Cardiac Biomarkers as Indicators of Hemodynamic Adaptation during Postasphyxial Hypothermia Treatment

Background: Little is known about the effects of hypothermia on the cardiovascular system in term newborns with neonatal encephalopathy. Objectives: To evaluate whether mild hypothermia for neonatal encephalopathy is cardioprotective as indicated by the cardiac biomarkers cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP). Methods: This was an observational cohort study of infants treated for perinatal asphyxia. In infants, mild total body hypothermia treatment of 33.5°C during 72 h was initiated (n = 20). Samples of cTnI and BNP were collected before the start of hypothermia, at 24 and 48 h after birth, and after rewarming (84 h). BNP and cTnI values were then compared with BNP and cTnI values of asphyxiated infants not treated with hypothermia (n = 28). Results: No differences were found between the groups in clinical patient characteristics or inotropic support. The hypothermia-treated patients seemed to be clinically more affected (5-min Apgar score, p < 0.05; umbilical artery pH, p = 0.08), but showed similar encephalopathy scores. Significantly lower values for BNP were found in hypothermia- compared to nonhypothermia-treated infants at 48 h and at normothermia after rewarming [144 pmol/l (95-286) vs. 75 pmol/l (45-143), 182 pmol/l (73-341) vs. 43 pmol/l (24-163)]. No differences were found for cTnI concentrations between both groups. Conclusions: The raised, but similar, cTnI values between hypothermia- and nonhypothermia-treated infants indicate similar myocardial damage in both groups. The lower BNP levels during hypothermia treatment suggest that hypothermia after perinatal asphyxia exerts a beneficial effect on cardiac function.     

Effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia – a randomized controlled trial

Objective: To evaluate the effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia.

Material and methods: This randomized controlled trial (RCT) conducted in a tertiary care teaching hospital, south India included 120 newborns with perinatal asphyxia that were randomized to two groups (therapeutic hypothermia and normothermia). Cardiac enzyme profile changes between groups were assessed at 0, 24, 72?h CPK-MB and troponin I levels were estimated by immune inhibition and quantitative immunochromatography methods, respectively. Electrocardiography (ECG) and Echocardiography (ECHO) were done at 0 and 72?h to evaluate the cardiac function and pulmonary hypertension. Neurodevelopment was assessed at 6 months of age in both groups using Developmental Assessment Scales for Indian Infants.

Results: The median values of CPK-MB in the normothermia and hypothermia groups at 0, 24, and 72?h were 198, 127, and 92?IU/L and 202, 111 and 64?IU/L, respectively. The median values of troponin I in normothermia and hypothermia groups at 0, 24, and 72?hrs were 2.45, 1.53, and 0.9?ng/mL and 1.97, 0.93, and 0.01?ng/mL, respectively. ECG and ECHO findings also suggest lesser myocardial dysfunction in therapeutic hypothermia group compared with the normothermia group.

Conclusions: Therapeutic hypothermia significantly decreases the myocardial damage in term asphyxiated neonates.     

Maternal and Perinatal Outcomes Among Adolescents and Mature Women: A Hospital-Based Study in the North of Mexico

Study ObjectiveTo compare maternal and newborn pregnancy outcomes from adolescents and mature women.Design, Setting, and ParticipantsA cross-sectional study was carried out in a public hospital, including women with singleton pregnancies, who were classified according to their age, as follows: group 1: younger than 16 years old (n = 37), group 2: 16-19 years old (n = 288), and group 3: 20-34 years old (n = 632).Interventions and Main Outcome MeasuresInformation on clinical characteristics, gynecological and obstetric history, pregnancy complications, and perinatal outcomes was obtained through interviews and from clinical records.ResultsThirty-four percent of deliveries were from adolescents. Mature women were more likely to have prepregnancy overweight or obesity than adolescents (odds ratio [OR] = 2.4, 95% confidence interval [CI], 1.7-3.4). The frequency of maternal complications during pregnancy or delivery was not different between groups. Birth asphyxia was more frequent in group 2 (P = .02). Women with inadequate prenatal care had an increased risk of preterm deliveries (OR = 1.64; 95% CI, 1.06-2.54) and of having newborns with low birth weight (OR = 2.02; 95% CI, 1.22-3.35). Weight of newborns from noncomplicated pregnancies was lower in group 1 (P = .02), after adjustment for prepregnancy body mass index, gestational weight gain, preterm delivery, and newborn sex.ConclusionThe frequency of maternal and perinatal complications was similar in adolescents and mature women. Birth weight was decreased in noncomplicated pregnancies of adolescents younger than 16 years of age. Adequate prenatal care might be helpful in prevention of some adverse perinatal outcomes.     

