2018/2019
Carina Sofia Beleza Parente Fatores de risco associados a uma ventilação mecânica prolongada em pré-termos < 29 semanas de gestação Factors associated with long-term mechanical ventilation in preterm infants < 29 weeks of gestational age
Mestrado Integrado em Medicina
Área: Pediatria Tipologia: Dissertação
Trabalho efetuado sob a Orientação de: Doutor Henrique Edgar Correia Soares E sob a Coorientação de: Professora Doutora Maria Hercília Ferreira Guimarães Pereira Areias
Trabalho organizado de acordo com as normas da revista: The Journal of Maternal-Fetal & Neonatal Medicine Carina Sofia Beleza Parente Fatores de risco associados a uma ventilação mecânica prolongada em pré-termos < 29 semanas de gestação Factors associated with long-term mechanical ventilation in preterm infants < 29 weeks of gestational age
Factors associated with long-term mechanical ventilation in preterm
infants <29 weeks of gestational age
Parente C.
1, Soares H.
1,2, Flor-de-Lima F.
1,2, Rocha G
2, Guimarães H
1,2.
Department of Neonatology, Faculty of Medicine of the University of Porto, Porto, Portugal
Corresponding author:
Name: Carina Sofia Beleza Parente
Phone: +351968418796
E-mail: [email protected]
1Faculty of Medicine of the University of Porto, Porto, Portugal
2Neonatal Intensive Care Unit, Department of Centro Hospitalar São João, E.P.E., Department
Factors associated with long-term mechanical ventilation in preterm
infants <29 weeks of gestational age
Mechanical ventilation has been one of the most important current interventions in neonatology for lifesaving support of neonates with respiratory failure. The majority of preterm infants with less than 29 weeks of gestational age need some kind of respiratory support. The aim of this study was the identification of risk factors associated with long-term mechanical ventilation in preterm infants below 29 weeks of gestational age.
A retrospective observational study was performed from 1st January 2011 to 30th
June 2018. All infants with less than 29 weeks of gestational age who were mechanically ventilated were included in the study. The cut-off point for long-term mechanical ventilation was defined as 28 days of mechanical ventilation (75th centile).
From the 50 neonates included in the study, 13 (26%) had prolonged mechanical ventilation and 37 (74%) without long-term mechanical ventilation. The
univariate analysis showed the following risk factors for long-term mechanical ventilation: gestational age; birth weight; maternal infectious risk; duration of oxygen therapy; the need of vasoactive amines in NICU; mean blood pressure in the first hour of life; pneumothorax; duration of parenteral nutrition and length of stay in NICU. The multivariate analysis showed an association between
gestational age (OR 0.195, 95% CI 0.02-0.73, p=0.016) and pneumothorax (OR 81.065, 95% CI 1.73-3814.46, p=0.025) with prolonged mechanical ventilation, adjusted to birth weight, bronchopulmonary dysplasia, persistent ductus
arteriosus and infectious risk.
Thus, pneumothorax and lower gestational age seem to be independent risk factors of long-term mechanical ventilation in newborns <29 weeks of gestational age.
Our findings highlight the crucial role of further larger trials focussing on identifying preterm newborns with risk factors associated with long-term mechanical ventilation in order to reduce neonatal morbidity and mortality, thus establishing preventive strategies, which in this case consists in reducing the number of preterm deliveries and reducing the incidence of pneumothorax in newborns.
Keywords: risk factors; long-term mechanical ventilation; preterm infants; newborns; neonatal intensive care unit
Introduction
Newborns have particular physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability and low functional residual capacity. [1]
Mechanical ventilation has been one of the most important current interventions in neonatology for lifesaving support of neonates with respiratory failure. [2]
The majority of preterm infants with less than 30 weeks of gestational age, especially those with fewer weeks of gestation, need some kind of respiratory support. [3] In addition to the administration of antenatal steroids and replacement surfactant therapy, mechanical ventilation has been improving the newborn survival, mainly for premature infants below 29 weeks of gestational age with immature lung function [2], that have a high risk of morbidity and mortality. [4]
The mains goals and advantages of neonatal mechanical ventilation during respiratory failure are the improvement gas exchange, mostly by lung recruitment to become ventilation/perfusion matching better, and the reduction the work of breathing. [5, 6]
Despite its benefits, prolonged mechanical ventilation in the extremely premature newborns may induce chronic lung injury culminating in bronchopulmonary dysplasia (BPD) [7] – a major complication of prematurity –, particularly in premature infants in whom the incidence of BPD remains high. [8]
DBP has been described as a state of inflammation, architectural disruption, fibrosis, and disordered/retarded development of the newborn lung. In addition to important complications in the neonatal period, BPD is related with continuing mortality, cardiopulmonary dysfunction, rehospitalization, growth failure and poor neurodevelopment outcome after hospital discharge. [9]
The aim of this study was the identification of risk factors associated with long-term mechanical ventilation in prelong-term infants below 29 weeks of gestational age.
Materials and methods
A retrospective observational study of all newborns with less than 29 weeks of gestational age who were born between the 1st January 2011 and the 30th June 2018 and
admitted at our center, a Level III Neonatal Intensive Care Unit (NICU) was performed. Neonates below 29 weeks of gestational age, born in our center and transferred after birth to the NICU, who have undergone any type of mechanical ventilation during hospitalization until the moment they were in spontaneous breathing, were included in the study.
Exclusion criteria were the following: all out born neonates, those transferred to another hospital, those died during hospitalization while still undergoing mechanical ventilation and newborns who have not undergone mechanical ventilation or have received only continuous positive airway pressure (CPAP) during hospitalization.
The cut-off point for long-term mechanical ventilation was defined after analysing the percentiles 25, 50 and 75, considering days of mechanical ventilation as the outcome. Thus, we chose the 75th percentile, corresponding to 28 days of
mechanical ventilation was the cut-off point for long-term mechanical ventilation. All the data were collected from the hospital electronic clinical database and medical records of the patients.
