Chorioamnionitis and Neonates; Which Strategy?

BACKGROUND: Chorioamnionitis (CAM) is one of the major risk factors for neonatal early-onset sepsis (EOS). Different international guidelines have been developed for diagnosis and care of such neonates. This research aimed to evaluate our neonates and compare them with the guidelines. METHODS: This prospective cohort study was conducted during five years (March 2012 to March 2017), and comprised of neonates (any gestational age) born to mothers with CAM (any criteria). The neonates' clinical findings and interventions were collected and analyzed. RESULTS: In total, out of 28,988 live born neonates, CAM was found in mothers of 169 neonates (1.7%). Among the studied neonates, 30.8% were born ≤34 week of gestation, 39% had birth weight <2500 g, and 58.6% were asymptomatic. Out of 99 asymptomatic neonates, 47 were observed near mothers and 52 admitted to the neonatal intensive care unit (NICU). The frequency of abnormal tests was 23.07% in asymptomatic vs. 35.7% in symptomatic neonates; three neonates developed culture positive EOS (2.75%) and 68.05% of the neonates received antibiotics. The length of stay was 2.59 ± 1.13 (median = 2.00, IQR = 1.00) days in asymptomatic vs. 15.15 ± 13.67 (median = 7.00, IQR = 15.25) days in symptomatic neonates (P<0.001). CONCLUSION: The use of guidelines increased the length of stay, lab tests, and antibiotics in asymptomatic and neonates with negative blood culture. In addition to the mother-neonate separation, these guidelines may increase nosocomial infection, antibiotic resistance, and costs; therefore, new guidelines are needed to be developed.

Predictors of Success Rate in Different Initial Respiratory Supports in Very Low Birthweight Infants with Respiratory Distress.

BACKGROUND: Ideal respiratory support for very low birth weight infants (VLBW) can be selected based on demographic and clinical status at birth. METHODS: In this prospective cohort study, we included 163 VLBW neonates treated with either invasive or non-invasive respiratory support in their first 72 hours of life in the neonatal intensive care unit of Mahdiyeh hospital, Tehran, Iran. We used descriptive statistics to describe the data, and multiple logistic regression to determine the factors associated with the success rate of different strategies and the choice of strategy for primary respiratory support. All analyses were done using SPSS version 20 and STATA version 12 at a significance level of 0.05. RESULTS: The success rates of initial respiratory supports with nasal continuous positive airway pressure (NCPAP), noninvasive positive pressure ventilation (NIPPV), and INSURE (intubation surfactant extubation) were 63.20%, 42.10% and 61.90%, respectively. The results of multiple logistic regression analysis showed patent arterial duct (PDA) (yes vs. no: OR = 0.42) had a significant effect on initial respiratory support success (P<0.05). Also, gestational age (>28 vs. ≤28 weeks: OR = 0.26) and 5-min APGAR (≤6 vs. >6: OR = 9.69) had a significant effect on the choice of initial respiratory support in VLBW infants (P<0.05). CONCLUSION: The neonatal clinical condition may be a predictor of success for initial respiratory support at birth. Since the arterial duct may be open during the first hours of life, more study is needed to verify if early closure of the arterial duct may help increase the success rate of non-invasive respiratory support.

Evaluation of Initial Respiratory Support Strategies in VLBW Neonates with RDS.

BACKGROUND: Non-invasive ventilation (NIV) has brought about a significant change in care and treatment of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates. The present study was designed and conducted to evaluate different strategies of initial respiratory support (IRS) in VLBW neonates hospitalized in the neonatal intensive care unit (NICU). METHODS: This prospective study was conducted over three years (March 21, 2011 to March 20, 2014). Each eligible VLBW baby with RDS diagnosis received a specific IRS, including room air (RA), oxygen therapy (O2 RX), n.CPAP, NIPPV, MV ± SURF, based on clinical evaluation; then, the next strategies were selected based on the disease progression. Obtained data was entered in SPSS and the groups were compared for disease consequences or death. Then, contributing factors to the failure of NIV strategies, and the need for endotracheal mechanical ventilation (eMV) were determined. RESULTS: In total, 499 neonates were included in the study. The mean birth weight was 1,125 ± 254 g and the gestational age was 29.2 ± 2.5 weeks. The IRS included: RA = 43, O2.RX = 60, n.CPAP/NIPPV = 219, INSURE = 83 and MV ± SURF = 177. In terms of the need for IRS upgrading during hospitalization, neonates not on mechanical ventilation (64.5%) were divided into three groups. In 45.3% of cases, the IRS did not change (Never upgrading); in 24.5% of cases, the level of IRS increased but there was no need for eMV in the first three days of life (Specific); in 24.8% of cases, there was need for eMV within the first three days of life (Absolute) and during hospitalization (after the first three days of life) 5.3% of cases were in need of eMV (General). In terms of correlation between the effective variables in IRS upgrading, univariable analyses showed that low gestational age, low birth weight, multiple pregnancy, maternal disease, low one-minute Apgar score, and need for surfactant therapy had significant correlation, and multivariable analysis showed that low gestational age, low birth weight and maternal disease were risk factors independently correlated to IRS upgrading, CLD and death. CONCLUSION: Early use of NIV in preterm neonates with mild to moderate respiratory distress and spontaneous breathing significantly reduced the need for intubation, surfactant, mechanical ventilation and thereby pulmonary and non-pulmonary complications and neonatal mortality.