Hypothermie pour la neuroprotection cérébrale de l’encéphalopathie anoxo-ischémique: certitudes et incertitudes

Cerebral hypothermia is one of the first neuroprotective strategies that can improve outcome of experimental and human perinatal cerebral hypoxia-ischemia. Now, international guidelines for hypoxic-ischemic encephalopathy in term neonates recommend hypothermia. At several places, hypothermia could block the cascade of neurochemical events that mediate brain damage insult in term infants. Extended cooling must be initiated 6 h after injury, after obtaining accurate data about perinatal asphyxia and the severity of hypoxic-ischemic encephalopathy. At 18 months of life, hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic-ischemic encephalopathy. However, longer-term data have not been available to assess whether the benefits of hypothermia persist after 2 years of age. Extensions of indication are debated for late preterm infants or newborns admitted in intensive care unit after 6 hours of life, and clinical studies are actually performed on these subjects. However, if prognosis at 18 months is improved, more than 40% of treated newborns will have an unfavorable evolution. Other neuroprotective strategies as erythropoietin, melatonin, and xenon or magnesium sulfate are actually evaluated. Results of these last studies would be interesting in the future, because these strategies could be associated with hypothermia.     

Neuroprotective effects of hypothermia and erythropoietin after perinatal asphyxia in newborn rats

Abstract

Objective: Evaluation of neuroprotective effects of hypothermia, erythropoietin and their simultaneous use after perinatal asphyxia in newborn rats.

Method: Histerectomy was performed to Wistar female rats on the last day of gestation. Perinatal asphyxia was induced by submersion of uterus containing pups in saline for 15?min. After resuscitation, pups were randomized into 4 groups, 15 animals in each: G1 – asphyxia; G2 – asphyxia?+?hypothermia (rectal temperature 33?°C for 1?h); G3 – asphyxia?+?erythropoietin (Darbepoetin-α 2.5?μg, intraperitoneally) and G4 – asphyxia?+?erythropoietin?+?hypothermia. Pups were sacrificed on 7th day of life and histopathological analysis of hippocampus was performed.

Results: Measure of damage to dorsal, ventral and entire hippocampus was significantly lower in groups G2, G3 and G4 than in group G1 (p?～?0.00; respectively). Measure of damage to hippocampus in group G4 was significantly lower than in group G2 (p?=?0.029).

Conclusions: This study demonstrates that simultaneous use of hypothermia and erythropoietin has more expressed neuroprotective effects than sole use of hypothermia after perinatal asphyxia in newborn rats.     

Effects of Delayed Newborn Bathing on Breastfeeding,Hypothermia, and Hypoglycemia

ObjectiveTo determine whether delaying the newborn bath by 24 hours increases the prevalence of breastfeeding initiation and exclusive breastfeeding at discharge in healthy full-term and late preterm newborns (34 0/7–36 6/7 weeks gestation) and to examine the effect of delayed newborn bathing on the incidences of hypothermia and hypoglycemia.DesignPre–post implementation, retrospective, cohort study.SettingProvincial children’s hospital with an average of 2,500 births per year.ParticipantsHealthy newborns (N = 1,225) born at 34 0/7 weeks or more gestation who were admitted to the mother–baby unit.MethodsWe compared newborns who were bathed before 24 hours (n = 680, preimplementation group) to newborns who were bathed after 24 hours (n = 545, postimplementation group).ResultsAfter adjustment for confounders, the odds of exclusive breastfeeding at discharge were 33% greater in the postimplementation group than in the preimplementation group (adjusted odds ratio = 1.334; 95% confidence interval [1.049,1.698]; p = .019). Delayed bathing was associated with decreased incidence of hypothermia and hypoglycemia (p = .007 and p = .003, respectively). We observed no difference in breastfeeding initiation between groups.ConclusionDelaying the newborn bath for 24 hours was associated with an increased likelihood of exclusive breastfeeding at discharge and a decreased incidence of hypothermia and hypoglycemia in healthy newborns. The implementation of a delayed bathing policy has the potential to improve breastfeeding rates and reduce the incidence of hypothermia and hypoglycemia.     

