Thais Agut

Impact of histological chorioamnionitis, funisitis and clinical chorioamnionitis on neurodevelopmental outcome of preterm infants

BACKGROUNDnThe role of chorioamnionitis in neurodevelopment of preterm infants is not fully understood.nnnAIMnTo examine the association between different indicators of intrauterine inflammation (clinical chorioamnionitis, histological chorioamnionitis and funisitis) and neurodevelopmental impairment in very preterm infants.nnnMETHODSnPreterm infants with a birth weight of <1500 g or a gestational age of <32 weeks were included. Follow-up evaluation up to 2 years of age consisted of neurological examination, neurodevelopmental assessment and visual and audiologic tests. Outcome data were compared between the chorioamnionitis and the control groups, controlling for gestational age, birth weight and Apgar score at 5 min.nnnRESULTSnOne hundred seventy-seven patients comprised the study population (mean gestational age 29±2 weeks, mean birth weight 1167±344 g). Histological chorioamnionitis was present in 49% of placentas, whereas funisitis was observed in 25%. In 57% cases clinical maternal chorioamnionitis was suspected. Follow-up was available for 130 (82%) patients. Infants with funisitis, compared with controls, had a significantly higher incidence of moderate to severe disability (18% vs 5%, OR 4.07; 95% CI 1.10-15.09).nnnCONCLUSIONnThe results of this study suggest that, unlike a broad definition of histological chorioamnionitis including inflammation of maternal or fetal placental tissues, funisitis may entail a higher risk of moderate to severe disability at 2 years of age in preterm infants.

Early identification of brain injury in infants with hypoxic ischemic encephalopathy at high risk for severe impairments: accuracy of MRI performed in the first days of life

BackgroundDespite therapeutic hypothermia 30-70% of newborns with moderate or severe hypoxic ischemic encephalopathy will die or survive with significant long-term impairments. Magnetic resonance imaging (MRI) in the first days of life is being used for early identification of these infants and end of life decisions are relying more and more on it. The purpose of this study was to evaluate how MRI performed around day 4 of life correlates with the ones obtained in the second week of life in infants with hypoxic-ischemic encephalopathy (HIE) treated with hypothermia.MethodsProspective observational cohort study between April 2009 and July 2011. Consecutive newborns with HIE evaluated for therapeutic hypothermia were included. Two sequential MR studies were performed: an •early’ study around the 4th day of life and a •late’ study during the second week of life. MRI were assessed and scored by two neuroradiologists who were blinded to the clinical condition of the infants.ResultsForty-eight MRI scans were obtained in the 40 newborns. Fifteen infants underwent two sequential MR scans. The localization, extension and severity of hypoxic-ischemic injury in early and late scans were highly correlated. Hypoxic-ischemic injury scores from conventional sequences (T1/T2) in the early MRI correlated with the scores of the late MRI (Spearman ρu2009=u20090.940; pu2009<u2009.001) as did the scores between diffusion-weighted images in early scans and conventional images in late MR studies (Spearman ρu2009=u20090.866; pu2009<u2009.001). There were no significant differences in MR images between the two sequential scans.ConclusionsMRI in the first days of life may be a useful prognostic tool for clinicians and can help parents and neonatologist in medical decisions, as it highly depicts hypoxic-ischemic brain injury seen in scans performed around the second week of life.

Hipotermia cerebral moderada en la encefalopatía hipóxico-isquémica. Experiencia en el primer año de su puesta en marcha

INTRODUCTIONnModerate cerebral hypothermia has been shown to be an effective intervention in decreasing mortality and major disabilities in infants with moderate-severe hypoxic-ischaemic encephalopathy (HIE).nnnOBJECTIVESnTo describe our experience within the first year of implementation, and to evaluate the feasibility and safety of this intervention.nnnMETHODSnRetrospective study of 20 patients with moderate-severe HIE treated with whole body hypothermia in the Agrupación Sanitaria Hospital Sant Joan de Déu-Hospital Clínic, between January 2009 and June 2010.nnnRESULTSnDuring this period, 50 patients with perinatal HIE, 26 of them moderate- severe, were admitted to our units. Twenty patients received hypothermia (13 with severe and 7 with moderate HIE). All of them had at least one risk factor for perinatal hypoxia-ischaemia, and clinical signs of HIE. Fifteen had clinical and/or EEG seizures. Core temperature was maintained at 33.5 ± 0.5°C in 76.5% of determinations for infants cooled with a manual control device, and in 93.6% for those cooled with a servo-controlled device (P<.0001). Re-warming took a median time of 10.5 hours. No potentially severe complications related to hypothermia were observed. Seven patients (35%) died, all of them with severe HIE.nnnCONCLUSIONSnThere were no difficulties in any of the steps of this intervention, and no potentially severe complications related to it were recorded. Both manual and servo-control methods are equally effective on maintaining the target temperature, although temperature shows less variability using the servo-controlled equipment.

