American journal of perinatology最新文献

Objective:  Distinguishing between medically indicated induction of labor (iIOL) and elective induction of labor (eIOL) is a daunting process for researchers. We aimed to develop a Natural Language Processing (NLP) algorithm to identify eIOLs from electronic health records (EHRs) within a large integrated health care system.

Study design:  We used structured and unstructured data from Kaiser Permanente Southern California's EHRs of patients who were <35 years old and had singleton deliveries between 37 and 40 gestational weeks. Induction of labor (IOL) pregnancies were identified if there was evidence of an IOL diagnosis code, procedure code, or documentation in a delivery flowsheet or progress note. A comprehensive NLP algorithm was developed and refined through an iterative process of chart reviews and adjudications, where IOL-associated reasons (medically indicated vs. elective induction) were reviewed. The final algorithm was applied to discern the indications of IOLs performed during the study period.

Results:  A total of 332,163 eligible pregnancies were identified between January 1, 2008, and December 31, 2022. Of these eligible pregnancies, 68,541 (20.6%) were IOL, of which 6,824 (10.0%) were eIOL. Validation of the NLP process against 300 randomly selected pregnancies (100 eIOL, iIOL, and non-IOL cases each) yielded a positive predictive value of 83.0% and 88.0% for eIOL and iIOL, respectively. The rates of eIOL among the maternal age groups ranged between 9.6 and 10.3%, except for the <20 years group (12.2%). Non-Hispanic White individuals had the highest rate of eIOL (13.2%), while non-Hispanic Asian/Pacific Islanders had the lowest rate of eIOL (7.8%). The rate of eIOL increased from 1.0% in the 37-week gestational age (GA) group to 20.6% in the 40-week GA group.

Conclusion:  Findings suggest that the developed NLP algorithm effectively identifies eIOL. It can be utilized to support eIOL-related pharmacoepidemiological studies, fill in knowledge gaps, and provide content more relevant to researchers.

Key points: · An NLP algorithm was developed to identify indications of IOL.. · The study algorithm was successfully implemented within a large integrated health care system.. · The study algorithm can be utilized to support eIOL-related studies..

Objective:  Fetal growth restriction (FGR) increases the risk for perinatal morbidity and mortality. The Society for Maternal-Fetal Medicine expanded the definition of FGR to independently include abdominal circumference (AC) < 10th percentile for gestational age (GA), regardless of estimated fetal weight (EFW). While studies have shown increased detection of small for GA neonates with expanded definition, no studies have evaluated the likelihood of abnormal umbilical artery Dopplers (UAD) detection with expanded definition. The objective of this study was to compare the likelihood of identifying UAD abnormalities in fetuses with normal EFW and restricted AC versus those by EFW alone.

Study design:  Single-institution retrospective cohort study of fetal growth ultrasounds meeting criteria for FGR either by EFW < 10th percentile or AC < 10th percentile with normal EFW. Those with FGR by AC alone were compared with those with FGR by EFW. Primary outcome was prevalence of UAD abnormalities, including elevated systolic/diastolic ratio, and absent and/or reversed end diastolic velocity. Receiver operator characteristic curves were generated to compare predictive value of UAD abnormalities by FGR definition.

Results:  A total of 619 scans met criteria for FGR between November 2020 and June 2021, with 441 (71%) meeting definition by EFW and 178 (29%) by AC criteria alone. Baseline characteristics were similar between groups. FGR by AC alone was identified earlier (30.4 ± 3.3 vs. 35.4 ± 3.0 weeks' gestation, p < 0.001) with higher proportion identified before 32 weeks (70 vs. 11%, p < 0.001). Proportion of abnormal UAD were similar between groups (15 vs. 15%, adjusted odds ratio: 1.12, 95% confidence interval: 0.61-2.23). Use of EFW alone would have failed to identify 29% of abnormal UAD. A combined definition of FGR had the highest detection of abnormal UAD (area under curve: 0.78 vs. AC alone 0.73 vs. EFW alone 0.69).

Conclusion:  A definition of FGR that considers both EFW and AC improves detection of abnormal UAD.

