Successful management of neonatal alloimmune thrombocytopenia in the second pregnancy: a case report / Sucesso no manejo da trombocitopenia aloimune neonatal na segunda gestação: relato de caso

Neonatal alloimmune thrombocytopenia is a serious disease, in which the mother produces antibodies against fetal platelet antigens inherited from the father; it is still an underdiagnosed disease. This disease is considered the platelet counterpart of the RhD hemolytic disease of the fetus and newborn, yet in neonatal alloimmune thrombocytopenia the first child is affected with fetal and/or neonatal thrombocytopenia. There is a significant risk of intracranial hemorrhage and severe neurological impairment, with a tendency for earlier and more severe thrombocytopenia in subsequent pregnancies. This article reports a case of neonatal alloimmune thrombocytopenia in the second pregnancy affected and discusses diagnosis, management and the clinical importance of this disease.

A púrpura trombocitopênica neonatal aloimune é uma doença grave, na qual a mãe produz anticorpos contra antígenos plaquetários fetais herdados do pai, e é ainda subdiagnosticada na prática clínica. É considerada o equivalente plaquetário da doença hemolítica do recém-nascido, com a diferença que o primeiro filho é afetado, apresentando trombocitopenia fetal e/ou neonatal. Há risco significativo de hemorragia intracraniana e sequelas neurológicas graves, com tendência a trombocitopenia mais grave e mais precoce nas gestações subsequentes. Este artigo relata um caso de trombocitopenia aloimune neonatal na segunda gestação afetada e discute diagnóstico, manejo e importância clínica dessa doença na prática clínica.

Should we definitively abandon prophylaxis for patent ductus arteriosus in preterm new-borns?

Although the prophylactic administration of indomethacin in extremely low-birth weight infants reduces the frequency of patent ductus arteriosus and severe intraventricular hemorrhage, it does not appear to provide any long-term benefit in terms of survival without neurosensory and cognitive outcomes. Considering the increased drug-induced reduction in renal, intestinal, and cerebral blood flow, the use of prophylaxis cannot be routinely recommended in preterm neonates. However, a better understanding of the genetic background of each infant may allow for individualized prophylaxis using NSAIDs and metabolomics.

Prevalence of Factors involved in intracranial hemorrhage of premature neonates less than 34 weeks' gestation

Intracranial hemorrhage is one of the major causes of neonatal mortality and morbidity. It is the most severe cranial problem in that period. Those who survive would be affected by hydrocephalus, encephalomalacia, and finally brain atrophy. With accurate knowledge of risk factors, hemorrhage may be diagnosed earlier and the complications managed earlier. This study was performed in Neonatal Intensive Care Unit of Imam Khomeini Hospital. All the neonates less than 34 weeks of gestation were undergone intracranial sonography from Feb 2005 to Feb 2006. Sonography was performed via anterior fontanel with proper probe according to neonatal age. 113 neonates less than 34 weeks of gestation have been studied. Mean gestational age was 32 weeks. Mean neonatal weight were 1566 +/- 734 grams. Intracranial hemorrhage was evident in 21% of them; 16.8% was grade 1, 0.9% grade 2, 2.7% grade 3, 0.9% grade 4. The mean weight of neonates with hemorrhage was 1504.11 grams. Intracranial hemorrhage had correlation with respiratory acidosis and pneumothorax. The latter was also correlated with hemorrhage grade. Supposing the safety and non-invasiveness of intacranial sonography, we suggest performing sonography in all premature neonates with low birth weight, and also in those neonates with pneumothorax and respiratory acidosis

Does treatment with N-butyl cyanoacrylate embolization protect against hemorrhage in cerebral arteriovenous malformations?

