American journal of perinatology最新文献

Objective:  The impact of type 1 DM (T1DM) on thromboembolism in pregnancy is uncertain. We hypothesized that T1DM is associated with higher rates of thrombotic events during pregnancy and the postpartum period.

Study design:  This is a retrospective cohort study utilizing the National Inpatient Sample database from HCUP/AHRQ for 2017-2019. Pregnant and postpartum patients with a history of T1DM were compared to those without. The primary outcome was a composite diagnosis of any thrombotic disease (pulmonary embolism [PE], deep vein thrombosis [DVT], cerebral vascular thrombosis [CVT], or other thromboses). Secondary outcomes were the diagnosis of each individual type of thromboembolic event. Groups were compared via student's test, chi-squared, and logistic regression analyses, controlling for confounders including age, race, obesity, tobacco use, cHTN, asthma, anemia, and cesarean section.

Results:  A total of 2,361,711 subjects met the criteria. Patients with T1DM encompassed 0.4% of subjects (n = 9,983). T1DM subjects were more likely to be younger, non-Hispanic white, obese, tobacco users, chronic hypertensive, asthmatic, and have a history of cesarean (all p < 0.001). They were less likely to be in the top income quartile. Thromboembolic events occurred more frequently in those with T1DM (0.45% vs. 0.20%, p < 0.001). DVT was the most common event (0.25%). After controlling for confounders, T1DM remained independently associated with any thromboembolic event in pregnancy (adjusted odds ratio [aOR] = 2.19, 95% confidence interval [CI]: 1.49-3.23), PE (aOR = 3.59, 95% CI: 1.65-7.82), and DVT (aOR = 2.43, 95% CI: 1.43-4.14).

Conclusion:  T1DM is associated with an increased risk of thromboembolic events in pregnancy.

Key points: · T1DM is independently associated with VTE.. · PE and DVT are the most common events.. · T1DM has an impact on VTE similar to obesity..

Objective:  This study aimed to assess thermoregulation and humidity within the Skincubator-a novel, wearable skin-to-skin incubator designed to attach to the caregiver.

Study design:  Preterm neonates (PN; born between 24 and 33 weeks gestational age [GA]) received skin-to-skin care (SSC) either via the Skincubator or traditional SSC (t-SSC) with continuous axillary temperature monitoring.

Results:  Twenty PN were enrolled in the study and treated in the Skincubator. One couple who consented to Skincubator care during delivery subsequently revoked their consent and the baby was excluded from further analysis. Fifty-four paired sessions of Skincubator and t-SCC were performed and compared for 19 babies. The average GA was 29 weeks (range: 26-32), the average weight was -1,296 ± 271 g, and the average day of life was 5 ± 2. The temperature drop after transfer to Skincubator care was smaller than in t-SSC (0.2°C [0.2-0.3] vs. 0.4°C [0.3-0.6]; Wilcoxon's signed rank test [WSRT], p < 0.001). The average hypothermia time per session was a median (25th-75th%) of 8.2 minutes (0-9) for Skincubator, compared to 27.8 minutes (0-56) for t-SSC, respectively (WSRT, p = 0.002). No baby had moderate hypothermia (35.5-35.9°C) during Skincubator care as compared with eight babies who experienced moderate hypothermia during t-SSC (Fisher's exact test p = 0.003). The average Skincubator humidity was 85 ± 7% and was above 70% during 93% of the time.

Conclusion:  Skincubator SSC was superior to t-SSC in maintaining PN temperature while also maintaining an optimally humidified environment. The Skincubator may promote early SSC in very and extremely PN. (Trial registration number MOH_2021-12-13_010470 registration date 24/10/21.) KEY POINTS: · Early prolonged SSC improves preterm infants' outcomes but may be challenging to perform.. · To mitigate several SSC barriers we invented the Skincubator, a wearable incubator for SSC.. · We have shown that the Skincubator reduces transient moderate hypothermia at SSC initiation.. · Average Skincubator humidity was 85 ± 7% and above 70% during 93% of SSC time..

Objective:  This study aimed to determine the prevalence of septo-optic dysplasia (SOD) in patients with prenatally identified absent cavum septi pellucidi (CSP), agenesis of the corpus callosum (ACC), or dysgenesis of the corpus callosum (DCC).

Study design:  This retrospective chart review investigated neonates prenatally diagnosed with an absent CSP, ACC, or DCC who were admitted to a single quaternary academic medical center in the Pacific Northwest between 2016 and 2023. This prenatal diagnosis prompted a routine and protocolized postnatal workup for SOD including laboratory evaluation, imaging, and specialty consultation. Sociodemographic and clinical data were collected for eligible neonates and their birthing persons. The prevalence of SOD in patients with midline callososeptal anomalies was calculated.

