Aim
To determine how the severity of antenatally diagnosed germinal matrix‐intraventricular hemorrhage (GMH‐IVH) relates to morbidity and mortality, and to explore potential risk factors.
Method
We ...conducted a systematic review and individual patient data meta‐analysis of antenatally diagnosed fetal GMH‐IVH. The primary outcomes were mortality and morbidity. Potential associations with clinical factors during pregnancy were explored. Analysis employed Fisher’s exact test and logistic regression.
Results
We included 240 cases from 80 studies. Presence of venous infarction was associated with mortality (odds ratio OR 4.3, 95% confidence interval CI 1.4–13.25), motor impairment (OR 103.2, 95% CI 8.6–1238), epilepsy (OR 6.46, 95% CI 2.64–16.06), and developmental delay (OR 8.55, 95% CI 2.12–48.79). Shunt placement was associated with gestational age at GMH‐IVH diagnosis and in utero progression. Many cases had uncomplicated pregnancies but possible co‐occurring conditions included twin gestation, small for gestational age, and congenital anomalies.
Interpretation
Severity of fetal GMH‐IVH, specifically venous infarction, is associated with overall mortality and morbidity. Risk factors for fetal GMH‐IVH are poorly understood and controlled studies are required.
What this paper adds
Preterm germinal matrix‐intraventricular hemorrhage (GMH‐IVH) grading can be applied to fetuses.
Many fetal germinal matrix hemorrhages occur in otherwise typical pregnancies.
Half of fetuses with post‐hemorrhagic ventricular dilatation receive a shunt after delivery.
Fetuses with grade I or II GMH‐IVH have few sequelae.
Fetuses with periventricular hemorrhagic infarction have a high burden of motor impairment.
What this paper adds
Preterm germinal matrix‐intraventricular hemorrhage (GMH‐IVH) grading can be applied to fetuses.
Many fetal germinal matrix hemorrhages occur in otherwise typical pregnancies.
Half of fetuses with post‐hemorrhagic ventricular dilatation receive a shunt after delivery.
Fetuses with grade I or II GMH‐IVH have few sequelae.
Fetuses with periventricular hemorrhagic infarction have a high burden of motor impairment.
Fetal germinal matrix‐intraventricular hemorrhage occurs in a variety of pregnancy conditions and outcome is associated with the grade of hemorrhage.
This article is commented on by de Vries and de Vries on page 126 of this issue.
Use of social media for study recruitment is becoming increasingly common. Previous studies have typically focused on using Facebook; however, there are limited data to support the use of other ...social media platforms for participant recruitment, notably in the context of a pregnancy study.
Our study aimed to evaluate the effectiveness of Facebook, Twitter, and Instagram in recruiting a representative sample of pregnant women in a longitudinal pregnancy cohort study in Calgary, Alberta, between September 27, 2021, and April 24, 2022.
Paid advertisements were targeted at 18- to 50-year-old women in Calgary, with interests in pregnancy. Data regarding reach, link clicks, and costs were collected through Facebook Ads Manager (Meta Platforms, Inc) and Twitter Analytics (Twitter, Inc). The feasibility of each platform for recruitment was assessed based on the recruitment rate and cost-effectiveness. The demographic characteristics of the participants recruited through each source were compared using the chi-square test.
Paid advertisements reached 159,778 social media users, resulting in 2390 link clicks and 324 participants being recruited. Facebook reached and recruited the highest number of participants (153/324, 47.2%), whereas Instagram saw the highest number of link clicks relative to the number of users who saw the advertisement (418/19,764, 2.11%). Facebook and Instagram advertisements were cost-effective, with an average cost-per-click of CAD $0.65 (US $0.84; SD $0.27, US $0.35) and cost-per-completer of CAD $7.89 (US $10.25; SD CAD $4.08, US $5.30). Twitter advertisements were less successful in terms of recruitment and costs. Demographic characteristics of participants did not differ based on recruitment source, except for education and income, where more highly educated and higher-income participants were recruited through Instagram or Twitter. Many issues related to fraudulent responses were encountered throughout the recruitment period.
Paid social media advertisements (especially Facebook and Instagram) are feasible and cost-effective methods for recruiting a large sample of pregnant women for survey-based research. However, future research should be aware of the potential for fraudulent responses when using social media for recruitment and consider strategies to mitigate this problem.
Post-hemorrhagic ventricular dilatation (PHVD) in preterm infants can be assessed with ventricular size indices from cranial ultrasound. We explored inter-observer reliability of these indices for ...prediction of severe PHVD.
