American journal of perinatology最新文献

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..

Objective:  This study aimed to describe feeding outcomes in neonates with hypoxic-ischemic encephalopathy (HIE) and compare characteristics and outcomes in groups discharged home on oral, total/partial nasogastric, and gastrostomy tube feedings.

Study design:  This was a retrospective, single-center cohort study of infants diagnosed with moderate or severe HIE using standard criteria who underwent cooling from January 2017 to June 2022. Data were abstracted from hospital course as well as until 6 months follow-up. Statistical analysis included chi-square test and ANOVA with post hoc Bonferroni correction for between-group comparisons.

Results:  Among 123 included infants, 95 (77%) fed orally, 11 (9%) required total/partial nasogastric feeds and 17 (14%) had gastrostomy tubes at discharge. A significantly greater proportion of infants with gastrostomy-tube feeds at discharge had intrapartum complications, Apgar scores <5 at 5 and 10 minutes, severe rather than moderate HIE, and seizures. They also had a longer hospital stay, prolonged respiratory support and intubated days, and delayed initiation of feeding. Infants discharged on nasogastric feeds all attained oral feeds at a median (IQR) duration of 54 (6-178) days follow-up. Among the 106 (86%) infants with follow-up data, the gastrostomy group had significantly lower median weight and head circumference centiles compared to the others. Criteria for gavage eligibility were met before discharge in 98 (80%) of the cohort; 42% stayed beyond this benchmark.

Conclusion:  Earlier identification of eventual gastrostomy tube insertion as well as discharge home on nasogastric feedings may reduce duration of hospitalization in infants with HIE. Our data may provide insights to guide practice improvement for enteral feedings in this population.

Key points: · In neonatal encephalopathy, impaired oral feedings is common.. · Antepartum complications and HIE severity are associated with gastrostomy insertion.. · Discharge home on gavage feeds could shorten hospital stay..

Objective:  This study aimed to evaluate rotating intravenous (IV) fluids compared with insulin infusion for maternal intrapartum glycemic control of neonatal blood glucose within 2 hours of birth.

Study design:  This randomized controlled trial compared the use of rotating IV fluids to continuous insulin infusion for intrapartum glycemic control for patients with type II diabetes mellitus (DM) or medication-controlled gestational diabetes (A2GDM). A sample size of 74 participants was studied to detect a 10-mg/dL difference in neonatal blood glucose within 2 hours of birth between the groups with a standard deviation of 15, 80% power, and α 0.05. Secondary neonatal outcomes included neonatal blood glucose within 24 hours after birth, Apgar < 7 at 5 minutes, and a composite including neonatal hypoglycemia, NICU admission, hyperbilirubinemia, and respiratory distress syndrome. Secondary maternal outcomes included intrapartum hypoglycemia, blood glucose immediately prior to delivery, mode of delivery, and postpartum complications. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed.

Results:  A total of 114 patients were randomized, 57 in each arm. For the PP analysis, 51 patients were analyzed in the rotating IV fluids arm and 32 patients in the insulin infusion arm. There was no significant difference in neonatal blood glucose within 2 hours of birth when rotating IV fluids were used (ITT: 54.5 mg/dL [IQR: 42.5, 72.5], PP: 56.0 mg/dL [IQR: 42.0, 76.0]) when compared with an insulin infusion (ITT: 59.0 mg/dL [IQR: 41.0, 69.0], PP: 62.5 mg/dL [IQR: 44.5, 68.5], p = 0.89 [ITT] and p = 0.68 [PP]). No significant differences were noted in secondary outcomes. The median intrapartum maternal blood glucose was 98.5 mg/dL (IQR: 90.5, 105.0) in the rotating fluids arm and 96.3 mg/dL (IQR: 90.0, 108.5) in the insulin infusion arm (p = 0.96), and the rate of neonatal hypoglycemia was 11.8 versus 15.6%, respectively (p = 0.61) in the PP analysis.

Conclusion:  There was no difference in neonatal blood glucose within 2 hours of birth when rotating IV fluids were used for intrapartum glycemic control compared with a continuous insulin infusion.

Key points: · There is no optimal option for maternal glycemic control in labor.. · Maternal glycemic control was comparable in the two study arms.. · There was no difference in neonatal blood glucose between study arms..

Objective:  This study aimed to examine the correlations between pairs of maternal, infant, and maternal-infant dyad quality measures to provide a comprehensive assessment of perinatal care.

Study design:  In a retrospective cohort study using birth and fetal death certificates linked to hospital discharge data from Michigan, Oregon, Pennsylvania, and South Carolina (2016-2018), we examined correlations between pairs of maternal, infant, and maternal-infant dyad quality measures. Maternal quality measures included nulliparous term singleton vertex (NTSV) cesarean birth, nontransfusion severe maternal morbidity (SMM), and a composite maternal outcome. Infant quality was assessed with a composite outcome measure, whereas the dyad measure combined maternal and infant outcomes.

