American journal of perinatology最新文献

Prevailing evidence underscores the critical influence of infant gut microbiota on systemic immune responses and intestinal health. The role of functional programming of effector immune cells at extra-intestinal mucosal sites is increasing in interest. Common connections between development of gut and lung microbiomes and reciprocal signaling between the two organ systems has reinforced the concept of a "gut-lung axis." Narrative review of existing literature evaluating mechanistic evidence linking microbial dysbiosis and necrotizing enterocolitis (NEC) to development of preterm acute lung injury and subsequent progression to chronic lung disease or bronchopulmonary dysplasia (BPD). Evidence across animal and human studies indicates that gut-derived microbial ligands and metabolites are foundational in programming respiratory immunity. Conversely, primary pulmonary insults appear to trigger reciprocal shifts in gut microbiome function. This bidirectional signaling likely drives the clinical association between NEC-associated systemic inflammation and the subsequent increased risk of BPD. By focusing on mediators involved in this gut-lung crosstalk, we seek to highlight avenues such as microbiome modulation or targeted anti-inflammatory signaling to prevent or reduce the severity of two of the major morbidities of prematurity. · Gut dysbiosis drives systemic inflammation and mediates pro-inflammatory responses in the lungs.. · The communication between gut and lungs is mediated by microbiome, metabolites and immune cells.. · Modulating the gut microbiome presents a promising strategy for prevention of BPD in preterm infants.

To evaluate obstetric, maternal and perinatal outcomes by delivery week for pregnancies with gestational diabetes mellitus (GDM) and without diabetes. We conducted a secondary analysis of electronic medical record data from 9,696 (5.3%) GDM pregnancies and 173,323 pregnancies without any diabetes delivered at 34 to 40 weeks. Composite and individual outcomes included maternal (e.g., death, hypertensive disorders, hemorrhage); primary neonatal morbidity and perinatal mortality (e.g., death, ventilation use, sepsis, seizures, injury); secondary neonatal (e.g., shoulder dystocia, hypoglycemia); and neonatal respiratory support/morbidity from chart review. Modified Poisson regression with generalized estimating equations calculated adjusted relative risks (RR) for differences in outcome rates by GDM status and fetus at risk model for outcomes at delivery compared to ongoing pregnancies. A higher proportion of GDM pregnancies delivered at each week prior to 39 weeks compared to no diabetes ( 2.5%, 3.9%, 7.4%, 17.2%, 32% and 36.9% for GDM and 1.4%, 2.3%, 5.0%, 11.0%, 24.6% and 38.4% for no diabetes, at 34, 35, 36, 37, 38 and 39 weeks, respectively, P<.001). Among GDM, compared to ongoing pregnancy, risk of maternal composite was higher for delivery at 37 weeks, 20.5% vs 11.6% (RR 1.71; 95%CI 1.51-1.92) and 38 weeks, 14.9% vs 9.4% (RR 1.62; 95%CI 1.42-1.84) driven by hypertensive disorders (18.3% at 37 and 23.5% at 38 vs 10.1% at 39 weeks); and risk of primary neonatal composite was higher at 37 weeks, 2.3% vs 1.1% (RR 2.00; 95%CI 1.33-3.00). Risk of stillbirth was higher at 37 weeks, 0.41% vs 0.11% (RR 3.62; 95%CI 1.22-10.75) among GDM suggesting it was an indication for earlier delivery. For GDM-complicated pregnancies, earlier delivery at 37 and 38 weeks compared to ongoing pregnancy was associated with higher risk of maternal morbidity likely due to having hypertensive disorders, and delivery at 37 weeks with higher risk for serious neonatal morbidity.

