List of Articles
- Maternal Obesity and Impact on Fetal Brain Development
Obesity is preventable. Body mass index (BMI) calculated at the first prenatal visit should be used to provide diet and exercise counseling. Because even small weight reduction before pregnancy in women with obesity may be associated with improved pregnancy outcomes, weight loss before pregnancy should be encouraged. Optimal control of obesity begins before pregnancy. The problems go beyond fetal metabolic programming. Maternal obesity has effects on fetal neurodevelopment. Impaired dopaminergic signaling has been implicated in the development of certain psychiatric disorders in humans. The effect of maternal obesity, high fat diet, and gestational weight gain on fetal neurodevelopment and offspring behavior is also the focus of this review. For patients with prepregnancy BMI of 35.0 – 39.9, weekly antenatal fetal surveillance may be considered beginning by 37 0/7 weeks of gestation. For patients with pre-pregnancy BMI 40 or greater, weekly antenatal fetal surveillance may be considered beginning at 34 0/7 weeks of gestation. Weight-based dosage for venous thromboembolism thromboprophylaxis may be considered rather than BMI-stratified dosage strategies in class III obese women after cesarean delivery. Consultation with anesthesia service should be considered for obese pregnant woman with obstructive sleep apnea, because they are at an increased risk of hypoxemia, hypercapnia, and sudden death. - Newborn Exposed to HIV: Prevention, Evaluation & Management
This review offers guidance on the evaluation and management of infants born to women with Human Immunodeficiency Virus (HIV) infection. In addition to standard clinical care for the newborn infant, it is important that appropriate steps are taken for early detection of HIV infection, appropriate vaccines are administered, and adequate counseling is provided to families living with HIV infection. Prevention of mother-to-child transmission of HIV is the best treatment. Early detection and proper management saves lives and long-term effects. Intrapartum administration of IV Zidovudine (ZDV) provides antiretroviral pre-exposure prophylaxis at a time when infants are at increased risk of exposure to maternal blood and body fluids. IV ZDV also is recommended for those with an initial diagnosis of HIV during labor and pregnant people with HIV whose HIV RNA level is unknown. For infants who are at high risk of perinatal HIV infection, virologic diagnostic testing in recommended at birth and at 2 to 6 weeks after antiretroviral (ARV) drugs are discontinued. Definitive exclusion of HIV infection in non-breastfed infants is based on two or more negative virologic tests conducted after infants have completed ARV prophylaxis or presumptive HIV therapy, with one negative test obtained at age >1 month and one at age >4 months, or two negative HIV antibody tests form separate specimens that were obtained at age > 6 months. - Rare Clotting Factor Deficiencies
The purpose of this document is to identify rare clotting factor deficiencies and management. By definition, rare factor deficiencies have a prevalence of less than 200,000 in the US population, or an incidence of less than 1 in 2,000 in Europe. The very small numbers of patients with rare clotting factor disorders present challenges in diagnosis, evaluation of bleeding risk and treatment. Use of new assays, full genome sequencing, and global clotting assays will significantly improve diagnosis of patients with rare bleeding disorders. Rare clotting factor deficiencies are bleeding disorders in which one of the other factors (i.e. factor I, II, V, V + VIII, VII, X, XI, or XIII) is missing or not working properly. Less is known about these disorders because they are diagnosed so rarely. In fact, many have only been discovered in the last 40 years. Understanding the pathophysiology, presentation, and treatment options for rare bleeding disorders is critical to facilitate genetic counseling, optimal patient management, and improved long-term outcomes. Ongoing efforts continue to promote international data harmonization. In the United States, the American Thrombosis and Hemostasis Network is expanding its data collection system to assure inclusion of individuals with rare bleeding disorders followed through the US federal Hemophilia Treatment Center Network. - Hemophilia: A Comprehensive Review
The review identifies the etiology of hemophilia, literature review the evaluation of hemophilia, outlines the treatment and management options available for hemophilia and describes interprofessional team strategies for improving care coordination and communication to advance hemophilia and improve outcomes. The principal aim of care should be to avoid and treat bleeding. The patient should receive treatment in a comprehensive treatment center where interprofessional services are offered at all times to the patients and their families. Hemophilia should be considered in the neonatal period in the case of unusual bleeding or in case of positive family history. The outlook for most hemophilia A is guarded. Repeated transfusions of blood products and related factors is not being event. Additionally, these patients are prone to bleeding, which can be life-threatening. Adeno-associated virus (AAV)- mediated gene transfer has successfully raised, and in some cases transiently normalized, FVIII or FIX activity levels in adults with severe hemophilia. Hemophilia dose not predispose to any mental illness, but the person with hemophilia and his environment may greatly benefit from having professionals help them manage to adapt to the disease. - Overview of Blood Coagulation System
