American journal of perinatology最新文献

Preterm prelabor rupture of membranes (PPROM) diagnosis is made through visualization of amniotic fluid (pooling), nitrizine testing, sonographic low amniotic fluid, and microscopic detection of amniotic fluid arborization (ferning). Data exits on the specificity and sensitivity of ferning detection but has not focused on the second trimester. Our objective is to evaluate the presence of ferning in transvaginally collected amniotic fluid in pregnancies with known second trimester PPROM to determine if there is a difference in ferning based on gestational age and sample drying time. This was a prospective study evaluating amniotic fluid in individuals undergoing termination of pregnancy between 15- and 24- weeks' gestation. A control vaginal swab was collected prior to rupture of membranes and a sample vaginal swab was collected at the time of rupture of membranes at a termination procedure. A 10-milliliter sample (mL) of amniotic fluid was collected too and then centrifuged to separate out blood. Slides were analyzed at 5 different drying time intervals after rupture of membranes, on both the vaginal and centrifuged samples, and examined by two blinded investigators to assess for ferning. Maternal demographics, obstetrical history, and termination information were collected. Statistical analysis was performed using descriptive statistics and regression analyses. A total of 99 individuals consented and 93 were included. The mean gestational age at the time of the termination was 19.5 + 2.5 weeks. There was a significant effect of drying time with the odds of observing ferning increasing with longer drying time, up to 10 minutes (p<0.001). Gestational age did not impact ferning detection (P=0.09). Centrifuging increased ferning detection by 15% at 10 minutes compared to the vaginal swab. In cases of known second trimester PPROM, ferning was detected more often after 10 minutes of sample drying and with centrifuging the amniotic fluid to remove blood.

Objective: 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 first prenatal visit was used as a proxy for pre-pregnancy 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%), 5429 (9.3%), and 3482 (6.0%) were in class I, II, and III obesity, respectively. Compared with non-obese patients, more 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 non-obese, 34% for class I, 39% for class II, and 46% for class III obesity); severe preeclampsia (8% in non-obese and 19% for class III obesity); and gestational diabetes (5% in non-obese 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.

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 thrombo-embolic 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 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. Thrombo-embolic 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 (aOR 2.19, 95%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 thrombo-embolic events in pregnancy. Key Words Type 1 Diabetes Mellitus, VTE, thromboembolism, pregnancy.

Objective:  Significant racial and ethnic disparities in maternal morbidity and mortality as well as gynecologic outcomes persist in the United States. The role of ambulatory care in obstetrics and gynecology (OBGYN), particularly in facilities that separate resident and attending care along payor (and de facto racial) lines, remains unclear. This study examines patient perspectives on payor-segregated health care delivery in an academic medical center (AMC) and opinions on possible integration.

Study design:  This is a qualitative study conducted at a single AMC with payor-segregated resident and attending outpatient sites. Interviews focused on patient perception of experience and value in outpatient OBGYN care, perspectives on the segregated care model, and attitudes about integration. Patients participated in a 30-minute semistructured interview with recruitment continuing until thematic saturation was reached (October 2022-August 2023). Interviews were coded using an integrated approach with grounded theory; 12% of transcripts were double-coded (k = 0.86).

Results:  We interviewed 26 patients (16 from resident, 10 from attending site). Patients prioritized practical aspects such as clinic proximity and quality of clinician interaction. Most were unaware of the payor-segregated clinic system and disapproved upon learning about it. Opinions varied on topics of telehealth and continuity, indicating diverse patient needs. Notably, minoritized patients valued race and class concordance in clinical spaces. Patients generally supported care integration, conditional upon the preservation of aspects of care they valued.

Conclusion:  Successful OBGYN care integration requires meeting individual needs while ensuring diversity, safety, and community-oriented care, alongside access and convenience. Incorporating patient voices is crucial for aligning services with expectations and improving patient experiences.

Key points: · Patients disapprove of payor-segregated care but prioritize practical aspects over care structure.. · Minoritized patients valued race/class concordance. Preferences varied on continuity, residents, and telehealth.. · Clear communication around prior payor segregation and motivations for integration will foster trust..

