Impact of maternal thyroid disorders on maternal and neonatal outcomes in women delivering after 34 weeks of gestation

Introduction: The association of altered thyroid regulation during pregnancy can lead to the development of hypothyroidism or hyperthyroidism, and the resultant thyroid dysfunction ultimately leads to pregnancy-related complications. Objective: The objective of this study was to determine the impact of maternal thyroid disorders on maternal and neonatal outcomes in women delivering at/after 34 weeks of gestation. Methods: The current study was a prospective observational case–control study done over 6 months. Comparisons were made between the pregnancy-related complications and the neonatal outcomes in 100 dysthyroid mothers with those of 100 euthyroid mothers, delivering at/after 34 weeks of gestation. Results: Enrollment of 200 mother-infant dyads, 100 in each group were done. The need for cesarean delivery was higher in hypothyroid patients as they failed induction oflabor (36.1%). Among the neonatal outcomes, the hypothyroid patients had a significantly higher incidence of late preterm delivery (31%) and had a higher incidence of small for gestational age infants (32%). Infants of such dysthyroid mothers did not show any significant abnormalities in their thyroid function tests. Conclusion: Abnormalities in thyroid function tests remain uncommon in infants born to dysthyroid mothers. Early screening and optimum treatment of thyroid disorders are extremely vital for optimum maternal and neonatal health outcomes. Knowledge of the associated comorbidities such as gestational diabetes, prematurity, growth retardation, and greater need for cesarean births can help to provide better medical care

Black hole complementarity from microstate models: A study of information replication and the encoding in the black hole interior

We study how the black hole complementarity principle can emerge from quantum gravitational dynamics within a local semiclassical approximation. Further developing and then simplifying a microstate model based on the fragmentation instability of a near-extremal black hole, we find that the key to the replication (but not cloning) of infalling information is the decoupling of various degrees of freedom. The infalling matter decouples from the interior retaining a residual time-dependent quantum state in the hair which encodes the initial state of the matter non-isometrically. The non-linear ringdown of the interior after energy absorption and decoupling also encodes the initial state, and transfers the information to Hawking radiation. During the Hawking evaporation process, the fragmented throats decouple from each other and the hair decouples from the throats. We find that the hair mirrors infalling information after the decoupling time which scales with the logarithm of the entropy (at the time of infall) when the average mass per fragmented throat (a proxy for the temperature) is held fixed. The decoding protocol for the mirrored information does not require knowledge of the interior, and only limited information from the Hawking radiation, as can be argued to be necessitated by the complementarity principle. We discuss the scope of the model to illuminate various aspects of information processing in a black hole.Comment: 44 pages, 21 figure

Clinical profile of late-preterm infants admitted to a tertiary care hospital

Background: Late-preterm babies account for nearly 10% of the total births. Understanding clinical profile of late-preterm infants is important for helping newborn care providers to anticipate and manage potential morbidity during the birth hospitalization and early follow-up. Objective: The objective of this study is to study the clinical profile of late-preterm newborns (340/7 to 366/7 weeks of gestation). Methods: This was a prospective observational study conducted in the neonatal unit of a tertiary care public hospital. All late-preterm babies delivered in the hospital from July 2016 to December 2016, who met the inclusion criteria, were enrolled after taking consent from parents. Detailed antenatal and natal history were noted along with neonatal morbidities and mortality, and the interventions and treatment required by the infants were noted in a structured pro forma. These late-preterm infants were followed up till death/discharge and readmission to hospital and reasons for readmission were evaluated. Results: We enrolled 110 late-preterm babies delivered in our center. The most common morbidity was jaundice requiring phototherapy (63.63%) followed by respiratory distress (24.54%). 25.45% of infants required respiratory support in the form of continuous positive airway pressure or mechanical ventilation. Hypocalcemia and sepsis were observed in 10% of the babies. Feed intolerance was also observed in 16.36% of the babies. The mortality in this group of late preterms was 4.54%. Conclusions: Late-preterm infants show a considerably high rate of medical complications, including need for respiratory support and prolonged hospital stay. Awareness about the neonatal morbidities in late-preterm newborns will facilitate better management of these neonates

Outcome in twin gestations: A prospective observational study

Background: Incidence of twinning has increased due to the widespread use of assisted reproductive techniques. Twin gestation is associated with many maternal, fetal, and neonatal complications. Objective: The objective of the study is to study the fetal and neonatal complications and outcome of twin pregnancies. Materials and Methods: This is a prospective observational study conducted in a tertiary referral neonatal intensive care unit. 50 consecutive pairs of twins were recruited at the time of admission of the mother to the labor ward. Demographic details of the mother and of the infants were recorded. The outcome of the pregnancy was noted, and the live born infants were followed during the hospital stay and then up till 6 months of corrected gestational age. Results: Incidence of prematurity was 60%. Moderate to severe discordancy was identified in 17 (34%) pairs of twins and 43% infants were born small for gestational age (SGA). Intrauterine Fetal Death was noted in 6 out of 54 infants with discordant growth and 1 out of 46 infants with concordant growth (p=0.046). The overall mortality in our study was 13.9%. Mortality in SGA infants was 23% and 6% in appropriate for gestational age infants (p=0.036). Conclusion: Twinning is associated with high incidence of prematurity, growth discordance, congenital anomalies, intrauterine fetal death, and neonatal mortality

Exploring infant & young child feeding (IYCF) practices & perceptions in the London Borough of Tower Hamlets