This review simplifies the understanding of the blood coagulation system as a whole, as well as discusses various abnormalities of the same, which may have an impact in the perioperative and Intensive Care Units (ICUs). Coagulation is a dynamic process, and the understanding of the blood coagulation system has evolved over the recent years in anesthetic practice. Although the traditional classification of the coagulation provide more authentic description of the same. The coagulation process is usually under the inhibitory control of several inhibitors that limit the clot formation, thus avoiding the thrombus propagation. This delicate balance is interrupted whenever the pro-coagulant activity of the coagulaiton factors is increased, or the activity of naturally occuring inhibitors is decreased. Imbalance between the two components predisposes a patient to either bleed or present with thrombosis. The physiology of the same therefore, needs to be understood to predict the pathological and clinical consequences of the same before implementing any pharmacological interverntions. Accurate reporting of PT/INR results has a direct effect on the management of patients undergoing vitamin K antagonists therapy. An appropriate standardization process, can significantly improve the accuracy of reported results. - Vitamin K Deficiency Bleeding
Prevention of early vitamin K deficiency bleeding (VKDB) of the newborn, with onset at birth to 2 weeks of age (formerly known as classic hemorrhagic disease of newborn), by oral or parenteral administration of vitamin K is accepted practice. Vitamin K is essential for the synthesis of few coagulation factors. Infants can easily develop vitamin K deficiency owing to poor placental transfer, low vitamin K content in breast milk, and poor intestinal absorption due to immature gut flora and malabsorption. VKDB in infancy is classified according to the time of presentation: early (within 24 hours), classic (within 1 week after birth), and late (between 2 week and 6 months of age). Prophylactic administration of vitamin K to prevent VKDB has been in practice for decades in USA, in both term and preterm infants. A single dose (1.0 mg) of intramuscular (IM) vitamin K after birth is effective in the prevention of classic VKDB in term infants. Either IM (1.0 mg) or oral vitamin K prophylaxis improves biochemical indices of coagulation status at one to seven days. This review presents updated recommendations for the use of vitamin K in the prevention of early and late VKDB. - Neonatal Seizures
Neonatal seizures typically indicate significant underlying disease. Neonatal seizures differ in clinical description from those in adults, and seizures in preterm infants differ from those in term infants. Cerebral cortical organization, synaptogenesis, and myelination of cortical efferent pathways are poorly developed in human neonates, leading to weakly propagated, fragmentary seizures whose electrical activity may not spread to surface EEG electrodes. There are four recognizable clinical seizure types: Subtle; Clonic; Tonic; and Myoclonic. The neonatal period is a period of intense physiological synaptic excitability, as synaptogenesis occurring at this time point is wholly dependent upon activity. In the human, synapse and dendritic spine density are both peaking around term gestation and into the first month of life. Recognition is often helpful in prognosis and treatment; the most common is hypoxic-ischemic encephalopathy (HIE). Patients generally have a poor prognosis, with most developing a severe encephalopathy and epilepsy. The review of literature suggest that neonatal seizures and their etiology have a significant impact on the developing brain; it is critical to recognize seizures early and initiate immediate antiepileptic therapy. Continuous computerized simultaneous video electroencephalograph (EEG) monitoring is imperative; at-risk infants will frequently have electrographic seizures without clinical manifestations. Poor prognosis for premature infants with seizures is reflected in high rates of subsequent long-term disability and mortality. The severity and timing of the pathologic process continue to be the major determinants for outcome. Although there are antiepileptic therapies for neonatal seizures, they are ineffective in over 35% of cases. The prognosis is determined primarily by etiology. The goal of research should be the development of more effective therapies for neonatal seizures, regardless of etiology. - Neonatal Group B Streptococcal Infection
