Diagnosis Of Intraventricular Hemorrhage Research Articles

Implementation of a Standardized Red Blood Cell Transfusion Policy in a Level IV Neonatal Intensive Care Unit: A Quality Improvement Project.

Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants. For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration. The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500g. The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data. Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

Implementation of a Standardized Red Blood Cell Transfusion Policy in a Level IV Neonatal Intensive Care Unit: A Quality Improvement Project.

Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants. For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration. The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500g. The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data. Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

Early red blood cell transfusion and the occurrence of intraventricular hemorrhage in very preterm infants

BackgroundPreterm infants are at risk of developing both intraventricular hemorrhage (IVH) and anemia of prematurity. Several studies reported an association between early postnatal red blood cell (RBC) transfusion and IVH, however the timing and causality between these two remains unclear. AimsTo describe the temporal sequence between administration of early RBC transfusion (within the first week of life) and diagnosis of IVH in very preterm infants. Study designRetrospective single center case-series. Subjects132 very preterm infants (<32 weeks' gestation), admitted to a level III neonatal intensive care unit, studied with serial cranial ultrasound (CUS), and diagnosed with any grade of IVH. Outcome measuresNumber and timing of early RBC transfusions in relation to the timing of IVH. ResultsMedian time of IVH diagnosis was 20.5 h after birth (interquartile range [IQR], 6.25–49.00 h). Of those who received an early RBC transfusion (36 %, 47/132), only 15 % (20/132) received it before the IVH diagnosis. Infants with RBC transfusion before IVH more frequently had lower birth weight, received less fequently antenatal steroids, required more often invasive mechanical ventilation and surfactant administration, had more often hypo- and hypercapnia, and received more fluid boluses, NaHCO3, and inotropes compared to the rest. ConclusionsIn the majority of infants, IVH was already present at the time of the first RBC transfusion. Studies including pre- and post RBC transfusion CUS are needed to assess the effect of early RBC transfusions on the development of IVH in preterm neonates.

Neurodevelopmental Outcomes in Infants Screened for Retinopathy of Prematurity

Preterm infants screened for retinopathy of prematurity (ROP) are at risk for heterogenous neurodevelopment outcomes that are difficult to predict. To characterize the potential association between socioeconomic and clinical risk factors and neurodevelopmental outcomes in a diverse, multicenter cohort of premature neonates screened for ROP. This was a retrospective cohort study using electronic medical records and US Census Bureau income data. This study was performed at academic (University of California, Los Angeles [UCLA] Mattel Children's Hospital and UCLA Santa Monica Hospital), community (Cedars-Sinai Medical Center), and LA county (Harbor-UCLA Medical Center) neonatal intensive care units. Participants included infants who met American Academy of Pediatrics guidelines for ROP screening and had records from at least 1 Bayley Scales of Infant and Toddler Development (BSID) neurodevelopment assessment between 0 and 36 months of adjusted age. Data analyses were conducted from January 1, 2011, to September 1, 2022. Demographic and clinical information, proxy household income, and health insurance type were collected as risk factors. Neurodevelopmental outcomes in the cognitive, language, and motor domains measured via BSID were the primary outcomes. A total of 706 infants (mean [SD] age, 28.6 [2.4] weeks; 375 male [53.1%]) met inclusion criteria. In a multivariable model, which included adjustments for birth weight, sex, insurance type, intraventricular hemorrhage (IVH), and age at assessment, public health insurance was associated with a 4-fold increased risk of moderate to severe neurodevelopmental impairment (NDI) in cognitive and language domains (cognitive, odds ratio [OR], 3.65; 95% CI, 2.28-5.86; P = 8.1 × 10-8; language, OR, 3.96; 95% CI, 2.61-6.02; P = 1.0 × 10-10) and a 3-fold increased risk in the motor domain (motor, OR, 2.60; 95% CI, 1.59-4.24; P = 1.4 × 10-4). In this adjusted model, clinical factors that were associated with an increased risk of moderate to severe NDI included lower birth weight, diagnosis of IVH, male sex, and older age at time of Bayley assessment. In unadjusted analyses, infants who received either laser or anti-VEGF treatment, compared with infants without treatment-requiring ROP, had lower BSID scores in multiple domains at 0 to 12 months, 12 to 24 months, and 24 to 36 months (DATA). In the multivariable model, treatment type was no longer associated with worse neurodevelopmental outcomes in any domain. Study results suggest an association between public insurance type and NDI in a diverse population screened for ROP, indicating the complexities of neurodevelopment. This study also supports the early neurodevelopmental safety of anti-VEGF treatment, as anti-VEGF therapy was not found to be independently associated with worse NDI in any domain.