Key points: · Fetuses with restricted AC are equally likely to exhibit abnormal UAD indices compared with those that meet criteria by EFW.. · Earlier GA of FGR detection and improved detection of abnormal UAD with expanded growth definition.. · Expanded definition of FGR significantly improves detection of abnormal UAD as compared with those diagnosed with EFW criteria alone.. · Expanded growth restriction definition improves Doppler identification..

Objective: Hypertensive disorders of pregnancy (HDP) may account for a considerable and growing clinical burden at rural hospitals which have been providing fewer obstetric services over the past two decades. The objectives of this analysis were to evaluate trends, risk factors, and outcomes associated with hypertensive disorders of pregnancy (HDP) during delivery hospitalizations at rural hospitals in the United States.

Study design: The 2000-2020 National Inpatient Sample was used for this repeated-cross sectional analysis. Delivery hospitalizations at rural hospitals to women 15-54 years of age with and without HDP (including preeclampsia and gestational hypertension) were identified. Trends in HDP were characterized with joinpoint regression and estimated as the average annual percent change (AAPC) with 95% CIs. The associations between (i) HDP risk factors and HDP and (ii) HDP and adverse maternal outcomes were estimated with adjusted logistic regression models.

Results: Among 8,885,683 deliveries that occurred at rural hospitals, the proportion with a HDP diagnosis increased significantly from 6.0% in 2000 to 11.1% in 2020 (AAPC 3.1%, 95% CI 2.8%, 3.4%). Preeclampsia with severe features (AAPC 5.5%, 95% CI 4.8%, 6.2%) and superimposed preeclampsia (AAPC 6.5%, 95% CI 5.6%, 7.5%) underwent the largest relative increases over the study period. Obesity, pregestational diabetes, chronic hypertension, multiple gestation, and chronic kidney disease were all associated with increased adjusted odds of HDP. HDP diagnoses were significant associated with severe maternal morbidity (SMM), transfusion, stroke, and disseminated intravascular coagulation. The proportion of overall delivery SMM associated with HDP more than doubled from 11.3% in 2000 to 24.7% of 2020.

Conclusion: Among delivery hospitalizations at rural hospitals, HDP and associated risk factors increased significantly over the study period. Deliveries with HDP accounted for an increasing proportion of population-level SMM. HDP is a major, growing contributor to maternal risk and adverse outcomes during deliveries at rural hospitals.

Objective: To investigate odds of vaginal delivery comparing induced versus spontaneous labor in nulliparas and multiparas with dichorionic twins.

Study design: Retrospective review of dichorionic twin pregnancies from 2008-2021. Those with scheduled or elective cesarean, malpresentation, prior uterine surgery, fetal anomaly, gestational age (GA) at delivery < 34 weeks, and multifetal reduction were excluded. Nulliparas and multiparas were analyzed separately. The primary outcome was vaginal delivery of both twins. Secondary outcomes included preterm delivery, postpartum hemorrhage, and hypertensive disorders of pregnancy (HDP). Outcomes were compared among induced versus spontaneous labor and assessed using univariable and multivariable logistic regression.

Results: Among 258 nulliparas, 176 (68.2%) were induced and 82 (31.8%) spontaneously labored. Induced patients were older (p=0.048), had higher proportion of intrahepatic cholestasis of pregnancy (IHCP) (p=0.04), HDP (p<0.0001) and later GA at delivery (p<0.0001). Patients who spontaneously labored had higher proportion of preterm delivery <37 (p<0.0001) and higher proportion of at least one twin admitted to the neonatal intensive care unit (p=0.01). On univariable analysis, induction was associated with decreased likelihood of vaginal delivery of both twins (p=0.01). However, after adjusting for augmentation, GA at delivery, gestational diabetes, and HDP/chronic hypertension, this was no longer statistically significant (p=0.14). Among 239 multiparas, 108 (45.2%) were induced and 131 (54.8%) spontaneously labored. Induced patients had higher proportion IHCP (p=0.02), chronic hypertension (p=0.02), HDP (p<0.0001), and later GA at delivery (p<0.0001). Spontaneous labor patients had higher proportion of preterm delivery <37 (p<0.0001). There was no significant difference in odds of vaginal delivery between spontaneous versus induced labor on univariate (p=0.74) or adjusted analysis after controlling for augmentation, GA at delivery, gestational diabetes and HDP/chronic hypertension (p=0.40) among multiparas.