Results:  Among 955,904 dyads across 266 hospitals, 25.9% had NTSV, 0.7% had nontransfusion SMM, 12.3% had the composite infant measure, and 19.3% had the dyad measure. The correlation between nontransfusion SMM and the dyad measure was 0.12, whereas the correlation between the composite infant measure and the dyad measure was 0.86, which was higher than the correlation between the composite maternal measure and the dyad measure (0.47).

Conclusion:  We observed minimal correlations among these perinatal quality measures, especially when aggregated beyond individual outcomes.

Key points: · There are minimal correlations among different perinatal quality measures.. · Quality is multifaceted, and hospitals vary in the level of quality they achieve.. · Assessing hospital care for pregnant patients and infants requires multiple quality measures..

Background: The incidence of substance use disorder (SUD) during pregnancy continues to increase; however, the identification of SUD is challenging. The significance of individual risk factors and their association with toxicology is contentious.

Objective: To identify maternal and neonatal risk factors associated with positive toxicology results for non-prescribed substance use during pregnancy.

Design/methods: This retrospective study included pregnant persons and their infants, who were screened for predetermined risk factors for SUD during pregnancy. The toxicology test results of pregnant persons' urine and infants' urine, meconium/umbilical cord, were correlated with risk factors.

Results: Maternal risk factors (history of pre-pregnancy or current SUD, on medication for opioid use disorders, insufficient prenatal care, sexually transmitted and blood-borne infections) and neonatal risk factors (neonatal opioid withdrawal syndrome, intrauterine growth restriction) showed a correlation with toxicology results.

Conclusion: Combining maternal and neonatal risk factors with toxicology testing may accurately identify SUD in pregnancy.

Objective:  Influenza and tetanus toxoid reduced diphtheria toxoid, and acellular pertussis (Tdap) are safe and effective vaccines that are recommended in pregnancy. Despite this, significant vaccine hesitancy exists in pregnancy. However, impact of the coronavirus disease 2019 (COVID-19) pandemic on vaccine hesitancy is not well understood. Thus, we sought to describe impact of the COVID-19 pandemic on influenza and Tdap vaccination rates in pregnant patients.

Study design:  Retrospective cohort study of patients delivering at single academic center from October 1, 2017 to August 31, 2021. Patients with missing vaccine data or delivering before 28 weeks (Tdap range) excluded. Patients delivering pre-COVID (October 1, 2017-August 31, 2019) compared with those delivering mid-COVID (October 1, 2020-August 31, 2021). Primary outcomes were vaccination rates for Tdap and influenza. Secondary outcome was rate of dual vaccination (receiving both) and variation by race/ethnicity. Chi-square tests and logistic regression were used to test for changes in vaccination rates.

Results:  Of 8,650 unique patient pregnancies, 5,925(68.5%) occurred pre-COVID. Median patient age (30 years) and gestational age at delivery (39 weeks) not clinically different between groups. Patients in mid-COVID group had lower numbers of government-assisted insurance (47.3%) and higher non-Hispanic Black compared with pre-COVID (31.5%). The rate of influenza vaccination decreased 8.2 percentage points from pre-COVID to mid-COVID (69.9 vs. 61.7%, p < 0.001). Tdap vaccination rates also decreased, although less-so (88.5 vs. 85.1%, p < 0.001). The rate of patients receiving both vaccines during pregnancy decreased from 66.0 to 58.4% (p < 0.001). Significant decreases in influenza vaccination rates mid-COVID versus pre-COVID was seen in all race-ethnicity groups except non-Hispanic White patients. For Tdap vaccinations, the effect of COVID on the odds of receiving Tdap did not differ across race-ethnicity groups.

Conclusion:  Rates of influenza, Tdap, and dual vaccination in pregnancy dropped significantly during the COVID-19 pandemic. For influenza, these were most pronounced in all race-ethnicities included with exception of non-Hispanic White. These data emphasize the importance of continued counseling and education on vaccinations in pregnancy and raise important questions regarding vaccine access and patient hesitancy during pandemic-mediated prenatal care.

Key points: · Influenza vaccination decreased with COVID-19.. · Tdap vaccination decreased with COVID-19.. · Decrease in flu vaccination in most race-ethnicity groups..

Objective: Extreme preterm (EPT) delivery, occurring before 28 weeks of gestation, carries high morbidity and mortality risks. Small for Gestational Age (SGA) infants, about 8-20% of EPT neonates, face increased risks. Mortality risk varies with gestational age and birth weight, with mixed reports on specific morbidities. This study aims to determine mortality rates and common causes of death among EPT SGA infants.

