Superior vena cava flow and intraventricular haemorrhage in extremely preterm infants

Objective: To evaluate the relationship between superior vena cava flow (SVCF) measurements within the first 24?h of life, and development of intraventricular haemorrhage (IVH) in extremely preterm infants.

Study design: Single centre retrospective cohort study of 108 preterm infants born less than 28 weeks’ gestation. Main outcome measure was degree of IVH at day 7 postnatal age.

Results: The mean GA of the study group was 25.4 weeks. Mean SVCF was lower (75?ml/kg/min) in infants later diagnosed with IVH (n?=?46) compared to infants, who did not develop IVH (87.7?ml/kg/min, p?=?0.055). PDA diameter was inversely associated with SVCF (p?=?0.024) and reversal of flow in the descending aorta (p?=?0.001). Sensitivity analysis did not confirm an independent association of SVCF with development of IVH [OR 0.990 (0.978–1.002), p?=?0.115].

Conclusion: Our study describes early SVCF in extremely preterm infants is associated with the extent of ductal shunting, but insensitive in predicting IVH.     

Neurodevelopmental outcome of extremely premature infants exposed to incomplete,no or complete antenatal steroids

Abstract

Objective: To compare the neurodevelopmental outcomes at 18–22 months’ corrected age of extremely premature infants exposed to a complete course, an incomplete course or no dose of antenatal steroids (ANS).

Methods: Retrospective chart review of extremely premature (<28 weeks gestational age) neonates over a 3-year period. Neurodevelopmental assessment at 18–22 months’ corrected age included a standardized neurologic examination and the Bayley Scales of Infant and Toddler development II or III. Intact survival was defined as survival without cerebral palsy (CP), blindness or deafness and mental developmental index (MDI)/cognitive score ≥85. Neurodevelopmental impairment (NDI) was defined as any of the following: moderate or severe CP, MDI/cognitive score <70, deafness or blindness. Patients were categorized into three groups: (A) no ANS; (B) incomplete course and (C) complete course of ANS.

Results: Outcome data were available for 134 (88%) patients of our cohort (n?=?153). Severe intraventricular hemorrhage (IVH) was significantly lower and intact survival was higher in the complete ANS group (p?<?0.01). On logistic regression, with gestational age, gender, maternal insurance and ANS exposure as covariates, an incomplete (versus complete) course of ANS (p?=?0.006) and gestational age were significantly associated with lower intact survival at 18–22 months.

Conclusions: A complete course of ANS was associated with an increased likelihood of intact survival at a corrected age of 18–22 months among extremely premature infants, compared with an incomplete course. Follow-up studies should account for the differential benefit of complete versus incomplete course of ANS administration.     

Impact of oral probiotics on neurodevelopmental outcomes in preterm infants

Objective: The aim of the study was to evaluate the neurodevelopment outcomes of very low birth weight (VLBW) preterm infants supplemented with oral probiotics for the prevention of necrotizing enterocolitis (NEC).

Methods: A prospective follow-up study was performed in a cohort of VLBW preterm infants enrolled in a single center randomized controlled clinical trial to evaluate the efficacy of oral probiotics for the prevention of NEC. Cognitive and neuromotor developments were assessed by using the Bayley scales of infant development II. Sensory and neurological performance was evaluated by standard techniques. The primary outcome was neurodevelopmental impairment at 18–24 months’ corrected age.

Results: A total of 400 infants completed the trial protocol. Of the 370 infants eligible for follow-up, 249 infants (124 in the probiotics group and 125 in the control group) were evaluated. There was no significant difference in any of the neurodevelopmental and sensory outcomes between the two groups.

Conclusion: Oral probiotic given to VLBW infants to reduce the incidense and severity of NEC started with the first feed did not affect neuromotor, neurosensory and cognitive outcomes at 18–24 months’ corrected age.     

绝经激素治疗与心血管疾病

绝经增加了绝经后女性患心血管疾病的风险,绝经激素治疗（MHT）不仅能有效缓解更年期血管舒缩等症状,还可以改善心血管疾病发展的中间指标,从而减少围绝经期女性心血管疾病的发生。目前多项临床研究结果表明,对绝经后10年内和60岁以下健康女性在围绝经期开始MHT,心血管疾病发生率和死亡率有所下降。目前缺少MHT能够改善已确诊的心脏疾病的最终证据,不推荐MHT用于心血管疾病的一级预防,也不应用于冠心病的二级预防。     

Effect of multiple INSURE procedures in extremely preterm infants

Abstract

Objectives.?Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants.

