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Shepherd E, Karim T, McIntyre S, Goldsmith S, Keir A, Badawi N, Hunt RW, Galinsky R. Neonatal magnesium sulphate for neuroprotection: A systematic review and meta-analysis. Dev Med Child Neurol 2024; 66:1157-1172. [PMID: 38468452 DOI: 10.1111/dmcn.15899] [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] [Received: 06/21/2023] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 03/13/2024]
Abstract
AIM To review the evidence of the effects of neonatal magnesium sulphate for neuroprotection in perinatal asphyxia and hypoxic-ischaemic encephalopathy (HIE). METHOD This was a systematic review of randomized controlled trials (RCTs) (with meta-analysis) and non-RCTs assessing magnesium sulphate for treating perinatal asphyxia and HIE at 35 weeks or more gestation (primary outcomes: neonatal death and death or long-term major neurodevelopmental disability). RESULTS Twenty-five RCTs (2099 infants) and four non-RCTs (871 infants) were included, 23 in low- and middle-income countries (LMICs). In RCTs, reductions in neonatal death with magnesium sulphate versus placebo or no treatment (risk ratio [RR] = 0.68; 95% confidence interval [CI] = 0.53-0.86; 13 RCTs), and magnesium sulphate with melatonin versus melatonin alone (RR = 0.74; 95% CI = 0.58-0.95; one RCT) were observed. No difference in neonatal death was seen for magnesium sulphate with therapeutic hypothermia versus therapeutic hypothermia alone (RR = 0.66, 95% CI = 0.34-1.26; three RCTs), or magnesium sulphate versus phenobarbital (RR = 3.00; 95% CI = 0.86-10.46; one RCT). No reduction in death or long-term neurodevelopmental disability (RR = 0.52; 95% CI = 0.14-1.89; one RCT) but reductions in several short-term adverse outcomes were observed with magnesium sulphate. Evidence was low- to very-low certainty because of risk of bias and imprecision. INTERPRETATION Given the uncertainty of the current evidence, further robust neonatal magnesium sulphate research is justified. This may include high-quality studies to determine stand-alone effects in LMICs and effects with and after therapeutic hypothermia in high-income countries.
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Affiliation(s)
- Emily Shepherd
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Tasneem Karim
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah McIntyre
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Shona Goldsmith
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Keir
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Grace Centre for Newborn Intensive Care, The Children's Hospital, Sydney, New South Wales, Australia
| | - Rod W Hunt
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Minor KC, Liu J, Druzin ML, El-Sayed YY, Hintz SR, Bonifacio SL, Leonard SA, Lee HC, Profit J, Karakash SD. Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort. Am J Obstet Gynecol 2024:S0002-9378(24)00478-2. [PMID: 38580044 DOI: 10.1016/j.ajog.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy contributes to morbidity and mortality among neonates ≥36 weeks of gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic-ischemic encephalopathy, and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with preeclampsia with severe features. OBJECTIVE (1) Determine trends in the incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate, and hypoxic-ischemic encephalopathy; (2) evaluate the association between hypertensive disorders of pregnancy and hypoxic-ischemic encephalopathy; and (3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic-ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN We analyzed a prospective cohort of live births ≥36 weeks of gestation between 2012 and 2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic-ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic-ischemic encephalopathy. RESULTS Among 44,314 unique infants, the diagnosis of hypoxic-ischemic encephalopathy, maternal hypertensive disorders of pregnancy, and the use of magnesium sulfate increased over time. Compared with patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a high-risk population. They were more likely to be publicly insured, born between 36 and 38 weeks of gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, experience preterm labor and fetal distress, and undergo operative delivery (all P<.002). Hypertensive disorders of pregnancy were associated with hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.13-1.40]; P<.001) and specifically moderate/severe hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.42]; P<.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.71 [95% confidence interval, 0.52-0.97]; P=.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.63 [95% confidence interval, 0.42-0.94]; P=.03). CONCLUSION Hypertensive disorders of pregnancy are associated with hypoxic-ischemic encephalopathy and, specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with a significant reduction in the odds of hypoxic-ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to neonatal intensive care unit at ≥36 weeks of gestation. The findings of this observational study cannot prove causality and are intended to generate hypotheses for future clinical trials on magnesium sulfate in term infants.
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Affiliation(s)
- Kathleen C Minor
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA.
| | - Jessica Liu
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Maurice L Druzin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Yasser Y El-Sayed
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Susan R Hintz
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Sonia L Bonifacio
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
| | - Henry C Lee
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA; California Perinatal Quality Care Collaborative, Stanford, CA
| | - Scarlett D Karakash
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
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Gowda BB, Rath C, Muthusamy S, Nagarajan L, Rao S. Outcomes of Neonates with Hypoxic-Ischemic Encephalopathy Treated with Magnesium Sulfate: A Systematic Review with Meta-analysis. J Pediatr 2023; 262:113610. [PMID: 37468038 DOI: 10.1016/j.jpeds.2023.113610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To assess magnesium sulfate (MgSO4) as a neuroprotective agent in hypoxic-ischemic encephalopathy. STUDY DESIGN For this systematic review, PubMed, EMBASE, the Cochrane Library, EMCARE, and MedNar were searched in November 2022 for randomized controlled trials (RCTs). Meta-analysis was conducted using Stata 16.0 and RevMan 5.3. RESULTS Twenty RCTs with a total sample size of 1485 were included, of which 16 were from settings where therapeutic hypothermia (TH) was not offered. Regarding MgSO4 in settings where TH was not offered, only 1 study evaluated composite outcome of death or disability at ≥18 months and reported such poor outcome in 8 of 14 control infants and 4 of 8 in the MgSO4 group. MgSO4 was not associated with mortality (RR, 0.86; 95% CI, 0.72-1.03; 13 RCTs) or hypotension (RR, 1.02; 95% CI, 0.88-1.18; 5 RCTs). Thirteen studies reported that MgSO4 improved in-hospital outcomes, such as reduced seizure burden and improved neurological status at discharge. MgSO4 reduced the risk of poor suck feeds (RR, 0.52; 95% CI, 0.40-0.68; 6RCTs) and abnormal electroencephalogram (RR, 0.64; 95% CI, 0.45-0.93; 5 RCTs). Certainty of evidence was moderate for mortality and low or very low for other outcomes. For studies with MgSO4 as an adjunct to TH, none reported on death or neurodevelopmental disability at ≥18 months. MgSO4 was not associated with mortality (RR, 0.65; 95% CI, 0.34-1.27; 3 RCTs) or hypotension (RR, 1.0; 95% CI, 0.71-1.40; 3 RCTs). CONCLUSIONS Evidence around long-term outcomes of MgSO4 when used with or without TH was scant. MgSO4 therapy may improve in-hospital neurological outcomes without affecting mortality in settings where TH is not offered. Well-designed RCTs for neuroprotection are needed, especially in low-resource settings. TRIAL REGISTRATION "Open Science Forum" (https://doi.org/10.17605/OSF.IO/FRM4D).
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Affiliation(s)
- Bhanu B Gowda
- Neurology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Chandra Rath
- Neonatology, Joondalup Health Campus, Joondalup, Western Australia, Australia; Pediatrics, Rockingham General Hospital, Coolongup, Western Australia, Australia
| | - Saravanan Muthusamy
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia; School of Medicine, University of Western Australia, Nedlands, Western Australia, Australia
| | - Lakshmi Nagarajan
- Neurology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Shripada Rao
- Neonatology, Joondalup Health Campus, Joondalup, Western Australia, Australia; Pediatrics, Rockingham General Hospital, Coolongup, Western Australia, Australia.
