Neonatal Hypertension Research Articles

EBNEO commentary: Oral versus intravenous sildenafil for pulmonary hypertension in neonates.

Chetan C, Suryawanshi P, Patnaik A, Soni SB, Rath C, Pareek P, Gupta B, Garergrat RR, Verma A, Singh, Y. Oral versus intravenous sildenafil for pulmonary hypertension in neonates: a randomised trial. BMC Pediatr. 2022 May27; 22(1):311. DOI: 10.1186/s12887-022-03366-3. PMID: 35624452. Persistent pulmonary hypertension (PPHN) involves persistent pulmonary vascular resistance, which occurs in approximately 2 in every 1000 live infants.1 This is associated with sequelae, including chronic lung disease, neurodevelopmental complications, and death. The current well-understood management of PPHN includes inhaled nitric oxide (iNO), which is used as the first-line treatment of PPHN in higher-resourced countries.1 However, less-resourced countries have limited availability to iNO. There is some literature on other treatments, including sildenafil; however as recommended in the 2017 Cochrane review which evaluated five randomised clinical trials and several case reports that sildenafil has the potential to increase survival in neonates with PPHN, particularly in settings where iNO is not available.2 Subsequently, Chetan et al., at a single centre in a level III neonatal intensive care unit in an urban centre in India, developed an open labelled, parallel, randomised trial to determine if oral versus intravenous sildenafil have similar efficacy, safety, and response in the management of mild-to-moderate pulmonary hypertension in late preterm and term neonates. Pulmonary hypertension was defined as pulmonary arterial pressure (PAP) >25 mmHg on echocardiography within 72 h of birth. The primary outcome sought the time taken for PAP to <25 mmHg, comparing 6 hourly oral sildenafil 1 mg/kg/dose versus IV sildenafil given with a loading dose of 0.4 mg/kg of sildenafil over 3 h followed by continuous infusion of 1.6 mg/kg/day. Once treatment was started, echocardiograms were repeated every 12 h until PAP <25 mmHg and sildenafil were tapered within 4 days and stopped. Between February 2019 and December 2020, 40 infants were randomised in this study. Both groups had similar follow-up rates of 17/20 in the oral group and 15/20 in the IV group, and the sildenafil could be tapered after a median of 48 h in both groups. Complications of hypotension (n = 4) and reduced cardiac contractility (n = 1) were seen in the IV group requiring inotropes, compared to none in the oral group.3 Whilst there was no difference in the median time for sildenafil tapering between the two groups, this was in the context of 12 hourly echocardiograms. Perhaps, more frequent intervals of echocardiogram performed whilst on sildenafil may have found a difference between the two groups. This remains a small, unblinded trial with the clinicians managing the patients and performing the echocardiogram unblinded. Furthermore, the other limitations of this study were a small sample size of 40 babies which was not powered to detect a statistical or meaningful difference between the two preparations of sildenafil. Research directions could include a blinded, multicentre trial to increase further knowledge of the safety and efficacy of oral versus intravenous preparations of sildenafil in resource-limited settings. Whilst iNO will continue to be the first line, there may be scope to demonstrate sildenafil benefits as a dual therapy with iNO. Research performed in higher-resourced countries can lend further knowledge in this area. https://ebneo.org/ebneo-commentary-po-vs-iv-sildenafil-for-ph. AK receives funding from the Australian National Health and Medical Research Council (NHMRC) (APP1161379). The contents of this paper are solely the responsibility of the individual authors and do not reflect the views of the NHMRC. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. The authors have no conflicts of interest to declare.

Cerebral haemodynamic response to somatosensory stimulation in preterm lambs is enhanced following sildenafil and inhaled nitric oxide administration.