Antibiotic Therapy for Very Low Birth Weigh Newborns in NICU.

BACKGROUND: Prolonged empiric antibiotics therapy in neonates results in several adverse consequences including widespread antibiotic resistance, late onset sepsis (LOS), necrotizing enterocolitis (NEC), prolonged hospital course (HC) and increase in mortality rates. OBJECTIVES: To assess the risk factors and the outcome of prolonged empiric antibiotic therapy in very low birth weight (VLBW) newborns. MATERIALS AND METHODS: Prospective study in VLBW neonates admitted to NICU and survived > 2 W, from July 2011 - June 2012. All relevant perinatal and postnatal data including duration of antibiotics therapy (Group I < 2W vs Group II > 2W) and outcome up to the time of discharge or death were documented and compared. RESULTS: Out of 145 newborns included in the study, 62 were in group I, and 83 in Group II. Average duration of antibiotic therapy was 14 days (range 3 - 62 days); duration in Group I and Group II was 10 ± 2.3 vs 25.5 ± 10.5 days. Hospital stay was 22.3 ± 11.5 vs 44.3 ± 14.7 days, respectively. Multiple regression analysis revealed following risk factors as significant for prolonged empiric antibiotic therapy: VLBW especially < 1000 g, (P < 0.001), maternal Illness (P = 0.003), chorioamnionitis (P = 0.048), multiple pregnancy (P = 0.03), non-invasive ventilation (P < 0.001) and mechanical ventilation (P < 0.001). Seventy (48.3%) infants developed LOS; 5 with NEC > stage II, 12 (8.3%) newborns died. Infant mortality alone and with LOS/NEC was higher in group II as compared to group I (P < 0.002 and < 0.001 respectively). CONCLUSIONS: Prolonged empiric antibiotic therapy caused increasing rates of LOS, NEC, HC and infant mortality.

Hyperglycemia in VLBW infants; incidence, risk factors and outcome.

BACKGROUND: Neonatal hyperglycemia, which is relatively common in very low birth weight (VLBW) infants, is associated with increased risk of morbidity and mortality. OBJECTIVE: To study the incidence of neonatal hyperglycemia, associated risk factors and the outcome of it in VLBW infants hospitalized in a level III NICU in Tehran. METHODS: All VLBW newborns admitted to the NICU of Mahdieh Hospital from April 2009 to March 2011 were considered eligible for this retrospective study. All relevant prenatal and perinatal data, as well as details of the hospital stay until discharge or death, were extracted from the case notes and analyzed. RESULTS: Hyperglycemia (blood suger above 150 mg/dL) was observed in 179 (31.7%) of the 564 VLBW infants included in the study; 48 infants (26.8%), had received insulin. Risk factors included: low gestational age, (OR = 4.07, 95% CI = 2.09-7.93, P < 0.001), extremely low birth weight (ELBW) , (OR = 5.97, 95% CI = 3.77-9.44, P < 0.001), dopamine administration (OR = 2.19, 95% CI = 1.32-3.65, P = 0.003), intralipid (OR = 1.52, 95% CI = 1.04-2.22, P = 0.03), Low APGAR score at 5 minutes (OR = 4.44, 95% CI = 2.48-7.94, P < 0.001), RDS and its complications (OR = 4.20, 95% CI = 2.55-6.93, P < 0.001), were independently associated with hyperglycemia. Other findings with hyperglycemia were: high incidence of IVH >grade II (OR = 2.88, 95% CI = 1.28-6.49, P = 0.01), hospital stay more than 28 days in survivors,(OR = 3.56, 95% CI = 2.02-6.25, P < 0.001), mortality (OR = 4.42, 95% CI = 3.00-6.52, P < 0.001) and more retinopathy of prematurity (ROP ≥ stage II) in survivors (OR = 2.05, 95% CI = 1.11-3.78, P = 0.02). CONCLUSION: Neonatal hyperglycemia developed in approximately one-third of our VLBW neonates. Relative prevalence and associated findings underscore the need for preventive measures and prompt management.

Neonatal resuscitation in the delivery room from a tertiary level hospital: risk factors and outcome.