The objective of this study is to estimate the difference in first-recorded weight associated with deferred cord clamping (DCC) among very preterm infants (< 32 weeks' gestational age) using real-world neonatal intensive care unit dataRetrospective cohort study using the California Perinatal Care Collaborative data from 2016 to 2023 across 138 hospitals. Infants with gestational ages between 22 and 31^6/7 weeks were included. Exclusions were cord milking, death in the delivery room, or missing data. DCC exposure was defined as a delay in cord clamping of at least 30 seconds. Analyses used linear regression adjusting for gestational age (in days) as a second-order polynomial and intrauterine growth restriction (IUGR).Of 39,013 eligible infants, 6,626 were excluded (cord milking, delivery room deaths, and missing DCC information), leaving 32,387 very preterm infants for the analysis. The mean weight for infants who received DCC was 1,338 g (standard deviation [SD]: 404) compared with 1,290 g (SD: 431) for those who did not. After adjusting for gestational age and IUGR, DCC was associated with 24-g higher first-recorded weight (95% confidence interval: 18-29).In very preterm infants, at least 30 seconds of DCC is associated with a modest increase (24 g) in first-recorded weight. This finding reinforces evidence from small clinical trials showing increased blood volumes and weight gains attributed to DCC. · DCC of at least 30 seconds is linked to 24 g higher weights in very preterm infants.. · Weight gain from DCC is modest but aligns with prior physiological evidence.. · Real-world evidence on DCC's impact on early weight is limited..

Systematic reviews depend on rigorous risk-of-bias (RoB) assessments to ensure credibility, yet manual evaluation using the Cochrane RoB 2 tool is resource-intensive. While large language models (LLMs) offer potential for automation, their alignment with human judgment remains underexplored. This study evaluates the reliability of ChatGPT-4o, ChatGPT-5, and Claude 3.5 Sonnet in assessing RoB in randomized controlled trials (RCTs), comparing their agreement with human reviewers and internal consistency.We retrospectively analyzed 180 RCTs from systematic reviews published in the American Journal of Obstetrics and Gynecology (2021-2023) reporting complete human RoB 2 ratings. Each LLM processed full-text PDFs using a standardized prompt incorporating the complete RoB 2 algorithm. Model performance was evaluated against human benchmarks using Cohen's kappa and prevalence- and bias-adjusted kappa. Intramodel reliability was assessed across three independent runs to measure consistency.ChatGPT-5 consistently outperformed other models, achieving the highest agreement in randomization (Domain 1; 76%), missing outcome data (Domain 3; 80%), and outcome measurement (Domain 4; 76%). It showed moderate concordance for deviations from intended interventions (69%). However, all models struggled with selective reporting (Domain 5), where agreement dropped to 47 to 51%. For overall RoB judgments, ChatGPT-5 demonstrated superior concordance (60-62%, κ = 0.36-0.40) compared with ChatGPT-4o (45%) and Claude 3.5 Sonnet (43%). ChatGPT-5 also exhibited substantial to near-perfect internal consistency.Among the evaluated models, ChatGPT-5 most closely approximated human RoB 2 assessments and achieved superior internal consistency, suggesting it could serve as a practical first-pass tool to reduce reviewer burden. However, persistent limitations in detecting selective reporting-likely due to the inability to cross-reference external trial registries-highlight that expert human oversight remains essential for accurate evidence synthesis. · GPT-5, GPT-4o, and Claude evaluated 180 RCTs.. · GPT-5 outperformed GPT-4o and Claude models.. · Models struggled with selective reporting bias..

Patients with hypertensive disorders of pregnancy (HDPs) are recommended to attend an early postpartum follow-up visit for blood pressure monitoring. Follow-up frequency for patients with HDPs can vary widely, with some patients requiring multiple office visits. We sought to determine factors associated with multiple postpartum blood pressure visits among patients with HDPs.We retrospectively identified patients with HDPs who delivered at our maternity center in 2019 and compared factors between patients who attended a single blood pressure follow-up appointment without requiring further clinical evaluation for hypertension and patients who required multiple postpartum clinical evaluations for persistent hypertension. Univariate logistic regression models were used to identify factors associated with increased odds of having multiple clinically indicated postpartum visits for blood pressure monitoring.We identified 328 patients with HDPs, of whom 260 (79.3%) attended an initial postpartum blood pressure follow-up appointment and were included in further analyses. Of the 260 patients, 70 (26.9%) had multiple blood pressure visits. Factors associated with multiple blood pressure visits included delivery between 34 and less than 37 weeks of gestation (odds ratio [OR], 3.62; 95% CI, 1.07-12.30), systolic blood pressure before discharge of 140 mm Hg or higher (OR, 5.02; 95% CI, 2.57-9.82), and discharge with blood pressure medication (OR, 3.42; 95% CI, 1.82-6.41).Patients with HDPs who deliver preterm, have persistent hypertension before discharge, or are discharged with antihypertensive medication require continued close postpartum observation and continuity of care. · Postpartum follow-up care for patients with HDPs should be tailored to the patient.. · Preterm delivery, persistence of hypertensive blood pressure at discharge, and discharge with antihypertensive medication are associated with multiple postpartum ambulatory office visits.. · High-risk patients should be diligently monitored with postpartum continuity of care..