Hypothermia for neonatal hypoxic-ischemic encephalopathy: may an early amplitude-integrated EEG improve the selection of candidates for cooling?

Objective: To report our experience in the selection of newborns candidate to therapeutic hypothermia. Methods: Retrospective study involving 47 newborns suffering from perinatal asphyxia from January 2008 to September 2011. Results: Thirty-five of 47 newborns admitted to our hospital fulfilled metabolic and neurological criteria for recruitment and were cooled. aEEG was carried out in 26 of them and resulted always abnormal. In three of the 12 newborns with only metabolic criteria, aEEG was moderately abnormal. They were cooled and their outcome (evaluated by General Movements and Griffiths Mental Development Scales for children aged 0–2 years) is good. Three additional newborns who only met the metabolic criterion reached our hospital after the therapeutic window for hypothermia and exhibited seizures; their outcome is poor. Conclusions: In our experience, the inclusion of aEEG in the entry criteria would not have precluded newborns with neurological criteria from cooling. On the contrary, without an early aEEG, we would have excluded from hypothermia infants with moderate hypoxic-ischemic encephalopathy without precocious neurological signs who exhibited only the metabolic criterion, but with abnormal aEEG. If further studies will confirm that early aEEG might identify newborns suitable for cooling even in the absence of clinical signs, a revision of the entry criteria should be considered.     

Parents’ Experiences With a Model of Integrated Maternity and Neonatal Care Designed to Empower Parents

ObjectiveTo explore the experiences of parents with an integrated maternity and neonatal ward designed to empower parents by providing family-integrated care (FICare) to mother–newborn couplets in single-family rooms.DesignA qualitative analysis with a contextual constructivist approach.SettingAn integrated maternity and neonatal level 2 ward designed to empower parents in a teaching hospital in Amsterdam, the Netherlands. Maternity and neonatal care, up to and including highly complex care, is provided to mother–newborn couplets in single-family rooms according to the principles of FICare.ParticipantsTwenty-seven mothers and nine fathers of newborns who were hospitalized for at least 7 days.MethodsWe held four focus group discussions and eight semistructured interviews 1 to 3 months after discharge of the newborn to explore which experiences (mechanisms) facilitated or impeded aspects of parent empowerment (outcomes) under which specific conditions of the integrated infrastructure (contexts). We used the realist evaluation model to analyze the data.ResultsOur analysis revealed five themes of parent empowerment (outcomes): Feeling Respected, Gaining Self-Management Tools, Insights Into the Newborn’s Condition, Perceived Control, and Self-Efficacy. For each theme, participants reported facilitating and impeding experiences (mechanisms) that were initiated and influenced by the combination of single-family rooms, couplet care, rooming-in, and FICare (contexts). Unrestricted physical proximity to their newborns, 24 hours per day, in a safe private environment offered parents intensive learning experiences through active participation in care. It helped them to achieve independent parenthood at the time of discharge, but it also generated challenges such as power conflicts with the staff; prioritizing care for themselves, siblings, or the newborn; feelings of isolation; and lack of sleep.ConclusionProviding FICare to mother–newborn couplets in single-family rooms offers parents an intensive learning context for independent parenthood at the time of discharge. Health care professionals should be aware of the challenges and facilitators experienced by parents in the context of close physical proximity to their newborns 24 hours per day in single-family rooms. This awareness will allow them to better support parents in their empowerment process toward independent parenthood at the time of discharge.     

