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Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: August 2010
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Inhaled Nitric Oxide in Preterm Infants

To systematically review the evidence on the use of inhaled nitric oxide (iNO) in preterm infants born at or before 34 weeks gestation age who receive respiratory support.

Evidence Reports/Technology Assessments - Agency for Healthcare Research and Quality (US).

Version: October 2010
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Volume-targeted versus pressure-limited ventilation for preterm infants: a systematic review and meta-analysis

BACKGROUND: The causes of bronchopulmonary dysplasia (BPD) are multifactorial. Overdistension of the lung (volutrauma) is considered an important contribution. As an alternative to traditional pressure-limited ventilation (PLV), modern neonatal ventilators offer modes which can target a set tidal volume.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Dopamine versus dobutamine for hypotensive preterm infants

Dopamine improves low blood pressure (hypotension) in preterm babies more effectively than dobutamine in the short‐term, but evidence on safety and long‐term effectiveness is needed. Hypotension may cause brain injury and other serious problems for preterm babies (born before 37 weeks). Treatment aims to maintain blood flow to the brain and other organs, by using fluids or drugs to increase blood pressure. Inotrope drugs, including dopamine and dobutamine, are commonly used to increase blood pressure. However, the safest and most effective drug for treating hypotension in preterm babies has been unclear. The review found that dopamine was more effective than dobutamine for short‐term treatment, but the effects of these drugs on long‐term outcomes is unknown. More trials are needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Superoxide dismutase for preventing chronic lung disease in mechanically ventilated preterm infants

Not enough evidence to show the effectiveness of superoxide dismutase in preventing chronic lung disease in premature babies. Chronic lung disease (CLD) is a common problem in preterm babies who are mechanically ventilated (machine assisted breathing). Free oxygen radicals are believed to cause CLD. Superoxide dismutase is an enzyme normally present in the body to provide a defence against free radicals but preterm infants do not have a sufficient supply to provide natural resistance. Giving superoxide dismutase to preterm infants may therefore prevent CLD. The review of trials found there is not enough evidence yet to show if this is effective. More research is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Early neonatal dexamethasone treatment for prevention of bronchopulmonary dysplasia: randomised trial and meta-analysis evaluating the duration of dexamethasone therapy

The aim of the aborted trial was to determine whether the short early dexamethasone (DX) given after the birth improves the early outcome. We also reviewed the evidence (meta-analysis) to determine whether the duration of early DX treatment influences the early outcome, particularly in terms of bronchopulmonary dysplasia (BPD). The participants of the randomised multicentre, double-blinded placebo-controlled trial had a birth weight 500-999 g, gestation < or = 31.0 weeks, and respiratory failure by the age of 4 h. The infants received either four doses of DX (0.25 mg/kg at 12 h intervals) or placebo. The meta-analysis was performed to determine the beneficial and adverse effects of early short (<96 h duration) versus early prolonged (>96 h) DX treatment. The trial was discontinued after 109 infants had been enrolled. There was a non-significant improvement in the outcome (survival without BPD, severe intracranial haemorrhage or periventricular leukomalacia; RR 1.27; 95% CI 0.87-1.85). The risks for gastrointestinal perforation and hyperglycaemia tended to increase. A total of 15 trials were included in the meta-analysis: 10 involved prolonged (i.e. >96 h; 1594 infants) and five short interventions (1069 infants). Early prolonged DX decreased the RR for BPD to 0.72 (95% CI 0.61-0.87), whereas early short DX course did not significantly decrease the risk (RR 0.82; 95% CI 0.64-1.05). Gastrointestinal haemorrhages and perforations were significantly increased only in the early prolonged DX group.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Cerebral injury and neurodevelopmental impairment after amnioreduction versus laser surgery in twin-twin transfusion syndrome: a systematic review and meta-analysis

OBJECTIVE: To estimate the odds of severe cerebral injury and long-term neurodevelopmental impairment in monochorionic twins treated with amnioreduction versus laser surgery for twin-twin transfusion syndrome.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Oral lactoferrin for prevention of sepsis and necrotizing enterocolitis in preterm infants