Data collected included:
• Individual characteristics of the mother and prenatal period – maternal chronic diseases prior to pregnancy, maternal pregnancy diseases (gestational diabetes,
hypertension, pre-eclampsia, HELLP syndrome, infectious risk), maternal habits during pregnancy (tobacco, drugs), fetal growth restriction, abnormal umbilical blood flow, abnormal placenta, clinical and histological chorioamnionitis, premature rupture of membranes, antenatal corticosteroids, prophylactic antibiotic;
• Peripartum period: type of delivery, Apgar Score at 1st minute and 5th minute;
• Demographic characteristics: gender, gestational age, birth weight, multiple gestation, medically assisted reproduction;
• Management in the delivery room: resuscitation at birth (adrenaline, oxygen (O2), positive pressure, endotracheal intubation, compressions);
• Laboratory data collected in the first hour of life: umbilical cord pH, hemoglobin (g/dL), mean blood pressure (mmHg);
• Management and evolution in the NICU: days of mechanical ventilation, Continuous Positive Airway Pressure (CPAP) and days of CPAP, the need of O2
therapy and days of supplementary of O2, umbilical artery catheter, umbilical
vein catheter, need for surfactant, vasoactive amines, blood cells transfusion, early and late onset sepsis, pneumothorax, hyaline membrane disease, bronchopulmonary dysplasia, persistent ductus arteriosus (medical and/or surgical treatment), necrotizing enterocolitis (if grade ≥ 2), intraventricular hemorrhage (if grade ≥ III), cystic periventricular leukomalacia, retinopathy of prematurity (if grade ≥ 2), hydrocephalus with periventricular derivation (shunt or reservoir), parenteral nutrition and days of parenteral nutrition, length of stay in NICU.
Gestational age was evaluated by post-menstrual age, ultrasound examination or the New Ballard Score (in the absence of obstetrical indexes). [10, 11] Small for
gestational age was characterized as a birth weight below the 3rd centile of Fenton’s
growth charts. [12]
A protocol for positive pressure ventilation that includes different ventilatory strategies according to different lung diseases and favors the use of permissive hypercapnia is established in our NICU. For the very low birth weight infants nasal nCPAP just after birth is the preferable mode of ventilation. [13] nCPAP is done using Infant Flow (Pulmocor, USA). SIPPV was available with guaranteed volume on all ventilators (Babylog 8000; Drager, Germany or Fabian; Acutronic, Switzerland). HFOV is performed as a rescue ventilation mode.
Sepsis was considered when there was a positive blood culture, combined with clinical and laboratory parameters. [14]
Pneumothorax was diagnosed by chest radiography and the type of pneumothorax was assessed according to clinical setting and medical history. [15]
BPD was diagnosed according to the NIH Consensus definition. [16]
Patent ductus arteriosus (PDA) was defined according to SIBEN consensus. [17] Necrotizing enterocolitis (NEC) was determined by clinical findings and radiological features, according to the modified Bell criteria. [18]
Intraventricular hemorrhage (IVH) was defined according to Papile [19] and Volpe [20] (before and after 2010, respectively), intraventricular bleeding with ventricular dilatation is classified as IVH III and with parenchymal involvement as IVH IV.
Cystic periventricular leukomalacia (PVL) was diagnosed by ultrasound. [21] Retinopathy of prematurity (ROP) was determined and classified according to the International Classification of Retinopathy of Prematurity revised. [22]
This study was approved by our institutional ethics committee and access to medical records was authorized by the office designated for this function.
Statistical analysis
Statistical analysis was performed using SPSS, version 25. Categorical variables were analysed by absolute and relative frequencies and continuous variables were analyses according to their distribution by mean (± standard deviation) for symmetric distribution or median (minimum-maximum) for asymmetric distribution. Categorical variables were evaluated by Chi-square or Fisher’s Exact Test and continuous variables by Independent T Test or Mann-Whitney U Test. Predictors for long-term mechanical ventilation were evaluated by a multivariate analysis using logistic regression. A p value less than 0.05 was considered as statistically significant.
Results
Out of 178 neonates, 50 were included in the study, 13 (26%) had prolonged mechanical ventilation (³28 days) and 37 (74%) without long-term mechanical ventilation (<28 days). Twenty-six (52.0%) neonates were males, with mean gestational age 26.70 (±1.093) weeks and mean birth weight was 915.20 (±199.056) grams.
Comparing neonates under long-term ventilation with controls, the univariate analysis showed: both lower gestational age [25.77 (±0.927) weeks vs 27.03 (±0.957) weeks; p<0.001] and lower birth weight [770.77 (±118.530) g vs 965.95 (±197.659) g; p=0.002] were risk factors for long-term mechanical ventilation group; both maternal infectious risk [5 (38.5%) cases vs 26 (70.3%) controls; p=0.042] and mean blood pressure in the first hour of life [27.58 (±7.255) mmHg vs 34.17 (±9.056) mmHg;
p=0.031] were significant lower in long-term mechanical ventilation group; the total number of days of supplementary oxygen [98 (1-107) days vs 26 (0-109) days; p<0.001], vasoactive amines in the NICU [3 (60%) cases vs 0 controls; p=0.006]; the total number of days of parenteral nutrition [42 (0-90) days vs 24.5 (0-53) days; p=0.001] and length of stay in NICU [108 days (92-191) vs 76 (22-136) days; p<0.001], all of them demonstrated a significant increase in prolonged mechanical ventilation cases; besides that, pneumothorax also shown to had a prevalence significantly higher in the prolonged mechanical ventilation group [4 (30.8%) cases vs 1 (2.7%) control; p=0.013] (Table 1).
The multivariate analysis showed an association between gestational age (OR 0.195, 95% CI 0.02-0.73, p=0.016) and pneumothorax (OR 81.065, 95% CI 1.73-3814.46, p=0.025) to long-term mechanical ventilation, adjusted to birth weight, bronchopulmonary dysplasia, persistent ductus arteriosus and infectious risk (Table 2).
Discussion
Lower gestational age and birth weight were more likely to occur in patients needing long-term mechanical ventilation, findings consistent with other studies. [23] After multivariate analysis, the only factor which remained significant among the last two was gestational age. The association between gestational age and birth weight with prolonged mechanical ventilation can be possibly explained by the fact of this particular cohort of neonates born at the extremes of viability. Furthermore, considering the issue of birth weight does not demonstrate association when using a multiple logistic regression may be probably explained by the fact that the variation in gestational age studied is limited (25-28 weeks), as in the Yossef et al. study. [23]
Pneumothorax happens more often in the neonatal period and is associated with increased morbidity and mortality. [15, 24] Pneumothorax is a relatively usual demanding condition in the NICU and may occurs symptomatically in about 3.8% to 9% in low birth weight infants. [25, 26, 27] The prevalence of pneumothorax was higher among term and early preterm infants admitted to the NICU; besides that, morbidity and mortality associated with pneumothorax were significantly higher in early preterm newborns. [24] In our study, it has been demonstrated that pneumothorax is higher in the long-term mechanical ventilated group, findings consistent with other studies, which state that pneumothorax prolongs length of stay in NICU in preterm newborns by the need for prolonged mechanical ventilation [23, 28] (a requirement for chest tube drainage, which is part of the treatment of pneumothorax [27, 28]).
