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Ertekin O, Ozer Bekmez B, Buyuktiryaki M, Akin MS, Alyamac Dizdar E, Sari FN. Antenatal corticosteroid administration is associated with lower risk of severe ROP in preterm twin infants. Early Hum Dev 2024; 190:105952. [PMID: 38335761 DOI: 10.1016/j.earlhumdev.2024.105952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Robust evidence revealed the impact of antenatal corticosteroid (ACS) administration on lower mortality and short-term neonatal outcomes in singleton preterm infants. We aimed to investigate the impact of ACS therapy on morbidity and mortality in preterm twin infants. METHODS We conducted this retrospective single-center study from to the records of twin babies of 24-30 weeks of gestation admitted to the neonatal intensive care unit. The study population was grouped based on the exposure to ACS 1-7 days before birth as received or not. Groups were compared regarding in-hospital mortality and neonatal outcomes. RESULTS Data from 160 twin infants were analyzed. Of those, 102 (64 %) were administered ACS. The median (IQR) gestational age and birth weight of the whole cohort were 28 (27-29) weeks and 1060 (900-1240) g, respectively. ACS administration was associated with a significant decline in respiratory distress syndrome (RDS), requirement ≥2 doses of surfactant, severe intraventricular hemorrhage (IVH), early-onset sepsis (EOS), and retinopathy of prematurity (ROP) requiring treatment (p < 0.05). Logistic regression analysis revealed that gestational age (OR 0.29 95 % CI 0.14-0.62; p = 0.001), ACS administration (OR 0.14 95 % CI 0.03-0.85; p = 0.032), and time to achieve full enteral feeding (OR 1.16 95 % CI 1.03-1.31; p = 0.019) were independently associated with the risk of severe ROP. CONCLUSION The reduction in the risk of severe ROP besides RDS, severe IVH, and EOS among preterm twins who received ACS was remarkable in our study similar to the trials conducted in preterm singletons. However, large-scale prospective observational studies are required to reveal the efficacy of ACS in preterm twins.
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Affiliation(s)
- Omer Ertekin
- Division of Neonatology, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey
| | - Buse Ozer Bekmez
- Division of Neonatology, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey.
| | - Mehmet Buyuktiryaki
- Division of Neonatology, Department of Pediatrics, Istanbul Medipol University, Istanbul, Turkey
| | - Mustafa Senol Akin
- Division of Neonatology, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey
| | - Evrim Alyamac Dizdar
- Division of Neonatology, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey
| | - Fatma Nur Sari
- Division of Neonatology, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Ankara, Turkey
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Behera S, Behuria S, Moharana JJ, Mohpatra BN, Naik R. Effect of Steroids on the Biophysical Profile and Doppler Indices of Umbilical and Middle Cerebral Arteries in Preterm Fetuses. Cureus 2023; 15:e42334. [PMID: 37621794 PMCID: PMC10445050 DOI: 10.7759/cureus.42334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction Preterm birth is a major cause of perinatal death and disability and emerges as an important global public health problem. The antenatal administration of corticosteroids for preventing neonatal death due to respiratory distress syndrome and the serious morbidities associated with preterm birth has become an accepted standard in worldwide obstetric practice since 1994. After administering corticosteroids, the biophysical score deteriorates transiently, leading to a high cesarean section rate. Thus, Doppler indices of the umbilical and middle cerebral arteries are taken into account before the termination of pregnancy in preterm labor. Materials and methods This is an interventional study conducted over a period of one year and six months among 59 eligible singleton pregnancies at risk for preterm delivery, i.e., at risk of preterm birth <34 weeks of gestation, having no contraindication to antenatal steroids, who were admitted to the labor room of the Srirama Chandra Bhanja (SCB) Medical College, Cuttack, India, from January 2014 to August 2015. The participants were prospectively recruited, after giving informed consent to participate in the study. The main indication for hospital admission and steroid use was preterm lower abdominal pain. Results Out of 59 eligible cases, 27 (45.8%) were <25 years of age, 26 (44.1%) were between 25 and 30 years of age, and six (10.2%) were >30 years of age. The range is 14 years (between 19 and 33 years). The mean age is 25.31 years, with a standard deviation of 3.74. The mean of the biophysical profile (BPP) score before steroid administration decreased from 9.19 ± 1.23 to 5.56 ± 1.05 after 48 hours of first dose of steroid. The p-value of this is <0.001, which is statistically significant. The results show that the administration of betamethasone decreased fetal movements by 78.6% and breathing by 71.8%. As a result, the BPP scores decreased significantly. However, the Doppler indices did not change significantly even after administering corticosteroids. Conclusion Doppler indices play an important role in differentiating between steroid-induced compromise in the fetus and real fetal distress. Thus, umbilical and middle cerebral artery (MCA) Doppler should always be done before the termination of pregnancy on the ground of fetal compromise after administering corticosteroids.