Methods.?We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO₂?>?0.30 without need of MV) or multiple (FiO₂?>?0.40 without need of MV) INSURE procedures.

Results.?Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO₂, lower a/ApO₂, and pO₂/FiO₂) than the former.

Conclusions.?Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.     

Method of delivery and intraventricular haemorrhage in extremely preterm infants

Objectives.?It has been reported that caesarean delivery (CD) protects against intraventricular haemorrhage (IVH) in the extremely preterm infant, but it is not known whether this effect involve the more severe grades of IVH. Thus, our aim was to confirm the correlation between the occurrence of IVH and the mode of delivery, and to evaluate this correlation for each grade of IVH.

Methods.?All infants with gestational age (GA)?≤?28 weeks admitted to the neonatal intensive care unit of a tertiary hospital were studied for each grade IVH and major complications rate.

Results.?We found that vaginally born infants had a higher rate of each grade of IVH, but the increase was statistically significant only for grade 3 IVH (18% vs. 2%, p?<?0.0001) and all grades IVH (45% vs. 20%, p?<?0.0001). Multivariate analysis demonstrated that CD (RR: 0.42, 95% CI 0.28–0.63), birth weight?≥?800?g (RR: 0.48, 95% CI 0.32–0.73), 27–28 weeks of GA (RR: 0.38, 95% CI 0.25–0.60) and antenatal steroids (0.66, 95% CI 0.22–0.46) decrease independently the risk of developing IVH.

Conclusions.?Our study demonstrates that CD decreases the risk of developing IVH in extremely preterm infants including the most severe grades of IVH.     

Outcomes of preterm premature rupture of membranes in twin pregnancies

Objective. To describe outcomes in twin pregnancies with preterm premature rupture of membranes (PPROM).

Methods. Dichorionic twin pregnancies complicated by PPROM at <34 weeks of gestation for the period 2003 to 2006 were identified. Outcomes were obtained through chart review. The relationship between gestational age at premature rupture of membranes (PROM), latency from PROM to delivery, and infection were examined.

Results. In 49 twin pregnancies, the median gestational age at PROM was 31 weeks with a median latency between PROM and delivery of 0 days (interquartile range 0–6). Latency intervals of ≥2 and ≥7 days were achieved by 40.8% and 22.4%, respectively. PPROM at <30 weeks was associated with significantly higher rates of latency of ≥ 2 days (70.6% vs. 25.0%) and ≥7 days (47.1% vs. 9.4%). There was a significant relationship between latency and clinical and histologic signs of infection.

Conclusions. After 30 weeks, most twin pregnancies with PPROM delivered within 2 days. Infection appears to be a consequence rather than a cause of PPROM in most cases.     

Outcomes after expectant management of extremely preterm premature rupture of the membranes

OBJECTIVE: This study was undertaken to assess contemporary outcomes in pregnancies managed expectantly after extremely preterm premature (< or =24 weeks) premature rupture of the membranes (EPPROM). STUDY DESIGN: We queried antepartum and ultrasound databases for patients with EPPROM. Data on pregnancy outcome and short-term neonatal outcomes were collected. RESULTS: Forty-six patients with EPPROM were studied. Patients were hospitalized at 24 weeks' gestation and given antibiotics and antenatal steroids. Median gestational age at PPROM was 22.0 weeks (range 16.9-24 weeks); 43 (93%) elected expectant management, 2 of whom later had an intrauterine fetal death. Median latency period to delivery was 13 days (range 0-96 days), with mean gestational age at delivery of 25.8+/-3.4 weeks. Overall survival was 47% (27 of 57 infants), after a median hospital stay of 71 days (range 17-209 days). Ten (37%) of the survivors have serious sequelae. CONCLUSION: Although significant pregnancy prolongation after previable PPROM occurs in many cases, neonatal outcomes remain poor.     

