserve University School of Medicine; Cleveland OH USA
| | - Jun Sugimoto
- Department of Reproductive Biology; Case Western Reserve University School of Medicine; Cleveland OH USA
| | - Manas Tetarbe
- Department of Physiology and Biophysics; Case Western Reserve University School of Medicine; Cleveland OH USA
| | - Andrea M. Romani
- Department of Physiology and Biophysics; Case Western Reserve University School of Medicine; Cleveland OH USA
| | | | - Helene B. Bernstein
- Department of Reproductive Biology; Case Western Reserve University School of Medicine; Cleveland OH USA
- Department of Molecular Biology and Microbiology; Case Western Reserve University School of Medicine; Cleveland OH USA
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Brumback RA. "3 . . 2 . . 1 . . Impact [factor]: target [academic career] destroyed!": just another statistical casualty. J Child Neurol 2012. [PMID: 23183597 DOI: 10.1177/0883073812465014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
"Publish or perish" is the time-honored "principle" for academicians who race to accumulate lines under the "publications" section of a curriculum vitae. The original intent of publication-to inform others of findings and further scientific knowledge-has been corrupted by factors including (1) exponential growth of journals and the journal industry, fueled in part by intrusion of the Internet into all aspects of academic life; and (2) adoption of journal metrics (rather than written content) as the measure of scientific quality. The proprietary Thomson Reuters Impact Factor is the most pernicious metric, having caused editors and publishers to change editorial practices to boost the number. At the same time, gullible administrators and government agencies have been persuaded that metrics for the journal in which materials are published can be used as a measure of the worth of individual investigators (and institutions) and their research efforts: simple numbers can be substituted for the burdensome effort required to read and assess research quality. Thus, granting of research funds, awarding of academic rank and tenure, and determination of salaries (including bonus payments) have become tied to manipulable journal metrics rather than the significance or quality of reported research. Therefore, it is no wonder that the integrity of science is more often being questioned. How should a young investigator approach the "publish or perish" dilemma? Performing sound research and preparing optimal materials for publication must remain the overriding goals: properly articulate the question addressed by the study; thoroughly document all methods and case information; carefully describe results including any conflicting or negative findings; discuss the importance of the findings along with how the results address the initial question and whether findings refute or confirm previous studies; prepare properly cited bibliographic references; list all author contributions, potential conflicts of interest, financial support, and required ethical approvals; and provide a catchy title and an abstract containing sufficient information that other investigators perusing scientific indices will be enticed to read the published article. Submit the completed manuscript to the most appropriate journal based on that journal's previously published content and relevance to the field of study regardless of journal metrics. On publication, notify investigators in the same field to ask for their comments on the work. Thus, an individual will become known for the quality of his or her work product and the worshiping of publication metrics will be unnecessary.
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Bain E, Bubner T, Ashwood P, Crowther CA, Middleton P. Implementation of a clinical practice guideline for antenatal magnesium sulphate for neuroprotection in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2012; 53:86-9. [DOI: 10.1111/ajo.12008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/08/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Emily Bain
- Australian Research Centre for Health of Women and Babies; Discipline of Obstetrics and Gynaecology; Robinson Institute; The University of Adelaide; Adelaide; South Australia; Australia
| | - Tanya Bubner
- Australian Research Centre for Health of Women and Babies; Discipline of Obstetrics and Gynaecology; Robinson Institute; The University of Adelaide; Adelaide; South Australia; Australia
