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Bart Y, Meyer R, Moran O, Tsur A, Kassif E, Mohr-Sasson A, Hamilton E, Sivan E, Yinon Y, Mazaki-Tovi S, Yoeli R. Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment. Am J Perinatol 2024; 41:e1479-e1485. [PMID: 36894155 DOI: 10.1055/a-2051-4047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. STUDY DESIGN A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. RESULTS The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. CONCLUSION Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. KEY POINTS · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..
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Affiliation(s)
- Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Orit Moran
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Abraham Tsur
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Eran Kassif
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Emily Hamilton
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Eyal Sivan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Rakefet Yoeli
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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2
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Lapinsky SE, Vasquez DN. Acute Respiratory Failure in Pregnancy. Crit Care Clin 2024; 40:353-366. [PMID: 38432700 DOI: 10.1016/j.ccc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.
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Affiliation(s)
- Stephen E Lapinsky
- Mount Sinai Hospital, Toronto, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue, Toronto M5G1X5, Canada.
| | - Daniela N Vasquez
- ICU Head of Department, Sanatorio Anchorena, Tomás M. de Anchorena 1872, City of Buenos Aires, Argentina
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Abati I, Micaglio M, Giugni D, Seravalli V, Vannucci G, Di Tommaso M. Maternal Oxygen Administration during Labor: A Controversial Practice. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1420. [PMID: 37628419 PMCID: PMC10453930 DOI: 10.3390/children10081420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Oxygen administration to the mother is commonly performed during labor, especially in the case of a non-reassuring fetal heart rate, aiming to increase oxygen diffusion through the placenta to fetal tissues. The benefits and potential risks are controversial, especially when the mother is not hypoxemic. Its impact on placental gas exchange and the fetal acid-base equilibrium is not fully understood and it probably affects the sensible placental oxygen equilibrium causing a time-dependent vasoconstriction of umbilical and placental vessels. Hyperoxia might also cause the generation of radical oxygen species, raising concerns for the developing fetal cells. Moreover, this practice affects the maternal cardiovascular system, causing alterations of the cardiac index, heart rate and vascular resistance, and unclear effects on uterine blood flow. In conclusion, there is no evidence that maternal oxygen administration can provide any benefit in the case of a non-reassuring fetal heart rate pattern, while possible collateral effects warn of its utilization. Oxygen administration during labor should be reserved for cases of maternal hypoxia.
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Affiliation(s)
- Isabella Abati
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (M.M.); (D.G.)
| | - Dario Giugni
- Department of Anesthesia and Intensive Care, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (M.M.); (D.G.)
| | - Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Giulia Vannucci
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
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Bragança J, Pinto R, Silva B, Marques N, Leitão HS, Fernandes MT. Charting the Path: Navigating Embryonic Development to Potentially Safeguard against Congenital Heart Defects. J Pers Med 2023; 13:1263. [PMID: 37623513 PMCID: PMC10455635 DOI: 10.3390/jpm13081263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
Congenital heart diseases (CHDs) are structural or functional defects present at birth due to improper heart development. Current therapeutic approaches to treating severe CHDs are primarily palliative surgical interventions during the peri- or prenatal stages, when the heart has fully developed from faulty embryogenesis. However, earlier interventions during embryonic development have the potential for better outcomes, as demonstrated by fetal cardiac interventions performed in utero, which have shown improved neonatal and prenatal survival rates, as well as reduced lifelong morbidity. Extensive research on heart development has identified key steps, cellular players, and the intricate network of signaling pathways and transcription factors governing cardiogenesis. Additionally, some reports have indicated that certain adverse genetic and environmental conditions leading to heart malformations and embryonic death may be amendable through the activation of alternative mechanisms. This review first highlights key molecular and cellular processes involved in heart development. Subsequently, it explores the potential for future therapeutic strategies, targeting early embryonic stages, to prevent CHDs, through the delivery of biomolecules or exosomes to compensate for faulty cardiogenic mechanisms. Implementing such non-surgical interventions during early gestation may offer a prophylactic approach toward reducing the occurrence and severity of CHDs.