Group B streptococcal (GBS) infection remains the most common cause of neonatal early-onset sepsis and a significant cause of late-onset sepsis among young infants. This review addresses the epidemiology, microbiology, disease pathogenesis, and management strategies for neonatal early- and late-onset GBS infection. While most babies recover from their GBS infection, some are stillborn, more die in the first weeks of life and others suffer lifelong disability. Prevention strategies (intrapartum antibiotic prophylaxis) for early-onset invasive infant GBS disease are currently limited to developed countries, and only around the time of birth. Recurrent neonatal and young infant GBS disease can occur after completed appropriate treatment of the primary infection. There are no good prospective studies to indicate optimal choice of therapy in newborn infant with possible sepsis, but ampicillin and gentamycin are usually appropriate based on the usual susceptibilities of the predominant organisms causing early-onset sepsis. Vaccination against GBS would be acceptable to most women and GBS vaccines are in the early stages of development. While most babies recover from their GBS infection, some are stillborn, more die in the first weeks of life and others suffer lifelong disability. - Newborn Hearing Loss Detection and Intervention
Hearing loss can affect a child’s ability to develop communication, language, and social skills. The earlier children with hearing loss start getting services, the more likely they are to reach their full potential. The most important time for a child to learn language is in the first 3 years of life, when the brain is developing and maturing. In fact, children begin learning speech and language in the first 6 months of life. In 2017 the Early Hearing Detection and Intervention (EHDI) law re-authorizes Health Resources and Service Administration (HRSA) to continue funding awards to states, territories, and healthcare providers to support continuous improvement of EHDI programs. These projects help to identify effective strategies to address screening, loss to follow-up diagnosis and services, enrollment into early intervention services, and family engagement. There are different types of communication options and interventions available for children with hearing loss. With help from healthcare providers and intervention specialists, families are able to select the options that best meet their needs. - Neonatal Abstinence Syndrome
Neonatal Abstinence Syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used for or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. Opioid medications such as morphine or methadone are recommended as first-line therapy, with phenobarbital or clonidine as second-line adjunctive therapy. Further research is needed to determine best practice for assessment, non-pharmacologic intervention, and pharmacologic management of infants with NAS in order to improve outcomes. The lessons learned from prenatal alcohol exposure might be relevant for opioids. Full consideration must be given to the to the postnatal environment of children with prenatal opioid exposures, which might include social and economic complexities that adversely impact child development. Prescribe post-cesarean delivery opioids more appropriately by considering individual inpatient opioid requirements or a shared decision-making model. Prioritize acetaminophen and ibuprofen during breastfeeding. - Birth Trauma: Neonatal Brachial Plexus Injury
The review emphasizes on neonatal brachial plexus palsy (NBPP) with special focus on its pathophysiology, causation, and management. Some strategies that demonstrate either a reduction in NBPP or an increased rate of successful resolution of shoulder dystocia are included. The primary objective in the presence of clinically recognizable shoulder dystocia continues to be the delivery of fetus before the fetal brain experiences hypoxic-ischemic injury. Perinatal disorders are prone to malpractice litigation. NBPP results from stretching the nerves in the perinatal period and may lead to paresis or paralysis and sensory loss in the affected arm. The knowledge about NBPP is continually evolving. What is known at this time with reasonable certainty is that NBPP occurs infrequently and can be caused by maternal (endogenous) forces or clinician-applied (exogenous) forces or a combination of both. Regularly perform multidisciplinary drills for shoulder dystocia. Cesarean birth reduces, but does not eliminate, the risk of birth trauma and NBPP associated with macrosomia. In general, with regard to surgical treatment, primary surgery includes surgical procedures involving nerve transfer, and the ulnar, median, and phrenic nerves are used as grafts/donors in this type of surgery. - Sudden Infant Death Syndrome
Significant new information has been forthcoming in recent decades on sudden infant death and apnea during early infancy. Sudden Infant Death Syndrome (SIDS) also known as Sudden Unexpected Infant Death (SUID) and Sudden Unexpected Death in Infancy (SUDI), are the terms used to describe unexpected death of an infant less than 12 months of age. The cause of death that cannot be explained after thorough investigation, death scene examination, and review of clinical history. Back-to-Sleep position for every sleep time campaign, has helped educate millions of caregivers, parents, grandparents, aunts, uncles, babysitters, childcare providers, health care providers, and others, about ways to reduce the risk to reduce SIDS and other sleep-related causes of infant death. Tummy Time describes the times when you place your baby on his or her stomach while your baby is awake and while someone is watching. Tummy Time is important. Newborn safety should be routinely taught in obstetrics curricula, and the Women's Health and Education Center (WHEC) has partnered with the United Nations (UN) and the World Health Organization (WHO), to disseminate updated literature and guidelines to health care providers regarding newborn safety. - Neonatal Jaundice: Part I