Introduction: The aim of the research was to gain a greater understanding of infant and young child feeding perceptions and practices in the London Borough of Tower Hamlets and the role of early years’ providers in supporting healthy feeding practices. The research was used to feed into ongoing commissioning and resource allocation priorities, taking into consideration continuing budget restrictions, to achieve nutrition outcomes through effective early years’ public health interventions. Methodology: A qualitative methodology was applied. The target groups were mothers with children under five years old, early years ‘service providers and carers. The participants were selected using purposeful, convenience and snowball sampling methods. In total 18 focus group discussions, 36 interviews and 3 direct observation sessions were carried out with 144 participants across the borough. Findings: There was generally widespread knowledge that breastfeeding is best for infants, however, there was less clarity on the best time for introducing complementary food and drinks to infants. Mothers trust health providers for information, but most used the internet, family and friends for information as it was easier to access. Some mothers reported mixed messages, pain, and pressure from the media, families and friends as the main reasons for changing from exclusive breastfeeding to mixed feeding. Some mothers reported lack of support postnatally and inconsistent advice such as service providers giving mixed messages, especially regarding feeding in public, mixed feeding and when to introduce other fluids and foods. The borough’s infant and young child feeding support workers were valued, but not all mothers knew about the service. Certain groups, such as those with English as a second language, teenage mothers and mothers without childcare reported not using services routinely. Conclusions: Following presentation of the key findings, and a discussion with early years’ service providers, the Tower Hamlets Public Health Division suggested practice changes which were adopted by the LBTH council. The council committed to continue supporting the Infant Feeding & Wellbeing Service (known as the Baby Feeding Service) to continue to improve infant and young child feeding practices. Health visitors are encouraged to use their new 3-4 month contact with post-natal mothers, in addition to the five mandated universal contacts, as an opportunity to offer nutrition support to mothers. The council also approved increased nutrition capacity within the Health Visiting and Public Health team. More information is now available on the Tower Hamlets website to support mothers with clear nutrition and infant feeding information with details of the many services mothers can access in the borough

Hypothermia for encephalopathy in low-income and middle-income countries: feasibility of whole-body cooling using a low-cost servo-controlled device

Although therapeutic hypothermia (TH) is the standard of care for hypoxic ischaemic encephalopathy in high-income countries, the safety and efficacy of this therapy in low-income and middle-income countries (LMICs) is unknown. We aimed to describe the feasibility of TH using a low-cost servo-controlled cooling device and the short-term outcomes of the cooled babies in LMIC. Design: We recruited babies with moderate or severe hypoxic ischaemic encephalopathy (aged <6 hours) admitted to public sector tertiary neonatal units in India over a 28-month period. We administered whole-body cooling (set core temperature 33.5°C) using a servo-controlled device for 72 hours, followed by passive rewarming. We collected the data on short-term neonatal outcomes prior to hospital discharge. Results: Eighty-two babies were included-61 (74%) had moderate and 21 (26%) had severe encephalopathy. Mean (SD) hypothermia cooling induction time was 1.7 hour (1.5) and the effective cooling time 95% (0.08). The mean (SD) hypothermia induction time was 1.7 hour (1.5 hour), core temperature during cooling was 33.4°C (0.2), rewarming rate was 0.34°C (0.16°C) per hour and the effective cooling time was 95% (8%). Twenty-five (51%) babies had gastric bleeds, 6 (12%) had pulmonary bleeds and 21 (27%) had meconium on delivery. Fifteen (18%) babies died before discharge from hospital. Heart rate more than 120 bpm during cooling (P=0.01) and gastric bleeds (P<0.001) were associated with neonatal mortality. Conclusions: The low-cost servo-controlled cooling device maintained the core temperature well within the target range. Adequately powered clinical trials are required to establish the safety and efficacy of TH in LMICs. Clinical trial registration number: NCT01760629

Whole-Body Hypothermia, Cerebral Magnetic Resonance Biomarkers, and Outcomes in Neonates With Moderate or Severe Hypoxic-Ischemic Encephalopathy Born at Tertiary Care Centers vs Other Facilities: A Nested Study Within a Randomized Clinical Trial

IMPORTANCE: The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. OBJECTIVE: To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). Design, Setting, and PARTICIPANTS: This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. Exposure: 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. MAIN OUTCOMES AND MEASURES: Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. RESULTS: Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). CONCLUSIONS AND RELEVANCE: In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02387385

Hypothermia for encephalopathy in low and middle-income countries (HELIX): Study protocol for a randomised controlled trial

BACKGROUND: Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as standard therapy in these settings. However, the safety and efficacy of cooling therapy in low- and middle-income countries (LMICs), where 99% of the disease burden occurs, remains unclear. We will examine whether whole body cooling reduces death or neurodisability at 18-22 months after neonatal encephalopathy, in LMICs. METHODS: We will randomly allocate 408 term or near-term babies (aged ≤ 6 h) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries (India, Bangladesh or Sri Lanka), to either usual care alone or whole-body cooling with usual care. Babies allocated to the cooling arm will have core body temperature maintained at 33.5 °C using a servo-controlled cooling device for 72 h, followed by re-warming at 0.5 °C per hour. All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1-2 weeks after birth. Our primary endpoint is death or moderate or severe disability at the age of 18 months. DISCUSSION: Upon completion, HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs. The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02387385. Registered on 27 February 2015