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Affiliation(s)
- José Bragança
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences (FMCB), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Champalimaud Research Program, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal
| | - Rute Pinto
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
| | - Bárbara Silva
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences (FMCB), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- PhD Program in Biomedical Sciences, Faculty of Medicine and Biomedical Sciences, Universidade do Algarve, 8005-139 Faro, Portugal
| | - Nuno Marques
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
| | - Helena S. Leitão
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences (FMCB), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
| | - Mónica T. Fernandes
- Algarve Biomedical Center-Research Institute (ABC-RI), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- Algarve Biomedical Center (ABC), University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
- School of Health, University of Algarve Campus Gambelas, 8005-139 Faro, Portugal
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5
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Chuai F, Dong T, Liu Y, Jiang W, Zhang L, Chen L, Chuai Y, Zhou Y. The effect of intrapartum prolonged oxygen exposure on fetal metabolic status: secondary analysis from a randomized controlled trial. Front Endocrinol (Lausanne) 2023; 14:1204956. [PMID: 37441500 PMCID: PMC10335765 DOI: 10.3389/fendo.2023.1204956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/15/2023] [Indexed: 07/15/2023] Open
Abstract
Objective The aim of the study is to assess the effect of maternal prolonged oxygen exposure during labor on fetal acid-base status, fetal heart rate tracings, and umbilical cord arterial metabolites. Design The study was conducted as a secondary analysis. Settings The study was set in three tertiary teaching hospitals in Beijing, China. Participants Approximately 140 women in the latent phase of labor with no complications participated in the study. Intervention Participants were randomly allocated in a 1:1 ratio to receive either 10 L of oxygen per minute in a tight-fitting simple facemask until delivery or room air only. Main outcome measures The primary outcome was the umbilical cord arterial lactate. Results Baseline demographics and labor outcomes were similar between the oxygen and room air groups; the time from randomization to delivery was 322 ± 147 min. There were no differences between the two groups in the umbilical cord arterial lactate (mean difference 0.3 mmol/L, 95% confidence interval -0.2 to 0.9), the number of participants with high-risk category II fetal heart rate tracings (relative risk 0.94, 95% confidence interval 0.68 to 1.32), or the duration of those high-risk tracings (mean difference 3.6 min, 95% confidence interval -9.3 to 16.4). Prolonged oxygen exposure significantly altered 91 umbilical cord arterial metabolites, and these alterations did not appear to be related to oxidative stress. Conclusion Maternal prolonged oxygen exposure during labor did not affect either the umbilical cord arterial lactate or high-risk category II fetal heart rate tracings but might result in alterations to the umbilical cord arterial metabolic profile. Clinical trial registration www.clinicaltrials.gov, identifier NCT03764696.
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Affiliation(s)
- Fang Chuai
- Department of Obstetrics and Gynaecology, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tong Dong
- Department of Obstetrics and Gynaecology, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuan Liu
- Department of Obstetrics and Gynaecology, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Wen Jiang
- Department of Obstetrics and Gynaecology, Seventh Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lanmei Zhang
- Department of Obstetrics and Gynecology, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Lei Chen
- Department of Obstetrics and Gynaecology, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yunhai Chuai
- Department of Obstetrics and Gynaecology, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuhang Zhou
- Department of Day Treatment, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
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6
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Burd J, Raghuraman N. Intrapartum Oxygen for Fetal Resuscitation: State of the Science. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023; 12:1-5. [PMID: 37360259 PMCID: PMC10191681 DOI: 10.1007/s13669-023-00363-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review aims to summarize the current evidence regarding maternal oxygen supplementation for Category II fetal heart tracings (FHT) in labor. We aim to evaluate the theoretical rationale for oxygen administration, the clinical efficacy of supplemental oxygen, and the potential risks. Recent Findings Maternal oxygen supplementation is an intrauterine resuscitation technique rooted in the theoretic rationale that hyperoxygenating the mother results in increased oxygen transfer to the fetus. However, recent data suggest otherwise. Randomized controlled trials on the efficacy of oxygen supplementation in labor suggest no improvement in umbilical cord gases or other adverse maternal and neonatal outcomes compared to room air. Two meta-analyses demonstrated that oxygen supplementation is not associated with an improvement in umbilical artery pH or reduction in cesarean delivery. Although we lack data on definitive clinical neonatal outcomes with this practice, there is some suggestion of adverse neonatal outcomes with excess in utero oxygen exposure, including lower umbilical artery pH. Summary Despite historic data suggesting the benefit of maternal oxygen supplementation in increasing fetal oxygenation, recent randomized trials and meta-analyses have demonstrated a lack of efficacy of this practice and some suggestion of harm. This has led to conflicting national guidelines. Further research is needed on short- and long-term neonatal clinical outcomes following prolonged intrauterine oxygen exposure.