Does Antenatal Progesterone Administration Modify the Risk of Neonatal Intraventricular Hemorrhage?

Progesterone administration has been associated with improved neurological outcomes following traumatic brain injury in adults. However, studies examining the effect of progesterone on the risk of neonatal intraventricular hemorrhage (IVH) are inconsistent. We sought to determine if maternal administration of intramuscular 17-α-hydroxyprogesterone caproate (17-OHPC) is associated with decreased rates of IVH in infants born before 32-weeks gestation. This is a retrospective study of liveborn singleton deliveries between 20- and 32-weeks gestation at two large academic medical centers from January 1, 2012 to August 30, 2020. Data were extracted from hospital electronic medical record data warehouses using standardized definitions and billing and diagnosis codes. We evaluated receipt of 17-OHPC in the antepartum period and diagnosis of IVH (grade I-IV, per Volpe classification) during the neonatal delivery hospitalization encounter. Bivariate and multivariate analyses were performed to examine the association between 17-OHPC and neonatal IVH adjusting for potential confounders. Odds ratio (ORs) and 95% confidence intervals (CIs) were presented. Among 749 neonates born between 20- and 32-week gestation, 140 (18.7%) of their mothers had received antenatal 17-OHPC and 148 (19.8%) were diagnosed with IVH after birth. No significant association was observed between maternal 17-OHPC and neonatal IVH in unadjusted (OR 1.14, 95% CI 0.72-1.78) or adjusted analyses (adjusted odds ratio 1.14, 95% CI 0.71-1.84). Independent of exposure to 17-OHPC, as expected, infants born <28-weeks gestation or those with very low birthweight (<1,500 g) were at an increased risk of IVH (OR 2.32, 95% CI 1.55-3.48 and OR 2.19, 95% CI 1.09-4.38, respectively). Antenatal maternal 17-OHPC administration was not associated with the risk of neonatal IVH. Further research may be warranted to determine whether timing, route of delivery, and duration of progesterone therapy impact rates of neonatal IVH. · This study aimed to compare the frequency of intraventricular hemorrhage in preterm neonates exposed to antenatal 17-α-hydroxyprogesterone caproate to those not exposed.. · In neonates born at <32-weeks gestation, maternal use of progesterone is not associated with the risk of intraventricular hemorrhage.. · In contrast to preclinical and adult data, this study suggests that progesterone exposure is not associated with the prevention of neonatal brain injury..

The Value of Cranial Ultrasound in the Detection and Diagnosis of Intraventricular Hemorrhage and Focal White Matter Damage in Premature Infants

The Value of Cranial Ultrasound in the Detection and Diagnosis of Intraventricular Hemorrhage and Focal White Matter Damage in Premature Infants

Potential Risk Factors for Ventriculoperitoneal Shunt Implantation in Paediatric Patients with Posthemorrhagic Hydrocephalus of Prematurity Treated with Subcutaneous Reservoir: An Institutional Experience.