This study aims to evaluate variation in neurodevelopmental care utilization in the Military Health System (MHS) for preterm infants.Retrospective cohort study of infants born preterm within the MHS from 2017 to 2021. Preterm birth was categorized as extreme preterm, very preterm, moderate preterm, late preterm, or unknown. Patient demographics were extracted. The primary outcome was the use of neurodevelopmental care within 2 years of birth.Compared with late preterm births, total use of specialty care was significantly higher (p < 0.05) in moderate, very, and extreme preterm births. Black infants had fewer total visits than White infants (-1.54, p < 0.05). Disparities by region of birth were noted, with lower utilization in the Pacific and West South-Central census divisions (p < 0.05).There are differences in neurodevelopmental care utilization among preterm infants in the MHS, driven by gestational age, race, and geography. These findings support the need for a standardized policy on neurodevelopmental follow-up. · Neurodevelopmental utilization varies by sociodemographic factors.. · Despite universal access to care, neurodevelopmental care utilization varies in the military health care system.. · Standardized neurodevelopmental follow-up is needed to ensure equitable access to care..

The objective of this study is to explore real-world practices in managing sedation-analgesia in a population of neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia.Retrospective data from neonates admitted with hypoxic-ischemic encephalopathy to the neonatal intensive care unit of Lille University Hospital were collected, between December 31, 2018, and July 15, 2022. Drug and dosage of sedation-analgesia during the 96 hours following therapeutic hypothermia initiation were collected. Neonates were divided into four subgroups for principal component analysis, according to neurological examination at discharge: death, severe sequelae, moderate sequelae, no sequelae.Neonates with a favorable outcome were exposed to higher cumulative doses. They were more likely to be exposed to polypharmacy, midazolam, and dexmedetomidine, and increasing doses of these. Daily doses of opioids did not vary significantly. Newborns with acute renal failure had lower cumulative doses. There was no significant difference between newborns with and without hepatic cytolysis.Practice assessments highlight heterogeneity regarding sedation-analgesia, especially within patient groups. Findings indicate that sedation-analgesia is not reassessed as often as it should be to account for specific pharmacokinetic parameters and the physiologic course of recovery. · Although sedation-analgesia is considered standard of care during therapeutic hypothermia, its use may be iatrogenic; therefore, we evaluated our practices to move toward optimized, personalized management.. · Neonates with a favorable outcome were more likely to have been exposed to a higher cumulative dose; increasing doses; polypharmacy; midazolam; and dexmedetomidine.. · Findings indicate that sedation-analgesia is not reassessed as often as it should be..

The use of continuous glucose monitors (CGM) and insulin pumps has revolutionized the care of patients with type 1 diabetes (T1D). Few data are available regarding the use of diabetes technology use in the pregnant T1D population. This study was conducted to evaluate temporal trends of diabetes technology use and predictors of use among pregnant individuals with TID in the United States from 2009 to 2020.MarketScan Research Databases from 2009 to 2020 were used to identify pregnant individuals with T1D who were and were not using CGM and/or insulin pumps. Joinpoint regression analysis was used to estimate the average annual percent change (AAPC) in diabetes technology use over time. Unadjusted and adjusted log-linear Poisson regression models were developed to assess the associations between the outcomes of CGM and insulin pump use and demographic and clinical predictors. Associations were reported as adjusted risk ratios (ARR) with 95% confidence intervals (CI).Among 9,201 pregnancies with T1D, CGM use increased from 2.3% in 2009 to 13.7% in 2020 (AAPC: 13.9%; 95% CI: 11.7-17.1), while insulin pump use remained unchanged from 10.9% in 2009 to 11.8% in 2020 (AAPC: -2.4%; 95% CI: -4.4 to 0.4). Medicaid insurance and obesity were associated with a lower likelihood of CGM use and insulin pump use, while a high obstetric comorbidity index score was associated with a higher likelihood of insulin pump use (ARR: 1.26; 95% CI: 1.05-1.51).From 2009 to 2020, CGM use among pregnant individuals with T1D increased, while insulin pump use remained unchanged. Use varied by patient demographic and clinical factors, most notable for lower likelihood of CGM use and insulin pump use with Medicaid insurance. Although CGM use increased over time, overall CGM use remained lower than expected despite the known benefits of CGM use in improving neonatal outcomes in pregnancies complicated by T1D. · CGM use in pregnant individuals with T1D increased from 2.3 to 13.7%, but pump use was stable.. · Medicaid and obesity were associated with lower CGM and pump use in pregnant individuals with T1D.. · Low CGM use in pregnant T1D individuals highlights barriers and the need for equitable access..