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Affiliation(s)
- Swayamprava Behera
- Department of Obstetrics and Gynecology, Srirama Chandra Bhanj Medical College & Hospital, Cuttack, IND
| | - Sasmita Behuria
- Department of Obstetrics and Gynecology, Srirama Chandra Bhanj Medical College & Hospital, Cuttack, IND
| | - Jayashree J Moharana
- Department of Obstetrics and Gynecology, Srirama Chandra Bhanj Medical College & Hospital, Cuttack, IND
| | - Biranchi N Mohpatra
- Department of Obstetrics and Gynecology, Srirama Chandra Bhanj Medical College & Hospital, Cuttack, IND
| | - Rabindra Naik
- Department of Obstetrics and Gynecology, Srirama Chandra Bhanj Medical College & Hospital, Cuttack, IND
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Ramachandran S, Foglia EE, DeMauro SB, Chawla S, Brion LP, Wyckoff MH. Perinatal management: Lessons learned from the neonatal research network. Semin Perinatol 2022; 46:151636. [PMID: 35835614 PMCID: PMC10894037 DOI: 10.1016/j.semperi.2022.151636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Recent contributions of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) regarding obstetrical perinatal interventions and neonatal delivery room practices include the following: the impact of multiple antepartum factors including maternal diabetes, hypertension, obesity and mode of delivery on outcomes of extremely preterm newborns, effects of delayed delivery interval for extremely preterm multiples, effects of antenatal steroids on preterm newborn outcomes and the impact of antenatal magnesium sulfate therapy on neurodevelopmental outcomes for extremely preterm infants. NRN studies also contribute important evidence for neonatal delivery room resuscitation guidelines including umbilical cord management and maintenance of euthermia immediately after birth. The updated NRN outcome calculator helps better counsel families regarding possible outcomes for the most immature newborns if resuscitation is attempted at birth. Thus, the NRN provides substantial information regarding effects of perinatal management on newborn infants.
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Affiliation(s)
- Shalini Ramachandran
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B DeMauro
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sanjay Chawla
- Departments of Pediatrics, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Luc P Brion
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA.