Background: Neurovascular coupling (NVC) leads to an increase in local cerebral blood flow and oxygenation in response to increased neural activity and metabolic demand. Impaired or immature NVC reported in the preterm brain, potentially reduces cerebral oxygenation following increased neural activity, predisposing to cerebral tissue hypoxia. Endogenous nitric oxide (NO) is a potent vasodilator and a major mediator of NVC and the cerebral haemodynamic response. NO modulators, such as inhaled nitric oxide (iNO) and sildenafil, induce vasodilation and are used clinically to treat pulmonary hypertension in preterm neonates. However, their impact on NVC in the preterm brain are unknown. We aimed to characterise the cerebral functional haemodynamic response in the preterm brain exposed to NO modulators. We hypothesized that iNO and sildenafil in clinical dosages would increase the baseline cerebral perfusion and the cerebral haemodynamic response to neural activation. Methods: Preterm lambs (126-7days' gestation) were delivered and mechanically ventilated. The cerebral functional haemodynamic response was measured using near infrared spectroscopy as changes in cerebral oxy- and deoxyhaemoglobin (ΔoxyHb, ΔdeoxyHb), following left median nerve stimulations of 1.8, 4.8, and 7.8s durations in control preterm lambs (n = 11), and following 4.8 and 7.8s stimulations in preterm lambs receiving either sildenafil citrate (n = 6, 1.33mcg/kg/hr) or iNO (n = 8, 20ppm). Results: Following 1.8, 4.8, and 7.8s stimulations, ∆oxyHb in the contralateral cortex increased (positive functional response) in 7/11 (64%), 7/11 (64%), and 4/11 (36%) control lambs respectively (p < 0.05). Remaining lambs showed decreased ΔoxyHb (negative functional response). Following 4.8s stimulations, more lambs receiving sildenafil or iNO (83% and 100% respectively) showed positive functional response compared to the controls (p < 0.05). No significant difference between the three groups was observed at 7.8s stimulations. Conclusion: In the preterm brain, prolonged somatosensory stimulations increased the incidence of negative functional responses with decreased cerebral oxygenation, suggesting that cerebral oxygen delivery may not match the oxygen demand. Sildenafil and iNO increased the incidence of positive functional responses, potentially enhancing NVC, and cerebral oxygenation.

Neonatal systemic hypertension across the PHIS database: An update

BackgroundThe definition of systemic hypertension in the neonatal population remains elusive given the variability of normative blood pressure measurements. Inadequate literature exists about incidence, therapy and long-term management of systemic hypertension in neonates. We aimed to describe the current incidence of neonatal systemic hypertension, differences in demographic and risk factors data. MethodsRetrospective cohort of neonates (≤28 days) admitted to a neonatal intensive care unit participating in Pediatric Health Information System (PHIS) between Jan 2010 and December 2020 with an ICD 9/10 code for hypertension. Patients were excluded if they had congenital heart disease lesions that might contribute to systemic hypertension or had incomplete data. ResultsThere were a total of 2494 hypertensive patients among the 432,367 NICU patients meeting the study inclusion criteria, with an incidence of 0.6%. Patients with hypertension were significantly more likely to die before discharge compared to patients without HTN (8.4% versus 3.8%, respectively, p < 0.001). Of the 2494, 52.8% received at least one antihypertensive agent, with hydralazine being the most prescribed agent (29.7%). ConclusionDiagnosis of Systemic hypertension continues to increase in the neonatal population, despite absence of well-defined criteria necessitating targeted medical management. A consensus guideline which addresses this very important condition is beneficial.

Clinico-aetiological Profile of Neonatal Hypertension: An Observational Study

Introduction: The incidence of hypertension among neonates admitted to the Neonatal Intensive Care Unit (NICU) is increasing. The reported incidence is between 0.2% and 3%. Blood Pressure (BP) among neonates varies considerably in the immediate postnatal period. The BP in neonates determined by birthweight, gestational age at birth and postnatal age. This variability in BP makes it challenging to diagnose neonatal hypertension. There is a paucity of Indian studies on neonatal hypertension. A systematic diagnostic evaluation of neonatal hypertension aids in early identification of the aetiology and further management. Aim: To assess the incidence of hypertension in neonates in the NICU and to evaluate the aetiology and clinical profile of neonatal hypertension. Materials and Methods: This was a hospital-based prospective observational study done at Sri Dharmasthala Manjunatheswara College of Medical Sciences and Hospital, Dharwad, Karnataka, India, between August 2016 and August 2021. A total of 29 neonates who had neonatal hypertension were included in the study after obtaining ethical committee clearance. All relevant data regarding demographic details, risk factors for hypertension, clinical features, probable aetiology, and relevant investigations were collected in a predesigned proforma. These neonates were followed- up once a month until six months of age. All the data were entered in Microsoft Excel version 2203 and analysed using the Statistical Package for Social Sciences (SPSS) software version 20.0. The categorical variables were described as percentages. The numerical variables were compared using a Student’s t-test and a Chi-square test. A p-value of 0.05 was considered statistically significant. Results: In the present study, out of 13,345, a total of 29 (0.22%) neonates had hypertension. Hypertension was more prevalent among term (82.7%). Of the 29 neonates, 19 (65.5%) had an antenatal risk for hypertension. A total of 14 (48.3%) of neonates had an antenatally diagnosed renal and/or cardiac anomaly. The most common presentation of hypertension is asymptomatic. Thirteen (44.8%) neonates had transient hypertension, which resolved at the time of discharge, and 16 (55.2%) neonates had persistent hypertension, requiring antihypertensive medication and follow-up. The most common aetiology for hypertension was renal and renovascular causes (44.8%). Mortality in the present study was 10.3% (n=3). Conclusion: Hypertension is an uncommon yet important problem in the NICU. In the majority of neonates, the presentation of hypertension is asymptomatic. Most common aetiology of hypertension being renal cause. Neonates with persistent hypertension may require long-term antihypertensive treatment and regular follow-up.

