American journal of perinatology最新文献

We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity.   This is a secondary analysis of a prospective cohort study conducted 2010-2015 that included all term gravidas who reached active labor (six centimeters). Primary outcomes were composite maternal morbidity (maternal fever, postpartum hemorrhage, transfusion, endometritis, and severe perineal lacerations) and composite neonatal morbidity (respiratory distress syndrome, mechanical ventilation, birth injury, seizures, hypoxic ischemic encephalopathy, therapeutic hypothermia, or umbilical artery pH < 7.1). Outcomes were compared between patients with and without PLP, defined as > 90th percentile of labor duration between admission and active phase. Results were stratified by induction (IOL) vs. spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders. In this cohort of 6509 patients, 51% underwent induction of labor. 650 patients had a PLP with a median length of 8.5 hours in spontaneous labor and 18.8 hours in IOL. Among patients with PLP, there was a significant increase in composite maternal morbidity with both IOL (aOR 1.36, 95% CI 1.01, 1.84) and spontaneous labor (aOR 1.49, 95% CI 1.09, 2.04) and an increase in composite neonatal morbidity with spontaneous labor only (aOR 1.57, 95% CI 1.01, 2.45). Cesarean delivery occurred more often in PLP group (14.0% versus 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared to those with normal latent phase. PLP at or above the 90th percentile in patients who reach active labor is associated with increased risk of maternal morbidity that is not mediated by cesarean delivery. PLP in spontaneous labor is associated with increased neonatal morbidity. These data suggest that further research is needed to establish latent phase cut-offs that may be incorporated into labor management guidelines.

Objective: Provide contemporary data on maternal and infant outcomes after delivery to better understand risks of Cesarean section (CS).

Study design: Data for deliveries in 2019 and 2020 were obtained from a large US commercial healthcare claims database. Maternal morbidity measures included twenty Severe Maternal Morbidity (SMM) outcomes and seven additional obstetric and mental health outcomes. Infant morbidity measures included eight outcomes related to respiratory health, digestive health, atopic dermatitis, and birth trauma. Outcome prevalence was ascertained at 42 days (maternal only) and 360 days after delivery. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for prevalence adjusted for risk factors for delivery mode and each outcome. Analyses were conducted for 2019 and 2020 to assess the influence of the COVID-19 pandemic.

Results: A total of 436,991 deliveries were identified (145,061 CS; 291,930 vaginal). The prevalence of SMM was 3.3% at 42 days and 4.1% at 360 days. The covariate-adjusted odds of SMM were higher among CS than vaginal deliveries at 42 days (OR: 2.0, 95% CI: 1.9, 2.1) and 360 days (OR: 1.7, 95% CI: 1.7, 1.8). There were 226,983 infants available for analysis of outcomes at 360 days. Most adverse infant outcomes were more prevalent at 360 days among CS than vaginal deliveries, and the covariate-adjusted odds of any adverse infant outcome at 360 days were higher among CS than vaginal deliveries (OR: 1.2; 95% CI: 1.1, 1.3). Respiratory morbidity was most affected by delivery mode. Maternal and infant mortality up to 360 days was rare. Similar trends were observed in the 2019 and 2020 cohorts.

Conclusion: This observational study, performed using recent data obtained from a large US commercial claims database, provides contemporary evidence of risks to mothers and infants of CS relative to vaginal delivery.

Objective: Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT.

Study design: This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010-2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included non-transfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes (PROM) or preterm prelabor rupture of membranes (PPROM), cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size and teaching status, were also used to produce adjusted relationships between HHT status and outcomes.

Results: The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p<0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared to patients without HHT (7.8% vs 1.7%, adjusted relative risk (aRR) 4.49 [95% CI 3.06, 6.58]). Rates of preterm birth (14.2% vs 8.5%, aRR 1.57 [95% CI 1.22, 2.03]), cesarean delivery (41.0% vs 32.9%, aRR 1.23 [95% CI 1.07, 1.41]), respiratory bleeding (2.1% vs <0.1%, aRR 94.44 [56.64, 157.46]) and cerebrovascular complications (0.9% vs <0.1%, aRR 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups.

Conclusion: Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared to the baseline population.