Premature babies are at risk for blood infection (sepsis) and/or gastrointestinal injury (necrotizing enterocolitis, or NEC). A number of babies with sepsis or NEC die or develop long‐term brain and lung injury despite treatment with antibiotics. Lactoferrin, which is present in human milk, has been shown to be effective against infection when tested in animals and in the laboratory. Lactoferrin also enhances the ability of babies to fight infection. We found four studies that enrolled 1103 preterm babies. Evidence of moderate to low quality suggests that oral lactoferrin with or without a probiotic decreases sepsis and NEC in preterm infants with no adverse effects. When given alone, lactoferrin decreases deaths among preterm infants. We also found large studies that are ongoing, and their results when available may increase the strength of our analysis. Clarification regarding dosing, duration, type of lactoferrin (human or bovine), and development of preterm babies is still needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: a systematic review and meta-analysis

OBJECTIVE: To assess the effect of volume-targeted ventilation (VTV) compared with pressure-limited ventilation (PLV) in preterm infants.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

There is no evidence to show the benefit of midazolam as a sedative for newborn babies in neonatal intensive care. Newborn babies undergoing uncomfortable procedures in intensive care units may need sedation to reduce stress and avoid complications. It is difficult to measure their pain so sedatives or pain killers are sometimes overlooked for newborn babies. Midazolam is a short‐acting sedative increasingly used in neonatal intensive care. The review of trials found no evidence to support the use of midazolam as a sedative for neonates undergoing intensive care. Babies receiving midazolam stayed in hospital longer and had more adverse effects. More research is needed to address the safety and effect of midazolam.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Vasopressin and its analogues for the treatment of refractory hypotension in neonates

Hypotension or low blood pressure occurs frequently in newborn infants after infection or surgery or in very preterm infants. Sometimes, the hypotension does not respond to fluids or other drug such as catecholamines or steroids. In those unresponsive infants, vasopressin may be useful in improving blood pressure and overall survival. We searched the literature for studies that used vasopressin or its analogue terlipressin in the newborn in the first 28 days of life for unresponsive hypotension. We found no ongoing or completed studies. Currently there is no evidence to recommend the use of vasopressin or terlipressin, but we recommend that studies be carried out in the future to study the effectiveness and safety in unresponsive hypotension in newborn infants.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Tracheal gas insufflation for the prevention of morbidity and mortality in mechanically ventilated newborn infants

Tracheal gas insufflation (TGI) is a new technique to supplement mechanical ventilation in neonatal intensive care, but benefit and safety have not been proven. Tracheal gas insufflation (TGI ‐ also called 'dead space washout') is a new add‐on technique for mechanical ventilation (machine‐assisted breathing) for babies in neonatal intensive care. It requires new and expensive specialised equipment and skills. TGI involves sending a continuing flow of air/oxygen into the lower part of a baby's trachea (windpipe). The review found only one trial of TGI, which showed it might reduce the length of time babies need mechanical ventilation, but not necessarily reduce the time on oxygen therapy or the stay in hospital. More research is needed to establish if this technology is safe and beneficial.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Dopamine versus no treatment to prevent renal dysfunction in indomethacin‐treated preterm newborn infants

Dopamine has not been shown to prevent adverse effects of indomethacin on the kidneys of preterm babies. Indomethacin is a drug used in preterm babies to prevent brain hemorrhage or to help close off PDA (patent ductus arteriosus ‐ when a channel between the lungs and heart does not close off after birth as it should). Indomethacin often causes fluid retention and reduced flow of urine, which can sometimes cause deterioration in kidney (renal) function. The drug dopamine is sometimes used along with indomethacin to try and prevent negative impact on the kidneys. The review found there is not enough evidence from trials to show there is any value in giving dopamine to babies being treated with indomethacin.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Recombinant human activated protein for severe sepsis in neonates

