Hemorragia intraventricular y leucomalacia periventricular en neonatos de bajo peso al nacer en tres hospitales de Lima, Perú / Intraventricular hemorrhage and periventricular leukomalacia in low birth-weight neonates in three hospitals in Lima, Peru

RESUMEN Con el objetivo de describir la frecuencia y severidad de la hemorragia intraventricular y leucomalacia periventricular en neonatos de bajo peso en tres hospitales de Lima, Perú se evaluaron 385 neonatos menores de 2000 g de peso al nacer durante mayo del 2012 a julio del 2014. Se obtuvo ultrasonidos cerebrales a las 40 semanas de gestación, 3-5 días de vida y 3-4 semanas de vida. Hemorragia intraventricular se presentó en 19,2% neonatos con menos de 1500 g y fue severa (grado III o con infarto hemorrágico periventricular) en 9,6% neonatos menores de 1500 g. La mortalidad en neonatos con hemorragia intraventricular fue de 47,1%, se encontró leucomalacia periventricular en 5,4% de los neonatos menores de 1500 g. Ambos diagnósticos fueron más frecuentes en neonatos con menor peso. La frecuencia de hemorragia intraventricular es similar a lo reportado en otros países; sin embargo, la severidad y mortalidad es mayor.

ABSTRACT To describe the frequency and severity of intraventricular hemorrhage and periventricular leukomalacia in low birth-weight neonates in three hospitals in Lima, Peru, 385 newborn babies weighing under 2,000 g at birth were evaluated between May 2012 and July 2014. Brain ultrasounds were obtained at 40 weeks' gestation, 3-5 days of life, and 3-4 weeks of life. Intraventricular hemorrhage occurred in 19.2% of neonates weighing under 1,500 g and was severe (grade III or with periventricular hemorrhagic infarction) in 9.6% of neonates under 1,500 g. Mortality in infants with intraventricular hemorrhage was 47.1%, while periventricular leukomalacia was found in 5.4% of neonates 1,500 g and under; both diagnoses were more frequent in lower-weight babies. The frequency of intraventricular hemorrhage is similar to that reported in other countries; however, severity and mortality are greater.

La encefalopatía de la prematuridad, una entidad nosológica en expansión / Encephalopathy of prematurity, a developing nosological entity

Con frecuencia se emplean los términos leucomalacia periventricular, daño a la sustancia blanca y encefalopatía de la prematuridad como sinónimos; sin embargo, no son exactamente lo mismo. Se realiza esta revisión con el objetivo de fundamentar la consistencia del término encefalopatía de la prematuridad, a partir de una actualización sobre su fisiopatología, diagnóstico y pronóstico. La leucomalacia periventricular tiene 2 componentes principales, uno macroscópico quístico y otro microscópico, que puede ser focal o difuso. El daño a la sustancia blanca es el hallazgo neuropatológico más común de parálisis cerebral en los recién nacidos pretérminos, que identifica cualquier anormalidad en la sustancia blanca. La encefalopatía de la prematuridad, en cambio, es un término mucho más abarcador, porque en su origen parecen tener importancia los trastornos destructivos primarios y los relacionados con el desarrollo cerebral. Su fisiopatología se ha tratado de explicar mediante 2 modelos teóricos: el infeccioso-inflamatorio y el hemodinámico. Para su diagnóstico resultan necesarias la evaluación neuroimaginológica y la del neurodesarrollo, en la que a menudo se diagnostica la presencia de parálisis cerebral o trastornos del desarrollo intelectual, aisladamente o en asociación. Es muy probable que la encefalopatía de la prematuridad tienda a afianzarse cada día más como una entidad nosológica independiente, dadas sus implicaciones médicas y sociales.

