American journal of perinatology最新文献

Objective: To externally validate the fullPIERS risk prediction model in a cohort of pregnant individuals with preeclampsia in the United States.

Study design: This was a retrospective study of individuals with preeclampsia who delivered at 22 weeks or greater from January 1, 2010, to December 31, 2020. The primary outcome was a composite of maternal mortality or other serious complications of preeclampsia occurring within 48 hours of admission. We calculated the probability of the composite outcome using the fullPIERS prediction model based on data available within 12 hours of admission including, gestational age, chest pain or dyspnea, serum creatinine levels, platelet count, aspartate transaminase levels, and oxygen saturation. We assessed the model performance using the area under the curve (AUC) of the receiver operating characteristic curve. The optimal cutoff point was determined using Liu's method. A calibration plot was used to evaluate the model's goodness-of-fit.

Results: Among 1,510 individuals with preeclampsia, 82 (5.4%) experienced the composite outcome within 48 hours. The fullPIERS model achieved an AUC of 0.80 (95% confidence interval: 0.75-0.86). The predicted probability for individuals with the composite outcome (median: 18.8%; interquartile range: 2.9-59.1) was significantly higher than those without the outcome (median: 0.9%; interquartile range: 0.4-2.7). The optimal cutoff point of 5.5% yielded a sensitivity of 70.7% (95% CI: 59.6-80.3), a specificity of 85% (95% CI: 82.7-86.5), a positive likelihood ratio of 4.6 (95% CI: 3.8-5.5), and an odds ratio of 13.3 (95% CI: 8.1-21.8). The calibration plot indicated that the model underestimated risk when the predicted probability was below 1% and overestimated risk when the predicted probability exceeded 5%.

Conclusion: The fullPIERS model demonstrated good discrimination in this U.S. cohort of individuals with preeclampsia, suggesting it may be a useful tool for healthcare providers to identify individuals at risk for severe complications.

Objective: Psychological birth trauma (BT), defined as an event that occurs during labor and delivery involving actual or threatened harm or death to the pregnant person and/or their baby, has been reported in up to one-third of births. Obstetrician-Gynecologists (OBGYNs) who personally experience BT are at a unique risk of re-traumatization upon return to work. We aimed to investigate the prevalence of personal BT among obstetricians and their perceptions of how personal BT impacts their experience of caring for obstetric patients.

Methods: We performed a web-based survey of OBGYNs who had given birth. Participants were recruited from the "OMG (OBGYN Mom Group)" on Facebook. The questionnaire assessed individual's personal experience of childbirth using items adapted from the "City Birth Trauma Scale" to assess post-traumatic symptoms related to their childbirth and patient interactions following personal experience of BT. Responses were categorized by whether or not the participant considered one or more of their own births to be traumatic. Post-traumatic stress symptoms (PTSS) and symptoms of occupational re-traumatization were compared by reported BT. Bivariable analyses were used.

Results: Of the 591 OBGYNs who completed the survey, 180 (30.5%) reported experiencing BT. Ninety-two percent of OBGYNs cared for birthing patients after giving birth. There were no differences in demographic or clinical practice characteristics between those with and without BT. OBGYNs with BT experienced PTSS including flashbacks (60.6% vs 14.4%), amnesia (36.7% vs 20.9%), and insomnia (24.4% vs 1.2%) at higher rates than those without BT (p<0.001).

Conclusion: Almost 1/3 of OBGYNs in this sample reported personally experiencing BT, mirroring data from reported BT rates in the general population. Given OBGYNs are at a high risk for occupational re-traumatization, initiatives focused on improving support for birthing OBGYNs upon returning to work should be studied to assess impact on emotional wellness among practicing OBGYNs.

Objective: To evaluate if an estimated fetal weight (EFW) between the 10-15th percentiles at time of anatomy ultrasound, referred to as borderline fetal growth, is associated with progression to fetal growth restriction (FGR) on subsequent ultrasound, delivery of a SGA neonate or neonatal intensive care (NICU) admission.

Study design: We performed a secondary analysis using the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be data (NuMom2b). The exposures were normotensive pregnancies with non-anomalous singleton gestations with normal growth, defined as EFW >15th percentile at the anatomy scan compared to borderline fetal growth fetuses defined as those with an EFW in the 10-15th percentile. The primary outcome was FGR at subsequent ultrasound, defined as EFW or AC <10%. The secondary outcomes were NICU admission and small for gestational age (SGA) neonate. Univariable analyses were performed comparing maternal baseline demographic and clinical characteristics. Multivariable analysis was performed for the primary outcome with variables adjusted a priori for body mass index, smoking status, race/ethnicity, insurance status, and drug use.

