Complete Course Of Antenatal Steroids Research Articles

Does perinatal management have the potential to reduce the risk of intraventricular hemorrhage in preterm infants?

Intraventricular hemorrhage (IVH) is an important cause of neurodevelopmental impairment in preterm infants. A number of risk factors for IVH have already been proposed; however, some controversies regarding optimal perinatal management persist. This study aimed to identify perinatal and neonatal attributes associated with IVH in a representative population of preterm infants. Perinatal data on 1,279 very preterm infants (<32 weeks of gestation) admitted to a tertiary neonatal intensive care unit were analyzed. The records were assessed using univariate analysis and logistic regression model to evaluate the risk factors for any and high-grade IVH (grade III-IV according to the classification by Papile) within the first week after birth. The incidence of any IVH was 14.3% (183/1,279); the rate of low-grade (I-II) and high-grade (III-IV) IVH was 9.0% (115/1,279) and 5.3% (68/1,279), respectively. Univariate analysis revealed multiple factors significantly associated with intraventricular hemorrhage: lower gestational age and birth weight, absence of antenatal steroids, vaginal delivery, low Apgar score at 5 min, delivery room intubation, surfactant administration, high frequency oscillation, pulmonary hypertension, pulmonary hemorrhage, tension pneumothorax, persistent ductus arteriosus, hypotension and early onset sepsis. Logistic regression confirmed lower gestational age, vaginal delivery, ductus arteriosus and early onset sepsis to be independent predictors for any IVH. Pulmonary hemorrhage, tension pneumothorax and early onset sepsis were independent risk factors for high-grade IVH. Complete course of antenatal steroids was associated with a lower risk for any (odds ratio 0.58, 95% confidence interval 0.39-0.85; P = .006) and for high-grade intraventricular hemorrhage (odds ratio 0.36, 95% confidence interval 0.20-0.65; P < .001). The use of antenatal steroids and mode of delivery are crucial in the prevention of IVH; however, our study did not confirm the protective effect of placental transfusion. Severe respiratory insufficiency and circulatory instability remain to be powerful contributors to the development of IVH. Early detection and management of perinatal infection may also help to reduce the rate of brain injury and improve neurodevelopment in high-risk newborns.

Less invasive surfactant administration via infant feeding tube versus InSurE method in preterm infants: a randomized control trial

There is growing evidence that less invasive surfactant administration (LISA) is a better alternative to the standard Intubate-surfactant-extubate (InSurE) procedure in spontaneously breathing preterm infants with RDS. The infant feeding tube is easily available and cost-effective in comparison to special catheters used for surfactant administration in various studies on LISA and cost-effective health care is the need of the hour for countries like ours which are Low and middle-income countries(LMICs).The present study was planned to compare the total duration of respiratory support in preterm babies between 26 to 34 weeks of gestation with RDS requiring surfactant therapy administered by LISA technique using an infant feeding tube or InSurE method. In this unblinded randomised controlled trial, 150 infants were allocated to LISA (n = 74) or InSurE group (n = 76). An 8F feeding tube was used for surfactant delivery in the LISA group. The primary outcome was the total duration of respiratory support required and secondary outcomes included the proportion of babies developing BPD, IVH, PDA, NEC, ROP, air leaks, CPAP failure, and those requiring a repeat dose of surfactant along with the duration of hospitalization, time to regain birth weight and Death. The baseline variables including birth weight and gestation age were similar in the two groups. Nearly 27% of the mothers did not receive any dose of antenatal steroids (ANS) while around 37% of the mothers received complete course of ANS. A high proportion of babies (57%) were delivered by cesarean section. Intrapharyngeal reflux was significantly more in babies who received surfactant with the LISA method in comparison to InSurE technique (32% v/s 3%, p < 0.001). There was no statistically significant difference in the primary outcome of the total duration of respiratory support in both groups with a median duration of 120 h, 95% CI (69–235), and p = 0.618. The need for invasive mechanical ventilation was significantly lower in the LISA group (p = 0.017) with RR (95% CI) 0.498 (0.259–0.958). The rate of CPAP failure was significantly lower in the LISA group (p = 0.005) with RR (95% CI) 0.55 (0.34–0.89). In this study, the total duration of hospital stay was reduced in the LISA group (19 days) compared to InSurE group (26 days), although the same was not statistically significant. LISA with an 8F feeding tube is feasible and an effective strategy for surfactant administration which resulted in a significant reduction in CPAP failure and the need for invasive mechanical ventilation.Trial registration: www.ctri.nic.in id CTRI/2020/05/025360. Trial was registered at CTRI on 26/05/2020. First case of trial was enrolled on 28/05/2020.

