Fetal general movements and brain sonography in a population at risk for preterm birth

Background

General movements (GMs) assessed three months post term are related to brain injury and neurological outcome.

Aims

To study GMs in fetuses and their predictive value for echogenicity changes in the fetal brain.

Study design

Prospective study of fetal GMs (classified as normal or abnormal) and echogenicity changes in the periventricular, basal ganglia/thalami area, and ventricular system (classified as absent, mild or moderate).

Subjects

121 fetuses from pregnancies affected by hypertensive disorders and/or preterm labour, at risk for preterm birth (26-34 weeks gestational age).

Outcome measures

Prevalence of abnormal GMs, GM parameters (amplitude, speed and complexity), and moderate echogenicity changes in the fetal brain (periventricular ≥ IB, intraventricular grade II/III, and basal ganglia/thalamus locally increased). Predictive values of GMs for clinical parameters and moderate echogenicity changes.

Results

GMs were abnormal in 58%, with amplitude affected in 96%, and speed and complexity in 59%. Abnormal GMs correlated with oligohydramnios (p = 0.002) and hypertensive disorders (p = 0.015). Echogenicity changes of the brain were absent, mild and moderate in 27%, 39% and 31%, respectively. The sensitivity of GMs for moderate echogenicity changes in the three areas combined was 0.65, and the periventricular area 0.85, specificity both 0.44, negative predictive values 0.73 and 0.96 respectively.

Conclusions

Qualitative abnormal GMs are frequent in fetuses of compromised pregnancies, and correlate with hypertensive disorders and oligohydramnios. The amplitude of GMs was most frequently affected. Abnormal GMs relate to moderate echogenicity changes especially in the periventricular area of the fetal brain, while normal GMs predict absence of moderate echogenicity changes.     

General movements in infants born from mothers with early-onset hypertensive disorders of pregnancy in relation to one year's neurodevelopmental outcome

Background:

Assessment of general movements (GMs) at three months is considered useful for prediction of adverse neurological outcome in high risk infants.

Aims:

To study the prevalence of abnormal GMs in infants born from women with early-onset hypertensive disorders of pregnancy and the association of GMs with neurodevelopmental outcome at one year.

Study design:

Prospective study, part of a randomised controlled trial of pre-birth management strategies.

Subjects:

Infants born from women with early-onset hypertensive disorders of pregnancy.

Outcome measures:

GMs observation and neurological examination at term and three months corrected age; at one year neurological examination and Bayley Scales of Infant Development.

Results:

From 216 women included, 175 of 178 surviving infants (mean gestational age 31.6 weeks [SD 2.3], mean birth weight 1346 grams [SD 458]), were examined at three months. At term age normal, mildly abnormal and definitely abnormal GMs were observed in 54%, 36% and 10% respectively; and at three months in 47%, 40% and 13%. Mildly or definitely abnormal GMs at three months were not associated with abnormal neurological examination at one year, however, they were associated with delayed psychomotor development at one year (p = 0.01).

Conclusions

In this prospective study, including small for gestational age, preterm infants about half of them did not have normal GMs at term and three months. There was no association of GMs at term nor three months with neurological outcome at one year, but there was a significant association of GMs at three months with one year psychomotor development.     

Qualitative changes in general movements and their prognostic value in preterm infants

Qualitative asessments of general movements have been shown to have considerable power in predicting neurological outcomes in preterm infants with brain damage. In the present study such assessments were made in 35 preterm infants without major neurological problems before term age, born between 27 and 34 weeks gestation, of whom 12 were small-for-gestational-age (SGA). Most infants maintained a normal or (mildly) abnormal quality from 35 weeks postmenstrual age through 6, 12, 18 to 24 weeks corrected age. Seven changed from initially abnormal movements to a normal quality, six of them after 12 weeks. Differences between SGA and appropriate-for-gestational-age infants became less evident with age, particularly after 12 weeks. This was not the case when comparisons were made on the basis of gestational ages below or above 32 weeks. The prediction of neurological and mental outcomes at 1 year also improved after 12 weeks, around which age a major transformation in neural functions occurs. It is concluded that assessments of movement quality are particularly successful in predicting abnormal outcomes in comparison to examinations based on muscle tone and elicited responses.     