Results: 4883 patients met inclusion criteria with 114 in the borderline fetal growth group and 4769 in the normal growth group. There were no significant differences in maternal demographic or medical characteristics (Table 1). In adjusted multivariable analysis, patients with borderline growth had significantly higher odds of being diagnosed with FGR at their subsequent scan (aOR 6.68, CI 3.98-11.20) compared to those with normal growth. For secondary outcomes, patients with borderline fetal growth were significantly more likely to have SGA neonates (6.14% vs. 2.67%, p= 0.025). There was no difference in admissions to the NICU between groups.

Conclusion: Diagnosis of borderline fetal growth at time of anatomy scan was associated with a significantly increased odds of progression to FGR at subsequent scan and delivery of a SGA neonate.

Objective To compare neonatal and maternal outcomes based on the attempted mode of delivery, stratified by prepregnancy body mass index (BMI kg/m2) in nulliparous individuals. Study Design This was a repeated cross-sectional analysis of US vital statistics Live Birth and Infant Death linked data from 2011 to 2020. The analysis was restricted to nulliparas with singleton pregnancies and cephalic presentation who delivered at term. Our primary outcome was a composite neonatal outcome. We also examined a composite maternal outcome. We compared outcomes between individuals who attempted labor and those who opted for non-labor cesarean delivery, categorized by BMI (< 18.5, 18.5-24.9, 25-29.9, 30-39.9, ≥ 40). To account for significant differences in baseline characteristics between groups, Coarsened Exact Matching was applied using a k-to-k solution. We employed modified Poisson regression and calculated a difference-in-difference (DID) to compare differences in predicted proportions across BMI categories. Results Out of 9,709,958 individuals, 1,083,332 were included in the matched analysis. Compared to attempted vaginal delivery, non-labor cesarean delivery was associated with an increased risk of the composite neonatal outcome across all BMI categories. However, the increase in risk was less pronounced in higher BMI categories compared to the reference group (BMI 18.5-24.9). For maternal outcomes, non-labor cesarean delivery was associated with an increased risk of the composite maternal outcome in the BMI 18.5-24.9 and 25-29.9 categories. In contrast, the risk of adverse maternal outcomes associated with non-labor cesarean delivery was lower in higher BMI groups compared to the reference group, with DID values ranging from -0.12 in the BMI 30-39.9 group to -0.16 in the BMI ≥ 40 group. Conclusion Non-labor cesarean delivery, as compared to attempted vaginal delivery, was associated with adverse neonatal outcomes across all BMI categories, though the relative increase in risk was diminished in higher BMI groups.

Background: The global issue of greenhouse gas emissions has significant implications for the environment and human health. Telemedicine provides a valuable tool for delivering healthcare while reducing gas emissions by limiting the need for patient travel. However, the environmental effects of telemedicine in high-risk pregnancy populations remain unassessed.

Objective: The aim of this study was to estimate the economic and environmental impact of an outpatient teleMFM program.

Study design: This retrospective cohort study examined all visits at 3 teleMFM clinics more than 90 miles away from the nearest in-person MFM office between 10/1/2021 and 6/1/2022. Travel distances and times were calculated for each appointment between the patient's home, telemedicine clinic, and nearest in-person clinics, using zip code data and Google Maps web-based map calculator tools. Travel cost savings and environmental impact were calculated by determining differences in mileage reimbursement rate and emissions between those incurred in attending telemedicine appointments and those that would have been incurred if in-person using inflation-adjusted Internal Revenue Service annual standard mileage reimbursement rate ($0.58 per mile), and the U.S. Environmental Protection Agency Office of Transportation and Air Quality's average annual emissions and fuel consumption for gasoline-fueled passenger vehicles.

Results: During the study period a total number of 2,712 appointments were scheduled, of which 2,454 were kept (cancellations removed) and analyzed. Visiting a teleMFM clinic resulted in 204 miles, 200 minutes and 118.32 dollars saved per patient visit compared to visiting the nearest in-person clinic. Over a 7 month period a total of 96.6 metric tons of emissions were saved.

