Seminars in perinatology
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Seminars in perinatology · Feb 2009
ReviewPlatelets, frozen plasma, and cryoprecipitate: what is the clinical evidence for their use in the neonatal intensive care unit?
Transfusion of blood components such as platelets, frozen plasma, and cryoprecipitate is a common practice in the neonatal intensive care unit. Although it is intuitive that these components would be transfused in the context of bleeding, their use in neonatology has often been on a prophylactic basis. Due to a lack of consensus guidelines regarding indications for transfusion, however, the neonatologist is left to his/her opinion as to when to transfuse. This article seeks to review the available evidence regarding the use of platelets, frozen plasma, and cryoprecipitate in neonates, as well as the risks associated with the administration of these products.
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Abnormal fetal growth is associated with preterm birth, stillbirth, neonatal death, respiratory distress syndrome, and necrotizing enterocolitis. An optimal fetal growth standard would be one that most correctly identifies the fetus at risk for poor perinatal outcome. A growth standard that is created using population-specific data is more applicable than generalized growth curves since there is evidence that optimal neonatal outcome is achieved at different birth weights in different populations. ⋯ Likewise, employing clinically derived ultrasound standards for term gestations would include a population that is more likely to have abnormal growth. Novel approaches to defining normal intrauterine growth combine birth weights at term and fetal growth patterns in-utero to create growth curves useful in defining the normal intrauterine growth experience. This review examines the performance of a variety of the growth characterizing standards that have been employed to define abnormal growth and examines their performance in the prediction of adverse perinatal outcome.
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Seminars in perinatology · Dec 2007
ReviewImmunosuppressant therapy in pregnant organ transplant recipients.
Transplant recipients are becoming pregnant with increasing frequency, and successful pregnancy outcomes have now been reported for women with all types of solid organ transplants. To prevent rejection of the transplanted organ, these patients are maintained on a life-long immunosuppressive regimen that must also be continued through pregnancy. ⋯ These observational studies suggest that successful pregnancy outcomes are possible in female organ transplant recipients, although sporadic adverse outcomes have been reported after immunosuppressant use in pregnancy. In this chapter, we will outline the information available regarding the use of immunosuppressive medications in pregnant transplant recipients as well as general concepts regarding fetal exposure to immunosuppressants.
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Pain in the developing fetus is controversial because of the difficulty in measuring and interpreting pain during gestation. It has received increased attention lately because of recently introduced legislation that would require consideration of fetal pain during intentional termination of pregnancy. During development, sensory fibers are abundant by 20 weeks; a functional spinal reflex is present by 19 weeks; connections to the thalamus are present by 20 weeks; and connections to subplate neurons are present by 17 weeks with intensive differentiation by 25 weeks. ⋯ Whereas evidence for conscious pain perception is indirect, evidence for the subconscious incorporation of pain into neurological development and plasticity is incontrovertible. Scientific data, not religious or political conviction, should guide the desperately needed research in this field. In the meantime, it seems prudent to avoid pain during gestation.
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Seminars in perinatology · Oct 2007
ReviewPremedication for tracheal intubation in neonates: confusion or controversy?
Tracheal intubation is performed frequently in the NICU and delivery room. This procedure is extremely distressing, painful, and has the potential for airway injury. Premedication with sedatives, analgesics, and muscle relaxants is standard practice for pediatric and adult intubation, yet the use of these drugs is not common for intubation in neonates. ⋯ Schematically, these studies have been of three main types: (a) studies comparing awake intubation versus those with sedation or analgesia, (b) studies comparing different premedication regimens comprising sedatives, analgesics, and anesthetics, and (c) case series of neonates in which some authors have reported their experience with a specific premedication regimen. The clinical benefits described in these studies and the need for pain control in neonates make the case for using appropriate premedication routinely for elective or semi-urgent intubations. Tracheal intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or other life-threatening situations when intravenous access is unavailable.