Conclusion: Among nulliparas and multiparas with dichorionic twins, induction of labor does not appear to be associated with decreased odds of vaginal delivery.

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Objective: To examine the association between elective induction of labor (EIOL) start time and labor duration among nulliparous women Methods: The ARRIVE trial was a multi-center randomized controlled trial of induction of labor at 39 weeks 0 days to 39 weeks 4 days versus expectant management in low-risk nulliparous women. In this secondary analysis, we included participants randomized to the induction group who had an EIOL without spontaneous labor or rupture of membranes prior to the induction start. Start time of EIOL was categorized as: early AM (midnight to 5:59 AM), late AM (6 AM-11:59 AM), early PM (noon-5:59 PM), or late PM (6 PM-11:59 PM). The primary outcome was labor duration. Cesarean delivery rates by induction start time were also examined. Multivariable analysis was conducted controlling for age, body mass index, insurance status, and modified Bishop score on admission (< 5 or ≥5).

Results: Of 3,062 women randomized to EIOL, 2,197 were included in this analysis. EIOL occurred in the early AM in 13%, in late AM in 28%, in early PM in 13%, and in late PM in 45%. Participants induced in the late AM had the shortest mean labor durations (21.5 ±11.3 hours) and the highest frequency of delivery at < 24 hours (68%). In adjusted analyses, induction in the late AM (vs. grouped other time periods) remained significantly associated with shorter labor duration (-1.5 hrs, 95% CI -2.5, -0.4, p=0.006), and there was no interaction between Bishop score and time of EIOL. Cesarean delivery rates did not differ by start time.

Conclusions: Induction of labor starting between 6AM and 11:59 AM was associated with shorter labor durations, independent of baseline maternal characteristics including cervical status on admission.

Objectives: To determine the correlation between decreased or increased retinol-binding protein (RBP) levels during pregnancy and adverse pregnancy outcomes.

Study design: A retrospective cohort study was conducted to analyze the data of 16,094 pregnant women who participated in serum RBP level detection during pregnancy. The chi-square test or Mann-Whitney U test was used for univariate analysis of qualitative or quantitative data. Multiple logistic regression analysis, odds ratio, and 95% confidence interval were used to evaluate the effect of RBP levels on adverse pregnancy outcomes.

Results: The groups showed a significant difference in RBP levels (P < 0.001). The results of multiple logistic regression analysis revealed that twins (OR=2.631), upper respiratory tract infection (URTI, OR=2.596), premature delivery (OR=1.833), and macrosomia (OR=1.524), were correlated with L-RBP (low retinol-binding protein), while preeclampsia (PE, OR=0.147), intrahepatic cholestasis of pregnancy (OR=1.654), gestational hypertension (GH, OR=1.646), oligohydramnios (OR=1.487), and advanced maternal age (OR=1.470) were correlated with H-RBP (high retinol-binding protein). Decreased or increased RBP levels were correlated with hyperlipidemia (OR=1.738, 2.857), Antenatal anemia (OR=1.378, 0.791), gestational diabetes mellitus (GDM, OR=1.272, 0.796), and small infant size (OR=0.664, 1.444). L-RBP may indicate an increased risk of antenatal anemia and GDM, whereas H-RBP may indicate a decreased risk of antenatal anemia and GDM. Pregnant women with H-RBP were more likely to give birth to smaller infants, whereas those with L-RBP had a lower risk of this outcome. Additionally, mothers with H-RBP were not likely to give birth to male infants.

Conclusion: Hyperlipidemia, URTI, GH, PE, and GDM affect serum RBP levels, and these exposure factors can lead to different degrees of adverse pregnancy outcomes.

Objective:  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.

Study design:  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.

Results:  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.

Conclusion:  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.

