Význam změn tkáňové oxygenace u monochoriálních dvojčat v predikci závažné neonatální morbidity

Despite improvements in perinatal outcome in recent decades, multiple pregnancies are associated with increased risk of complications including preterm birth, fetal growth restriction (FGR) and twin-twin transfusion syndrome (TTTS). Fetal circulatory disturbances and immature cerebral vasculature increase the risk for serious perinatal injury and adverse neurodevelopmental outcome in multiple births. Cerebral oxygenation (crSO2) monitoring using near-infrared spectroscopy (NIRS) is increasingly used in high-risk infants. However, limited data are available in twin preterm infants with respect to cerebral tissue perfusion. The aim of this project was to measure crSO2 using NIRS in preterm monochorionic and dichorionic twins during the first 72 hours of life and find out correlation between underlying fetal conditions and crSO2 development. We divided the study population into 4 subgroups based on major fetal pathology: donor (1) and recipient (2) monochorionic twins (with TTTS), selective FGR infants (3) and twins without fetal compromise (4). We observed significant variation in crSO2 among the subgroups using mixed model analysis. The recipient twins exhibited the lowest crSO2 throughout the study period, whereas the FGR and donor twins presented with the highest values. Nevertheless, we found no...Přestože došlo ke zlepšení perinatální péče v posledních desetiletích, jsou vícečetná těhotenství asociovaná se zvýšeným rizikem komplikací, jako např. předčasný porod, fetální růstová restrikce (fetal growth restriction - FGR) a transfuzní syndrom (twin-twin transfusion syndrome - TTTS). Intrauterinní cirkulační nestabilita a nezralá mozková vaskulatura významně přispívají k riziku vážného perinatálního poškození a zhoršeného neurologického vývoje dětí z vícečetných gravidit. Měření cerebrální oxygenace (crSO2) pomocí metody Near-Infrared Specotroscopy (NIRS) se používá stále častěji u rizikových novorozenců. I přes rozšířenost metody však existují omezená data s ohledem na nezralá dvojčata a jejich cerebrální tkáňovou perfuzi. Cílem práce bylo analyzovat crSO2 pomocí metody NIRS u nezralých monochoriálních a bichoriálních dvojčat v prvních 72 hodinách života a objasnit korelaci mezi fetálními komplikacemi a postnatálním vývojem crSO2. Na základě dominantních fetálních komplikací jsme rozdělili studijní populaci na 4 skupiny: donoři (1) a recipienti (2) z monochoriální gravidity s TTTS, novorozenci s FGR (3) a novorozenci bez významné fetální komplikace (4). Použitím analýzy smíšeného modelu jsme zjistili signifikantní rozdíly v crSO2 mezi jednotlivými skupinami. Ve skupině recipientů byly...Ústav pro péči o matku a dítě v Praze PodolíDepartment of Mother and Child Care in Prague PodoliThird Faculty of Medicine3. lékařská fakult

The importance of tissue oxygenation changes in monochorionic twins for predicting severe neonatal morbidity

Despite improvements in perinatal outcome in recent decades, multiple pregnancies are associated with increased risk of complications including preterm birth, fetal growth restriction (FGR) and twin-twin transfusion syndrome (TTTS). Fetal circulatory disturbances and immature cerebral vasculature increase the risk for serious perinatal injury and adverse neurodevelopmental outcome in multiple births. Cerebral oxygenation (crSO2) monitoring using near-infrared spectroscopy (NIRS) is increasingly used in high-risk infants. However, limited data are available in twin preterm infants with respect to cerebral tissue perfusion. The aim of this project was to measure crSO2 using NIRS in preterm monochorionic and dichorionic twins during the first 72 hours of life and find out correlation between underlying fetal conditions and crSO2 development. We divided the study population into 4 subgroups based on major fetal pathology: donor (1) and recipient (2) monochorionic twins (with TTTS), selective FGR infants (3) and twins without fetal compromise (4). We observed significant variation in crSO2 among the subgroups using mixed model analysis. The recipient twins exhibited the lowest crSO2 throughout the study period, whereas the FGR and donor twins presented with the highest values. Nevertheless, we found no..

Placental Transfusion and Cardiovascular Instability in the Preterm Infant

Postnatal adaptation in preterm newborn comprises complex physiological processes that involve significant changes in the circulatory and respiratory system. Increasing hemoglobin level and blood volume following placental transfusion may be of importance in enhancing arterial oxygen content, increasing cardiac output, and improving oxygen delivery. The European consensus on resuscitation of preterm infants recommends delayed cord clamping (DCC) for at least 60 s to promote placenta–fetal transfusion in uncompromised neonates. Recently, published meta-analyses suggest that DCC is associated with fewer infants requiring transfusions for anemia, a lower incidence of intraventricular hemorrhage, and lower risk for necrotizing enterocolitis. Umbilical cord milking (UCM) has the potential to avoid some disadvantages associated with DCC including the increased risk of hypothermia or delay in commencing manual ventilation. UCM represents an active form of blood transfer from placenta to neonate and may have some advantages over DCC. Moreover, both methods are associated with improvement in hemodynamic parameters and blood pressure within first hours after delivery compared to immediate cord clamping. Placental transfusion appears to be beneficial for the preterm uncompromised infant. Further studies are needed to evaluate simultaneous placental transfusion with resuscitation of deteriorating neonates. It would be of great interest for future research to investigate advantages of this approach further and to assess its impact on neonatal outcomes, particularly in extremely preterm infants

Cerebral Oximetry Monitoring in Extremely Preterm Infants

Background: The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking. Methods: In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we assigned extremely preterm infants (gestational age, <28 weeks), within 6 hours after birth, to receive treatment guided by cerebral oximetry monitoring for the first 72 hours after birth or to receive usual care. The primary outcome was a composite of death or severe brain injury on cerebral ultrasonography at 36 weeks' postmenstrual age. Serious adverse events that were assessed were death, severe brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and late-onset sepsis. Results: A total of 1601 infants underwent randomization and 1579 (98.6%) were evaluated for the primary outcome. At 36 weeks' postmenstrual age, death or severe brain injury had occurred in 272 of 772 infants (35.2%) in the cerebral oximetry group, as compared with 274 of 807 infants (34.0%) in the usual-care group (relative risk with cerebral oximetry, 1.03; 95% confidence interval, 0.90 to 1.18; P = 0.64). The incidence of serious adverse events did not differ between the two groups. Conclusions: In extremely preterm infants, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth was not associated with a lower incidence of death or severe brain injury at 36 weeks' postmenstrual age than usual care. (Funded by the Elsass Foundation and others; SafeBoosC-III ClinicalTrials.gov number, NCT03770741.)