Effect of persistent pulmonary hypertension on brain oxygenation in asphyxiated term newborns treated with hypothermia

Objective: To better understand the impact of persistent pulmonary hypertension (PPHN) on brain oxygenation in term asphyxiated newborns treated with hypothermia.

Methods: The regional cerebral oxygenation saturation (rSO₂) measured by near-infrared spectroscopy was compared to pre/post-ductal oxygen saturation and mean arterial blood pressure in three term asphyxiated newborns with documented PPHN during their first 4 days of life while they were being treated with hypothermia.

Results: The cerebral oxygen saturation remained relatively stable when oxygen saturation was more than 92% and when there was no difference between pre- and post-ductal oxygen saturations. Episodes of desaturations with a difference between pre- and post-ductal saturations, as well as episodes of hypotension, caused a significant decrease in rSO₂ in these newborns.

Conclusion: This case series demonstrates that PPHN has a profound impact on brain oxygenation in term asphyxiated newborns treated with hypothermia during the first days of life after birth. PPHN may represent an additional risk factor for brain injury in these newborns during the first days of life.     

Strategies for reducing the incidence of skin complications in newborns treated with whole-body hypothermia

Objective: To present the results of a strategy designed to reduce the incidence of skin complications in newborns with hypoxic–ischemic encephalopathy treated with moderate whole-body hypothermia. Design: Retrospective study. Setting: Neonatal Intensive Care Unit (NICU). Patients: Thirty-nine neonates cooled in the considered period. Intervention: Starting from January 2008, for neonates treated with moderate whole-body hypothermia (33.5 °C), the cooling system was set in “automatic servo-controlled mode (ACM)”, where the temperature of the circulating water could vary between 4 °C and 42 °C. Starting from January 2009, cooling blankets were used in another type of automatic mode, the “gradient variable mode (GVM)”, where the circulating water was maintained at a specific pre-set gradient towards the patient’s body temperature, and a specific nursing protocol (NP) was adopted. Measurements and main results: Two of the eleven newborns treated with the “ACM” exhibited skin complications compatible with subcutaneous fat necrosis (SFN). None of the twenty-eight newborns treated with the “GVM” exhibited skin complications. A comparison of the biochemical and hematological data between these two groups revealed that newborns treated after the adopting of a NP and the “GVM” showed lower serum protein C and calcium levels, and higher platelet levels. Conclusions: Our data suggest that newborns undergoing therapeutic cooling may benefit from a specific NP and correct cooling unit setting. Should further studies confirm our data, this nursing approach could be easily adopted.     

Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy: magnetic resonance imaging findings and neurological outcomes in a Brazilian cohort

Objective: To determine the neurodevelopment outcomes after therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy (HIE) and identify the neonatal magnetic resonance imaging (MRI) findings associated with neurological outcome in a middle-income country.

Study design: All infants born after 35 completed weeks’ gestation with signs of moderate to severe encephalopathy and evidence of perinatal asphyxia before 6?hours of life were submitted to whole-body hypothermia and were imaged at 18?±?8.4 days of life (range 7–33 days) after birth. Surviving infants had the neurodevelopment outcome assessed at 12 to 18 months of age by trained professional masked to MRI findings.

Results: Forty-eight infants included, MRI scans were obtained from 34 infants; 14 (29.1%) patients died during hospitalization before MRI was performed. Nine (64.3%) of 14 patients were classified as severe encephalopathy presented Posterior Limb Internal Capsule (PLIC) sign at the MRI, 10 (71.4%) thalamus and basal ganglia (TBG) lesion, 9 (64.3%) white matter (WM) lesion, and 7 (50.0%) cortical lesion. Severe encephalopathy was associated with the motor delay at 12–18 months by Bayley III, Alberta Infant Motor Scale (AIMS), and Gross Motor Function Classification System (GMFCS) scores (p?=?.020, p?=?.048, p?=?.033, respectively), but not for the cognitive (p?=?.167) or language skills (p?=?.309). Lower BSID-III motor, cognitive, and language composite scores were associated with PLIC sign (p?=?.047; p?=?.006 and p?=?.003, respectively). TBG lesion (p?=?.051) and cortical lesion (p?=?.030) were associated with lower language composite score. Motor delay by AIMS and the presence of PLIC sign, TBG lesion, WM lesion, and Cortical lesion on MRI were observed (p?p?=?.002; p?=?.001 and p?=?.027, respectively); as well as higher GMFCS score were associated with the presence of PLIC sign, TBG lesion, WM lesion, and Cortical lesion on MRI (p?p?=?.001; p?=?.001, and p?=?.011, respectively).

