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1.
Z Geburtshilfe Neonatol ; 223(6): 373-394, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31801169

RESUMO

AIMS: This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. METHODS: The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). RECOMMENDATIONS: Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.


Assuntos
Ruptura Prematura de Membranas Fetais , Trabalho de Parto Prematuro/prevenção & controle , Guias de Prática Clínica como Assunto , Nascimento Prematuro , Sociedades Médicas , Prevenção Terciária , Incompetência do Colo do Útero , Áustria , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Humanos , Recém-Nascido , Obstetrícia , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Sistema de Registros
2.
Lakartidningen ; 1162019 Oct 08.
Artigo em Sueco | MEDLINE | ID: mdl-31593290

RESUMO

Due to a low level of understanding of mechanisms involved in spontaneous preterm delivery there is a lack of reliable biomarkers. Existing biomarkers have a low positive predictive value but a high negative predictive value. Use of tests with high negative predictive value will reduce unnecessary interventions and hospitalization of women with threatening preterm delivery. When given to the right pregnant women, antenatal corticosteroid treatment are still the most important obstetrical intervention and reduces both neonatal mortality and short- and long-term morbidity.Several ongoing national Swedish multicenter studies may increase the understanding of the roles of cervical length, preeclampsia screening and magnesium sulfate dosage in the context of preterm delivery in a Nordic setting. Major development has been achieved in prediction and prevention of preterm preeclampsia at the cost of a 10% screen positive rate.


Assuntos
Nascimento Prematuro , Corticosteroides/administração & dosagem , Biomarcadores/análise , Cerclagem Cervical , Medida do Comprimento Cervical , Colo do Útero/anatomia & histologia , Feminino , Fibronectinas/análise , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Sulfato de Magnésio/administração & dosagem , Pessários , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/prevenção & controle , Gravidez , Nascimento Prematuro/diagnóstico , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Cuidado Pré-Natal/métodos , Progesterona/administração & dosagem , Suécia , Tocolíticos/administração & dosagem
3.
BMC Res Notes ; 12(1): 542, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31455414

RESUMO

OBJECTIVE: Neonatal sepsis is one of the most common causes of neonatal hospitalization in developing countries. It is also a major cause of mortality in the world affecting both developed and developing countries. Diagnosis and management of sepsis are a great challenge facing neonatologists in neonatal intensive care units due to nonspecific signs and symptoms. This study, therefore, was aimed to determine proportion and risk factors of neonatal sepsis at university of Gondar comprehensive specialized hospital, North West Ethiopia. RESULT: The proportion of neonatal sepsis was 11.7%. Factors significantly associated with neonatal sepsis were: Neonatal related factors were: Premature rupture of membrane (AOR = 2.74; 95% Cl (1.39, 5.38), congenital anomaly (AOR = 3.14; 95% CI (1.09, 10.28), and low Apgar score (AOR = 2.69; 95% Cl (1.37, 5.26). Maternal factors were: foul-smelling vaginal discharge (AOR = 2.75; 95% Cl (1.40, 5.38), and Intrapartum fever (AOR = 3.35; 95% Cl (1.7, 6.62). In this finding proportion of Neonatal sepsis was low as compared to previous studies. Measures targeting the prevention of premature rupture of membranes and low Apgar score need to be taken, like strengthening maternal birth preparedness and complication readiness plans. Also, identification of congenital anomalies earlier in pregnancy and taking measures to avoid birth injury may decrease neonatal sepsis.


Assuntos
Hospitais Especializados , Hospitais Universitários , Doenças do Recém-Nascido/diagnóstico , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Sepse Neonatal/diagnóstico , Cuidado Pré-Natal/métodos , Adulto , Etiópia/epidemiologia , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/epidemiologia , Doenças do Recém-Nascido/terapia , Sepse Neonatal/epidemiologia , Sepse Neonatal/terapia , Gravidez , Nascimento Prematuro/diagnóstico , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/terapia , Fatores de Risco , Adulto Jovem
6.
BMC Pregnancy Childbirth ; 19(1): 78, 2019 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-30791873