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Mwita S, Kamala BA, Konje E, Ambrose EE, Izina A, Chibwe E, Kongola G, Dewey D. Association between antenatal corticosteroids use and perinatal mortality among preterm singletons and twins in Mwanza, Tanzania: an observational study. BMJ Open 2022; 12:e059030. [PMID: 35393329 PMCID: PMC8991063 DOI: 10.1136/bmjopen-2021-059030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To examine the association between antenatal corticosteroids (ACS) use and perinatal mortality in singletons and twins delivered before 35 weeks of gestation. DESIGN Secondary analysis of data from an observational prospective chart review study that investigated if exposure to ACS was associated with lower rates of perinatal mortality in preterm infants. SETTING This study was conducted in four hospitals located in Mwanza region, Tanzania. PARTICIPANTS The study population included all preterm singletons and twins delivered at these hospitals between 24 weeks 0 days and 34 weeks 6 days of gestation from July 2019 to February 2020. OUTCOME MEASURES The primary outcome was perinatal mortality; the secondary outcome was respiratory distress syndrome (RDS). RESULTS The study included 844 singletons and 210 twin infants. Three hundred and fourteen singletons (37.2%) and 52 twins (24.8%) were exposed to at least one dose of ACS. Adjusted multivariate analyses revealed that among singletons' exposure to ACS was significantly associated with a lower likelihood of perinatal mortality, adjusted relative risk (aRR) 0.30 (95% CI 0.22 to 0.40) and RDS, aRR 0.92 (95% CI 0.87 to 0.97). In twin infants, exposure to ACS was associated with a reduced risk of RDS only, aRR 0.87 (95% CI 0.78 to 0.98). CONCLUSION The use of ACS between 24 weeks 0 days and 34 weeks 6 days of gestation in both singletons and twins in low-resource settings is associated with positive infant outcomes. No adverse effects were noted. Further research that examines the benefits of ACS for twin infants is needed.
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Affiliation(s)
- Stanley Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Benjamin Anathory Kamala
- Department of Research, Haydom Lutheran Hospital, Mbulu, Manyara, United Republic of Tanzania
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Eveline Konje
- Department of Epidemiology and Biostatistics, Catholic University of Health and Allied, Mwanza, United Republic of Tanzania
| | - Emmanuela Eusebio Ambrose
- Department of Peadiatrics and Child Health, Bugando Medical Centre, Mwanza, United Republic of Tanzania
| | - Angelina Izina
- Department of Radiology, Bugando Medical Centre, Mwanza, United Republic of Tanzania
| | - Elieza Chibwe
- Department of Obstetrics and Gynaecology, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Gilbert Kongola
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Deborah Dewey
- Owerko Centre at the Alberta Children's Hospital Research Institute and Departments of Pediatrics and Community Health Sciences, The University of Calgary, Calgary, Alberta, Canada
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Cerritelli F, Frasch MG, Antonelli MC, Viglione C, Vecchi S, Chiera M, Manzotti A. A Review on the Vagus Nerve and Autonomic Nervous System During Fetal Development: Searching for Critical Windows. Front Neurosci 2021; 15:721605. [PMID: 34616274 PMCID: PMC8488382 DOI: 10.3389/fnins.2021.721605] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/19/2021] [Indexed: 12/17/2022] Open
Abstract
The autonomic nervous system (ANS) is one of the main biological systems that regulates the body's physiology. Autonomic nervous system regulatory capacity begins before birth as the sympathetic and parasympathetic activity contributes significantly to the fetus' development. In particular, several studies have shown how vagus nerve is involved in many vital processes during fetal, perinatal, and postnatal life: from the regulation of inflammation through the anti-inflammatory cholinergic pathway, which may affect the functioning of each organ, to the production of hormones involved in bioenergetic metabolism. In addition, the vagus nerve has been recognized as the primary afferent pathway capable of transmitting information to the brain from every organ of the body. Therefore, this hypothesis paper aims to review the development of ANS during fetal and perinatal life, focusing particularly on the vagus nerve, to identify possible "critical windows" that could impact its maturation. These "critical windows" could help clinicians know when to monitor fetuses to effectively assess the developmental status of both ANS and specifically the vagus nerve. In addition, this paper will focus on which factors-i.e., fetal characteristics and behaviors, maternal lifestyle and pathologies, placental health and dysfunction, labor, incubator conditions, and drug exposure-may have an impact on the development of the vagus during the above-mentioned "critical window" and how. This analysis could help clinicians and stakeholders define precise guidelines for improving the management of fetuses and newborns, particularly to reduce the potential adverse environmental impacts on ANS development that may lead to persistent long-term consequences. Since the development of ANS and the vagus influence have been shown to be reflected in cardiac variability, this paper will rely in particular on studies using fetal heart rate variability (fHRV) to monitor the continued growth and health of both animal and human fetuses. In fact, fHRV is a non-invasive marker whose changes have been associated with ANS development, vagal modulation, systemic and neurological inflammatory reactions, and even fetal distress during labor.