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Kumar C, Adhisivam B, Bobby Z, Bhat BV. Magnesium Sulfate as an Adjunct to Therapeutic Hypothermia in the Management of Term Infants with Hypoxic-Ischemic Encephalopathy: A Randomized, Parallel-Group, Controlled Trial. Indian J Pediatr 2023; 90:886-892. [PMID: 35849276 DOI: 10.1007/s12098-022-04289-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/23/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate whether magnesium sulfate and therapeutic hypothermia in combination decreases mortality and/or major neurodevelopmental disability at 1 y of age among term neonates with hypoxic-ischemic encephalopathy. METHODS A total of 134 term neonates were randomized to receive intravenous magnesium sulfate at a dose of 250 mg/kg (at 8 mg/kg/min) once daily for 3 d starting within 6 h after birth along with therapeutic hypothermia in the intervention group and therapeutic hypothermia alone in the comparator group. The primary outcome was the composite outcome of mortality and/or major neurodevelopmental disability (Developmental Assessment Scale for Indian Infants score < 70) at 1 y of age. RESULTS A total of 115 infants were included in the primary analysis. The composite primary outcome occurred in 14 (24%) infants in the intervention group and 19 (33%) infants in the comparator group, and the difference was not statistically significant (p = 0.30; relative risk 0.72; 95% confidence interval 0.40-1.30). The secondary outcomes including neonatal mortality, major neurodevelopmental disability at 1 y of age, neurological status at discharge, level of oxidative stress markers, and adverse effects including hypotension and respiratory depression requiring support were also comparable between the groups. CONCLUSIONS The combination of magnesium sulfate and therapeutic hypothermia did not improve the composite outcome of neonatal mortality and/or major neurodevelopmental disability at 1 y of age. TRAIL REGISTRATION Clinical Trials Registry of India (CTRI/2018/06/014594), prospectively registered.
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Affiliation(s)
- Chanchal Kumar
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India.
| | - Zachariah Bobby
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - B Vishnu Bhat
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
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Okazaki K, Nakamura S, Koyano K, Konishi Y, Kondo M, Kusaka T. Neonatal asphyxia as an inflammatory disease: Reactive oxygen species and cytokines. Front Pediatr 2023; 11:1070743. [PMID: 36776908 PMCID: PMC9911547 DOI: 10.3389/fped.2023.1070743] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Neonatologists resuscitate asphyxiated neonates by every available means, including positive ventilation, oxygen therapy, and drugs. Asphyxiated neonates sometimes present symptoms that mimic those of inflammation, such as fever and edema. The main pathophysiology of the asphyxia is inflammation caused by hypoxic-ischemic reperfusion. At birth or in the perinatal period, neonates may suffer several, hypoxic insults, which can activate inflammatory cells and inflammatory mediator production leading to the release of larger quantities of reactive oxygen species (ROS). This in turn triggers the production of oxygen stress-induced high mobility group box-1 (HMGB-1), an endogenous damage-associated molecular patterns (DAMPs) protein bound to toll-like receptor (TLR) -4, which activates nuclear factor-kappa B (NF-κB), resulting in the production of excess inflammatory mediators. ROS and inflammatory mediators are produced not only in activated inflammatory cells but also in non-immune cells, such as endothelial cells. Hypothermia inhibits pro-inflammatory mediators. A combination therapy of hypothermia and medications, such as erythropoietin and melatonin, is attracting attention now. These medications have both anti-oxidant and anti-inflammatory effects. As the inflammatory response and oxidative stress play a critical role in the pathophysiology of neonatal asphyxia, these drugs may contribute to improving patient outcomes.
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Affiliation(s)
- Kaoru Okazaki
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shinji Nakamura
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kosuke Koyano
- Maternal Perinatal Center, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yukihiko Konishi
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Masatoshi Kondo
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Xie Y, Yang Y, Yuan T. Brain Damage in the Preterm Infant: Clinical Aspects and Recent Progress in the Prevention and Treatment. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2023; 22:27-40. [PMID: 35209835 DOI: 10.2174/1871527321666220223092905] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 12/16/2022]
Abstract
Although the prevalence of brain injury and related neurodevelopmental disabilities resulting from preterm birth are major public health concerns, there are no definite neuroprotective strategies to prevent or reduce brain injury. The pattern of brain injury seen in preterm infants has evolved into more subtle lesions that are still essential to diagnose regarding neurodevelopmental outcomes. There is no specific effective method for the treatment of premature infant brain injury, and the focus of clinical treatment is still on prevention. Prevention of this injury requires insight into the pathogenesis, but many gaps exist in our understanding of how neonatal treatment procedures and medications impact cerebral hemodynamics and preterm brain injury. Many studies provide evidence about the prevention of premature infant brain injury, which is related to some drugs (such as erythropoietin, melatonin, mesenchymal stem cells, etc.). However, there are still some controversies about the quality of research and the effectiveness of therapy. This review aims to recapitulate the results of preclinical studies and provide an update on the latest developments around etiological pathways, prevention, and treatment.
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Affiliation(s)
- Yixuan Xie
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Yue Yang
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Tianming Yuan
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
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Abdel-Aziz SM, Rahman MSMA, Shoreit AH, Din MEE, Hamed EA, Gad EF. Outcome of Infants with Hypoxic-Ischemic Encephalopathy Treated by Whole Body Cooling and Magnesium Sulfate. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1736562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractTherapeutic hypothermia (TH) either by selective head cooling or whole-body cooling decreases brain damage and provide neuroprotection and reduced mortality rate in cases of moderate-to-severe hypoxia-ischemia encephalopathy (HIE) of newborns, especially if started at first 6 hours after birth. Also, management with adjuvant therapies like magnesium sulfate (MS) provides more neuroprotection. The interventional randomized controlled research aimed to assess short-term actions of TH as sole therapy and in combination with MS as a neuroprotective agent for the treatment of HIE newborn infants. A total of 36 full-terms and near-term infants delivered at Assiut University Children's Hospital and fulfilled HIE criteria were enrolled. They were divided equally into three groups; Group 1 (n = 12) received whole body cooling during first 6 hours of life as a sole therapy; Group 2 (n = 12) received whole body cooling in addition to MS as adjuvant therapy; Group 3 (n = 12) received supportive intensive care measures as a control. TH plus MS group (group 2) had a significantly good short-term outcomes as short period of respiratory support and mechanical ventilation (p-value =0.001), less in incidence of convulsion (p-value = 0.001) and early in feeding initiation (p-value = 0.009), compared with other groups managed by TH (group 1) or by supportive treatment (group 3). In conclusion, whole body cooling in addition to MS as adjunctive therapy for the treatment of HIE neonates is safe therapy that improves short-term outcome both clinically and radiologically.
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Affiliation(s)
- Safwat M. Abdel-Aziz
- Department of Pediatrics and Neonatology, Assiut University Children's Hospital, Assiut, Egypt
| | | | - Asmaa H. Shoreit
- Department of Pediatrics and Neonatology, Assiut University Children's Hospital, Assiut, Egypt
| | - Moustafa Ez El Din
- Department of Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Enas A. Hamed
- Department of Medical Physiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Eman Fathalla Gad
- Department of Pediatrics and Neonatology, Assiut University Children's Hospital, Assiut, Egypt
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Iqbal N, Younus J, Malik M, Fatima B, Imran A, Maqbool S, Irfan Waheed KA, Haque K. The Neuroprotective Efficacy of Postnatal Magnesium Sulfate in Term or Near-Term Infants With Moderate-to-Severe Birth Asphyxia. Cureus 2021; 13:e16826. [PMID: 34513419 PMCID: PMC8407416 DOI: 10.7759/cureus.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background In Pakistan, the neonatal mortality rate is 41 per 1,000 live births and birth asphyxia is one of the leading causes of neonatal mortality and morbidity. The goal of this study was to determine whether postnatal magnesium sulfate therapy can improve short- and long-term neurological outcomes in term or near-term neonates with moderate-to-severe birth asphyxia. Methodology This prospective double-blind randomized controlled trial was conducted in the Neonatology Department of the Children's Hospital & The Institute of Child Health, Lahore. A total of 62 neonates (31 in each group) were randomized to receive either three doses of magnesium sulfate infusion at 250 mg/kg per dose, 24 hours apart (treatment group), or three doses of injection 10% distilled water infusion at 3 mL/kg, 24 hours apart (placebo group). Both groups received similar supportive care. The neurodevelopmental assessment was done at six months of age using the ShaMaq Developmental Inventory. Results Demographic data such as gestational age, mean weight, age at presentation, gender, hypoxic-ischemic encephalopathy grade, mode of delivery, and the presence of seizures at presentation were comparable between both groups. In the magnesium sulfate group, statistically significant results were seen in terms of early seizure control (p = 0.001), early initiation of feed (p = 0.002), and shorter duration of hospital stay (p = 0.003). Moreover, the magnesium sulfate group had lower mortality compared to the control group, though it was not statistically significant (p = 0.390). There was no significant difference in terms of cranial ultrasound findings between the two groups (p = 0.783) at the time of discharge. Regarding the neurodevelopmental delay, there was no significant difference between the magnesium sulfate and control groups (p = 0.535). Conclusions Postnatal magnesium sulfate treatment improves short-term neurologic outcomes at discharge in term or near-term neonates with moderate-to-severe perinatal asphyxia. However, no difference was noted in the neurodevelopmental outcome at six months.