Antenatalni kortikosteroidi - između leka i rizika za razvoj fetusa i programiranja odrastanja

Antenatal corticosteroid therapy (ACST) is very important in reducing the sequelae of prematurity, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). This therapy has short-term and long-term neonatal consequences that range from reduced neonatal body weight, brain growth, hypertension, hypoglycemia and obesity to delayed neurological development. In addition to undeniable importance this type of therapy has on fetal maturation, it may also impact programming of fetuses future development and health during childhood and adulthood. ACST must be personalized, as a single course, and determined by indications and assessment of the expected time of delivery, so that the exposure time of the fetus to the effects of endogenous and exogenous steroids is shortened.

Phthalates cause a low-renin phenotype commonly found in premature infants with idiopathic neonatal hypertension.

Since the 1970s, when the initial reports of neonatal hypertension related to renal artery thromboembolism were published, other secondary causes of neonatal hypertension have been reported. Those infants with no identifiable cause of hypertension were labeled with a variety of terms. Herein, we describe such infants as having idiopathic neonatal hypertension (INH). Most, but not all, of these hypertensive infants were noted to have bronchopulmonary dysplasia (BPD). More recently, reports described common clinical characteristics seen in INH patients, whether or not they had BPD. This phenotype includes low plasma renin activity, presentation near 40weeks postmenstrual age, and a favorable response to treatment with spironolactone. A small prospective study in INH patents showed evidence of mineralocorticoid receptor activation due to inhibition of 11β-HSD2, the enzyme that converts cortisol to the less potent mineralocorticoid-cortisone. Meanwhile, phthalate metabolites have been shown to inhibit 11β-HSD2 in human microsomes. Premature infants can come in contact with exceptionally large phthalate exposures, especially those infants with BPD. This work describes a common low-renin phenotype, commonly seen in patients categorized as having INH. Further, we review the evidence that hypertension in INH patients with the low-renin phenotype may be mediated by phthalate-associated inhibition of 11β-HSD2. Lastly, we review the implications of these findings regarding identification, treatment, and prevention of the low-renin hypertension phenotype seen in premature infants categorized as having INH.

Pharmacokinetics of L-Citrulline in Neonates at Risk of Developing Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension.

Options to treat pulmonary hypertension (PH) in neonates with bronchopulmonary dysplasia (BPD) are few and largely ineffective. Improving the bioavailability of nitric oxide (NO) might be an efficacious treatment for BPD-PH. When administered orally, the NO-L-arginine precursor, L-citrulline, increases NO production in children and adults, however, pharmacokinetic (PK) studies of oral L-citrulline have not been performed in infants and children. This study characterized the PK of enterally administered L-citrulline in neonates at risk of developing BPD-PH to devise a model-informed dosing strategy. Ten premature neonates (≤28 weeks gestation) were administered a single dose of 150 mg/kg (powder form solubilized in sterile water) oral L-citrulline at 32 ± 1 weeks postmenstrual age. Due to the need to limit blood draws, time windows were used to maximize the sampling over the dosing interval by assigning neonates to one of two groups (ii) samples collected pre-dose and at 1- and 2.5-h post-dose, and (ii) pre-dose and 0.25- and 3-h post-dose. The L-arginine concentrations (µmol/L) and the L-citrulline (µmol/L) plasma concentration-time data were evaluated using non-compartmental analysis (Phoenix WinNonlin version 8.1). Optimal dosage strategies were derived using a simulation-based methodology. Simulated doses of 51.5 mg or 37.5 mg/kg given four times a day produced steady-state concentrations close to a target of 50 µmol/L. The volume of distribution (V/F) and clearance (CL/F) were 302.89ml and 774.96ml/h, respectively, with the drug exhibiting a half-life of 16 minutes. The AUC from the time of dosing to the time of last concentration was 1473.3h*μmol/L, with Cmax and Tmax of 799μmol/L and 1.55h, respectively. This is the first PK study in neonates presenting data that can be used to inform dosing strategies in future randomized controlled trials evaluating enteral L-citrulline as a potential treatment to reduce PH associated with BPD in premature neonates. Clinical trials.gov Identifier: NCT03542812.

