American journal of perinatology最新文献

Objective:  Neonatal sepsis has been established as a risk factor for retinopathy of prematurity (ROP) but previous meta-analyses have predominately focused on late-onset sepsis (LOS). This meta-analysis aims to explore the association between early-onset sepsis (EOS) and the risk of ROP.

Study design:  Observational studies reporting (unadjusted) data on proven EOS in neonates with ROP were included. PubMed, Embase, and Cochrane Library were searched. Proven EOS was defined as a positive blood or cerebrospinal fluid culture. Effect sizes were calculated by using logistic random-effects models and meta-regression analyses. Primary outcomes were any stage ROP and severe ROP (≥stage 3, type I, aggressive [posterior] ROP, plus disease or requiring treatment). Potential confounders explored were gestational age at birth, birth weight, small for gestational age, maternal steroid use, necrotizing enterocolitis, LOS, and mechanical ventilation duration.

Results:  Seventeen studies reporting the incidence of proven EOS in neonates with ROP were included. Proven EOS showed no significant association with any stage ROP (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 0.96-3.79, p = 0.067) but heterogeneity between studies was significantly high. Neonates with proven EOS had an increased risk for severe ROP (OR = 2.21; 95% CI: 1.68-2.90), and no significant confounders influencing this effect size were found in the meta-regression analysis.

Conclusion:  Neonates with proven EOS are at increased risk of severe ROP. Neonatologists need to be aware that EOS is an early predictor of ROP and should adapt their policy and treatment decisions where possible to reduce ROP.

Key points: · This meta-analysis reveals a 2.2-fold increased risk of severe ROP in neonates with proven EOS.. · Future studies should distinguish between EOS and LOS when investigating risk factors of ROP.. · Treatment decisions should be adapted where possible in neonates with EOS before ROP screening begins..

Objective:  Maternal preconception diet influences pregnancy health and fetal outcomes. We examined the relationship between preconception fatty acid (FA) intake and uterine artery indices in mid-gestation in a large, heterogeneous cohort of nulliparous individuals.

Study design:  This is a secondary analysis of the nuMom2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be) study. Dietary ω-6 and ω-3 FA intake was assessed with food frequency questionnaires and uterine artery indices were obtained via Doppler studies in the second trimester. For our primary outcome of pulsatility index (PI) > 1.6, we compared proportions by each dichotomous FA exposure and tested differences with chi-square test.

Results:  For PI > 1.6, odds ratio for the unfavorable FA quartile compared with remaining quartiles for the exposures were 0.96 to 1.25, p = 0.157 (ω-6 FA); 0.97 to 1.26, p = 0.124 (ω-3 FA); 0.87 to 1.14, p = 1.00 (ω-6:ω-3 FA ratio).

Conclusion:  No significant associations between self-reported maternal preconception ω-6 and ω-3 FA intake and uterine artery Doppler indices measured during the second trimester were observed.

Key points: · Maternal diet impacts pregnancy health/fetal outcomes.. · ω-3 and ω-6 FA intake influences cardiovascular health.. · FA intake may affect blood flow to fetoplacental unit.. · Results are limited by inadequate adherence to dietary recommendations..

Objective:  This study aimed to determine whether administration of a late preterm (34-36 weeks) course of antenatal corticosteroids (ACS) is associated with improved short-term neonatal outcomes among pregnancies complicated with hypertensive disorders of pregnancy (HDP) who delivered in the late preterm period.

Study design:  A single tertiary center retrospective cohort study, including pregnant individuals with singleton fetuses who delivered between 34.0 and 36.6 weeks following an HDP diagnosis. Exclusion criteria were major fetal anomalies and treatment with ACS before 34 weeks. Cases were divided into two groups: exposed group, consisting of individuals treated with a late ACS course, and nonexposed group, receiving no ACS. The primary outcome was a composite adverse neonatal outcome, including intensive care unit admission, oxygen treatment, noninvasive positive pressure ventilation, mechanical ventilation, respiratory distress syndrome, transient tachypnea, or apnea of prematurity. Secondary neonatal outcomes included birth weight, Apgar score, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, surfactant use, hypoglycemia, hyperbilirubinemia, sepsis, and neonatal death. Multivariable regression models were used to determine adjusted odds ratio (aOR)and 95% confidence intervals (CIs).