Some terms such as periventricular leukomalacia (PVL), white matter damage (WMD) and encephalopathy of prematurity are used as synonyms; however, they are not exactly the same. This review was aimed at substantiating the consistency of the term encephalopathy of prematurity, on the basis of its physiopathology, diagnosis and prognosis. Periventricular leukomalacia has two main components, one macroscopic cystic and the other microscopic one which can be focal or diffuse. The white matter damage is the most common neuropathological feature of cerebral palsy in preterm infants, which identifies any anomalies in the white matter. In turn, encephalopathy of prematurity is a much more comprehensive term because it seems that both primary destructive disorders and those related to brain development are influential in its origin. Its physiopathology has been explained by two theoretical models: the infective-inflammatory one and the hemodynamic one. Neuroimaginological and neurodevelopmental evaluations are necessary for the diagnosis, where the presence of cerebral palsy and of intellectual development disorders, either isolated or combined, is detected. It is much likely that encephalopathy of prematurity tends to increasingly consolidate as an independent nosological entity, taking into account its medical and social implications.

Avaliação do neurodesenvolvimento de prematuros de muito baixo peso ao nascer entre 18 e 24 meses de idade corrigida pelas escalas Bayley III / Neurodevelopmental assessment of very low birth weight preterm infants at corrected age of 18-24 months by Bayley III scales

OBJETIVO: Avaliar a prevalência de atraso e fatores associados aos escores de desenvolvimento em crianças nascidas prematuras. MÉTODOS: Estudo transversal para avaliar o desenvolvimento por escalas Bayley III, incluindo-se prematuros de muito baixo peso de 18 a 24 meses de idade corrigida, acompanhados no Ambulatório de Prematuros da instituição. Excluíram-se: malformação congênita, síndrome genética, infecção congênita sintomática ao nascimento, surdez e cegueira. As variáveis numéricas foram comparadas por teste t de Student ou Mann-Whitney, e as categóricas, por qui-quadrado ou teste exato de Fisher. Para análise dos fatores associados aos escores de desenvolvimento, utilizou-se a regressão linear, considerando-se significante p < 0,05. RESULTADOS: Das 58 crianças avaliadas, quatro (6,9%) apresentaram alteração cognitiva; quatro (6,9%), motora; 17 (29,3%), de linguagem; 16 (27,6%), socioemocional; e 22 (37,9%), de comportamento adaptativo. À regressão linear múltipla, os fatores classe socioeconômica CDE (-13,27; IC95% -21,23 a -5,31) e dependência de oxigênio com 36 semanas de idade corrigida (-8,75; IC95% -17,10 a -0,39) diminuíram o escore cognitivo. A leucomalácia periventricular diminuiu o escore cognitivo (-15,21; IC95% -27,61 a -2,81), motor (-10,67; IC95% -19,74 a -1,59) e de comportamento adaptativo (-21,52; IC95% -35,60 a -7,44). O sexo feminino se associou ao maior escore motor (10,67; IC95% 2,77-12,97), de linguagem (15,74; IC95% 7,39-24,09) e socioemocional (10,27; IC95% 1,08-19,46). CONCLUSÕES: Prematuros de muito baixo peso apresentaram com maior frequência alterações na linguagem, comportamento adaptativo e socioemocional. As variáveis classe socioeconômica CDE, leucomalácia periventricular, displasia broncopulmonar e sexo masculino contribuíram para reduzir os escores de desenvolvimento.

OBJECTIVE: To evaluate the prevalence of delay and factors associated with neurodevelopmental scores in premature infants. METHODS: Cross-sectional study to assess the development by Bayley Scales III, including very low birth weight preterm infants aged 18 to 24 months who were under follow-up at the outpatient clinic for preterm infants. Congenital malformation, genetic syndrome, symptomatic congenital infection at birth, deafness, and blindness were excluded. Numerical variables were compared by Mann-Whitney or Student t test and categorical variables by chi-square or Fisher's exact test. Factors associated with developmental scores were analyzed by linear regression, and statistical significance level was established at p < 0.05. RESULTS: Out of the 58 children included, four (6.9%) presented cognitive delay, four (6.9%) motor, 17 (29.3%) language, 16 (27.6%) social-emotional and 22 (37.0%) adaptive-behavior delay. By multiple linear regression, the variables: social classes CDE (-13.27; 95%CI: -21.23 to -5.31), oxygen dependency at 36 weeks of corrected age (-8.75; 95%CI: -17.10 to -0.39) decreased the cognitive developmental score. Periventricular leukomalacia decreased the cognitive (-15.21; 95%CI: -27.61 to -2.81), motor (-10.67; 95%CI:-19.74 to -1.59) and adaptive-behavior scores (-21.52; 95%CI: -35.60 to -7.44). The female sex was associated with higher motor (10.67; 95%CI: 2.77 to 12.97), language (15.74; 95%CI: 7.39 to 24.09) and social-emotional developmental scores (10.27; 95%CI: 1.08 to 19.46). CONCLUSIONS: Very low birth weight preterm infants aged from 18 to 24 months of corrected age presented more frequently language, social-emotional and adaptive-behavior delays. The variables: social classes CDE, periventricular leukomalacia, bronchopulmonary dysplasia and male sex reduced the neurodevelopmental scores.

Corioamnionitis histológica y morbimortalidad neonatal: aproximación al síndrome de respuesta inflamatoria fetal / Chorioamnionitis neonatal morbidity: approach to fetal inflammatory response syndrome

Antecedentes: El síndrome de respuesta inflamatoria fetal (SRIF) es una entidad relacionada con la presencia de inflamación intrauterina y suele asociarse a infección intraamniótica. Su consecuencia más grave es la lesión cerebral y posterior desarrollo de parálisis cerebral. Objetivo: Evaluar la relación entre el síndrome de respuesta inflamatoria fetal y el desarrollo de complicaciones neonatales. Método: Estudio descriptivo y retrospectivo, realizado en el Hospital Universitario La Paz de Madrid, buscando una aproximación al SRIF desde la corioamnionitis histológica/funiculitis. El grupo de estudio constituido por 35 gestaciones simples pretérmino recogidas durante el primer semestre de 2008 y en las que la anatomía patológica de la placenta y anexos ovulares demostró la presencia de una corioamnionitis histológica y/o funiculitis. Resultados: Siete casos (20 por ciento) presentaban clínica sospechosa de infección intraamniótica, si bien en 28 gestantes (80 por ciento) existían factores de riesgo asociados al síndrome de respuesta inflamatoria fetal. Mortalidad perinatal en el grupo estudiado fue de 11,4 por ciento (4 casos). Sólo en 2 pacientes (5,7 por ciento) se pudo relacionar la muerte con el SRIF. En 28 recién nacidos (80 por ciento) se encontró algún tipo de patología, siendo la misma inherente a dicho síndrome en 17 casos (48,6 por ciento), destacando sepsis neonatal (40 por ciento), leucomalacia periventricular (14,3 por ciento) y displasia broncopulmonar (5,7 por ciento). Conclusión: Se comprueba el alto riesgo neonatal del SRIF. El conocimiento de esta condición, abre una serie de controversias diagnósticas y terapéuticas que obliga a una reevaluación de los protocolos actuales de manejo de la amenaza de parto pretérmino y la rotura prematura de membranas de pretérmino.