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis, and invasive pneumococcal disease among adults in the United States, with higher rates of disease occurring among individuals with chronic medical and immunocompromising conditions. Pregnant individuals, especially those with comorbid conditions, are also at increased risk of infection due to S. pneumoniae due to physiological and immunologic changes in pregnancy. Vaccination against pneumococcus is recommended for adults living with HIV aged 19 to 49, congenital or acquired immunodeficiency, asplenia, chronic renal failure, sickle cell disease, alcohol abuse, cerebrospinal fluid leaks, congestive heart failure and cardiomyopathies, chronic lung disease, chronic liver disease, and diabetes mellitus. During pregnancy, the American College of Obstetricians and Gynecologists (ACOG) recommends vaccination against S. pneumoniae for individuals meeting the criteria for immunization outside of pregnancy. Pneumococcal vaccine uptake has been low. There are no data available for vaccine uptake in pregnancy, but we suspect it is lower than nonpregnant populations. Low uptake of immunization rates in pregnancy is likely multifactorial and includes general vaccine hesitancy among pregnant individuals, cost, access to care, and supply shortages. While data in support of pneumococcal vaccines during pregnancy are limited, sufficient evidence exists to support the safety and efficacy of vaccination in the antepartum period. Pregnancy provides an opportunity to continuously engage individuals in care, allowing obstetricians and gynecologists to establish rapport, work to reduce vaccine hesitancy, and to provide pneumococcal immunization to those who are eligible. Medical indications for pneumococcal vaccination will increasingly apply to pregnant persons as the population acquires comorbidities and there is a need for improved education among obstetricians on the topic of antenatal pneumococcal vaccination. KEY POINTS: · Pregnant persons are at risk of S. pneumoniae.. · Adult pneumococcal vaccine uptake has been low.. · Obstetricians and gynecologists can benefit from education on pneumococcal vaccines.. · Encourage pneumococcal vaccines for eligible pregnant people..

Background: From 2002 to 2023, palivizumab was the only intervention to reduce RSV-associated hospitalizations in high-risk infants in Canada, but advances in RSV prevention are drastically changing this landscape. Eligibility criteria for this monoclonal antibody for preterm infants varied over time across each of 10 Canadian provinces and 3 territories. The national professional pediatric association (Canadian Paediatric Society) revised its eligibility recommendations in 2015, removing access for preterm infants 30 to 32 weeks gestation (WG). The province of Nova Scotia (NS) followed these recommendations the next season.

Objectives: To determine if the removal of access to palivizumab in these previously infants was associated with a change in hospital admissions, deaths or ambulatory visits associated with RSV.

Methods: We identified a retrospective cohort of NS infants born between 30 and 32 WG, without other risk factors for RSV-H, from April 2012 to September 2019 by linking 6 population-based provincial databases, and followed each infant through the first year of life. Episodes of RSV-associated hospitalization, ambulatory visits or death were identified by International Statistical Classification of Diseases and Related Health Disorders (ICD) RSV- associated diagnostic codes.

Results: Of 4835 infants born during the study period, 250 were 30-32 WG were eligible for the cohort. RSV-H increased about 10-fold following restricted access to palivizumab (0/123, to 9.4%; (95% CI 5.0, 15.9, risk difference 9.4), but no RSV-associated deaths occurred. RSV-A also increased from 5.7% to 17.3% (risk difference 11.6).

Conclusions: Discontinuation of access to a prophylactic anti-RSV monoclonal antibody in very preterm infants was associated with a higher risk of RSV-H and RSV-A. Evaluation of healthcare policy change on patient well-being is essential to assess impact and guide future decision making at the population level.

Objective:  A single-center randomized trial showed improved latency with use of indomethacin and cefazolin (I/C) during and following exam-indicated cerclage (EIC). The same center recently published a pre/post comparison demonstrating similar results. This research aimed to validate the protocol in a different setting.

Study design:  Retrospective cohort study of singleton pregnancies undergoing EIC at a single center between 2013 and 2022. EIC was performed for painless cervical dilation between 16 and 23 weeks' gestation with dilation ≥1 cm. Exposure was defined as receipt of I/C during and following EIC. The primary outcome was latency ≥ 28 days after cerclage placement. Secondary outcomes included latency; gestational age at delivery; delivery ≤ 28 weeks; preterm premature rupture of membranes; intra-amniotic infection (IAI); and median birth weight. Bivariate statistics were used to analyze data; multivariable regression analyses were used to control for confounders (progesterone use, cervical dilation at time of cerclage placement, history of preterm birth, and prolapsing membranes).

Results:  EIC was placed in 81 pregnancies and 48 (59%) received I/C. Baseline characteristics did not differ between groups, except that prolapsing membranes were significantly less likely in patients receiving I/C (6.2 vs. 21.2%; p = 0.04). Latency ≥ 28 days occurred in 90% of I/C recipients and 82% of the controls (p = 0.32); this difference remained nonsignificant after controlling for confounders (adjusted relative risk: 1.02 [95% confidence interval: 0.85, 1.21]). I/C recipients had lower rates of IAI (4.2 vs. 24.2%, p = 0.007), even after adjustment (adjusted relative risk: 0.18 [95% confidence interval: 0.04, 0.74]). Other secondary outcomes did not differ.