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Affiliation(s)
- Julia Burd
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63108 USA
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63108 USA
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7
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Vasung L, Xu J, Abaci-Turk E, Zhou C, Holland E, Barth WH, Barnewolt C, Connolly S, Estroff J, Golland P, Feldman HA, Adalsteinsson E, Grant PE. Cross-Sectional Observational Study of Typical in utero Fetal Movements Using Machine Learning. Dev Neurosci 2022; 45:105-114. [PMID: 36538911 PMCID: PMC10233700 DOI: 10.1159/000528757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
Early variations of fetal movements are the hallmark of a healthy developing central nervous system. However, there are no automatic methods to quantify the complex 3D motion of the developing fetus in utero. The aim of this prospective study was to use machine learning (ML) on in utero MRI to perform quantitative kinematic analysis of fetal limb movement, assessing the impact of maternal, placental, and fetal factors. In this cross-sectional, observational study, we used 76 sets of fetal (24-40 gestational weeks [GW]) blood oxygenation level-dependent (BOLD) MRI scans of 52 women (18-45 years old) during typical pregnancies. Pregnant women were scanned for 5-10 min while breathing room air (21% O2) and for 5-10 min while breathing 100% FiO2 in supine and/or lateral position. BOLD acquisition time was 20 min in total with effective temporal resolution approximately 3 s. To quantify upper and lower limb kinematics, we used a 3D convolutional neural network previously trained to track fetal key points (wrists, elbows, shoulders, ankles, knees, hips) on similar BOLD time series. Tracking was visually assessed, errors were manually corrected, and the absolute movement time (AMT) for each joint was calculated. To identify variables that had a significant association with AMT, we constructed a mixed-model ANOVA with interaction terms. Fetuses showed significantly longer duration of limb movements during maternal hyperoxia. We also found a significant centrifugal increase of AMT across limbs and significantly longer AMT of upper extremities <31 GW and longer AMT of lower extremities >35 GW. In conclusion, using ML we successfully quantified complex 3D fetal limb motion in utero and across gestation, showing maternal factors (hyperoxia) and fetal factors (gestational age, joint) that impact movement. Quantification of fetal motion on MRI is a potential new biomarker of fetal health and neuromuscular development.
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Affiliation(s)
- Lana Vasung
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Junshen Xu
- Department of Electrical Engineering and Computer Science, MIT, Cambridge, Massachusetts, USA
| | - Esra Abaci-Turk
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Zhou
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Holland
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - William H Barth
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Carol Barnewolt
- Department of Radiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Connolly
- Department of Radiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Estroff
- Department of Radiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Polina Golland
- Department of Electrical Engineering and Computer Science, MIT, Cambridge, Massachusetts, USA
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, MIT, Cambridge, Massachusetts, USA
| | - Henry A Feldman
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elfar Adalsteinsson
- Department of Electrical Engineering and Computer Science, MIT, Cambridge, Massachusetts, USA
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, MIT, Cambridge, Massachusetts, USA
| | - P Ellen Grant
- Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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8
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Abstract
Although the pregnant population was affected by early waves of the COVID-19 pandemic, increasing transmission and severity due to new viral variants has resulted in an increased incidence of severe illness during pregnancy in many regions. Critical illness and respiratory failure are relatively uncommon occurrences during pregnancy, and there are limited high-quality data to direct management. This paper reviews the current literature on COVID-19 management as it relates to pregnancy, and provides an overview of critical care support in these patients. COVID-19 drug therapy is similar to that used in the non-pregnant patient, including anti-inflammatory therapy with steroids and IL-6 inhibitors, although safety data are limited for antiviral drugs such as remdesivir and monoclonal antibodies. As both pregnancy and COVID-19 are thrombogenic, thromboprophylaxis is essential. Endotracheal intubation is a higher risk during pregnancy, but mechanical ventilation should follow usual principles. ICU management should be directed at optimizing maternal well-being, which in turn will benefit the fetus.
