American journal of perinatology最新文献

When vasa previa is diagnosed, guidelines support recommendations about timing and route of delivery, as well as steroid administration. While elective admission to ensure proximity to care is common, the evidence does not support a clear recommendation. Our objective was to compare patients with vasa previa managed as inpatients versus outpatients.This is a single-institution cohort study of patients with a prenatal diagnosis of vasa previa from 2013 to 2023. Decisions about inpatient versus outpatient management and delivery planning were made by physicians and patients. Data was obtained through chart review. Cohorts managed with elective admission for vasa previa were compared with those managed as outpatients. Mann-Whitney U and Fisher's Exact test were used for statistical comparison.Eighty-nine patients were included, including 72 (80.9%) electively admitted versus 17 (19.1%) managed as outpatients. The groups were of similar age and parity. A higher proportion of patients managed as outpatients had public insurance. There were no differences in the rate of short cervix or vaginal bleeding between the cohorts, and the rates of nonscheduled cesarean delivery were similar. Betamethasone was administered at a median gestational age of 32 to 33 weeks in both groups. Elective admission was associated with earlier delivery overall, as well as earlier scheduled delivery. There were no stillbirths or neonatal deaths, and the rates of NICU admission were not significantly different.Patients electively admitted for vasa previa do not appear to have been at higher risk for emergent delivery, though admission was associated with earlier delivery, including scheduled deliveries. The lower rate of admission in those with public insurance could indicate a disparity in management, though further study is necessary. While our data do not rule out a benefit to routine admission, the benefits remain unproven. · Inpatient admission was associated with earlier gestational age at delivery.. · Inpatient versus outpatient management showed no difference in neonatal morbidity.. · Rates of unscheduled (urgent or emergent) delivery were not significantly different between groups..

The objective of this study was to estimate the average hospitalization cost (AHC) for deliveries affected by severe maternal morbidity (SMM) and analyze trends from 2014 to 2019. The study also aimed to explore cost stratification based on patient, delivery, and hospital characteristics.Using the National Inpatient Sample dataset, all delivery hospitalizations from 2014 to 2019 were identified. Deliveries affected by SMM were determined based on the Centers for Disease Control definition. Deliveries were categorized into three groups: no SMM (nSMM), any SMM (aSMM), and SMM excluding cases with blood transfusion as the only indicator (SMMeBTo). A regression model accounting for survey design and adjusting for variables including age, race/ethnicity, primary payer, income, delivery method, hospital location/teaching status, and hospital region was used to test the trends in incidence. Hospital charges were adjusted using cost-to-charge ratios and presented in 2022 U.S. dollars ($). A regression model adjusting for the same variables was used to assess costs.From 2014 to 2019, 4,444,957 deliveries were identified, with a weighted estimate of 22,224,775. The rates of aSMM and SMMeBTo were 1.9 and 0.7%, respectively. AHC was $5,218 (95% confidence intervals [CI]: $5,200-5,235) for nSMM, $11,101 (95% CI: $11,038-11,165) for aSMM, and $11,541 (95% CI: $114,330-11,650) for SMMeBTo. Hospitalization costs across all SMM categories rose annually from 2014 to 2017, decreased in 2018, and peaked in 2019. All races had significantly higher costs than non-Hispanic Whites across all SMM categories. SMM costs were higher for cesarean deliveries. The highest cost was in deliveries involving a temporary tracheostomy. Urban teaching hospitals and those in the Northeast had the highest SMM costs.Deliveries affected by SMM incur significantly higher costs, with these costs increasing over time. Understanding disparities across patient factors, delivery methods, and hospital characteristics can inform interventions aimed at addressing inequities. · Costs of SMM hospitalizations are rising, even after adjusting for inflation.. · The escalating cost burden is disproportionately shouldered by different racial groups.. · Factors in delivery and hospital settings contribute to the variation in cost..