The majority of preterm newborns receive parenteral nutrition in the first weeks of life due to transient gut immaturity. [29] In addition, suboptimal nutrition is associated with adverse outcomes such as increased susceptibility to infections, increased need for mechanical ventilation, and development of chronic lung disease, according to other studies. [30] After an univariate analysis, our study demonstrated that the total number of days of parenteral nutrition shown to be significantly higher in prolonged mechanical ventilation group, findings consistent with other studies. [30]
Besides that, Comert et al. study [31] suggests that some strategies such as the use of prenatal steroids, prevention of asphyxia and sepsis, implementation of less aggressive ventilation techniques with early weaning approaches from mechanical ventilation may further reduce the need for mechanical ventilation and consequently, shorten the length of stay in NICU. Our findings demonstrated that the length of stay in NICU, as expected [23], was significantly higher in long-term mechanical ventilation group.
Limitations of this study include its retrospective nature and small sample. The introduction of mechanical ventilation in the NICU during the 1960-70s [32] and their judicious use since then, have revolutionized the outcome and survival of ill newborns. [33] Since its beginning, neonatal mechanical ventilation has been recognized a crucial tool for the management of preterm newborns with respiratory distress syndrome and is still considered an essential element of neonatal respiratory care continuum [34].
Despite its benefits, prolonged mechanical ventilation in the extremely premature newborns may induce chronic lung injury culminating in BPD [7], a major complication of prematurity, due to their greater vulnerability to mechanical ventilation in the phase following birth, because their lungs are partially filled with amniotic fluid, they are not uniformly ventilated and their surfactant content is generally insufficient. BPD is a common occurrence in extremely low birth weight preterm infants and its incidence ranges from 30% to 75% among newborns with birth weight <1,000 g. [35]
The main risk factors for BPD include premature birth, respiratory failure, oxygen supplementation and mechanical ventilation [9]. BPD has some adverse outcomes such as continuing mortality, cardiopulmonary dysfunction, rehospitalization, growth failure and poor neurodevelopment outcome after hospital discharge. [8]
In conclusion, long-term mechanical ventilation was associated with lower gestational age and pneumothorax in preterm infants <29 weeks of gestational age.
Our findings highlight the crucial role of further larger trials focussing on identifying preterm newborns with risk factors associated with long-term mechanical ventilation in order to reduce neonatal morbidity and mortality, thus establishing preventive strategies, which in this case consists in reducing the number of preterm deliveries and reducing the incidence of pneumothorax in newborns.
Declaration of interest statement Disclosure of interest
References
1. Rocha G, Soares P, Gon, et al. Respiratory Care for the Ventilated Neonate. Canadian Respiratory Journal. 2018;2018:12. doi: 10.1155/2018/7472964. 2. Abdul Mannan M, Jahan N, Iqbal S, et al. Short Term Outcome of Preterm
Neonates Required Mechanical Ventilation. Vol. 15. 2017.
3. St John EB, Carlo WA. Respiratory distress syndrome in VLBW infants: changes in management and outcomes observed by the NICHD Neonatal Research Network. Seminars in perinatology. 2003 Aug;27(4):288-92. PubMed PMID: 14510319; eng.
4. da Cunha Duraes MI, Flor-De-Lima F, Rocha G, et al. Morbidity and mortality of preterm infants less than 26 weeks of gestational age. Minerva pediatrica. 2019 Feb;71(1):12-20. doi: 10.23736/s0026-4946.16.04609-0. PubMed PMID:
27405904; eng.
5. Petty J. Understanding neonatal ventilation: strategies for decision making in the NICU. Neonatal Netw. 2013 Jul-Aug;32(4):246-61. doi: 10.1891/0730-0832.32.4.246. PubMed PMID: 23835544; eng.
6. Cairo JM. Pilbeam's mechanical ventilation: physiological and clinical applications. 6 ed2016. p. 461-462.
7. Robbins M, Trittmann J, Martin E, et al. Early extubation attempts reduce length of stay in extremely preterm infants even if re-intubation is necessary. Journal of neonatal-perinatal medicine. 2015;8(2):91-7. doi: 10.3233/npm-15814061. PubMed PMID: 26410431; eng.
8. Fanaroff AA, Hack M, Walsh MC. The NICHD neonatal research network: changes in practice and outcomes during the first 15 years. Seminars in perinatology. 2003 Aug;27(4):281-7. PubMed PMID: 14510318; eng.
9. D'Angio CT, Maniscalco WM. Bronchopulmonary dysplasia in preterm infants: pathophysiology and management strategies. Paediatric drugs. 2004;6(5):303-30. doi: 10.2165/00148581-200406050-00004. PubMed PMID: 15449969; eng. 10. MacDonald H. Perinatal care at the threshold of viability. Pediatrics. 2002
Nov;110(5):1024-7. PubMed PMID: 12415047; eng.
11. Ballard JL, Khoury JC, Wedig K, et al. New Ballard Score, expanded to include extremely premature infants. The Journal of pediatrics. 1991 Sep;119(3):417-23. PubMed PMID: 1880657; eng.
12. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC pediatrics. 2013;13:59-59. doi:
10.1186/1471-2431-13-59. PubMed PMID: 23601190.
13. Tavares PN, Flor-de-Lima F, Soares H, et al. Early nCPAP versus intubation in very low birth weight infants. Journal of Pediatric and Neonatal Indivualizes Medicine. 2013;2(2):e020201.
14. Vergnano S, Menson E, Kennea N, et al. Neonatal infections in England: the NeonIN surveillance network. Arch Dis Child Fetal Neonatal Ed. 2011
Jan;96(1):F9-f14. doi: 10.1136/adc.2009.178798. PubMed PMID: 20876594; eng.
15. Martin RJ, Fanaroff AA, Walsh MC. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. Elsevier Saunders. 10th edition, vol.2. [1113-36].
16. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. American journal of respiratory and critical care medicine. 2001 Jun;163(7):1723-9. doi: 10.1164/ajrccm.163.7.2011060. PubMed PMID: 11401896; eng. 17. Golombek SG, Sola A, Baquero H, et al. [First SIBEN clinical consensus:
diagnostic and therapeutic approach to patent ductus arteriosus in premature newborns]. Anales de pediatria (Barcelona, Spain : 2003). 2008 Nov;69(5):454-81. PubMed PMID: 19128748; spa.
18. Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatric clinics of North America. 1986 Feb;33(1):179-201. PubMed PMID: 3081865; eng.