RESUMO

BACKGROUND: The Cord Pilot Trial compared two alternative policies for cord clamping at very preterm birth at eight UK maternity units: clamping after at least 2 min and immediate neonatal care (if needed) with cord intact, or clamping within 20 s and neonatal care after clamping. This paper reports follow-up of the women by two self-completed questionnaires up to one year after the birth. METHODS: Women were given or posted the first questionnaire between four and eight weeks after birth, usually before their baby was discharged, and were posted a second similar questionnaire at one year. The questionnaire included the Hospital Anxiety and Depression Scale; the Preterm Birth Experience and Satisfaction Scale (P-BESS) and questions about their baby's feeding. RESULTS: Of 261 women randomised (132 clamping ≥2 min, 129 clamping ≤20 s), six were excluded as birth was after 35+ 6 weeks (2, 4 in each group respectively). Six were not sent either questionnaire. The first questionnaire was given/sent to 244 and returned by 186 (76%) (79, 74%). The second, at one year, was sent to 242 and returned by 133 (55%) (66, 43%). On the first questionnaire, 89 (49%) had a score suggestive of an anxiety disorder, and 55 (30%) had a score suggestive of depression. Satisfaction with care at birth was high: median total P-BESS score 77 [interquartile range 68 to 84] (scale 17 to 85). There was no clear difference in anxiety, depression, or satisfaction with care between the two allocated groups. The median number of weeks after birth women breastfed/expressed was 16 (95% confidence interval (CI) 13 to 20, n = 119) for those allocated clamping ≥2 min and 12 (95% CI 11 to 16, n = 103) for those allocated clamping ≤20 s. CONCLUSIONS: The response rate was higher for the earlier questionnaire than at one year. A high proportion of women reported symptoms of anxiety or depression, however there were no clear differences between the allocated groups. Most women reported that they had breastfed or expressed milk and those allocated deferred cord clamping reported continuing this for slightly longer. TRIAL REGISTRATION: ISRCTN 21456601, registered 28th February 2013, http://www.isrctn.com/ISRCTN21456601.


Assuntos
Protocolos Clínicos , Nascimento Prematuro/terapia , Fatores de Tempo , Cordão Umbilical , Ansiedade/etiologia , Aleitamento Materno/psicologia , Constrição , Depressão Pós-Parto/etiologia , Feminino , Seguimentos , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Satisfação do Paciente , Projetos Piloto , Período Pós-Parto/psicologia , Gravidez
8.
J Matern Fetal Neonatal Med ; 32(21): 3577-3580, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29681199

RESUMO

Objective: Women who have had a spontaneous periviable delivery are at high risk for recurrent preterm delivery. The objective of our study was to determine interpregnancy interval (IPI) after periviable birth as well as percentage of women taking 17 alpha hydroxyprogesteronecaproate (17OHP-C) after periviable birth. We then examined the association between adherence with a postpartum visit after a periviable birth and IPI as well as receipt of 17OHP-C. Materials and methods: We included all women with a periviable delivery (20-26-week gestation) due to spontaneous preterm birth at Magee Women's Hospital between 2009 and 2014, who had their subsequent delivery at our institution during or before May of 2016. Information on maternal, fetal, and neonatal outcomes was obtained from the Magee Obstetrical Medical and Infant (MOMI) database as well as chart abstraction. We calculated IPI, proportion of women who received 17OHP-C in their next pregnancy, and attendance rates with a postpartum visit. The relationship between attendance with a postpartum visit and IPI, and receipt of 17OHP-C was examined with a logistic regression. Results: During the study period, 361 women had a spontaneous periviable birth. A total of 60 women had a subsequent delivery at Magee Women's Hospital. Only 33/60 (52.5%) presented for a postpartum visit after their periviable delivery. The median IPI for the cohort was 12.5 months (interquartile range: 6.4, 17.5 months) and 21.0% (n = 13) had an IPI less than 6 months. Adherence with the postpartum visit was not associated with an IPI less than 6 months. A total of 18.33% (11 women) did not receive 17OHP-C in their subsequent pregnancy. Women who attended a postpartum visit were much more likely to receive 17OHP-C (p = .001). Conclusions: Many women with a history of a periviable birth do not optimize strategies to reduce their risk of recurrent preterm birth. While attendance with a postpartum visit was associated with greater receipt of 17OHP-C in the subsequent pregnancy, given the overall poor rate of attendance with the postpartum visit in this cohort, novel strategies to counsel women about interpregnancy health are needed.


