Annemiek M. Roescher

Placental Pathology, Perinatal Death, Neonatal Outcome, and Neurological Development: A Systematic Review

Background The placenta plays a crucial role during pregnancy for growth and development of the fetus. Less than optimal placental performance may result in morbidity or even mortality of both mother and fetus. Awareness among pediatricians, however, of the benefit of placental findings for neonatal care, is limited. Objectives To provide a systematic overview of the relation between placental lesions and neonatal outcome. Data sources Pubmed database, reference lists of selected publications and important research groups in the field. Study appraisal and synthesis methods We systematically searched the Pubmed database for literature on the relation between placental lesions and fetal and neonatal mortality, neonatal morbidity and neurological outcome. We conducted three separate searches starting with a search for placental pathology and fetal and neonatal mortality, followed by placental pathology and neonatal morbidity, and finally placental pathology and neurological development. We limited our search to full-text articles published in English from January 1995 to October 2013. We refined our search results by selecting the appropriate articles from the ones found during the initial searches. The first selection was based on the title, the second on the abstract, and the third on the full article. The quality of the selected articles was determined by using the Newcastle-Ottawa Quality Assessment Scale. Results Placental lesions are one of the main causes of fetal death, where placental lesions consistent with maternal vascular underperfusion are most important. Several neonatal problems are also associated with placental lesions, whereby ascending intrauterine infection (with a fetal component) and fetal thrombotic vasculopathy constitute the greatest problem. Conclusions The placenta plays a key role in fetal and neonatal mortality, morbidity, and outcome. Pediatricians should make an effort to obtain the results of placental examinations.

Hydrocortisone vs. dexamethasone treatment for bronchopulmonary dysplasia and their effects on general movements in preterm infants

Introduction:Hydrocortisone (HC) and dexamethasone (DXM) are used to treat preterm infants at risk for bronchopulmonary dysplasia (BPD). This may, however, affect their long-term neurological development. We aimed to determine the effect of HC and DXM therapy in preterm infants on neurological functioning as assessed by the quality of general movements (GMs) until 3 months after term.Results:We found no difference in the quality of GMs between HC and DXM infants until term age. At 3 months, HC infants had a higher median motor optimality score (MOS) than DXM infants (25 vs. 21, P = 0.015). In the DXM group, MOS on the first day of treatment was lower than before treatment (10 vs. 11, P = 0.030).Discussion:MOS decreased in DXM infants on the first day following treatment and at 3 months after term. This was not the case in HC infants. Our study suggests that neurological functioning at 3 months after term is better in infants treated with HC than in infants treated with DXM.Methods:We performed a longitudinal, observational study including 56 preterm infants (n = 17 HC, n = 17 DXM, n = 22 controls). GM quality, videoed before and after treatment, was assessed. In addition, a MOS was assigned to details of the GMs.

Placental pathology is associated with illness severity in preterm infants in the first twenty-four hours after birth

BACKGROUND Placental pathology is associated with long-term neurological morbidity. Little is known about the association of placental pathology and illness severity directly after birth in preterm infants. OBJECTIVE To determine the association between placental pathology and illness severity in preterm infants during the first 24 h after birth. STUDY DESIGN Placentas of 40 preterm infants, born after singleton pregnancies (gestational age 25.4-31.7 weeks, birth weight 560-2250 g) were assessed for histopathology. Illness severity was measured using the Score of Neonatal Acute Physiology Perinatal Extension (SNAPPE). A high SNAPPE reflects high illness severity. RESULTS Examination of the 40 placentas revealed: pathology consistent with maternal vascular underperfusion (MVU) (n=24), ascending intrauterine infection (AIUI) (n=17), villitis of unknown aetiology (VUE) (n=6), foetal thrombotic vasculopathy (FTV) (n=6), elevated nucleated red blood cells (NRBCs) (n=6), and chronic deciduitis (n=10). SNAPPE ranged from 1 to 53 (median 10). Infants with elevated NRBCs had a higher SNAPPE than infants without elevated NRBCs (median 30 vs. 10, p=0.014). The same was found for the presence of FTV (median 30 vs. 10, p=0.019). No relation existed between SNAPPE and the other placental pathologies. CONCLUSIONS Elevated NRBCs and FTV were associated with higher illness severity during the first 24 h after birth in preterm infants. Ascending intrauterine infection was not associated with high illness severity.