| | - Pat Ashwood
- Australian Research Centre for Health of Women and Babies; Discipline of Obstetrics and Gynaecology; Robinson Institute; The University of Adelaide; Adelaide; South Australia; Australia
| | - Caroline A. Crowther
- Australian Research Centre for Health of Women and Babies; Discipline of Obstetrics and Gynaecology; Robinson Institute; The University of Adelaide; Adelaide; South Australia; Australia
| | - Philippa Middleton
- Australian Research Centre for Health of Women and Babies; Discipline of Obstetrics and Gynaecology; Robinson Institute; The University of Adelaide; Adelaide; South Australia; Australia
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Love ER, Crum J, Bhattacharya S. Independent effects of pregnancy induced hypertension on childhood development: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2012; 165:219-24. [PMID: 22948131 DOI: 10.1016/j.ejogrb.2012.08.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 08/07/2012] [Accepted: 08/09/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess whether maternal hypertension in pregnancy was independently associated with additional support needs in children. STUDY DESIGN Retrospective cohort study using linkage of birth records of all singleton deliveries occurring in primigravidae between 1995 and 2008 in Aberdeen Maternity and Neonatal Databank with the Support Needs System (SNS) dataset in Grampian. Crude and adjusted odds ratios with 95% confidence intervals of having a record in SNS in the presence of maternal pregnancy induced hypertension were calculated using logistic regression taking account of confounders such as preterm birth and low birth weight. RESULTS After adjusting for confounding factors, neither pre-eclampsia {Adj OR 0.80 (95% CI 0.60, 1.07)} nor gestational hypertension {Adj OR 1.16 (95% CI 0.99, 1.36)} showed statistically significant associations with additional support needs. An association of pre-eclampsia with cerebral palsy seen on univariate analysis also disappeared on adjusting for confounders {Adj OR 1.26 (95% CI 0.43, 3.68)}. Birth before 32 weeks gestation and birthweight below 1500g were independently associated with additional support needs in children. CONCLUSIONS While maternal hypertension was not found to be independently associated with special needs in children, very preterm birth and very low birthweight showed an association.
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Sugimoto J, Romani AM, Valentin-Torres AM, Luciano AA, Ramirez Kitchen CM, Funderburg N, Mesiano S, Bernstein HB. Magnesium decreases inflammatory cytokine production: a novel innate immunomodulatory mechanism. THE JOURNAL OF IMMUNOLOGY 2012; 188:6338-46. [PMID: 22611240 DOI: 10.4049/jimmunol.1101765] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
MgSO(4) exposure before preterm birth is neuroprotective, reducing the risk of cerebral palsy and major motor dysfunction. Neonatal inflammatory cytokine levels correlate with neurologic outcome, leading us to assess the effect of MgSO(4) on cytokine production in humans. We found reduced maternal TNF-α and IL-6 production following in vivo MgSO(4) treatment. Short-term exposure to a clinically effective MgSO(4) concentration in vitro substantially reduced the frequency of neonatal monocytes producing TNF-α and IL-6 under constitutive and TLR-stimulated conditions, decreasing cytokine gene and protein expression, without influencing cell viability or phagocytic function. In summary, MgSO(4) reduced cytokine production in intrapartum women, term and preterm neonates, demonstrating effectiveness in those at risk for inflammation-associated adverse perinatal outcomes. By probing the mechanism of decreased cytokine production, we found that the immunomodulatory effect was mediated by magnesium and not the sulfate moiety, and it was reversible. Cellular magnesium content increased rapidly upon MgSO(4) exposure, and reduced cytokine production occurred following stimulation with different TLR ligands as well as when magnesium was added after TLR stimulation, strongly suggesting that magnesium acts intracellularly. Magnesium increased basal IĸBα levels, and upon TLR stimulation was associated with reduced NF-κB activation and nuclear localization. These findings establish a new paradigm for innate immunoregulation, whereby magnesium plays a critical regulatory role in NF-κB activation, cytokine production, and disease pathogenesis.