Conclusion: This study demonstrates the positive economic and environmental impact of teleMFM utilization in communities remote from in-person care. Given the contribution of greenhouse gas emissions to climate change, such findings may provide strategies for our specialty make informed policy, advocacy, and business decisions.

Objective:  Neonatal resuscitation is a high-acuity, low-occurrence event and many rural pediatricians report feeling underprepared for these events. We piloted a longitudinal telesimulation (TS) program with a rural hospital's interprofessional delivery room teams aimed at improving adherence to Neonatal Resuscitation Program (NRP) guidelines and teamwork.

Study design:  A TS study was conducted monthly in one rural hospital over a 10-month period from November 2020 to August 2021. TS sessions were remotely viewed and debriefed by experts, a neonatologist and a simulation educator. Sessions were video recorded and assessed using a scoring tool with validity evidence for NRP adherence. Teamwork was assessed using both TeamSTEPPS 2.0 Team Performance Observation Tool and Mayo High-Performance Teamwork Scale.

Results:  We conducted 10 TS sessions in one rural hospital. There were 24 total participants, who rotated through monthly sessions, ensuring interdisciplinary team composition was reflective of realistic staffing. NRP adherence rate for full code scenarios improved from a baseline of 39 to 95%. Compared with baseline data for efficiency, multiple NRP skills improved (e.g., cardiac lead placement occurred 12× faster, 0:31 seconds vs. 6:21 minutes). Teamwork scores showed improvement in all domains.

Conclusion:  Our results demonstrate that a TS program aimed at improving NRP and team performance is possible to implement in a rural setting. Our pilot study showed a trend toward improved NRP adherence, increased skill efficiency, and higher-quality teamwork and communication in one rural hospital. Additional research is needed to analyze program efficacy on a larger scale and to understand the impact of training on patient outcomes.

Key points: · Optimal newborn outcomes depend on skillful implementation of NRP.. · Telesimulation can deliver medical education that circumvents challenges in rural areas.. · A longitudinal NRP TS program is possible to implement in a rural setting.. · A rural NRP telesimulation program may improve interprofessional resuscitation performance.. · A rural NRP telesimulation program may improve interprofessional resuscitation teamwork..

Objective:  Acute kidney injury (AKI) is common in hospitalized preterm neonates. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a promising noninvasive AKI biomarker. However, normal values of uNGAL in preterm neonates without AKI are poorly characterized. The objective of this study was to evaluate the current literature to determine normal uNGAL values for preterm neonates without AKI.

Study design:  Systematic review and meta-analysis of all articles published before November 2021 evaluating uNGAL values in preterm neonates without AKI.

Results:  Of 1,607 studies evaluated for eligibility, 11 were included in the final meta-analysis (210 males, 202 females). uNGAL values were higher in the preterm neonates <29 weeks and ranged between 20.7 and 782.65 ng/mL. Meta mean estimates of gestational age (GA), birthweight, and neutrophil gelatinase-associated lipocalin were 29.4 weeks (95% confidence interval [CI]: 28.8-30.0), 1,241 g (95% CI: 1,111-1,372), and 148.9 ng/mL (95% CI: 48-231), respectively.

Conclusion:  In limited studies, a wide range of uNGAL values in preterm neonates without AKI are reported. Future studies should identify normal uNGAL values in preterm neonates using larger cohorts by GA and birthweight.

Key points: · Urinary NGAL is a promising noninvasive biomarker of neonatal AKI.. · A wide range of uNGAL is reported in preterm neonates but the baseline values are not well defined.. · Urine NGAL values are higher in extremely preterm compared with preterm neonates..

Objective:  The aim of the study was to investigate the virulence factors in Escherichia coli producing extended-spectrum β-lactamase (ESBL) derived from the perinatal fecal colonization flora of mothers and their newborns in a Chinese obstetric ward.

Study design:  Rectal swabs were obtained from mothers prenatally and from their newborns postnatally, and analyzed for ESBL-producing Escherichia coli. The isolates were then whole-genome sequenced.

Results:  Maternal and neonatal colonization by ESBL-producing E. coli in a Chinese obstetric ward was 18% (31/177) and 5% (9/170), respectively. Fecal ESBL-producing isolates exhibited a significantly lower frequency of virulence factors compared with invasive E. coli.