Conclusions: Brain MRI in neonates with HIE after therapeutic hypothermia is a valuable tool for diagnosis of encephalopathy cerebral abnormalities and is an early predictor of outcome in infants treated with whole body hypothermia for HIE in the Brazilian experience.     

Review of the first 1502 cases of ECG-ST waveform analysis during labour in a teaching hospital

Objective  To assess the impact of introduction of the STAN monitoring system.
Study design  Prospective observational study.
Setting  Tertiary referral labour ward, St George's Hospital, London.
Population  High-risk term pregnancies.
Methods  We report all consecutive cases of intrapartum monitoring using the STAN S 21 fetal heart monitor. Cases with adverse neonatal outcome were evaluated in relation to the ST waveform analysis and cardiotocography (CTG).
Main outcome measures  Cord artery metabolic acidosis, neonatal encephalopathy (NNE) and reasons behind cases with poor outcome.
Results  Between 2002 and 2005, there were 1502 women monitored by STAN. Based on combined STAN analysis in the 1502 women, action was indicated in 358 women (23.8%), while in 1108 women (73.8%) no action was indicated. Traces were not interpretable in 36 women (2.4%). Of the 836 cases (55.7%) where cord blood gases were available, there were 23 cases (2.8%) of metabolic acidosis and 16 of these (70%) were identified by STAN. Overall, there were 14 cases of NNE monitored by STAN. Retrospective analysis of these highlights human errors, such as poor CTG interpretation, delay in taking appropriate action and not following the guidelines.
Conclusions  Our experience suggests the need for more intense training on interpretation of CTG and strict adherence to guidelines.     

Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI): a feasibility study

Purpose: To investigate the feasibility of a study based on treatment with topiramate (TPM) added to moderate hypothermia in newborns with hypoxic ischemic encephalopathy (HIE).

Materials and methods: Multicenter randomized controlled trial. Term newborns with precocious metabolic, clinical and electroencephalographic (EEG) signs of HIE were selected according to their amplified integrated EEG pattern and randomized to receive either TPM (10?mg/kg once a day for the first three days of life) plus moderate hypothermia or hypothermia alone. Safety was assessed by monitoring cardiorespiratory parameters and blood samples collected to check renal, liver, metabolic balance and TPM pharmacokinetics. Efficacy was evaluated by the combined frequency of mortality and severe neurological disability as primary outcome. Incidence of magnetic resonance injury, epilepsy, blindness, hearing loss, neurodevelopment at 18–24 months of life was assessed as secondary outcomes.

Results: Forty-four asphyxiated newborns were enrolled in the study. Twenty one newborns (10 with moderate and 11 with severe HIE) were allocated to hypothermia plus TPM and 23 (12 moderate and 11 severe HIE) to hypothermia. No statistically or clinically significant differences were observed for safety, primary or secondary outcomes. However, a reduction in the prevalence of epilepsy was observed in newborns co-treated with TPM.

Conclusions: Results of this pilot trial suggest that administration of TPM in newborns with HIE is safe but does not reduce the combined frequency of mortality and severe neurological disability. The role of TPM co-treatment in preventing subsequent epilepsy deserves further studies.     

Spontaneous regression of intralobar pulmonary sequestration during the pregnancy: report of two cases through relationships between mass and fetal biometry and review of the literature

Intralobar pulmonary sequestration is a rare bronchopulmonary malformation consisting of a non-functioning lung mass that receives its arterial blood supply from systemic circulation and that does not adequately communicate with the tracheobronchial tree through a normal bronchus. These sequestrations account for 1.1–1.8% of all lung resections. Herein we present two clinical cases with a prenatal diagnosis of pulmonary sequestration using ultrasound and magnetic resonance imaging. Pulmonary images indicated a progressive decrease in the size and echogenicity of the lung mass with fetal growth, resulting in asymptomatic neonates with normal chest radiographs. We emphasize the importance of combining imaging examinations with follow-up by a multidisciplinary team working in a center specialized in maternal–fetal medicine. For the successive monitoring of the size of the lung tissue mass, we propose the calculation of the following two biometric ratios that are not yet described in the literature: mass area/head circumference and mass volume/estimated fetal weight. The second ratio was similar in both cases, a result which suggests its potential for use in estimating the probability of the spontaneous regression of intralobar pulmonary sequestration.     