19. Papile LA, Burstein J, Burstein R, et al. Incidence and evolution of
subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. The Journal of pediatrics. 1978 Apr;92(4):529-34. PubMed PMID: 305471; eng.
20. Volpe JJ. Neurology of the Newborn. 2001. Philadelphia: W.B. Saunders. 4th edition. xiii, 912 p. p.
21. Kuk JY, An JJ, Cha HH, et al. Optimal time interval between a single course of antenatal corticosteroids and delivery for reduction of respiratory distress syndrome in preterm twins. American journal of obstetrics and gynecology. 2013 Sep;209(3):256.e1-7. doi: 10.1016/j.ajog.2013.06.020. PubMed PMID: 23810815; eng.
22. The International Classification of Retinopathy of Prematurity revisited. Archives of ophthalmology (Chicago, Ill : 1960). 2005 Jul;123(7):991-9. doi: 10.1001/archopht.123.7.991. PubMed PMID: 16009843; eng.
23. Yossef L, Shepherd EG, Lynch S, et al. Factors associated with long-term mechanical ventilation in extremely preterm infants. Journal of neonatal-perinatal medicine. 2018;11(1):29-35. doi: 10.3233/npm-181711. PubMed PMID: 29689738; eng.
24. Duong HH, Mirea L, Shah PS, et al. Pneumothorax in neonates: Trends,
predictors and outcomes. Journal of neonatal-perinatal medicine. 2014;7(1):29-38. doi: 10.3233/npm-1473813. PubMed PMID: 24815703; eng.
25. Kitsommart R, Martins B, Bottino MN, et al. Expectant management of pneumothorax in preterm infants receiving assisted ventilation: report of 4 cases and review of the literature. Respiratory care. 2012 May;57(5):789-93. doi: 10.4187/respcare.01446. PubMed PMID: 22152128; eng.
26. Smith J, Schumacher RE, Donn SM, et al. Clinical course of symptomatic
spontaneous pneumothorax in term and late preterm newborns: report from a large cohort. Am J Perinatol. 2011 Feb;28(2):163-8. doi:
10.1055/s-0030-1263300. PubMed PMID: 20700862; eng.
27. Terzic S, Heljić S, Panic J, et al. Pneumothorax in premature infants with respiratory distress syndrome: Focus on risk factors. Vol. 5. 2016.
28. Ilce Z, Gundogdu G, Kara C, et al. Which patients are at risk? Evaluation of the morbility and mortality in newborn pneumothorax. Indian pediatrics. 2003 Apr;40(4):325-8. PubMed PMID: 12736404; eng.
29. Darmaun D, Lapillonne A, Simeoni U, et al. Parenteral nutrition for preterm infants: Issues and strategy. Archives de pediatrie : organe officiel de la Societe
francaise de pediatrie. 2018 May;25(4):286-294. doi:
10.1016/j.arcped.2018.02.005. PubMed PMID: 29656825; eng.
30. Velaphi S. Nutritional requirements and parenteral nutrition in preterm infants. South African Journal of Clinical Nutrition. 2011 2011/01/01;24(sup3):27-31. doi: 10.1080/16070658.2011.11734377.
31. Comert S, Agzikuru T, Akin Y, et al. The Cost Analysis of Preterm Infants from a NICU of a State Hospital in Istanbul. Iranian journal of pediatrics. 2012
Jun;22(2):185-90. PubMed PMID: 23056884; PubMed Central PMCID: PMCPMC3446073. eng.
32. Carlo WA, Martin RJ. Principles of neonatal assisted ventilation. Pediatric clinics of North America. 1986 Feb;33(1):221-37. PubMed PMID: 3513100; eng.
33. Singh M, Deorari AK, Paul VK, et al. Three-year experience with neonatal ventilation from a tertiary care hospital in Delhi. Indian pediatrics. 1993 Jun;30(6):783-9. PubMed PMID: 8132260; eng.
34. Brown MK, DiBlasi RM. Mechanical ventilation of the premature neonate. Respiratory care. 2011 Sep;56(9):1298-311; discussion 1311-3. doi: 10.4187/respcare.01429. PubMed PMID: 21944682; eng.
35. Carvalho CG, Silveira RC, Procianoy RS. Ventilator-induced lung injury in preterm infants. Revista Brasileira de terapia intensiva. 2013 Oct-Dec;25(4):319-326. doi: 10.5935/0103-507X.20130054. PubMed PMID: 24553514.
Appendices
Table 1. Demographic, maternal, gestational and delivery data, clinical characteristics and management during hospitalization.
Total (n=50) Cases (n=13) Controls (n=37) p value Gender, n (%) Male Female 26 (52.0) 24 (48.0) 8 (61.5) 5 (38.5) 18 (48.6) 19 (51.4) 0.424*
Gestational age (weeks), mean (±SD) 26.70 (±1.093) 25.77 (±0.927) 27.03 (±0.957) <0.001∞
Birth weight (grams), mean (±SD) 915.20
(±199.056) 770.77 (±118.530) 965.95 (±197.659) 0.002∞ Multiple gestation n (%)
- Number of newborns, median (min-max)
12 (24.0) 2 (2-3) 4 (30.8) 2 (2-3) 8 (21.6) 2 (2-2) 0.707** 0.570§
Medically assisted reproduction, n (%) 8 (16.0) 3 (23.1) 5 (13.5) 0.413**
Maternal chronic diseases, n (%) 15 (30.0) 5 (38.5) 10 (27.0) 0.439*
Maternal habits during pregnancy, n (%) - Tobacco
- Drugs 4 (8.0) 1 (2.0) 2 (15.4) 1 (7.7) 2 (5.4) 0 (0.0) 0.275
**
0.260**
Maternal pregnancy diseases, n (%) - Gestational Diabetes - Pre-eclampsia - HELLP Syndrome - Infectious Risk 15 (30.0) 7 (14.0) 9 (18.0) 5 (10.0) 31 (62.0) 5 (38.5) 2 (15.4) 2 (15.4) 1 (7.7) 5 (38.5) 10 (27.0) 5 (13.5) 7 (18.9) 4 (10.8) 26 (70.3) 0.899** 0.888** 0.998** 0.788** 0.042*
Fetal growth restriction, n (%) 6 (12.0) 3 (23.1) 3 (8.1) 0.173**
Abnormal umbilical blood flow, n (%) 6 (12.0) 3 (23.1) 3 (8.1) 0.173**