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Affiliation(s)
- Nadeem Iqbal
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Javaria Younus
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Muneeba Malik
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Bushra Fatima
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Ahmed Imran
- Pediatric Radiology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Shazia Maqbool
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | | | - Khalid Haque
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
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Samaiya PK, Krishnamurthy S, Kumar A. Mitochondrial dysfunction in perinatal asphyxia: role in pathogenesis and potential therapeutic interventions. Mol Cell Biochem 2021; 476:4421-4434. [PMID: 34472002 DOI: 10.1007/s11010-021-04253-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 08/20/2021] [Indexed: 01/13/2023]
Abstract
Perinatal asphyxia (PA)-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and long-term sequelae such as spastic motor deficits, intellectual disability, seizure disorders and learning disabilities. The brain injury is secondary to both the hypoxic-ischemic event and oxygenation-reperfusion following resuscitation. Following PA, a time-dependent progression of neuronal insult takes place in terms of transition of cell death from necrosis to apoptosis. This transition is the result of time-dependent progression of pathomechanisms which involve excitotoxicity, oxidative stress, and ultimately mitochondrial dysfunction in developing brain. More precisely mitochondrial respiration is suppressed and calcium signalling is dysregulated. Consequently, Bax-dependent mitochondrial permeabilization occurs leading to release of cytochrome c and activation of caspases leading to transition of cell death in developing brain. The therapeutic window lies within this transition process. At present, therapeutic hypothermia (TH) is the only clinical treatment available for treating moderate as well as severe asphyxia in new-born as it attenuates secondary loss of high-energy phosphates (ATP) (Solevåg et al. in Free Radic Biol Med 142:113-122, 2019; Gunn et al. in Pediatr Res 81:202-209, 2017), improving both short- and long-term outcomes. Mitoprotective therapies can offer a new avenue of intervention alone or in combination with therapeutic hypothermia for babies with birth asphyxia. This review will explore these mitochondrial pathways, and finally will summarize past and current efforts in targeting these pathways after PA, as a means of identifying new avenues of therapeutic intervention.
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Affiliation(s)
- Puneet K Samaiya
- Department of Pharmacy, Shri G.S. Institute of Technology and Science, Indore, MP, 452003, India.
| | - Sairam Krishnamurthy
- Neurotherapeutics Lab, Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, 221005, India
| | - Ashok Kumar
- Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi, UP, India
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Pisani F, Fusco C, Nagarajan L, Spagnoli C. Acute symptomatic neonatal seizures, brain injury, and long-term outcome: The role of neuroprotective strategies. Expert Rev Neurother 2020; 21:189-203. [PMID: 33176104 DOI: 10.1080/14737175.2021.1848547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal seizures are frequent but underdiagnosed manifestations of acute brain dysfunction and an important contributor to unfavorable outcomes. Etiology and severity of brain injury are the single strongest outcome determinants. AREAS COVERED The authors will discuss the prognostic role of acute symptomatic seizures versus brain injury and the main neuroprotective and neurorestorative strategies for full-term and preterm infants. EXPERT OPINION Prolonged acute symptomatic seizures likely contribute to long-term outcomes by independently adding further brain injury to initial insults. Correct timing and dosing of therapeutic interventions, depending on etiology and gestational ages, need careful evaluation. Although promising strategies are under study, the only standard of care is whole-body therapeutic hypothermia in full-term newborns with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine and Surgery Department, University of Parma , Parma, Italy
| | - Carlo Fusco
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, University of Western Australia , Perth, Australia
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
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Greco P, Nencini G, Piva I, Scioscia M, Volta CA, Spadaro S, Neri M, Bonaccorsi G, Greco F, Cocco I, Sorrentino F, D'Antonio F, Nappi L. Pathophysiology of hypoxic-ischemic encephalopathy: a review of the past and a view on the future. Acta Neurol Belg 2020; 120:277-288. [PMID: 32112349 DOI: 10.1007/s13760-020-01308-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/13/2020] [Indexed: 12/14/2022]
Abstract
Hypoxic-ischemic encephalopathy, also referred as HIE, is a type of brain injury or damage that is caused by a lack of oxygen to the brain during neonatal period. The incidence is approximately 1.5 cases per 1000 live births in developed countries. In low and middle-income countries, the incidence is much higher (10‒20 per 1000 live births). The treatment for neonatal HIE is hypothermia that is only partially effective (not more than 50% of the neonates treated achieve an improved outcome). HIE pathophysiology involves oxidative stress, mitochondrial energy production failure, glutaminergic excitotoxicity, and apoptosis. So, in the last years, many studies have focused on peptides that act somewhere in the pathway activated by severe anoxic injury leading to HIE. This review describes the pathophysiology of perinatal HIE and the mechanisms that could be the target of innovative HIE treatments.
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Affiliation(s)
- P Greco
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, 44121, Ferrara, Italy
| | - G Nencini
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, 44121, Ferrara, Italy
| | - I Piva
- Department of Women Health, Infancy and Adolescence, AUSL Ravenna, 48121, Ravenna, Italy
| | - M Scioscia
- Department of Obstetrics and Gynaecology, Policlinico Hospital of Abano Terme, Padua, Italy
| | - C A Volta
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44121, Ferrara, Italy
| | - S Spadaro
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44121, Ferrara, Italy
| | - M Neri
- Section of Forensic Medicine, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44121, Ferrara, Italy
| | - G Bonaccorsi
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, 44121, Ferrara, Italy
| | - F Greco
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, 71121, Foggia, Italy
| | - I Cocco
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, 71121, Foggia, Italy
| | - F Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, 71121, Foggia, Italy.
| | - F D'Antonio
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, 71121, Foggia, Italy
| | - L Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, 71121, Foggia, Italy
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Abstract
Perinatal brain injury is a major cause of neurological disability in both premature and term infants. In this review, we summarize the evidence behind some established neuroprotective practices such as administration of antenatal steroids, intrapartum magnesium for preterm delivery, and therapeutic hypothermia. In addition, we examine emerging practices such as delayed cord clamping, postnatal magnesium administration, recombinant erythropoietin, and non-steroidal anti-inflammatory agents and finally inform the reader about novel interventions, some of which are currently in trials, such as xenon, melatonin, topiramate, allopurinol, creatine, and autologous cord cell therapy.