Results:  Of the 86 patients prenatally diagnosed with absent CSP, ACC, and/or DCC, 36.0% (n = 31) were diagnosed postnatally with SOD. Of those diagnosed with SOD, 71.0% (n = 22) had isolated optic nerve hypoplasia, 9.7% (n = 3) had pituitary hormone abnormalities, and 19.4% (n = 6) had both. Seven patients required maintenance hydrocortisone, one required thyroid hormone replacement, and one required thyroid and growth hormones. Of the 26 patients with SOD who underwent genetic testing, 9 (34.6%) had one or more genetic differences detected.

Conclusion:  SOD was diagnosed in 36.0% of cases of prenatally diagnosed midline callososeptal anomalies. For patients with prenatally diagnosed midline callososeptal anomalies, a standardized, postnatal SOD evaluation allows timely diagnosis and prompts early intervention and hormone replacement, thus avoiding the consequences of a delayed diagnosis.

Key points: · Thirty-six percent of patients with midline callososeptal anomalies were diagnosed with SOD.. · Most patients (71.0%) diagnosed with SOD had optic nerve hypoplasia without pituitary abnormalities.. · Although most patients received genetic testing, no findings were linked to SOD..

Objective:  NICU graduates are frequently technology dependent including home oxygen, pulse oximetry, and/or nasogastric (NG) feedings. Primary care provider (PCP) perceptions, practices, and barriers to managing these infants are not well described, especially at altitude. We sought to 1) describe PCP comfort and 2) determine practices and barriers in managing this technology at higher altitudes.

Study design:  This cross-sectional survey assessed Colorado and Wyoming PCP perceptions and practices surrounding technology in NICU graduates. We explored bivariate analysis between clinic altitude, location, and provider's experience with comfort caring for infants discharged with technology using chi-squared or Fisher's exact tests. Significant relationships were modeled using logistic regression for odds ratios and 95% confidence intervals.

Results:  Among 203 respondents, 82% were pediatricians, and 86% practiced in urban/suburban environments. Clinic altitude ranged 2,500-9,000 ft. PCPs endorsed comfort managing oxygen in term (92%) and moderately/late preterm infants (82%), versus 52% comfort in very/extremely preterm infants. 62% utilized an oxygen-weaning algorithm. Comfort managing oxygen was greater in suburban versus urban locations (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.6-11.7) and providers practicing for >10 versus <5 years (OR = 3.5, 95% CI: 1.5, 8.4). 60% found pulse oximetry useful, though 70% perceived caregiver stress. 69% accepted infants on NG feeds, though 61% endorsed discomfort with management.

Conclusion:  PCPs are comfortable managing home oxygen in moderately preterm to term infants but find caring for most preterm infants challenging. Discomfort in managing NG feeds is prevalent. This highlights peridischarge barriers and improvement opportunities for high-risk, technology-dependent infants.

Key points: · PCPs are uncomfortable managing very/extremely preterm infants on home oxygen after NICU discharge.. · PCPs perceive frequent commercial pulse oximetry use in NICU graduates.. · Most PCPs are uncomfortable managing home NG feedings..

Objective:  This study aimed to evaluate the frequency of adverse maternal and neonatal outcomes associated with maternal obesity in a Hispanic population. We hypothesized that obesity confers a dose-dependent risk associated with these outcomes.

Study design:  This was a retrospective cohort study of singleton pregnancies delivered between 24 and 42 weeks gestation at an urban county hospital between 2013 and 2021. Body mass index (BMI) at the first prenatal visit was used as a proxy for prepregnancy weight. Patients were excluded if their first-trimester BMI was not available. Trends in adverse outcomes across increasing obesity classes were assessed.

Results:  During the study period, 58,497 patients delivered a singleton infant, of which 12,365 (21.1%), 5,429 (9.3%), and 3,482 (6.0%) were in class I, II, and III obesity, respectively. Compared with nonobese patients, obese patients were more likely to be younger and nulliparous with a higher incidence of hypertension and pregestational diabetes. Higher BMI was associated with a significant dose-dependent increase in cesarean delivery (27% for nonobese, 34% for class I, 39% for class II, and 46% for class III obesity); severe preeclampsia (8% in nonobese and 19% for class III obesity); and gestational diabetes (5% in nonobese and 15% in class III obesity). There were significant trends in increasing morbidity for infants born to patients with correspondingly higher obesity classes. Some of these adverse outcomes included respiratory distress syndrome, neonatal intensive care unit admission, fetal anomalies, and sepsis (all p < 0.001).

Conclusion:  Increasing body mass index is associated with a significant dose-dependent increase in multiple adverse perinatal outcomes in a Hispanic population. Associated adverse maternal outcomes include severe preeclampsia, gestational diabetes, and cesarean delivery. Infants born to patients with correspondingly higher BMI class have significantly increased associated morbidity. Often, only higher BMI classes are significantly associated with these adverse outcomes.