Abnormal placenta, n (%) 26 (52.0) 7 (53.8) 19 (51.4) 0.877* Clinical chorioamnionitis, n (%) 2 (4.3) 0 (0.0) 2 (5.7) 0.899** Histological chorioamnionitis, n (%) 5 (10.0) 0 (0.0) 5 (13.5) 0.309** Antenatal corticosteroids, n (%) - Full cycle, n (%) 47 (97.9) 27 (62.8) 12 (92.3) 8 (66.7) 35 (100.0) 19 (61.3) 0.271 ** 0.989**
Premature rupture of membranes, n (%) 14 (28.6) 2 (16.7) 12 (32.4) 0.466**
Prophylactic antibiotic, n (%) 13 (26.0) 2 (15.4) 11 (29.7) 0.469** C-section, n (%) 36 (72.0) 7 (53.8) 29 (78.4) 0.090* Apgar Score, n (%) - 1st minute <7 - 5th minute <7 36 (72.0) 17 (34.0) 10 (76.9) 6 (46.2) 26 (70.3) 11 (29.7) 0.734 ** 0.282* Resuscitation at birth, n (%) - Adrenaline - O2 - Positive Pressure - Endotracheal Intubation - Compressions 0 47 (94.0) 47 (94.0) 31 (62.0) 0 0 (0.0) 12 (92.3) 12 (92.3) 9 (69.2) 0 (0.0) 0 (0.0) 35 (94.6) 35 (94.6) 22 (59.5) 0 (0.0) - 0.899** 0.899* 0.742** -
Mechanical ventilation, n (%)
Total number of days, median (min-max)
50 (100.0) 10.5 (1-112) 13 (100.0) 39 (28-112) 37 (100.0) 7 (1-26) - <0.001§ CPAP, n (%)
Total number of days, median (min-max)
50 (100.0) 36.5 (1-81) 13 (100.0) 32 (1-63) 37 (100.0) 37 (16-81) - 0.254§ Supplementary oxygen, n (%)
Total number of days, median (min-max)
47 (94.0) 37.5 (0-109) 13 (100.0) 98 (1-107) 34 (91.9) 26 (0-109) 0.558** <0.001§ Surfactant administration, n (%) 43 (86.0) 12 (92.3) 31 (83.8) 0.660**
Umbilical artery catheter, n (%) 26 (72.2) 7 (70.0) 19 (73.1) 0.988**
Umbilical vein catheter, n (%) 32 (88.9) 10 (100.0) 22 (84.6) 0.559**
Vasoactive amines in the NICU, n (%) 3 (13.0) 3 (60.0) 0 (0.0) 0.006**
Umbilical cord pH, mean (±SD) 7.181
(±0.213) 7.098 (±0.282) 7.229 (±0.169) 0.353∞
Hemoglobin in the first hour of life, mean (±SD) 15.228 (±2.840) 14.227 (±3.292) 15.525 (±2.668) 0.186∞
Mean blood pressure in the first hour of life, mean (±SD) 32.29 (±9.010) 27.58 (±7.255) 34.17 (±9.056) 0.031∞
Blood cells transfusion, n (%) 44 (88.0) 13 (100.0) 31 (83.8) 0.319**
Early onset sepsis, n (%) 10 (20.0) 4 (30.8) 6 (16.2) 0.420**
Late onset sepsis, n (%) 33 (66.0) 10 (76.9) 23 (62.2) 0.499**
Pneumothorax, n (%) 5 (10.0) 4 (30.8) 1 (2.7) 0.013**
Hyaline membrane disease, n (%) 47 (94.0) 13 (100.0) 34 (91.9) 0.558**
Bronchopulmonary dysplasia, n (%) 29 (58.0) 10 (76.9) 19 (51.4) 0.191**
Persistent ductus arteriosus, n (%) Medical treatment, n (%) Surgical treatment, n (%) 42 (84.0) 37 (92.5) 7 (18.4) 11 (84.6) 11 (100.0) 4 (36.4) 31 (83.8) 26 (89.7) 3 (11.1) 0.944** 0.548** 0.161**
NEC grade ≥ 2 Bell, n (%) 0 (0.0) 0 (0.0) 0 (0.0) -
Intraventricular hemorrhage grade ≥III, n (%) 11 (55.0) 5 (71.4) 6 (46.2) 0.374**
Cystic periventricular leukomalacia, n (%) 8 (16.0) 4 (30.8) 4 (10.8) 0.181**
Retinopathy of prematurity grade ≥ 2, n (%) 21 (53.8) 8 (72.7) 13 (46.4) 0.171**
Hydrocephalus with periventricular derivation (shunt or reservoir), n (%)
5 (10.0) 3 (23.1) 2 (5.4) 0.103**
Parenteral nutrition, n (%)
Number of days, median (min-max) 50 (100.0) 28 (0-90) 42.0 (0-90) 13 (100.0) 24.5 (0-53) 37 (100.0) 0.001- §
Length of stay in NICU (days), median (min-max) 85 (22-191) 108 (92-191) 76 (22-136) <0.001§
* Chi square test; ** Fisher’s exact test; ∞Independent T test; §Mann Whitney U test
SD – standard derivation; CPAP – continuous positive airway pressure; NICU – Neonatal Intensive Care Unit
Table 2. Predictors of long-term ventilation in preterm infants <29 weeks of gestational age.
OR – Odds Ratio; CI – Confidence Interval; p <0.05, statistical significance (Multivariate analysis)
* Multivariable analysis by logistic regression
OR* 95% CI p value
Pneumothorax 81.065 1.73-3814.46 0.025
Gestational Age 0.195 0.02-0.73 0.016
Birth Weight 0.994 0.94-1.04 0.267
Bronchopulmonary Dysplasia 1.241 0.94-1.04 0.267
Persistent Ductus Arteriosus 0.292 0.01-12.02 0.518
Acknowledgments
To Henrique Soares, MD, for the tireless support and crucial guidance for the accomplishment of this dissertation.
To Filipa Flor-de-Lima, MD, for the indispensable help in the statistical analysis of the data and for the assisting with the final review of this paper.
To Hercília Guimarães, MD, PhD and to Gustavo Rocha, MD also for the help in assisting with the final review of this project.
To my boyfriend for all the support and endless patience. To all those who supported me throughout this project.
Annexes
• Ethics Committee for Health’s authorization
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 1/14
Journal
The Journal of Maternal-Fetal & Neonatal Medicine
This journal
Instructions for authors
Thank you for choosing to submit your paper to us. These instructions will ensure we have everything required so your paper can move through peer review, production and publication smoothly. Please take the time to read and follow them as closely as
possible, as doing so will ensure your paper matches the journal's requirements. For general guidance on the publication process at Taylor & Francis please visit our Author Services website.