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Affiliation(s)
- Stephen E Lapinsky
- Faculty of Medicine, University of Toronto, Canada,Intensive Care Unit, Mount Sinai Hospital, Canada,Interdepartmental Division of Critical Care Medicine, University of Toronto,
Canada,Stephen Lapinsky, Faculty of Medicine, University
of Toronto, 600 University Ave, #18-214, Toronto, ON M5G1X5, Canada
| | - Maha Al Mandhari
- Interdepartmental Division of Critical Care Medicine, University of Toronto,
Canada
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9
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Schabel MC, Roberts VHJ, Gibbins KJ, Rincon M, Gaffney JE, Streblow AD, Wright AM, Lo JO, Park B, Kroenke CD, Szczotka K, Blue NR, Page JM, Harvey K, Varner MW, Silver RM, Frias AE. Quantitative longitudinal T2* mapping for assessing placental function and association with adverse pregnancy outcomes across gestation. PLoS One 2022; 17:e0270360. [PMID: 35853003 PMCID: PMC9295947 DOI: 10.1371/journal.pone.0270360] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/09/2022] [Indexed: 11/21/2022] Open
Abstract
Existing methods for evaluating in vivo placental function fail to reliably detect pregnancies at-risk for adverse outcomes prior to maternal and/or fetal morbidity. Here we report the results of a prospective dual-site longitudinal clinical study of quantitative placental T2* as measured by blood oxygen-level dependent magnetic resonance imaging (BOLD-MRI). The objectives of this study were: 1) to quantify placental T2* at multiple time points across gestation, and its consistency across sites, and 2) to investigate the association between placental T2* and adverse outcomes. 797 successful imaging studies, at up to three time points between 11 and 38 weeks of gestation, were completed in 316 pregnancies. Outcomes were stratified into three groups: (UN) uncomplicated/normal pregnancy, (PA) primary adverse pregnancy, which included hypertensive disorders of pregnancy, birthweight <5th percentile, and/or stillbirth or fetal death, and (SA) secondary abnormal pregnancy, which included abnormal prenatal conditions not included in the PA group such as spontaneous preterm birth or fetal anomalies. Of the 316 pregnancies, 198 (62.6%) were UN, 70 (22.2%) PA, and 48 (15.2%) SA outcomes. We found that the evolution of placental T2* across gestation was well described by a sigmoid model, with T2* decreasing continuously from a high plateau level early in gestation, through an inflection point around 30 weeks, and finally approaching a second, lower plateau in late gestation. Model regression revealed significantly lower T2* in the PA group than in UN pregnancies starting at 15 weeks and continuing through 33 weeks. T2* percentiles were computed for individual scans relative to UN group regression, and z-scores and receiver operating characteristic (ROC) curves calculated for association of T2* with pregnancy outcome. Overall, differences between UN and PA groups were statistically significant across gestation, with large effect sizes in mid- and late- pregnancy. The area under the curve (AUC) for placental T2* percentile and PA pregnancy outcome was 0.71, with the strongest predictive power (AUC of 0.76) at the mid-gestation time period (20–30 weeks). Our data demonstrate that placental T2* measurements are strongly associated with pregnancy outcomes often attributed to placental insufficiency. Trial registration: ClinicalTrials.gov: NCT02749851.
