202 - Real-world impact of routine screening and early targeted PDA treatment approach on intraventricular hemorrhage in extremely low gestational age neonates: A single-center pre-post cohort study

Publication Number: 202.6212

Federica Savio, The Hospital for Sick Children, Toronto, ON, Canada; Faith Zhu, Faith Zhu, Staff Neonatologist, Mount Sinai Hospital, Toronto, Toronto, ON, Canada; Ashraf Kharrat, Mount Sinai Hospital, Toronto, ON, Canada; Thaiani Wulff, Mount Sinai Hospital, Toronto, Toronto, ON, Canada; Phoebe Thum, Mount Sinai Hospital, Toronto, Markham, ON, Canada; Laura Thomas, Mount Sinai Hospital, Toronto, Toronto, ON, Canada; Yi-Chen Su, mount sinai hospital, RichmonHill, ON, Canada; Amish Jain, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; Poorva Deshpande, Mount Sinai Hospital, Toronto, ON, Canada

Background: Despite improvements in preterm care, the burden of intraventricular hemorrhage (IVH) is high and largely unchanged for extremely low gestational age neonates [ELGANs, < 29 weeks gestational age (GA)]. While patent ductus arteriosus (PDA) is associated with IVH, the real-world impact of its early detection and treatment remains debatable.

Objective: To evaluate the impact of routine screening and early targeted PDA treatment approach on the incidence and severity of IVH in ELGANs.

Design/Methods: A retrospective pre-post cohort study was conducted at the tertiary NICU of Mount Sinai Hospital in Toronto, comparing outcomes of ELGANs admitted during 18-months before (Pre-epoch) and after (Post-epoch) January 1st, 2023, when the PDA management policy was changed from “symptomatic treatment” [PDA evaluation by targeted neonatal echocardiography (TNE) at the discretion of attending clinicians, in the context of suggestive clinical signs] to “routine screening and targeted treatment” [TNE PDA screening < 72 hours of age for all ELGANs]. In both epochs, PDA with diameter >=1.5 mm and predominantly unrestrictive left-to-right shunt were selected for treatment. IVH grade >=2 was considered the primary outcome. Secondary outcomes were all grade IVH, severe IVH (grades 3 or 4), pre-discharge mortality, and bronchopulmonary dysplasia. Adjusted odds ratios (aOR) were computed for birth during post-epoch and clinical outcomes using, 1) multivariate logistic regression (MLR) in the whole cohort, and 2) propensity score matching analysis (PSM) including matched pairs, with the following covariates: GA, small for GA, antenatal steroids, outborn, delayed cord clamping and chest compressions at delivery. Rates of ultrasound-diagnosed brain injury, PDA- and prematurity-related outcomes were also compared.

Results: 282 and 256 ELGANs comprised the pre- and post-epochs, respectively; 243 matched pairs were identified for PSM. Baseline characteristics were largely similar between epochs (Table 1). Expectedly, more post-epoch ELGANs had TNE for PDA, and received treatment at an earlier age; PDA treatment rates were similar. Post-epoch showed lower rates of IVH >= grade 2, all grade IVH, grade 1, and grade 3 IVH; other outcomes were similar (Table 2). PDA screening and targeted treatment approach did not reduce aOR of IVH > grade 2 but was associated with lower all grade IVH and severe IVH on MLR and PSM analyses (Table 3).

Conclusion(s): This real-world pre-post study suggests that early screening and targeted PDA treatment may help reduce the burden of any IVH or severe IVH among ELGANs without impacting other adverse outcomes.

Table 1: Comparison of Baseline characteristics, perinatal variables and TNE implementation between ELGANs before and after adoption of routine screening and early PDA treatment approach
Data presented as frequency (percentage), mean (standard deviation) or medium (interquartile range). Denominator included whole cohort unless specifically shown.
GA (Gestational age), SD (standard deviation), SGA (small for gestational age), TNE (targeted neonatal echocardiography).

Table 2: Comparison of primary and secondary outcomes and TNE implementation between ELGANs before and after adoption of routine screening and early PDA treatment approach
Data presented as frequency (percentage), mean (standard deviation) or medium (interquartile range).
Denominator included whole cohort unless specifically shown.
*2 patients in the Pre-implementation and 1 in post implementation died prior to diagnosis of IVH on brain ultrasound.
† In infants who survived to discharge
BPD (bronchopulmonary dysplasia), IVH (intraventricular hemorrhage), PDA (patent ductus arteriosus)

Table 3: Adjusted odds ratios (AOR) of primary and secondary clinical outcomes for post- vs. pre-PDA screening after adjusting for covariates using propensity score method
Propensity score method matched cohort (n=243 in each group) accounting for gestational age, small for gestational age, no antenatal corticosteroids, outborn status, delayed cord clamping and resuscitation at birth with chest compression/epinephrine.
† = for survivors only. In bold statistically significant results.
BPD (bronchopulmonary dysplasia), IVH (intraventricular hemorrhage), PVHI (periventricular hemorrhagic infarction).