Assuntos
Intervalo entre Nascimentos , Viabilidade Fetal/fisiologia , Nascimento Prematuro/terapia , Cuidado Pré-Natal/métodos , Caproato de 17 alfa-Hidroxiprogesterona/uso terapêutico , Adulto , Assistência Ambulatorial/estatística & dados numéricos , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Nascimento Vivo/epidemiologia , Cooperação do Paciente/estatística & dados numéricos , Gravidez , Nascimento Prematuro/diagnóstico , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , Cuidado Pré-Natal/normas , Cuidado Pré-Natal/estatística & dados numéricos , Terapias em Estudo/métodos , Terapias em Estudo/normas , Adulto Jovem
9.
J Matern Fetal Neonatal Med ; 32(2): 301-309, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28870134

RESUMO

BACKGROUND: Neonatal hyperbilirubinemia (NNH) is one of the leading causes of admissions in nursery throughout the world. It affects approximately 2.4-15% of neonates during the first 2 weeks of life. AIMS: To evaluate the role of massage therapy for reduction of NNH in both term and preterm neonates. METHOD: The literature search was done for various randomized control trials (RCTs) by searching the Cochrane Library, PubMed, and EMBASE. RESULTS: This review included total of 10 RCTs (two in preterm neonates and eight in term neonates) that fulfilled inclusion criteria. In most of the trials, Field massage was given. Six out of eight trials reported reduction in bilirubin levels in term neonates. However, only one trial (out of two) reported significant reduction in bilirubin levels in preterm neonates. Both trials in preterm neonates and most of the trials in term neonates (five trials) reported increased stool frequencies. CONCLUSION: Role of massage therapy in the management of NNH is supported by the current evidence. However, due to limitations of the trials, current evidences are not sufficient to use massage therapy for the management of NNH in routine practice.


Assuntos
Hiperbilirrubinemia Neonatal/prevenção & controle , Massagem , Nascimento Prematuro/terapia , Nascimento a Termo , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Massagem/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Resultado do Tratamento
10.
J Matern Fetal Neonatal Med ; 32(2): 351-355, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28889767

RESUMO

INTRODUCTION: Delayed delivery is sometimes performed in selected multifetal pregnancies when the first twin birth occurs inevitably. The aim of this procedure is to improve the prognosis and decrease the morbidity and mortality of the second twin. We report three cases of delayed-interval delivery of dichorionic-diamniotic twin pregnancies assisted in our center between 2015 and 2017. After the first twin delivery, the second twin was left in utero and the patient received tocolytic therapy and antibiotics. Cervical cerclage was not performed. RESULTS: Our patients were admitted between 21 + 3 and 23 + 6 weeks of gestation. We achieved an average interval delivery of 6.33 d. Four out of six twins did not survive the delayed interval procedure. The average stay of the first and second twins that were admitted to the neonatal intensive care unit (NICU) was of 72 d (28-116) and 39.5 d (12-67), respectively. The first twin birth was vaginal in all cases, while the second twin delivery was performed by cesarean section in two out of our three patients. Our neonatal results are not favorable, probably due to the extreme prematurity. CONCLUSIONS: Delayed delivery of the second twin before 28 weeks of gestation can be an alternative for the obstetrician since it could prolong the pregnancy until a gestational age which confers a better prognosis and a better perinatal outcome for the second twin.


Assuntos
Cerclagem Cervical/métodos , Parto Obstétrico/métodos , Gravidez de Gêmeos , Nascimento Prematuro/terapia , Gêmeos , Adulto , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Gravidez , Resultado da Gravidez , Fatores de Tempo
11.
J Matern Fetal Neonatal Med ; 32(2): 271-278, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28936902

RESUMO

OBJECTIVE: To determine the association between maternal obesity and delivery due to chorioamnionitis prior to labor onset, among expectantly managed women with preterm premature rupture of membranes (pPROM). METHODS: This was a secondary analysis of a multicenter randomized trial of magnesium sulfate versus placebo to prevent cerebral palsy or death among offspring of women with anticipated delivery at 24-31-week gestation. After univariable analysis, Cox proportional hazard evaluated the association between maternal obesity and chorioamnionitis, while Laplace regression investigated how obesity affects the gestational age at delivery of the first 20% of women developing the outcome of interest. RESULTS: A total of 164 of the 1942 women with pPROM developed chorioamnionitis prior to labor onset. Obese women had a 60% increased hazard of developing such complication (adjusted HR 1.6, 95%CI 1.1-2.1, p = .008), prompting delivery 1.5 weeks earlier, as the 20th survival percentile was 27.2-week gestation (95%CI 26-28.6) among obese as opposed to 28.8 weeks (95%CI 27.4-30.1) (p = .002) among nonobese women. CONCLUSIONS: Maternal obesity is a risk factor for chorioamnionitis prior to labor onset. Future studies will determine if obesity is important enough to change the management of latency after pPROM according to maternal BMI.


