American journal of perinatology最新文献

This study aimed to evaluate trends in the frequency of pharmacologic prophylaxis following the implementation of a postpartum venous thromboembolism (VTE) prevention protocol. Secondarily, to evaluate the association between protocol implementation and incidence of VTE and complications.Retrospective cohort of patients delivering from 2015 to 2022 at a single academic institution. Those with an antepartum VTE or receiving therapeutic anticoagulation were excluded. An inpatient thromboprophylaxis protocol was implemented in January 2017 and further updated in July 2020 to expand risk factors to qualify for prophylaxis and extend the length of therapy to the outpatient setting (total 14 days). The cohort was divided into three time periods: preimplementation (January 1, 2025-December 31, 2016), initial protocol (January 1, 2017-June 30, 2020), and updated (July 1, 2020-December 31, 2022) protocol. The primary outcome was the receipt of inpatient heparin-based pharmacologic prophylaxis. Secondary outcomes included filling an outpatient pharmacologic prophylaxis prescription, VTE, and wound complications observed through 6 weeks postpartum. Baseline characteristics and outcomes were compared across the three protocol periods. Logistic regression modeling estimated the association between outcomes and the updated protocol period compared with prior periods.Overall, 22.6% (95% confidence interval [CI]: 22.1-23.0) of 34,217 included deliveries received inpatient pharmacologic prophylaxis: 7.7% (7.1-8.2%) preimplementation, 15.8% (15.2-16.4%) initial protocol, and 41.2% (40.4-42.1%) during the updated protocol period. The rates of inpatient and outpatient prophylaxis increased significantly over time (p < 0.001 test of trend). Delivery in the updated protocol period was not associated with differences in VTE (pre: 0.1%, initial: 0.2%, and updated: 0.1%) nor wound complications (pre: 3.4%, initial: 2.7%, and updated: 2.7%).Single-center implementation of a postpartum prophylaxis protocol resulted in increased use of inpatient and outpatient pharmacologic prophylaxis without changes in rates of VTE or wound complications. · Implementation of a postpartum thromboprophylaxis protocol resulted in increased rates of pharmacologic prophylaxis.. · No differences in wound complications were observed by the protocol period.. · Rates of VTE did not change over time..

This study aimed to identify the neonatal training needs of levels I and II community health centers (CHCs).We conducted a mixed-methods study involving a questionnaire, focus groups (FG), and an audit of neonatal transport data. The questionnaire assessed the felt needs of CHC staff, FGs identified normative needs with an expert neonatal transport team, and the audit captured expressed needs using data from the Canadian neonatal transport network.A total of 158 respondents from 12 CHCs completed the questionnaire (98% completeness rate). Key findings indicated significant challenges in human resources, procedural training, management of critical situations including neonatal resuscitation, nutrition, and neurodevelopmental care (NDC), and crisis resource management. Simulation emerged as the preferred training modality. FGs (three sessions, 17 participants) emphasized the importance of regular, multidisciplinary simulation-based training and stress management. The audit (947 means of transport, 2017-2020) revealed frequent respiratory, neurological, and surgical diagnoses, reinforcing the need for advanced training in respiratory support, neonatal resuscitation, and select high-acuity-specific pathologies.Targeted outreach education is essential to address the identified training needs in neonatal care at CHCs. Key components should include simulation-based training, comprehensive procedural modules, and specialized modules on extreme prematurity, pneumothorax, hypoxic-ischemic encephalopathy/seizures, and surgical conditions. Enhanced training in nutrition and NDC is also critical for community health practitioners. · CHC lack neonatal care training.. · In situ simulation training is the preferred modality of CHC.. · Key training gaps include resuscitation and ventilation.. · Crisis resource management and stress management are key team training components.. · Training must cover prematurity, respiratory, neurological, and surgical conditions..