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Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
- Department of Pediatric Neurology, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
| | - Michael Johnston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
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13
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Lee CYZ, Chakranon P, Lee SWH. Comparative Efficacy and Safety of Neuroprotective Therapies for Neonates With Hypoxic Ischemic Encephalopathy: A Network Meta-Analysis. Front Pharmacol 2019; 10:1221. [PMID: 31708771 PMCID: PMC6824259 DOI: 10.3389/fphar.2019.01221] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
Context: Several interventions are available for the management of hypoxic ischemic encephalopathy (HIE), but no studies have compared their relative efficacy in a single analysis. This study aims to compare and determine the effectiveness of available interventions for HIE using direct and indirect data. Methods: Large randomized trials were identified from PubMed, EMBASE, CINAHL Plus, AMED, and Cochrane Library of Clinical Trials database from inception until June 30, 2018. Two independent reviewers extracted study data and performed quality assessment. Direct and network meta-analysis of randomized controlled trials was performed to obtained pooled results comparing the effectiveness of different therapies used in HIE on mortality, neurodevelopmental delay at 18 months, as well as adverse events. Their probability of having the highest efficacy and safety was estimated and ranked. The certainty of evidence for the primary outcomes of mortality and mortality or neurodevelopmental delay at 18 months was evaluated using GRADE criteria. Results: Fifteen studies comparing five interventions were included in the network meta-analysis. Whole body cooling [Odds ratio: 0.62 (95% credible interval: 0.46–0.83); 8 trials, high certainty of evidence] was the most effective treatment in reducing the risk of mortality, followed by selective head cooling (0.73; 0.48–1.11; 2 trials, moderate certainty of evidence) and use of magnesium sulfate (0.79; 0.20–3.06; 2 trials, low certainty of evidence). Whole body hypothermia (0.48; 0.33–0.71; 5 trials), selective head hypothermia (0.54; 0.32–0.89; 2 trials), and erythropoietin (0.36; 0.19–0.66; 2 trials) were more effective for reducing the risk of mortality and neurodevelopmental delay at 18 months (moderate to high certainty). Among neonates treated for HIE, the use of erythropoietin (0.36; 0.18–0.74, 2 trials) and whole body hypothermia (0.61; 0.45–0.83; 7 trials) were associated with lower rates of cerebral palsy. Similarly, there were lower rates of seizures among neonates treated with erythropoietin (0.35; 0.13–0.94; 1 trial) and whole body hypothermia (0.64; 0.46–0.87, 7 trials). Conclusion: The findings support current guidelines using therapeutic hypothermia in neonates with HIE. However, more trials are needed to determine the role of adjuvant therapy to hypothermia in reducing the risk of mortality and/or neurodevelopmental delay.
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Affiliation(s)
| | | | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia.,School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
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14
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Albrecht M, Zitta K, Groenendaal F, van Bel F, Peeters-Scholte C. Neuroprotective strategies following perinatal hypoxia-ischemia: Taking aim at NOS. Free Radic Biol Med 2019; 142:123-131. [PMID: 30818057 DOI: 10.1016/j.freeradbiomed.2019.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/07/2019] [Accepted: 02/19/2019] [Indexed: 12/13/2022]
Abstract
Perinatal asphyxia is characterized by oxygen deprivation and lack of perfusion in the perinatal period, leading to hypoxic-ischemic encephalopathy and sequelae such as cerebral palsy, mental retardation, cerebral visual impairment, epilepsy and learning disabilities. On cellular level PA is associated with a decrease in oxygen and glucose leading to ATP depletion and a compromised mitochondrial function. Upon reoxygenation and reperfusion, the renewed availability of oxygen gives rise to not only restoration of cell function, but also to the activation of multiple detrimental biochemical pathways, leading to secondary energy failure and ultimately, cell death. The formation of reactive oxygen species, nitric oxide and peroxynitrite plays a central role in the development of subsequent neurological damage. In this review we give insight into the pathophysiology of perinatal asphyxia, discuss its clinical relevance and summarize current neuroprotective strategies related to therapeutic hypothermia, ischemic postconditioning and pharmacological interventions. The review will also focus on the possible neuroprotective actions and molecular mechanisms of the selective neuronal and inducible nitric oxide synthase inhibitor 2-iminobiotin that may represent a novel therapeutic agent for the treatment of hypoxic-ischemic encephalopathy, both in combination with therapeutic hypothermia in middle- and high-income countries, as well as stand-alone treatment in low-income countries.
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Affiliation(s)
- Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cacha Peeters-Scholte
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Neurophyxia BV, 's Hertogenbosch, the Netherlands.
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Nonomura M, Harada S, Asada Y, Matsumura H, Iwami H, Tanaka Y, Ichiba H. Combination therapy with erythropoietin, magnesium sulfate and hypothermia for hypoxic-ischemic encephalopathy: an open-label pilot study to assess the safety and feasibility. BMC Pediatr 2019; 19:13. [PMID: 30621649 PMCID: PMC6325796 DOI: 10.1186/s12887-018-1389-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although therapeutic hypothermia improves the outcome of neonatal hypoxic-ischemic encephalopathy (HIE), its efficacy is still limited. This preliminary study evaluates the safety and feasibility of the combination therapy with erythropoietin (Epo), magnesium sulfate and hypothermia in neonates with HIE. METHODS A combination therapy with Epo (300 U/kg every other day for 2 weeks), magnesium sulfate (250 mg/kg for 3 days) and hypothermia was started within 6 h of birth in neonates who met the institutional criteria for hypothermia therapy. All patients received continuous infusion of dopamine. Vital signs and adverse events were recorded during the therapy. Short-term and long-term developmental outcomes were also evaluated. RESULTS Nine patients were included in the study. The mean age at first intervention was 3.9 h (SD, 0.5). Death, serious adverse events or changes in vital signs likely due to intervention were not observed during hospital care. All nine patients completed the therapy. At the time of hospital discharge, eight patients had established oral feeding and did not require ventilation support. Two patients had abnormal MRI findings. At 18 months of age, eight patients received a follow-up evaluation, and three of them showed signs of severe neurodevelopmental disability. CONCLUSION The combination therapy with 300 U/kg Epo every other day for 2 weeks, 250 mg/kg magnesium sulphate for 3 days and therapeutic hypothermia is feasible in newborn patients with HIE. TRIAL REGISTRATION ISRCTN33604417 retrospectively registered on 14 September 2018.
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Affiliation(s)
- Miho Nonomura
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Sayaka Harada
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Yuki Asada
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hisako Matsumura
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hiroko Iwami
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Yuko Tanaka
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hiroyuki Ichiba
- Department of Neonatology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan.
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Kasdorf E, Perlman JM. General Supportive Management of the Term Infant With Neonatal Encephalopathy Following Intrapartum Hypoxia-Ischemia. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00005-4] [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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17
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Nair J, Kumar VHS. Current and Emerging Therapies in the Management of Hypoxic Ischemic Encephalopathy in Neonates. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E99. [PMID: 30029531 PMCID: PMC6069156 DOI: 10.3390/children5070099] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023]
Abstract
Neonatal hypoxic ischemic encephalopathy (HIE) presents a significant clinical burden with its high mortality and morbidity rates globally. Therapeutic hypothermia (TH) is now standard of care for infants with moderate to severe HIE, but has not definitively changed outcomes in severe HIE. In this review, we discuss newer promising markers that may help the clinician identify severity of HIE. Therapies that are beneficial and agents that hold promise for neuroprotection are described, both for use either alone or as adjuncts to TH. These include endogenous pathway modifiers such as erythropoietin and analogues, melatonin, and remote ischemic post conditioning. Stem cells have therapeutic potential in this condition, as in many other neonatal conditions. Of the agents listed, only erythropoietin and analogues are currently being evaluated in large randomized controlled trials (RCTs). Exogenous therapies such as argon and xenon, allopurinol, monosialogangliosides, and magnesium sulfate continue to be investigated. The recognition of tertiary mechanisms of brain damage has opened up new research into therapies not only to attenuate brain damage but also to promote cell repair and regeneration in a developmentally disorganized brain long after the perinatal insult. These alternative modalities may be especially important in mild HIE and in areas of the world where there is limited access to expensive hypothermia equipment and services.