Results: Of 7,624 preterm singleton deliveries during the study period, 438 (5.7%) were diagnosed with HDP and delivered between 34.0 and 36.6 weeks. Infants who received ACS were diagnosed more commonly with fetal growth restriction (16.0 vs. 5.6%, p < 0.01) and were delivered at an earlier gestational age (GA) (mean GA: 35.6 vs. 36.3 weeks, p < 0.01). The composite neonatal morbidity did not differ between the groups after adjustments (aOR: 0.97, 95% CI: 0.47, 1.98). Neonatal hypoglycemia and hyperbilirubinemia were more common in the exposed group than in the nonexposed group (46.9 vs. 27.4%; aOR: 2.27; 95% CI: 1.26, 4.08 and 64.2 vs. 46.5%; aOR: 2.08; 95% CI: 1.16, 3.72 respectively).

Conclusion:  In people with HDP, a course of ACS given in the late preterm period did not improve neonatal morbidity.

Key points: · In people with HDP, a late preterm ACS course did not improve neonatal morbidity.. · Respiratory morbidity rate was similar between infants who received late ACS and those who did not.. · Neonatal hypoglycemia and hyperbilirubinemia were more common in infants who received late ACS..

Objective:  From 2002 to 2023, palivizumab was the only intervention to reduce respiratory syncytial virus (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 Pediatric Society) revised its eligibility recommendations in 2015, removing access for preterm infants 30 to 32 weeks gestation (WG). The province of Nova Scotia followed these recommendations the next season. This study aimed to determine if the removal of access to palivizumab in these previously eligible infants was associated with a change in hospital admissions, deaths, or ambulatory visits associated with RSV.

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

Results:  Of 4,835 infants born during the study period, 250 were 30 to 32 WG and eligible for the cohort. RSV-H increased approximately 10-fold following restricted access to palivizumab (from no RSV-H (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).

Conclusion:  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 health care policy change on patient well-being is essential to assess the impact and guide future decision-making at the population level.

Key points: · Discontinuation of access to a prophylactic anti-RSV monoclonal antibody in very preterm infants 30 to 32 WG was associated with a higher risk of RSV-H and RSV-A. Evaluation of changes to health care policy on patient well-being is essential to assess impact and guide future decision-making at the population level.. · Removing access to palivizumab led to higher RSV admissions in 30 to 32 WG infants.. · The effect of health care policy changes on child well-being should be assessed routinely.. · No deaths associated with RSV were identified prior to or after the policy change..

Objective:  Establishing clinical factors associated with histological changes in the lungs of very preterm infants with evolving or established bronchopulmonary dysplasia (BPD) is essential for the development of more effective preventive interventions.

Study design:  Thirty-two infants with a gestational age (GA) of <32 weeks who died of BPD or had BPD but died due to other causes were included in the study. The associations of clinical data with histopathological changes in the lungs were assessed.

Results:  The mean (standard deviation) GA of infants was 26.7 (1.9) weeks, and the mean birth weight was 919.7 (242.9) g. We revealed significant associations of maternal smoking with vascular hypertension lesions (r _s = 0.5, p < 0.05) in infants' lungs. Intrauterine growth retardation increased the risk of extensive fibroproliferation (r _s = 0.4, p < 0.05). In infants with patent ductus arteriosus (PDA) requiring treatment, muscle hyperplasia (r _s = 0.5, p < 0.05) was detected more often. The longer duration of mechanical ventilation (MV) correlated with diffuse interstitial fibroproliferation (r _s = 0.5, p < 0.05), airway epithelial lesions (r _s = 0.3, p < 0.05), and airway muscle hyperplasia (r _s = 0.4, p < 0.05). In infants who needed the longer MV and/or oxygen supplementation, an increased incidence of extensive fibroproliferation was found (r _s = 0.4 and r _s = 0.4 respectively, p < 0.05). Antenatal steroids decreased the incidence of diffuse interstitial fibrosis (r _s = - 0.4, p < 0.05).

Conclusion:  In very preterm infants with a GA of less than 32 weeks, lack of antenatal steroid prophylaxis, intrauterine growth restriction, presence of hemodynamically significant PDA, and prolonged MV or oxygen supplementation are associated with the pathomorphological lung changes that are more typical for "old" BPD. Traditional preventive measures against BPD remain essential in a modern population of very preterm infants.