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Affiliation(s)
- Francesco Cerritelli
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Martin G. Frasch
- Department of Obstetrics and Gynecology and Center on Human Development and Disability, University of Washington, Seattle, WA, United States
| | - Marta C. Antonelli
- Facultad de Medicina, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis”, Universidad de Buenos Aires, Buenos Aires, Argentina
- Department of Obstetrics and Gynecology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chiara Viglione
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Stefano Vecchi
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Marco Chiera
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Andrea Manzotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
- Department of Pediatrics, Division of Neonatology, “V. Buzzi” Children's Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco, Milan, Italy
- Research Department, Istituto Osteopatia Milano, Milan, Italy
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Cardiovascular effects of prenatal stress-Are there implications for cerebrovascular, cognitive and mental health outcome? Neurosci Biobehav Rev 2019; 117:78-97. [PMID: 31708264 DOI: 10.1016/j.neubiorev.2018.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 01/17/2023]
Abstract
Prenatal stress programs offspring cognitive and mental health outcome. We reviewed whether prenatal stress also programs cardiovascular dysfunction which potentially modulates cerebrovascular, cognitive and mental health disorders. We focused on maternal stress and prenatal glucocorticoid (GC) exposure which have different programming effects. While maternal stress induced cortisol is mostly inactivated by the placenta, synthetic GCs freely cross the placenta and have different receptor-binding characteristics. Maternal stress, particularly anxiety, but not GC exposure, has adverse effects on maternal-fetal circulation throughout pregnancy, probably by co-activation of the maternal sympathetic nervous system, and by raising fetal catecholamines. Both effects may impair neurodevelopment. Experimental data also suggest that severe maternal stress and GC exposure during early and mid-gestation may increase the risk for cardiovascular disorders. Human data are scarce and especially lacking for older age. Programming mechanisms include aberrations in cardiac and kidney development, and functional changes in the renin-angiotensin-aldosterone-system, stress axis and peripheral and coronary vasculature. Adequate experimental or human studies examining the consequences for cerebrovascular, cognitive and mental disorders are unavailable.
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Tendais I, Figueiredo B, Mulder EJH, Lopes D, Montenegro N. Developmental trajectories of general and breathing movements in fetal twins. Dev Psychobiol 2019; 61:626-633. [PMID: 30942503 DOI: 10.1002/dev.21846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/14/2019] [Accepted: 02/09/2019] [Indexed: 11/08/2022]
Abstract
This study examined the developmental trajectories of general and breathing movements in fetal twins. Fetal movement patterns were assessed from real-time ultrasound recordings performed at 12-15, 20-23, and 28-32 weeks of gestation in 42 twin pairs. Results indicated that both general movements and breathing movements followed a curvilinear, inverted U-shaped curve. Developmental trajectories were unrelated within pairs of twins and were not associated with gestational age at birth and birth weight. However, sex differences were found for general movements with males displaying more time making general movements at 21 weeks and a steeper decline in time spent making general movements during the second half of pregnancy than females. These age-related changes in fetal movements may reflect CNS development. These findings also suggest that twins' behavioral development is largely independent of co-twin development, gestational age at birth, and birth weight, but not of fetal sex.