Posthemorrhagic hydrocephalus of prematurity (PHHP) is a result of intraventricular hemorrhage (IVH). IVH occurs in 6 to 23% of the preterms in countries with advanced medical health care. Most of these patients will eventually require the use of ventriculoperitoneal shunt (VPS). The purpose of this study is to assess the risk factors of VPS implantation in patients with PHHP who have been treated with ventricular catheter with subcutaneous reservoir (VCSR). The retrospective study was conducted evaluating 35 premature patients who suffered from severe IVH. Their mean gestational age was 28 weeks. The assessment included antenatal factors such as gestational age, birth weight, and intrauterine and perinatal infection. Postparturient period factors such as the IVH grade, time between diagnosis, and VCSR implantation and body weight on VCSR implantation were also considered in the study. Postprocedural complications, such as bacterial cerebrospinal fluid (CSF) infection, sepsis, and skin lesions, were evaluated. Data were calculated with R program, version 4.04. From among 35 evaluated patients, 23 (65.71%) required a VPS. Median of birth weight was 1,190 g. Infections were observed in 11 (31.43%) cases. Mean time between IVH diagnosis and VCSR implantation was 2.6 weeks. Postprocedural complications occurred in 19 (54.29%) patients. None of the evaluated factors has proven its statistical significance (p > 0.05) for being a potential risk factor for VPS implantation. External factors seem to not affect the necessity of VPS implantation in patients after the severe IVH. Ostensibly, there seems to be no difference between the grades III and the IV of Papile's IVH scale regarding VPS implantation necessity.

748 Does antenatal progesterone administration modify the risk of neonatal intraventricular hemorrhage?

Progesterone has been associated with improved neurologic outcomes following traumatic brain injury in adults. We sought to determine if maternal administration of intramuscular progesterone (17-OHP) is associated with decreased rates of intraventricular hemorrhage (IVH) in infants born before 32 weeks’ gestation. This is a retrospective study of liveborn singleton deliveries between 20-32 weeks’ gestation at two large academic medical centers from January 2012 to November 2019. Data were extracted from hospital electronic medical record data warehouses using standardized definitions and billing and diagnosis codes. Women whose neonates were diagnosed with IVH (Grade I-IV, per Volpe classification) during their birth hospitalization encounter were compared to those whose neonates were not. The exposure of interest was receipt of intramuscular 17-OHP in the antepartum period. Bivariate and multivariate analyses were performed. Variables that were clinically significant were adjusted for in the models, maternal smoking status, parity, receipt of betamethasone and/or magnesium administration, gestational age at birth, birthweight, and neonatal sex. Of 911 neonates born between 20-32 weeks’ gestation, 187 (20.5%) had a diagnosis of IVH. A total of 140 (15.4%) received antenatal 17-OHP. Of these, 34 (24.3%) developed IVH and 106 (75.7%) did not. No significant association was seen between maternal 17-OHP and neonatal IVH in either unadjusted or adjusted analyses (Table 1). Multivariate analyses did show an increased risk of IVH with birth prior to 28 weeks’ gestation and a decreased risk of IVH with betamethasone administration prior to delivery. Antenatal maternal 17-OHP administration was not associated with a significant change in the risk of neonatal IVH. We could not account for adherence with 17-OHP administration, which may impact results. Additionally, it is unknown if vaginal progesterone could impact IVH incidence in exposed neonates due to a local effect. Further research may be warranted to see if vaginal progesterone impacts rates of neonatal IVH.

Does the Umbilical Cord Nucleated Red Blood Cellcan Help Predict Intraventricular Hemorrhage

Background: Intraventricular hemorrhage (IVH) is one of the most serious complications of premature deliveries, especially in very low birth weight (VLBW) newborns. The current study compared the number of nucleated red blood cells (NRBCs) in newborns with and without IVH.Methods: This cross-sectional study was carried out on 109 VLBW neonates who were referred to the Neonatal Intensive Care Unit (NICU) Department of Ghaem Hospital in Mashhad, Iran. They were investigated to evaluate the predictive value of cord NRBC in the diagnosis of IVH. To this end, 77 neonates who had normal brain ultrasonographywere assigned to the control group and 32 newborns with IVH were allocated to the case group. The percentage of NRBC per 100 white blood cells was determined by a blood sample. These neonates underwent brain ultrasonography3-5 days after the birth; thereafter, mean NRBC/100 WBC and the absolute number of NRBC swere compared in both groups.Results: In the current study, the mean scores of NRBC/100 WBC and the absolute number of NRBCs in neonates with IVH were obtained as 15.19 and 2272.38/μl. In the group without IVH, these values were reported as 40.95% and 5459.17/μl, respectively (P>0.05). Based on receiver operating characteristic (ROC) curve, the NRBC value does not have a diagnostic value in predicting the incidence of IVH.Conclusion: As illustrated by the obtained results, the number of absolute NRBCs and the percentage of NRBC/100 WBC cannot help to predict the probability of neonatal IVH. Nonetheless, further studies are recommended in this regard.