Association of Antenatal Steroid Exposure at 21 to 22 Weeks of Gestation With Neonatal Survival and Survival Without Morbidities

The provision of antenatal corticosteroids to pregnant patients at gestational age (GA) 22 6/7 weeks or less remains controversial and lacks support from randomized clinical trials. To compare rates of survival and survival without major morbidities among infants born at GA 22 0/7 to 23 6/7 weeks after exposure to antenatal steroids at 22 6/7 weeks' gestation or less vs no exposure to antenatal steroids. This cohort study enrolled infants born at GA 22 0/7 to 23 6/7 weeks between January 1, 2016, and December 31, 2019, at centers in the National Institute of Child Health and Human Development Neonatal Research Network. Infants who did not receive intensive care and infants with antenatal steroid exposure after GA 22 6/7 weeks were excluded. Infants were classified as having no, partial, or complete exposure to antenatal steroids. The primary outcome was survival to discharge. The main secondary outcome was survival without major neonatal morbidity. The associations of differential exposures to antenatal steroids with outcomes were evaluated using logistic regression, adjusting for GA, sex, race, maternal education, small for GA status, mode of delivery, multiple birth, prolonged rupture of membranes, year of birth, and Neonatal Research Network center. A total of 431 infants (mean [SD] GA, 22.6 [0.5] weeks; 232 [53.8%] boys) were included, with 110 infants (25.5%) receiving no antenatal steroids, 80 infants (18.6%) receiving partial antenatal steroids, and 241 infants (55.9%) receiving complete antenatal steroids. Seventeen infants were exposed to antenatal steroids at GA 21 weeks. Among infants exposed to complete antenatal steroids, 130 (53.9%) survived to discharge, compared with 30 infants (37.5%) with partial antenatal steroid exposure and 239 infants (35.5%) with no antenatal steroids. Infants born after complete antenatal steroid exposure, compared with those without antenatal steroid exposure, were more likely to survive to discharge (adjusted odds ratio [aOR], 1.95 [95% CI, 1.07-3.56]) and to survive without major morbidity (aOR, 2.74 [95% CI, 1.19-6.30]). In this retrospective cohort study, among infants born between GA 22 0/7 and 23 6/7 weeks who received intensive care, exposure to a complete course of antenatal steroids at GA 22 6/7 weeks or less was independently associated with greater odds of survival and survival without major morbidity. These data suggest that the use of antenatal steroids in patients at GA 22 6/7 weeks or less could be beneficial when active treatment is considered.

Early Hypoxic Respiratory Failure in Extreme Prematurity: Mortality and Neurodevelopmental Outcomes.

To evaluate the survival and neurodevelopmental impairment (NDI) in extremely low birth weight (ELBW) infants at 18 to 26 months with early hypoxemic respiratory failure (HRF). We also assessed whether African American infants with early HRF had improved outcomes after exposure to inhaled nitric oxide (iNO). ELBW infants ≤1000 g and gestational age ≤26 weeks with maximal oxygen ≥60% on either day 1 or day 3 were labeled as "early HRF" and born between 2007 and 2015 in the Neonatal Research Network were included. Using a propensity score regression model, we analyzed outcomes and effects of exposure to iNO overall and separately by race. Among 7639 ELBW infants born ≤26 weeks, 22.7% had early HRF. Early HRF was associated with a mortality of 51.3%. The incidence of moderate-severe NDI among survivors was 41.2% at 18 to 26 months. Mortality among infants treated with iNO was 59.4%. Female sex (adjusted odds ratio [aOR]: 2.4, 95% confidence interval [CI]: 1.8-3.3), birth weight ≥720 g (aOR: 2.3, 95% CI: 1.7-3.1) and complete course of antenatal steroids (aOR: 1.6, 95% CI: 1.1-2.2) were associated with intact survival. African American infants had a similar incidence of early HRF (21.7% vs 23.3%) but lower exposure to iNO (16.4% vs 21.6%). Among infants with HRF exposed to iNO, intact survival (no death or NDI) was not significantly different between African American and other races (aOR: 1.5, 95% CI: 0.6-3.6). Early HRF in infants ≤26 weeks' gestation is associated with high mortality and NDI at 18 to 26 months. Use of iNO did not decrease mortality or NDI. Outcomes following iNO exposure were not different in African American infants.