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Affiliation(s)
- Jayasree Nair
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
| | - Vasantha H S Kumar
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
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18
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Bennet L, Galinsky R, Draghi V, Lear CA, Davidson JO, Unsworth CP, Gunn AJ. Time and sex dependent effects of magnesium sulphate on post-asphyxial seizures in preterm fetal sheep. J Physiol 2018; 596:6079-6092. [PMID: 29572829 DOI: 10.1113/jp275627] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/12/2018] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS We evaluated the effect of magnesium sulphate (MgSO4 ) on seizures induced by asphyxia in preterm fetal sheep. MgSO4 did not prevent seizures, but significantly reduced the total duration, number of seizures, seizure amplitude and average seizure burden. Saline-asphyxia male fetuses had significantly more seizures than female fetuses, but male fetuses showed significantly greater reduction in seizures during MgSO4 infusion than female fetuses. A circadian profile of seizure activity was observed in all fetuses, with peak seizures seen around 04.00-06.00 h on the first and second days after the end of asphyxia. This study is the first to demonstrate that MgSO4 has utility as an anti-seizure agent after hypoxia-ischaemia. More information is needed about the mechanisms mediating the effect of MgSO4 on seizures and sexual dimorphism, and the influence of circadian rhythms on seizure expression. ABSTRACT Seizures are common in newborns after asphyxia at birth and are often refractory to anti-seizure agents. Magnesium sulphate (MgSO4 ) has anticonvulsant effects and is increasingly given to women in preterm labour for potential neuroprotection. There is limited information on its effects on perinatal seizures. We examined the hypothesis that MgSO4 infusion would reduce fetal seizures after asphyxia in utero. Preterm fetal sheep at 0.7 gestation (104 days, term = 147 days) were given intravenous infusions of either saline (n = 14) or MgSO4 (n = 12, 160 mg bolus + 48 mg h-1 infusion over 48 h). Fetuses underwent umbilical cord occlusion (UCO) for 25 min, 24 h after the start of infusion. The start time for seizures did not differ between groups, but MgSO4 significantly reduced the total number of seizures (P < 0.001), peak seizure amplitude (P < 0.05) and seizure burden (P < 0.005). Within the saline-asphyxia group, male fetuses had significantly more seizures than females (P < 0.05). Within the MgSO4 -asphyxia group, although both sexes had fewer seizures than the saline-asphyxia group, the greatest effect of MgSO4 was on male fetuses, with reduced numbers of seizures (P < 0.001) and seizure burden (P < 0.005). Only 1 out of 6 MgSO4 males had seizures on the second day post-UCO compared to 5 out of 6 MgSO4 female fetuses (P = 0.08). Finally, seizures showed a circadian profile with peak seizures between 04.00 and 06.00 h on the first and second day post-UCO. Collectively, these results suggest that MgSO4 may have utility in treating perinatal seizures and has sexually dimorphic effects.
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Affiliation(s)
- Laura Bennet
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Vittoria Draghi
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Christopher A Lear
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Charles P Unsworth
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, The Department of Physiology, The University of Auckland, Auckland, New Zealand
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19
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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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21
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Rigo J, Pieltain C, Christmann V, Bonsante F, Moltu SJ, Iacobelli S, Marret S. Serum Magnesium Levels in Preterm Infants Are Higher Than Adult Levels: A Systematic Literature Review and Meta-Analysis. Nutrients 2017; 9:nu9101125. [PMID: 29035309 PMCID: PMC5691741 DOI: 10.3390/nu9101125] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/06/2017] [Accepted: 10/07/2017] [Indexed: 12/20/2022] Open
Abstract
Magnesium (Mg) is an essential mineral in the body, impacting the synthesis of biomacromolecules, bone matrix development, energy production, as well as heart, nerve, and muscle function. Although the importance of Mg is evident, reference values for serum Mg (sMg) in pediatric patients (more specifically, in neonates) are not well established. This systematic literature review and meta-analysis (using 47 eligible studies) aims to quantify normal and tolerable ranges of sMg concentrations during the neonatal period and to highlight the factors influencing Mg levels and the importance of regulating sMg levels during pregnancy and birth. In newborns without Mg supplementation during pregnancy, magnesium levels at birth (0.76 (95% CI: 0.52, 0.99) mmol/L) were similar to that of mothers during pregnancy (0.74 (95% CI: 0.43, 1.04) mmol/L), but increased during the first week of life (0.91 (95% CI: 0.55, 1.26) mmol/L) before returning to adult levels. This pattern was also seen in newborns with Mg supplementation during pregnancy, where the average was 1.29 (95% CI: 0.50, 2.08) mmol/L at birth and 1.44 (95% CI: 0.61, 2.27) mmol/L during the first week of life. Factors influencing these levels include prenatal Mg supplementation, gestational age, birth weight, renal maturity/function, and postnatal Mg intake. Elevated Mg levels (>2.5 mmol/L) have been associated with an increased risk of mortality, admission into intensive care, hypotonia, hypotension, and respiratory depression but sMg concentrations up to 2.0 mmol/L appear to be well tolerated in neonates, requiring adequate survey and minimal intervention.
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Affiliation(s)
- Jacques Rigo
- Department of Neonatology, Université de Liège, CHR Citadelle, 4000 Liège, Belgium.
| | - Catherine Pieltain
- Department of Neonatology, Université de Liège, CHR Citadelle, 4000 Liège, Belgium.
| | - Viola Christmann
- Radboudumc Amalia Children's Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands.
| | - Francesco Bonsante
- Centre d'Etudes Périnatales de l'Océan Indien (EA 7388), CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
- Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
| | - Sissel J Moltu
- Department of Neonatal Intensive Care, Oslo University Hospital, 0318 Oslo, Norway.
| | - Silvia Iacobelli
- Centre d'Etudes Périnatales de l'Océan Indien (EA 7388), CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
- Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
| | - Stéphane Marret
- Department of Neonatal Pediatrics and Intensive Care and Neuropediatrics, Rouen University Hospital, and INSERM, Laboratoire NeoVasc ERI28, Normandy University, 76000 Rouen, France.
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Nunes RD, Schutz FD, Traebert JL. Association between the use of magnesium sulfate as neuroprotector in prematurity and the neonatal hemodynamic effects. J Matern Fetal Neonatal Med 2017; 31:1900-1905. [PMID: 28521581 DOI: 10.1080/14767058.2017.1332033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Cerebral palsy is often associated with prematurity and magnesium sulfate (MgSO4) has been used as a neuroprotector, with favorable results. However, its mechanism of action has not been fully elucidated. This study aimed to evaluate the association between MgSO4 at the imminent premature delivery and neonatal hemodynamic effects. MATERIALS AND METHODS A cross-sectional study involving 94 newborns (NB) between 24 and 32 weeks at a Brazilian hospital was performed. Bivariate analysis between the use or the non-use of MgSO4 and hemodynamic characteristics was performed, using the Chi-square test. RESULTS NB were evaluated between those who received MgSO4 (27.7) and those who did not (72.3%). Normal heart rate was verified in 62.8% of NB, normal respiratory rate in 70.2%, and normal temperature in 22.3%. Oxygen saturation higher or equal than 95% was evidenced in 85.1% of NB, normal hemoglucotest in 74.5%, and hemoglobin greater or equal than 16.4 g/dL in 30.9%. Non-invasive ventilation was performed in 48.9% of NB, while 51.1% were submitted to endotracheal ventilation. There was no significance relation detected between the use of MgSO4 and the hemodynamic characteristics. CONCLUSIONS MgSO4 does not appear to influence hemodynamic factors as a cause of the neuroprotection in premature NB.
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Affiliation(s)
- Rodrigo Dias Nunes
- a Graduate Program in Health Sciences , Universidade do Sul de Santa Catarina , Palhoca , Brazil
| | - Flávia Duarte Schutz
- a Graduate Program in Health Sciences , Universidade do Sul de Santa Catarina , Palhoca , Brazil
| | - Jefferson Luiz Traebert
- a Graduate Program in Health Sciences , Universidade do Sul de Santa Catarina , Palhoca , Brazil
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Yıldız EP, Ekici B, Tatlı B. Neonatal hypoxic ischemic encephalopathy: an update on disease pathogenesis and treatment. Expert Rev Neurother 2016; 17:449-459. [PMID: 27830959 DOI: 10.1080/14737175.2017.1259567] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hypoxic ischemic encephalopathy (HIE) is the most important reason for morbidity and mortality in term-born infants. Understanding pathophysiology of the brain damage is essential for the early detection of patients with high risk for HIE and development of strategies for their treatments. Areas covered: This review discusses pathophysiology of the neonatal HIE and its treatment options, including hypothermia, melatonin, allopurinol, topiramate, erythropoietin, N-acetylcyctein, magnesium sulphate and xenon. Expert commentary: Several clinical studies have been performed in order to decrease the risk of brain injury due to difficulties in the early diagnosis and treatment, and to develop strategies for better long-term outcomes. Although currently standard treatment methods include therapeutic hypothermia for neonates with moderate to severe HIE, new supportive options are needed to enhance neuroprotective effects of the hypothermia, which should aim to reduce production of the free radicals and to have anti-inflammatory and anti-apoptotic actions.