Key points: · Pathomorphological lung changes correlate with clinical data in very preterm infants who died of BPD.. · Lack of antenatal steroids prophylaxis, growth retardation, PDA, and prolonged mechanical ventilation affect lungs.. · Traditional BPD preventive measures remain essential in the modern population of preterm infants..

Objective:  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 exist on the specificity and sensitivity of ferning detection but have 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.

Study design:  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-mL sample of amniotic fluid was collected too and then centrifuged to separate blood. Slides were analyzed at five 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.

Results:  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.

Conclusion:  In cases of known second-trimester PPROM, ferning was detected more often after 10 minutes of sample drying, and centrifuging the amniotic fluid to remove blood.

Key points: · The detection of ferning in the second trimester was improved with longer drying times.. · The highest detection rate was seen after at least 10 minutes of drying time.. · Gestational age did not impact the rates of ferning.. · Blood contamination impacts the ability to see ferning on microscopic examination..

Objective:  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-week deliveries. The objective of this study was to evaluate the trends in perinatal mortality by body mass index (BMI) category from 2015 to 2020.

Study design:  This was a retrospective cohort study of U.S. 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 to 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 and 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.

Conclusion:  Perinatal mortality rates improved in 2019, reversing the increasing trend from 2015 to 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 coronavirus disease 2019 pandemic.

Key points: · There was a trend toward decreasing perinatal mortality in 2019 compared with previous years.. · The downward trend in perinatal mortality may be attributed to an increase in 39-week deliveries.. · The downward trend in perinatal mortality did not persist into 2020, likely due to COVID-19..

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 <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 (1,926 vs. 1,804 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 to 27 weeks, the weight at 36 weeks was significantly higher in the HFNC group (1,809 vs. 1,730 g, adjusted difference = 113.4 g, 95% CI: 5.0-221.8). There was no significant difference in time at initial and reached full oral feeding.

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

Key points: · HFNC showed better weight gain compared with NCPAP/NIPPV in preterm infants.. · HFNC was associated with higher weight at 36 weeks postmenstrual age in extremely preterm infants.. · This study suggests that HFNC may have benefits in postnatal growth among extremely preterm infants..

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 the 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 eight 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 24/28 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. On both days 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.

Key points: · Safety of acetaminophen (APAP) in extremely premature infants has not been established.. · The major urinary APAP metabolite was detected in the majority of urine samples.. · No association was found between APAP levels and either bronchopulmonary dysplasia or retinopathy of prematurity..

Objective:  Colpocephaly is a congenital brain defect characterized by enlargement of the occipital horns of the lateral ventricles. Few population-based studies have focused on this central nervous system (CNS) defect. This study aimed to evaluate the birth prevalence and survival of Texas infants with colpocephaly delivered between 1999 and 2020.

Study design:  Cases from the Texas Birth Defects Registry (TBDR) with a diagnosis of colpocephaly were identified. Unadjusted birth prevalence, 1-year survival estimates, and crude hazard ratios with 95% confidence intervals (CIs) were calculated from data collected from the medical record abstraction and linked vital records. Select maternal and infant variables were assessed overall and across four medical classification groups (presence of isolated, chromosomal, syndromic, or multiple major defects).

Results:  From 1999 to 2020, 1,146 cases with colpocephaly were identified. The overall birth prevalence of colpocephaly was 1.36/10,000 live births (95% CI: 1.28-1.44). Significantly higher prevalence was noted for male infants, infants with low birth weight (<2,500 g), and very preterm (<32 weeks) infants. Overall, 1-year survival was 89.5%, with statistically significant differences observed in each medical classification group (e.g., isolated) across levels of maternal education, Texas/Mexico border maternal residence at delivery, infant birth weight, and gestational age.

Conclusion:  These findings have important implications for pediatric neurology and future research, such as counseling on the prevalence and prognosis of colpocephaly. Additionally, these findings highlight that the population burden of CNS defects may be higher than previously believed, supporting the expansion of research of rare brain defects.

Key points: · The overall birth prevalence of colpocephaly for Texas infants delivered between 1999 and 2020 was 1.36/10,000 live births.. · Statistically significant differences in 1-year survival were observed across select maternal and infant variables.. · Longitudinal studies are necessary to fully ascertain the prevalence of colpocephaly beyond the first year of life..