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Affiliation(s)
- Matthias C. Schabel
- Advanced Imaging Research Center, Oregon Health and Science University (OHSU), Portland, Oregon, United States of America
| | - Victoria H. J. Roberts
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center (ONPRC), OHSU, Portland, Oregon, United States of America
- * E-mail:
| | - Karen J. Gibbins
- Department of Obstetrics and Gynecology, OHSU, Portland, Oregon, United States of America
| | - Monica Rincon
- Department of Obstetrics and Gynecology, OHSU, Portland, Oregon, United States of America
| | - Jessica E. Gaffney
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center (ONPRC), OHSU, Portland, Oregon, United States of America
| | - Aaron D. Streblow
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center (ONPRC), OHSU, Portland, Oregon, United States of America
| | - Adam M. Wright
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center (ONPRC), OHSU, Portland, Oregon, United States of America
| | - Jamie O. Lo
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center (ONPRC), OHSU, Portland, Oregon, United States of America
- Department of Obstetrics and Gynecology, OHSU, Portland, Oregon, United States of America
| | - Byung Park
- Biostatistics Shared Resource, Knight Cancer Institute, OHSU, Portland, Oregon, United States of America
| | - Christopher D. Kroenke
- Advanced Imaging Research Center, Oregon Health and Science University (OHSU), Portland, Oregon, United States of America
- Division of Neuroscience, ONPRC, OHSU, Portland, Oregon, United States of America
| | - Kathryn Szczotka
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Nathan R. Blue
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Jessica M. Page
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Kathy Harvey
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Antonio E. Frias
- Department of Obstetrics and Gynecology, OHSU, Portland, Oregon, United States of America
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Chuai Y, Jiang W, Zhang L, Chuai F, Sun X, Peng K, Gao J, Dong T, Chen L, Yao Y. Effect of long-duration oxygen vs room air during labor on umbilical cord venous partial pressure of oxygen: a randomized controlled trial. Am J Obstet Gynecol 2022; 227:629.e1-629.e16. [PMID: 35580635 DOI: 10.1016/j.ajog.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND There are limited data to guide the duration and dose of oxygen supplementation for pregnant women undergoing labor. OBJECTIVE To assess the effect of maternal long-duration high-concentration oxygen administration during labor on umbilical cord venous partial pressure of oxygen. STUDY DESIGN This randomized clinical trial was conducted between January and October of 2021 in the obstetrics wards of 3 tertiary teaching hospitals in Beijing, China. Women undergoing the latent phase of labor with no existing medical conditions or obstetrical complications who were admitted for delivery were eligible. The women who met inclusion criteria with category I fetal heart rate tracings in labor were randomized in a 1:1 ratio to oxygen or room air. The oxygen group received 10 L of oxygen per minute by simple, tight-fitting face mask until delivery. The room-air group received room air only, without a face mask. The primary outcome was the umbilical cord venous partial pressure of oxygen. RESULTS A total of 661 women were screened, and 521 were excluded; 140 participants with category I fetal heart rate tracings were enrolled and randomized to oxygen (N=70) or room air (N=70). A total of 135 women with valid paired umbilical cord venous and arterial gas values were included in the umbilical cord venous partial pressure of oxygen and arterial pH analyses. All 140 women were included in the fetal heart rate tracings analysis. Baseline characteristics were similar between the oxygen and room-air groups. The duration of oxygen exposure was approximately 322±147 minutes. There were no differences between the oxygen and room-air groups in the umbilical cord venous partial pressure of oxygen (mean difference, 1.1 mm Hg; 95% confidence interval, -1.0 to 3.2; P=.318) or the proportion of participants with category II fetal heart rate tracings (81.4% vs 78.6%; relative risk, 1.04; 95% confidence interval, 0.88-1.22; P=.672). However, the umbilical cord arterial pH was significantly lower in the oxygen group than in the room-air group (median, 7.23; interquartile range, 7.20-7.27 vs median 7.27; interquartile range, 7.20-7.30; P=.005). CONCLUSION Maternal long-duration high-concentration oxygen administration during labor did not affect either the umbilical cord venous partial pressure of oxygen or fetal heart rate pattern distribution but resulted in a deterioration of the umbilical cord arterial pH at birth.