Sepsis (a generalized blood stream infection) is common in neonates. Severe sepsis carries a high mortality and morbidity even with current critical care management. Activated Protein C (APC) is a protein formed within the human body to prevent formation of blood clots and helps in breaking down clots. Recombinant human APC (rhAPC) is a synthesized version of APC using recombinant technology. It has been shown to reduce mortality in severe sepsis in adults. The review authors investigated whether treatment of severe sepsis in newborn infants with rhAPC will help to reduce mortality and severe morbidity. The review authors found no controlled studies in this age group. On October 25, 2011 rhAPC (Xigris®) was withdrawn from the market by Eli Lilly due to side effect in adults. RhAPC should no longer be used in any age category and the product should be returned to the distributor.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Pentoxifylline for the prevention of bronchopulmonary dysplasia in preterm infants

Babies who are born early (preterm) often suffer from long‐lasting breathing problems known as bronchopulmonary dysplasia, which can lead to poor health in childhood and adulthood. Drugs that act on the body's self‐defense system may help to lower the risk of long‐lasting breathing problems. Pentoxifylline is one such drug. The main aim of this review was to find out whether pentoxifylline compared with placebo (an inactive drug) or no drug offers important advantages to babies born early. Only one study of moderate size and quality was identified in this review. This study did not show strong evidence that pentoxifylline offers important advantages to babies born early. We have therefore been unable to determine the effects of pentoxifylline in preventing long‐lasting breathing problems in babies born early. Future high‐quality studies are needed to answer this question.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Permissive hypercapnia for the prevention of morbidity and mortality in mechanically ventilated newborn infants

Not enough evidence to show the effect of permissive hypercapnia compared to routine ventilation for preterm babies needing mechanical ventilation. Sometimes preterm babies need help from a machine to breathe (mechanical ventilation). Very low carbon dioxide levels, produced by mechanical ventilation of the lungs are thought to cause lung damage and developmental problems. Hypercapnia (increasing the levels of carbon dioxide in the blood) is used for adults in critical care. It may also help newborn babies, especially those with lung damage on mechanical ventilation. The review of trials found there was not enough evidence to show the effect of permissive hypercania compared to routine ventilation for preterm babies. More research is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Intratracheal Clara cell secretory protein (CCSP) administration in preterm infants with or at risk of respiratory distress syndrome

There is insufficient evidence from randomised controlled trials to guide the use of CCSP administration in preterm infants at risk of respiratory distress syndrome.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

A comparison of volume targeted ventilation modes with traditional pressure limited ventilation modes for newborn babies

Preterm babies may need help to breathe. The risk of lung problems increases with increasing immaturity. For some babies, the assistance of a ventilator (breathing machine) can be life saving, however ventilators may also injure the baby’s immature lungs. New ‘volume targeted’ modes of ventilation have been developed which aim to reduce lung injury by controlling the amount of air entering the lungs with each breath. This review has compared the outcome of infants ventilated with volume targeted modes, with infants ventilated using traditional ‘pressure limited’ modes.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Cysteine, cystine or N‐acetylcysteine supplementation in parenterally fed neonates

Sick or preterm newborn infants may require intravenous nutrition, including intravenous administration of solutions containing amino acids. Newborn infants need cysteine (an amino acid) for growth under certain conditions. Cysteine may decrease the chance of liver disease and brittle bones. This systemic review was done to analyze whether adding cysteine (or related compounds) to intravenous nutrition affects growth and other outcomes in newborn infants. Five trials studied the effects of adding cysteine to intravenous nutrition that did not contain cysteine. Addition of cysteine significantly improved the babies' ability to build body proteins (analyzed in four studies); however, it did not improve growth (analyzed in one study); no other outcomes were available. One large randomized trial studied the effect of adding another chemical, N‐acetyl‐cysteine, to intravenous nutrition that already contained cysteine. This study showed no benefit and no toxicity of this intervention. We conclude that present data are insufficient to justify routine addition of cysteine to the intravenous nutrition of newborn infants that does not contain cysteine. Available evidence does not support routine addition of N‐acetylcysteine to intravenous nutrition of newborn infants containing cysteine.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Multiple vs. single doses of exogenous surfactant for the prevention or treatment of neonatal respiratory distress syndrome

Multiple doses of surfactant have more benefit than a single dose.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

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