Assuntos
Corioamnionite/epidemiologia , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/terapia , Obesidade/epidemiologia , Complicações na Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Adulto , Cesárea/estatística & dados numéricos , Corioamnionite/terapia , Feminino , Humanos , Recém-Nascido , Sulfato de Magnésio/uso terapêutico , Obesidade/complicações , Obesidade/terapia , Gravidez , Complicações na Gravidez/terapia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/terapia , Estudos Retrospectivos , Fatores de Tempo
12.
Br J Haematol ; 184(3): 436-439, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30460693

RESUMO

Aplastic anaemia (AA) is infrequently observed in pregnancy. We describe 19 pregnancies in 9 women at a tertiary care centre over a period of 30 years. Spontaneous resolution of AA did not occur postpartum in the five pregnancies where AA was first diagnosed in pregnancy. In the remaining pregnancies, although haematological indices declined and transfusion support was needed in 35% of pregnancies, relapses were not observed. There were no deaths, but complications occurred in 79% of pregnancies. Preterm delivery and postpartum haemorrhage were observed in 21% and 26% of pregnancies, respectively.


Assuntos
Anemia Aplástica/epidemiologia , Hemorragia Pós-Parto/epidemiologia , Nascimento Prematuro/epidemiologia , Adulto , Anemia Aplástica/terapia , Transfusão de Sangue , Feminino , Humanos , Hemorragia Pós-Parto/terapia , Gravidez , Complicações Hematológicas na Gravidez , Nascimento Prematuro/terapia , Estudos Retrospectivos
13.
BJOG ; 126(6): 763-769, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30461172

RESUMO

OBJECTIVE: To identify the current status of specialist preterm labour (PTL) clinics and identify changes in management trends over the last 5 years following release of the NICE preterm birth (PTB) guidance. DESIGN: Postal Survey of Clinical Practice. SETTING: UK. POPULATION: All consultant-led obstetric units. METHODS: A questionnaire was sent by post to all 187 NHS consultant-led obstetric units. Units with a specialist PTL clinic were asked to answer a further six questions defining their protocol for risk stratification and management. MAIN OUTCOME MEASURES: Current practice in specialist PTL clinics. Changes in treatment trends over 5 years. RESULTS: Thirty-three PTL prevention clinics were identified, with 73% running weekly. NHS staff (84%) have replaced university staff as the lead clinicians (from 69% in 2012 to 21% in 2017), suggesting this clinic has become increasingly integrated with standard care for women at the highest risk of PTB. There has been a large shift from nearly half of clinics offering cerclage as primary treatment for short cervix to offering more choice (30%) between at least two of cerclage, vaginal progesterone or pessary and combinations of primary treatments (18%), demonstrating more equipoise among clinicians regarding therapies for short cervix. CONCLUSIONS: Over 5 years, there has been a 44% increase in the number of specialist PTL clinics in the UK. Although there is a better consensus over the target high-risk population, there is increasing heterogeneity among first-line treatments for short cervix. TWEETABLE ABSTRACT: UK PTB prevention clinics have increased by 44% over 5 years, with increasing clinical equipoise to best Rx for short cervix.