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Affiliation(s)
| | - Barış Ekici
- b Department of Pediatric Neurology , Liv Hospital , Istanbul , Turkey
| | - Burak Tatlı
- a Department of Pediatric Neurology , Istanbul University , Istanbul , Turkey
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Abstract
Magnesium plays important roles in many physiologic functions including protein synthesis, bone development, and cell membrane function. There is some evidence to suggest a role for magnesium sulfate as a therapeutic neuroprotective agent along with therapeutic hypothermia in infants with hypoxic-ischemic encephalopathy, but studies are inconclusive. Ischemic insult and hypothermia may both play a role in altered magnesium levels in this population.
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Golshani-Hebroni S. Mg(++) requirement for MtHK binding, and Mg(++) stabilization of mitochondrial membranes via activation of MtHK & MtCK and promotion of mitochondrial permeability transition pore closure: A hypothesis on mechanisms underlying Mg(++)'s antioxidant and cytoprotective effects. Gene 2015; 581:1-13. [PMID: 26732303 DOI: 10.1016/j.gene.2015.12.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 12/13/2022]
Abstract
Evidence points to magnesium's antioxidant, anti-necrotic, and anti-apoptotic effects in cardio- and neuroprotection. With magnesium being involved in over 300 biochemical reactions, the mechanisms underlying its cytoprotective and antioxidant effects have remained elusive. The profound anti-apoptotic, anabolic, and antioxidant effects of mitochondrion bound hexokinase (MtHk), and the anti-apoptotic, anti-necrotic, and antioxidant functions of mitochondrial creatine kinase (MtCK) have been established over the past few decades. As powerful regulators of the mitochondrial permeability transition pore (PTP), MtHK and MtCK promote anti-apoptosis and anti-necrosis by stabilizing mitochondrial outer and inner membranes. In this article, it is proposed that magnesium is essentially and directly involved in mitochondrial membrane stabilization via (i) Mg(++) ion requirement for the binding of mitochondrial hexokinase (ii) Mg(++)'s allosteric activation of mitochondrial bound hexokinase, and stimulation of mitochondrial bound creatine kinase activities, and (iii) Mg(++) inhibition of PTP opening by Ca(++) ions. These effects of Mg(++) ions are indirectly supplanted by the stimulatory effect of magnesium on the Akt kinase survival pathway. The "Magnesium/Calcium Yin Yang Hypothesis" proposes here that because of the antagonistic effects of Ca(++) and Mg(++) ions in the presence of high Ca(++) ion concentration at MtHK, MtCK, and PTP, magnesium supplementation may provide cytoprotective effects in the treatment of some degenerative diseases and cytopathies with high intracellular [Ca(++)]/ [Mg(++)] ratio at these sites, whether of genetic, developmental, drug induced, ischemic, immune based, toxic, or infectious etiology.
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Itoh K, Maki T, Shindo A, Egawa N, Liang AC, Itoh N, Lo EH, Lok J, Arai K. Magnesium sulfate protects oligodendrocyte lineage cells in a rat cell-culture model of hypoxic-ischemic injury. Neurosci Res 2015; 106:66-9. [PMID: 26699082 DOI: 10.1016/j.neures.2015.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 01/02/2023]
Abstract
Hypoxic-ischemic (HI) brain injury in newborns results in serious damage. Magnesium sulfate has been clinically used as a cyto-protective agent against HI brain injury in newborns in some countries, including Japan. However, it is not clear how magnesium exerts this effect and how it acts on the individual types of cells within the newborn brain. In this study, we exposed cultured rat oligodendrocyte precursor cells to magnesium sulfate during the period when they differentiate into oligodendrocytes, and showed that magnesium-exposed oligodendrocytes exhibited more resistance to HI injury. Our data may support the use of magnesium sulfate in the clinical setting.
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Affiliation(s)
- Kanako Itoh
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Takakuni Maki
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Akihiro Shindo
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Naohiro Egawa
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Anna C Liang
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Naoki Itoh
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Eng H Lo
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Josephine Lok
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ken Arai
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA.
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Merchant NM, Azzopardi DV, Edwards AD. Neonatal hypoxic ischaemic encephalopathy: current and future treatment options. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1021776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Cotten CM, Shankaran S. Hypothermia for hypoxic-ischemic encephalopathy. ACTA ACUST UNITED AC 2014; 5:227-239. [PMID: 20625441 DOI: 10.1586/eog.10.7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Moderate to severe hypoxic-ischemic injury in newborn infants, manifested as encephalopathy immediately or within hours after birth, is associated with a high risk of either death or a lifetime with disability. In recent multicenter clinical trials, hypothermia initiated within the first 6 postnatal hours has emerged as a therapy that reduces the risk of death or impairment among infants with hypoxic-ischemic encephalopathy. Prior to hypothermia, no therapies directly targeting neonatal encephalopathy secondary to hypoxic-ischemic injury had convincing evidence of efficacy. Hypothermia therapy is now becoming increasingly available at tertiary centers. Despite the deserved enthusiasm for hypothermia, obstetric and neonatology caregivers, as well as society at large, must be reminded that in the clinical trials more than 40% of cooled infants died or survived with impairment. Although hypothermia is an evidence-based therapy, additional discoveries are needed to further improve outcome after HIE. In this article, we briefly present the epidemiology of neonatal encephalopathy due to hypoxic-ischemic injury, describe the rationale for the use of hypothermia therapy for hypoxic-ischemic encephalopathy, and present results of the clinical trials that have demonstrated the efficacy of hypothermia. We also present findings noted during and after these trials that will guide care and direct research for this devastating problem.
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Affiliation(s)
- C Michael Cotten
- Associate Professor of Pediatrics, Duke University Medical Center, Box 2739 DUMC, Durham, NC 27710, USA, Tel.: +1 919 681 4844, ,
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Doll E, Wilkes J, Cook LJ, Korgenski EK, Faix RG, Yoder BA, Srivastava R, Sherwin CMT, Spigarelli MG, Clark EAS, Bonkowsky JL. Neonatal magnesium levels correlate with motor outcomes in premature infants: a long-term retrospective cohort study. Front Pediatr 2014; 2:120. [PMID: 25414842 PMCID: PMC4220726 DOI: 10.3389/fped.2014.00120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 10/22/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Chronic neurological deficits are a significant complication of preterm birth. Magnesium supplementation has been suggested to have neuroprotective function in the developing brain. Our objective was to determine whether higher neonatal serum magnesium levels were associated with better long-term neurodevelopmental outcomes in very-low birth weight infants. STUDY DESIGN A retrospective cohort of 75 preterm infants (<1500 g, gestational age <27 weeks) had follow-up for the outcomes of abnormal motor exam and for epilepsy. Average total serum magnesium level in the neonate during the period of prematurity was the main independent variable assessed, tested using a Wilcoxon rank-sum test. RESULTS Higher average serum magnesium level was associated with a statistically significant decreased risk for abnormal motor exam (p = 0.037). A lower risk for epilepsy in the group with higher magnesium level did not reach statistical significance (p = 0.06). CONCLUSION This study demonstrates a correlation between higher neonatal magnesium levels and decreased risk for long-term abnormal motor exam. Larger studies are needed to evaluate the hypothesis that higher neonatal magnesium levels can improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Elizabeth Doll
- Division of Pediatric Neurology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Jacob Wilkes
- Intermountain Healthcare , Salt Lake City, UT , USA
| | - Lawrence J Cook
- Division of Critical Care Medicine, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | | | - Roger G Faix
- Division of Neonatology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Bradley A Yoder
- Division of Neonatology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Rajendu Srivastava
- Intermountain Healthcare , Salt Lake City, UT , USA ; Division of Inpatient Medicine, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Michael G Spigarelli
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Erin A S Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, School of Medicine, University of Utah , Salt Lake City, UT , USA
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Anabrees J. Magnesium sulphate for newborns with HIE; synopsis of evidence from a systematic review. J Clin Neonatol 2013; 2:114-6. [PMID: 24251252 PMCID: PMC3830143 DOI: 10.4103/2249-4847.119989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jasim Anabrees
- Consultant Neonatologist, Neonatal Division, Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia. E-mail:
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Magnesium for newborns with hypoxic-ischemic encephalopathy: a systematic review and meta-analysis. J Perinatol 2013; 33:663-9. [PMID: 23743671 DOI: 10.1038/jp.2013.65] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/29/2013] [Accepted: 05/08/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Magnesium may have a role in neuroprotection in neonatal hypoxic-ischemic encephalopathy (HIE). The objective of this study was to systematically review the efficacy and safety of postnatal magnesium therapy in newborns with HIE. STUDY DESIGN MEDLINE, EMBASE, CINAHL and CCRCT were searched for studies of magnesium for HIE. Randomized controlled trials that compared magnesium to control in newborns with HIE were selected. The primary outcome was a composite outcome of death or moderate-to-severe neurodevelopmental disability at 18 months. When appropriate, meta-analyses were conducted using random effects model and risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. RESULT Five studies with sufficient quality were included. There was no difference in the primary outcome between the magnesium and the control groups (RR 0.81, 95% CI 0.36 to 1.84). There was significant reduction in the unfavorable short-term composite outcome (RR 0.48, 95% CI 0.30 to 0.77) but no difference in mortality (RR 1.39, 95% CI 0.85 to 2.27), seizures (RR 0.84, 95% CI 0.59 to 1.19) or hypotension (RR 1.28, 95% CI 0.69 to 2.38) between the magnesium and the control groups. CONCLUSION The improvement in short-term outcomes without significant increase in side effects indicate the need for further trials to determine if there are long-term benefits of magnesium and to confirm its safety. Mortality was statistically insignificant between the magnesium and the control groups. However, the trend toward increase in mortality in the magnesium group is a major clinical concern and should be monitored closely in future trials.