OBJETIVO: Avaliar o papel deste procedimento na prevenção de hemorragia em casos de malformação arteriovenosa (MAV) cerebrais. MÉTODO: Entre 1992 e 2000, estudamos 104 pacientes submetidos a embolização como tratamento principal. Os pacientes foram seguidos até a ocorrência de hemorragia ou morte. RESULTADOS: O período de seguimento variou de 1,6 mês a 8 anos. As apresentações mais freqüentes foram hemorragia (50%) e convulsões (38%). Além disso, 40% das lesões eram pequenas (<30 mm); 56% eram médias (30-60 mm). O grau de obliteração foi <1/3 em 11% dos casos; 1/3 a <2/3 em 49%; >2/3 em 36%; completa em 5%. O risco de morte foi 1%/ano, e de sangramento, 5,4%/ano. Apresentação com hemorragia e baixo grau de obliteração foram os principais fatores associados com hemorragia. CONCLUSÃO: A embolização em MAVs cerebrais confere proteção limitada contra hemorragia, com graus de obliteração abaixo de 2/3. Apresentação com hemorragia é o principal fator preditivo de hemorragia.

Indomethacin prophylaxis for intraventricular hemorrhage in very low birth weight babies.

OBJECTIVE: To study the efficacy and complications of low dose indomethacin in the reduction of major intraventricular hemorrhage (IVH) in very low birth weight (VLBW) babies. DESIGN: prospective randomized controlled trial (interim analysis) SETTING: Level III neonatal intensive care unit of a perinatal tertiary care center. PATIENTS: Newborn babies with birth weights between 750-1250 g were randomized into indomethacin or control groups. They were further stratified into two birth weight groups 750-999 g and 1000-1250 g for subgroup analysis. INTERVENTIONS: 3 doses of indomethacin were administered to the indomethacin group at the dose of 0.1 mg/kg/dose intravenously. The control group did not receive any specific intervention other than standard neonatal intensive care. OUTCOME MEASURES: The primary outcome measure was the occurrence of IVH and the secondary outcome measures were necrotising enterocolitis, symptomatic patent ductus arteriosus (PDA), bleeding episodes, renal failure, chronic-lung disease and death. RESULTS: Out of 115 eligible newborn babies, 56 babies received indomethacin and 59 were controls. Perinatal characteristics were similar between the two groups. There was no difference in the incidence of IVH between the groups but on subgroup analysis the incidence of major IVH (grades III and IV) were significantly increased in babies in the lower birth weight category who received indomethacin P = 0.03). The incidence of chronic lung disease was significantly higher in the indomethacin group (P = 0.005) and bleeding episodes other than IVH were also significantly increased in the indomethacin group (P = 0.04) in the lower birth weight category. The incidence of PDA was lower in the indomethacin group but only reached significant level in the higher birth weight subgroup (P = 0.02). There were no significant differences in the other outcome measures studied. CONCLUSIONS: Indomethacin prophylaxis did not confer protection against IVH in very low birth weight babies. Instead it showed an increase in the risk of IVH, other bleeding episodes and chronic lung disease. Based on this data we felt that we were not ethically justified in continuing the use of indomethacin and have since terminated this study.

Kinesiterapia respiratoria en prematuros extremos y hemorragia intracraneana / Respiratory kinesitherapy in extreme premature infants and intracranial hemorrhage

La kinesiterapia respiratoria neonatal ha sido fuertemente cuestionada a nivel internacional por su asociación con la hemorragia intracraneana especialmente en prematuros extremos. Sin embargo, nuestra experiencia clínica a nivel nacional nos dice lo contrario. En esta actualización temática, hemos abordado el cuestionamiento anterior basándonos en la ausencia de un razonamiento lógico, clínico y coherente del tipo de intervención utilizado versus los antecedentes anatómicos y fisiológicos existentes en prematuros extremos, los cuales son descritos en detalle, y que a nuestro parecer son la piedra angular para explicar los nefastos resultados observados en estudios internacionales. Se enfatiza en la prevención de alteraciones hemodinámicas sistémicas durante cualquier intervención, por estar directamente asociado con la génesis de la hemorragia intracraneana. Para lo cual se describen "factores de riesgo hemodinámicos" que deben ser considerados previo a la ejecución de los procedimientos de kinesiterapia respiratoria y que en definitiva comandan la instauración de medidas preventivas en este grupo etario.