Reduced cerebellar diameter in very preterm infants with abnormal general movements

Background

Abnormal General Movements (GMs) early in life are predictive of later neuromotor deficits and are related to white matter abnormalities on magnetic resonance imaging (MRI). However, other structural correlates of abnormal GMs have not been defined.

Aims

The objective of this study was to explore brain-metrics (linear brain measurements on MRI representative of 3-D brain volumes) at term as a predictor of abnormal GMs at 1 and 3 months' corrected age in preterm infants. It was hypothesized that abnormal GMs would be related to reduced brain-metrics in primary motor areas, namely the cerebellum and parietal lobes.

Study design

Eighty three preterm infants (< 30 weeks' gestational age) were scanned at term-equivalent age. MRI was assessed for white matter abnormality and brain-metrics in six predefined brain regions (i.e. bifrontal, biparietal, lateral ventricles and transverse cerebellar diameters, and inter-hemispheric distance).

Outcome measures

At 1 and 3 months' corrected age infants' GMs were assessed from video-taped footage and rated as normal or abnormal using standardized methodology.

Results

At 1 month, 63% (n = 52) of infants had abnormal GMs with no association between any of the brain-metrics and abnormal GMs. At 3 months, 23% (n = 18) of infants had abnormal GMs (absent fidgety movements n = 18; abnormal fidgety movements n = 0). Reduced bifrontal, biparietal, and cerebellar transverse diameters, along with an increase in lateral ventricle sizes were associated with an increased risk of abnormal GMs at 3 months' corrected age. After controlling for white matter abnormality and grade III/IV intraventricular haemorrhage, only the cerebellar transverse diameter was predictive of abnormal GMs at 3 months.

Conclusions

Reduced cerebellar diameter at term equivalent age is related to abnormal GMs at 3 months' corrected age, independent of white matter abnormality and intraventricular haemorrhage.     

Connecting the developing preterm brain

White matter injury and abnormal maturation are thought to be major contributors to the neurodevelopmental disabilities observed in children and adolescents who were born preterm. Early detection of abnormal white matter maturation is important in the design of preventive, protective, and rehabilitative strategies for the management of the preterm infant. Diffusion Tensor Imaging (DTI) allows non-invasive, in vivo visualization and quantification of white matter tracts and has become a valuable tool in assessing white matter maturation in children born preterm. We will review the use of DTI to study white matter maturation and injury in the preterm brain.     

A comparison of the general movements assessment with traditional approaches to newborn and infant assessment: concurrent validity

BACKGROUND: Assessment of the quality of general movements (GMs) is an early clinical marker for prediction of cerebral palsy. AIMS: To explore how the General Movements Assessment (GMsA) relates to traditional newborn and infant measures currently in use. STUDY DESIGN: A prospective cohort design was used to examine concurrent validity of the GMsA in Neonatal Intensive Care (NICU) survivors (n=100) at three age points: preterm (34 weeks gestational age GA), term (38-40 weeks GA), and post term (12 weeks adjusted age [AA]) with traditional assessments (see below). Correlation analysis was used to determine the strength of the associations between tests at each age point. SUBJECTS: Preterm infants born at 相似文献   

Insights into early brain development from modern brain imaging and outcome studies

Recent brain imaging and outcome studies of infants born at very early gestation have cast new light on brain development at a vulnerable stage. Some of these new developments are reviewed in this editorial. Conclusion: The anatomical differences between the brains of babies born extremely prematurely and those born at term appear to translate into disturbances of function. The challenge for paediatricians is to discover the causes, with the aim of promoting normal brain development.     