The aim of this study is to provide an extensive review of the published literature regarding the use of nasogastric (NG) feeds at discharge in the neonatal population as well as our experience with the implementation of an NG feeds at discharge program in our level IV neonatal intensive care unit.We reviewed and compared the use of NG tubes at discharge and gastrostomy tubes in the neonatal population. We provide an extensive review of previous publications regarding programs of NG feeds at discharge in neonates across the United States and Europe including preterm neonates, neonates with chronic lung disease, and neurological injury. We also reviewed parents' perspectives on NG use at discharge in the neonatal population as well as the use of telehealth in remote monitoring of neonates discharged on NG feeds. We reviewed the economic benefits of such programs. We finally provide our center's algorithm and workflow as well as our center's experience.Twenty-five patients have been discharged so far from this program since its implementation in December 2020. Only 1 patient of the 25 patients discharged on NG tube feeds required gastrostomy tube placement.Discharge with NG tube feeds in a carefully selected population is safe, and feasible and can lead to increased parent satisfaction, besides offering a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds. · Discharge with NG tube feeds in a carefully selected neonatal population is safe and feasible.. · Nasogastric feeds at discharge can lead to increased parent satisfaction and a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds.. · Carefully structured education at discharge, as well as follow-up programs in place can ensure adequate parental support during this process.. · Telehealth can play a key role in implementation of such programs..

This study aimed to determine if the rate of hysterotomy extensions increases with increasing cervical dilation in unscheduled cesarean deliveries, and to develop a measure of the severity of hysterotomy extension for quantifying morbidity.This is a retrospective study of unscheduled cesarean deliveries relating to labor dystocia and/or nonreassuring tracings from January 1, 2021, to December 31, 2021. Severe extension was defined as bilateral or adjacent to a structure such as the uterine artery, broad ligament, or cervix, and was compared with uterine artery extensions alone.There were 990 unscheduled cesarean deliveries included. Extensions (n = 233) significantly increased with increasing cervical dilation (p < 0.0001), complicating more than 30 and 50% at 6 and 10 cm of cervical dilation, respectively. Apart from this trend, a logistic regression analysis indicated cervical dilation was an independent risk factor for extension. Transfusions of at least 2 units of blood were five times (26 vs. 5%) more likely for patients with severe extensions than no extension (p < 0.0001).Hysterotomy extensions significantly increase with increasing cervical dilation, and cervical dilation is an independent risk factor for extension. A composite measure of severity accounts for different types of extension when quantifying morbidity, but uterine artery extension is the primary driver of maternal morbidity in cases without hysterectomy. · We report higher than previously published rates of extension, in our study of unscheduled cesareans.. · Extension rates rise with cervical dilation-33% at 6 cm, over 50% at 10 cm.. · Cervical dilation is an independent risk factor for extension.. · Severe extensions were fivefold more likely to be transfused two units than no extension.. · The composite measure for severity was driven by uterine artery extensions..

Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with ≥3 maneuvers, compared with fewer, is associated with a higher likelihood of adverse outcomes. The secondary objective was to examine if postpartum hemorrhage is associated with SD managed with ≥3 maneuvers versus fewer.This was a secondary analysis of the assessment of perinatal excellence (APEX) study, an observational cohort of over 115,000 deliveries in 25 U.S. hospitals from 2008 to 2011. We included individuals with singleton, vertex, and nonanomalous fetuses at ≥34 weeks who had SD requiring at least one maneuver. We stratified participants according to if ≥3 maneuvers, versus fewer, were utilized to resolve the SD. The primary outcome was the incidence of a neonatal composite adverse outcome including APGAR <5 at 5 minutes, fetal fractures, intracranial hemorrhage, brachial plexus palsy, facial nerve palsy, hypotension treated, hypoxic-ischemic encephalopathy, or neonatal death. Using modified-Poisson-regression, we calculated adjusted incidence relative risk (aIRR) with 95% confidence intervals (CI).The rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 cases of SD, 96% met the inclusion criteria. ≥3 maneuvers were utilized in 18.9% (391/2,062) of SD cases. The composite neonatal adverse outcome occurred in 8.1% (168/2,062) of cases, and in adjusted models, the risk for the composite outcome was significantly higher with SD requiring ≥3 maneuvers (15.1%) versus <3 maneuvers (6.5%; aIRR: 2.08; 95% CI: 1.50-2.89). Additionally, APGAR <5 at 5 minutes (aIRR: 4.10; 95% CI: 1.18-14.25), neonatal brachial plexus palsy (aIRR: 2.58; 95% CI: 1.45-4.60), and hypoxic-ischemic encephalopathy (aIRR: 2.83; 95% CI: 1.36 and 5.89) were significantly more likely when ≥3 were used. No significant difference was noted for postpartum hemorrhage (PPH) by number of maneuvers (aIRR: 0.74; 95% CI: 0.44 and 1.21).SD relieved by ≥3 maneuvers, compared with <3, was associated with a 2-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for PPH. · ≥3 Maneuvers increase neonatal adverse outcomes.. · With ≥3 maneuvers, higher risk of low APGAR and HIE.. · PPH rates similar for ≥3 versus <3 maneuvers..