Background: The fetal inflammatory response syndrome (FIRS) is an entity related to intrauterine inflammation which is commonly associated with intraamniotic infection. The most serious consequence is the neurologic damage and the subsequent development of cerebral palsy. Aims: To evaluate the relationship between the fetal inflammatory response syndrome and the development of neonatal complications. Method: Descriptive and retrospective study realized in "La Paz" University Hospital of Madrid, looking for an approximation to the FIRS from histologic chorioamnionitis/funisitis. Group of study constituted by 35 single preterm gestations collected during the first semester of 2008 and in which the pathologic anatomy study of the placenta and annexes showed the presence of histological corioamnionitis and / or funisitis. Results: Suspicious clinic was found in 7 cases (20 percent) but in 28 cases (80 percent) risk factors associated to FIRS were present. Perinatal mortality found was 11.4 percent (4 cases). Only in 2 cases (5.7 percent) the cause was relationated with FIRS. Pathology associated was found in 28 newborn (80 percent), being 17 cases (48.6 percent) pathology associated with the fetal inflammatory response syndrome, enhancing neonatal sepsis (40 percent), periventricular leukomalacia (14.3 percent), and bronchopulmonar dysplasia (5.7 percent). Conclusion: It is verified that FIRS enteals a high neonatal risk. The knowledge of this entity opens some diagnostic and therapeutic controversies. Current management protocols of preterm labor and preterm premature rupture of membranes should be revised.

Incidencia de hemorragia intracraneana y leucomalacia en el recién nacido de muy bajo peso de nacimiento y/o menor de 32 semanas al nacer / Intracranial hemorrhage and periventricular leukomalacia incidence in the very low birth weight newbor and/or younger than 32 weeks of gestation

Introducción: La incidencia de hemorragia intraventricular (HIV) y leucomalacia periventricular (LPV) era desconocida en nuestra provincia. Mediante la adjudicación del proyecto FONADIS 0393/01, "Prevención de discapacidad por daño neurológico mediante pesquisa ecográfica precoz de HIV y LPV en recién nacidos de muy bajo peso de nacimiento(RNMBPN) en la provincia de Valdivia" se logró contar con el equipo necesario para la ejecución. Objetivos: Determinar la incidencia de HIV y LPV en recién nacidos (RN) menores de 1500grs. y/o menores de 32 semanas de gestación y factores asociados. Método: Se practicó ecografía cerebral a 118 RNMBPN en el periodo Agosto 2001-Julio 2003. Se efectuó examen neurológico a las 40 semanas de edad gestacional (EG). Se recopiló antecedentes clínico epidemiológicos, analizándose con estadística descriptiva e inferencial. Resultados: La incidencia de HIV de cualquier grado fue de 13.6 por ciento (14/103) en la 1ª ecografía correspondiendo a un 57.1 por ciento GI (8/14), 21.4 por ciento, (3/14) GII, 7.1 por ciento (1/14) GIII y 14.2 por ciento (2/14) GIV. a LPV fue encontrada en un 16 por ciento, e hiperecogenicidad periventricular persistente (H) sin quistes en el 12.7 por ciento. En relación a la distribución de LPV y H por categoría de peso se observó que el 40 por ciento (14/35) se concentró en el grupo de 700 a 900 grs. En relación a la LPV y la EG existe diferencia estadísticamente significativa estimándose un RR 1.9 (IC95 por ciento 1.3- 2.7, p: 0.0012) para los < de 30 semanas de EG. En relación a la distribución de HIC por categoría de peso se observa que la mayoría se presentó entre los 800 y 1000 grs. (9/15). La evaluación neurológica a las 40 semanas fue anormal en el 13.8 por ciento de los casos. Conclusiones: El uso de ecografía cerebral permitió dimensionar el problema y establecer medidas terapéuticas oportunas para la prevención.