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Affiliation(s)
- Iva Tendais
- Department of Applied Psychology, School of Psychology, University of Minho, Braga, Portugal
| | - Bárbara Figueiredo
- Department of Applied Psychology, School of Psychology, University of Minho, Braga, Portugal
| | - Eduard J H Mulder
- Department of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dulcina Lopes
- Hospital Pedro Hispano, ULS de Matosinhos, Porto, Portugal
| | - Nuno Montenegro
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Department of Obstetrics and Gynecology of Centro Hospitalar de São João, Porto, Portugal
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Herrera TI, Vaz Ferreira MC, Toso A, Villarroel L, Silvera F, Ceriani-Cernadas JM, Tapia JL. Neonatal outcomes of antenatal corticosteroids in preterm multiple pregnancies compared to singletons. Early Hum Dev 2019; 130:44-50. [PMID: 30665038 DOI: 10.1016/j.earlhumdev.2019.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antenatal corticosteroids (ACS) during preterm labour reduce neonatal mortality and morbidity. Evidence on preterm multiple pregnancies is limited and contradictory. OBJECTIVE Compare the effect of ACS on very low birth weight infant's (VLBW) mortality and morbidity among singleton and multiple pregnancies. STUDY DESIGN Retrospective cohort study, employing prospectively collected data, of infants 23 to 34 weeks' gestation and 500 to 1500 g born at the Neocosur Neonatal Network centers during 2007-2016. Neonatal outcomes were compared among singleton and multiple pregnancies exposed to at least one dose of ACS to those not exposed using logistic regression analyses controlled for birthweight, gestational age, sex, small for gestational age (SGA) and mode of delivery. RESULTS A total of 13,864 infants were studied; 2948 multiple (21.3%) and 10,904 singleton pregnancies (78.7%). Overall, 11,218 (81.4%) received at least one dose of ACS with a significant reduction in the risk of death, RDS and grade III or IV IVH compared to those not exposed. Both singleton and multiple pregnancies exposed to ACS showed similar reduced risk of death (aRR 0.41 [95% CI, 0.36-0.47] vs. aRR 0.46 [95% CI, 0.34-0.64]). However, ACS were not associated with reduced odds of RDS (aRR 0.89 [95% CI, 0.66-1.23]) or grade III or IV IVH (aRR 0.99 [95% CI, 0.67-1.48]) in multiple pregnancies. CONCLUSION The benefit of administration of at least one dose of ACS in VLBW multiple and singleton pregnancies is comparable in terms of death. However, ACS showed no relevant impact in short-term morbidity in multiple pregnancies.
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Affiliation(s)
- Tamara I Herrera
- Departamento de Neonatología, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay.
| | - María C Vaz Ferreira
- Departamento de Neonatología, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Alberto Toso
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Luis Villarroel
- Departamento de Salud Pública, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Fernando Silvera
- Departamento de Neonatología, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | | | - José L Tapia
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
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Noben L, Verdurmen KMJ, Warmerdam GJJ, Vullings R, Oei SG, van Laar JOEH. The fetal electrocardiogram to detect the effects of betamethasone on fetal heart rate variability. Early Hum Dev 2019; 130:57-64. [PMID: 30677639 DOI: 10.1016/j.earlhumdev.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Betamethasone is widely used to enhance fetal lung maturation in case of threatened preterm birth. Antenatal corticosteroids are known to reduce fetal heart rate variability (fHRV) in the days following administration. Since decreased fHRV is a marker for fetal distress, this transient decrease of fHRV can cause unnecessary medical intervention. AIM To describe the effect of betamethasone on fHRV, by applying spectral analysis on non-invasive fetal electrocardiogram (fECG) recordings. STUDY DESIGN Secondary analysis of a prospective cohort study. SUBJECTS Women with a singleton pregnancy, at risk for preterm delivery and receiving betamethasone, admitted to the obstetric high care unit in the period from March 2013 until July 2016. OUTCOME MEASURES The primary outcome measure was fHRV in both time- and frequency-domain. Secondary outcome measures included basal fetal heart rate (fHR) and fHR variance. FHRV parameters were then calculated separately for the quiet and active state. RESULTS Following 68 inclusions, 22 patients remained with complete series of measurements and sufficient data quality. FHRV parameters and fHR showed a decrease on day 2 compared to day 1, significant for short-term variability and high-frequency power. Similar results were found when analyzing for separate behavioral states. The number of segments in quiet state increased during days 1 and 2. Normalized values showed no difference for all behavioral states. CONCLUSION FHRV decreases on day 2 after betamethasone administration, while periods of fetal quiescence increase. No changes were found in the normalized values, indicating that the influence of autonomic modulation is minor. Clinical trial registration number NL43294.015.13.