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Topjian AA, Berg RA, Bierens JJLM, Branche CM, Clark RS, Friberg H, Hoedemaekers CWE, Holzer M, Katz LM, Knape JTA, Kochanek PM, Nadkarni V, van der Hoeven JG, Warner DS. Brain resuscitation in the drowning victim. Neurocrit Care 2013; 17:441-67. [PMID: 22956050 DOI: 10.1007/s12028-012-9747-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.
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Affiliation(s)
- Alexis A Topjian
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 7C23, Philadelphia, PA 19104, USA.
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Westermaier T, Stetter C, Kunze E, Willner N, Raslan F, Vince GH, Ernestus RI. Magnesium treatment for neuroprotection in ischemic diseases of the brain. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2013; 5:6. [PMID: 23618347 PMCID: PMC3642016 DOI: 10.1186/2040-7378-5-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 04/21/2013] [Indexed: 01/01/2023]
Abstract
This article reviews experimental and clinical data on the use of magnesium as a neuroprotective agent in various conditions of cerebral ischemia. Whereas magnesium has shown neuroprotective properties in animal models of global and focal cerebral ischemia, this effect could not be reproduced in a large human stroke trial. These conflicting results may be explained by the timing of treatment. While treatment can be started before or early after ischemia in experimental studies, there is an inevitable delay of treatment in human stroke. Magnesium administration to women at risk for preterm birth has been investigated in several randomized controlled trials and was found to reduce the risk of neurological deficits for the premature infant. Postnatal administration of magnesium to babies after perinatal asphyxia has been studied in a number of controlled clinical trials. The results are promising but the trials have, so far, been underpowered. In aneurysmal subarachnoid hemorrhage (SAH), cerebral ischemia arises with the onset of delayed cerebral vasospasm several days after aneurysm rupture. Similar to perinatal asphyxia in impending preterm delivery, treatment can be started prior to ischemia. The results of clinical trials are conflicting. Several clinical trials did not show an additive effect of magnesium with nimodipine, another calcium antagonist which is routinely administered to SAH patients in many centers. Other trials found a protective effect after magnesium therapy. Thus, it may still be a promising substance in the treatment of secondary cerebral ischemia after aneurysmal SAH. Future prospects of magnesium therapy are discussed.
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Affiliation(s)
- Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Nadine Willner
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Furat Raslan
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
| | - Giles H Vince
- Department of Neurosurgery, Klinikum Klagenfurt, Feschnigstraße 11, Klagenfurt am Wörthersee 9020, Austria
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, Würzburg 97080, Germany
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Kim SY, El-Dib M, Ahmad T, Aly H. Baseline serum magnesium concentrations and neurodevelopmental outcomes of extremely low birth weight premature infants. Early Hum Dev 2013; 89:239-42. [PMID: 23453362 DOI: 10.1016/j.earlhumdev.2013.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/30/2013] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
AIM To test the hypothesis that, in ELBW infants who did not receive antenatal MgSO4, lower baseline serum Mg is associated with poorer neurodevelopmental outcomes (NDO). STUDY DESIGN The study was conducted in two phases: phase 1-- retrospective, and phase 2--prospective. SUBJECTS Extremely low birth weight infants. OUTCOME MEASURES Mortality and adverse NDO were assessed in relation to initial serum Mg measured in the first 12 hours of age. RESULTS We studied 156 ELBW infants. In phase 1 (n=102): initial serum Mg (median [IQ range]) was greater in the infants who died compared to those who survived (1.7 [1.5-2.2] mg/dL vs. 1.6 [1.4-1.7] mg/dL, p=0.034). In phase 2 (n=54): initial serum Mg was greater in infants who died or had adverse NDO at 9 months when compared to those who survived with better NDO (1.7 [1.55-2.1] mg/dL vs. 1.5 [1.4-1.68] mg/dL, p=0.008). Using receiver operating characteristic (ROC) curve, increased Mg concentration in the first 12 hours>1.6 mg/dL was associated with unfavorable outcomes with sensitivity of 73%, specificity of 67%, and odds ratio of 5.5 (CI=1.2-24.8, p=0.037). CONCLUSIONS In a cohort of preterm infants without antenatal exposure to MgSO4, initial serum Mg concentrations associated positively with poor outcomes. Further studies are needed in ELBW infants with poor NDO to determine whether they have a dysfunctional transport system that prevents Mg from entering into cells, or they have an active process that excretes Mg extracellularly.
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Affiliation(s)
- Susan Y Kim
- Department of Neonatology, the George Washington University and Children's National Medical Center, Washington, DC, USA
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Paradisis M, Osborn DA, Evans N, Kluckow M. Randomized controlled trial of magnesium sulfate in women at risk of preterm delivery-neonatal cardiovascular effects. J Perinatol 2012; 32:665-70. [PMID: 22094492 DOI: 10.1038/jp.2011.168] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Use of antenatal magnesium sulfate (MgSO(4)) may reduce cerebral palsy in infants born very preterm. Low systemic blood flow in the first day in very preterm infants has been associated with cerebral injury and adverse motor outcome. The aim was to determine the effect of MgSO(4) on systemic blood flow in preterm infants. STUDY DESIGN Randomized trial of MgSO(4) versus saline placebo given to mothers at risk of delivery before 30 weeks gestation. Echocardiographic monitoring performed at 3 to 5, 10 to 12 and 24 h. RESULT A total of 48 infants were exposed to MgSO(4) and 39 to placebo. Infants exposed to MgSO(4) were significantly more likely to receive volume expansion (42% versus 21%). Inotrope use did not differ significantly (40% versus 26%). There was no significant difference in mean lowest superior vena cava (SVC) flow or right ventricular output (RVO), or incidence of low SVC flow or RVO in the first 24 h. Infants exposed to MgSO(4) had a significantly higher heart rate and were more likely to have low SVC flow at 10 to 12 h but not other times. CONCLUSION Antenatal MgSO(4) produced no consistent cardiovascular effects in the infant in the first 24 h. There is no evidence from this study to suggest the mechanism by which antenatal MgSO(4) prevents cerebral palsy is through a cardiovascular effect in the newborn.
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Affiliation(s)
- M Paradisis
- Department of Neonatal Medicine, Royal North Shore Hospital, Sydney, Australia
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Abstract
Magnesium sulfate (MgSO4) has been widely used in the perinatal arena for many decades. It has been used for tocolysis in the U.S. for more than 60 years. Estimations of MgSO4 use for preterm labor (less than 34 weeks of gestation) run as high as 80 percent. Magnesium sulfate is a smooth, skeletal, and cardiac muscle depressant. It is used for preterm labor because of its potential to decrease muscle contractility by interfering with calcium uptake in the cells. Thousands of moms and babies have been exposed to this medication even though tocolysis remains an off-label use, the exact mechanism of action is not completely understood, and there are studies that show that it is ineffective for this indication, and no evidence that it improves perinatal outcomes.1-3 Additionally, it is a high alert medication because of its narrow therapeutic window and the risk of causing an immediate life-threatening condition (acute respiratory failure) if an error in administration occurs.4.