Study design: The study used data from the CDC National Vital Statistics System, covering births and deaths from 2016-2021, with follow-up through 2022. It included infants born between 22 and 27 weeks gestation who were admitted to the neonatal intensive care unit. The outcome was all-cause in-hospital mortality within 30 days of birth, with causes of mortality classified based on ICD-10 codes. Small for Gestational Age (SGA) was the primary independent variable.

Results: Based on a sample of N=96134 infants, we estimated 13% were born SGA and 30-day mortality rates were higher among SGA compared to non-SGA infants (31% vs. 13%). On multivariable analysis SGA infants had higher 30-day mortality than non-SGA (odds ratio: 3.82; 95% CI: 3.64, 4.01; p<0.001), and were more likely to have death ascribed to complications of short gestation rather than other causes of death (Relative Risk Ratio: 1.42; 95% CI: 1.27, 1.59; p<0.001).

Conclusions: SGA infants receiving intensive care have high mortality risk, especially due to complications of short gestation and low birthweight complications.

Objective:  This study aimed to estimate and compare the recurrence risk of preterm birth (PTB), gestational diabetes mellitus (GDM), gestational hypertension (GH), and preeclampsia and eclampsia (PE and E) in subsequent pregnancy groups (index-subsequent) of singleton-singleton (n = 49,868), twin-singleton (n = 448), and singleton-twin (n = 723) pregnancies.

Study design:  Birthing individuals from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Consecutive Pregnancy Study (2002-2010) with ≥ 2 singleton or twin deliveries were examined. Adjusted relative risks (aRR) and 95% confidence intervals (CI) for recurrent PTB, GDM, GH, and PE and E were estimated using Poisson regression models with robust variance estimators.

Results:  The aRR of PTB and GDM ranged from 1.4 to 5.1 and 5.2 to 22.7, respectively, with the greatest recurrence relative risk for both conditions in singleton-singleton subsequent pregnancies (PTB: aRR = 5.1 [95% CI: 4.8-5.5], GDM: aRR = 22.7 [95% CI: 20.8-24.8]). The aRR of GH and PE and E ranged from 2.8 to 7.6 and 3.2 to 9.2, respectively, with the greatest recurrence relative risk for both conditions in twin-singleton subsequent pregnancies (GH: aRR = 7.6 [95% CI: 2.8-20.5], PE and E: aRR = 9.2 [95% CI: 2.9-28.6]).

Conclusion:  Recurrence relative risk was increased for PTB, GDM, GH, and PE and E in all subsequent pregnancy groups, which varied in magnitude based on the birth number of the index and subsequent pregnancy. This information provides insight into risk management for subsequent pregnancies including multiples.

Key points: · Recurrence risk for all conditions is persistent in all subsequent pregnancy groups.. · The magnitude of risk varies by the presence of multiples in the index or subsequent pregnancy.. · Singleton-singleton pregnancies are at the greatest risk of PTB.. · Singleton-singleton pregnancies are at the greatest risk of GDM.. · Twin-singleton pregnancies are at the greatest risk of hypertensive disorders..

Objective:  Factors associated with the development and expression of Neonatal Opioid Withdrawal Syndrome (NOWS) are poorly understood. There are conflicting data on the role of infant sex in NOWS. Some studies have suggested that infant sex predicts NOWS severity and adverse outcomes, with male infants being more vulnerable. This study aimed to analyze if infant sex is associated with the severity of NOWS among those who require pharmacologic treatment.

Study design:  This is a retrospective cohort study of term and late-preterm infants (≥35 weeks gestation) exposed to in utero opioids, born between September 2006 and August 2022, and required pharmacologic treatment for NOWS. Maternal and infant demographics were collected. Indicators of the severity of NOWS (duration of medical treatment (DOT), duration of hospitalization, maximum dose of opioid treatment, and use of secondary medications) were compared between male and female infants. Standard statistical tests and regression analysis were used to establish the differences in outcomes after accounting for confounders and baseline differences.

Results:  Out of the 1,074 infants included in the study, 47.9% were female, and 52.1% were male. There was no significant difference in demographic and baseline clinical characteristics between groups except for anthropometry (birth weight, head circumference, and length) and Apgar score at 5 minutes. The median DOT (25 days [14, 39] vs. 23 days [13, 39], p = 0.57), length of hospital stay (31.5 days [20, 44] vs. 28 days [20, 44], p = 0.35), treatment with phenobarbital (24.7 vs. 26.3%, p = 0.56), and clonidine (3.9 vs. 3.8%, p = 0.9) were similar in both groups. The differences remained nonsignificant after adjusting for birth anthropometric measurements, gestational age, 5-minute Apgar score, small for gestational age status, and maternal exposure to benzodiazepines.

Conclusion:  In this cohort of neonates, sex-related differences were not identified to influence the severity of NOWS among those who required pharmacological treatment.

Key points: · Vulnerability to NOWS is multifactorial.. · The role of infant sex in the severity of NOWS is not concrete.. · We noted that sex did not impact NOWS severity in those treated..