Comparison of the Effectiveness of Bosentan and Sildenafil in the Management of Persistent Pulmonary Arterial Hypertension in Neonates

Comparison of the Effectiveness of Bosentan and Sildenafil in the Management of Persistent Pulmonary Arterial Hypertension in Neonates

Methylglyoxal in Correlation with Persistent Pulmonary Hypertension of Neonates

Methylglyoxal in Correlation with Persistent Pulmonary Hypertension of Neonates

SMART MULTIPARAMETER INFANT APNOEA MONITOR

Apnoea is a common disorder in preterm infants who may also suffer from neonatal hypertension. Conventional apnoea monitors used in neonatal intensive care units (NICUs) do not include features for measuring neonatal blood pressure and real-time remote monitoring. Smart devices to monitor this problem in resource-poor environments are expensive and sparsely available. This paper presents the development of a smart multiparameter infant apnoea monitor in a resource-poor setting. The circuit was designed and simulated in Proteus software. The signals were processed using Arduino mega microcontrollers. The microcontroller concurrently communicates apnoea events to the GSM modem and alarm which notify the doctor and caregivers by SMS alert and audible alarm, respectively. Preliminary testing on stable infants at the NICU of Lagos University Teaching Hospital showed promising results. The device can effectively be used to monitor apnoea in infants as well as transmit the results to the doctor in a remote location by SMS. It can also be used to monitor other parameters like oxygen saturation, respiratory rate, heart rate and blood pressure. The documented experiences will provide useful insights for smart infant apnoea monitor development in resource-poor environments.

A Strangulated Congenital Diaphragmatic Bochdalek Hernia Diagnosed in an Adult

Although Bochdalek hernias are uncommon in adults and difficult to diagnose, such congenital diaphragmatic hernias (CDHs) are some of the most serious malformations among newborns. In particular, CDHs are accompanied by high mortality and marked disability later in life due to concomitant morbidity (i.e., caused by pulmonary lung hypoplasia and persisting pulmonary hypertension of neonates) and require long-lasting neonatal treatment in an intensive care unit. Late-diagnosed CDHs are extremely rare and always show small defects that justify a better prognosis than CDHs with large defects. In most cases, such CDHs go undiagnosed due to their mild, delayed symptoms. In the case described here, an 18-year-old Asian male presented with abdominal pain and a bowel contour in the epigastric region and left upper quadrant. A chest X-ray and thoracoabdominal computerized tomography scan confirmed the diagnosis of bowel obstruction due to a left diaphragmatic hernia. Moreover, a defect was revealed in the posterolateral left diaphragm, and the transverse colon, spleen, and half of the stomach had herniated through it. A segmentectomy was performed on the transverse colon, followed by an end-to-end anastomosis, a diaphragmatic plasty, and the placement of an intrapleural catheter. In conclusion, diagnosing a diaphragmatic hernia before surgery can be difficult due to its rarity and wide range of symptoms. Although prenatal diagnosis using ultrasonography is possible in up to 80% of fetuses, that method may not be available in all regions in Indonesia or in all countries, where doctors thus continue to face a diagnostic challenge when dealing with CDHs.

Pilot Study Investigating Brain Natriuretic Peptide, Troponin, Galectin-3, and miRNA-126a-5p as Biomarkers of Persistent Pulmonary Hypertension in Neonates with Hypoxic-Ischemic Injury Receiving Therapeutic Hypothermia.