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Affiliation(s)
- Jun Sugimoto
- Department of Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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Dasgupta S, Ghosh D, Seal SL, Kamilya G, Karmakar M, Saha D. Randomized controlled study comparing effect of magnesium sulfate with placebo on fetal umbilical artery and middle cerebral artery blood flow in mild preeclampsia at ≥34 weeks gestational age. J Obstet Gynaecol Res 2012; 38:763-71. [DOI: 10.1111/j.1447-0756.2011.01806.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Antenatal magnesium individual participant data international collaboration: assessing the benefits for babies using the best level of evidence (AMICABLE). Syst Rev 2012; 1:21. [PMID: 22587882 PMCID: PMC3351723 DOI: 10.1186/2046-4053-1-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The primary aim of this study is to assess, using individual participant data (IPD) meta-analysis, the effects of administration of antenatal magnesium sulphate given to women at risk of preterm birth on important clinical outcomes for their child such as death and neurosensory disability. The secondary aim is to determine whether treatment effects differ depending on important pre-specified participant and treatment characteristics, such as reasons at risk of preterm birth, gestational age, or type, dose and mode of administration of magnesium sulphate. METHODS DESIGN The Antenatal Magnesium Individual Participant Data (IPD) International Collaboration: assessing the benefits for babies using the best level of evidence (AMICABLE) Group will perform an IPD meta-analysis to answer these important clinical questions. SETTING/TIMELINE: The AMICABLE Group was formed in 2009 with data collection commencing late 2010. INCLUSION CRITERIA Five trials involving a total 6,145 babies are eligible for inclusion in the IPD meta-analysis. PRIMARY STUDY OUTCOMES: For the infants/children: Death or cerebral palsy. For the women: Any severe maternal outcome potentially related to treatment (death, respiratory arrest or cardiac arrest). DISCUSSION Results are expected to be publicly available in 2012.
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Bain E, Middleton P, Crowther CA. Different magnesium sulphate regimens for neuroprotection of the fetus for women at risk of preterm birth. Cochrane Database Syst Rev 2012; 2012:CD009302. [PMID: 22336863 PMCID: PMC11472847 DOI: 10.1002/14651858.cd009302.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The effectiveness of antenatal magnesium sulphate for neuroprotection of the fetus, infant, and child prior to very preterm birth, when given to women considered at risk of preterm birth, has been established. There is currently no consensus as to the regimen to use in terms of the dose, duration, the use of repeat dosing and timing. OBJECTIVES To assess the comparative effectiveness and adverse effects of different magnesium sulphate regimens for neuroprotection of the fetus in women considered at risk of preterm birth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011). SELECTION CRITERIA Randomised trials comparing different magnesium sulphate regimens when used for neuroprotection of the fetus in women considered at risk of preterm birth. We planned to include cluster trials. We planned to exclude quasi-randomised trials and those with a crossover design. We planned to include trials published as full-text papers, along with those published in abstract form only. DATA COLLECTION AND ANALYSIS We planned that at least two review authors would assess trial eligibility. MAIN RESULTS No eligible completed trials were identified. AUTHORS' CONCLUSIONS Although strong evidence supports the use of antenatal magnesium sulphate for neuroprotection of the fetus prior to very preterm birth, no trials comparing different treatment regimens have been completed. Research should be directed towards comparisons of different dosages and other variations in regimens, evaluating both maternal and infant outcomes.
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Affiliation(s)
- Emily Bain
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia.
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Cahill AG, Odibo AO, Stout MJ, Grobman WA, Macones GA, Caughey AB. Magnesium sulfate therapy for the prevention of cerebral palsy in preterm infants: a decision-analytic and economic analysis. Am J Obstet Gynecol 2011; 205:542.e1-7. [PMID: 22000669 DOI: 10.1016/j.ajog.2011.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 08/14/2011] [Accepted: 09/07/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to estimate the cost-effectiveness of magnesium neuroprophylaxis for all women at risk for preterm birth <32 weeks. STUDY DESIGN A decision analytic and cost-effectiveness model was designed to compare use of magnesium for neuroprophylaxis vs no treatment for women at risk for preterm birth <32 weeks due to preterm premature rupture of membranes or preterm labor from 24-32 weeks. Outcomes included neonatal death and moderate-severe cerebral palsy. Effectiveness was reported in quality-adjusted life years. RESULTS Magnesium for neuroprophylaxis led to lower costs ($1739 vs $1917) and better outcomes (56.684 vs 56.678 quality-adjusted life years). However, sensitivity analysis revealed the model to be sensitive to estimates of effect of magnesium on risk of moderate or severe cerebral palsy as well as neonatal death. CONCLUSION Based on currently published evidence for efficacy, magnesium for neuroprophylaxis in women at risk to deliver preterm is cost-effective.