Reports indicate that street drugs are frequently adulterated with fentanyl. However, standard urine drug toxicology may not detect fentanyl, and neonates with prenatal fentanyl exposure often experience severe withdrawal. This study aimed to determine the frequency of fentanyl-adulterated street drugs consumed by mothers with substance use disorders (SUD) using umbilical cord tissue toxicology (UCT).This retrospective observational study (2020-2022) analyzed mothers with SUD and their neonates, utilizing UCT to confirm fentanyl exposure. Additionally, we compared maternal characteristics between those who acknowledged fentanyl use during pregnancy and those who did not, along with neonatal outcomes.Among 353 infants born to 342 mothers with opioid use, 21.8% (77/353) had in-utero fentanyl exposure confirmed by UCT. Notably, 54% (40/74) of mothers in the fentanyl-positive group did not acknowledge fentanyl use. However, these mothers more frequently reported using other substances, including marijuana (p < 0.01) and cocaine (p < 0.03), suggesting fentanyl adulteration in street drugs. Umbilical cord fentanyl concentrations were similar between groups, though variance was higher among those who did not report fentanyl use, indicating potential inconsistent exposure. No significant differences were observed in neonatal characteristics.Our study highlights the high frequency of prenatal fentanyl exposure due to adulterated street drugs used by mothers. Although the infant's characteristics and the severity of NOWS were similar in both groups, long-term outcomes may depend on UCT fentanyl concentrations. Therefore, umbilical cord drug screening is a crucial tool for detecting fetal exposure to fentanyl and appropriate neonatal assessment and intervention. · Fentanyl, a potent synthetic opioid, is increasingly found in street drugs, often unbeknownst to users.. · Mothers struggling with substance use may be exposed to illicit fentanyl without their knowledge.. · Umbilical cord testing is crucial for identifying substance exposures in newborns.. · Newborn assessment and treatment can differ and impact their short- and long-term outcomes..

This study aimed to evaluate whether the implementation of a surgical bundle reduces surgical site infections (SSI), hospital readmission rates, and emergency department (ED) visits within 6 weeks in individuals with a body mass index (BMI) of 40 kg/m² or greater after cesarean delivery.This was a retrospective study including individuals with morbid obesity undergoing cesarean delivery at 23 weeks of gestation or greater. The preintervention period spanned from January 2017 to December 2020. The postintervention period extended from January 2021 to April 2023. The surgical bundle included standard preprocedure prophylactic antibiotics and a 48-hour course of oral cephalexin and metronidazole. The primary outcome was SSIs while secondary outcomes included hospital readmission or ED visits within 6 weeks postpartum or wound complications (dehiscence, seroma, or hematoma). Adjusted relative risks (aRR) with 95% confidence intervals (95% CI) were calculated using modified Poisson regression, adjusting for potential confounders.Of 2,105 pregnancies, 1,308 (62.1%) underwent cesarean in the preintervention period and 797 (37.9%) in the postintervention period. Compared to the preintervention period, the postintervention period had increased use of azithromycin (30.6 vs. 35.9%; p = 0.012), cephalexin (1.8 vs. 52.8%; p < 0.001), and metronidazole (3.1 vs. 60.4%; p < 0.001). However, compared to the preintervention period, the postintervention period had a similar risk of SSIs (6.6 vs. 5.9%; aRR: 0.92; 95% CI: 0.66-1.28), readmission or ED visits (19.8 vs. 19.8%; aRR: 0.94; 95% CI: 0.80-1.11), and wound complications (4.7 vs. 6.4%; aRR: 1.37; 95% CI: 0.96-1.96). In individuals with labor or ruptured membranes, the postintervention period had increased use of azithromycin (74.9 vs. 82.3%; p = 0.022), cephalexin (2.5 vs. 56.1%; p < 0.001), and metronidazole (4.3 vs. 63.8%; p < 0.001). In this subgroup, outcomes remained insignificant.A morbid obesity surgical bundle increased antibiotic use but did not reduce SSIs, hospital readmission, ED department visits, and wound complications. · A surgical bundle for individuals with morbid obesity increased the use of postoperative antibiotics.. · The surgical bundle did not significantly reduce SSIs.. · The surgical bundle did not significantly reduce hospital readmissions and ED visits..

Generalized arterial calcification of infancy (GACI) is an ultra-rare, potentially life-threatening disorder of the mineralization of which obstetricians and neonatologists shall be aware.This study aimed to describe twins with ATP binding cassette subfamily C member-6 (ABCC6) mutations leading to type II-GACI phenotype in one of them, their multidisciplinary management, and very long-term (10 years) follow-up.One of the twins had typical calcifications in the ascending aorta and the aortic arc, leading to severe neonatal arterial hypertension needing anti-hypertensive treatment. A therapy with bisphosphonates was also provided for 3 weeks with the disappearance of calcifications and resolution of hypertension. Ten-year follow-up was completely normal. Patients were found to carry a heterozygous mutation of ABCC6.Type II-GACI can be managed with a multi-disciplinary approach and good long-term outcomes despite the occurrence of severe neonatal arterial hypertension. · GACI is an ultra-rare, potentially life-threatening disorder of the mineralization processes of which obstetricians and neonatologists shall be aware.. · Type II-GACI can be managed with a multi-disciplinary approach and good long-term outcome despite the occurrence of severe neonatal arterial hypertension.. · Type-II GACI phenotype can be similar to that of pseudoxanthoma elasticum due to heterozygous mutations of the ABCC6 gene.. · Further research is needed to understand the pathobiology of this disorder..