Jaundice (hyperbilirubinemia) occurs in most newborns. Jaundice is benign in most newborns, but because of potential toxicity of bilirubin, newborns must be monitored to identify those who might develop severe hyperbilirubinemia, and in rare cases, acute bilirubin encephalopathy or kernicterus. Based on a consensus of expert opinion and review of available evidence, universal pre-discharge bilirubin screening is recommended. This can be accomplished by measuring the total serum bilirubin level (ideally at the time of routine metabolic screening) or transcutaneous bilirubin level and plotting the result on an hour-specific nomogram to determine the risk of subsequent hyperbilirubinemia that will require treatment. If an infant is discharged before 24 hours postnatal age, the bilirubin should be rechecked within 48 hours. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. Kernicterus in detail is discussed in Neonatal Jaundice: Part II. In every infant, the Women’s Health and Education Center (WHEC) recommends that clinicians: 1) Promote and support successful breastfeeding; 2) Perform a systematic assessment before discharge for the risk of severe bilirubinemia; 3) Provide early and focused follow-up based on the risk assessment; and when indicated 4)Treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia, and possibly bilirubin encephalopathy (kernicterus). - Neonatal Jaundice: Part II
The term kernicterus literally means "yellow kern," with kern indicating the most commonly afflicted region of the brain (i.e. the nuclear region). Historically, the term refers to an anatomic diagnosis made at autopsy based on a characteristic pattern of staining found in babies who had marked hyperbilirubinemia before they died. This document discusses overview, clinical management and management of kernicterus. Despite the lack of a clear-cut cause-and-effect relationship between kernicterus and the degree of hyperbilirubinemia. Laboratory investigations have demonstrated that bilirubin is neurotoxic at a cellular level. Prevention of hyperbilirubinemia is the best way to minimize the incidence of kernicterus. However, because some babies develop kernicterus with relatively modest bilirubin levels, no known absolute level of bilirubin below which the infant is completely safe is recognized. Additionally, because other factors contribute to the ability of bilirubin to cross the blood-brain barrier, management of these components must be appropriately considered. Any infant at risk for significant hyperbilirubinemia and possible neurotoxicity should be cared for in a nursery capable of rendering appropriate care for the hyperbilirubinemia and any contributing diagnoses. Developmental potential can be maximized by early identification of and intervention for neurologic deficits. - Newborn Male Circumcision
Newborn male circumcision is a surgical procedure to remove the foreskin, the skin that covers the tip of the penis. In the United States, a large percentage of male newborns are circumcised. Although circumcision has known medical benefits, the procedure generally is performed for family, religious, or cultural reasons. Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision. However, these data are not sufficient to recommend routine neonatal circumcision. Circumcision is a safe and straightforward procedure but has its risks and potential complications. In the United States, it is often done before a new baby leaves the hospital. Possible benefits include a lower risk of urinary tract infections, penile cancer, and sexually transmitted diseases. There is a low risk of bleeding or infection. The baby might also feel some pain. The Women's Health and Education Center (WHEC) recommends that parents should discuss circumcision with their baby's healthcare provider. The World Health Organization's (WHO's) program for male circumcision and HIV prevention is also discussed. Parents should make their decision based on the benefits and risks, as well as their own religious, cultural, and personal preferences. As with most surgeries, the best outcomes are achieved by practitioners who are well trained, who perform the procedure under supervision until their experience is sufficient, and who follow correct protocol during the entire operation. - Newborn Nutrition
The landscape of breastfeeding has changed over the past several decades as more women initiate breastfeeding in the postpartum period and more hospitals are designated as Baby-Friendly Hospitals by following the evidence-based Ten Steps to Successful Breastfeeding. Human milk feeding supports optimal growth and development of the infant while decreasing the risk of a variety of acute and chronic diseases. The use of donor human milk is increasing for high-risk infants, primarily for infants born weighing <1,500 g or those who have severe intestinal disorders. Pasteurized donor milk may be considered in situations in which the supply of maternal milk is insufficient. Intramuscular vitamin K1 (phytonadione) at a dose of 0.5 to 1.0 mg should routinely be administered to all infants on the first day to reduce the risk of hemorrhagic disease of newborn. Vitamin D deficiency/insufficiency and rickets has increased in all infants because of decreased sunlight exposure secondary to changes in lifestyle, dress habits, and use of topical sunscreen preparations. Supplementary fluoride should not be provided during the first 6 months. From age 6 months to 3 years, fluoride supplementation should be limited to infants residing in communities where the fluoride concentration in water is <0.3 ppm. The Women's Health and Education Center (WHEC) strongly supports the national and international associations in endorsing the consumption of only pasteurized milk and milk products for pregnant women, infants and children. - Newborn Screening Program in the United States
Newborn screening is the largest screening program in the United States with approximately four million newborns screened yearly. It is a mandated public health program designed for the identification of disorders in children. It is designed to provide rapid diagnosis and allow early therapy for specific metabolic, infections, and other genetic disorders for which early intervention reduces disabilities and death. This important practice typically occurs before the development of signs or symptoms of disease. Newborn screening programs are comprised of a complex, integrated clinical service of education, screening, diagnosis, follow-up, evaluation, and often long-term management. The list of recommended conditions for newborn screening programs is continually being evaluated. Integrating education about newborn screening into prenatal care allows parents to be prepared for having their child undergo screening as well as for receiving newborn screening test results. Furthermore, parents often view their care from prenatal management through pediatrics as a continuum of care without health care provider distinctions. This can be accomplished at different moments in prenatal care: 1) during the first-trimester new obstetric visit and include written or web-site information along with other patient education materials, 2) later in pregnancy with other educational information is routinely distributed, such as at the time of glucola or group B streptococcal screening in the third trimester, 3) during a discussion of past adverse pregnancy outcomes related to a positive newborn screening test result or birth defect, at the same time that options for prenatal or preimplantation genetic screening or diagnostic testing are considered. - The Apgar Score
The purpose of this document is to place the Apgar score in its proper perspective. The Apgar score describes the condition of newborn infant immediately after birth, and when properly applied, it is a tool for standardized assessment. It also provides a mechanism to record fetal-to-neonatal transition. Apgar scores do not predict individual mortality or adverse neurologic outcome. However, based on population studies, Apgar scores of less than 5 at 5-minutes and 10-minutes clearly confer an increased relative risk of cerebral palsy, and the degree of abnormality correlates with the risk of cerebral palsy. Most infants with low Apgar score, however, will not develop cerebral palsy. The Apgar score is affected by many factors, including gestational age, maternal medications, resuscitation, and cardiorespiratory and neurologic conditions. If the Apgar score at 5- minutes is 7 or greater, it is unlikely that peripartum hypoxia-ischemia caused neonatal encephalopathy. The Neonatal Resuscitation Program (NRP) guidelines, Apgar score and subsequent neurological dysfunctions are also discussed. The review also examines the occurrence of 5-minute Apgar score of 0 and seizures or serious neurologic dysfunctions. Perinatal asphyxia is a major cause of neurologic sequelae in term newborns. Apgar score is useful for conveying information about the newborn’s overall status and response to resuscitation. However, resuscitation must be initiated, if needed, before the 1-minute score is assigned. Therefore, Apgar score is not used to determine whether the need for initial resuscitation steps are necessary, or when to use them. - Newborn Care: Initial Assessment & Resuscitation
Approximately 10% of term and late-preterm infants require some assistance to begin breathing that includes stimulation at birth; less than 1% will need extensive resuscitative measures. Although the vast majority do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births a sizable number of babies will require some degree of resuscitation. Recognition and immediate resuscitation of a distressed newborn infant requires an organized plan of action that includes the immediate availability of proper equipment and on-site qualified personnel. Anticipated newborn problems should be thoroughly communicated by the obstetric care provider to the responsible lead member of the resuscitation team. Assessment and resuscitation of the infant at delivery should be provided in accordance with the principles of guidelines for neonatal resuscitation. Most of the principles are applicable throughout the neonatal period and early infancy. Each hospital should have policies and procedures addressing the care and resuscitation of the newborn infant, including the qualifications of physicians and other health care practitioners who provide this care. The Women's Health and Education Center (WHEC) with its partners has launched the series on Newborn Care to disseminate updated literature and guidelines to health care providers regarding newborn care and safety. Current guidelines are summarized in this section.
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www.womenshealthsection.com