The relationship between some neonatal and maternal factors during pregnancy with the prevalence of congenital malformations in Iran: a systematic review and meta-analysis

Introduction: Congenital malformations are one of the main causes of death and disability in children. These malformations arise during embryogenesis and fetal development during pregnancy due to exposure to some environmental factors and genetic mutations. Given the high prevalence of congenital malformations in Iran, the current study was conducted to investigate the relationship between some neonatal and maternal factors during pregnancy with the prevalence of congenital malformations in Iran.

Methods: This was a systematic review and meta-analysis study. All studies conducted in Iran were extracted between 2000 and 2016 during a search in internal and external databases of Medlib, Medline, Pubmed, Web of Science, Google Scholar, Scopus, Magiran, SID, Cochrane, Irandoc, and all articles published. Then, the required data were entered into the Spss16 software (SPSS Inc., Chicago, IL); and the model of fixed and random effects was analyzed in meta-analysis, Cochran, meta-regression using statistical tests.

Results: A total of 30 studies with a sample size of 928,311 patients were enrolled. Baby’s gender (1–1.55: CI95%) OR: 1.25, preterm delivery (1.71–3.69: CI 95%) OR: 2.51, low birth weight (1.13–2.67: CI95%) OR: 1.74, age older than 35 for the pregnant mother (1.41–6.3: CI 95%) OR: 2.98, multiple births (1.14–3.46: CI 95%) OR: 1.99, mother suffering from chronic diseases (1.68–3.31: CI 95%) OR: 2.36 are significantly related with the risk of congenital malformations.

Conclusion: Based on the results the baby’s gender, premature birth, low birth weight, mother’s age, consanguineous marriages, multiple births, family history of congenital malformations, and the risk of chronic diseases in the mother during pregnancy increase the birth of children with congenital malformations. As a result, control or modification of the above factors implementing a health and education intervention program can reduce the birth of children with congenital malformations.     

Lumbar epidural analgesia with bupivacaine in labor. Drug concentration in maternal and neonatal blood at birth and during the first day of life.

Lumbar epidural analgesia with bupivacaine was administered to 33 women for relief of pain during labor. At delivery blood samples were drawn from the umbilical cord vessels and from a maternal peripheral vein. Blood samples were also collected from the noenate and its mother, 1, 4, and 20 hours after delivery. Analyses of bupivaccaine concentrations were carried out in all samples with a gas-chromatographic technique. The drug concentration in the umbilical vein (UV) was usually higher than the corresponding umbilical artery value (UA), but with increasing time interval between the last bupivaccaine infection and delivery the UA/UV drug concentration ratio rose. After delivery the rate of drug decline in blood was similar in mother and newborn infant. The clinical condition of the infant was unrelated to the drug concentration in the umbilical cord vessels.     

Impact of operator experience on the variability of fetal lung volume estimation by 3D-ultrasound (VOCAL) and magnetic resonance imaging in fetuses with congenital diaphragmatic hernia

Objective: To evaluate the impact of operator experience in volumetric measurements on intra- and inter-observer variability of lung volume estimation by 3-dimensional (3D) ultrasound and magnetic resonance imaging (MRI) in fetuses with congenital diaphragmatic hernia (CDH).

Methods: We conducted a retrospective single-center study. Total fetal lung volume (TFLV) was measured twice using 52 stored 3D-ultrasound volumes and 52 corresponding MRI exams by a fetal medicine specialist with no experience in volumetric measurements and two operators experienced in the respective techniques. Bland–Altman analysis was performed to evaluate intra- and inter-observer variability.

Results: Measurements of TFLV by 3D-ultrasound showed higher intra-observer variability compared with MRI irrespective of operator experience, with narrower 95% limits of agreement on MRI as compared with ultrasound measurements. Similarly, 3D-ultrasound showed higher inter-observer variability as compared with MRI. Finally the 95% limits of agreement at ultrasound were quite comparable for intra-observer variability between the experienced and the inexperienced operator.

Conclusion: Our study shows that operator experience has an impact on the variability of TFLV and, in the absence of experience in volumetric measurements, estimation of TFLV in fetuses with CDH by 3D-ultrasound shows higher variability than MRI measurements, but even in experienced hands variability is greater for 3D-ultrasound.