Key points: · As BMI increases, pregnant patients are more likely to experience adverse maternal and neonatal outcomes.. · Many adverse pregnancy outcomes are associated only with a BMI greater than 40 kg/m2.. · Obesity is associated with cesarean delivery, likely due to an increase in labor dystocia..

Objective: Though amnioinfusion decreases the rate of uterine atony, its effect on postpartum hemorrhage (PPH) is uncertain. This study aimed to assess whether amnioinfusion reduces the risk of PPH in laboring individuals.

Study design: A retrospective study of all laboring singletons at a tertiary center between 01/2013 and 12/2022 at ≥ 34 weeks. Individuals with known major fetal anomalies, stillbirths, or missing delivery records were excluded. The primary outcome was PPH. Neonatal and secondary maternal outcomes were also explored. Adjusted odds ratios (aOR) were estimated using multivariable regression models.

Results: Out of 113,816 deliveries during the study period, 83,152 (77.1%) met inclusion criteria, and among them 4,597 (4.03%) had amnioinfusion. Laboring individuals with amnioinfusion were more commonly nulliparous, had more polyhydramnios, oligohydramnios, preeclampsia, gestational diabetes, and fetal growth restriction. Furthermore, individuals with amnioinfusion had a higher rate of labor induction (54.54% vs. 27.8%; P<0.01) and a higher cesarean rate (36.9% vs. 9.5%; P<0.01). Following multivariable regression, there was no significant difference in the rate of PPH among individuals who had an amnioinfusion (2.6%) versus those who did not (3.1%; aOR 0.95, 95% CI 0.87, 1.27). The rates of endometritis (aOR 1.4; 95% CI 1.04-1.89) and postpartum fever (aOR 1.70; 95% CI 1.36-2.12), were higher in those who had amnioinfusion compared to those that did not.

Conclusion: Among laboring individuals ≥ 34 weeks, intrapartum amnioinfusion was not associated with a reduction in the rate of postpartum hemorrhage and was associated with a higher likelihood of infectious morbidity.

Objective: To examine the impact of COVID-19 on the racial disparity in prenatal care utilization in the United States before and during the pandemic.

Study design: This was a cross-sectional study using the National Vital Statistics Data from 2018 to 2022. Our focus was on low-risk individuals who delivered singleton pregnancies at term. The analysis was restricted to Black and White individuals to explore racial disparities. The study periods based on the last menstrual period (LMP) were pre-pandemic (March 2018-February 2020) and pandemic (March 2020-February 2022). The primary outcome was the rate of no prenatal care. We employed interrupted time series analysis (ITSA), negative binomial regression models, adjusting for confounders, seasonality, and autocorrelation. We conducted post-estimation analyses to calculate the counterfactual and actual incidences of outcomes for individuals with an LMP in March 2020 and February 2022. Difference-in-difference (DID) with 95% confidence intervals (95% CI) was estimated.

Results: The analysis included 3,511,813 individuals in the pre-pandemic period and 5,163,486 in the pandemic period. For individuals with LMP in March 2020, the actual incidences of no prenatal care per 100 births were 3.2 (95% CI 3.0, 3.3) for Black individuals and 1.6 (95% CI 1.2, 2.0) for White individuals. The difference between counterfactual and actual no prenatal care rates per 100 births for Black individuals was 0.4 (95% CI 0.2, 0.5), indicating a significant increase in no prenatal care. Conversely, there was no significant difference for White individuals. DID analysis further demonstrated that this increase was greater in Black individuals compared to White individuals (DID per 100 births 0.3 [95% CI 0.1, 0.5]). For individuals with LMP in February 2022, this difference in disparity further worsened (DID per 100 births 0.8 [95% CI 0.4, 1.2]).

Conclusion: The COVID-19 pandemic increased the incidence of no prenatal care, which disproportionately affected Black individuals.

Objective:  It is well established that antibiotics administered in preterm prelabor rupture of membranes increase latency to delivery. While data are limited for membrane rupture prior to viability, antibiotics may also increase latency in this population. This study aimed to assess the effect of prophylactic antibiotics on the duration of latency in individuals with previable prelabor rupture of membranes.

Study design:  Retrospective cohort of pregnancies with previable prelabor rupture of membranes prior to 23^0/7 weeks in a single health system (2013-2022). Patients opting for termination or with a contraindication to expectant management were excluded. The primary outcome was latency from previable prelabor rupture of membranes diagnosis to delivery. Secondary outcomes included subanalysis by gestational age as well as maternal and neonatal morbidity and mortality. Bivariate statistics compared patients who did and did not receive antibiotics (ampicillin, gentamicin). Kaplan-Meier/Cox proportional hazards ratios using significant covariates (p < 0.1) in bivariate analysis models examined antibiotic impact on latency.

