American journal of perinatology最新文献

Objective:  We compared the cost of faculty time preparing educational materials for traditional didactic (TD) education provided at local institutions with that of faculty time preparing National Neonatology Curriculum (NNC) flipped classroom (FC) educational materials shared among institutions for fellow education across the United States.

Study design:  Using survey data and the national average for faculty educators' salaries, we calculated the cost of developing TD versus FC materials. Wilcoxon rank-sum test and comparison of two Poisson rates were utilized to evaluate the time to create versus update TD materials and the cost to create new TD versus FC materials, respectively.

Results:  FC materials required more time to develop than TD materials (FC, median 17 h, interquartile range [IQR]: 17; TD, median, 5 h, IQR: 5; p < 0.001). However, when the size of individual fellowship programs was factored into the cost analysis, FC materials shared nationally among programs resulted in a 19- to 72-fold cost savings when compared to the creation of new locally used TD materials (FC, $2.49 per fellow; TD $32.05-576.90 per fellow at very large-to-small fellowship programs; p < 0.001).

Conclusion:  Educational materials developed and disseminated to fellowship programs across the country confer significant savings in faculty educator time and cost per learner. Standardized programs such as the NNC may serve as a model to develop shared peer-reviewed educational resources for other specialties.

Key points: · Educational materials developed for national use confer time and cost savings.. · Small fellowships benefit greatly from having access to shared resources.. · Shared, peer-reviewed resources promote equity in education.. · Shared resources can free faculty time to focus on other academic interests..

Objective:  This study aimed to compare maternal and neonatal outcomes between labor induction versus cesarean delivery (CD) without labor among nulliparous individuals with class III obesity (body mass index [BMI] ≥40 kg/m²).

Study design:  A retrospective cohort study of all nulliparous singleton deliveries at ≥37 weeks with a BMI of ≥40 kg/m² at delivery between March 2020 and February 2022. We excluded individuals with spontaneous labor, fetal malformations, and stillbirths. The primary outcome was a composite of maternal mortality and morbidity, including infectious and hemorrhagic morbidity. The secondary outcome was a neonatal composite. A subgroup analysis evaluated patients with a BMI of ≥50 kg/m². Another subgroup analysis compared outcomes between CD without labor and an indicated CD following induction. A multivariable logistic regression was applied. For adjustment, we used possible confounders identified in a univariate analysis.

Results:  Among 8,623 consecutive deliveries during the study period, 308 (4%) met the inclusion criteria. Among them, 250 (81%) underwent labor induction, and 58 (19%) had a CD without labor. The most common indications for CD without labor were fetal malpresentation (26; 45%), suspected macrosomia (8; 14%), and previous myomectomy (5; 9%). Indicated CD occurred in 140 (56%) of the induced individuals, with the two leading indications being labor arrest (87; 62%) and non-reassuring fetal heart rate tracing (51; 36%). The rates of composite maternal morbidity (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 0.64-7.13) and composite neonatal morbidity (aOR = 3.62, 95% CI: 0.42-31.19) did not differ following a CD without labor compared to labor induction. The subgroup analyses did not demonstrate different outcomes between groups.

Conclusion:  Among nulliparous individuals with class III obesity at term who underwent induction, more than 50% had indicated CD; the rate of short-term maternal and neonatal morbidity, however, did not differ between labor induction and CD without labor.

Key points: · The rate of unplanned CD among those who underwent labor induction was relatively high (56.0%).. · Outcomes did not differ between those who underwent CD without labor and those who were induced.. · Outcomes also did not differ between those who underwent CD without labor and those with CD in labor..

Previable premature prelabor rupture of membranes (pPPROM) can lead to significant maternal and neonatal morbidity and mortality. Limited literature exists describing long-term outcomes in neonates surviving pPPROM. Our study describes 2-year survival and outcomes after expectantly managed pPPROM at a single, tertiary, academic center. This is a retrospective review including individuals with pPPROM defined as membrane rupture before 24^0/7 weeks who were candidates and opted for expectant management at a single tertiary academic center between 2013 and 2022. Patients were included if they delivered after 22 weeks. Patients opting for termination, with contraindication to expectant management or who chose expectant management without planned neonatal resuscitation at birth were excluded. Electronic records of patients and associated neonates were reviewed for demographic information, PPROM management, and neonatal outcomes at 2 years including gastrointestinal, respiratory, cognitive, motor, and hearing or vision issues. Descriptive statistical analysis was performed. Of 111 pregnancies with pPPROM, 50(45%) pregnant individuals met inclusion criteria (46 singletons; 4 multiples [3 twins, 1 set of quads]). Of 46 singletons, 31 (67%) survived to 2 years with 1(3%) alive but less than 2 years. In 3/4 (75%) twin gestations, both twins survived to 2 years. A total of 3/4 (75%) quadruplets survived to 2 years. Most surviving infants (95.0%, n = 38) had at least one documented adverse outcome. A total of 55.0% (n = 22) of neonates had gross motor delay, and 77.5% (n = 31) had documented speech delay. Most had respiratory issues with reactive airway disease most common (22.5% n = 9). Gastrointestinal issues were common with gastrostomy tube in 32.5% (n = 13) and short gut syndrome in 15% (n = 6). Over half of neonates with expectantly managed pPPROM survived with high rates of adverse outcomes with over half with documented gross motor and speech delay present at 2 years. Respiratory and gastrointestinal issues were also common. These data provide information for important patient counseling on long-term outcomes in expectantly managed pPPROM. KEY POINTS: · Adverse outcomes at 2 years after pPPROM were prevalent.. · Speech delay at 2 years was the most common outcome.. · Motor delay occurred in 55% of neonates at 2 years.. · Long-term pPPROM data can guide counseling..