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Affiliation(s)
- L Noben
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, the Netherlands.
| | - K M J Verdurmen
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, the Netherlands
| | - G J J Warmerdam
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, the Netherlands
| | - R Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, the Netherlands
| | - S G Oei
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - J O E H van Laar
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, the Netherlands
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Melamed N, Shah J, Yoon EW, Pelausa E, Lee SK, Shah PS, Murphy KE, Shah PS, Harrison A, Synnes A, Ting J, Cieslak Z, Sherlock R, Yee W, Aziz K, Toye J, Fajardo C, Kalapesi Z, Sankaran K, Daspal S, Seshia M, Alvaro R, Shivananda S, Da Silva O, Nwaesei C, Lee KS, Dunn M, Lemyre B, Dow K, Pelausa E, Barrington K, Drolet C, Piedboeuf B, Claveau M, Faucher D, Bertelle V, Masse E, Canning R, Makary H, Ojah C, Monterrosa L, Deshpandey A, Afifi J, Kajetanowicz A, Lee SK. The role of antenatal corticosteroids in twin pregnancies complicated by preterm birth. Am J Obstet Gynecol 2016; 215:482.e1-9. [PMID: 27260974 DOI: 10.1016/j.ajog.2016.05.037] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Data regarding the effects of antenatal corticosteroids in twin pregnancies are limited because of the insufficient number of women with twins enrolled in randomized controlled trials on antenatal corticosteroids. Furthermore, the interpretation of available data is limited by the fact that the interval from the administration of antenatal corticosteroids to delivery is greater than 7 days in a large proportion of twins, a factor that has been shown to affect the efficacy of antenatal corticosteroids and has not been controlled for in previous studies. OBJECTIVE The objective of the study was to compare neonatal mortality and morbidity in preterm twins receiving a complete course of antenatal corticosteroids 1-7 days before birth to those who did not receive antenatal corticosteroids and to compare these outcome effects with those observed in singletons. STUDY DESIGN We performed a retrospective cohort study using data collected on singleton and twin neonates born between 24(0/7) and 33(6/7) weeks' gestational age and were admitted to tertiary neonatal units in Canada between 2010 and 2014. A comparison of neonatal outcomes between twin neonates who received a complete course of antenatal corticosteroids 1-7 days before birth (n = 1758) and those who did not receive antenatal corticosteroids (n = 758) and between singleton neonates who received a complete course of antenatal corticosteroids 1-7 days before birth (n = 4638) and those did not receive antenatal corticosteroids (n = 2312) was conducted after adjusting for gestational age, sex, hypertension, outborn status, small for gestational age, parity, and cesarean birth. Adjusted odds ratios and 95% confidence intervals for various neonatal outcomes were calculated. RESULTS Administration of a complete course of antenatal corticosteroids within 1-7 days before birth in both twins and singletons was associated with similar reduced odds of neonatal death (for twins adjusted odds ratio 0.42 [95% confidence interval, 0.24-0.76] and for singletons adjusted odds ratios, 0.38 [95% confidence interval, 0.28-0.50]; P = .7 for comparison of twins vs singletons), mechanical ventilation (for twins adjusted odds ratio, 0.47 [95% confidence interval, 0.35-0.63] and for singletons adjusted odds ratio, 0.47 [95% confidence interval, 0.41-0.55]; P = .9), respiratory distress syndrome (for twins adjusted odds ratio, 0.53 [95% confidence interval, 0.40-0.69], and for singletons adjusted odds ratio, 0.54 [95% confidence interval, 0.47-0.62]; P = .9) and severe neurological injury (for twins adjusted odds ratio, 0.50 [95% confidence interval, 0.30-0.83] and for singletons adjusted odds ratio, 0.45 [95% confidence interval, 0.34-0.59]; P = .7). Administration of a complete course of antenatal corticosteroids was not associated with a reduced odds of bronchopulmonary dysplasia, severe retinopathy of prematurity, or necrotizing enterocolitis in both twins and singletons. CONCLUSION Administration of a complete course of antenatal corticosteroids 1-7 days before birth in twin pregnancies is associated with a clinically significant decrease in neonatal mortality, short-term respiratory morbidity, and severe neurological injury that is similar in magnitude to that observed among singletons.