Neonatal mortality rate: Relationship to birth weight and gestational age

A total of 2063 live births were studied during one year period from July 1994 to June 1995. Neonatal mortality rate (NMR) was 35.4 per thousand live births. The case fatality rate among low birth weight and preterms was 10.1% and 18.1% respectively. Though, low birth weight babies accounted for 27.8% of the live births but contributed for 79.5% of neonatal deaths [p<0.001]. Similarly, preterm babies accounted for 13.2% of the live births but contributed for 69.9% of neonatal deaths [p<0.001]. The causes of neonatal deaths found were birth asphyxia (31.1%), infections (23.3%), immaturity (17.8%), hypothermia (9.6%), hyaline membrane disease (2.7%) and cogenital malformation (1.4%). There is need to identify strategies to reduce the incidence of prematurity and low birth weight babies. Comprehensive antenatal coverage and adequate care followed by optimal management of newborns at birth is likely to reduce NMR and improve quality of life among survivors.     

The influence of the mode of delivery on circulating cytokine concentrations in the perinatal period

BACKGROUND: Cytokines play an important role during labor and full- or preterm delivery. They influence physical immunity of the fetus-neonate and express a leading role in the perinatal period, being present in maternal and fetal tissues. AIM: To investigate whether cytokine concentrations in the mother, fetus and neonate depend on the labor and the mode of the delivery. STUDY DESIGN: Prospective study. SUBJECTS: Seventy-eight healthy, non-smoking parturients (mean age 28+/-4, range 21-39 years, delivering vaginally: n=52 or by elective cesarean section: n=26) and their single, healthy, appropriate for gestational age, full-term neonates. OUTCOME MEASURES: We correlated determined circulating levels of IL-2, sIL-2R, IL-4, sIL-4R, IL-6, sIL-6R, IL-1beta, IL-8, IFN-gamma, TNF-alpha, sTNF RI, sTNF RII and RANTES in the mothers before delivery (MS), the fetuses (UC) and the neonates in days 1 (N1) and 4 (N4) of life, with the mode of delivery. RESULTS: sIL-2R in N1 and N4, sIL-4R in MS, IL-6 in MS and UC, IL-1beta in MS, UC and N1, IFN-gamma in MS and UC, TNF-alpha in UC, N1 and N4, sTNF RI in UC were significantly higher in cases of vaginal delivery than in cases of elective cesarean section (p ranging from 0.0005 to 0.05). CONCLUSIONS: Vaginal delivery promotes the production of various cytokines and their receptors, which are implicated in neonatal immunity.     

NICU新生儿败血症心肌损害与出生状况的相关性研究

目的研究新生儿败血症心肌损害的发生与其出生时状况的相关关系,以改善新生儿败血症的预后。方法采用前瞻性临床观察研究方法,对郑州大学第三附属医院NICU2005-11-15—2006-05-31收治的112例败血症新生儿心肌损害的发生与其出生时胎龄、体重、性别、产式及有无窒息史等状况的关系进行了相关性分析。结果112例患儿中发生心肌损害者57例(50.9%)。23例早产儿心肌损害的发生率为78.3%,显著高于足月儿(43.4%),早产与新生儿败血症心肌损害的发生有显著的正相关性(r=0.288,P<0.05);28例低出生体重儿心肌损害的发生率为67.9%,显著高于正常出生体重儿(45.2%),低出生体重与新生儿败血症心肌损害的发生有显著的正相关性(r=0.196,P<0.05);新生儿败血症合并窒息者34例,心肌损害的发生率为85.3%,显著高于无窒息者(35.9%),窒息与新生儿败血症心肌损害的发生有显著的正相关性(r=0.454,P<0.05)。而不同性别及分娩方式对患婴心肌损害的发生率无影响。结论早产、低体重、窒息是新生儿败血症发生心肌损害的3个高危因素,对于这些新生儿发生败血症时,更要关注其心肌损害的发生以降低病死率。     

Magnetic resonance imaging in perinatal brain injury: clinical presentation, lesions and outcome