Antenatal corticosteroids and the influence of sex on morbidity and mortality of preterm infants

Objective To study the associated effect of a complete course of antenatal corticosteroids (ACSs) on mortality and morbidity rates among preterm infants in our population. Study design Observational prospective study of infants born at less than 32 weeks’ gestation and admitted to our Neonatal Care Unit between January 2012 and December 2018. We analyzed mortality at discharge and respiratory and neurological morbidity, both during hospitalization and at 24 months’ postmenstrual age. Results The study included a total of 710 patients with a median gestational age of 28.5 weeks (IQR 26.4–30.5) and mean weight of 1.090 g (IQR 800–1.391). Of which, 62.4% received a complete course of antenatal steroids. Given the differences observed in the baseline characteristics of patients who either did or did not receive a full course of antenatal steroids, a propensity score covariate adjustment was performed for all estimations. The effect of ACS therapy differs depending on sex with a positive effect on acute respiratory morbidity and mortality in male patients of less than 29 weeks’ gestation. In female infants, there is no significant beneficial association between ACS therapy and mortality or any of the morbidities studied. Conclusion In our population of preterm infants, treatment with antenatal steroids is associated with a different effect depending on sex. Antenatal steroids therapy associated with a positive effect in male patients with a gestational age of less than 29 weeks.

Case 2: Newborn with Acute-Onset Central Cyanosis

A female infant of 31 weeks’ gestational age and birthweight of 1.19 kg is born to a gravida 2 woman. The mother had received a complete course of antenatal steroids 2 days before delivery. There is no history of early infantile deaths, early-onset stroke, or coronary heart disease in any of the family members. The infant is delivered via cesarean section for fetal bradycardia and maternal eclampsia. At birth, she requires resuscitation with bag and mask for 1 minute, which is followed by delivery room continuous positive airway pressure (CPAP). Respiratory distress in the immediate neonatal period is supported with bubble CPAP in the first 48 hours after birth. For hemodynamically significant patent ductus arteriosus (PDA), the newborn is treated with diuretics, inotropes, and then ibuprofen syrup from day 3 to day 6 after birth. Echocardiography performed on day 6 after birth shows a closed PDA and no structural heart defect or vegetation. On day 8 after birth, in view of recurrent apneas, positive sepsis screen, and a positive blood culture for coagulase-negative Staphylococcus , the infant is given intravenous vancomycin. Her general condition is improving; she is tolerating feeds and is being transferred to a stepdown unit. On day 14 after birth, the infant develops repeated desaturations, which progress to recurrent apnea over the duration of 12 hours. She continues to require an increasing fraction of inspired oxygen (FiO2), bubble CPAP, and then ventilation with 100% FiO2. On examination, the infant …

Efficacy of antenatal corticosteroids in preterm twins: the EPIPAGE-2 cohort study.

To investigate the efficacy of antenatal corticosteroid (ACS) therapy on short-term neonatal outcomes in preterm twins, and further document the influence of the ACS-to-delivery interval. EPIPAGE-2 is a nationwide observational multicentre prospective cohort study of neonates born between 22 and 34 completed weeks of gestation. All French maternity units, except in a single administrative region, between March and December2011. A total of 750 twin neonates born between 24 and 31weeks of gestation. Exposure to ACSs was examined in four groups: single complete course, with an ACS administration-to-delivery interval of ≤7days; single complete course, with an ACS-to-delivery interval of >7days; repeated courses; or no ACS treatment. Neonatal outcomes analysed were severe bronchopulmonary dysplasia, periventricular leukomalacia or intraventricular haemorrhage gradeIII/IV, in-hospital mortality, and a composite indicator of severe outcomes. Compared with no ACSs, in multivariable analysis, a single course of ACSs with an administration-to-delivery interval of ≤7days was significantly associated with a reduced rate of periventricular leukomalacia or intraventricular haemorrhage gradeIII/IV (aOR 0.2; CI 95% 0.1-0.5), in-hospital mortality (0.3; 0.1-0.6), and the composite indicator (0.1; 0.1-0.3), whereas a single course of ACDs with an administration-to-delivery interval of >7days did not significantly reduce the frequency of in-hospital mortality (0.7; 0.3-1.8). No significant differences in terms of benefit or risk were found when comparing repeated courses with a single complete course. In preterm twins, a single complete course of antenatal corticosteroids was associated with an improvement of severe neurological outcome, whereas reduced in-hospital mortality was seen only when the ACS-to-delivery interval was ≤7days. A single complete course of antenatal steroids reduced severe neurological morbidity in preterm twins (24-31weeks).

Case 2: A Late Preterm Newborn with Cyanosis

A male newborn is delivered at 35 -6/7 weeks’ gestational age with a birthweight of 2,700 g (50th percentile) to a gravida 3, para 2, 33-year old mother by elective lower segment cesarean section for prolonged rupture of membranes. Fetal ultrasound is unremarkable; a complete course of antenatal steroids and 2 doses of benzylpenicillin are administered. Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. Maternal history is unremarkable except for a treated urinary tract infection at 33 weeks. Group B streptococcal screening is negative. Umbilical arterial blood gas shows a pH of 7.30; base deficit of 1.5 mmol/L; and lactate of 3.6 mmol/L. At 1 hour of age, the infant is noted to have cyanosis and tachypnea, with respiratory rates of 80 to 90 breaths per minute, requiring 50% of incubator oxygen and subsequently nasal continuous positive airway pressure to maintain oxygen saturation of 91% to 95%. There is no pre- and postductal saturation gradient, and thoracic transillumation excludes a significant pneumothorax. On examination, the precordial impulse and femoral pulses are normal, heart sounds are dual, and a 1/6 systolic murmur at the lower left sternal edge is heard. There is no hepatosplenomegaly. Capillary blood gas shows the following: pH, 7.26; partial pressure of carbon dioxide, 62 mm Hg (8.2 kPa); partial pressure of oxygen (Pao2), 34 mm Hg (4.5 kPa); base excess, –1.8; plasma lactate, 30.6 mg/dL (3.4 mmol/L); and serum glucose, 45 mg/dL (2.5 mmol/L). Intravenous access is obtained with a full blood count and blood culture, and benzylpenicillin and gentamicin are administered. Arterial blood sampling from the right radial artery demonstrates Pao2 of 49 mm Hg (6.5 kPa) in 50% inspired oxygen (Fio2), which does not increase in 90% Fio2. An echocardiogram at 5 …

Empirical estimation of the normative blood pressure in infants

ObjectiveTo determine the expected systolic, mean and diastolic blood pressures at birth and respective rates of change during the first 72 hours of life in infants born <28 weeks EGA with a favorable short-term outcome, defined as survival to 14 days with grade II or less IVH.Study DesignSystolic, mean and diastolic blood pressures were continuously sampled at 0.5 Hz via umbilical artery catheter from birth through 72 hours. The raw data were aligned by postnatal hour and underwent error correction. For each infant, the mean values of systolic, mean and diastolic blood pressure were calculated for each postnatal hour. The slope and intercept of best-fit line for each of the three blood pressure parameters was then calculated. Infants that received inotropic medications, died in the first 14 days of life, or had IVH grade III or IV were excluded.ResultUsing 11.9 million valid data points from 35 infants (mean EGA = 25.7±1.5 weeks, mean birth weight = 865 ± 201 grams), we found independent associations of African-American race (p<0.01) and a complete course of antenatal steroids (p<0.01) with higher blood pressures at birth and a slower rate of increase. Acute chorioamnionitis was independently associated (p=0.02) with lower blood pressures at birth and a faster rate of increase. EGA and birth weight were not independently predictive of blood pressure parameters.ConclusionWe found that (i) the estimated mean blood pressure at birth is approximately 33 mmHg in a cohort of very preterm infants (ii) blood pressure gradually increases with postnatal age (iii) systolic blood pressure increases at a faster rate than diastolic blood pressure, (iv) race, antenatal steroid exposure, and chorioamnionitis are independent modulators of blood pressure while EGA and birth weight are not.

Postnatal Respiratory Compliance among Premature Ventilated Neonates Associated with Variable Timing and Dosing of Antenatal Steroids

Antenatal steroids (ANSs) improve the respiratory compliance of premature infants. Many premature neonates are born before the administration of a complete course of ANS. The objective of this study was to evaluate the respiratory system compliance (Crs) of premature (≤ 32 weeks gestation), intubated neonates in relation to the dose, and timing of ANS administration. Neonates (n = 61) were divided into four groups based on the dose and timing of ANS exposure: Group 1: no ANS; Group 2: partial course (one dose of betamethasone); Group 3: complete course (two doses of betamethasone administered within 2 weeks of delivery); and Group 4: remote course (two doses of betamethasone administered > 2 weeks before delivery). Crs was measured by single-breath occlusion technique. Indexed respiratory compliance ± standard error of the mean (mL/cmH2O/kg) adjusted for gestational ages were 0.359 ± 0.074, 0.366 ± 0.080, 0.625 ± 0.038, and 0.505 ± 0.060 for Groups 1 to 4, respectively. The mean indexed Crs in complete ANS was significantly higher than that of no ANS (0.266 ± 0.085; p = 0.016) as well as partial ANS group (0.259 ± 0.086; p = 0.025). Crs after birth was significantly higher among premature intubated neonates born to mothers who received a complete course of ANS within 2 weeks, compared with no ANS or a partial course of ANS.

Index of Suspicion in the Nursery

A female preterm infant was born at 28-weeks’ gestation to a G3P2A1 mother (third degree consanguineous marriage) by emergency cesarean delivery due to severe fetal growth restriction, oligohydramnios, and increasing liver transaminase levels in the mother. First conception was miscarriage at 12-weeks’ gestation. The second conception was intrauterine fetal demise at 30-weeks’ gestation; the pregnancy was complicated with acute fatty liver of pregnancy (AFLP) and acute kidney injury. Placenta showed massive perivillous fibrin deposition. Present pregnancy was spontaneously conceived. Pre-pregnancy, mother was diagnosed as hypothyroid and was started on thyroxine. She had also been started on aspirin since the last pregnancy and had received a complete course of antenatal steroids at 27-weeks’ gestation. Blood pressure of the mother at the time of admission was 140/90 mm Hg. This pregnancy was also complicated with AFLP, with serum glutamic-pyruvic transaminase levels of 586 U/L and lactate dehydrogenase levels of 863 U/L. The infant at birth weighed 960 g, required resuscitation with bag and mask for 30 seconds, and had Apgar scores of 5 and 7 at 1 minute and 5 minutes, respectively. Immediately after resuscitation, the infant was noted to have respiratory distress (Silverman-Andersen score of 8 of 10). In view of this distress, the infant was shifted to the NICU on a T-piece resuscitator and was started on continuous positive airway pressure at 15 minutes of age with a positive end-expiratory pressure of 5 cm and fraction of inspired oxygen of 0.50. Chest radiograph revealed surfactant deficiency. Surfactant (INSURE [intubation, surfactant administration, and extubation]) was given at 2 and 6 hours after birth in view of persistent respiratory distress and increased fraction of inspired oxygen requirement, respectively. She also had poor circulation, was off-color, and had increased capillary perfusion starting from 2 hours after birth. This shock was initially managed with a …

Antenatal steroid exposure and outcomes of very premature infants: a regional cohort study

ObjectiveTo compare mortality, short-term morbidity and long-term neurodevelopmental outcomes of <29 week premature infants with antenatal steroid exposure (none, incomplete and complete).Patients and methodsMulticentre retrospective cohort study, within a geographically...

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

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.

1219 Differences in Mortality/Morbidity with a Complete Course of Antenatal Steroids Compared to an Incomplete/No Course in Extremely Premature Neonates

BackgroundAntenatal steroids have been shown to reduce mortality and morbidity in neonates born less than 29 weeks gestation. Counselling of parents regarding outcomes is generally based on data that includes...

Outcomes of extremely low birth weight infants with varying doses and intervals of antenatal steroid exposure

To compare outcomes of extremely low birth weight (ELBW) infants exposed to no antenatal steroids (ANS); incomplete ANS and complete course of ANS at varying intervals prior to delivery. A retrospective review was performed on 169 ELBW infants with ANS exposure at varied dose-intervals. The odds of mortality, intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD) were compared between Group 1, infants born without ANS exposure, Group 2, infants born after one dose of ANS, Group 3, infants born after two doses of ANS given within a week, and Group 4, infants born after two doses of ANS >7 days prior to delivery. Mortality and IVH were significantly lower in Groups 3 (30% and 10%) and 4 (15% and 30%), compared to Groups 1 (56% and 69%) and 2 (56% and 38%). Increasing gestational age and exposure to complete course of ANS were significantly associated with decrease in mortality, BPD/mortality and IVH. Infants who received one dose of ANS had significantly lower incidence of severe IVH compared to infants without ANS exposure. Beneficial impact of ANS on mortality and composite BPD/mortality is evident only after a complete course and persists even with its administration beyond a week from delivery.

Does time interval between antenatal steroid administration and delivery affect neonatal outcomes in very low birth weight neonates—A cohort study

DELIVERY AFFECT NEONATAL OUTCOMES IN VERY LOW BIRTH WEIGHT NEONATESDA COHORT STUDY ALLISON GOEDEN, JEFFERY GARLAND, GAIL PECKMAN, MARGARET CARR, RICHARD PIRCON, Medical College of Wisconsin Affiliated Hospitals, OB/GYN, Wauwatosa, Wisconsin, St. Joseph Regional Medical Center, Pediatrics, Milwaukee, Wisconsin, St. Joseph Regional Medical Center, Center for Obstetrical Research and Education, Milwaukee, Wisconsin, Perinatal Medicine, Ltd., Milwaukee, Wisconsin, St. Joseph Regional Medical Center, Director-Center for Obstetrical Research and Education, Milwaukee, Wisconsin OBJECTIVE: To determine whether the neonatal benefit of a single course of antenatal steroids diminishes beyond fourteen days from administration. STUDY DESIGN: This retrospective cohort study included all women who received a complete course of antenatal steroids and delivered a living singleton between 26 and 34 weeks’ gestation between January 1999 and December 2004. Maternal charts were reviewed to obtain histories and confirm treatment. Neonatal demographic data and outcomes were collected prospectively and retrospectively reviewed. Individuals reviewing maternal data were blinded to neonatal outcomes. Comparisons were made between those delivering within seven days of receiving antenatal steroids and those beyond fourteen days using Student’s t-test, chi-square analysis, Fisher’s exact test and regression analysis. RESULTS: Two hundred and fifty-one patients met inclusion criteria. Patients were grouped based upon time from administration of steroids to delivery. In univariate analysis, neonates delivering greater than 14 days from antenatal steroids had higher Scores for Acute Neonatal Physiology (SNAP) (measures the severity of illness at 24 hours of life) (9.7 G 5.6 vs 7.3 G 4.4, p = 0.001). This difference remained in regression models that controlled potential confounders [RR = 1.76 (95 percent CI = 1.2, 2.5), p=0.006]. Risk of death or chronic lung disease was statistically significant in univariate analysis (17% vs 10%, p = 0.02). When corrected for potential confounders in regression analysis, statistical significance was not achieved [RR = 2.1 (95 percent CI = 0.98, 6.2), p=0.054]. There was no difference in IVH risk in either univariate (11% vs 12%, p = 0.8) or regression analysis [RR = 0.88 (95 percent CI = 0.38, 2.0)]. S118 SMFM Abstracts

Antenatal steroids may reduce adverse neurological outcome following chorioamnionitis: Neurodevelopmental outcome and chorioamnionitis in premature infants

To examine the effect of antenatal steroid exposure and in utero inflammation on the development of severe intraventricular haemorrhage, periventricular leukomalacia and long-term neurological outcome in infants less than 30 completed weeks gestation. Infants less than 30 completed weeks gestation from January 1996 to July 2001 were identified from a prospectively managed database. Placental pathology was reviewed for the presence or absence of chorioamnionitis and funisitis. Infants were divided into three groups depending on the degree of exposure to fetal inflammation (no inflammation, chorioamnionitis only and chorioamnionitis and funisitis). Data relating to gestational age, birthweight, sex, antenatal steroid exposure, surfactant treatment, days of positive pressure ventilation and days of oxygen requirement were collected. Cerebral ultrasound studies were examined for evidence of intraventricular or intraparenchymal echodensity and periventricular leukomalacia. Long-term neurological outcome was assessed by neurological examination for cerebral palsy and by Griffiths Mental Developmental Assessment for general developmental quotient. Two hundred and twenty infants were identified. The mean gestational age was 27.7 weeks and the mean birthweight 1092 g. Seventy-two per cent of mothers had received a complete course of antenatal steroids. The risk of Grade III intraventricular haemorrhage or intraparenchymal echodensity was associated with exposure to in utero inflammation if a complete course of antenatal steroids had not been received (P = 0.002). This association did not exist if a complete course of antenatal steroids was given (P = 0.62). Fourteen infants had cerebral palsy (7%). The presence of cerebral palsy was also associated with in utero inflammation in the absence of complete antenatal steroid cover (P = 0.03) and not in the presence of complete cover (P = 0.59). The mean general developmental quotient on Griffiths Mental Developmental Assessment at 12 months or 3 years was not affected by exposure to in utero inflammation regardless of antenatal steroid exposure. Risk of intraventricular haemorrhage or intraparenchymal echodensity and cerebral palsy was associated with in utero inflammation in the absence of a complete course of antenatal steroids. A complete course of antenatal steroids appeared to extinguish any association between in utero inflammation and adverse neurological outcome.

Diagnosis and Treatment of Low Systemic Blood Flow in Preterm Infants

After completing this article, readers should be able to: 1. Delineate the short- and long-term adverse outcomes associated with low systemic blood flow. 2. Explain why it is not appropriate to use blood pressure and population criteria for hypotension to determine which infants who have low systemic blood flow need cardiovascular support. 3. Describe the various hemodynamic states in neonates and the assessment that is useful in allowing discrimination between these states. 4. Characterize the hemodynamic effects of dopamine and dobutamine in neonates. 5. Delineate the most common characteristics of infants who fail to maintain superior vena cava flows despite the use of inotropes. Low systemic blood flow (SBF) commonly occurs in preterm infants who have respiratory distress in the first postnatal day. Such low flows are strongly associated with neonatal morbidity, including peri/intraventricular hemorrhage (P/IVH), developmental impairments, and mortality. Diagnosing which infants have low SBF is problematic; use of blood pressure (BP) and signs of poor tissue perfusion, including capillary refill times (CRT), poor renal function, and acidosis, results in substantial delays in the initiation of cardiovascular support and a proportion of affected infants missing treatment. The traditional approach to cardiovascular support of the preterm infant has been to identify infants who have hypotension and to use agents, particularly dopamine, titrated to improve BP. However, this strategy may not be the best for improving SBF, and it is yet to be demonstrated that this approach improves neonatal outcomes. This review focuses on identifying which infants have low SBF or organ blood flow, discusses mechanisms for low flows, and examines potential therapies for treating or preventing low flow. Cardiovascular compromise occurs in a number of clinical scenarios in preterm infants, but it is most common on the first postnatal day. Not all infants who have low SBF will be suspected based on clinical signs, including …

Changes in neurotrophin levels in umbilical cord blood from infants with different gestational ages and clinical conditions.