Mild hypothermia via selective head cooling as neuroprotective therapy in term neonates with perinatal asphyxia: an experience from a single neonatal intensive care unit.

OBJECTIVE: The objective of this study was to determine the efficacy of mild hypothermia via selective head cooling as a neuroprotective therapy in term infants with perinatal asphyxia. STUDY DESIGN: Full-term newborns who had 5 min Apgar scores <6, first arterial blood gas pH<7.10 or BD>15 mEq/l, and with the clinical signs of encephalopathy were enrolled within 6 h after birth. Patients were randomized to receive mild hypothermia treatment via selective head cooling for a total of 72 h or receive routine treatment as a control. Brain hypoxic-ischemic injury was quantified based on the head computed tomographic scan (CT scan) at postnatal age 5-7 days and a Neonatal Behavioral Neurological Assessment (NBNA) score at 7-10 days of life. RESULTS: A total of 58 patients (30 hypothermia, 28 control) completed the study. Hypothermia was well tolerated in this study and attenuated the hypoxic-ischemic brain injury due to perinatal asphyxia. Head CT scan demonstrated moderate to severe hypoxic-ischemic changes in only 4/30 cases from the hypothermic group. In contrast, 18/28 cases in the control group showed moderate to severe hypoxic-ischemic changes (chi (2)=15.97, P<0.01). Brain hypothermia also significantly improved the NBNA score (32+/-2 in the hypothermic group vs 28+/-3 in the control group, P<0.01). CONCLUSIONS: Our results suggest that selective head cooling may be used as a neuroprotective therapy in term neonates with perinatal asphyxia. A long-term follow-up study is needed to further validate the results of this study.     

The golden hour in Finnish birthing units - An ethnographic study

ObjectiveTo explore midwives’ and parents’ perceptions and actions as well as the culture surrounding the first hour after the birth of a baby – the golden hour.DesignShort-term ethnographic study, which included observations, informal interviews and focus group interviews. Thematic network analysis was used to analyse the data.SettingTwo birthing hospitals in Finland.ParticipantsThe first hour following 16 births was observed and informal interviews of attending midwives (n = 10) and parents (n = 3 couples and n = 6 mothers) were conducted to supplement the observations. The 16 cases included both primiparous (n = 8) and multiparous (n = 8) women, as well as vaginal (n = 12) and elective caesarean births (n = 4). Furthermore, two focus group interviews with midwives (n = 9) were conducted to deepen the understanding.FindingsThe over-arching theme Unchallenged hospital ‘rules’ comprised the two main themes of Safety-driven support by midwives and Silent voices of the parents. The hospital guidelines and practices guided the first hour, unchallenged by parents and midwives. Based on the guidelines, all the babies were given skin-to-skin contact early but not immediately. Midwives strictly followed the guidelines and performed many activities with the mothers during the first hour. Embedded power was present: midwives were in control but tended to listen to the parents. Although the mothers displayed a strong need to be close to their babies, their voices were silent in the units. The parents’ compliance with midwives and parents’ intense focus on the baby strengthened the midwives’ embedded power.Key conclusionCare culture in birthing units was ‘rule-based’ and the guidelines and practices sometimes inhibited uninterrupted skin-to-skin contact without questioning. The golden hour was mainly controlled by the maternity care staff.Implications for practiceRe-evaluation of hospital guidelines should enable more woman- and family-centred care. The golden hour is unique to families, and unnecessary separation and interventions should be avoided.     

Hypoxic ischemic encephalopathy in newborns linked to placental and umbilical cord abnormalities

Objective: Birth asphyxia and hypoxic ischemic encephalopathy (HIE) of the newborn remain serious complications. We present a study investigating if placental or umbilical cord abnormalities in newborns at term are associated with HIE.

Materials and methods: A prospective cohort study of the placenta and umbilical cord of infants treated with hypothermia (HT) due to hypoxic brain injury and follow-up at 12 months of age has been carried out. The study population included 41 infants treated for HT whose placentas were submitted for histopathological analysis. Main outcome measures were infant development at 12 months, classified as normal, cerebral palsy, or death. A healthy group of 100 infants without HIE and normal follow-up at 12 months of age were used as controls.