OBJECTIVE: Timely identification and prompt resuscitation of newborns in the delivery room may cause a decline in neonatal morbidity and mortality. We try to identify risk factors in mother and fetus that result in birth of newborns needing resuscitation at birth. METHODS: Case notes of all deliveries and neonates born from April 2010 to March 2011 in Mahdieh Medical Center (Tehran, Iran), a Level III Neonatal Intensive Care Unit, were reviewed; relevant maternal, fetal and perinatal data was extracted and analyzed. FINDINGS: During the study period, 4692 neonates were delivered; 4522 (97.7%) did not require respiratory assistance. One-hundred seven (2.3%) newborns needed resuscitation with bag and mask ventilation in the delivery unit, of whom 77 (1.6%) babies responded to bag and mask ventilation while 30 (0.65%) neonates needed endotracheal intubation and 15 (0.3%) were given chest compressions. Epinephrine/volume expander was administered to 10 (0.2%) newborns. In 17 patients resuscitation was continued for >10 mins. There was a positive correlation between the need for resuscitation and following risk factors: low birth weight, preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, abruptio placentae, prolonged labor, meconium staining of amniotic fluid, multiple pregnancy and fetal distress. On multiple regression; low birth weight, meconium stained liquor and chorioamnionitis revealed as independent risk factors that made endotracheal intubation necessary. CONCLUSION: Accurate identification of risk factors and anticipation at the birth of a high-risk neonate would result in adequate preparation and prompt resuscitation of neonates who need some level of intervention and thus, reducing neonatal morbidity and mortality.

Outcome of very low birth weight infants over 3 years report from an Iranian center.

OBJECTIVE: Very low birth weight (VLBW) infants are at high risk for morbidity and mortality. This article determines the frequency of disease, rate od survival, complications and risk factors for morbidity and mortality in VLBW neonates admitted to a level III neonatal intensive care unit (NICU) at Mahdieh Hospital in Tehran. METHODS: This cross-sectional retrospective study was performed from April 2007 to March 2010 on all hospitalized VLBW neonates. Relevant pre- and peri-natal data up to the time of discharge from the hospital or death, including complications during the course of hospitalization, were collected from the case notes, documented on a pre-designed questionnaire and analyzed. FINDINGS: Out of 13197 neonates, 564 (4.3%) were VLBW with 51.4% males. Mean gestational age was 29.6±2.5 weeks; mean birth weight 1179±257 grams. Mean birth weight, gestational age and Apgar scores were significantly higher in babies who survived than in those who died, (1275±189 vs. 944±253 grams; 30.5±2.2 vs. 27.5±2 weeks and 6.9±1.7 vs. 5±2.1 respectively, P<0.001 in all instances). Overall survival was 70.9%; in extremely low birth weight (ELBW) newborns this figure was 33.3% rising to 84.1% in infants weighing between 1001-1500 grams. Respiratory failure resulting from RDS in ELBW babies was the major factor leading to death. Need for mechanical ventilation, pulmonary hemorrhage and gastro-intestinal bleeding were also significant predictive factors for mortality. CONCLUSION: Birth weight and mechanical ventilation are the major factors predicting VLBW survival.

Retinopathy of prematurity: incidence, risk factors, and outcome.

BACKGROUND: This study was planned to determine the rate, the predisposing factors, and the outcome of retinopathy of prematurity (ROP) in very low birth weight (VLBW) infants hospitalized in the neonatal intensive care unit (NICU) of a tertiary care hospital in Tehran.  METHODS: All VLBW neonates admitted to the NICU, from April 2007 through March 2010 were enrolled. All relevant perinatal data, including the hospital course up to the time of discharge were documented. Repeated ophthalmologic examinations were done by a single ophthalmologist to observe the progression and subsequent resolution of ROP. RESULTS: Out of 414 infants undergoing ophthalmologic examination, ROP was detected in 71 infants (17.14 %); 3.4 % stage I, 8.7 % stage II, and 5.1 % stage III. ROP stages IV or V were not detected. After adjustment for different variables, the following independent risk factors were identified: VLBW (P = 0.002, OR = 4.89), multiple gestation (P = 0.001, R = 3.51), resuscitation at birth (P = 0.003, OR = 3), blood transfusion more than 45 mL/kg (P = 0.02, OR = 4.91), oxygen therapy for more than five days (P = 0.009, OR = 3.11), and age more than 10 days to regain birth weight (P = 0.008, OR = 1.06).Thirty-three patients with stages II and III ROP were treated with laser therapy, all of them improved and none progressed to blindness.  CONCLUSION: Our findings identify the major risk factors for ROP; skillful management of high-risk pregnancies, prevention of preterm births, appropriate neonatal care, high index of suspicion, routine screening, and prompt treatment are crucial to prevent the development and progression of ROP.