Ferritin, commonly used for diagnosing iron deficiency (ID) in pregnancy, is limited by high cost and false elevations during inflammation. Reticulocyte hemoglobin equivalent (Ret-He), an alternative marker for ID, is unaffected by inflammation and analyzed on the same collection tube as the standard complete blood count (CBC). We aimed to determine the accuracy of Ret-He in detecting ID in pregnancy compared to ferritin in a United States cohort. This prospective cohort study enrolled 200 pregnant participants, recruited in any trimester if a CBC was drawn as part of routine prenatal care. For those who agreed to participate, Ret-He and ferritin were collected concurrently with the CBC. ID was defined as ferritin level below 30 ng/mL. Patients were classified into three groups based on hemoglobin and ferritin results to determine the severity of ID: no ID, ID alone and iron deficiency anemia (IDA). Four participants with anemia but normal ferritin were excluded. Receiver operating curve analysis (ROC), including the area under the curve (AUC), was performed to assess the accuracy of Ret-He in detecting ID. A one-way ANOVA with post-hoc analysis was used to compare differences in Ret-He between the three groups of ID severity. The prevalence of ID in our cohort was 82% (161/196). The AUC for Ret-He was 0.65 (95% confidence interval 0.55-0.75), indicating suboptimal discrimination between patients with and without ID. Ret-He was significantly different among the three groups (p<0.001). In post-hoc analysis, Ret-He was significantly lower in the IDA group compared to the ID group (p<0.001) but there was only a trend of lower Ret-He in the ID group compared to the non-ID group (p=0.38). Ret-He has low accuracy in diagnosing ID in pregnancy. It may be useful in detecting severe ID resulting in anemia but not a mild iron deficient state resulting in ID alone.

Background: Between 2008-2016, 23% of pregnancy-related deaths in Ohio occurred in an emergency department (ED) or outpatient setting. Prior research showed 98% of Ohio's delivery hospitals conduct obstetric (OB) emergency simulations, while only 30% include ED staff. The goal of the grant was to increase knowledge, skill, and self-efficacy of emergency medicine (EM) professionals in managing OB emergencies. In addition to EM professionals, there was high interest by obstetrics and gynecology (OB/GYN) and other professionals in the course. Therefore, the goal of the project was to increase these elements for all professionals including EM and non-EM professionals in managing OB emergencies.

Methods: Twelve virtual training courses using simulated patient encounters and video-based skills training were conducted across Ohio on the management of OB emergencies. Scenarios focused on common causes of pregnancy-related death using data from the Ohio Pregnancy-Associated Mortality Review (PAMR) committee. Pre- and post-tests assessed training effectiveness.

Results: Between August 1, 2020, and June 30, 2023, 258 learners completed the course. Most were female (76.76%), White (90.61%), and under 45 years old (69.40%). Most (66.49%) were from EM, followed by OB/GYN (18.09%), and other specialties (15.43%) including family medicine and Pediatric EM. Most worked in hospital settings (89.19%). Learners reported a median 10.00 (IQR 15.00) years in clinical practice. Overall, mean knowledge scores increased by 0.81 (95% CI 0.62, 1.01), after the course (p<0.001). Mean knowledge scores increased by 0.90 (95% CI 0.64, 1.16; p<0.001), 0.67 (95% CI 0.24, 1.09; p=0.003), and 0.60 (95% CI 0.16, 1.04; p=0.01) for those from EM, OB/GYN, and other specialties, respectively. Median scores for reported self-efficacy increased by 24.00 (IQR 22.33) and self-reported skills increased by 30.42 (IQR 22.83) points (p<0.001).

Conclusion: Virtual simulations can be effective in improving EM, OB, and other professionals' knowledge, self-efficacy, and self-reported skills in managing OB emergencies.