Results: A velamentous or marginal umbilical cord insertion and histological abruption was associated with the risk of severe HIE, OR?=?5.63, p?=?0.006, respectively, OR?=?20.3, p?=?0.01 (multiple-logistic regression). Velamentous or marginal umbilical cord insertion was found in 39% among HIE cases compared to 7% in controls.

Conclusions: Placental and umbilical cord abnormalities have a profound association with HIE. A prompt examination of the placentas of newborns suffering from asphyxia can provide important information on the pathogenesis behind the incident and contribute to make a better early prognosis.     

Impact of transient period of metabolic adaptation on perinatal asphyxia in neonates with intrauterine growth retardation

Introduction: Temperature, glycemia and respiration make neonatal energy triangle (NET). In growth retardation (IUGR) neonates pathological metabolic adaptation exists in transient neonatal period.

Aim: The of this study was to examine the occurrence of pathological NET and check its impact on perinatal asphyxia during the transient period in IUGR neonates.

Material and methods: One hundred and fifty-nine neonates with IUGR were classified into – early preterm, late preterm and term neonates. By the presence of hypothermia, hypoglycemia and hypoxia in the first hour after birth neonates were classified into: group of pathological NET, group of unstable NET and group of stable NET. We analyzed distribution per body mass, gestational age, type of IUGR, gender and the frequency of perinatal asphyxia between the groups.

Results: The late preterm neonates were the most frequent in the group of pathological NET. Perinatal asphyxia was diagnosed in 52 (32.7%) neonates, with highest frequency in the group of pathological NET. Univariate binary logistic regression analysis showed that pathological NET in neonates with IUGR is significant predictor for perinatal asphyxia occurrence (OR?=?8.57; CI?=?4.05–18.12; p?R²?=?0.27).

Conclusion: Poor metabolic adaptation in neonates with IUGR in the first hour after birth is significant risk factor for the perinatal asphyxia.     

Heat Loss Prevention (Help) After Birth in Preterm Infants Using Vinyl Isolation Bag or Polyethylene Wrap

ObjectiveTo examine the effects of using vinyl isolation bags or polyethylene wrap for the prevention of postnatal hypothermia in preterm infants at ≤ 32 weeks gestation.DesignA prospective, randomized controlled trial.SettingThe neonatal intensive care unit (NICU) of the Istanbul Faculty of Medicine in Turkey.ParticipantsFifty‐nine preterm infants.MethodsParticipants were randomly assigned to either the vinyl isolation‐bag experimental group (n = 22) or the polyethylene‐wrap control group (n = 37). Infant body temperature was measured at four time points after birth.ResultsLoss of body temperature was significantly less in the vinyl isolation‐bag group during the first 60 minutes after birth (p = .041). Body temperature decreased by 1.41 ± 1.65 °C in the vinyl isolation‐bag group and 2.75 ± 1.68 °C in the polyethylene wrap group. Body temperature was significantly less in the polyethylene wrap group compared to the vinyl isolation‐bag group at birth to 60 minutes (p = .004).ConclusionWrapping preterm infants of gestational age  ≤ 32 weeks in vinyl bags immediately after birth is associated with lower incidences of hypothermia.     