Older patients with Intraventricular Hemorrhage are Prone to Infection after External Ventricular Drainage

External ventricular drainage (EVD) is a life-saving and emergent procedure in neurosurgery. However, infection is the main problem in patients with EVD. The present study aims to analyze the infection rate of patients with EVD and to investigate the factors that contribute to infection and mortality rates. The data of patients who underwent emergent EVD procedure between 2018 and 2019 were retrospectively analyzed in this study. The demographic features of the patients were recorded. The correlation between age, gender, indication and duration of EVD, and the infection and mortality rate were investigated. In this study, 47 patients underwent emergent EVD in two years. Thirty (63.83%) patients were male, and 17 were female with a mean age of 28.02 years. The mean duration of drainage was 6.2 days. Fifty-eight cerebrospinal fluid (CSF) samples were analyzed during the drainage period and CSF culture was positive in 14 (24.14%) samples. The most common microorganism was Staphylococcus epidermidis. The infection rate was high in older and male patients with duration longer than six days. Nine (19.15%) patients died during the treatment period and six of them had IVH. The duration of EVD should be shorter in patients older than 65 years with the diagnosis of intraventricular hemorrhage, which is mostly related to dea.

Predictors of mortality for preterm infants with intraventricular hemorrhage: a population-based study.

The goal of this longitudinal, population-level study was to examine factors affecting mortality in preterm infants with intraventricular hemorrhage (IVH). The study examined patients who were born at 36weeks estimated gestational age (EGA) or less with a diagnosis of IVH between the years 2005 and 2014 using data from the New York and Nebraska State Inpatient Databases. Potential predictors for mortality were investigated with multivariable survival analysis. The cohort included 7437 preterm infants with IVH. All-cause inpatient mortality occurred in 746 (10.0%). The majority of deaths were in infants born at less than 25weeks EGA (378 or 50.7%) and with birthweight less than 750g (459 or 61.5%). Mortality was highest for children with grade IV IVH (306/848 or 36.1%), followed by grades III (203/955 or 21.3%), II (103/1328 or 7.8%), and I (134/4306 or 3.1%). Hydrocephalus was diagnosed within 6months in 627 (8.4%) patients, with cerebrospinal fluid shunts required in 237 (3.2%). Shunts were eventually revised in 122 (51.5% of shunts), and 43 (18.1%) had infections. Multivariable Cox survival analyses found male sex (HR 1.3 [95% CI 1.1-1.5]), Asian race (HR 1.5 [1.1-2.2]), lower EGA (HR 9.9 [6.3-15.5] for < 25weeks), higher IVH grade (HR 6.1 [4.9-7.6] for grade IV), gastrostomy (HR 4.0 [2.0-7.7]), tracheostomy (HR 3.5 [1.7-7.1]), and shunt infection (HR 3.2 [1.0-9.9]) to be independently associated with increased mortality risk. This database is the first of its kind assembled for population-based investigations of long-term neurosurgical outcomes in preterm infants with IVH.

THE EFFECT OF EYEMASKS ON REDUCING DISTRESS ASSOCIATED WITH THE RETINOPATHY OF PREMATURITY EXAM

Abstract BACKGROUND Retinopathy of prematurity (ROP) is a disorder of retinal development in the low birthweight preterm infant. Eye screening is routinely performed for infants at risk of developing this disorder. While these examinations help prevent blindness, they can be physiologically stressful for infants, with changes in oxygen saturation, blood pressure and heart rate occurring during the exam and increased apneic episodes reported the 24–48 hours period afterward. The cause of these increased apneic episodes is not currently known. OBJECTIVES To evaluate the effect of decreasing light simulation during mydriasis on the frequency of stressful episodes after ROP screening. DESIGN/METHODS Multi-centre randomized study. This study was approved by hospital ethics boards at all sites. After informed consent was obtained, infants with a birthweight &lt;1500g or gestational age of ≤32 weeks and scheduled for their first ROP screening were randomized to receive either standard of care or a phototherapy mask during pupil dilation, in addition to routine care. Dilated retinal exams were performed by retinal surgeons and fellows. The primary outcome was the frequency of any desaturation, bradycardic event, or apneic event 12 hours following the examination, compared to a baseline rate 12 hours prior to the exam. Heart rate, respiratory rate and oxygen saturation were recorded for up to 48 hours following the examination and compared to baseline. RESULTS A total of 51 infants were enrolled; 28 randomized to the masked group and 23 to the control group. 10 and 13 infants were on ventilator support at the time of examination in each group, respectively. There was a 57.7% decrease in the total number of all stressful events in the masked group compared to controls in the 12 hour post exam period (Rate Ratio 0.42, 95% CI 0.2–0.9, P=0.024). There was a 61.3% decrease in the number of bradycardic events in the masked group compared to controls (RR 0.39, 95% CI 0.2–1.0, P=0.042). Heart rate was significantly higher in both groups after the exam (Effect by time P=0.04), with no difference in between groups (Effect by group P=0.31). There was no significant difference seen in either group in respiratory rate or oxygen saturation at 2 or 4 hours after the ROP examination compared to baseline. Risk factors that were associated with increased stress included: younger gestational age (RR=1.32 95%CI [1.2–1.5] per week), lower birthweight (RR=1.39 [1.2–1.5] per 100g), ventilator support around the time of exam (RR=2.67 [1.3–5.6]), diagnosis of intraventricular hemorrhage (RR=3.78 [1.9–7.3]), and hyponatremia (RR=3.42 [1.8–6.6]). No adverse events occurred while using eye masks. CONCLUSION The infants who wore a phototherapy mask during pupillary dilation had lower rates of stressful episodes following screening for retinopathy of prematurity, particularly lower episodes of bradycardia.

Prenatal diagnosis of intraventricular hemorrhage

The case of prenatal ultrasound diagnosis of intraventricular hemorrhage of the third degree in the fetus at 35 weeks of gestation is presented. The child died after birth. The article discusses prenatal diagnosis and prognosis for children in this pathology.

Time-to-event analysis of surgically treated posthemorrhagic hydrocephalus in preterm infants: a single-institution retrospective study.

The purpose of this study is to report time points relevant to the neurosurgical management of posthemorrhagic hydrocephalus (PHH). Data were collected retrospectively on 104 preterm infants with intraventricular hemorrhage (IVH) who received neurosurgical intervention for PHH at St. Louis Children's Hospital from 1994 to 2016. Kaplan-Meier curves were constructed for various endpoints. IVH grade on head ultrasound obtained through routine clinical care was II, III, and IV in 5 (4.8%), 33 (31.7%), and 66 (63.5%) of the patients, respectively. Neither IVH size nor location appeared to affect development of PHH. Days from birth to IVH, ventriculomegaly, temporizing neurosurgical procedure (TNP), and permanent neurosurgical intervention were 2.0 (95% CI 1.7-2.3), 3.0 (2.5-3.5), 24.0 (22.2-25.8), and 101.0 (90.4-111.6), respectively. Grades III and IV IVH did not differ in age at IVH diagnosis (Χ 2 (1 d.f.)=1.32, p=0.25), ventriculomegaly (Χ 2=0.73, p=0.40), TNP (Χ 2=0.61, p=0.43), or permanent intervention (Χ 2=2.48, p=0.17). Ventricular reservoirs and ventriculosubgaleal shunts were used in 71 (68.3%) and 30 (28.8%), respectively. Eighty (76.9%) of the patients ultimately received a VPS. Five (4.8%) underwent a primary endoscopic third ventriculostomy (ETV), and two (1.9%) had ETV for a revision procedure. Four of the seven ETVs had choroid plexus cauterization. Although most infants who develop IVH and ventriculomegaly will do so within a few days of birth, at-risk infants should be observed for at least 4weeks with serial head ultrasounds to monitor for PHH requiring surgery.

Mean Platelet Volume as a Marker of Intraventricular Hemorrhage in Very Premature Infants

Background: Since the intraventricular hemorrhage (IVH) is still a serious problem in premature infants associated with poor neurodevelopmental outcomes, there is a need for an accessible tool in order to identify these at high risk neonates. Objectives: To determine if high mean platelet volume (MPV) within 24 hours of birth can identify preterm infants prone to IVH as a simple accessible test. Methods: One hundred premature infants with gestational age (GA) of < 34 weeks with respiratory distress syndrome (RDS) were eligible in this study and were divided into two groups based on the diagnosis of IVH. Measurements of MPV and platelet counts were performed during the first hours of admission and on the third day of life. Elevated MPV was defined as a value of ≥ 11 fL. Results: Seventy four percent of infants with IVH had an MPV of more than 11 fL compared to twenty six percent in infants without IVH (Crude OR: 10.71, 95%CI: 4.26 to 26.90, P < 0.001). Multivariate logistic regression analysis of selected variables demonstrated that MPV (Adjusted OR: 10.68, 95%CI: 3.20 to 35.59, P < 0.001) and GA (Adjusted OR: 0.54, 95%CI: 0.40 to 0.74, P < 0.001) were related to the occurrence of IVH. Conclusions: High MPV within 24 hours of birth can be determined as a simple available laboratory test for identifying NICU-admitted premature infants at risk of IVH.

Intraventricular hemorrhage in neonates born before 32weeks of gestation-retrospective analysis of risk factors.

IntroductionIntraventricular hemorrhage (IVH) affects 15–20 % of babies born before 32 weeks of pregnancy. A lot of risk factors of developing IVH are known. The making appropriate recommendations for dealing with infant born less than 32 weeks of gestation aimed at reducing the incidence of IVH is still needed. The study aim was to determine the incidence and analyze risk factors of IVH stage 3 and 4 in infants born before 32 + 0 weeks of pregnancy.MethodsThe retrospective analysis of 267 preterm babies (24 to 32 weeks of gestation) hospitalized in 2011–2013 at Department of Neonatology, Poznan University of Medical Sciences was performed. The diagnosis of IVH was confirmed by ultrasound scans according to Papille criteria. Stage 3 and 4 of IVH was confirmed in 14 (25 %) newborns from 23 to 24 weeks of gestation; 21 (37.5 %) from 25 to 26 weeks of gestation; 11 (19.6 %) from 27 to 28 weeks of gestation; 9 (16.1 %) from 29 to 30 weeks of gestation; and 1 (1.8 %) from 31 to 32 weeks of gestation.ResultThe incidence of IVH stage 3 and 4 was higher in children: with less use of AST (OR 1.27; 0.62–2.61), born out of third-level hospitals (OR 2.25; 1.23–4.08), born with asphyxia (OR 3.46; 1.8–6.64), with acidosis treated with NaHCO3 (OR 6.67; 3.78–11.75), those who in the first days of life were treated for hypotension (OR 9.92; 5.12–19.21).ConclusionNo or uncompleted antenatal steroid therapy increased probability for development of severe intraventricular hemorrhage. Antenatal steroids therapy should be promoted among women at risk of a premature delivery. Hypotension therapy with catecholamines and acidosis with sodium hydrogen carbonate should be carefully considered. The use of appropriate prophylaxis of perinatal (antenatal steroids therapy women at risk of preterm birth, limiting the indications for the use of catecholamines for hypotension treatment and sodium hydrogen carbonate for acidosis therapy, limitation of preterm deliveries outside tertiary referral centeres) significantly reduces the incidence of intraventricular hemorrhage stage 3 and 4. The significance of intraventricular hemorrhage creates a need to carry out periodical analysis, at regional level, concerning its incidence, causes and effects to improve local treatment outcomes by identifying further courses of action.

Posthemorrhagic hydrocephalus in extremely low birth weight infants: Ommaya reservoir vs. ventriculoperitoneal shunt.