Results:  Of 115 patients, 46 (40%) met inclusion criteria, of whom 34 (74%) received latency antibiotics. Median latency did not differ with antibiotic receipt (1 [0.4, 2.6] vs. 0.6 weeks [0.3, 0.9], p = 0.27). When adjusted for gestational age at rupture of membranes, antibiotics were not associated with longer latency (hazard ratio = 1.33 [0.91, 1.93]). Antibiotic receipt was associated with lower rates of previable delivery (23.0, [22.7, 24.0] vs. 21.3 weeks [20.5, 23.1], p = 0.006). Adjusted odds of previable delivery remained lower with receipt of antibiotics (adjusted odds ratio = 0.20, [0.04, 0.90]). Antibiotics were associated with longer latency in patients with rupture of membranes at less than 22 weeks gestation (2.4 [1.3,4.4] vs. 0.6 weeks [0.1,0.9], p = 0.02).

Conclusion:  Antibiotic administration at the time of previable prelabor rupture of membranes was associated with longer latency prior to 22 weeks gestation. Antibiotic administration increased the odds of delivering after viability. Further study should address optimal antibiotic strategies for this unique population.

Key points: · No significant increase in latency after antibiotics with rupture of membranes prior to 23 weeks.. · Significantly longer latency after antibiotics with rupture of membranes before 22 weeks.. · Antibiotic receipt associated with increased likelihood of delivering after viability..

Objective:  This study aimed to explore barriers and perspectives of premedication use for non-emergent intubations of very low birth weight (VLBW) infants (<1,500 g).

Study design:  A cross-sectional, online survey was distributed from January to April 2023 to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Data was analyzed using descriptive statistics and chi-square tests.

Results:  Of the 521 respondents, the majority (81%, n = 415) were neonatologists. Over half of respondents (69%, n = 359) consider patient weight when selecting premedication. Most providers (78%, n = 407) agreed that premedication should be used for non-emergent intubation of VLBW infants, while only 41% (n = 216) felt similarly that muscle relaxants should be used. For infants over 1,500 g, 43% (n = 153) reported frequent or regular muscle relaxant use compared with 28% (n = 101) for VLBW infants. The most cited barrier to muscle relaxant use was surfactant delivery with a planned return to non-invasive support. Unit guidelines were associated with significantly more premedication and muscle relaxant use (56 vs. 44%; odds ratio [OR] = 5.2, 95% confidence interval [CI]: 3.4-7.7, p < 0.0001).

Conclusion:  Most neonatal providers favor premedication for non-emergent intubation but are hesitant to use muscle relaxants for VLBW infants. Premedication guidelines may facilitate the use of both premedication and muscle relaxants for this population.

Key points: · Study of intubation premedication perceptions and practices for VLBW infants.. · Premedication is used less for intubation of VLBW infants compared to their larger peers.. · Unit premedication guidelines and available intubation backup may facilitate premedication use..

Objective:  Prior studies have yielded mixed results regarding ambulation with neuraxial analgesia and labor outcomes, and studies did not include a significant obese population. We sought to evaluate the feasibility of ambulation with optimized neuraxial analgesia in laboring nulliparous obese patients.

Study design:  This was a pilot study at the University of Chicago (approval no.: IRB 19-1600, CT NCT04504682). Inclusion criteria were delivery BMI of ≥35 kg/m², nulliparity, and term gestation. Contraindications to ambulation or vaginal delivery conferred ineligibility. Combined spinal-epidural analgesia was initiated per our institution's policy. Following epidural catheter placement, serial blood pressure measurements and motor assessments including a straight leg test and a step stool test were completed per safety protocol. Patients who passed these assessments were enrolled. Patients were encouraged to ambulate for 20 minutes every hour while on fetal and uterine telemetry. Ambulation was discouraged after complete dilation. Demographics and delivery outcomes were collected. Our primary objective was to evaluate feasibility through acceptability, and safety via the number of falls, and percentage of patients with any ambulation. The study was closed early due to enrollment difficulties and in the setting of the COVID-19 pandemic.

Results:  A total of 105 patients were identified for the trial: 20 were ineligible for the study, 20 could not be approached, and 40 declined study participation, leaving 25 patients who consented. Of those 25, 14 completed the study. Out of 14 participants, 11 were ambulated. The average BMI of these participants was 43 kg/m². No patients fell during the trial.

Conclusion:  A pilot trial of ambulation during neuraxial analgesia among an obese nulliparous population demonstrated no safety concerns, but with concern regarding feasibility as there was low acceptance.

Key points: · Pilot trial of ambulation with neuraxial analgesia among obese patients had limited enrollment.. · Trial of ambulation with epidural among obese nulliparous patients demonstrated no safety concerns.. · Further studies are needed for efficacy..