American journal of perinatology最新文献

Objective: Postpartum pain management practices have significant variation and are known to be influenced by non-clinical factors. We aimed to examine factors which contribute to clinicians' assessment and management of postpartum pain, including the role of opioids.

Study design: We conducted a qualitative study of obstetric clinicians providing postpartum care at a single, large, tertiary care center (11/2021-6/2022). Attending and trainee OB/GYN physicians and advance practice providers (APPs) completed in-depth interviews using a semi-structured interview guide. Purposive sampling was employed to ensure a representative sample of each clinician type was included. Participants were asked about factors that influence postpartum pain management. Data were analyzed using the constant comparative method.

Results: Of 46 participants, 48% were attending physicians, 32% trainee physicians, and 20% APPs. Analysis demonstrated three key themes related to postpartum assessment and management: influencing factors (knowledge or experiences that influence practice), objective findings, and the role of counseling (Table 1). While clinicians reported guidelines and patient satisfaction as major influencing factors, several also shared the inherent conflict that may arise between them. Objective findings, specifically the impact of pain on patients achieving functional goals, also influenced clinician decision making. Conversely, many participants reported the limited utility of the numeric pain scale as an objective metric. Additionally, the role of counseling in shared decision-making and providing anticipatory guidance was emphasized. Finally, clinicians had a range of opinions on the role of opioids in pain management, but many spoke to the value of opioids as second-line treatment and the impact of the opioid epidemic on prescribing practices.

Conclusion: The factors that influence clinicians' assessment and management of postpartum pain are occasionally in conflict. Furthermore, objective measures, such as the numeric pain scale, have significant limitations.

Objective: The clinically-modified obstetric co-morbidity index (OB-CMI) is a co-morbidity-based scoring system that has been validated to predict severe maternal morbidity (SMM) in a single tertiary, academic hospital using an internal SMM definition. We aimed to validate the OB-CMI for prediction of SMM as defined by the CDC during delivery admissions across a diverse health system.

Study design: This is a retrospective cohort study evaluating all deliveries in a large health system encompassing academic and community hospitals. Data from 2019-2021 were extracted from the electronic health record (EHR) and validated with chart review. An OB-CMI score was calculated for each patient using established diagnosis codes and EHR data. The primary outcome was non-transfusion SMM (defined by the CDC) during the delivery admission. Patient characteristics were evaluated by hospital, and hospital-specific receiver-operator characteristic (ROC) curves were constructed and compared.

Results: 42,130 deliveries were included with significant differences in all demographic, clinical, and obstetric characteristics across the hospitals including age, BMI, race/ethnicity, insurance type, preterm birth and preeclampsia rates. (Table). Median OB-CMI score and rate of elevated OB-CMI score (≥ 6) were also significantly different. ROC curves for OB-CMI and SMM for each hospital are noted in the Figure with an area-under-the curve (AUC) range from 0.77 - 0.83, and no significant differences across hospitals (p = 0.32).

Conclusion: In a large cohort of patients delivering across a diverse hospital system, the clinical OB-CMI score similarly predicted SMM despite differences in demographic and clinical characteristics among the hospitals. This validation of the OB-CMI supports the use of this scoring system in variegated clinical settings, which can inform widescale uptake and clinical integration of OB-CMI scoring to improve obstetric risk stratification.

Objective First trimester transabdominal ultrasound is sometimes used to diagnose placenta previa and counsel patients accordingly. We aimed to determine the predictive capacity of a first trimester transabdominal ultrasonographic placenta previa diagnosis for persistence to the second trimester. Study Design Retrospective cohort study of patients with singleton pregnancies and first trimester transabdominal ultrasonographic placenta previa diagnoses from January to December 2022. The primary outcome was the predictive capacity of a first trimester transabdominal ultrasound diagnosis of placenta previa for placenta previa persistence into the second trimester. Secondary outcomes included the predictive capacity of a first trimester transabdominal ultrasound for placenta previa persistence to delivery and risk factors associated with placenta previa persistence. Chi-square and Student's t test were used to determine statistical significance, and a multivariable logistic regression determined the strength of associations. Results Of the 185 patients with a first trimester transabdominal ultrasound diagnosis of placenta previa, 159 (86.0%) resolved by the second trimester resulting in a predictive capacity for persistence to the second trimester of 14.0%. Moreover,182 (98.4%) resolved by delivery, resulting in a predictive capacity for persistence to delivery of 1.6%. Among the 27 patients with a prior cesarean delivery, the predictive capacity of a first trimester placenta previa diagnosis for persistence to the second trimester was 22.2% and to delivery was 7.4%. Advanced maternal age and posterior placenta in the first trimester were risk factors for previa persistence to the second trimester, while prior cesarean delivery and reproductive assistance were not. Conclusion First trimester transabdominal ultrasonographic placenta previa diagnosis has a poor predictive capacity for placenta previa persistence to the second trimester and even lower for persistence to delivery. Counseling patients regarding placenta previa diagnosis in the first trimester may result in unnecessary patient anxiety and activity restrictions.