State of the Science on Perinatal Palliative Care

ObjectiveTo report the state of the science since 1995 on the concept of palliative care for parents who opt to continue a pregnancy after receiving a life‐limiting fetal diagnosis.Data SourcesPubMed, Ovid, PsycInfo, CINAHL, and Medline were searched from 1995 to July 2012 using the terms perinatal palliative care and perinatal hospice.Study SelectionInclusion criteria included empirical studies written in English that focused on experiences of parents who opted to continue a pregnancy in which the fetus had a life‐limiting condition or on perinatal palliative care. Twenty studies met inclusion criteria.Data ExtractionResults from empirical studies contributing to the knowledge base of perinatal palliative care are presented.Data SynthesisWomen are confronted with powerful emotions, challenging decisions, and considerable uncertainty following the news of a life‐limiting fetal anomaly. Women choose to continue their pregnancies for a variety of reasons and when doing so embark on a search for meaning. The science suggests that perinatal palliative care is welcomed by parents and is a medically safe and viable option. Women voiced positive feedback about their decisions to continue their pregnancies, and parents cited personal growth in the aftermath. Perinatal palliative care programs provide services that incorporate early and integrative care beginning in the antenatal period. A multidisciplinary coordinated approach provides parents with comprehensive, holistic support.ConclusionMore research is needed to elucidate the factors that will benefit parents who continue their pregnancies. Investigating the needs and perceptions of clinicians and their willingness to participate in this new model of care is necessary as is examining barriers that may undermine care. Nurses can lead research on these topics and implement evidence‐based practice grounded on study findings.     

Does therapeutic hypothermia reduce acute kidney injury among term neonates with perinatal asphyxia? – a randomized controlled trial

Objective: The objective of this study is to evaluate whether therapeutic hypothermia reduces the incidence of acute kidney injury (AKI) among term neonates perinatal asphyxia.

Methods: This randomized controlled trial conducted in a tertiary care teaching hospital, south India included 120 term neonates with perinatal asphyxia who were randomized to receive either therapeutic hypothermia or standard supportive care. Renal parameters of neonates in both the groups were monitored and AKI was ascertained as per Acute Kidney Injury Network criteria.

Results: The incidence of AKI was less in therapeutic hypothermia group compared to standard treatment group (32% versus 60%, p?<?0.05). The incidence of Stages 1, 2, and 3 AKI was 22%, 5%, and 5% in therapeutic hypothermia group compared with 52%, 5%, and 3%, respectively, in the standard treatment group. The mortality was less in therapeutic hypothermia group compared with the standard treatment group (26% versus 50%, p?<?0.05).

Conclusion: Therapeutic hypothermia reduces the incidence and severity of AKI among term neonates with perinatal asphyxia.     

Evaluation of a Nurse-Led Program for Rural Pregnant Women With Opioid Use Disorder to Improve Maternal–Neonatal Outcomes

ObjectivesTo generate effect sizes of preliminary program outcomes and identify areas for program improvement related to a nurse-led, community-based screening, referral, and advocacy program for women with perinatal opioid use disorder (OUD): the Engaging Mothers for Positive Outcomes with Early Referrals (EMPOWER) program.DesignWe extracted outcomes retrospectively from medical records for the first 19 mother–newborn dyads who participated in the program (postintervention group). We compared these outcomes with those of 19 randomly selected mother–newborn dyads in which mothers had perinatal OUD and received care before the program launch (preintervention group).Setting/Local ProblemA maternity care practice and community hospital in a rural Massachusetts county with high rates of perinatal OUD.PatientsWomen with perinatal OUD and their neonates.Intervention/MeasurementsAs part of the EMPOWER program, women with perinatal OUD developed individualized pregnancy plans; were referred to community resources in the prenatal period; and received education about neonatal abstinence syndrome, nonpharmacologic newborn care, and breastfeeding. We compared the pre- and postintervention groups for maternal and neonatal outcomes and prenatal community referrals and generated effect sizes using Cohen’s d and Cramer’s phi (Φ).ResultsRates of breastfeeding initiation (Φ = 0.289) and continuation (Φ = 0.318), mean neonatal birth weight (d = 0.675), and length of hospital stay (d = 0.541) were greater in the postintervention group with medium effect sizes. Diagnosis of neonatal abstinence syndrome and admission to the NICU were also greater in the postintervention group, with small effect sizes (Φ = 0.246 and Φ = –0.144, respectively.) Significantly more women in the postintervention group received prenatal referrals for peer/family support services. We identified areas for program improvement as prenatal education on smoking and postpartum contraceptive use.ConclusionPreliminary findings suggest that the EMPOWER program may contribute to improved outcomes for mothers and newborns affected by OUD; however, further data collection after instituting program improvements is needed.