PurposeThe aim of this study was to analyze morbidity and initial surgery in infants with posthemorrhagic hydrocephalus (PHH) by comparing infants who were treated with a subcutaneous cerebrospinal fluid reservoir (Ommaya reservoir = CSF_R) with infants who primarily received a ventriculoperitoneal shunt (VPS).MethodInclusion criteria were infants born between January 2006 and June 2014 who had a diagnosis of intraventricular hemorrhage (IVH) and underwent surgical intervention for hydrocephalus.ResultsTwenty-five infants, with a median gestational age (GA) of 26.5 (28 ± 4) weeks and a median birth weight (BW) of 980 g (1205 ± 837), were included. The median umbilical artery pH (UApH) was 7.30 (7.20 ± 0.25). The median Apgar score at 10 min was 8 (7.4 ± 2). Twenty-five peri- and postnatal adverse events were encountered preoperatively. The IVH grades were grade II (n = 1), grade III (n = 17), grade IV (n = 6), and unknown grade (n = 1). Primary treatment consisted of CSF_R (n = 18) or VPS (n = 7) placement. There was a statistically significant difference between the postnatal ages of infants with CSF_R (32.5 days; 42 ± 28) and infants with VPS (163 days; 161 ± 18). Furthermore, we found a difference regarding GA but not BW between both groups. Arrest of PHH with shunt independence occurred in two infants from the CSF_R group (11 %).ConclusionsIn the present study, early insertion of CSF_R allowed stabilization of the infants and thus postponement of permanent VPS insertion. However, in a subgroup of patients, PHH develops over a more prolonged course, and VPS insertion can be performed initially without the need for CSF_R.

Appearance of a neural bypass between injured cingulum and brainstem cholinergic nuclei of a patient with traumatic brain injury on follow-up diffusion tensor tractography images.

Appearance of a neural bypass between injured cingulum and brainstem cholinergic nuclei of a patient with traumatic brain injury on follow-up diffusion tensor tractography images.

Impaired white matter development in extremely low-birth-weight infants with previous brain hemorrhage.

Brain hemorrhage is common in premature infants. The purpose of the study is to evaluate white matter development in extremely low-birth-weight infants with or without previous brain hemorrhage. Thirty-three extremely low-birth-weight infants were prospectively enrolled and included in this institutional review board-approved study. Another 10 healthy term infants were included as controls. The medical records of the extremely low-birth-weight infants were reviewed for sonography diagnosis of intraventricular hemorrhage. All infants had an MR imaging examination at term-equivalent age for detection of previous hemorrhage, and their white matter was scored and compared among different groups. DTI measured fractional anisotropy values were also compared voxelwise by tract-based spatial statistics. Compared with controls, the white matter score was not significantly different in extremely low-birth-weight infants without blood deposition on MR imaging (P = .17), but was significantly worse in extremely low-birth-weight infants with blood deposition on MR imaging but no intraventricular hemorrhage diagnosis by sonography (P = .02), in extremely low-birth-weight infants with grade 1 or 2 intraventricular hemorrhage on sonography (P = .003), and in extremely low-birth-weight infants with grade 3 or 4 intraventricular hemorrhage on sonography (P = .0001). Extremely low-birth-weight infants without blood deposition on MR imaging did not show any white matter regions with significantly lower fractional anisotropy values than controls. Extremely low-birth-weight infants with blood deposition on MR imaging, but no intraventricular hemorrhage diagnosis, did show white matter regions with significantly lower fractional anisotropy values, and extremely low-birth-weight infants with intraventricular hemorrhage diagnosis had widespread white matter regions with lower fractional anisotropy values. Previous brain hemorrhage is associated with abnormal white matter in extremely low-birth-weight infants at term-equivalent age, and sonography is not sensitive to minor hemorrhages that are sufficient to cause white matter injury.