Apoptotic neuronal loss may be responsible for altered brain development associated with prematurity and perinatal insults. Neurotrophins play crucial roles in protecting neurons from entering or progressing along an apoptotic pathway. The present study examined levels of neurotrophins in human umbilical cord blood from infants at different gestational ages and clinical conditions. We collected 60 samples of cord blood and categorized them accordingly into three gestational age groups: group A (24-28 wk), group B (29-35 wk), and group C (>/=36 wk). Neurotrophin levels were determined by using brain-derived neurotrophic factor (BDNF) and neurotrophin 3 (NT3) ELISA. Clinical data were obtained by medical chart analysis. The BDNF levels were 884 +/- 386, 1421 +/- 616, and 2190 +/- 356 pg/mL in group A, group B, and group C, respectively. Significant differences were found between groups A and B (p = 0.038), groups A and C (p = 0.0001), and groups B and C (p = 0.001). Infants with severe intraventricular hemorrhage had significantly lower cord blood BDNF levels (925 +/- 513 pg/mL) compared with their normal counterparts (1650 +/- 674 pg/mL; p = 0.021). NT3 levels did not show significant change either across gestational ages or with the presence of intraventricular hemorrhage. Cord blood levels of BDNF may reflect the degree of neural maturity in premature infants. Interestingly, when a complete course of antenatal steroids was given, BDNF and NT3 cord blood levels were higher than when no steroid was given. Increased neurotrophins levels may also mediate improved neurodevelopmental outcome in infants who received antenatal steroids.

Neurodevelopmental outcome of premature infants after antenatal phenobarbital exposure

Objective: We previously demonstrated that antenatal phenobarbital does not decrease the risk of intracranial hemorrhage or early death in premature infants. The objective of the present study was to evaluate the impact of antenatal phenobarbital exposure on the neurodevelopmental outcome of premature infants born to women who were participating in the randomized clinical trial of antenatal phenobarbital exposure. Study Design: Infants were evaluated at 18 to 22 months corrected age with a standard neurologic examination and the Bayley scales of infant development measuring the mental developmental index and the psychomotor developmental index. Results: Of the 578 infants <34 weeks of gestational age who were born to women who were enrolled in the primary study, 7 infants died after discharge from the neonatal intensive care unit, and 135 infants were lost to follow-up. Infants who were lost to follow-up had a higher mean birth weight and gestational age and a lower maternal education, but the rates of intracranial hemorrhage were comparable to those infants who were evaluated. Among the infants who were evaluated (n = 436; 76%), the mean birth weight and gestational age, maternal education, and frequency and distribution of intracranial hemorrhage were similar in the antenatal phenobarbital exposed and placebo groups. Eighteen infants (8%) in the antenatal phenobarbital exposed group and 21 infants (11%) in the placebo group had cerebral palsy (P = not significant). There was no difference between the 2 groups in either the median Bayley II mental developmental index (85 in the antenatal phenobarbital and 86 in the placebo group) or the Psychomotor Developmental Index (91 in the antenatal phenobarbital and 91 in the placebo group). Infants with intracranial hemorrhage (23%) had significantly lower mental developmental index and psychomotor developmental index scores than infants with no intracranial hemorrhage, independent of antenatal phenobarbital exposure. In the total cohort of 436 infants, the presence of intracranial hemorrhage or periventricular leukomalacia was associated with lower mental developmental index and psychomotor developmental index scores; the presence of increasing birth weight, maternal education, and a complete course of antenatal steroids was associated with a higher mental developmental index score. Conclusion: Antenatal phenobarbital exposure did not favorably or adversely affect the neurodevelopmental outcome of premature infants at 18 to 22 months of age. (Am J Obstet Gynecol 2002;187:171-7.)