In preterm infants, ascending intrauterine infection is associated with lower cerebral tissue oxygen saturation and higher oxygen extraction

Background:Placental lesions are associated with neurological morbidity but the mechanism leading to morbidity is unclear. To provide insight into such a possible mechanism, we determined whether placental lesions were associated with regional cerebral tissue oxygen saturation (rcSO2) and fractional tissue oxygen extraction (FTOE) in preterm infants during their first 5 d after birth. We hypothesized that as a result of cerebral hypoperfusion, rcSO2 would be lower and FTOE would be higher.Method:In a prospective, observational study of 42 preterm infants (gestational age <32 wk), the infants’ placentas were examined for histopathology. We measured rcSO2 and transcutaneous arterial oxygen saturation (SpO2) on days 1–5. FTOE was calculated as FTOE = (transcutaneous SpO2 − rcSO2)/transcutaneous SpO2.Results:Only three placentas showed no pathology. Ascending intrauterine infection (AIUI) (n = 16) was associated with lower rcSO2 and higher FTOE values on days 2, 3, and 4 (P ≤ 0.05). Other placental lesions were not associated with rcSO2 and FTOE.Conclusion:AIUI is associated with lower rcSO2, and higher FTOE shortly after birth. The effect it has on cerebral oxygenation might be the mechanism leading to neurodevelopmental problems.

1256 Quality of General Movements After Treatment with Low-Dose Dexamethasone in Preterm Infants at Risk for Bronchopulmonary Dysplasia

Background Postnatal dexamethasone (DXM) is widely used to treat preterm infants at risk for bronchopulmonary dysplasia. Previously, it was reported that high-dose DXM leads to deteriorated quality of general movements (GMs). We determined neurological functioning in infants after low-dose DXM treatment, assessed by the GM-quality until three months post term. Methods We included preterm infants, admitted to our NICU between 2010−2012 and treated with DXM (starting dose 0.25 mg/kg/d). GM-quality was assessed before (day 0), during and after treatment until three months post term. We determined the change in GM-quality by comparing the GM-quality of day 0 with the GM-quality of the last video recording. Additionally, we calculated a motor optimality score (MOS), ranging from 8 (low optimality) to 18 (high optimality). Results Sixteen infants were included [median GA 26.9 wks (25.0–29.7); BW 800 g (620–1665)]. Before treatment, 4 infants had normal GMs which remained normal after starting treatment. GM-quality improved in 8 of 12 initially abnormal infants (Mc Nemar; P=0.008), whilst MOS slightly increased: median 10.5, 12.0 and 12.5 on days 0, 1 and 7, respectively (NS). Cumulative DXM doses, treatment duration and postnatal ages at starting DXM were not associated with change in GM-quality. Infants whose GMs improved were ventilated for a shorter period than infants whose GMs remained the same quality (P=0.065). Conclusions GM-quality did not deteriorate after DXM treatment but rather improved in infants with initial abnormal GMs. Our findings suggest that neurological functioning until three months post term is not adversely affected after low-dose DXM.

PLACENTAL PATHOLOGY IS ASSOCIATED WITH NEUROLOGICAL DEVELOPMENT IN PRETERM INFANTS DURING THE FIRST TWO WEEKS AFTER BIRTH

566 Placental Pathology is Associated with Neurological Development in Preterm Infants During the First Two Weeks After Birth

HYDROCORTISONE VERSUS DEXAMETHASONE TREATMENT FOR BRONCHOPULMONARY DYSPLASIA AND NEUROLOGICAL OUTCOME IN PRETERM INFANTS

194 Hydrocortisone Versus Dexamethasone Treatment for Bronchopulmonary Dysplasia and Neurological Outcome in Preterm Infants