Objective Chronic hypertension is a known risk factor for the development of preeclampsia and obstetrical morbidity. However, recent risk estimates, particularly in the era of use of low-dose acetylsalicylic acid for preeclampsia prevention, are lacking. This study aimed to estimate the association between chronic hypertension and preeclampsia and other adverse pregnancy outcomes in a contemporary cohort of births spanning the period since the introduction of a low-dose acetylsalicylic acid protocol. The secondary outcome was to estimate trends in preeclampsia and preterm birth among patients with chronic hypertension during the study period. Study Design A retrospective, population-based cohort study was conducted using the National Inpatient Sample (NIS) Database to identify individuals discharged from hospitals in the United States following obstetrical delivery from 2014 to 2019. Pregnancies complicated by chronic hypertension were identified using ICD 9/10 codes. Multivariable logistic regression models were used to estimate the adjusted odds ratios (OR) for the association between chronic hypertension and adverse pregnancy outcomes compared to pregnancies not complicated by chronic hypertension. Temporal trends in preeclampsia and preterm birth among patients with chronic hypertension were estimated over the study period. Results Among 4,451,667 obstetrical delivery-related admissions, 139,556 (3.1%) included pregnancies complicated by chronic hypertension. Of these, 27,146 (19.4%) admissions included pregnancies with superimposed preeclampsia, compared to 222,351 (5.2%) of admissions that included pregnancies with preeclampsia without prior diagnosis of chronic hypertension. Pregnancies complicated by chronic hypertension were associated with 3.29 times the odds of preeclampsia compared to pregnancies without chronic hypertension (95% CI 3.22-3.36), but the odds of preeclampsia (p-value for linear trend <0.0001) and preterm birth (p-value for linear trend = 0.0001) in this subgroup decreased over the study period. Conclusion While the odds of preeclampsia are increased among pregnancies complicated by chronic hypertension, the odds of preeclampsia in this population have decreased over time.

Objective:  This study aimed to evaluate the most effective regimen to raise hemoglobin (Hb) by comparing alternate-day dosing of iron to daily dosing in pregnant women with iron deficiency anemia.

Study design:  Women with Hb < 11.0 g/dL and ferritin ≤ 25 µg/L between 12^0/7 and 34^0/7 weeks' gestation were recruited. A total of 88 patients were randomized using block randomization with 1:1 allocation to receive either 1 tablet of 325 mg ferrous sulfate on consecutive days or 2 tablets every other day. The primary outcome, the change in Hb after 6 weeks of treatment was assessed using an analysis of covariance to adjust for baseline level. Secondary outcomes included change in ferritin, hepcidin, side effects, and compliance. Patients completed a questionnaire to assess for adverse symptoms and adherence was monitored by installing a pill reminder app on smartphones of patients.

Results:  A total of 88 patients were consented. The daily iron group had a greater proportion of nulliparous women (40 vs. 7%). Most patients (98%) had mild anemia (Hb: 9-10.9 g/dL) at recruitment, with a median gestational age of 28.1 weeks (interquartile range [IQR]: 25.6, 30.9) and median duration of treatment of 42 days (IQR: 35, 45). At 6 weeks, the daily iron group had a mean increase in Hb of 0.8 ± 0.9 g/dL, whereas the alternate-day iron group had a mean increase of 0.5 ± 1.0 g/dL (baseline adjusted difference of means: -0.3 [95% confidence interval: -0.7, 0.1], p = 0.15). Frequency of adverse effects attributable to iron were similar between groups. Patient self-reported compliance to treatment was also similar between groups. Among those that used the app, compliance was higher among the daily group compared with the alternate daily group (median: 95.5% [IQR: 75, 100] vs. 85% [IQR: 40, 92]), although this difference was not statistically significant (p = 0.07).

Conclusion:  This trial suggests that there are no significant differences between alternate-day iron supplementation and daily iron supplementation for treating iron deficiency anemia.

Key points: · Intermittent iron provides no additional benefit compared to daily iron in the treatment of anemia.. · Patient compliance to treatment was similar between the groups.. · The frequency of side effects was not significantly different between the groups..