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Affiliation(s)
- Alison G Cahill
- Department of Obstetrics and Gynecology at Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Tsitouras V, Sgouros S. Infantile posthemorrhagic hydrocephalus. Childs Nerv Syst 2011; 27:1595-608. [PMID: 21928026 DOI: 10.1007/s00381-011-1521-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 06/28/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Intraventricular/germinal matrix hemorrhage affects 7-30% of premature neonates, 25-80% of whom (depending on the grade of the hemorrhage) will develop hydrocephalus requiring shunting. Predisposing factors are low birth weight and gestational age. MATERIAL There is increasing evidence for the role of TGF-β1 in the pathogenesis of hydrocephalus, but attempts to develop treatment modalities to clear the cerebrospinal fluid (CSF) from blood degradation products have not succeeded so far. Ultrasound is a valuable screening tool for high-risk infants and magnetic resonance imaging is increasingly utilized to differentiate progressive hydrocephalus from ex vacuo ventriculomegaly, evaluate periventricular parenchymal damage, decide on the surgical treatment of hydrocephalus, and follow up these patients in the long term. Treatment of increasing ventriculomegaly and intracranial hypertension in the presence of hemorrhagic CSF can involve a variety of strategies, all with relative drawbacks, aiming to drain the CSF while gaining time for it to clear and the neonate to reach term and become a suitable candidate for shunting. Eventually, patients with progressive ventriculomegaly causing intracranial hypertension, who have reached term and their CSF has cleared from blood products, will need shunting. CONCLUSION Cognitive long-term outcome is influenced more by the effect of the initial hemorrhage and other perinatal events and less by hydrocephalus, provided that this has been addressed timely in the early postnatal period. Shunting can have many long-term side effects due to mechanical complications and overdrainage. In particular, patients with posthemorrhagic hydrocephalus are more susceptible to multiloculated hydrocephalus and encysted fourth ventricle, both of which are challenging to treat.
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Affiliation(s)
- Vasilios Tsitouras
- Department of Neurosurgery, Mitera Childrens Hospital, Erythrou Stavrou 6, Marousi, 151 23 Athens, Greece
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Amash A, Holcberg G, Sheiner E, Huleihel M. Magnesium sulfate normalizes placental interleukin-6 secretion in preeclampsia. J Interferon Cytokine Res 2011; 30:683-90. [PMID: 20715974 DOI: 10.1089/jir.2010.0011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Interleukin-6 (IL-6) is one of the main proinflammatory mediators of hypertension and endothelial dysfunction in preeclampsia. In this study, we investigated the capacity of the preeclamptic placenta to secrete IL-6 and the effect of magnesium sulfate (MgSO(4)) on it. Placentas from normotensive (37-40 weeks) and preeclamptic (36-40 weeks) pregnancies were dually perfused for 6 h in the absence [normotensive (n = 3); preeclamptic (n = 4)] and presence [normotensive (n = 3); preeclamptic (n = 4)] of MgSO(4). Perfusate samples from the maternal and the fetal circulations were collected at each 30 min throughout the perfusion period and examined for IL-6 by enzyme-linked immunoassay. Statistical analysis was performed using the 2-way analysis of variance. In the absence of MgSO(4), IL-6 levels in the maternal and the fetal circulations of preeclamptic placentas (4.2 ± 1.3 and 0.9 ± 0.5 pg/mL/g cotyledon; respectively) were significantly higher, when compared with normotensive placentas (1.9 ± 0.5 and 0.2 ± 0.2 pg/mL/g cotyledon; respectively) (P < 0.05). Addition of MgSO(4) to the perfusate of normotensive placentas did not affect IL-6 secretion. However, exposure of preeclamptic placentas to MgSO(4) resulted in decreased IL-6 levels in the maternal circulations (1.7 ± 0.3 pg/mL/g cotyledon), when compared with the control group (P < 0.05). In the fetal circulation, the addition of MgSO(4) resulted only in a nonstatistical significant tendency toward decreased IL-6 levels, when compared with the control group. Our findings indicate that the perfused preeclamptic placenta secretes increased levels of IL-6 into the fetal and the maternal circulations and that MgSO(4) may normalize these increased secreted IL-6 levels.
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Affiliation(s)
- Alaa Amash
- The Shraga Segal Department of Microbiology and Immunology, Ben-Gurion University of the Negev, Beer Sheva, Israel
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