The objective was to evaluate the utility of brain natriuretic peptide (BNP), troponin, galectin-3 (Gal-3), and microRNA (miRNA)-126a-5p as screening biomarkers for persistent pulmonary hypertension of the newborn (PPHN) by comparing expression in serum of infants with hypoxic-ischemic injury that develop PPHN to those that do not. This was a prospective, observational pilot study including neonates with hypoxic-ischemic injury undergoing therapeutic hypothermia (TH) at two regional perinatal medical centers. PPHN in this population was diagnosed clinically and confirmed by echocardiogram. Serial measurements of biomarkers were performed from 6 to 96 hours post-TH initiation in 40 patients. Of 40 infants in the study, 10 (25%) developed PPHN and 30 (75%) did not. Baseline demographics and hemodynamics were similar between the groups. Patients with PPHN had a significantly higher need for vasopressors compared with patients without PPHN (70 vs. 27%, p = 0.007). Mean serum BNP and troponin levels were significantly higher in the PPHN group peaking at 12 to 24 hours and decreasing following PPHN treatment initiation. miRNA-126a-5p expression was increased in patients with PPHN compared with patients without, with statistical significance detected at 12 hours (p = 0.005) and 96 hours (p = 0.01). Mean circulating Gal-3 levels were not statistically different between the two groups; however, Gal-3 was elevated in all patients with hypoxic-ischemic injury on TH compared with healthy infants from prior studies. BNP and troponin are readily available, low-cost biomarkers that showed significant serial elevations in the PPHN group of the study and, thus, may have value in screening for PPHN in the setting of hypoxic-ischemic encephalopathy (HIE). Gal-3 was elevated in all patients with HIE and may be a useful biomarker of hypoxic injury in infants being evaluated for TH. Elevations in miRNA-126a-5p were not consistently seen in this study. Larger studies are required to establish an association between PPHN and these biomarkers in patients with and without HIE. · Serum biomarkers of persistent pulmonary hypertension of the newborn. · Serum biomarkers of hypoxic-ischemic injury.

Neonatal hypertension: concerns within and beyond the neonatal intensive care unit.

Neonatal hypertension occurs in 1%–2% of neonates in the neonatal intensive care unit (NICU) although may be underdiagnosed. Blood pressure values in premature neonates change rapidly in the first days and weeks of life which may make it more difficult to recognize abnormal blood pressure values. In addition, the proper blood pressure measurement technique must be used to ensure the accuracy of the measured values as most blood pressure devices are not manufactured specifically for this population. In premature neonates, the cause of the hypertension is most commonly related to prematurity-associated complications or management while in term neonates is more likely to be due to an underlying condition. Both oral and intravenous antihypertensive medications can be used in neonates to treat high blood pressure although none are approved for use in this population by regulatory agencies. The natural history of most neonatal hypertension is that it resolves over the first year or two of life. Of concern are the various neonatal risk factors for later cardiovascular and kidney disease that are present in most NICU graduates. Prematurity increases the risk of adulthood hypertension while intrauterine growth restriction may even lead to hypertension during childhood. From neonates through to adulthood NICU graduates, this review will cover each of these topics in more detail and highlight the aspects of blood pressure management that are established while also highlighting where knowledge gaps exist.

Oral versus intravenous sildenafil for pulmonary hypertension in neonates: a randomized trial

BackgroundSildenafil is the drug of choice for neonatal pulmonary hypertension in developing countries where inhaled nitric oxide is not available. Available as oral and intravenous preparation – no study has been done in the past to compare the two forms. Each has its own benefits – but requires comparison in terms of efficacy and safety. This study was done to compare the efficacy of oral versus intravenous (IV) sildenafil in infants with mild to moderate pulmonary hypertension.MethodsAn open labelled randomized trial was conducted in a neonatal intensive care unit of urban tertiary hospital in western India between February 2019 to December 2020. Infants born after 34 weeks of gestation with Pulmonary arterial pressure (PAP) > 25 mm Hg measured by echocardiography, within 72 h of birth, were enrolled for the study. Participants were randomly assigned to receive sildenafil either orally or by intravenous route. Primary outcome was the time taken for PAP to decrease below 25 mm Hg. Secondary outcomes were time taken for oxygenation index to decrease by 25%, duration of invasive and non-invasive mechanical ventilation, nasal oxygen, hospital stay, time to achieve full feeds, mortality, and side effects.ResultsForty patients were enrolled. The baseline characteristics of neonates in both groups were similar except for APGAR scores at 1 min and 5 min, with oral group having lower score [MEDIAN (IQR) 5.00 (4.00- 7.00) and 7.00 (6.00- 8.00)] compared to IV group [MEDIAN (IQR) 7.00 (6.00–8.00) and 9.00 (8.00–9.00)] respectively. Time taken for PAP to decrease below 25 mm was not statistically different between the oral and intravenous groups. Systemic hypotension occurred in 4 neonates of the intravenous group but none in the oral group.ConclusionOral and intravenous sildenafil had equal efficacy at reducing PAP in neonatal pulmonary hypertension, albeit intravenous sildenafil use was associated with a greater complication rate.Trial registrationTrial was registered in the clinical trials registry of India [CTRI/2019/04/018781][25/04/2019].

