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Maternal and child health
Apollo Medicine 2011 December Volume 8, Number 4; pp. 320–322
Journal Scan
Maternal and child health Piyush Chandel*, Anjali Kulkarni** *Fellow, **Senior Consultant, Department of Neonatology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi – 110076, India.
1 A randomized trial of prenatal versus postnatal repair of myelomeningocele. Adzick NS, Thom EA, Spong CY, et al, for the MOMS Investigators. N Engl J Med 2011;364:993–1004.
COMMENT This study revealed that the prenatal repair of myelomeningocele has better outcome as compared with the postnatal repair. Spina bifida is the most common congenital anomalies of the central nervous system that are compatible with life and the most frequent form is myelomeningocele. Despite folic acid fortification, the incidence of myelomeningocele is 3.4 per 10,000 live births in the USA. Live born infants with myelomeningocele have a death rate of about 10%, and long-term survivors have major disabilities including paralysis and bowel and bladder dysfunction. Eligible women were randomly assigned to undergo either prenatal surgery before 26 weeks of gestation or standard postnatal repair. Prenatal surgery for myelomeningocele that was performed before 26 weeks of gestation decreased the risk of death or a need for shunting by the age of 12 months and also improved mental and motor function. Prenatal surgery also decreased the risk of hindbrain herniation and increased the likelihood of being able to walk independently, as compared with postnatal surgery. Prenatal surgery was associated with higher rates of preterm birth, intraoperative complications and uterine-scar defects apparent at delivery, along with a higher rate of maternal transfusion at delivery.
2 Short-term complications of late preterm infants. Rojas Feria P, Pavón Delgado A, Rosso González M, Losada Martínez A. An Pediatr (Barc) 2011;75:169–74.
COMMENT Late preterm infants, born at 34–36 (+6) weeks gestation, are physiologically more immature than term infants. As a consequence, they have an increased risk of morbidity and mortality. Late preterm were compared with term babies. This retrospective observational study found that the late preterm group was associated with assisted reproduction, twin pregnancy, cesarean delivery and pre-eclampsia during pregnancy. The risk of hospitalization was 6 times greater in these infants and neonatal intensive care admissions were twice as common as that in the term babies. Neonatal respiratory morbidity and jaundice were greater in the preterm group. The use of surfactant, oxygen and respiratory support (continuous positive airway pressure and cytomegalovirus [CMV]) was also higher. There were no significant differences in hypoglycemia and neonatal mortality between both groups.
Correspondence: Dr. Anjali Kulkarni, E-mail: [email protected] doi: 10.1016/S0976-0016(11)60022-7
© 2011, Indraprastha Medical Corporation Ltd
Maternal and child health
Journal Scan
321
3 Impact of maternal diabetes mellitus on mortality and morbidity of preterm infants (24–33 weeks’ gestation). Bental Y, Reichman B, Shiff Y, Weisbrod M, Boyko V, Lerner-Geva L, Mimouni FB, in Collaboration with the Israel Neonatal Network. Pediatrics 2011;128:e848–55.
COMMENT Israel National Very Low Birth Weight Infant Database from 1995 to 2007 was analyzed to assess the independent effect of the maternal diabetes mellitus (DM) status on infant mortality, respiratory distress syndrome (RDS) and other complications of prematurity. Mothers with DM were more likely to have received a complete course of prenatal steroids than control mothers. Infants of diabetic mothers (IDMs) had a slightly higher gestational age and birth weight than non-IDMs. There were no significant differences between IDMs and non-IDMs in terms of delivery room mortality, RDS and other major complications of prematurity. The adjusted odds ratios for mortality, RDS, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leucomalacia, retinopathy of prematurity, necrotizing enterocolitis and patent ductus arteriosus were not significantly increased in the IDM group. With modern management and adequate prenatal care, the IDMs born with very low birth weight do not seem to be at an excess risk of developing RDS or other major complications of prematurity compared with non-IDM.
4 Evaluation of human milk fortification from the time of the first feeding: Effects on infants of less than 31 weeks gestational age. Tillman S, Brandon DH, Silva SG. J Perinatol 2011 Sep 29.