Key points: · 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..

Objective:  This study aimed to assess the effectiveness of ultrasound cervical length (CL) screening in reducing preterm births among individuals with various preterm birth histories, aiming to optimize prevention strategies.

Study design:  This retrospective cohort study included 576 pregnant individuals with singleton pregnancies and a history of preterm birth, who underwent transvaginal ultrasound CL screening between January 2014 and December 2020. The primary outcome was the detection of a short cervix (≤2.5 cm). We compared outcomes among individuals with a previous gestational age (GA) of 34 to 36, 28 to 33, 24 to 27, and <24 weeks. Adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs) were calculated using modified Poisson's regression with robust variance, controlling for predefined confounders.

Results:  Of 576 (35%), 139 (24.1%) had a previous birth at 34 to 36 weeks, 129 (22.4%) had a previous birth at 28 to 33 weeks, 90 (15.6%) had a previous birth at 24 to 27 weeks, and 218 (37.8%) had a previous birth <24 weeks. Compared with individuals with a previous GA 34 to 36 weeks, the risk of short cervix was higher in those with a previous <24 weeks (21.6 vs. 52.8%, aRR = 2.56, 95% CI: 1.81-3.62) and GA 24 to 27 weeks (40.0%, aRR = 1.80, 95% CI: 1.20-2.71), but no difference was found with those with previous GA 28 to 33 weeks (24.8%, aRR = 1.12, 95% CI: 0.72-1.72). Compared with individuals with previous GA 28 to 33 weeks, individuals with prior GA 34 to 36 weeks had the same risk of cerclage placement and preterm birth <34 weeks, but a lower risk of composite neonatal outcomes.

Conclusion:  Based on our results of similar incidence of the short cervix between individuals with previous GA 34 to 36 weeks and those with previous GA 28 to 33 weeks, individuals with a history of late preterm birth should receive CL screening in a similar manner.

Key points: · Similar short cervix for prior 34 to 36 versus 28 to 33 weeks.. · Lower risk of neonatal outcomes in the prior 34 to 36 weeks of birth.. · Screening is warranted for any prior preterm birth..

Objective: To determine the incidence of reoperation after uncomplicated cesarean birth, describe the types of procedures and indications for reoperation, and identify risk factors associated with reoperation using a national surgical database.

Study design: A retrospective cross-sectional study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, encompassing data from January 1, 2019, to December 31, 2021. A total of 43,492 patients who underwent cesarean birth were included. Patients who underwent concurrent non-gynecologic procedures or hysterectomy were excluded. The primary outcomes measured were the incidence of unplanned reoperation within 30 days of cesarean birth, types of reoperative procedures, indications for reoperation, and associated risk factors. Statistical analyses included Student's t-test, Wilcoxon rank-sum test, Chi-squared test, and multivariable logistic regression.

Results: Out of 43,492 cesarean deliveries, 397 (0.9%) required unplanned reoperation. Significant risk factors for reoperation included smoking (aOR 1.96, 95% CI 1.49-1.56), hypertension (aOR 1.83, 95% CI 1.27-2.62), bleeding disorders (aOR 2.11, 95% CI 1.15-3.89), ASA class > 3 (aOR 2.23, 95% CI 1.29-3.84), and concurrent myomectomy (aOR 4.39, 95% CI 1.06-18.2). The most common indications for reoperation were postpartum hemorrhage (47%), wound disruption or infection (18%), and hematoma or hemoperitoneum (14%). The most frequently performed reoperative procedures were exploratory laparotomy without hysterectomy (27%), uterine curettage (23%), and wound debridement or drainage (22%).

Conclusion: Reoperation following cesarean birth is a relatively uncommon but significant event, occurring in 0.9% of cases. Key risk factors include smoking, hypertension, bleeding disorders, ASA class > 3, and concurrent myomectomy. This study provides comprehensive data on the clinical characteristics and indications for reoperation following cesarean birth in a diverse, multi-institutional U.S.

Cohort: The findings highlight the need for enhanced perioperative monitoring and targeted interventions for high-risk patients to improve maternal outcomes.