Conclusion:  Providing balanced information on screening results is essential, along with conducting a risk assessment for antibiotic treatment strategies.

Key points: · High ESBL E. coli colonization rates in mothers and neonates perinatally. · Fecal ESBL-producing E. coli showed fewer virulence traits.. · ESBL-producing E. coli knowledge may prompt antibiotic overuse..

Objective:  The majority of breech fetuses are delivered by cesarean birth as few physicians are trained in vaginal breech birth. An external cephalic version (ECV) can prevent cesarean delivery and the associated morbidity in these patients. Current guidelines recommend that all patients with breech presentation be offered an ECV attempt. Not all attempts are successful, and an attempt does carry some risks, so shared decision-making is necessary. To aid in patient counseling, over a dozen prediction models to predict ECV success have been proposed in the last few years. However, very few models have been externally validated, and thus, none have been adopted into clinical practice. This study aims to use data from a U.S. hospital to provide further data on ECV prediction models.

Study design:  This study retrospectively gathered data from Carle Foundation Hospital and used it to test six models previously proposed to predict ECV success. These models were Dahl 2021, Bilgory 2023, López Pérez 2020, Kok 2011, Burgos 2010, and Tasnim 2012 (GNK-PIMS score).

Results:  A total of 125 patients undergoing 132 ECV attempts were included. A total of 69 attempts were successful (52.2%). Dahl 2021 had the greatest predictive value (area under the curve [AUC]: 0.779), whereas Tasnim 2012 performed the worst (AUC: 0.626). The remaining models had similar predictive values as each other (AUC: 0.68-0.71). Bootstrapping confirmed that all models except Tasnim 2012 had confidence intervals not including 0.5. The bootstrapped 95% AUC confidence interval for Dahl 2021 was 0.71 to 0.84. In terms of calibration, Dahl 2021 was well calibrated with predicted probabilities matching observed probabilities. Bilgory 2023 and López Pérez were poorly calibrated.

Conclusion:  Multiple prediction tools have now been externally validated for ECV success. Dahl 2021 is the most promising prediction tool.

Key points: · Prediction models can be powerful tools for patient counseling.. · The odds of ECV success can estimated based on patient factors and clinical findings.. · Of the six tested models, only Dahl 2021 appears to have good predictive value and calibration..

Objective:  There are no universal guidelines for transvaginal ultrasound (TVUS) at the time of the anatomy scan. TVUS can provide information on placental location and cervical length (CL) but may lead to more interventions. As a quality assurance initiative, a universal TVUS (UTVUS) protocol at the time of the anatomy scan was started at our institution. This study was conducted to assess whether there was a decrease in preterm birth (PTB), postpartum hemorrhage (PPH), and neonatal intensive care unit (NICU) admission once UTVUS was implemented.

Study design:  This was a retrospective cohort study performed on singleton gestations from February 2021 to January 2022. In the first 6 months of the study period, patients only had TVUS based on risk factors (pre group). In the second half of the study period, UTVUS was implemented at the time of the anatomy scan (post group).

Results:  A total of 2,118 patients were included in the study. There were 1,037 patients in the pre group, of which 161 underwent TVUS based on high-risk factors (history of the cervical procedure, history of prior PTB, and placenta appearing low lying or cervix appearing short on abdominal ultrasound). The post group/UTVUS included 1,081 patients. Patients in the pre group had statistically significantly earlier gestational age at first TVUS (p < 0.0001), were less likely to have had a prior PTB <36 weeks (p = 0.03), and were more likely to have a history of cervical procedure (p = 0.0006) than patients in the post group. There was an increased use of vaginal progesterone in the UTVUS with 33 patients (as opposed to 10 patients in the pre group; p = 0.0007). The proportion of patients with PTB, PPH, or NICU admission did not significantly differ between the two groups even after adjusting for cofounders (p > 0.05).

Conclusion:  Our data show that UTVUS did not decrease the adverse pregnancy outcomes. In addition, the implementation of UTVUS adds more discomfort for a patient, more time to the patient's scan, and is an additional cost. Therefore, surveillance by abdominal ultrasound and adding TVUS based on risk factors may be a reasonable alternative.

Key points: · UTVUS showed no difference between CLs.. · There is not sufficient evidence to conclude a difference between PTB or PPH in the two groups.. · There was significantly more placenta previa diagnosed in the post group, yet most resolved..