Periodontal disease and bacterial vaginosis as genetic and environmental markers for the risk of spontaneous preterm labor and preterm birth

Objective.?The aim of this study was to review the evidence associating periodontal disease, and bacterial vaginosis with preterm birth, and the link with gene polymorphism, as well as the preventions and interventions which might reduce the risk of spontaneous preterm labor and preterm births in women with periodontal disease and/or bacterial vaginosis.

Background.?Preterm birth accounts for 70% of perinatal mortality, nearly 50% of long term neurological morbidity, and a significant impact on health care costs. There is evidence that spontaneous preterm labor and preterm birth are associated with intrauterine infection due to abnormal genital and/or oral colonization. Periodontal disease and bacterial vaginosis share microbiological similarities, and both conditions are associated with spontaneous preterm labor and preterm birth. In addition, periodontal disease and bacterial vaginosis have been linked through gene polymorphism.

Methods.?A review of the literature using widely accepted scientific search engines in English language.

Results.?Studies evaluating antibiotic administration to eradicate periodontal disease and/or bacterial vaginosis responsible organisms, and minimize the risk of preterm births have yielded conflicting results. With respect to bacterial vaginosis, the timing and the choice of antibiotic administration might partly explain the conflicting results. The use of scaling and/or root planning for women with periodontal disease appears to reduce the risk of preterm birth, but routine administration of antibiotics has not demonstrated any impact on preterm birth.

Conclusion.?Prospective studies evaluating the association of gene polymorphism with preterm birth, and the contribution of periodontal disease and bacterial vaginosis are needed.     

Effect of Kangaroo mother care in reducing pain due to heel prick among preterm neonates: a crossover trial

Abstract

Background: Preterm neonates undergo several painful procedures in NICU including heel prick for blood sugar monitoring. Nonpharmacological interventions have been tried to decrease this procedural pain. There are only few studies on Kangaroo mother care (KMC) in reducing pain among preterm neonates.

Method: This crossover trial was conducted at a tertiary care teaching hospital in south India. Premature Infant Pain Profile (PIPP) related to heel prick was assessed in 50 preterm neonates undergoing KMC and compared with 50 preterm babies without KMC.

Results: PIPP scores at 15 minutes and 30 minutes after heel prick were significantly less in KMC group compared to control group. Mean PIPP difference between baseline and 30 minutes after heel prick was also significantly low in KMC group compared to control group.

Conclusion: KMC is effective in reducing pain due to heel prick among preterm babies.     

Difficulties in establishing routine amniocentesis for preterm labor evaluation

After a recent practice change implementing amniocentesis into the evaluation of preterm labor (PTL) or preterm premature rupture of membranes (PPROM), actual performance of the procedure was tracked. Fifty-nine patients were admitted with these diagnoses. Twenty-three patients (39%) were offered amniocentesis and 36 patients (61%) were not offered amniocentesis as part of the clinical protocol. Seven (30%) patients of those offered an amniocentesis underwent the procedure. The predominant reasons for not performing an amniocentesis were patient refusal and provider discomfort. In conclusion, implementation of amniocentesis to evaluate for subclinical infection/inflammation in the setting of PTL or PPROM proved difficult, as only 7 of 59 (11.9%) patients admitted with these diagnoses actually received an amniocentesis.     

Fetal sex and indicated very preterm birth: results of the EPIPAGE study

OBJECTIVE: This study was undertaken to explore the association between fetal sex, mode of onset of labor, and principal cause of very preterm birth.Study design The analysis uses data on 2624 very preterm singleton births less than 33 weeks' gestation from a prospective study of all very preterm births in 9 French regions in 1997. RESULTS: Fifty-seven percent of the spontaneous births were male versus 50.8% of births after medical decision (P=.005). This pattern was explained by sex differences in causes of preterm birth. Male infants had a greater incidence of very preterm birth after spontaneous labor (relative risk [RR]=1.42 [1.21-1.66]), but one third less risk of indicated preterm birth associated with hypertension both with and without growth restriction (RR=0.73 [0.55-0.97] and 0.77 [0.60-0.97]). CONCLUSION: These results support previous reports of greater male susceptibility to preterm labor. The finding that pregnancies carrying female infants have a greater predisposition to indicated very preterm birth associated with hypertension has not been reported previously and merits further study.     