Perinatal and maternal morbidity in the setting of preterm birth may differ by delivery indication. We compared perinatal and maternal outcomes of second trimester (24 0/7 - 27 6/7 weeks' gestation) deliveries indicated for preeclampsia with severe features (PE-SF) with those following preterm premature rupture of membranes (PPROM). Secondary analysis of an observational cohort study of singleton and twin preterm deliveries before 35 weeks' gestation at 33 hospitals across the United States. Singletons without congenital anomalies who were delivered due to PE-SF or PPROM from 24 0/7 - 27 6/7 weeks gestation were included. The primary outcome was a composite of perinatal morbidity or death, defined as fetal or neonatal death, severe bronchopulmonary dysplasia grade III, intraventricular hemorrhage grade III-IV, necrotizing enterocolitis stage IIA or greater, periventricular leukomalacia, retinopathy of prematurity stage III-IV, or culture-proven sepsis. Secondary outcomes included components of the primary outcome, small-for-gestational-age (SGA) birth, and a composite of maternal morbidity. Among 7515 in the original cohort, 164 deliveries for PE-SF and 119 deliveries following PPROM were included. Individuals with PE-SF were more likely to have BMI ≥ 30 kg/m2, hypertensive disorder of pregnancy in a prior pregnancy, chronic hypertension, and cesarean birth (p <0.05) compared with those who delivered following PPROM. Composite perinatal morbidity or death did not differ between groups (aOR 1.60, 95% CI 0.89, 2.85, p=0.11), but fetal death was significantly higher in the PE-SF group (aOR 6.04, 95% CI 1.42, 25.71). Neonates delivered for PE-SF were more likely to be SGA (aOR 13.45, 95% CI 2.92, 61.94). Composite maternal morbidity did not differ between groups (aOR 1.18, 95% CI 0.62, 2.26). Second-trimester preterm birth indicated for PE-SF was associated with a higher rate of fetal death than birth for PPROM. Composite neonatal and maternal morbidity did not differ by indication.

Neonatal late-onset sepsis is associated with increased mortality and morbidity, adversely impacting long-term outcome. The objective of this study was to examine neurodevelopmental (ND) outcomes at 18 to 24 months' corrected age (CA) in infants with late-onset bacterial sepsis (LOS) and to categorize outcomes based on type of bacterial pathogen in a cohort of preterm infants born less than 29 weeks gestation in Canada.We conducted a retrospective cohort study of all non-anomalous infants born at <29 weeks gestational age (GA) who were admitted to Canadian NICUs, from January 1, 2010, to December 31, 2017, who had an ND assessment at 18 to 24 months' CA at Canadian Neonatal Follow-Up Network clinics. The primary outcome was the composite outcome of death or ND impairment (NDI). Secondary outcomes included significant NDI, and each component of primary outcome. We compared ND outcomes among infants with Gram-positive (GP) sepsis, Gram-negative (GN) sepsis, mixed sepsis, and no sepsis using bivariate and multivariate analyses after adjusting for potential confounders.Of the 3,640 infants included, 823 (22.6%) developed LOS. Of the 823 infants, 569 (69.1%) had GP sepsis, 172 (20.9%) had GN sepsis, and 82 (10%) had mixed sepsis. Infants with LOS had significantly lower birth weight, GA, younger mothers, and significantly higher rates of major neonatal morbidities compared with the no-sepsis group. In multivariable logistic regression, infants with GN sepsis and mixed sepsis had significantly higher odds of death/NDI (GN sepsis, adjusted odds ratio [aOR] = 1.80; 95% CI: 1.27, 2.54; mixed LOS, aOR = 2.38, 95% CI: 1.41, 4.01) as compared with no sepsis.Late-onset bacterial sepsis, particularly Gram-negative and mixed sepsis, was associated with an increased risk of adverse outcomes including death or NDI at 18 to 24 months CA in infants born <29 weeks' GA in Canada. · Late-onset sepsis is an important risk factor for morbidity and mortality in preterm infants.. · The clinical presentations vary depending on the causative bacteria.. · There is limited data on neurodevelopmental outcomes based on type of bacterial pathogen..

This study aimed to evaluate the efficacy and safety of continuous intravenous (IV) glucagon infusion in the management of neonatal hypoglycemia in infants of diabetic mothers (IDMs).This retrospective case-control study included IDMs treated for hypoglycemia at Turku University Hospital, Finland, over 11 years. Sixteen infants received IV glucose and continuous IV glucagon, while 26 matched controls received IV glucose only.Prior to glucagon initiation, cases had higher IV glucose requirements and lower plasma glucose levels than controls. Following infusion, plasma glucose normalized rapidly. The mean (SD) duration of glucagon treatment was 5.6 (1.2) days. Maternal prepregnancy body mass index (BMI) was significantly higher in cases (mean = 35.0 kg/m² [SD = 8.2 kg/m²]) than in controls (mean = 27.6 kg/m² [SD = 7.1 kg/m²]), p = 0.006. No significant differences in adverse effects were observed.Continuous IV glucagon infusion is an effective and safe treatment for refractory hypoglycemia in IDMs. · There are limited data on glucagon use in neonatal hypoglycemia.. · Newborns of diabetic mothers could be a target population.. · Glucagon infusion may be a valuable adjunctive therapy..