The incidence of gestational diabetes mellitus (GDM) continues to increase in the United States and globally. While the first-line treatment of GDM remains diet and exercise, 30% of patients with GDM will require pharmacotherapy. However, many controversies remain over the specific glycemic threshold values at which pharmacotherapy should be started, how intensified the therapy should be, and whether oral agents are effective in GDM and remain safe for long-term offspring health. This review will summarize recently completed and ongoing trials focused on GDM pharmacotherapy, including those examining different glycemic thresholds to initiate therapy and treatment intensity. KEY POINTS: · The incidence of GDM continues to increase in the United States and globally.. · While the first-line treatment of GDM remains diet, 30% of patients require pharmacotherapy.. · Controversies remain over the specific glycemic threshold values at which pharmacotherapy is needed.. · Another controversy is how tightly to control GDM.. · Additional controversies are the safety of metformin and incretins in terms of offspring's long-term health..

Objective:  This study aims to estimate the frequency of unintended upper uterine wall extensions during cesarean delivery (CD) and identify associated risk factors and adverse outcomes.

Study design:  A multicenter retrospective cohort study was conducted, including patients who underwent CD between 2005 and 2021. Demographic factors, obstetric history, CD indications, delivery and surgical characteristics, adverse maternal and neonatal outcomes were compared between those with unintended upper uterine wall extensions during CD and those without extensions. Crude and adjusted estimates (odds ratios [ORs] and 95% confidence intervals [CIs]) were used.

Results:  Among 30,517 patients meeting inclusion criteria, 117 (0.4%) had an unintended upper uterine wall extension. In univariate analysis, upper uterine wall extensions were associated with higher rates of intrapartum CD, second-stage CD, unplanned or emergency CD, CD following failed vacuum delivery or trial of labor after CD, chorioamnionitis, prolonged labor, increased vaginal exams, lower fetal head station, and higher birth weight. During surgery, higher rates of general anesthesia, significant intraperitoneal adhesion, fetal malpresentation, and fetal extraction by the leg were observed. Multivariable analysis identified fetal extraction not by head (adjusted OR [aOR]: 9.17, 95% CI: 5.35-15.73), vertex fetal presentation (aOR: 3.65, 95% CI: 1.81-7.35), second-stage CD (aOR: 3.07, 95% CI: 1.24-7.59), and trial of labor after cesarean (aOR: 2.04, 95% CI: 1.08-3.84) as significant risk factors for unintended upper uterine wall extensions. Additionally, upper uterine wall extensions were associated with higher rates of maternal and neonatal complications, including longer operating times, excessive bleeding, postpartum hemorrhage, intraperitoneal drainage, blood product transfusion, puerperal fever, paralytic ileus, Apgar score < 7 at 1 and 5 minutes, and fetal intracranial hemorrhage.

Conclusion:  Our study identifies risk factors for unintended upper uterine wall extensions during CD. While these extensions are infrequent, their occurrence is associated with increased maternal and neonatal morbidity.

Key points: · Unintended upper uterine wall extensions occur in 0.4% of cesarean deliveries.. · Significant risk factors include fetal extraction not by head and second-stage CD.. · Extensions are associated with increased maternal complications like excessive bleeding and prolonged surgery.. · Neonatal complications include lower Apgar scores and intracranial hemorrhage.. · Awareness of these risks is critical for improving cesarean delivery outcomes..