Explore the effect of a 6-week online program of yogic breathing, meditation, and gentle postures for parents of infants hospitalized in the neonatal intensive care unit (NICU).From October 2021 to October 2023, we conducted a two-center pilot study of yoga for NICU parents. We assigned consented parents of NICU inpatients to receive yoga classes (YG) and/or usual care (UC) for parent support within 14 days of admission to the NICU. Self-directed yoga sessions were completed using an online platform. UC included parental support as practiced in each NICU and served as a control group. Primary outcomes were assessed at the study entrance, midpoint, and conclusion using the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) and the Postpartum Bonding Questionnaire (PBQ) in English and Spanish.A total of n = 51 parents (71%) mothers, were allocated using parallel assignment to UC (n = 28, 55%) or YG (n = 23, 45%). A total of n = 39 (76%) parents completed the classes to the midpoint of the study and n = 33 (65%) completed all 6 weeks of the study. There were no differences in baseline characteristics for parents or infants between groups. Average participation in the online yoga materials was 3 hours and 45 minutes per parent. A significant decrease in NICU-related parent stress emerged for all PSS: NICU subscales and total PSS: NICU scores for parents assigned to YG between enrollment and the midpoint of the study. Neither parents in UC nor YG approached thresholds indicating disorders of the parent-infant relationship as assessed by the PBQ.When initiated early, an online, asynchronous yoga intervention designed for parents may reduce NICU parent stress. · Yoga may reduce stress and enhance emotional health for parents of critically ill newborns.. · Virtual and self-directed mindfulness interventions for parents are feasible in the NICU environment.. · Sustaining parental wellness over an extended NICU hospitalization is challenging..

Incarceration of the gravid uterus is a rare obstetric complication in which the retroverted uterus becomes trapped in the pelvis, often resulting in maternal and fetal morbidity if not recognized and managed early.We present the case of a 36-year-old multigravida at 15 weeks' gestation with no prior abdominal surgeries who initially presented with urinary retention and was diagnosed with an incarcerated gravid uterus. Multiple attempts at manual reduction under spinal and general anesthesia were unsuccessful. Intraoperative transabdominal ultrasound demonstrated a live intrauterine pregnancy with normal fetal heart rate, a uterine fundus wedged behind the sacral promontory consistent with persistent incarceration, and raised concern for a Grade 1 (minor) placenta previa. Diagnostic laparoscopy revealed dense posterior adhesions between the uterus and sigmoid mesentery. Adhesiolysis was performed, resulting in successful uterine repositioning and symptom resolution. Although the patient initially recovered well, she re-presented with vaginal bleeding with resolution of her previa but with evidence of chorion-amnion separation. Ultimately, she experienced previable preterm premature rupture of membranes and was subsequently diagnosed with intrauterine fetal demise at 22 weeks and 4 days. Placental pathology demonstrated severe acute chorioamnionitis, funisitis, umbilical vasculitis, and features of uteroplacental underperfusion.Laparoscopy allowed for successful uterine reduction through adhesiolysis. Despite technical success, the patient experienced chorion-amnion separation, preterm premature rupture of membranes, and intrauterine fetal demise. Placental pathology indicated infectious and vascular findings.This case demonstrates the role of laparoscopy in management of gravid uterine incarceration refractory to manual reduction. It also underscores that technically successful surgical intervention may not preclude adverse pregnancy outcomes, emphasizing the importance of close antenatal surveillance. · Laparoscopy enables effective uterine reduction when manual methods are unsuccessful.. · Adhesive disease may underlie uterine incarceration even without prior surgical history.. · Operative anatomical correction may not prevent complications and continued monitoring is essential..