Maternal substance use during pregnancy is a known risk factor for poor birth outcomes and lifelong health consequences. In addition, exposure to domestic and community violence can be associated with adverse birth outcomes. Due to limited research examining public health challenges linked to prenatal substance exposure (PSE)/neonatal abstinence syndrome (NAS) at the population level, we examined possible geographic and temporal intersections between (1) community violence and PSE/NAS, and (2) community gun violence and PSE/NAS.We conducted a study using abstracted records of neonates born at a tertiary referral hospital from 2012 to 2019 having a diagnosis code for PSE/NAS (n = 1,523). Cases of community violence were identified using a hospital-based Trauma Registry during the 2012 to 2019 period (n = 1,580). We identified zones of spatial clustering and geographic overlap between community violence and PSE/NAS using emerging hot spot analysis.Geographic and temporal clustering of PSE/NAS occurred. PSE/NAS had statistically significant zones of overlap with community assault cases (New Hot Spot 15 zones, Consecutive 5 zones, Sporadic Hot Spot 62 zones with a p < 0.01). PSE/NAS also clustered with community gun violence (New Hot Spot 11 zones, Consecutive Hot Spot 90 zones, Intensifying Hot Spot 13 zones, Sporadic Hot Spot 20 zones with a p < 0.01).Spatiotemporal overlap occurred between community violence and the adverse neonatal event of PSE/NAS. By allocating resources to identified geographic areas of increased risk, the health of vulnerable communities can be improved. · PSE/NAS geographically and temporally clusters with community violence.. · PSE/NAS geographically and temporally clusters with community gun violence.. · Resources should be provided to communities with increased risk.. · By allocating resources, communities members' health can be improved..

To clarify survival for infants affected by periviable prolonged preterm premature rupture of membranes (PPROM) in the military health system (MHS). To add to current literature on outcomes following expectant management, including long-term neurodevelopment outcomes.Retrospective matched cohort review of six level 3 military neonatal intensive care units (NICUs; 2010-2020). Cases were matched 1:1 with control infants, matched by location, gender, gestational age (within 1 week), birth weight (within 300 g), and rupture of membranes (ROM) within 24 hours of delivery. Follow-up data were obtained for each infant through 48 months' corrected age or age of last documented health visit in a military treatment facility.Forty-nine infants met inclusion criteria. Mean ROM for cohort infants was 20.7 weeks, with mean latency period of 34.6 days and mean gestational age at delivery of 25.7 weeks. Cohort infants had a mean birth weight of 919 g. Cohort survival to NICU discharge was 75.5 versus 77.6% of controls (p = 0.81). Statistically significant short-term outcomes: oligohydramnios or anhydramnios at delivery (p < 0.0001), pulmonary hypertension (p = 0.0003), and high-frequency ventilation (p = 0.004) were higher in cohort infants. No differences were found regarding rates of early sepsis, intraventricular hemorrhage, surgical necrotizing enterocolitis, oxygen at 36 weeks or at discharge. No statistical difference in long-term outcomes at 18 to 48 months of age or incidence of autism, cerebral palsy, attention deficit hyperactivity disorder, or asthma.Cohort survival to discharge in the MHS was 75.5%, higher than previously reported and not different from matched controls. Infants born after periviable PPROM should deliver at centers with access to high-frequency ventilation and ability to manage pulmonary hypertension. There was no difference in long-term neurodevelopment between the groups. · Survival to NICU discharge is similar between infants exposed to periviable PPROM and controls.. · Cohort survival to discharge was 75.5%, higher than previously reported in recent literature.. · Infant with periviable PPROM should delivery at centers capable of managing pulmonary complications..

Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes.We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay.A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications.Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay. · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay..