Background: The incidence of intraventricular hemorrhage (IVH) and periventricular leucomalacy (PVL) was unknown for us, because of by the unavailability of ecography in the neonatology unit. The acquisition of the necessary equipment, in the year of 2001 by means of the financial support of FONADIS, the national foundation for the discapacity. Purpose: To determine the incidence of IVH y PVL in newborn (NB) with less than 1500 grs of weigh or less than 32 weeks of gestational age and asociated factors. Method: 118 NB were examined between August 2001 and July 2003. All of them were neurologically evaluated at 40 weeks of gestational age (GA). The clinical and epidemiological data were analyzed by t-test and (2 test or Fisher, by Stata 8.0(r) software.Results: The total IVH incidence was 13.6 percent (14/ 103) at the time of the first ecography, with 57.1 percent GI (8/14), 21.4 percent, (3/14) GII, 7.1 percent (1/14)GIII and 14.2 percent (2/14) GIV. PVL was present in 16 percent, with persistent periventricular hyperecogenicity without cystic formation (H) in 12.7 percent. The distribution of PVL and H according to NB weigh, showed a 40 percent (14/35) in the group of 700 to 900 gr. The association between PVL and GA was statistically significant with RR 1.9 (IC95 percent 1.3 - 2.7, p: 0.0012) for the NB with less than 30 weeks of GA. The IVH, was highly observed in the group 800 to 1000 gr. (9/15).The neurological evaluation at the 40 weeks was abnormal in13,8 percent of the NB. Conclusion: Using the cerebral ecography we could establish the dimension of the neurological complications in premature NB, in our unit, and to propose therapeutic and preventive measures, so we could contribute to the better clinical results in our children.

Incidence of periventricular leucomalacia among a cohort of very low birth weight neonates(< 1500 g).

BACKGROUND: Periventricular leucomalacia (PVL) is the most important neuropathologic lesion underlying major neuro-motor deficits of pre-term very low birth weight (VLBW) infants. Published data regarding PVL is not available from our country. OBJECTIVES: A study was planned with main objectives to estimate incidence and describe natural history of PVL among a very low birth weight cohort. STUDY DESIGN: A cohort study was performed on inborn VLBW babies over one year period at a tertiary neonatal intensive care unit. Serial weekly cranial ultrasounds were performed on 97 enrolled subjects until discharge, to diagnose and describe natural history of PVL. RESULTS: 31 out of 97 enrolled subjects developed PVL. No case of PVL developed beyond 19 days of postnatal life. Serial ultrasounds for each baby were tracked until discharge or death. Majority of lesions at onset were flares. Cysts tended to develop in over one third of cases during course of hospital stay. About 50% of ultrasound had normalized at discharge and sequelae such as cerebral atrophy and ventriculomegaly had appeared in few, the rest of lesions being either flares or cysts of PVL. CONCLUSIONS: PVL is fairly common among very low birth weight neonates. Ultrasonographic lesions of PVL undergo dynamic evolution from time of first detection to either progress, regress or leave sequelae before discharge. Ultrasound remains an important bedside diagnostic tool for PVL.

Alterações cerebrais em recém-nascidos pré-termos detectadas por ultra-sonografia e associação com procedimentos de reanimação na sala de parto / Association of ultrasonogtaphic cerebral alterations in preterm infants and resuscitation procedures

Objetivo: avaliar no prematuro a prevalência de hemorragia intraventricular (HIV) e leucomalácia periventricular (LPV) e sua associação aos procedeimentos de reanimação em sala de parto. Métodos: estudo prospectivo, tipo coorte, em crianças nascidas com peso igual ou menor que 1.500 g no Hospital das Clínicas da UFMG, no período de outubro de 2000 a fevereiro de 2002. Os exames ultra-sonográficos foram realizados pelo autor e os dados perinatais obtidos do prontuário do serviço. Resultados: dos 104 pacientes estudados, 14 (13,5 por cento) apresentaram HIV e 9 (8,7 por cento), LPV. Na análise multivariada por regressão logística, as variáveis que se associaram significativamente à HIV foram: uso de corticosteróide no pré-natal, dias de ventilação mecânica, tempo de bolsa rota e necessidade de ventilação compressão positiva na sala de parto. Associaram-se à LPV o peso de nascimento e a necessiddade de intubação na sala de parto. Conclusões: as alterações neurológicas derectáveis pela ultra-sonografia transfontanelar, principalmente as hemorragias perintraventriculares e a leucomalácia periventricular, têm alta prevalência entre os prematuros. A necessidade de ventilação co pressão positiva na sala de parto e a intubação associaram-se significativamente à HIV e à LPV.