This journal uses ScholarOne Manuscripts (previously Manuscript Central) to peer review manuscript submissions. Please read the guide for ScholarOne authors before making a submission. Complete guidelines for preparing and submitting your
manuscript to this journal are provided below.
Contents
About the Journal Peer Review
Preparing Your Paper Structure
Word Limits Style Guidelines
Formatting and Templates References
Editing Services
Log in | Register13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 2/14
Checklist
Using Third-Party Material Disclosure Statement Clinical Trials Registry
Complying With Ethics of Experimentation Consent
Health and Safety Submitting Your Paper Data Sharing Policy Publication Charges Copyright Options
Complying with Funding Agencies Open Access
Accepted Manuscripts Online My Authored Works
Reprints
About the Journal
The Journal of Maternal-Fetal & Neonatal Medicine is an international, peer-reviewed journal publishing high-quality, original research. Please see the journal's Aims & Scope for information about its focus and peer-review policy.
Please note that this journal only publishes manuscripts in English.
The Journal of Maternal-Fetal & Neonatal Medicine accepts the following types of article: Original Articles
Review Articles: Review articles should examine published research on topics relevant to maternal-fetal medicine. The review article should provide a critical analysis of the available information, should lead to a rational conclusion, and highlight areas of future investigation.
Short Reports: These should be of original laboratory or clinical contributions.
Letters to the Editor: These may o er criticism of published material in an objective, constructive and educational manner. Within these limits, Letters to the Editor may be provocative and inducive of further debate. They may also discuss matters of general interest. The material for such can be taken from any source of information so long as it pertains to the general eld of maternal-fetal medicine, newborn medicine, perinatal
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 3/14
genetics, and perinatal ethics in the broadest sense. They will be reviewed by the
appropriate editor and will be subject to editing and possible abridgement. If accepted, a copy will be sent to the author(s) of the original article referred to in the Letter to the Editor, giving the author(s) the opportunity to provide a rebuttal with new material considered for publication with the Letter to the Editor.
Opinions and Hypotheses
Education and Debate Articles: These are usually invited, but reports on all aspects of medicine and health are welcomed. They will be peer-reviewed, and should contain an unstructured abstract of no more than 150 words.
The Journal of Maternal-Fetal & Neonatal Medicine considers all manuscripts on the strict condition that:
they are the property (copyright) of the submitting author(s), have been submitted only to The Journal of Maternal-Fetal & Neonatal Medicine,
that they have not been published already, nor are they under consideration for publication, nor in press elsewhere.
Authors who fail to adhere to this condition will be charged all costs which The Journal of Maternal-Fetal & Neonatal Medicine incurs, and their papers will not be published.
Copyright will be transferred to the journal The Journal of Maternal-Fetal & Neonatal Medicine and Informa UK Ltd., if the paper is accepted.
The Journal of Maternal-Fetal & Neonatal Medicine considers all manuscripts at the Editors' discretion; the Editors' decision is nal.
In general, the Journal will not publish papers which are merely con rmatory of earlier work, or that describe relatively minor modi cations of existing techniques or methods.
Co-Editors-in-Chief:
Professor Gian Carlo Di Renzo
Professor and Chairman Dept. of Ob/Gyn and Centre for Perinatal and Reproductive Medicine Santa Maria della Misericordia University Hospital
06132 San Sisto, Perugia, Italy
Tel. +39 075 5783829, +39 075 5783231 Fax +39 075 5783829
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 4/14 Professor Dev Maulik
UMKC School of Medicine 2411 Holmes Street Room M1-103B Kansas City, MO 64108, USA
Tel: 816-235-1788 Fax: 816-235-6579
Email address: [email protected]
Peer Review
Taylor & Francis is committed to peer-review integrity and upholding the highest
standards of review. Once your paper has been assessed for suitability by the editor, it will then be single blind peer reviewed by independent, anonymous expert referees. Find out more about what to expect during peer review and read our guidance on publishing ethics.
Preparing Your Paper
All authors submitting to medicine, biomedicine, health sciences, allied and public health journals should conform to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, prepared by the International Committee of Medical Journal Editors (ICMJE).
Structure
Your paper should be compiled in the following order: title page; abstract; keywords; main text introduction, materials and methods, results, discussion; acknowledgments; declaration of interest statement; references; appendices (as appropriate); table(s) with caption(s) (on individual pages); gures; gure captions (as a list).
Word Limits
Please include a word count for your paper.
Original Articles: The maximum length is 3000 words (excluding references), including headings and 600-word abstract, maximum of 2 gures and/or tables, a brief rationale and an addendum. The addendum allows to include materials, methods, statistics, references etc. Original articles should have a maximum of 50 references.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 5/14
Review articles: Review articles should examine published research on topics relevant to maternal-fetal medicine. The review article should provide a critical analysis of the available information, should lead to a rational conclusion, and highlight areas of future investigation. The maximum length is 3000 words (excluding references), including headings and max 400-word abstract, maximum of 3 gures and/or tables, and up to 30 references. Review articles should have a maximum of 50 references.
Short Reports: These should be of original laboratory or clinical contributions. The maximum length is 1200 words (excluding references), including headings and 300-word abstract, maximum of 1 gure and/or table. The addendum allows to include materials, methods, statistics, references etc. Short reports should have a maximum of 20
references.
Letters to the Editor: Letters to the Editor may o er criticism of published material in an objective, constructive and educational manner. Within these limits, Letters to the Editor may be provocative and inducive of further debate. They may also discuss matters of general interest. The material for such can be taken from any source of information so long as it pertains to the general eld of Maternal-Fetal Medicine,
Newborn Medicine, Perinatal Genetics, and Perinatal Ethics in the broadest sense. They will be reviewed by the appropriate editor and will be subject to editing and possible abridgement. If accepted, a copy will be sent to the author(s) of the original article referred to in the Letter to the Editor, giving the author(s) the opportunity to provide a rebuttal with new material considered for publication with the Letter to the Editor. Letters to the editor should have a maximum of 20 references.
Opinions and Hypotheses: These should be 400-600 words in length with one gure or table and a maximum of ve references. Opinions and hypotheses should have a maximum of 20 references.
Education and Debate Articles: These are usually invited and should not exceed 2000 words, but reports on all aspects of medicine and health are welcomed. They will be peer-reviewed, and should contain an unstructured abstract of no more than 150 words. Education and debate articles should have a maximum of 20 references.