Conclusion:  Use of I/C at the time of EIC at this center was not associated with increased latency to delivery (albeit in a small cohort) but was associated with lower rates of intra-amniotic infection. Larger-scale validation studies would be helpful to confirm the value of this intervention.

Key points: · Indomethacin/cefazolin (I/C) increased latency for exam-indicated cerclage in a trial.. · We performed an observational comparison to validate these findings.. · I/C use for exam-indicated cerclages was associated with decreased intra-amniotic infection.. · I/C was not associated with change in latency.. · Larger-scale validation studies needed to confirm the value of intervention..

Background: Obesity is associated with an increased risk of stillbirth and neonatal death. Since the publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE) in 2018, there was an increase in 39 weeks deliveries. The objective of this study was to evaluate the trends in perinatal mortality by BMI category from 2015 to 2020.

Study design: This was a retrospective cohort study of US births between 2015 and 2020. The rates of stillbirths, infant deaths, and perinatal mortality were calculated for each BMI category. Logistic regression models were constructed based on specific outcome rates from 2015 - 2018 to predict the rates in 2019 and 2020. The predicted rates were compared with the actual rates to determine possible deviations due to policy and practice changes that occurred.

Results: Between 2015 - 2018, the stillbirth rate increased for ascending BMI categories. Whereas the neonatal death rate decreased for all except the underweight group, the perinatal death rate increased in all except for those with category III obesity. In 2019 the perinatal mortality rate decreased for every BMI category except underweight group. In 2020, the rate of infant deaths increased for all BMI categories compared with the predicted rates. The results were similar after excluding common comorbidities.

Conclusions: Perinatal mortality rates improved in 2019, reversing the increasing trend from 2015-2018. However this trend did not persist for some BMI categories in 2020. These findings may suggest a beneficial effect of policy changes since the ARRIVE trial publication and the negative effects from the COVID-19 pandemic.

Objective: High-flow nasal cannula (HFNC) is generally considered to have fewer enteral feeding problems than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation (NIPPV). However, the effects of HFNC on the feeding outcomes in preterm infants are still controversial. The aim of this study was to assess the effect of HFNC on postnatal growth and feeding.

Study design: We conducted a secondary analysis of a multicenter randomized controlled trial. Preterm infants born at <34 weeks were randomly assigned to the HFNC or NCPAP/NIPPV groups after initial extubation between 2015 and 2018. Data on postnatal growth and oral feeds were analyzed.

Results: Among 338 infants in the intention-to-treat analysis, the weight at 36 weeks in the HFNC group was significantly higher than that in the NCPAP/NIPPV group (1926 vs 1804 g, p = 0.04). In the per-protocol analysis, HFNC showed increased daily weight gain from extubation to discharge after adjusting for confounding factors (24.2 vs 22.4 g/day, adjusted difference 1.65 g/day, 95% confidence interval [CI] 0.12-3.18). In the subgroup of infants born at 22-27 weeks, the weight at 36 weeks was significantly higher in the HFNC group (1809 vs 1730 g, adjusted difference 113.4 g, 95% CI 5.0-221.8). There was no significant difference in time at initial oral feeding and reached full oral feeding.

Conclusion: In preterm infants, especially extremely preterm infants, the use of HFNC may be associated with better weight gain.

Objective: Extremely premature infants are treated with acetaminophen (APAP) for pain and patent ductus arteriosus. High doses of APAP in adults are toxic, and a recent study found an association between APAP metabolite levels in mothers' breast milk and both bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) in their premature infants. In this study, we determined levels of APAP metabolites in urine of infants at high risk for BPD and ROP.

Study design: Biorepository urine samples from 314 infants <29 weeks' gestation in the multicenter TOLSURF and PROP studies were analyzed by untargeted UHPLC:MS/MS (Metabolon, Inc.). We performed multivariate logistic regression and meta-analysis to examine associations between APAP metabolite levels and clinical outcomes.

Results: 4-APAP sulfate was the most abundant of 8 detected APAP metabolites and was present in 95% of urines. There were high correlations between levels of 4-APAP sulfate and the other APAP metabolites. In longitudinal studies on a subgroup of infants (day 6-56), periods of elevated 4-APAP sulfate occurred in 24 of 28 infants and were of longer duration (10.5 vs 4.2 days, p=0.001) with higher levels (13.3 vs 5.6, p=0.01) in infants after transition to enteral from total parenteral nutrition. Episodes of elevated metabolite did not differ by BPD status. At both day 10 and 28 there were no significant associations between levels of APAP metabolites and either BPD or ROP for all infants or for infants exclusively on parenteral or enteral nutrition.

Conclusion: In two cohorts of extremely premature infants, levels of urinary APAP metabolites were not associated with increased risk for two adverse clinical outcomes.