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Boghossian NS, McDonald SA, Bell EF, Carlo WA, Brumbaugh JE, Stoll BJ, Laptook AR, Shankaran S, Walsh MC, Das A, Higgins RD. Association of Antenatal Corticosteroids With Mortality, Morbidity, and Neurodevelopmental Outcomes in Extremely Preterm Multiple Gestation Infants. JAMA Pediatr 2016; 170:593-601. [PMID: 27088897 PMCID: PMC5270648 DOI: 10.1001/jamapediatrics.2016.0104] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about the effects of antenatal corticosteroids (ANS) on extremely preterm multiples. OBJECTIVE To examine if use of ANS is associated with improvement in major outcomes in extremely preterm multiples. DESIGN, SETTING, AND PARTICIPANTS Infants with a gestational age between 22 and 28 weeks born at a National Institute of Child Health and Human Development Neonatal Research Network center were studied between January 1998 and December 2013. Generalized estimating equation models were used to generate adjusted relative risks (aRR) controlling for important maternal and neonatal variables. EXPOSURE Antenatal corticosteroids. MAIN OUTCOMES AND MEASURES In-hospital mortality and the composite outcome of neurodevelopmental impairment at 18 to 22 months' corrected age or death before assessment. RESULTS A total of 6925 multiple-birth infants were studied; 5775 of 6925 (83.4%) were twins, and 4276 (61.7%) were white. Of the total study population, 6094 (88%) were born to women who received ANS. In-hospital mortality was lower among infants with exposure to ANS vs no exposure (aRR = 0.87; 95% CI, 0.78-0.96). Neurodevelopmental impairment or death was not significantly lower among those exposed to ANS vs no exposure (aRR = 0.93; 95% CI, 0.84-1.03). Other adverse outcomes that occurred less frequently among infants of women receiving ANS included severe intraventricular hemorrhage (aRR = 0.68; 95% CI, 0.58-0.78) and the combined outcomes of necrotizing enterocolitis or death and severe intraventricular hemorrhage or death. Subgroup analyses indicated that exposure to ANS was associated with a lower risk of mortality and a lower composite of neurodevelopmental impairment or mortality among nonsmall for gestational age multiples (aRR = 0.82; 95% CI, 0.74-0.92; and aRR = 0.89; 95% CI, 0.80-0.98, respectively) and a higher risk among small for gestational age multiples (aRR = 1.40; 95% CI, 1.02-1.93; and aRR = 1.62; 95% CI, 1.22-2.16, respectively). Antenatal corticosteroids were associated with higher neurodevelopmental impairment or mortality among multiple-birth infants of mothers with diabetes (aRR = 1.55; 95% CI, 1.00-2.38) but not among infants of mothers without diabetes (aRR = 0.91; 95% CI, 0.83-1.01). CONCLUSIONS AND RELEVANCE Compared with no exposure, exposure to ANS was associated with a lower risk of mortality in extremely preterm multiples, with no significant differences in the composite of neurodevelopmental impairment or death. Future research should investigate the increased risks of mortality and the composite of neurodevelopmental impairment or death associated with exposure to corticosteroids among small for gestational age multiples.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | | | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Barbara J. Stoll
- Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas (beginning Oct. 1, 2015)
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University and Women & Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies & Children’s Hospital, Cleveland, Ohio
| | - Abhik Das
- RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
Fetal movements and fetal heart rate (FHR) are well-established markers of fetal well-being and maturation of the fetal central nervous system. The purpose of this paper is to review and discuss the available knowledge on fetal movements and heart rate patterns in twin pregnancies. There is some evidence for an association or similarity in fetal movement incidences or FHR patterns between both members of twin pairs. However, the temporal occurrence of these patterns seems to be for the most part asynchronous, especially when stricter criteria are used to define synchrony. The available data suggest that fetal behavior is largely independent of sex combination, fetal position, and presentation. Conversely, chorionicity appears to have some influence on fetal behavior, mainly before 30 weeks of gestation. There is preliminary evidence for the continuity of inter-individual differences in fetal activity and FHR patterns over pregnancy. Comparisons between studies are limited by large methodological differences and absence of uniform concepts and definitions. Future studies with high methodological quality are needed to provide a more comprehensive knowledge of normal fetal behavior in twin pregnancy.