Neonatal MR imaging is invaluable in assessing the term born neonate who presents with an encephalopathy. Successful imaging requires adaptations to both the hardware and the sequences used for adults. The perinatal and postnatal details often predict the pattern of lesions sustained and are essential for correct interpretation of the imaging findings, but additional or alternative diagnoses in infants with apparent hypoxic ischaemic encephalopathy should always be considered. Perinatally acquired lesions are usually at their most obvious between 1 and 2 weeks of age. Very early imaging (<3 days) may be useful to make management decisions in ventilated neonates, but abnormalities may be subtle at that stage. Diffusion-weighted imaging is clinically useful for the early identification of ischaemic white matter in the neonatal brain but is less reliable in detecting lesions within the basal ganglia and thalami. The pattern of lesions seen on MRI can predict neurodevelopmental outcome. Additional useful information may be obtained by advanced techniques such as MR angiography, venography and perfusion-weighted imaging. Serial imaging with quantification of both structure size and tissue damage provides invaluable insights into perinatal brain injury.     

慢性亚致死性缺氧对未成熟脑结构和发育的影响

现代新生儿学的发展促使极低体质量早产儿的存活率显著提高,同时严重慢性肺部疾病患儿增多,特别是支气管肺发育不良(BPD).中重度BPD患儿多数有远期感觉、运动和认知缺陷.有些功能缺陷可能发展至学龄期或成年甚至持续终生.越来越多的临床数据表明BPD显著影响新生儿脑生长和发育,其病程中伴随的慢性亚致死性缺氧是引起极低体质量早产儿远期脑损伤和脑瘫等神经系统并发症的重要因素之一.动物研究发现慢性缺氧导致新生鼠脑皮层下和胼胝体白质损伤、进行性脑室扩大和胶质增生,突触发育前后失衡及神经递质传导障碍,从而可能显著影响感觉、运动及认知等脑功能发育.     

Structural and functional brain correlates of behavioral outcomes during adolescence

Several studies have described an association between very preterm birth and behavioral and psychiatric outcomes in childhood and adolescence. The exact mechanisms underlying this association are unknown, but impaired neurodevelopment has been proposed as a possible etiological factor.     

Brain ultrasonography findings in neonates with exposure to cocaine during pregnancy

Background  Cocaine exposure during pregnancy has been reported to have detrimental effects on the fetus. Objective  To describe the findings on cranial ultrasonography (CUS) as part of a neonatal screening programme for exposed neonates. Materials and methods  The study was a semiprospective analysis of a 12-year cohort of neonates born to mothers who had used cocaine during their pregnancy and who had follow-up according to a strict clinical protocol. Results  In total, 154 neonates (78 boys, 76 girls) were included, of whom 29 (19%) were born preterm, and 125 (81%) were born full-term. Abnormalities on CUS were seen in 37 neonates (24%; 95% CI 18–31%). The abnormalities were classified as minor in 20 (13%; 95% CI 9–19%) and mildly abnormal in 17 (11%; 95% CI 7–17%). None of the infants showed severe abnormalities. The abnormalities were not associated with the duration or maximum amount of cocaine use during pregnancy. Conclusion  None of the infants had severe abnormalities. Detected abnormalities were not correlated with the duration or maximum amount of cocaine use. Given these findings, we feel that routine cranial ultrasonography in this population is not warranted.     

环状RNA在炎症所致早产小鼠脑损伤中的作用及机制初步研究

目的 探讨环状RNA（circular RNA,circRNA）及circRNA-微小RNA（microRNA,miRNA）网络调控与炎症诱导早产小鼠脑损伤的关系,为早产儿脑损伤的防治提供依据。方法 以孕鼠腹腔注射脂多糖建立炎症诱导早产小鼠脑损伤模型（炎症早产组,n=3）,正常孕鼠剖宫产早产小鼠作为对照（非炎症早产组,n=3）。采用微阵列基因芯片技术筛选早产儿脑损伤相关的circRNA,通过miRNA靶预测软件预测circRNA和miRNA相互作用的结合位点,研究其调控机制。结果 与非炎症早产组比较,炎症早产组显著差异表达的circRNA有365条（差异倍数 > 1.5,P < 0.05）,包括差异表达上调206条,差异表达下调159条。对差异表达倍数4倍以上的circRNA行进一步分析,发现这些circRNA可与miRNA结合并调节其活性,从而调控与神经系统相关基因的表达。结论 炎症诱导早产小鼠脑组织circRNA表达谱发生明显变化;circRNA的表达变化可通过调控miRNA的活性在炎症诱导早产小鼠脑损伤及之后的脑发育中发挥作用。     