Enhanced recovery after surgery programs for cesarean deliveries (ERAC) aim to optimize the quality of care for all patients. Race is not routinely monitored in ERAC programs. Given the extensive reports of racial disparities in obstetrical care, the goal of this study was to investigate racial differences in adherence rates to individual ERAC protocol elements.A cohort study was performed among cesarean delivery patients enrolled in an ERAC program at two hospitals from October 2016 to September 2020. Compliance with anesthesia-specific ERAC metrics, including ketorolac, ondansetron, and active warming methods, were compared by race. Race was self-reported by all patients. Logistic regression models stratified by pre- and post-ERAC status were used to assess relationships.The sample consisted of 7,812 cesarean delivery patients, of which 4,640 were pre-ERAC (59.4%) and 3,172 were post-ERAC (40.6%). There were no racial differences found in overall ERAC protocol adherence, active warming methods, or ondansetron administration in the pre- and post-ERAC groups. The odds of ketorolac administration in Black patients (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.55-0.95; p = 0.020) and Asian patients (aOR: 0.81; 95% CI: 0.68-0.98; p = 0.027) pre-ERAC were significantly lower compared with white patients. In the post-ERAC group, this disparity persisted in Black (aOR: 0.80; 95% CI: 0.65-0.99; p = 0.042) and Asian patients (aOR: 0.85; 95% CI: 0.73-0.98; p = 0.023).Appropriate implementation and adherence to all elements of the ERAC program may provide a practical approach to reducing disparities in outcomes and ensuring equitable treatment for all patients. · No racial differences were found in ondansetron administration pre- and post-ERAC.. · No racial differences were found in active warming methods pre- and post-ERAC.. · Black patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · Asian patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · ERAC metrics must be routinely monitored by race to resolve any observed inequities..

The clinically-modified obstetric comorbidity index (OB-CMI) is a comorbidity-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 the prediction of SMM as defined by the CDC during delivery admissions across a diverse health system.This is a retrospective cohort study evaluating all deliveries in a large health system encompassing academic and community hospitals. Data from 2019 to 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 nontransfusion SMM (defined by the CDC) during the delivery admission. Patient characteristics were evaluated by the hospital, and hospital-specific receiver-operator characteristic (ROC) curves were constructed and compared.In total, 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. 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 range from 0.77 to 0.83, and no significant differences across hospitals (p = 0.32).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. · The clinically-modified OB-CMI consistently predicted nontransfusion SMM across multiple hospitals.. · This OB-CMI can be used for obstetric risk stratification across different clinical settings.. · Future research should explore the impact of using the OB-CMI to mitigate risk in clinical practice..

The study objective was to evaluate the relationship between the first hip ultrasound (HUS) result and developmental dysplasia of the hip (DDH) diagnosis in preterm infants. Additionally, we report the types of treatment for preterm infants diagnosed with DDH.This is a retrospective chart review of infants born between January 1, 2009, and December 31, 2018, at <37 weeks of gestation who had HUS in the first year of life. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity for abnormal and normal HUS results were calculated.From 2,397 infants analyzed, 71 (3%) infants were diagnosed with DDH. The majority (n = 2,140; 89%) of patients had normal HUS, with only 5 (0.2%) infants later diagnosed with DDH. The sensitivity of HUS was 0.91 PPV 0.8, the specificity was 0.99 and NPV was 0.99. Of the 196 (8%) infants with equivocal results, 17 (9%) had subsequent DDH diagnoses.For infants diagnosed with DDH, the majority (n = 41; 58%) were treated nonoperatively with Pavlik harness. Surgical correction was performed in 26 (36%) patients.A normal first HUS result in preterm infants has an excellent NPV for the diagnosis of DDH. Abnormal first HUS has a good PPV. Those with an equivocal result may need close follow-up. · A normal HUS in preterm infants strongly rules out DDH.. · An abnormal HUS result in preterm infants has a good PPV for DDH.. · Most preterm infants with developmental DDH are managed nonsurgically..