COMMENT The study was done to assess whether human milk fortification from the time of the first feeding significantly improves weight gain and bone mineral status in infants of < 31 weeks estimated gestational age as compared with delayed or standard human milk fortification. Infants in the early fortification group (EFG) and in the delayed fortification group (DFG) were compared with regard to the weight gain at 34 weeks postmenstrual age (PMA), and their serum levels of calcium, phosphorus and alkaline phosphatase were compared as an indicator of the bone mineral status. The usual practice of fortification took place once an infant had reached a feeding volume of 50–100 mL Kg–1 day–1. The new practice fortified all human milk with a powdered human milk fortifier to 24 calories per ounce, starting with the first feeding, no matter how small the volume. There were no differences in the weight gain between the EFG and the DFG. The group that received fortification from the time of the first feeding were significantly less likely to have alkaline phosphatase levels > 500 U L–1 from 33 weeks PMA onwards. There was no incidence of feeding intolerance with early fortification. Fortification of human milk from the time of the first feeding does not affect weight gain at 34 weeks PMA, but is related to a lower incidence of elevated alkaline phosphate levels and does not cause feeding intolerance.
5 Vitamin D supplementation during pregnancy: Double-blind, randomized clinical trial of safety and effectiveness. Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. J Bone Miner Res 2011;26:2341–57.
COMMENT The need, safety, and effectiveness of vitamin D supplementation during pregnancy remain controversial. In this randomized controlled trial, women with a singleton pregnancy at 12–16 weeks’ gestation received 400, 2000 or 4000 IU of vitamin D3 per day until delivery. The primary outcome was maternal/neonatal circulating 25-hydroxyvitamin D [25(OH)D] concentration
© 2011, Indraprastha Medical Corporation Ltd
322
Apollo Medicine 2011 December; Vol. 8, No. 4
Chandel and Kulkarni
at delivery with secondary outcomes of 25(OH)D concentration of 80 nmol L–1 or greater, and the 25(OH)D concentration required to achieve maximal 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] production. Circulating 25(OH)D had a direct influence on the circulating 1,25(OH)2D3 concentrations throughout pregnancy with the maximal production of 1,25(OH)2D3 in all strata in the 4000 IU group. There were no differences between groups on any safety measure. Not a single adverse event was attributed to vitamin D supplementation or to circulating 25(OH)D levels. It is concluded that vitamin D supplementation of 4000 IU per day for pregnant women is safe and most effective in achieving sufficiency in all women and their neonates regardless of race, whereas the current estimated average requirement is comparatively ineffective at achieving adequate circulating 25(OH)D concentrations.
6 Prenatal diagnosis, management and outcome of fetal dysrhythmia: A tertiary fetal medicine center experience over an 8-year period. Rasiah SV, Ewer AK, Miller P, Kilby MD. Fetal Diagn Ther 2011;30:122–7.
COMMENT Prenatal diagnosis, management and outcomes of fetuses with dysrhythmia were reviewed retrospectively (01/01/1997 to 31/12/2004). Over an 8-year period, 318 pregnant mothers were referred for the assessment of suspected fetal dysrhythmias. Median gestation was 30 weeks (range 19–41 weeks). Fetal dysrhythmia was identified in 182 (57%) and classified as (i) 126 atrial extrasystoles; (ii) 26 tachyarrhythmia and (iii) 30 bradyarrhythmia. Of the fetuses with tachyarrhythmia, 23 had supraventricular tachycardia (SVT), 2 atrial flutter and 1 sinus tachycardia. One death associated with severe hydrops occurred in the tachyarrhythmia group. Nineteen cases of SVT were successfully treated in utero. Both cases of atrial flutter required direct current cardioversion in the neonatal period. In the bradyarrhythmia group, there were 15 isolated cases and 10 cases associated with congenital heart disease with 73% and 20% survival, respectively. Benign atrial extrasystoles are the commonest cause for referral and assessment of fetal dysrhythmia. The overall prognosis for SVT is good with the majority responding to the transplacental therapy. In cases with congenital atrioventricular block, the outcome was less favorable, especially when the atrioventricular block was associated with congenital heart disease.