A low 1-hour glucose challenge test (GCT) result (<10th percentile for population) has been associated with neonatal morbidity, including small-for-gestational-age birth weight, and it is hypothesized that underlying maternal hypoglycemia may contribute to this neonatal morbidity. We sought to assess whether eligible patients would undergo continuous glucose monitoring to allow comparison of maternal hypoglycemia between those with a low GCT result versus controls.This exploratory study enrolled patients who completed a GCT between 24 and 30 weeks' gestation from June to September 2022. English- or Spanish-speaking participants aged ≥18 years wore a blinded continuous glucose monitor (CGM) for 10 days. There were 10 participants each in the low GCT (<82 mg/dL) and normal GCT group. Proportions were calculated to determine recruitment rates and describe the low versus normal glycemic groups across clinical and sociodemographic characteristics. Maternal hypoglycemia, defined using various proposed thresholds, was analyzed as continuous data (time duration) with Student's t-tests and categorical data (number of episodes) with chi-square tests and bivariate analyses were performed comparing participants with a low versus normal GCT. Primary outcome measures were recruitment, enrollment, and adherence rates, and overall glycemic values for each group.Of 64 eligible patients, 58 (91%) were approached, and of them, 20 (35%) were enrolled. All 20 participants had CGM data to review with 100% adherence. Average glucose values were similar between participants in the low GCT and normal GCT groups (111.7 ± 18.0 vs. 111.6 ± 11.7 mg/dL, p = 0.99), and participants with a low GCT value did not demonstrate more hypoglycemia than those with a normal GCT value across five proposed thresholds on CGM analysis.In this pilot study, participants wore blinded CGMs to collect glycemic data, and those with a low GCT result did not experience more hypoglycemia than those with a normal GCT on CGM analysis. · Study participants wore continuous glucose monitors in blinded mode to gather glycemic data with 100% adherence.. · Participants with a low GCT result (<82 mg/dL) as compared with those with a normal GCT result were not more likely to demonstrate maternal hypoglycemia using several thresholds on CGM analysis.. · In our cohort, there were few participants in either glycemic group who reported food insecurity or lived in a food desert..

Acute kidney injury (AKI) is common in hospitalized preterm neonates. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a promising noninvasive AKI biomarker. However, normal values of uNGAL in preterm neonates without AKI are poorly characterized. The objective of this study was to evaluate the current literature to determine normal uNGAL values for preterm neonates without AKI.Systematic review and meta-analysis of all articles published before November 2021 evaluating uNGAL values in preterm neonates without AKI.Of 1,607 studies evaluated for eligibility, 11 were included in the final meta-analysis (210 males, 202 females). uNGAL values were higher in the preterm neonates <29 weeks and ranged between 20.7 and 782.65 ng/mL. Meta mean estimates of gestational age (GA), birthweight, and neutrophil gelatinase-associated lipocalin were 29.4 weeks (95% confidence interval [CI]: 28.8-30.0), 1,241 g (95% CI: 1,111-1,372), and 148.9 ng/mL (95% CI: 48-231), respectively.In limited studies, a wide range of uNGAL values in preterm neonates without AKI are reported. Future studies should identify normal uNGAL values in preterm neonates using larger cohorts by GA and birthweight. · Urinary NGAL is a promising noninvasive biomarker of neonatal AKI.. · A wide range of uNGAL is reported in preterm neonates but the baseline values are not well defined.. · Urine NGAL values are higher in extremely preterm compared with preterm neonates..

Perinatal Depression (PD) is one of the most common complications of pregnancy and childbirth affecting as many as 1 out of 5 women in high income countries. The prevalence is even higher in low- and middle-income countries. Untreated PD can result in serious short-term and long-term negative effects on both the mother and newborn including adverse perinatal outcomes and negatively impacting mother-infant bonding, breastfeeding, and child neurocognitive development. Therefore, evaluation of the current standard of treatment is necessary. Historically, PD has lacked effective evidenced-based treatment guidelines. Current first-line treatment options include psychotherapy, psychopharmacology or both, but lack specificity regarding good clinical practice guidelines. New approaches consist of a combination of early screening, preventative psychoeducation, optimizing timely diagnosis, and novel synergistic psychotherapy and psychopharmacology approaches to provide a comprehensive therapeutic approach. Future initiatives and research should evaluate improving screening tools, enhancing patient engagement, and explore the efficacy of therapy utilizing multiple treatment modalities, to refine good clinical practice guidelines.

Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy- and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT.This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size, and teaching status, were also used to produce adjusted relationships between HHT status and outcomes.The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in the HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p < 0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, CI: 3.06, 6.58]). Rates of preterm birth (14.2 vs. 8.5%, aRR: 1.57 [95% CI: 1.22, 2.03]), cesarean delivery (41.0 vs. 32.9%, aRR: 1.23 [95% CI: 1.07, 1.41]), respiratory bleeding (2.1 vs. <0.1%, aRR: 94.44 [56.64, 157.46]), and cerebrovascular complications (0.9 vs. <0.1%, aRR: 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups.Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared with the baseline population. · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..