A functional progesterone withdrawal has been thought to contribute to the pathophysiology of spontaneous preterm birth (PTB). The density of the progesterone receptor (PR) in gestational tissues could play a role in functional progesterone withdrawal. We sought to understand the relationship between placental pathology and the density of PR in the basal decidua in the setting of spontaneous preterm delivery.This is a secondary analysis of a retrospective cohort study of 40 patients with spontaneous PTB < 37 weeks from a prior study at NorthShore University HealthSystem previously described. Placental pathology was categorized according to the Amsterdam criteria into acute inflammation (AI), chronic inflammation (CI), maternal vascular malperfusion (MVM), and fetal vascular malperfusion (FVM). Slides containing basal decidua were stained for PR. Ten distinct images were obtained from the basal plate of each placenta. The positive cell detection program in QuPath image analysis software was used to estimate the percentage of cells positive for PR (%PR + ). The mean %PR+ cells were calculated from the ten representative images and were correlated with patterns of placental injury using t-tests. Models were adjusted for gestational age at delivery.The median gestational age at delivery was 32.5 weeks (interquartile range: 30.5, 34.1). There was a lower density of %PR+ cells among those with AI (12.9%PR+ without AI vs. 9.1%PR +  with AI, p = 0.03). There were no differences in the percent of %PR+ cells based on CI, MVM, or FVM. Models adjusted for gestational at delivery demonstrated persistent association with PR density and AI and no difference in the other pathologies.The presence of AI is associated with the lower density of PR expression in the basal decidua by quantitative immunohistochemical analysis. Further research is needed to investigate these findings in the context of spontaneous PTL and the prevention of PTB. · AI is associated with a lower density of PR expression.. · PR is expressed in the basal decidua in the placenta.. · Further research is needed to investigate findings in the context of PTB..

Pregnancy is associated with increased risk for the development of iron deficiency anemia. Pregnant patients with anemia are at increased risk for significant morbidity and mortality. Iron therapies for the correction of anemia during pregnancy are available in intravenous and oral formulations; however, the cost-effectiveness of these therapies in the United States has not been previously evaluated. The objective of this study is to estimate the cost-effectiveness of oral and intravenous iron therapies as treatments for prepartum anemia in the United States.We constructed a Markov decision-analytic model to evaluate the cost-effectiveness of three common therapies for repleting iron in patients with prepartum anemia in the United States: oral iron, intravenous iron sucrose, and intravenous ferric carboxymaltose. Each strategy differentially modified the proportion of patients with anemia at time of delivery by the therapeutic efficacy of each treatment option demonstrated in the literature. Outcomes of interest included net costs, quality-adjusted life-years, and adverse outcomes averted. Costs were considered from the health system and societal perspectives over a lifetime time horizon for a hypothetical cohort of 3.8 million pregnant patients. Deterministic and Monte Carlo probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.All iron therapies were dominant versus the "do nothing" strategy in the majority of simulations, implying that they were simultaneously more effective and cost-saving. Ferric carboxymaltose produced the most favorable results overall, with $696,920,137 in cost-savings and 26,660 postpartum hemorrhage cases, 888 hysterectomies, and 43 postnatal suicides averted per cohort. Threshold analysis suggested that oral iron was cost-saving below a threshold of $14.40 per 325 mg, and iron sucrose and ferric carboxymaltose were cost-saving below thresholds of $1996.86 and $2,893.97 per course, respectively.Our findings suggest that treating prepartum anemia with currently available iron therapies would result in significant cost-savings and reductions in adverse outcomes associated with anemia in this context. Ferric carboxymaltose likely confers the greatest overall benefit among competing options. This conclusion is robust to parameter uncertainty, even when the cost of these therapies is significantly higher than demonstrated in the literature. · Oral and intravenous iron therapies are likely cost-effective for the treatment of antepartum anemia.. · Intravenous ferric carboxymaltose is likely the most clinically and economically favorable treatment.. · This is the first U.S. estimate of the cost-effectiveness of oral and intravenous iron for antepartum anemia..