Pregestational diabetes, either type 1 or type 2 diabetes, induces structural birth defects including neural tube defects and congenital heart defects in human fetuses. Rodent models of type 1 and type 2 diabetic embryopathy have been established and faithfully mimic human conditions. Hyperglycemia of maternal diabetes triggers oxidative stress in the developing neuroepithelium and the embryonic heart leading to the activation of proapoptotic kinases and excessive cell death. Oxidative stress also activates the unfolded protein response and endoplasmic reticulum stress. Hyperglycemia alters epigenetic landscapes by suppressing histone deacetylation, perturbing microRNA (miRNA) expression, and increasing DNA methylation. At cellular levels, besides the induction of cell apoptosis, hyperglycemia suppresses cell proliferation and induces premature senescence. Stress signaling elicited by maternal diabetes disrupts cellular organelle homeostasis leading to mitochondrial dysfunction, mitochondrial dynamic alteration, and autophagy impairment. Blocking oxidative stress, kinase activation, and cellular senescence ameliorates diabetic embryopathy. Deleting the mir200c gene or restoring mir322 expression abolishes maternal diabetes hyperglycemia-induced senescence and cellular stress, respectively. Both the autophagy activator trehalose and the senomorphic rapamycin can alleviate diabetic embryopathy. Thus, targeting cellular stress, miRNAs, senescence, or restoring autophagy or mitochondrial fusion is a promising approach to prevent poorly controlled maternal diabetes-induced structural birth defects. In this review, we summarize the causal events in diabetic embryopathy and propose preventions for this pathological condition. KEY POINTS: · Maternal diabetes induces structural birth defects.. · Kinase signaling and cellular organelle stress are critically involved in neural tube defects.. · Maternal diabetes increases DNA methylation and suppresses developmental gene expression.. · Cellular apoptosis and senescence are induced by maternal diabetes in the neuroepithelium.. · microRNAs disrupt mitochondrial fusion leading to congenital heart diseases in diabetic pregnancy..

Objectives: Neonatal resuscitation is a high acuity, low-occurrence (HALO) 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 ten month period from November 2020 to August 2021. TS sessions were remotely viewed and debriefed by experts. 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 ten 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 12x faster). Teamwork scores showed improvement in all domains.

Conclusions: 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 towards 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.

Background: Non-Hispanic Black pregnancies are disproportionately affected by preterm birth (PTB), a major driver of the racial disparity in infant mortality in the US.

Objective: Identify indicators of social determinants of health (SDoH) that contribute to preterm birth amongst non-Hispanic Black pregnancies.

Study design: Population-based retrospective case-control study of US birth records (2012-2016). Factors potentially associated with PTB and considered indicators of SDoH were compared between singleton live births of non-Hispanic Black individuals delivering preterm (<37 weeks) and term (≥37 weeks gestation). Logistic regression quantified the association between SDoH and PTB such as maternal age, insurance, education, and prenatal care visits, and reported as odds ratios (95% confidence interval, CI).

Results: Of 2,763,235 live births to Black pregnancies, 340,480 (12%) occurred <37 weeks. Factors most strongly associated with PTB (P< .001), presented as odds ratio (95% CI) included no prenatal care 3.0 (95% CI, 2.9-3.1) or insufficient prenatal care 2.7 (95% CI, 2.7-2.8); smoking during pregnancy 1.4 (95% CI, 1.43-1.47), age ≥ 35 years 1.3 (95% CI, 1.3-1.35), unmarried 1.18 (95% CI, 1.17-1.19), lack of high school diploma 1.1 (95% CI, 1.12-1.40), lack of father of baby listed on birth certificate 1.22 (1.21-1.23), and Black paternal race 1.10 (1.08-1.12). Utilization of WIC during the pregnancy had a protective effect on PTB risk in Black pregnancies, OR 0.83 (0.83-0.84).

Conclusion: Pregnancies in Black individuals who are ≥35 years old, smoke tobacco, utilize Medicaid insurance, with less than a high school education, unmarried, little to no prenatal care, Black paternal race, and lack of father of baby listed on birth record had increased risk of PTB. Understanding the lived experience of Black pregnant people and these selected indicators of SDoH that contribute to the risk of PTB may inform development of interventions to address the racial disparity in PTB in the US.

Objective: Hypertensive disorders of pregnancy (HDP) can be diagnosed prior to labor, during labor, or postpartum. We evaluated whether the timing of HDP diagnosis impacts postpartum blood pressure (BP) outcomes.

Study design: Secondary analysis of 384 patients with HDP from a trial evaluating furosemide use on BP outcomes. The timing of HDP diagnosis was categorized into: diagnosis in the antepartum period, prior to labor versus diagnosis peripartum (during labor or first day postpartum). Outcomes included time to resolution of hypertension, and persistent hypertension 7 days postpartum. Logistic and Cox regression models were used.

Results: Patients diagnosed in the peripartum period had a shorter median time to postpartum BP resolution after adjusting for severity of HDP, mode of delivery and furosemide use (5.5 vs. 6.5 days, aHR 1.18, 95% CI [1.11 - 1.25]) Conclusion: Patients diagnosed with HDP in the peripartum period experience a faster BP resolution than those diagnosed in the antepartum period.

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 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 United States 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: 125 patients undergoing 132 ECV attempts were included. 69 attempts were successful (52.2%). Dahl 2021 had the greatest predictive value (AUC 0.779), while 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 0.71-0.84. 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.