© 2011, Indraprastha Medical Corporation Ltd
Journal Scan
Maternal and child health Piyush Chandel*, Anjali Kulkarni** *Fellow, **Senior Consultant, Department of Neonatology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi – 110076, India.
1 A randomized trial of prenatal versus postnatal repair of myelomeningocele. Adzick NS, Thom EA, Spong CY, et al, for the MOMS Investigators. N Engl J Med 2011;364:993–1004.
COMMENT This study revealed that the prenatal repair of myelomeningocele has better outcome as compared with the postnatal repair. Spina bifida is the most common congenital anomalies of the central nervous system that are compatible with life and the most frequent form is myelomeningocele. Despite folic acid fortification, the incidence of myelomeningocele is 3.4 per 10,000 live births in the USA. Live born infants with myelomeningocele have a death rate of about 10%, and long-term survivors have major disabilities including paralysis and bowel and bladder dysfunction. Eligible women were randomly assigned to undergo either prenatal surgery before 26 weeks of gestation or standard postnatal repair. Prenatal surgery for myelomeningocele that was performed before 26 weeks of gestation decreased the risk of death or a need for shunting by the age of 12 months and also improved mental and motor function. Prenatal surgery also decreased the risk of hindbrain herniation and increased the likelihood of being able to walk independently, as compared with postnatal surgery. Prenatal surgery was associated with higher rates of preterm birth, intraoperative complications and uterine-scar defects apparent at delivery, along with a higher rate of maternal transfusion at delivery.
2 Short-term complications of late preterm infants. Rojas Feria P, Pavón Delgado A, Rosso González M, Losada Martínez A. An Pediatr (Barc) 2011;75:169–74.
COMMENT Late preterm infants, born at 34–36 (+6) weeks gestation, are physiologically more immature than term infants. As a consequence, they have an increased risk of morbidity and mortality. Late preterm were compared with term babies. This retrospective observational study found that the late preterm group was associated with assisted reproduction, twin pregnancy, cesarean delivery and pre-eclampsia during pregnancy. The risk of hospitalization was 6 times greater in these infants and neonatal intensive care admissions were twice as common as that in the term babies. Neonatal respiratory morbidity and jaundice were greater in the preterm group. The use of surfactant, oxygen and respiratory support (continuous positive airway pressure and cytomegalovirus [CMV]) was also higher. There were no significant differences in hypoglycemia and neonatal mortality between both groups.
Correspondence: Dr. Anjali Kulkarni, E-mail: [email protected] doi: 10.1016/S0976-0016(11)60022-7
© 2011, Indraprastha Medical Corporation Ltd
Maternal and child health
Journal Scan
321
3 Impact of maternal diabetes mellitus on mortality and morbidity of preterm infants (24–33 weeks’ gestation). Bental Y, Reichman B, Shiff Y, Weisbrod M, Boyko V, Lerner-Geva L, Mimouni FB, in Collaboration with the Israel Neonatal Network. Pediatrics 2011;128:e848–55.
COMMENT Israel National Very Low Birth Weight Infant Database from 1995 to 2007 was analyzed to assess the independent effect of the maternal diabetes mellitus (DM) status on infant mortality, respiratory distress syndrome (RDS) and other complications of prematurity. Mothers with DM were more likely to have received a complete course of prenatal steroids than control mothers. Infants of diabetic mothers (IDMs) had a slightly higher gestational age and birth weight than non-IDMs. There were no significant differences between IDMs and non-IDMs in terms of delivery room mortality, RDS and other major complications of prematurity. The adjusted odds ratios for mortality, RDS, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leucomalacia, retinopathy of prematurity, necrotizing enterocolitis and patent ductus arteriosus were not significantly increased in the IDM group. With modern management and adequate prenatal care, the IDMs born with very low birth weight do not seem to be at an excess risk of developing RDS or other major complications of prematurity compared with non-IDM.
4 Evaluation of human milk fortification from the time of the first feeding: Effects on infants of less than 31 weeks gestational age. Tillman S, Brandon DH, Silva SG. J Perinatol 2011 Sep 29.