Association between antenatal corticosteroids and neonatal hypoglycemia in indicated early preterm births*

Purpose: We sought to determine if administration of antenatal corticosteroids in early preterm births (<34 weeks) is associated with an increased risk of developing neonatal hypoglycemia (<40?mg/dL) within the first 48?h of neonatal life.

Materials and methods: Retrospective cohort of all indicated singleton preterm births (23?34 weeks) in a single tertiary center from 2011 to 2014. The primary outcome was neonatal hypoglycemia (<40?mg/dL) within the first 48?h of life. The outcome was compared by antenatal corticosteroids received at any point during the gestation, within 2–7 d of delivery, and whether the patient received a partial, full, or repeat course of antenatal corticosteroids. Logistic regression was used to adjust for confounders.

Results: Six hundred thirty-five patients underwent an indicated preterm birth during the study period. Six hundred and four (95%) received antenatal corticosteroids prior to delivery and 31 (5%) did not. The incidence of neonatal hypoglycemia within 48?h of life was not significantly different between those who received any antenatal corticosteroids and those who did not (23.0 versus 16.1%, adjusted odds ratio [OR] 1.3, 95%CI 0.5–3.6). Infants who received a full antenatal corticosteroid course within 2–7 d of delivery had similar incidences of hypoglycemia compared with those who received antenatal corticosteroids more than 7?d before delivery (20.4 versus 25.4%, adjusted OR 1.5, 95% confidence interval(CI) 0.8–2.9). Neonatal hypoglycemia was not increased by the number of antenatal corticosteroid doses (partial, full, or repeat course) administered. There was not a correlation between timing of antenatal corticosteroid administration before delivery, up to 250?h, and the lowest neonatal blood sugar in the first 48?h of life.

Conclusion: Our findings suggest antenatal corticosteroid administration in indicated early preterm infants (<34 weeks) may not increase the risk of developing neonatal hypoglycemia within the first 48?h of life. Further studies should validate our findings.     

Nitric oxide metabolite levels in preterm labor

AIM: To investigate the role of nitric oxide metabolites as markers of infection in subjects with preterm labor or preterm premature rupture of membranes (PTPROM). PTPROM means that there was spontaneous rupture of fetal membrane before the onset of labor and gestational age was <37 weeks. This occurs because of imbalance between matrix metalloproteinase and tissue inhibitor of matrix metalloproteinase. The cause of this imbalance that leads to degradation of collagen causing PTPROM is infection. The bactericidal, fungicidal, viricidal and tumoricidal activities of macrophages are determined in part by elaboration of nitric oxide, hence nitric oxide levels have been found to be increased in infections. METHODS: During an 18-month period 50 women with preterm labor or PTPROM and 50 controls were enrolled prospectively. Blood and urine samples were obtained for analysis of nitric oxide metabolites. Patients with known causes of preterm labor were excluded. RESULT: The nitric oxide metabolites, which included both nitrite levels and citrulline levels were significantly higher both in blood as well as urine in patients with preterm labor and PTPROM compared to controls. Serum nitrite levels in subjects with preterm labor were 376.5 +/- 345 nmol/L while in subjects with PTPROM they were 295.7 +/- 161.1 nmol/L and in controls the levels were 62.7 +/- 33.9 nmol/L. Serum citrulline levels in subjects with preterm labor were 5293.8 +/- 2916.7 nmol/L; in PTPROM they were 6536.6 +/- 609.91 nmol/L and in controls they were 949.8 +/- 67.1 nmol/L. On comparing patients with preterm labor, those in whom preterm labor could not be inhibited had statistically significant higher levels of nitrite in both serum and urine (482.9 +/- 387.7 nmol/L and 754.5 +/- 336.5 nmol/L, respectively) compared to patients in whom labor could be inhibited (172.2 +/- 61.9 nmol/L and 401.8 +/- 236.9 nmol/L, respectively). The citrulline levels were also higher among the group who delivered preterm for both serum and urine (5355.4 +/- 3229.7 nmol/L and 11 482.8 +/- 2541.4 nmol/L, respectively) compared to patients in whom labor could be inhibited (5260.2 +/- 2897.08 nmol/L and 10 651.4 +/- 1502.7 nmol/L, respectively) but this did not reach statistical significance. CONCLUSION: Higher nitric oxide metabolites in women with preterm labor are marker of subclinical infection.