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Cottrell JE, Hartung J. Developmental Disability in the Young and Postoperative Cognitive Dysfunction in the Elderly After Anesthesia and Surgery: Do Data Justify Changing Clinical Practice? ACTA ACUST UNITED AC 2012; 79:75-94. [DOI: 10.1002/msj.21283] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Blanco D, García-Alix A, Valverde E, Tenorio V, Vento M, Cabañas F. [Neuroprotection with hypothermia in the newborn with hypoxic-ischaemic encephalopathy. Standard guidelines for its clinical application]. An Pediatr (Barc) 2011; 75:341.e1-20. [PMID: 21925984 DOI: 10.1016/j.anpedi.2011.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 01/24/2023] Open
Abstract
Standardisation of hypothermia as a treatment for perinatal hypoxic-ischaemic encephalopathy is supported by current scientific evidence. The following document was prepared by the authors on request of the Spanish Society of Neonatology and is intended to be a guide for the proper implementation of this therapy. We discuss the difficulties that may arise when moving from the strict framework of clinical trials to clinical daily care: early recognition of clinical encephalopathy, inclusion and exclusion criteria, hypothermia during transport, type of hypothermia (selective head or systemic cooling) and side effects of therapy. The availability of hypothermia therapy has changed the prognosis of children with hypoxic-ischaemic encephalopathy and our choices of therapeutic support. In this sense, it is especially important to be aware of the changes in the predictive value of the neurological examination and the electroencephalographic recording in cooled infants. In order to improve neuroprotection with hypothermia we need earlier recognition of to recognise earlier the infants that may benefit from cooling. Biomarkers of brain injury could help us in the selection of these patients. Every single infant treated with hypothermia must be included in a follow up program in order to assess neurodevelopmental outcome.
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Affiliation(s)
- D Blanco
- Servicio de Neonatología, Hospital Universitario Gregorio Marañón, Madrid, España.
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Gathwala G, Khera A, Singh J, Balhara B. Magnesium for neuroprotection in birth asphyxia. J Pediatr Neurosci 2011; 5:102-4. [PMID: 21559152 PMCID: PMC3087983 DOI: 10.4103/1817-1745.76094] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Magnesium ion gates the N-methyl-D-aspartate (NMDA) receptor and may protect the brain from NMDA receptor-mediated asphyxial injury. The present study evaluated the neuroprotective role of magnesium in birth asphyxia. Material and Methods: Forty term neonates with severe birth asphyxia were randomized to either the study group or the control group. Neonates in the study group received magnesium sulfate in a dose of 250 mg/kg initially within half an hour of birth followed by 125 mg/kg at 24 and 48 h of birth. Cranial computed tomography (CT) scan and electroencephalography (EEG) were performed for all the babies. Denver II was used for developmental assessment at the age of 6 months. Results: Two babies in each group died of severe hypoxic ischemic encephalopathy. EEG abnormalities occurred in 43.75% of the cases in the control group compared with 31.25% in the study group. CT scan abnormalities were present in 62.5% of the control group compared with 37.5% of the cases in the study group. The Denver II assessment at 6 months revealed that there were five babies that were either abnormal or suspect in the control group compared with three in the study group. Conclusion: Magnesium is well tolerated and does appear to have beneficial effects in babies with severe asphyxia. More data is however needed and a large multicenter trial should be conducted.
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Affiliation(s)
- Geeta Gathwala
- Department of Pediatrics, Neonatal Services Division, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India
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Characterization of a rat hypoxia-ischemia model where duration of hypoxia is determined by seizure activity. J Neurosci Methods 2011; 197:92-6. [DOI: 10.1016/j.jneumeth.2011.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 01/29/2011] [Accepted: 02/02/2011] [Indexed: 11/20/2022]
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Boog G. [Cerebral palsy and perinatal asphyxia (II--Medicolegal implications and prevention)]. ACTA ACUST UNITED AC 2011; 39:146-73. [PMID: 21354846 DOI: 10.1016/j.gyobfe.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 01/18/2023]
Abstract
Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.
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Affiliation(s)
- G Boog
- Service de gynécologie-obstétrique, hôpital Mère-et-Enfant, CHU de Nantes, 38 boulevard Jean-Monnet, Nantes cedex 1, France.
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Abstract
The current article covers some of the major themes that emerged in 2009 in the fields of obstetric anesthesiology, obstetrics, and perinatology, with a special emphasis on the implications for the obstetric anesthesiologist.
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Affiliation(s)
- J M Mhyre
- Department of Anesthesia, Division of Obstetric Anesthesia, Women's Hospital, University of Michigan Health System, Ann Arbor, MI 48109-5278, USA.
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Rao S, Bartle D, Patole S. Current and future therapeutic options for persistent pulmonary hypertension in the newborn. Expert Rev Cardiovasc Ther 2010; 8:845-62. [PMID: 20528642 DOI: 10.1586/erc.09.186] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a potentially life-threatening condition that is characterized by supra-systemic pulmonary vascular resistance causing right-to-left shunting through the ductus arteriosus and/or foramen ovale, leading to a vicious cycle of hypoxemia, acidosis and further pulmonary vasoconstriction. Advances in neonatology including surfactant instillation, high-frequency ventilation, extracorporeal membrane oxygenation and, most importantly, inhaled nitric oxide (INO), have revolutionized the management of PPHN. However, given that INO does not improve oxygenation in a significant proportion (30-40%) of cases, there is an urgent need to consider other therapeutic options for PPHN. The issue is more important for developing nations with a higher PPHN-related health burden and limited resources. This article discusses the evidence about INO in term and preterm neonates in brief, and focuses mainly on the potential alternative drugs in the management of PPHN.
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Affiliation(s)
- Shripada Rao
- Department of Neonatal Paediatrics, KEM Hospital for Women, Bagot road, Subiaco, Perth 6008, Western Australia, Australia
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Magnesium sulfate treatment alters fetal cerebellar gene expression responses to hypoxia. Int J Dev Neurosci 2009; 28:207-16. [PMID: 19903518 DOI: 10.1016/j.ijdevneu.2009.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/01/2009] [Accepted: 11/02/2009] [Indexed: 11/20/2022] Open
Abstract
Prenatal perturbation of brain circulation and oxygenation is a leading cause of perinatal brain damage affecting about 0.3-0.9% of births. Hypoxia-ischemia (HI) in preterm human infants at gestational week 23-32 results in neurodevelopmental abnormalities in childhood, presenting as learning disability, seizure activity, motor impairment and in the most severe cases, death. Here, we examined the potential of MgSO4 treatment, prior to foetal hypoxia, to attenuate hypoxia induced damage in a murine model of maternal hypoxia. We studied the time course of maternal hypoxia and MgSO4 pre-treatment effects on cerebellar tissue by means of DNA microarray analyses. Mild hypoxia induced minor expression changes in most genes. However, there were 5 gene sets which were down-regulated by maternal hypoxia. MgSO4 pre-treatment abrogated these decreases in gene. A cell cycle gene set which responded immediately (2 h) to hypoxia, showed a delayed response (24 h) when MgSO4 pre-treatment was given. Similar proportions of cell death were observed in all groups before P7, where combined hypoxia and MgSO4 treatment increased cell death in the internal granule layer. There were a higher number of BrdU positive cells at the end of hypoxic episodes and a down-regulation of Reelin signaling, compared to control. MgSO4 pre-treatment prevented the enhancement of cell proliferation due to hypoxia and increased Reelin levels. Altogether, MgSO4 pre-treatment both reduced the number of genes differentially affected by hypoxia and delayed the responses to hypoxia. In addition, MgSO4 pre-treatment modified the nature of the transcriptional response; while hypoxia induced down-regulation of gene sets, MgSO4 pre-treatment mostly up-regulated them. The dual reaction to the MgSO4 treatment may be the source of the ambiguity in observations reported for affected newborns.
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