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Ghafoor H, Abdus samad A, Bel Khair AOM, Ahmed O, Khan MNA. Critical Care Management of Severe COVID-19 in Pregnant Patients. Cureus 2022; 14:e24885. [PMID: 35572463 PMCID: PMC9097928 DOI: 10.7759/cureus.24885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 12/15/2022] Open
Abstract
Since December 2019, the coronavirus disease (COVID-19) pandemic has had a disastrous impact worldwide. COVID-19 is caused by the SARS-CoV-2 virus and was declared a pandemic by the WHO on March 11, 2020. The virus has been linked to a wide range of respiratory illnesses, ranging from mild symptoms to acute pneumonia and severe respiratory distress syndrome. Pregnant women are more vulnerable to COVID-19 complications owing to the physiological and immunological changes caused by pregnancy. According to the CDC, pregnant patients with COVID-19 are commonly hospitalized and often require admission to ICUs and ventilator support. Therefore, it is especially important for pregnant women to adhere to disease prevention measures to lower the risk of contracting the disease. In addition, the guidelines of several clinical societies and local health authorities should be followed when caring for pregnant women with suspected or confirmed COVID-19. In this review article, we discuss the epidemiology of COVID-19 during delivery, its effect on the physiological and immunological changes during pregnancy, the classification of COVID-19 severity, maternal and fetal risks, antenatal care, respiratory management, treatment/medication safety, timing and mode of delivery, anesthetic considerations, and the outcome of critically ill pregnant patients with COVID-19, as well as their post-delivery care and weaning from mechanical ventilation.
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McHugh A, El-Khuffash A, Franklin O, Breathnach FM. Calling into question the future of hyperoxygenation in pregnancy. Eur J Obstet Gynecol Reprod Biol 2020; 258:93-97. [PMID: 33421817 DOI: 10.1016/j.ejogrb.2020.12.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/09/2020] [Accepted: 12/28/2020] [Indexed: 01/07/2023]
Abstract
Maternal hyperoxygenation has been investigated as a potential diagnostic and therapeutic tool since the 1960s. Since then, it has been applied in many obstetric scenarios, both clinically and in the research setting. It is often administered without any determination of pre-hyperoxygenation maternal or fetal oxygen levels. Studies focussing on maternal oxygen therapy for the treatment of fetal growth restriction have been ongoing for over thirty years and there remains no clear evidence of benefit. Studies investigating the potential diagnostic or therapeutic role of maternal oxygen therapy in the setting of fetal congenital cardiac disease have reported varying success rates and some potentially worrying adverse effects. The purpose of this article is to review the effects of maternal hyperoxygenation on fetal and maternal health and to ascertain the safety of undertaking further clinical trials that employ the use of hyperoxygenation in pregnancy.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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The effect of intrapartum oxygen supplementation on category II fetal monitoring. Am J Obstet Gynecol 2020; 223:905.e1-905.e7. [PMID: 32585226 DOI: 10.1016/j.ajog.2020.06.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/04/2020] [Accepted: 06/18/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Maternal oxygen administration is a widely used intrauterine resuscitation technique for fetuses with category II electronic fetal monitoring patterns, despite a paucity of evidence on its ability to improve electronic fetal monitoring patterns. OBJECTIVE This study investigated the effect of intrapartum oxygen administration on Category II electronic fetal monitoring patterns. STUDY DESIGN This is a secondary analysis of a randomized trial conducted in 2016-2017, in which patients with fetuses at ≥37 weeks' gestation in active labor with category II electronic fetal monitoring patterns were assigned to 10 L/min of oxygen by face mask or room air until delivery. Trained obstetrical research nurses blinded to allocation extracted electronic fetal monitoring data. The primary outcome was a composite of high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, or minimal variability 60 minutes after randomization to room air or oxygen. Secondary outcomes included individual components of the composite high-risk category II features, resolution of recurrent decelerations within 60 minutes of randomization, and total deceleration area. The outcomes between the room air and oxygen groups were compared using univariable statistics. Time-to-event analysis was used to compare time to resolution of recurrent decelerations between the groups. Paired analysis was used to compare the pre- and postrandomization outcomes within each group. RESULTS All 114 randomized patients (57 room air and 57 oxygen) were included in this analysis. There was no difference in resolution of recurrent decelerations within 60 minutes between the oxygen and room air groups (75.4% vs 86.0%; P=.15). The room air and oxygen groups had similar rates of composite high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, and minimal variability 60 minutes after randomization. Time to resolution of recurrent decelerations and total deceleration area were similar between the room air and oxygen groups. Among patients who received oxygen, there was no difference in the electronic fetal monitoring patterns pre- and postrandomization. Similar findings were observed in the electronic fetal monitoring patterns pre- and postrandomization in room air patients. CONCLUSION Intrapartum maternal oxygen administration for category II electronic fetal monitoring patterns did not resolve high-risk category II features or hasten the resolution of recurrent decelerations. These results suggest that oxygen administration has no impact on improving category II electronic fetal monitoring patterns.