Assuntos
Trabalho de Parto Prematuro , Administração dos Cuidados ao Paciente , Nascimento Prematuro , Adulto , Centros de Assistência à Gravidez e ao Parto/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Trabalho de Parto Prematuro/terapia , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Guias de Prática Clínica como Assunto , Gravidez , Gravidez de Alto Risco , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Medição de Risco , Inquéritos e Questionários , Reino Unido
14.
Artigo em Inglês | MEDLINE | ID: mdl-30309793

RESUMO

Cervical length (CL) measured by transvaginal ultrasound examination (TVUE) best identifies the risk for preterm birth (PTB). It identifies women at risk who can benefit from corticosteroids or in utero transfer. Early screening improves effectiveness of tocolysis. It reduces iatrogenicity and cost. In preterm premature rupture of membranes (PPROM), CL is devoid of infectious risk and predicts duration of the latency phase but not the risk of perinatal sepsis. Asymptomatic women at risk should be screened at a 2-week interval starting from 16 to 18 weeks, up to 24 weeks. CLs <10th centile are at risk of PTB, especially with decrease in CL after 16 weeks. Repeat ultrasound improves predictive values. Stable CL calls for term delivery. Funneling does not improve predictivity of CL. In twin pregnancies, CL reduces unnecessary interventions. In symptomatic women, fetal fibronectin performs less than CL. Its combination with inconclusive CL has not emerged productive through randomized controlled trials (RCTs), and studies with homogeneous management for preterm labor (PTL) suggest that up to 15% of unjustified hospitalizations and treatment could be avoided.


Assuntos
Medida do Comprimento Cervical/métodos , Colo do Útero/fisiopatologia , Nascimento Prematuro/diagnóstico , Biomarcadores/análise , Colo do Útero/diagnóstico por imagem , Feminino , Ruptura Prematura de Membranas Fetais/etiologia , Idade Gestacional , Humanos , Programas de Rastreamento , Gravidez , Nascimento Prematuro/etiologia , Nascimento Prematuro/terapia , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco
15.
Respir Care ; 63(10): 1197-1206, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30237275

RESUMO

BACKGROUND: Bench and clinical data indicate that techniques for applying noninvasive respiratory support may vary in terms of effectiveness, application, and tolerability. We implemented a new nasal interface and flow-generation system for the delivery of noninvasive respiratory support (NRS) to replace previously used systems. Our goal was to determine whether there were significant differences in clinically relevant outcomes between our new method and conventional systems. METHODS: We conducted a prospective observational study of preterm infants requiring noninvasive respiratory support during our initial implementation of a new nasal interface (RAM), and compared these data with a historic control group. Demographic, baseline, and clinical outcome data were collected. Clinical outcomes and comorbid conditions were compared by using the chi-square test for categorical information and the Student t test or Wilcoxon rank-sum test for quantitative data, depending on normality testing when using the Shapiro-Wilk test. Uni- and multivariate logistic regression were conducted to determine predictive factors for the development of bronchopulmonary dysplasia. RESULTS: There were no significant group differences in important comorbid conditions, invasive mechanical ventilation days (P = .16), or NRS failure within the first 7 d after birth (P = .10). Although there were no significant differences in the use of CPAP or noninvasive ventilation, settings with were significantly higher (P < .001) in the RAM group. There were more incidences of retinopathy of prematurity (P = .02) post RAM implementation, and the time to first reintubation was significantly shorter in the RAM group (P = .044). However, there were significant reductions post RAM in total days on any respiratory support (P = .009), total NRS days (P = .02), and supplemental O2 duration (P = .02). There was a trend toward reductions in bronchopulmonary dysplasia rates (P = .053), and the incidence of device-related tissue breakdown was significantly reduced (P < .001) post RAM. Multivariate logistic regression results showed the type of system (odds ratio [OR] 0.19, 95% CI 0.04-0.87; P = .032) and total invasive ventilation time (OR 0.94, 95% CI 0.89-0.99; P = .02) were predictors for the development of bronchopulmonary dysplasia. CONCLUSIONS: The ability to apply continuous distending pressure through consistent application of NRS with the RAM cannula attached to a ventilator may improve clinical outcomes, including the duration of respiratory support and pressure-ulcer rates. The influence of this system on the development of bronchopulmonary dysplasia and the significantly increased retinopathy of prematurity requires further study.


Assuntos
Cânula , Recém-Nascido de Baixo Peso , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/instrumentação , Nascimento Prematuro/terapia , Displasia Broncopulmonar/etiologia , Feminino , Humanos , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Masculino , Oxigenoterapia , Estudos Prospectivos , Retinopatia da Prematuridade/etiologia , Fatores de Tempo
16.
J Med Ethics ; 44(11): 751-755, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30097459

RESUMO

In 2017, a Philadelphia research team revealed the closest thing to an artificial womb (AW) the world had ever seen. The 'biobag', if as successful as early animal testing suggests, will change the face of neonatal intensive care. At present, premature neonates born earlier than 22 weeks have no hope of survival. For some time, there have been no significant improvements in mortality rates or incidences of long-term complications for preterms at the viability threshold. Artificial womb technology (AWT), that might change these odds, is eagerly anticipated for clinical application. We need to understand whether AWT is an extension of current intensive care or something entirely new. This question is central to determining when and how the biobag should be used on human subjects. This paper examines the science behind AWT and advances two principal claims. First, AWT is conceptually different from conventional intensive care. Identifying why AWT should be understood as distinct demonstrates how it raises different ethico-legal questions. Second, these questions should be formulated without the 'human being growing in the AW' being described with inherently value laden terminology. The 'human being in an AW' is neither a fetus nor a baby, and the ethical tethers associated with these terms could perpetuate misunderstanding and confusion. Thus, the term 'gestateling' should be adopted to refer to this new product of human reproduction: a developing human being gestating ex utero. While this paper does not attempt to solve all the ethical problems associated with AWT, it makes important clarifications that will enable better formulation of relevant ethical questions for future exploration.


Assuntos
Órgãos Artificiais , Lactente Extremamente Prematuro , Terapia Intensiva Neonatal/métodos , Tecnologia Biomédica , Desenho de Equipamento , Feminino , Viabilidade Fetal/fisiologia , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Invenções , Gravidez , Nascimento Prematuro/mortalidade , Nascimento Prematuro/terapia , Medicina Reprodutiva , Útero
17.
J Pediatr Surg ; 53(10): 1896-1903, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29960740

RESUMO

PURPOSE: An artificial placenta (AP) utilizing extracorporeal life support (ECLS) could avoid the harm of mechanical ventilation (MV) while allowing the lungs to develop. METHODS: AP lambs (n = 5) were delivered at 118 days gestational age (GA; term = 145 days) and placed on venovenous ECLS (VV-ECLS) with jugular drainage and umbilical vein reinfusion. Lungs remained fluid-filled. After 10 days, lambs were ventilated. MV control lambs were delivered at 118 ("early MV"; n = 5) or 128 days ("late MV"; n = 5), and ventilated. Compliance and oxygenation index (OI) were calculated. After sacrifice, lungs were procured and H&E-stained slides scored for lung injury. Slides were also immunostained for PDGFR-α and α-actin; alveolar development was quantified by the area fraction of alveolar septal tips staining double-positive for both markers. RESULTS: Compliance of AP lambs was 2.79 ±â€¯0.81 Cdyn compared to 0.83 ±â€¯0.19 and 3.04 ±â€¯0.99 for early and late MV, respectively. OI in AP lambs was lower than early MV lambs (6.20 ±â€¯2.10 vs. 36.8 ±â€¯16.8) and lung injury lower as well (1.8 ±â€¯1.6 vs. 6.0 ±â€¯1.2). Double-positive area fractions were higher in AP lambs (0.012 ±â€¯0.003) than early (0.003 ±â€¯0.0005) and late (0.004 ±â€¯0.002) MV controls. CONCLUSIONS: Lung development continues and lungs are protected from injury during AP support relative to mechanical ventilation. LEVEL OF EVIDENCE: n/a (basic/translational science).


Assuntos
Órgãos Artificiais , Oxigenação por Membrana Extracorpórea , Pulmão/crescimento & desenvolvimento , Nascimento Prematuro/terapia , Animais , Animais Recém-Nascidos , Modelos Animais de Doenças , Feminino , Idade Gestacional , Pulmão/fisiologia , Placenta/fisiologia , Gravidez , Ovinos
19.
Am J Physiol Lung Cell Mol Physiol ; 315(2): L193-L201, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29671605