Echocardiographic Assessment of Pulmonary Hypertension in Neonates with Congenital Diaphragmatic Hernia Using Pulmonary Artery Flow Characteristics.

Background: Assessment of pulmonary hypertension (PH) is essential in neonates with congenital diaphragmatic hernia (CDH). Echocardiography is widely established to quantify PH severity, but currently used parameters have inherent limitations. The aim of our study was to investigate the prognostic utility of the index of the pulmonary artery acceleration time to the right ventricular ejection time (PAAT:ET) in CDH neonates assessed using echocardiography. Methods: PAAT:ET values were prospectively measured in CDH neonates on admission, on day of life (DOL) 2 and DOL 5–7. Optimal cut-off values to predict mortality and need for ECMO were calculated and PAAT:ET values were compared between non-ECMO survivors, ECMO-survivors, and ECMO-non-survivors. Results: 87 CDH neonates were enrolled and 39 patients required ECMO therapy. At baseline, PAAT:ET values were significantly lower in ECMO patients compared to non-ECMO patients (p < 0.001). ECMO survivors and ECMO non-survivors had similar values at baseline (p = 0.967) and DOL 2 (p = 0.124) but significantly higher values at DOL 5–7 (p = 0.003). Optimal PAAT:ET cut-off for predicting ECMO was 0.290 at baseline and 0.310 for predicting non-survival in patients on ECMO at DOL 5–7. Conclusion: PAAT:ET is a feasible parameter for early risk assessment in CDH neonates.

Neonatal Renovascular Hypertension in a Pediatric Patient due to Occult Renal Artery Thrombosis: A Case Report

Renovascular Hypertension (RVH) is the most common cause of neonatal hypertension seen in Neonatal Intensive Units (NICU) [1]. It accounts for 5-25% of childhood hypertension [2] and is the most common cause of surgically correctable hypertension.

Clinical analysis of 2860 cases of diabetes in pregnancy: a single-center retrospective study

BackgroundTo investigate the epidemiological, clinical characteristics and outcomes of diabetes in pregnancy (DIP).MethodsThis single-center, retrospective study included 16,974 pregnant women hospitalized during 2018–2019. Among them, 2860 DIP patients were grouped according to diabetes type, glycemic status, and insulin use. Multivariate logistic regression analysis was conducted.ResultsThe incidence of DIP [17.10%; pregestational diabetes mellitus (PGDM), 2.00% (type I, 0.08%; type 2, 1.92%); gestational diabetes mellitus (GDM), 14.85% (GDM A1, 13.58%; GDM A2, 1.27%)] increased annually. Premature birth, congenital anomalies, large for gestational age (LGA), neonatal asphyxia, neonatal intensive care unit transfer, hypertension, and puerperal infection were more common in DIP than in healthy pregnancies. The most common comorbidities/complications were hypertension, thyroid dysfunction, cervical incompetence, intrahepatic cholestasis, premature membrane rupture, oligo/polyhydramnios, and fetal distress. GDM incidence at ages ≥35 and ≥ 45 years was 1.91 and 3.26 times that at age < 35 years, respectively. If only women with high-risk factors were screened, 34.8% GDM cases would be missed. The proportion of insulin use was 14.06% (PGDM, 55%; GDM, 8.53%). Mean gestational age at peak insulin dose in DIP was 32.87 ± 5.46 weeks. Peak insulin doses in PGDM and GDM were 3.67 and 2 times the initial doses, respectively. The risks of LGA, premature birth, cesarean section, and neonatal hypoglycemia in PGDM were 1.845, 1.533, 1.797, and 1.368 times of those in GDM, respectively. The risks of premature birth and neonatal hypoglycemia in women with poor glycemic control were 1.504 and 1.558 times of those in women with good control, respectively.ConclusionsThe incidence of adverse outcomes in DIP is high.