COMMENT The study was done to assess whether human milk fortification from the time of the first feeding significantly improves weight gain and bone mineral status in infants of < 31 weeks estimated gestational age as compared with delayed or standard human milk fortification. Infants in the early fortification group (EFG) and in the delayed fortification group (DFG) were compared with regard to the weight gain at 34 weeks postmenstrual age (PMA), and their serum levels of calcium, phosphorus and alkaline phosphatase were compared as an indicator of the bone mineral status. The usual practice of fortification took place once an infant had reached a feeding volume of 50–100 mL Kg–1 day–1. The new practice fortified all human milk with a powdered human milk fortifier to 24 calories per ounce, starting with the first feeding, no matter how small the volume. There were no differences in the weight gain between the EFG and the DFG. The group that received fortification from the time of the first feeding were significantly less likely to have alkaline phosphatase levels > 500 U L–1 from 33 weeks PMA onwards. There was no incidence of feeding intolerance with early fortification. Fortification of human milk from the time of the first feeding does not affect weight gain at 34 weeks PMA, but is related to a lower incidence of elevated alkaline phosphate levels and does not cause feeding intolerance.
5 Vitamin D supplementation during pregnancy: Double-blind, randomized clinical trial of safety and effectiveness. Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. J Bone Miner Res 2011;26:2341–57.
COMMENT The need, safety, and effectiveness of vitamin D supplementation during pregnancy remain controversial. In this randomized controlled trial, women with a singleton pregnancy at 12–16 weeks’ gestation received 400, 2000 or 4000 IU of vitamin D3 per day until delivery. The primary outcome was maternal/neonatal circulating 25-hydroxyvitamin D [25(OH)D] concentration
© 2011, Indraprastha Medical Corporation Ltd
322
Apollo Medicine 2011 December; Vol. 8, No. 4
Chandel and Kulkarni
at delivery with secondary outcomes of 25(OH)D concentration of 80 nmol L–1 or greater, and the 25(OH)D concentration required to achieve maximal 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] production. Circulating 25(OH)D had a direct influence on the circulating 1,25(OH)2D3 concentrations throughout pregnancy with the maximal production of 1,25(OH)2D3 in all strata in the 4000 IU group. There were no differences between groups on any safety measure. Not a single adverse event was attributed to vitamin D supplementation or to circulating 25(OH)D levels. It is concluded that vitamin D supplementation of 4000 IU per day for pregnant women is safe and most effective in achieving sufficiency in all women and their neonates regardless of race, whereas the current estimated average requirement is comparatively ineffective at achieving adequate circulating 25(OH)D concentrations.
6 Prenatal diagnosis, management and outcome of fetal dysrhythmia: A tertiary fetal medicine center experience over an 8-year period. Rasiah SV, Ewer AK, Miller P, Kilby MD. Fetal Diagn Ther 2011;30:122–7.
COMMENT Prenatal diagnosis, management and outcomes of fetuses with dysrhythmia were reviewed retrospectively (01/01/1997 to 31/12/2004). Over an 8-year period, 318 pregnant mothers were referred for the assessment of suspected fetal dysrhythmias. Median gestation was 30 weeks (range 19–41 weeks). Fetal dysrhythmia was identified in 182 (57%) and classified as (i) 126 atrial extrasystoles; (ii) 26 tachyarrhythmia and (iii) 30 bradyarrhythmia. Of the fetuses with tachyarrhythmia, 23 had supraventricular tachycardia (SVT), 2 atrial flutter and 1 sinus tachycardia. One death associated with severe hydrops occurred in the tachyarrhythmia group. Nineteen cases of SVT were successfully treated in utero. Both cases of atrial flutter required direct current cardioversion in the neonatal period. In the bradyarrhythmia group, there were 15 isolated cases and 10 cases associated with congenital heart disease with 73% and 20% survival, respectively. Benign atrial extrasystoles are the commonest cause for referral and assessment of fetal dysrhythmia. The overall prognosis for SVT is good with the majority responding to the transplacental therapy. In cases with congenital atrioventricular block, the outcome was less favorable, especially when the atrioventricular block was associated with congenital heart disease.
© 2011, Indraprastha Medical Corporation Ltd