Three-Dimensional Map of Neonatal Arterial Ischemic Stroke Distribution From Early Multimodal Brain Imaging

Background and Purpose— Although neonatal arterial ischemic stroke (NAIS) location has considerable impact on long-term outcome, a map showing spatial distribution of NAIS is lacking. Our aim was to generate this distribution map, based on early magnetic resonance imaging data. Methods— Lesions from 34 consecutive neonates with NAIS from a single center were segmented using multimodal magnetic resonance imaging (median age at acquisition =5 days). Lesion masks for all subjects were registered onto a standard neonatal brain and then overlaid to generate a 3D map of NAIS distribution. Results— The region posterior to the central sulcus is the most frequently affected in neonates, with 24 of the 34 neonates (71%) showing lesions in this region in at least one hemisphere. Moreover, NAIS frequency is markedly higher in the left hemisphere. Conclusions— This is the first report of an NAIS distribution map. Regions posterior to the central sulcus present increased vulnerability. Our findings suggest that motor areas are not as frequently affected as has been previously reported. By contrast, we find high NAIS vulnerability in functional areas related to language. The distribution of ischemic strokes in neonates seems to be different from that seen in adults.

Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy

OBJECTIVEnTo determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy.nnnMETHODSnThis was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy, born between April 2009 and December 2013, who were transferred for therapeutic hypothermia and cooled during transport.nnnRESULTSnFifty-six newborns (84%) were transferred without external sources of heat and 11 (16%) needed an external heat source. The mean temperature at departure was 34.4±1.4°C and mean transfer time was 3.3±2.0h. Mean age at arrival was 5.6±2.5h. Temperature at arrival was between 33 and 35°C in 41 (61%) infants, between 35°C and 36.5°C in 15 (22%) and <33°C in 11 (16%). Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature<33°C (OR: 4.5; 95% CI: 1.1-19.3). The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission (p<0.05). Adverse events during transfer, mainly hypotension and bleeding from the endotracheal tube, occurred in 14 infants (21%), with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy.nnnCONCLUSIONnThe risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth. The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube. This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport.

Abandonos en el seguimiento de recién nacidos de muy bajo peso antes de los 2 años

INTRODUCTIONnThe increase in survival rates of very low weight newborns (VLWN) and their neurodevelopmental morbidity has led to the implementation of follow-up programmes. The withdrawal from follow up limits the achievement of care goals and the validity of studies in this field.nnnGOALSnTo assess the neurodevelopmental status, morbidity, social and economical data in the VLWN seen in our Neonatal Care Unit between 2002 and 2005 and lost in the follow up programme before the age of two, and compare these findings with the group who completed follow up.nnnPATIENTSnA total of 318 VLWN were included, of 53 had died. At the age of two, 215 had completed the monitoring visits (group S) and 50 had quit (group A).nnnMETHODSnUsing the SEN 1500 data base, and telephone interview of those parents who quit the programme.nnnRESULTSnA total of 30 cases were interviewed (Group R). Six patients had been admitted to hospital due to respiratory illness; 26.7% had neurodevelopmental impairment (1 case, severe; 1 case, moderate; 6 cases, mild) compared to 14% in group S (P<.05). In group R, compared with group S, included more immigrants (40 vs. 14%), parental education level was lower and distance between home and hospital was greater (P<.05). In group R, 57% of families had a low socioeconomic standard.nnnCONCLUSIONSnThe telephone interview allowed the clinical status of 60% of VLWN lost to follow up to be determined. Sequelae rate, mainly mild, was higher in the lost-to- follow-up group. Some unfavourable social, economical and cultural factors could have influenced the interruption. It is advisable to develop strategies to prevent loss in the follow up.

Neonatal Arterial Ischemic Stroke: Risk Related to Family History, Maternal Diseases, and Genetic Thrombophilia:

The objective of this study was to evaluate the heritability of neonatal arterial ischemic stroke (NAIS) in relation to family history of thromboembolic event, maternal diseases, and thrombophilia in both parents (F5G1691A, F2G20210A, and MTHFRC677 T mutations). Forty-two consecutive infants ≥36 weeks of gestation <28 days of life with acute symptomatic NAIS and their parents, as well as 129 controls, were prospectively recruited. Information on maternal data (age, body mass index, oral contraception, migraine, epilepsy, hypertension, and immune disease) and a 3-generation pedigree regarding myocardial infarction, pulmonary embolism, cerebrovascular event, and deep vein thrombosis were obtained. Thrombophilia and maternal diseases did not differ between cases and controls, except for the use of oral contraceptives (more frequent in mothers of controls). No differences were found regarding each studied antecedent of thromboembolic event in the families. The NAIS group showed a higher presence of positive family history among second-degree maternal relatives than did the control infants (odds ratio 4.10; 95% confidence interval 1.29-12.99). Our study does not support the hypothesis that common genetic thrombophilia or familial predisposition to thromboembolic events is associated with the occurrence of idiopathic NAIS.

Rombencefalosinapsis, una rara alteración del desarrollo del cerebelo de fácil diagnóstico

l m c y c Recién nacido a término, varón, primer hijo de padres sanos, no consanguíneos, que ingresa por sospecha prenatal de hipoplasia cerebelosa. Sin incidencias en el periodo perinatal. En el examen físico neonatal destacan una implantación baja de orejas, hipertelorismo e hipotonía generalizada. La ecografía trasfontanelar no identificó alteraciones de la fosa posterior. En la valoración del 5.◦ mes de vida presenta dificultad para mantener el sostén cefálico e iniciar sedestación en trípode, los rasgos faciales dismórficos descritos, objetivándose además un estrabismo convergente de ambos ojos. Adecuado crecimiento cefálico. Se realizó una RM cerebral que mostró una rombencefalosinapsis (RS) parcial aislada (fig. 1). La RS es una rara alteración en el desarrollo del cerebelo caracterizada por la agenesia parcial o total del vermis, con