For all 139 infants with IVH, serial neonatal ultrasound at 3 time points (days 4-7, day 14, 36 weeks PMA) were assessed independently by 3 observers with differing levels of training/experience. Ventricular index (VI), anterior horn width (AHW), and fronto-temporal horn ratio (FTHR) were measured and used to diagnose PHVD. For all, inter-observer reliability and predictive values for receipt of surgical intervention were calculated.
Inter-observer reliability for all observers varied from poor to excellent, with higher reliability for VI/AHW (ICC 0.49-0.84/0.51-0.81) than FTHR (0.41-0.82), particularly from the second week. Good-excellent inter-expertise reliability was found between observers with ample experience/training (0.65-0.99), particularly for VI and AHW, while poor-moderate when comparing with an inexperienced observer (0.28-0.88). Slightly higher predictive value for PHVD intervention (n = 12) was found for AHW (AUC 0.86-0.96) than for VI and FTHR (0.80-0.96/0.80-0.95).
AHW and VI are highly reproducible in experienced hands compared to FTHR, with AHW from the second week onwards being the strongest predictor for receiving surgical intervention for severe PHVD. AHW may aid in early PHVD diagnosis and decision-making on intervention.
While ventricular size indices from serial cUS are superior to clinical signs of increased intracranial pressure to assess PHVD, questions remained on their inter-observer reproducibility and reliability to predict severity of PHVD. AHW and VI are highly reproducible when performed by experienced clinicians. AHW from the second week of birth is the strongest predictor of PHVD onset and severity. AHW, combined with VI, may aid in early PHVD diagnosis and decision-making on need for surgical intervention. Consistent use of these indices has the potential to improve PHVD management and therewith the long-term outcomes in preterm infants.
To describe the sonographic characteristics of periventricular hemorrhagic infarction (PVHI) and their association with mortality and neurodevelopmental disability in very preterm infants born in ...2008-2013.
Retrospective multicenter observational cohort study. Diagonal PVHI size was measured and severity score assessed. PVHI characteristics were scored and temporal trends were assessed. Neurodevelopmental outcome at 2 years of corrected age was assessed using either the Bayley Scales of Infant and Toddler Development, Third Edition or the Griffiths Mental Development Scales. Multigroup analyses were applied as appropriate.
We enrolled 160 infants with median gestational age of 26.6 weeks. PVHI was mostly unilateral (90%), associated with an ipsilateral grade III intraventricular hemorrhage (84%), and located in the parietal lobe (51%). Sixty-four (40%) infants with PVHI died in the neonatal period. Of the survivors assessed at 2 years of corrected age, 65% had normal cognitive and 69% had normal motor outcomes. The cerebral palsy rate was 42%. The composite outcome of death or severe neurodevelopmental disability was observed in 58%, with no trends over the study period (P = .6). Increasing PVHI severity score was associated with death (P < .001). Increasing PVHI size and severity score were negatively associated with gross motor scores (P = .01 and .03, respectively). Trigone involvement was associated with cerebral palsy (41% vs 14%; P = .004). Associated posthemorrhagic ventricular dilation (36%) was an independent risk factor for poorer cognitive and motor outcomes (P < .001 for both).
Increasing PVHI size and severity score were predictive of less optimal gross motor outcome and death in very preterm infants.
In experienced hands, cranial ultrasonography (cUS) is an excellent tool to detect the most frequently occurring brain abnormalities in preterm and full-term neonates, to study the evolution of ...lesions, and to follow brain maturation. It enables screening of the brain and serial imaging in high-risk neonates. However, cUS also has limitations and magnetic resonance imaging is needed in most neonates with (suspected) parenchymal brain injury and/or neurological symptoms and in very preterm infants. In this review, we discuss the applications, possibilities, indications, predictive value, and limitations of neonatal cUS. We will pay attention to the standard cUS procedure and expand on optimizing the possibilities of cUS by using supplemental acoustic windows and changing transducers and focus points. For illustration numerous cUS images are provided.
To explore the association between diffuse excessive high signal intensity (DEHSI), punctate white matter (WM) lesions, and ventricular dilatation around term-equivalent age (TEA) and at clinical ...follow-up at 2 years in very preterm infants and the effect on neurodevelopment.
Ethical approval for this prospective study was given by the institutional review board, and informed parental consent was obtained. An unselected cohort of 110 preterm infants (gestational age, < 32 weeks) was imaged around or after TEA. Clinical follow-up was performed at a corrected age of 2 years and consisted of a neurologic examination and a mental and developmental assessment (Bayley Scales of Infant Development). Univariate analyses and logistic and linear regression were performed to examine the relationships between variables.