Development of smooth pursuit eye movements in very preterm infants: 1. General aspects

Aim: To investigate early oculo‐motor development in a population‐based cohort of very preterm infants. Methods: Early oculo‐motor development was prospectively studied by measuring smooth pursuit eye movements at 2 and 4 months corrected age in a population of very preterm infants born in Uppsala County 2004–2007. Eighty‐one preterm infants were studied, and 32 healthy term infants constituted the control group. Results: The study group consisted of infants with a mean gestational age of 28 + 5 weeks. At 2 and 4 months corrected age, infants born very preterm showed lower gain (p < 0.001) and proportion of smooth pursuit eye movements (p < 0.001) compared to the control group. The boys showed higher gain of smooth pursuit eye movements at both 2 and 4 months corrected age, compared to girls. Conclusions: Oculo‐motor development measured by smooth pursuit eye movements is delayed in very preterm infants at 2 and 4 months corrected age. This might be a risk factor or early indicator of later perceptual and behavioural impairment.     

Growth hormone levels in relation to birth weight and gestational age

Growth hormone levels were measured in 33 umbilical cord blood samples collected from babies born at JIPMER Hospital during April and May-1998. The study was done to evaluate the growth hormone profile in relation to birth weight and gestational age. There was statistically significant difference in the cord blood growth hormone levels between babies weighing > 2500 gms (28.1 ± 12.83 ng/dl) and low birth weight babies (76.8 ± 55.7 ng/dl). The difference in growth hormone levels between term babies weighing >2500 gms and preterm babies (72.5 ± 29.4 ng/dl) was also statistically significant. However, there was no significant difference in the cord blood growth hormone levels between term low birth weight and preterm babies. Growth hormone levels were higher in preterm babies and low birth weight babies as compared to term babies weighing >2500 gms indicating that growth hormone has an important role to play in intrauterine growth along with other growth promoting factors.     

Differential brain growth in the infant born preterm: current knowledge and future developments from brain imaging

Preterm birth is associated with a high prevalence of neuropsychiatric impairment in childhood and adolescence, but the neural correlates underlying these disorders are not fully understood. Quantitative magnetic resonance imaging techniques have been used to investigate subtle differences in cerebral growth and development among children and adolescents born preterm or with very low birth weight. Diffusion tensor imaging and computer-assisted morphometric techniques (including voxel-based morphometry and deformation-based morphometry) have identified abnormalities in tissue microstructure and cerebral morphology among survivors of preterm birth at different ages, and some of these alterations have specific functional correlates. This chapter reviews the literature reporting differential brain development following preterm birth, with emphasis on the morphological changes that correlate with neuropsychiatric impairment.     

Detection and management of life threatening arrhythmias in the perinatal period

The management of tachyarrhythmias and bradyarrythmias in the fetus requires a team approach with careful monitoring of fetal well-being as well as care in establishing a precise diagnosis with use of m-mode and Doppler echocardiography to determine the atrial and ventricular rate. A persistent fetal heart rate less than 80 beats per minute (bpm) suggests complete atrioventricular block. A persistent fetal heart rate over 180 bpm suggests pathological tachycardia, most of which are a supraventricular tachycardia mediated via an accessory pathway. However, around 20% are due to atrial flutter, and this review highlights why medical management should be different for these cases, and for those with hydrops or cardiac failure. It also illustrates which fetus or infant may be at particular risk, and illustrates key features in their management before and after birth.