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McHugh A, Breatnach C, Bussmann N, Franklin O, El-Khuffash A, Breathnach FM. Prenatal prediction of neonatal haemodynamic adaptation after maternal hyperoxygenation. BMC Pregnancy Childbirth 2020; 20:706. [PMID: 33213415 PMCID: PMC7678134 DOI: 10.1186/s12884-020-03403-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/06/2020] [Indexed: 11/17/2022] Open
Abstract
Abstract The reactivity of the pulmonary vascular bed to the administration of oxygen is well established in the post-natal circulation. The vasoreactivity demonstrated by the fetal pulmonary artery Doppler waveform in response to maternal hyperoxia has been investigated. We sought to investigate the relationship between the reactivity of the fetal pulmonary arteries to hyperoxia and subsequent neonatal cardiac function in the early newborn period. Methods This explorative study with convenience sampling measured pulsatility index (PI), resistance index (RI), acceleration time (AT), and ejection time (ET) from the fetal distal branch pulmonary artery (PA) at baseline and following maternal hyperoxygenation (MH). Oxygen was administered for 10 min at a rate of 12 L/min via a partial non-rebreather mask. A neonatal functional echocardiogram was performed within the first 24 h of life to assess ejection fraction (EF), left ventricular output (LVO), and neonatal pulmonary artery AT (nPAAT). This study was conducted in the Rotunda Hospital, Dublin, Ireland. Results Forty-six women with a singleton pregnancy greater than or equal to 31 weeks’ gestational age were prospectively recruited to the study. The median gestational age was 35 weeks. There was a decrease in fetal PAPI and PARI following MH and an increase in fetal PAAT, leading to an increase in PA AT:ET. Fetuses that responded to hyperoxygenation were more likely to have a higher LVO (135 ± 25 mL/kg/min vs 111 ± 21 mL/kg/min, p < 0.01) and EF (54 ± 9% vs 47 ± 7%,p = 0.03) in the early newborn period than those that did not respond to MH prenatally. These findings were not dependent on left ventricular size or mitral valve (MV) annular diameter but were related to an increased MV inflow. There was no difference in nPAAT. Conclusion These findings indicate a reduction in fetal pulmonary vascular resistance (PVR) and an increase in pulmonary blood flow and left atrial return following MH. The fetal response to hyperoxia reflected an optimal adaptation to postnatal life with rapid reduction in PVR increasing measured cardiac output. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-020-03403-y.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.
| | - Colm Breatnach
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Abstract
PURPOSE OF REVIEW The topic of perioperative hyperoxia remains controversial, with valid arguments on both the 'pro' and 'con' side. On the 'pro' side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the 'con' side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries. RECENT FINDINGS Some 'pro' articles leading to the Center for Disease Control and WHO guidelines advocating perioperative hyperoxia have been retracted, and the recommendations were downgraded from 'strong' to 'conditional'. At the same time, evidence that supports a tailored, more restrictive use of oxygen, for example, in patients with myocardial infarction or following cardiac arrest, is accumulating. SUMMARY The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation.
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Affiliation(s)
- Laveena Munshi
- Institute of Health Policy Management and Evaluation, Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Institute of Health Policy Management and Evaluation, Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, University of Toronto; University Health Network and Mount Sinai Hospitals, Toronto, Canada
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