RESUMO

Mechanical ventilation causes lung injury and systemic inflammatory responses in preterm sheep and is associated with bronchopulmonary dysplasia (BPD) in preterm infants. Budesonide added to surfactant decreased BPD by 20% in infants. We wanted to determine the effects of budesonide and surfactant on injury from high tidal volume (VT) ventilation in preterm lambs. Ewes at 125 ± 1 days gestational age had fetal surgery to expose fetal head and chest with placental circulation intact. Lambs were randomized to 1) mechanical ventilation with escalating VT to target 15 ml/kg by 15 min or 2) continuous positive airway pressure (CPAP) of 5 cmH2O. After the 15-min intervention, lambs were given surfactant 100 mg/kg with saline, budesonide 0.25 mg/kg, or budesonide 1 mg/kg. The fetuses were returned to the uterus for 24 h and then delivered and ventilated for 30 min to assess lung function. Budesonide levels were low in lung and plasma. CPAP groups had improved oxygenation, ventilation, and decreased injury markers compared with fetal VT lambs. Budesonide improved ventilation in CPAP lambs. Budesonide decreased lung weights and lung liquid and increased lung compliance and surfactant protein mRNA. Budesonide decreased proinflammatory and acute-phase responses in lung. Airway thickness increased in animals not receiving budesonide. Systemically, budesonide decreased monocyte chemoattractant protein-1 mRNA and preserved glycogen in liver. Results with 0.25 and 1 mg/kg budesonide were similar. We concluded that budesonide with surfactant matured the preterm lung and decreased the liver responses but did not improve lung function after high VT injury in fetal sheep.


Assuntos
Displasia Broncopulmonar , Budesonida , Feto , Nascimento Prematuro/terapia , Surfactantes Pulmonares , Animais , Displasia Broncopulmonar/metabolismo , Displasia Broncopulmonar/patologia , Displasia Broncopulmonar/fisiopatologia , Displasia Broncopulmonar/terapia , Budesonida/farmacocinética , Budesonida/farmacologia , Feminino , Feto/metabolismo , Feto/patologia , Feto/fisiopatologia , Fígado/metabolismo , Fígado/patologia , Fígado/fisiopatologia , Pulmão/metabolismo , Pulmão/patologia , Pulmão/fisiopatologia , Gravidez , Nascimento Prematuro/metabolismo , Nascimento Prematuro/patologia , Nascimento Prematuro/fisiopatologia , Surfactantes Pulmonares/farmacocinética , Surfactantes Pulmonares/farmacologia , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Ovinos
20.
Nutr Clin Pract ; 33(5): 647-655, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29603412

RESUMO

BACKGROUND: Growth is essential for very low birth weight infants. The purpose of this retrospective chart review was to evaluate the impact of a new standardized, evidenced-based feeding protocol for infants born < 1500 g in correlation with growth and clinical outcomes. METHODS: Growth and nutrition data was reviewed from 2 groups of infants born < 1500 g within a level III newborn intensive care unit (NICU). Epoch 1 infants (N = 32) received care following initial implementation of a standardized enteral feeding protocol. Epoch 2 infants (N = 32) received care following aggressive modification of this initial protocol based on newly available literature that promotes earlier initiation and advancement of enteral feedings. RESULTS: Epoch 2 infants weighed more at 36 weeks (2562 vs 2304 g) with higher discharge weight percentiles (32nd vs 15th percentile). Epoch 2 infants started and achieved full enteral feedings earlier (day of life 1 vs 4; 7 vs 22, P < 0.0001) and required less days of parenteral nutrition (5.5 vs 17.5 days, P < 0.0001), with indwelling central line for parenteral access (6 vs 17.5). There were no differences in retinopathy of prematurity (17% control vs 19% study), oxygen requirement at 36 weeks (22% epoch 1 vs 43%), necrotizing enterocolitis (3% epoch 1 vs 0%), intraventricular hemorrhage grade 3-4, periventricular leukomalacia, or death. CONCLUSION: In this sample of very low birth weight infants, a progressive standardized, evidence-based feeding protocol was associated with improved growth without increased risk for necrotizing enterocolitis.


Assuntos
Protocolos Clínicos , Nutrição Enteral/métodos , Doenças do Prematuro , Recém-Nascido de muito Baixo Peso , Nutrição Parenteral/métodos , Nascimento Prematuro/terapia , Ganho de Peso , Peso ao Nascer , Protocolos Clínicos/normas , Enterocolite Necrosante/etiologia , Enterocolite Necrosante/prevenção & controle , Feminino , Humanos , Lactente , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/mortalidade , Doenças do Prematuro/prevenção & controle , Unidades de Terapia Intensiva Neonatal , Masculino , Estado Nutricional , Nutrição Parenteral/efeitos adversos , Nascimento Prematuro/mortalidade , Estudos Retrospectivos
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