13: Method of delivery and neonatal outcomes in preterm, small for gestational age infants

in preterm, small for gestational age infants Erika F. Werner, David Savitz, Teresa Janevic, Stephen F. Thung, Edmund F. Funai, Heather Lipkind Johns Hopkins University, Gynecology and Obstetrics, Baltimore, MD, Brown University, Departments of Epidemiology and Obstetrics and Gynecology, Providence, RI, Yale University, Global Health Initiative, New Haven, CT, Yale University, Ob/Gyn & Reprod Science, New Haven, CT OBJECTIVE: Cesarean delivery (CD) has been proposed as an obstetric strategy to improve neonatal outcomes for premature fetuses with intrauterine growth restriction (IUGR). The relative rarity of this clinical situation has made prospective randomized studies challenging and has even limited retrospective cohort studies. This study was undertaken to compare neonatal outcomes by method of delivery in preterm ( 34 week), small for gestational age (SGA) infants in a large diverse cohort. STUDY DESIGN: Birth data for 1995 to 2003 from New York City were linked to hospital discharge data. Data were limited to singleton, live born, vertex neonates delivered between 25 and 34 weeks. Births complicated by known congenital anomalies, birth weight 500 grams and those requiring forceps or vacuum assistance were excluded. Deliveries were also excluded if there was a maternal history of prior CD. SGA was used as a surrogate for IUGR. Any diagnosis of intraventricular hemorrhage (IVH), seizure, sepsis, subdural hemorrhage, respiratory distress syndrome (RDS), or five minute Apgar 7 was considered a significant neonatal morbidity. Associations between method of delivery and neonatal morbidities were estimated using logistic regression. RESULTS: 2560 SGA neonates meeting the study criteria were identified; 46% were delivered vaginally and 54% were delivered by CD. There was no significant difference in IVH, subdural hemorrhage, seizure or sepsis between the CD and vaginal delivery (VD) groups. CD compared to VD was associated with increased odds of RDS. The increased odds persisted after controlling for maternal age, ethnicity, education, primary payor, pre-pregnancy weight, gestational age at delivery, diabetes and hypertension. CD compared to VD was associated with increased odds of five minute Apgar 7 using unadjusted odds (odds ratio: 1.4; 95% CI 1.1-1.9), but this difference dissipated after adjusting for confounding factors. CONCLUSION: CD was not associated with decreased odds of any neonatal complications and was associated with significantly higher odds of RDS in SGA preterm neonates. 14 Effect of prescription medications on 17-alphahydroxyprogesterone caproate (17-OHPC) metabolism Yang Zhao, Courtney Cuppett, Steve Caritis, Raman Venkataramanan University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, Magee-Womens Hospital, University of Pittsburgh, Maternal Fetal Medicine, Pittsburgh, PA OBJECTIVE: 17-OHPC and certain prescription medications are metabolized by the CYP3A4 enzyme. We hypothesize that these medications may compete with 17-OHPC for metabolism. Any alteration in 17-OHPC metabolism may affect the concentration of 17-OHPC and impact its efficacy. STUDY DESIGN: Pooled (n 5) human CYP3A4 microsomes were incubated for 60 min at 37C with 17-OHPC (2.5ug/mL) alone or in combination with 21 different medications known to be CYP3A4 substrates or inhibitors. Incubations were carried out in a solution of phosphate buffer and magnesium chloride. An NADPH-generating system was used to initiate metabolism. HPLC was performed to measure unmetabolized 17-OHPC concentration. RESULTS: Thirteen of the 21 drugs tested exhibited inhibitory effects on 17-OHPC metabolism. 17-OHPC metabolism was inhibited by 80% when incubated with montelukast, esomeprazole, nelfinavir, or ritonavir. Metabolism of 17-OHPC was inhibited by 50-80% in the presence of fluconazole, itraconazole, voriconazole, sertraline, haloperidol, trazodone, tacrolimus, or bergamottin. Only 20-50% inhibition was observed in the presence of fluticasone. CONCLUSION: 17-OHPC metabolism is inhibited by several prescription medications. Concomitant use of these medications during pregnancy may lead to significant alterations in 17-OHPC metabolism and ultimately impact the overall efficacy of 17-OHPC in the prevention of preterm birth. This work was supported by NICHD Obstetric-Fetal Pharmacology Research Units Network grant HD047905.