Style Guidelines
Please refer to these quick style guidelines when preparing your paper, rather than any published articles or a sample copy.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 6/14
Any form of consistent quotation style is acceptable. Please note that long quotations should be indented without quotation marks.
Formatting and Templates
Papers may be submitted in Word or LaTeX formats. Figures should be saved separately from the text. To assist you in preparing your paper, we provide formatting template(s). Word templates are available for this journal. Please save the template to your hard drive, ready for use.
A LaTeX template is available for this journal. Please save the LaTeX template to your hard drive and open it, ready for use, by clicking on the icon in Windows Explorer. If you are not able to use the template via the links (or if you have any other template queries) please contact us here.
References
Please use this reference guide when preparing your paper. An EndNote output style is also available to assist you.
Taylor & Francis Editing Services
To help you improve your manuscript and prepare it for submission, Taylor & Francis provides a range of editing services. Choose from options such as English Language Editing, which will ensure that your article is free of spelling and grammar errors, Translation, and Artwork Preparation. For more information, including pricing, visit this website.
Checklist: What to Include
1. Author details. Please ensure everyone meeting the International Committee of
Medical Journal Editors (ICMJE) requirements for authorship is included as an author of your paper. All authors of a manuscript should include their full name and a liation on the cover page of the manuscript. Where available, please also include ORCiDs and social media handles (Facebook, Twitter or LinkedIn). One author will need to be
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 7/14
identi ed as the corresponding author, with their email address normally displayed in the article PDF (depending on the journal) and the online article. Authors’ a liations are the a liations where the research was conducted. If any of the named co-authors moves a liation during the peer-review process, the new a liation can be given as a footnote. Please note that no changes to a liation can be made after your paper is accepted. Read more on authorship.
2. Should contain a structured abstract of 600 words. focused on key ndings (short summary of the article), including one of the main gures/tables: no mention to material, methods etc. Abstracts for Short Reports should not exceed 300 words. 3. Graphical abstract (optional). This is an image to give readers a clear idea of the
content of your article. It should be a maximum width of 525 pixels. If your image is narrower than 525 pixels, please place it on a white background 525 pixels wide to
ensure the dimensions are maintained. Save the graphical abstract as a .jpg, .png, or .gif. Please do not embed it in the manuscript le but save it as a separate le, labelled
GraphicalAbstract1.
4. You can opt to include a video abstract with your article. Find out how these can help your work reach a wider audience, and what to think about when lming.
5. Between 5 and 6 keywords. Read making your article more discoverable, including information on choosing a title and search engine optimization.
6. Funding details. Please supply all details required by your funding and grant-awarding bodies as follows:
For single agency grants
This work was supported by the [Funding Agency] under Grant [number xxxx]. For multiple agency grants
This work was supported by the [Funding Agency #1] under Grant [number xxxx]; [Funding Agency #2] under Grant [number xxxx]; and [Funding Agency #3] under Grant [number xxxx].
7. Disclosure statement. This is to acknowledge any nancial interest or bene t that has arisen from the direct applications of your research. Further guidance on what is a con ict of interest and how to disclose it.
8. Data availability statement. If there is a data set associated with the paper, please provide information about where the data supporting the results or analyses presented in the paper can be found. Where applicable, this should include the hyperlink, DOI or other persistent identi er associated with the data set(s). Templates are also available to support authors.
9. Data deposition. If you choose to share or make the data underlying the study open, please deposit your data in a recognized data repository prior to or at the time of
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 8/14
submission. You will be asked to provide the DOI, pre-reserved DOI, or other persistent identi er for the data set.
10. Geolocation information. Submitting a geolocation information section, as a separate paragraph before your acknowledgements, means we can index your paper’s study area accurately in JournalMap’s geographic literature database and make your article more discoverable to others. More information.
11. Supplemental online material. Supplemental material can be a video, dataset, leset, sound le or anything which supports (and is pertinent to) your paper. We publish supplemental material online via Figshare. Find out more about supplemental material and how to submit it with your article.
12. Figures. Figures should be high quality (1200 dpi for line art, 600 dpi for grayscale and 300 dpi for colour, at the correct size). Figures should be supplied in one of our
preferred le formats: EPS, PS, JPEG, GIF, or Microsoft Word (DOC or DOCX). For information relating to other le types, please consult our Submission of electronic artwork document.
13. Tables. Tables should present new information rather than duplicating what is in the text. Readers should be able to interpret the table without reference to the text. Please supply editable les.
14. Equations. If you are submitting your manuscript as a Word document, please ensure that equations are editable. More information about mathematical symbols and
equations.
15. Units. Please use SI units (non-italicized).
Using Third-Party Material in your Paper
You must obtain the necessary permission to reuse third-party material in your article. The use of short extracts of text and some other types of material is usually permitted, on a limited basis, for the purposes of criticism and review without securing formal permission. If you wish to include any material in your paper for which you do not hold copyright, and which is not covered by this informal agreement, you will need to obtain written permission from the copyright owner prior to submission. More information on requesting permission to reproduce work(s) under copyright.
Disclosure Statement
Please include a disclosure statement, using the subheading “Disclosure of interest.” If you have no interests to declare, please state this (suggested wording: The authors report no con ict of interest). For all NIH/Wellcome-funded papers, the grant number(s)
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 9/14
must be included in the declaration of interest statement. Read more on declaring con icts of interest.
Clinical Trials Registry
In order to be published in a Taylor & Francis journal, all clinical trials must have been registered in a public repository at the beginning of the research process (prior to patient enrolment). Trial registration numbers should be included in the abstract, with full details in the methods section. The registry should be publicly accessible (at no charge), open to all prospective registrants, and managed by a not-for-pro t
organization. For a list of registries that meet these requirements, please visit the WHO International Clinical Trials Registry Platform (ICTRP). The registration of all clinical trials facilitates the sharing of information among clinicians, researchers, and patients,
enhances public con dence in research, and is in accordance with the ICMJE guidelines.
Complying With Ethics of Experimentation
Please ensure that all research reported in submitted papers has been conducted in an ethical and responsible manner, and is in full compliance with all relevant codes of experimentation and legislation. All papers which report in vivo experiments or clinical trials on humans or animals must include a written statement in the Methods section. This should explain that all work was conducted with the formal approval of the local human subject or animal care committees (institutional and national), and that clinical trials have been registered as legislation requires. Authors who do not have formal ethics review committees should include a statement that their study follows the principles of the Declaration of Helsinki.