DEHSI was found in 58 of 65 (89%) infants imaged around TEA. DEHSI was never detected in infants imaged after postmenstrual age of 50 weeks and showed no association with neurodevelopmental outcome. Punctate WM lesions and ventricular dilatation were significantly associated with mental (P = .02 for punctate WM lesions) and psychomotor developmental delay (P < .001 and P = .03, respectively), motor delay (P = .002 and P = .02, respectively), and cerebral palsy (P = .01 and P = .03, respectively).
Because of its high incidence in preterm infants around TEA, its absence after a postmenstrual age of 50 weeks, and its association with normal neurologic outcome at a corrected age of 2 years, DEHSI should not be considered part of the spectrum of WM injury, but rather a prematurity-related developmental phenomenon.
We assessed the impact of early enteral feeding introduction during therapeutic hypothermia on time to reach full enteral feeding (FEF) and other feeding related outcomes in infants born at ≥35 weeks ...gestational age and diagnosed with moderate to severe Hypoxic-Ischemic Encephalopathy.
A prospective cohort with historical control study, conducted on infants admitted to the Alberta Children's Hospital level III NICU in Calgary between January 2013 and December 2018. Infants were divided into 2 groups: (1) unfed group (UG), which was kept nil per os during the 72 h of therapeutic Hypothermia (TH), with subsequent introduction of feeding and gradual increase to FEF; (2) fed group (FG), which received feeding at 10 mL/kg/day during TH then increased gradually to FEF. Groups were compared for time to FEF and the type of milk they were being fed on discharge. Other gut related health risks such as NEC and sepsis were examined.
During the study period, 146 infants received therapeutic hypothermia, of whom 75 in the UG and 71 in the FG. The FG compared to the UG received the first feed sooner after TH initiation (median 57 vs. 86.5 h, p < .001), reached FEF earlier (median 6 vs. 8 days, p = .012), had a higher rate of being fully fed in the first week of life (70 vs. 53%, p < .035), was kept NPO for shorter duration (median 2 vs. 4 days, p < .001), and had a higher rate of breast milk feeding at discharge (41 vs. 13%, p < .001). There were no cases of necrotizing enterocolitis or late onset sepsis in either group during the hospital stay.
Minimal enteral feeding during therapeutic hypothermia appears to be safe and leads to a shorter time to FEF and higher rates of breast milk feeding at discharge.
Children born very preterm (VPT) are at high-risk for altered brain development and impaired neurodevelopmental outcomes but are not well studied before school-age. We investigated 64 four-year-olds: ...37 VPT children (<32 weeks gestational age GA; 22 males; mean GA: 28.8 weeks ± 1.6), 25 full-term (FT) children (12 males), plus two VPT cases with ventriculomegaly and exceptionally resilient outcomes. All children underwent high-resolution structural magnetic resonance imaging and developmental assessments. Measures of brain volume, cortical thickness, and surface area were obtained. Children born VPT demonstrated reduced cerebral and cerebellar white matter volumes yet increased cerebral grey matter, temporal lobe, occipital lobe and ventricle volumes after adjusting for total brain volume. Cortical thickness was greater in the VPT children compared to FT children across all lobes. On developmental assessments, the VPT children scored lower on average than FT children while the two cases had intact cognitive abilities. In addition to larger ventricle volumes, the two cases had white matter and grey matter volumes within the ranges of the FT children. The VPT children displayed distinct differences in structural brain volumes at 4 years of age, consistent with delayed maturation. The cases with persistent ventriculomegaly and good cognitive outcomes displayed typical grey matter and increased white matter volumes, indicating a potential protective developmental phenomenon contributing to their intact cognitive abilities.
Acquired brain injury remains common in very preterm infants and is associated with significant risks for short- and long-term morbidities. Cranial ultrasound has been widely adopted as the ...first-line neuroimaging modality to study the neonatal brain. It can reliably detect clinically significant abnormalities that include germinal matrix and intraventricular hemorrhage, periventricular hemorrhagic infarction, post-hemorrhagic ventricular dilatation, cerebellar hemorrhage, and white matter injury. The purpose of this article is to provide a consensus approach for detecting and classifying preterm brain injury to reduce variability in diagnosis and classification between neonatologists and radiologists. Our overarching goal with this work was to achieve homogeneity between different neonatal intensive care units across a large country (Canada) with regards to classification, timing of brain injury screening and frequency of follow up imaging. We propose an algorithmic approach that can help stratify different grades of germinal matrix-intraventricular hemorrhage, white matter injury, and ventricular dilatation in very preterm infants.
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