This study aimed to determine whether unsupervised machine learning can identify phenotypically distinct subgroups at increased risk for preeclampsia among pregnant individuals with American Heart Association (AHA)-defined normal blood pressure in the first trimester.This was a secondary analysis of a prospective cohort study of singleton pregnancies enrolled at ≤13^6/7 weeks' gestation at two academic centers. Participants with prepregnancy chronic hypertension or major fetal/placental abnormalities were excluded. First-trimester blood pressure was categorized using the 2017 AHA guidelines. Among individuals with AHA-defined normal blood pressure (<120/80 mm Hg), unsupervised machine learning (k-means clustering) was applied to systolic, diastolic, and mean arterial pressure to identify distinct hemodynamic phenotypes. The primary outcome was preeclampsia; secondary outcomes included hypertensive disorders of pregnancy (HDP) and small-for-gestational age (SGA) neonates. Associations were assessed using multivariable Cox regression and Kaplan-Meier analyses.Of 570 participants, 378 (66.3%) had AHA-normal blood pressure. Among these, machine learning identified a high-risk cluster (7.4%) and a low-risk cluster (92.6%). Despite normotensive values, individuals in the high-risk cluster had a significantly higher incidence of preeclampsia (25.0 vs. 3.1%; p < 0.001) and HDP (28.6 vs. 5.7%; p < 0.001) compared to the low-risk cluster. After adjustment, the high-risk normotensive cluster had an eight-fold increased hazard of preeclampsia (adjusted hazard ratio [aHR] = 8.01; 95% CI: 3.09-20.74) and increased risk of SGA (adjusted odds ratio [aOR] = 3.36; 95% CI: 1.36-8.31). Risk within this group exceeded that of individuals with AHA-abnormal blood pressure.Among pregnant individuals with first-trimester AHA-normal blood pressure, unsupervised clustering identified a distinct subgroup at elevated risk for preeclampsia and SGA. These findings suggest that conventional thresholds may overlook early vascular risk and support further investigation into machine learning-based risk stratification in pregnancy. · Machine learning identified a distinct high-risk cluster (7.4%) within normotensive pregnancies.. · This cluster had an eight-fold higher risk of preeclampsia and a three-fold increased risk of SGA neonate.. · Machine learning may enhance early pregnancy risk stratification..

Respiratory support use in neonatal intensive care units (NICUs) varies worldwide, influenced by clinical practices, resources, and patient populations. Whether high-altitude independently affects the duration of respiratory support in preterm infants remains unclear. This study aimed to determine whether altitude is independently associated with the duration of respiratory support in preterm infants ≤32 weeks' gestational age (GA) admitted to Latin American NICUs.We performed a multicenter, observational cohort study by secondary analysis of prospectively collected data from the EpicLatino Network, a registry of NICUs across Latin America (2015-2022). Infants ≤32 weeks who received invasive or non-invasive respiratory support were included; supplemental oxygen delivered via low-flow nasal cannula or oxygen hood was not considered respiratory support, and those with missing outcome data were excluded. The primary outcome was total duration of respiratory support, measured as total days of support until discontinuation, discharge, transfer, or truncation by death. Altitude was classified as high (≥2,000 m) or low (<2,000 m). Multivariable analyses were adjusted for neonatal, maternal, and unit characteristics.A total of 4,428 infants were included; 2,723 (61.5%) in low-altitude NICUs and 1,705 (38.5%) in high-altitude NICUs. Overall, 81.4% discontinued respiratory support and 18.6% died. Mortality was 19.1% in low-altitude and 17.9% in high-altitude NICUs. Median duration of support was 8 days (interquartile range [IQR]: 5-14) overall, with 9 days (IQR: 4-27) in low-altitude and 7 days (IQR: 3-17) in high-altitude NICUs. High-altitude centers showed shorter respiratory support in unadjusted analyses. After adjustment for neonatal, maternal, and unit factors, altitude was not independently associated with support duration.After adjustment for neonatal, maternal, and unit factors, altitude was not independently associated with the duration of respiratory support. Importantly, high altitude was never associated with worse outcomes. · High-altitude NICUs showed shorter respiratory support use, likely reflecting environmental hypoxemia, but this association disappeared after adjusting for clinical and unit factors.. · Mortality was similar at high and low altitudes, indicating that shorter duration at altitude was not explained by earlier deaths.. · Altitude may influence initial decisions on invasive support, but patient and institutional characteristics appear more relevant in determining total duration..