Consent
All authors are required to follow the ICMJE requirements on privacy and informed consent from patients and study participants. Please con rm that any patient, service user, or participant (or that person’s parent or legal guardian) in any research,
experiment, or clinical trial described in your paper has given written consent to the inclusion of material pertaining to themselves, that they acknowledge that they cannot be identi ed via the paper; and that you have fully anonymized them. Where someone is deceased, please ensure you have written consent from the family or estate. Authors may use this Patient Consent Form, which should be completed, saved, and sent to the journal if requested.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 10/14 Health and Safety
Please con rm that all mandatory laboratory health and safety procedures have been complied with in the course of conducting any experimental work reported in your paper. Please ensure your paper contains all appropriate warnings on any hazards that may be involved in carrying out the experiments or procedures you have described, or that may be involved in instructions, materials, or formulae.
Please include all relevant safety precautions; and cite any accepted standard or code of practice. Authors working in animal science may nd it useful to consult the
International Association of Veterinary Editors’ Consensus Author Guidelines on Animal Ethics and Welfare and Guidelines for the Treatment of Animals in Behavioural Research and Teaching. When a product has not yet been approved by an appropriate regulatory body for the use described in your paper, please specify this, or that the product is still investigational.
Submitting Your Paper
This journal uses ScholarOne Manuscripts to manage the peer-review process. If you haven't submitted a paper to this journal before, you will need to create an account in ScholarOne. Please read the guidelines above and then submit your paper in the relevant Author Centre, where you will nd user guides and a helpdesk.
If you are submitting in LaTeX, please convert the les to PDF beforehand (you will also need to upload your LaTeX source les with the PDF).
Please note that The Journal of Maternal-Fetal & Neonatal Medicine uses Crossref™ to
screen papers for unoriginal material. By submitting your paper to The Journal of Maternal-Fetal & Neonatal Medicine you are agreeing to originality checks during the peer-review and production processes.
On acceptance, we recommend that you keep a copy of your Accepted Manuscript. Find out more about sharing your work.
Data Sharing Policy
This journal applies the Taylor & Francis Basic Data Sharing Policy. Authors are encouraged to share or make open the data supporting the results or analyses
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 11/14
presented in their paper where this does not violate the protection of human subjects or other valid privacy or security concerns.
Authors are encouraged to deposit the dataset(s) in a recognized data repository that can mint a persistent digital identi er, preferably a digital object identi er (DOI) and recognizes a long-term preservation plan. If you are uncertain about where to deposit your data, please see this information regarding repositories.
Authors are further encouraged to cite any data sets referenced in the article and provide a Data Availability Statement.
At the point of submission, you will be asked if there is a data set associated with the paper. If you reply yes, you will be asked to provide the DOI, pre-registered DOI, hyperlink, or other persistent identi er associated with the data set(s). If you have selected to provide a pre-registered DOI, please be prepared to share the reviewer URL associated with your data deposit, upon request by reviewers.
Where one or multiple data sets are associated with a manuscript, these are not formally peer reviewed as a part of the journal submission process. It is the author’s responsibility to ensure the soundness of data. Any errors in the data rest solely with the producers of the data set(s).
Publication Charges
There are no submission fees, publication fees or page charges for this journal. Colour gures will be reproduced in colour in your online article free of charge. If it is necessary for the gures to be reproduced in colour in the print version, a charge will apply.
Charges for colour gures in print are £300 per gure ($400 US Dollars; $500 Australian Dollars; €350). For more than 4 colour gures, gures 5 and above will be charged at £50 per gure ($75 US Dollars; $100 Australian Dollars; €65). Depending on your location, these charges may be subject to local taxes.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 12/14
Copyright allows you to protect your original material, and stop others from using your work without your permission. Taylor & Francis o ers a number of di erent license and reuse options, including Creative Commons licenses when publishing open access. Read more on publishing agreements.
Complying with Funding Agencies
We will deposit all National Institutes of Health or Wellcome Trust-funded papers into PubMedCentral on behalf of authors, meeting the requirements of their respective open access policies. If this applies to you, please tell our production team when you receive your article proofs, so we can do this for you. Check funders’ open access policy
mandates here. Find out more about sharing your work.
Open Access
This journal gives authors the option to publish open access via our Open Select publishing program, making it free to access online immediately on publication. Many funders mandate publishing your research open access; you can check open access funder policies and mandates here.
Taylor & Francis Open Select gives you, your institution or funder the option of paying an article publishing charge (APC) to make an article open access. Please contact
[email protected] if you would like to nd out more, or go to our Author Services website.
For more information on license options, embargo periods and APCs for this journal please go here.
Accepted Manuscripts Online
This journal posts manuscripts online as rapidly as possible, as a PDF of the nal,
accepted (but unedited and uncorrected) paper. This is clearly identi ed as an unedited manuscript and is referred to as the Accepted Manuscript Online (AMO). No changes will be made to the content of the original paper for the AMO version but, after copy-editing, typesetting, and review of the resulting proof, the nal corrected version (the Version of Record [VoR]), will be published, replacing the AMO version.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine
https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 13/14
The VoR is the article in its nal, de nitive and citable form (this may not be immediately paginated, but is the version that will appear in an issue of the journal). Both the AMO version and VoR can be cited using the same DOI (digital object identi er). To ensure rapid publication, we ask you to return your signed publishing agreement as quickly as possible, and return corrections within 48 hours of receiving your proofs.
My Authored Works
On publication, you will be able to view, download and check your article’s metrics (downloads, citations and Altmetric data) via My Authored Works on Taylor & Francis Online. This is where you can access every article you have published with us, as well as your free eprints link, so you can quickly and easily share your work with friends and colleagues.
We are committed to promoting and increasing the visibility of your article. Here are some tips and ideas on how you can work with us to promote your research.
Article Reprints
You will be sent a link to order article reprints via your account in our production
system. For enquiries about reprints, please contact the Taylor & Francis Author Services team at [email protected]. You can also order print copies of the journal issue in which your article appears.
Queries
Should you have any queries, please visit our Author Services website or contact us here.
13/03/2019 The Journal of Maternal-Fetal & Neonatal Medicine https://www.tandfonline.com/action/authorSubmission?journalCode=ijmf20&page=instructions 14/14 Information for Authors Editors Librarians Societies Open access Overview Open journals Open Select Cogent OA
Help and info
Help FAQs Newsroom Contact us Commercial services
Sign me up
Connect with Taylor & Francis
Get the latest news and o ers tailored to you.
Copyright © 2018 Informa UK Limited Privacy policy & cookies Terms &
conditions Accessibility
Registered in England & Wales No. 3099067 5 Howick Place | London | SW1P 1WG