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Mulder EJH, Derks JB, de Laat MWM, Visser GHA. Fetal behavior in normal dichorionic twin pregnancy. Early Hum Dev 2012; 88:129-34. [PMID: 21820822 DOI: 10.1016/j.earlhumdev.2011.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 07/07/2011] [Accepted: 07/11/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES A prospective study was performed to compare fetal behavioral development in healthy dichorionic twins and singletons, and identify twin intra-pair associations (synchrony) of fetal movements and rest-activity cycles using different criteria to define synchrony. SUBJECTS AND METHODS Twenty pregnant women carrying dichorionic twins participated. Serial simultaneous 1-hr recordings of fetal movements were made on twins between 11 and 40 weeks' gestation (wGA) using two ultrasound machines. All twins were born healthy after 36 wGA and of appropriate weight for gestation. The incidences of fetal generalized body movements (GM) and breathing movements in twins were compared with institutional reference values for singletons. A comprehensive smoothing procedure on the raw movement data was performed to evaluate previously reported variation in twin intra-pair synchrony. RESULTS Twin fetuses were less active (GM) than singletons throughout pregnancy, but their breathing activity was higher in the third trimester. The incidences of fetal GM, quiescence, and breathing were fairly correlated within twin pairs. However, the temporal association or simultaneous occurrence of these activities was poor, especially after 30 weeks' gestation, coinciding with emerging rest-activity cycles. There was no evidence of a consistently more active ('dominant') twin half. Potential confounders had no effect on behavioral development in fetal twins. CONCLUSIONS The results show differential behavioral development between normal dichorionic fetal twins and singletons. Within fetal twin-pairs, we found poor synchrony of movements and independent occurrence of rest-activity cycles. Previous research on fetal twin behavior appears to have overestimated the degree of intra-pair movement synchrony.
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Affiliation(s)
- E J H Mulder
- Department of Perinatology and Gynaecology, Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands.
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Antenatal corticosteroid therapy: short-term effects on fetal behaviour and haemodynamics. Semin Fetal Neonatal Med 2009; 14:151-6. [PMID: 19059817 DOI: 10.1016/j.siny.2008.10.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Antenatal corticosteroid therapy to enhance fetal lung maturity in threatened preterm delivery has a number of non-pulmonary side-effects, both beneficial and undesirable. This review focuses on the short-term (transient) effects of betamethasone and dexamethasone on aspects of fetal circulation and behaviour which are used clinically as markers of fetal well-being. We summarise the effects observed, discuss the proposed underlying mechanisms, and emphasise the consequences for clinical decision-making. Recommendations are given to optimise medical care and to minimise the risk of unwarranted iatrogenic preterm delivery.
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Current awareness in prenatal diagnosis. Prenat Diagn 2004; 24:1025-30. [PMID: 15828089 DOI: 10.1002/pd.784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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