Atresia of the Abdominal Aorta Presenting as Neonatal Arterial Hypertension: a Case Report with Literature Review

Objective − We present a case of neonatal arterial hypertension in a patient with atresia of the abdominal aorta diagnosed after an extensive diagnostic workup, emphasizing the importance of imaging methods in the detection of vascular malformations. The article reviews the vascular causes of neonatal arterial hypertension. Case Report − A case of a 5-day-old boy born after 38 weeks of gestation who was admitted to a tertiary level medical center due to arterial hypertension, tachypnea, and a heart murmur was reported. Abdominal Doppler US revealed high flow paraspinal vessels and huge bilateral subcutaneous collaterals extending from the pelvis towards the upper abdomen. Common iliac arteries and abdominal aorta at the level of renal arteries and below could not be differentiated. The main differential diagnostic options were stenosis of the abdominal aorta or paraspinal arterio-venous malformation. Magnetic resonance angiography revealed atresia of the abdominal aorta, with large caliber bilateral paraspinal collaterals, feeding the lower part of the body. Surgical treatment wasn’t indicated at that time. At the present the patient is four years old, developing normally on antihypertensive therapy. Conclusion − Neonatal arterial hypertension is rarely idiopathic, thus identifying a possible underlying illness becomes imperative. Imaging methods have a pivotal role in the early detection of the causes of neonatal arterial hypertension.

Recurrent preterm birth: data from the study "Birth in Brazil".

ABSTRACTOBJECTIVE Describe and estimate the rate of recurrent preterm birth in Brazil according to the type of delivery, weighted by associated factors.METHODS We obtained data from the national hospital-based study “Birth in Brazil”, conducted in 2011 and 2012, from interviews with 23,894 women. Initially, we used the chi-square test to verify the differences between newborns according to previous prematurity and type of recurrent prematurity. Sequentially, we applied the propensity score method to balance the groups according to the following covariates: maternal age, socio-economic status, smoking during pregnancy, parity, previous cesarean section, previous stillbirth or neonatal death, chronic hypertension and chronic diabetes. Finally, we performed multiple logistic regression to estimate the recorrence.RESULTS We analyzed 6,701 newborns. The rate of recurrence was 42.0%, considering all women with previous prematurity. Among the recurrent premature births, 62.2% were spontaneous and 37.8% were provider-initiated. After weighting by propensity score, we found that women with prematurity have 3.89 times the chance of having spontaneous recurrent preterm birth (ORaj = 3.89; 95%CI 3.01–5.03) and 3.47 times the chance of having provider-initiated recurrent preterm birth (ORaj = 3.47; 95%CI 2.59–4.66), compared to women who had full-term newborns.CONCLUSIONS Previous prematurity showed to be a strong predictor for its recurrence. Thus, expanding and improving the monitoring and management of pregnant women who had occurrence of prematurity strongly influence the reduction of rates and, consequently, the reduction of infant morbidity and mortality risks in the country.

Systemic Hypertension in Infants with Bronchopulmonary Dysplasia.

Neonatal hypertension is increasingly recognized as improvements in neonatal intensive care have led to increased survival of premature infants. Among infants with bronchopulmonary dysplasia (BPD), the rates of hypertension are much higher than the general neonatal population. However, the etiology and pathophysiology of this increased risk of hypertension in neonates with lung disease remain unclear. Among infants with bronchopulmonary dysplasia, the rates of hypertension are much higher than the general neonatal population. New studies suggest outcomes in neonates with BPD with hypertension are usually good, with resolution of hypertension in most infants with lung disease. Several potential mechanisms of hypertension in this patient population have been recently proposed. This review focuses on the recent epidemiologic data on prevalence of hypertension in neonates with bronchopulmonary dysplasia, reviews the typical clinical course, and discusses available strategies for management of infants with bronchopulmonary dysplasia that develop hypertension.