The consensus in the literature supports the need for careful monitoring and management of maternal blood glucose during labor to optimize neonatal outcomes. Guidelines generally recommend strict control of maternal blood glucose during labor, involving frequent checks, and the use of dextrose and insulin as needed. However, recent evidence has not consistently shown a strong association between strict control of blood glucose and a reduction in the rate of neonatal hypoglycemia. This raises questions about the extent to which intrapartum blood glucose control impacts neonatal hypoglycemia. This review aims to explore the literature on intrapartum maternal blood glucose management in individuals with pregestational or gestational diabetes, utilizing peer-reviewed journals and datasets, including PubMed, Google Scholar, and clinical guidelines. Observational studies, small sample sizes, variability in definitions of maternal hyperglycemia and neonatal hypoglycemia, and differences in measurement methods such as timing and thresholds for intervention limit the literature on this topic. Additionally, many studies may not fully account for confounding factors such as maternal body mass index, diet, and other comorbidities affecting blood glucose levels. These limitations underscore the need for a cautious interpretation of current findings and highlight the necessity for future research in this area. This review elaborates on the available data and summarizes evidence on managing labor in pregnancies complicated by diabetes. We also emphasize the need for further research to clarify the relationship between maternal blood glucose during labor and neonatal blood glucose. KEY POINTS: · The benefits of strict intrapartum blood glucose control are unclear.. · The optimal maternal blood glucose range to prevent neonatal hypoglycemia remains undefined.. · Additional research is necessary to understand the relationship between maternal and neonatal blood glucose..

Objective:  This study aimed to determine whether pregnant women who have "flat" oral glucose tolerance test (OGTT) curves in pregnancy are at increased risk of maternal or neonatal adverse outcomes.

Study design:  We conducted a retrospective cohort study of the perinatal outcomes of pregnant women whose 100-g OGTT curve was "flat," defined by a fasting serum glucose level below 95 mg/dL and the remaining values below 100 mg/dL. We compared their perinatal outcomes to women whose OGTT curve was "normal." The primary outcomes compared were the prevalence of macrosomic and small for gestational age (SGA) neonates. Secondary outcomes included hypertensive disorders of pregnancy (HDP), prelabor anemia, thrombocytopenia, intrauterine fetal demise, placental abruption, indicated induction of labor, meconium-stained amniotic fluid, mode of delivery, postpartum hemorrhage, blood product transfusion, postpartum readmission, neonatal gender, gestational age at delivery, preterm birth, birth weight, low birth weight, umbilical artery pH < 7.1, Apgar score <7 at 5 minutes, neonatal intensive care unit admission, neonatal respiratory and infectious morbidity, and hypoglycemia. Composite adverse maternal and neonatal outcomes were also evaluated.

Results:  There were 1,060 patients in the study group and 10,591 patients in the control group. Patients with a flat OGTT were younger (28.3 vs. 29.8, p < 0.001) and less likely to be over 35 years old (14.1 vs. 23.4%, p < 0.001). They had a reduced risk of delivering a macrosomic neonate (11.4 vs. 15.1%, OR = 0.7 [0.58-0.89], p = 0.001) and having an unplanned cesarean delivery (7.5 vs. 10.2%, OR = 0.8 [0.58-0.96], p = 0.002). There was no difference in the rate of composite adverse maternal (14.0 vs. 15.4%, OR = 0.9 [0.7-1.0], p = 0.1) or neonatal outcome (5.3 vs. 4.5%, OR = 1.2 [0.9-1.5], p = 0.15). Neonates had a slightly lower mean birth weight (3,474 vs. 3,505 g, p = 0.04) but the rate of SGA was similar in the two groups (2.5 vs. 1.8%, OR = 1.3 [0.9-2.0], p = 0.08).

Conclusion:  Pregnant women whose OGTT curve is flat have a lower risk of delivering macrosomic neonates and undergoing unplanned cesarean delivery and are not at increased risk of adverse maternal or neonatal outcomes. More research is required to evaluate the relationship between different OGTT curves and the fetal growth rate.

Key points: · Patients with a "flat" OGTT have a reduced risk of macrosomia.. · Patients with a "flat" OGTT have a reduced risk of cesarean delivery.. · Patients with a "flat" OGTT are not at increased risk of growth restriction..

Objective Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves pre-delivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes. Study Design We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented December 2021, recommends (1) IVFe for postpartum Hb 7.0-8.9 g/dL and (2) oral iron for postpartum Hb 9.0-9.9 g/dL. We compared all postpartum inpatients at a single site in April 2021 (PRE) to April 2022 (POST). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay. Results 805 patients were included (PRE=401; POST=404). Patients in the PRE and POST group differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p=0.003). IVFe use significantly increased from PRE to POST-implementation (PRE: 6.0% vs. POST: 11.1%, p=0.009) even when controlling for differences between groups (aOR 2.48, 95% CI [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared to patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p=0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p<0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications. Conclusion Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay.