American journal of perinatology最新文献

Structured clinical guidelines improve outcomes in neonatal care. At Oklahoma Children's Hospital, the need for a standardized approach to extremely low birth weight (ELBW) infants became urgent due to rising acuity and care variability. Despite existing nursing protocols, the unit lacked comprehensive interdisciplinary guidelines for ELBW infants. Key goals included reducing intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP).Multidisciplinary teams developed eight clinical pathways using evidence-based models. The Appreciative Inquiry framework was used to engage staff and build consensus. The interdisciplinary workgroups conducted literature reviews, developed system-based protocols, and facilitated iterative revisions. Pathways were implemented and were supported by education, exposure, and saturation strategies. Key metrics were benchmarked using Vermont Oxford Network (VON) data, with IVH, BPD, and ROP as outcome measures and mortality as a balancing measure. Real-time data collection was used to drive further improvement. PDSA (plan, do, study, act) cycles targeted thermoregulation, line placement, early surfactant administration, and glucose and oxygen management.Post implementation data (n = 130) showed a reduction in severe IVH (from 25 to ∼20%), a 7% reduction in grade 2 and grade 3 BPD, consistently low ROP rates (<3%), and a downward mortality trend in 2023.ELBW pathways improved care standardization and outcomes without increasing mortality. Continued efforts beyond the first week of life are needed to sustain and expand improvements. · Multidisciplinary pathways improved standardization and care for ELBW infants.. · Pathways led to modest gains in BPD and IVH, guiding future quality improvement priorities.. · Education and teamwork drove adoption and sustainability without major resource needs..

Withholding or starting, withdrawing or continuing, high-technology interventions available to extremely premature newborns is a fundamental challenge in obstetrics and neonatology. Attempting to save an infant's life is a judgment fraught with uncertainty and risk because suffering can be prolonged, long-term outcomes are frequently unfavorable, and socio-economic inequities are burdensome to families. Survival rates of 22-23-24-week infants are increasing in hospitals that promote "active care," yet morbidity rates and long-term neurodevelopmental impairments remain substantial and not improving. Outcomes acceptable to some pregnant women and families are not to others. Delivery of premature infants, particularly by cesarean section, is associated with maternal health risks. Intensive care of extremely premature infants is expensive, and lost opportunity costs are under-appreciated. Autonomy of pregnant women contrasted with the rights of the fetus and infant are culture and religion-affected, technology-influenced, and powerfully persuaded by physicians and institutions who possess a conflict of interest related to career goals, research, and income, all factors not necessarily shared by pregnant women.Physicians should resist dogmatic positions tethered to unproven technologies and nonrigorous evidence. Some hospitals promote near-universal intensive care of 22-23-24-week infants while others recommend palliative care, differences curiously seen between and within countries, even cities. The legitimate zone of parental discretion is characterized by the value pluralistic shared decision-making of informed consent and is endorsed by the American Academy of Pediatrics, the Canadian Paediatric Society, and the American College of Obstetricians and Gynecologists. Physicians should objectively provide clinical outcomes, compassionately listen to pregnant women's concerns and preferences, and resist presenting care options as a restrictive protocol, or a wide-open menu. Because there is no unifying cultural or bioethical ethos, we should embrace shared decision-making recognizing inherent contingencies and tensions, with humble circumspection of possible nihilism (which might influence palliative care), and therapeutic fury (which might promote unreasonable zeal for interventional care). · Extreme prematurity requires knowing outcomes.. · Parental discretion may broaden with uncertainty.. · Shared decision-making assumes informed consent.. · Parental values differ from the values of physicians.. · Asymmetry of responsibility supports parental values..

This study aimed to examine the association between physician sex, cesarean delivery, and neonatal complications.We analyzed the Consortium on Safe Labor database including 228,437 deliveries from 2002 to 2008. The study focused on singleton pregnancies with cephalic presentations, excluding cases with contraindications to vaginal delivery, elective cesarean deliveries, and nonobstetricians and gynecologists or maternal-fetal medicine physician management. The primary outcome of this study was cesarean delivery; secondary outcomes were cesarean delivery due to arrest of dilation or descent, cesarean delivery for nonreassuring fetal heart tracings (NRFHT), cesarean delivery for other indications, and a composite of neonatal complications. To estimate average marginal effects (AMEs) in percentage points (pp) with 95% confidence intervals (95% CI) of cesarean delivery between male and female physicians, we performed generalized estimating equations with Poisson distribution and exchange-correlation structure, adjusting for maternal, physician-level characteristics, and hospital-fixed effects.Of 108,004 individuals, 46,779 (43.3%) were attended by 183 female physicians, and 61,225 (56.7%) were attended by 250 male physicians. Female physicians were associated with a lower overall adjusted cesarean delivery proportion (11.93 vs. 13.47%; AME -1.54 pp [95% CI: -2.35, -0.73]), cesarean delivery for failure to progress (5.72 vs. 6.48%; AME -0.76 pp [95% CI: -1.24, -0.27]), and cesarean delivery for indications except for failure to progress or NRFHT (1.68 vs. 2.01%; AME -0.33 pp [95% CI: -0.56, -0.10]). There were no significant differences in cesarean outcomes for NRFHT or composite neonatal complications between male and female physicians.Compared with male physicians, female physicians had a lower rate of cesarean delivery. Further research is needed to understand the underlying mechanisms and develop targeted interventions. · Compared with male physicians, female physicians had a lower rate of cesarean delivery.. · This reduction was particularly evident for cesarean deliveries due to failure to progress.. · The reduction was not associated with an increased risk of neonatal complications..

Although cesarean hysterectomy (C-HYST) is standard management for placenta accreta spectrum (PAS), the type of hysterectomy performed, total abdominal (TAH), or supracervical (SCH), is left to surgeon discretion. TAH has been previously associated with higher estimated blood loss (EBL), transfusion requirements, and complications compared to SCH.This was a single-site retrospective cohort study examining outcomes of TAH compared to SCH for PAS performed from 2008 to 2023. PAS was confirmed by clinical and pathologic diagnoses. Cervical removal was confirmed by operative report, postoperative exam, and pathology. Associations were assessed using chi-square tests, Fisher's exact tests, Mann-Whitney U tests, or individual t-tests.During the study period, 90 TAH and 54 SCH were performed. There were no significant differences in patient demographics, except that planned C-HYST was more likely to be TAH. TAH was associated with significantly lower transfusion requirements. When unexpected hysterectomies were excluded, there was not a significant difference in blood products transfused between the TAH and SCH groups.In PAS, maternal outcomes after TAH are at least equivalent to SCH. The surgical approach for the management of PAS should be further explored. · In PAS, outcomes are at least equivalent between TAH and SCH.. · C-HYST is optimally performed in a planned manner with all multidisciplinary team members present.. · Vertical skin incision was significantly associated with TAH in this retrospective cohort study..

To estimate the association between maternal body mass index (BMI) at delivery, time from skin incision to infant delivery, and umbilical artery (UA) pH < 7.0.This was a secondary analysis of the Assessment of Perinatal Excellence, a multicenter observational study of an obstetrical cohort of individuals who delivered between 2008 and 2011 in the United States. This analysis included women who delivered via cesarean with known BMI at delivery, skin incision-to-delivery time, and UA pH. Multivariable linear regression assessed the association between BMI and time from skin incision to infant delivery while multivariable logistic regression estimated the associations of BMI and time from skin incision to delivery with UA pH < 7.0. An interaction between BMI and skin incision-to-delivery time was evaluated to examine their combined effect on UA pH < 7.0.A total of 16,723 women were included across five BMI groups. Increasing BMI was associated with longer time intervals from skin incision to delivery and higher rates of UA pH < 7.0. After controlling for potentially confounding factors, all BMI groups ≥25 kg/m² were associated with longer time intervals from skin incision to delivery. Specifically, BMI groups of 40 to 49.9 and ≥50 kg/m² had skin incision-to-delivery times that were 1.30 (95% confidence interval [CI]: 1.23-1.36) and 1.44 (95% CI: 1.34-1.55) times longer, respectively, compared with BMI < 25 kg/m². In the multivariable logistic regression, BMI group ≥50 kg/m² remained associated with higher odds of UA pH < 7.0. There was a significant interaction between BMI and time from skin incision to delivery regarding the risk of UA pH < 7.0 (p for the interaction term = 0.003).Maternal BMI ≥ 50 kg/m² was associated with a longer time from skin incision to infant delivery and higher odds of UA pH < 7.0. BMI differentially impacted UA pH at different skin incision-to-delivery time intervals. · Maternal BMI ≥ 25 kg/m2 was associated with longer skin incision-to-delivery times.. · Maternal BMI ≥ 50 kg/m2 was associated with higher odds of UA pH < 7.0.. · The effect of maternal BMI on UA pH varied at different skin incision-to-delivery time intervals.. · Reducing skin incision-to-delivery time may mitigate the risk of UA pH <7.0 in women with BMI ≥50.

In a survey conducted within the Children's Hospital Neonatal Consortium (CHNC), the Kidney Focus Group aimed to describe the resource and practice variations among participating level IV neonatal intensive care units.A 24-question survey was developed by neonatologists and pediatric nephrologists who belong to the Kidney Support Therapy (KST) subgroup of the CHNC Kidney Focus Group.The majority (89.5%) of responding centers offered some form of KST, with > 90% centers offered prenatal consultations. The most common KST modality offered were peritoneal dialysis (PD) and continuous renal replacement therapy (CRRT) while on ECMO. Prismaflex was the most common device used for stand-alone CRRT. The most common indication for KST initiation was fluid overload and body weight was indicated as the most common limiting factor with the majority of centers reporting weight limitation ≤ 1.5-2 kg.Advances in technology have made it possible to offer KST to a wider neonatal population than before. However, the availability of such technologies can vary significantly among institutions in addition to diversity of clinical experience and standardized protocols. This survey provides valuable insights into current KST practices across 19 level IV NICUs within the CHNC demonstrating expected practice variations amongst centers that may be dependent on location, center resources, and subspecialty providers, among others. · Considerable practice variation exists in KST among NICUs.. · Majority of NICUs utilize multi-disciplinary involvement, but subspecialties vary widely.. · The most common indication for KST initiation was fluid overload..

This study aimed to evaluate whether a custom warmer height improves the quality and consistency of chest compressions (CCs) compared with a standard warmer height during simulated neonatal resuscitation.Cross-over study using simulated neonatal resuscitation. A controlled research environment equipped with a 12-camera motion capture system, four in-floor multi-axis force plates, a neonatal manikin, and resuscitation equipment. Biomechanical assessments were recorded every 2 minutes during a 20-minute simulation for each condition. Twenty Neonatal Resuscitation Program (NRP)-trained providers. Each participant performed two 20-minute CC sessions-one with the warmer at the standard 100 cm height and one at a custom height selected by the participant. CC depth, force, and rate; participant back angle, heart rate, and self-reported exertion, were analyzed at 2-minute intervals.Compared with the standard height, the custom height resulted in greater and more consistent CC depth and force while maintaining compression rate. Participants also exhibited a greater back angle, and lower heart rate, and reported reduced exertion under the custom height condition.Allowing NRP-trained providers to adjust warmer heights led to improved CC quality and consistency, suggesting that customizable warmer heights may enhance neonatal resuscitation performance. KEY POINTS: · Custom warmer height chosen by NRP-trained providers resulted in more consistent and greater CC depth and force.. · It also was associated with less provider fatigue, compared with standard height.. · During neonatal resuscitation, frontline healthcare professionals changed.. · Participant heart rate was lower when using the custom versus standard height.. · Our findings support the need for guidelines on adjusting warmer height during neonatal cardiopulmonary resuscitation..

The goal of this study is to evaluate whether adjuvant progesterone following cerclage affords a reduction in the rate of preterm delivery.This is a retrospective cohort review of all individuals who underwent transvaginal cerclage placement at a tertiary care academic medical center between 2005 and 2021. The rate of delivery prior to 37 weeks and several secondary maternal and neonatal outcomes were compared between patients with and without progesterone supplementation after cerclage. Multivariable regression, subgroup, and matched pairs analyses were performed in order to account for the formulation of progesterone, indication for cerclage, and other potential confounding variables. The study was powered a priori to detect a difference in our primary outcome.Among 451 patients, there were 163 history-, 135 ultrasound-, and 153 examination-indicated cerclages. Overall, 284 (63%) received adjuvant progesterone. Adjuvant progesterone was associated with an increased rate of preterm delivery before 37 weeks (45 vs. 34%, p = 0.03) with an adjusted odds ratio of 1.78 (95% confidence interval: 1.14 and 2.80) in our multivariable model. The median latency from cerclage placement to delivery was shorter when progesterone was used (119 vs. 139 days, p < 0.001). There was no benefit of adjuvant progesterone when analyzed by formulation of progesterone or indication for cerclage or when analyzing pairs matched based on propensity score matching. There were no differences in secondary outcomes for pregnant patients or their offspring.Adjuvant progesterone does not decrease the preterm delivery rate and may in fact cause harm by decreasing latency from cerclage to delivery. Maternal and neonatal outcomes do not vary with supplemental progesterone after cerclage. Our data do not support a synergistic benefit of cerclage and postcerclage progesterone. · There are currently no guidelines for the use of progesterone after cerclage.. · Adjuvant progesterone does not decrease the preterm birth rate.. · Secondary maternal and neonatal outcomes do not improve with adjuvant progesterone..

Microplastics have been detected in human placental and neural tissues, raising urgent concerns about their potential effects on maternal and fetal health. Emerging evidence links microplastics to systemic inflammation, neurotoxicity, and endocrine disruption, yet their impact on pregnancy outcomes and fetal development remains poorly understood. Given the placenta's central role in early-life health, perinatal researchers are uniquely positioned to lead investigations into this environmental threat. We call for collaborative, multidisciplinary research to better understand and mitigate the effects of microplastic exposure during pregnancy. · Microplastics can cross the placenta and blood-brain barrier, reaching fetal tissues.. · Microplastics trigger inflammation, oxidative stress, and endocrine disruption in human cells.. · Perinatal research should explore links between microplastics and fetal development risks..