An Algorithm for Predicting Neonatal Mortality in Threatened Very Preterm Birth.

OBJECTIVE: To develop a prediction model for neonatal mortality using information readily available in the antenatal period. METHODS: A multiple logistic regression model of a complete population-based geographically defined cohort of very preterm infants of 23+0 to 30+6 weeks' gestation was used to identify antenatal factors which were predictive of mortality in this population. Infants lt; 23 weeks and those with major anomalies were excluded. RESULTS: Between 1996 and 2012, 1240 live born infants lt; 31 weeks' gestation were born to women residing in Nova Scotia. Decreasing gestational age strongly predicted an increased mortality rate. Other factors significantly contributing to increased mortality included classification as small for gestational age, oligohydramnios, maternal psychiatric disorders, antenatal antibiotic therapy, and monochorionic twins. Reduced neonatal mortality was associated with antenatal use of antihypertensive agents and use of corticosteroids of any duration of therapy given at least 24 hours before delivery. An algorithm was developed to estimate the risk of mortality without the need for a calculator. CONCLUSION: Prediction of the probability of neonatal mortality is influenced by maternal and fetal factors. An algorithm to estimate the risk of mortality facilitates counselling and informs shared decision making regarding obstetric management.

Objectif : Élaborer un modèle prédictif en ce qui concerne la mortalité néonatale au moyen de renseignements faciles à obtenir au cours de la période prénatale. Méthodes : Nous avons eu recours au modèle de régression logistique multiple d'une cohorte exhaustive, populationnelle et définie géographiquement de nouveau-nés très prématurés (âge gestationnel : de 23+0 à 30+6 semaines) pour identifier les facteurs prénataux permettant de prédire la mortalité au sein de cette population. Les nouveau-nés dont l'âge gestationnel était inférieur à 23 semaines et ceux qui présentaient des anomalies majeures ont été exclus. Résultats : Entre 1996 et 2012, 1 240 enfants nés vivants à moins de 31 semaines de gestation ont été issus de femmes résidant en Nouvelle-Écosse. La baisse de l'âge gestationnel constituait un facteur solide permettant de prédire une hausse du taux de mortalité. Parmi les autres facteurs contribuant de façon significative à la hausse du taux de mortalité, on trouvait l'hypotrophie fœtale, l'oligohydramnios, les troubles psychiatriques maternels, l'antibiothérapie prénatale et les jumeaux monozygotes. La baisse du taux de mortalité néonatale était associée à l'utilisation prénatale d'antihypertenseurs et à l'utilisation de corticostéroïdes (peu importe la durée du traitement) administrés au moins 24 heures avant l'accouchement. Nous avons élaboré un algorithme pour estimer le risque de mortalité sans avoir recours à une calculatrice. Conclusion : La prévision de la probabilité de la mortalité néonatale est influencée par des facteurs maternels et fœtaux. Le fait de disposer d'un algorithme pour estimer le risque de mortalité facilite le counseling et éclaire le processus décisionnel partagé en ce qui concerne la prise en charge obstétricale.

Successful outcome in pregnancy with arterial tortuosity syndrome.

BACKGROUND: Arterial tortuosity syndrome is a rare, autosomal recessive, severe, connective tissue disorder caused by a mutation in the SLC2A10 gene. We describe the pregnancy and delivery with this high-risk connective tissue disorder involving generalized abnormalities of the vasculature. CASE: A woman with an undefined connective tissue disorder was referred for tertiary prenatal care. Diagnostic imaging demonstrated multiple pulmonary artery aneurysms and arterial tortuosity, consistent with a clinical diagnosis of arterial tortuosity syndrome. With a team considering all potential complications, a delivery plan was undertaken involving cesarean delivery and intensive perioperative and postpartum monitoring. The outcome was optimal for mother and neonate. Concurrent molecular testing demonstrated homozygosity for the SLC2A10 gene. CONCLUSION: Optimal maternal, fetal and neonatal outcomes were obtained with comprehensive multidisciplinary care and close maternal and fetal surveillance.

Hypothermia for neonatal hypoxic ischemic encephalopathy: an updated systematic review and meta-analysis.

OBJECTIVE: To establish the evidence of therapeutic hypothermia for newborns with hypoxic ischemic encephalopathy(HIE). DATA SOURCES: Cochrane Central Register of Controlled Trials, Oxford Database of Perinatal Trials, MEDLINE, EMBASE, and previous reviews. STUDY SELECTION: Randomized controlled trials that compared therapeutic hypothermia to normothermia for newborns with HIE. INTERVENTION: Therapeutic hypothermia. MAIN OUTCOME MEASURES: Death or major neurodevelopmental disability at 18 months. RESULTS: Seven trials including 1214 newborns were identified. Therapeutic hypothermia resulted in a reduction in the risk of death or major neurodevelopmental disability(risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and increase in the rate of survival with normal neurological function (1.63; 1.36-1.95) at age 18 months. Hypothermia reduced the risk of death or major neurodevelopmental disability at age 18 months in newborns with moderate HIE (RR, 0.67; 95% CI, 0.56-0.81) and in newborns with severe HIE (0.83; 0.74-0.92). Both total body cooling and selective head cooling resulted in reduction in the risk of death or major neurodevelopmental disability(RR, 0.75; 95% CI, 0.66-0.85 and 0.77; 0.65-0.93,respectively). CONCLUSION: Hypothermia improves survival and neurodevelopment in newborns with moderate to severe HIE.Total body cooling and selective head cooling are effective methods in treating newborns with HIE. Clinicians should consider offering therapeutic hypothermia as part of routine clinical care to these newborns.

Increasing prevalence of cerebral palsy among very preterm infants: a population-based study.

OBJECTIVES: It is unclear whether declines in neonatal and infant mortality have led to changes in the occurrence of cerebral palsy. We conducted a study to examine and investigate recent temporal changes in the prevalence of cerebral palsy in a population-based cohort of very preterm infants who were 24 to 30 weeks of gestational age. METHODS: A population-based cohort of very preterm infants who were born between January 1, 1993, and December 31, 2002, was evaluated by the Perinatal Follow-up Program of Nova Scotia. Follow-up extended to age 2 years to ascertain the presence or absence of cerebral palsy and for overall survival. Infant survival and cerebral palsy rates were compared by year and also in two 5-year periods, 1993-1997 and 1998-2002. Logistic regression analyses were used to identify factors that potentially were responsible for temporal changes in cerebral palsy rates. RESULTS: A total of 672 liveborn very preterm infants were born to mothers who resided in Nova Scotia between 1993 and 2002. Infant mortality among very preterm infants decreased from 256 per 1000 live births in 1993 to 114 per 1000 live births in 2002, whereas the cerebral palsy rates increased from 44.4 per 1000 live births in 1993 to 100.0 per 1000 live births in 2002. Low gestational age, postnatal dexamethasone use, patent ductus arteriosus, severe hyaline membrane disease, resuscitation in the delivery room, and intraventricular hemorrhage were associated with higher rates of cerebral palsy, whereas antenatal corticosteroid use was associated with a lower rate. CONCLUSION: Cerebral palsy has increased substantially among very preterm infants in association with and possibly as a consequence of large declines in infant mortality.