American journal of perinatology最新文献

Objective:  Few studies have explored the impact of county-level variables on severe maternal morbidity (SMM) subtypes. To address this gap, this study used a large commercial database to examine the associations between individual- and county-level factors and SMM.

Study design:  This retrospective cohort study used data from the Optum's deidentified Clinformatics Data Mart Database from 2008 to 2018. The primary outcomes of this study were any SMM, nontransfusion SMM, and nine specific SMM subtypes. Temporal trends in the prevalence of SMM and SMM subtypes were assessed using Joinpoint Regression. Multilevel logistic regression models were used to investigate the association of individual- and county-level factors with SMM.

Results:  Between 2008 and 2018, there was not a significant change in the prevalence of any SMM (annual percent change [APC]: -0.9, 95% confidence interval [CI]: -2.2, 0.5). Significant increases in prevalence were identified for three SMM subtypes: other obstetric (OB) SMM (APC: 10.3, 95% CI: 0.1, 21.5) from 2013 to 2018, renal SMM (APC: 8.5, 95% CI: 5.5, 11.6) from 2008 to 2018, and sepsis (APC: 23.0, 95% CI: 6.5, 42.1) from 2014 to 2018. Multilevel logistic regression models revealed variability in individual and county risk factors across different SMM subtypes. Adolescent mothers (odds ratio [OR]: 2.10, 95% CI: 1.29, 3.40) and women in the 40 to 55 (OR: 1.67, 95% CI: 1.12, 2.51) age group were found to be at significant risk of other OB SMM and renal SMM, respectively. For every increase in rank within a county's socioeconomic social vulnerability index (SVI), the risk of respiratory SMM increased 2.8-fold, whereas an increase in rank in the racial/ethnic minority SVI was associated with a 1.6-fold elevated risk of blood transfusion.

Conclusion:  This study underscores the complex association between individual and county factors associated with SMM, emphasizing the need for multifaced approaches to improve maternal care.

Key points: · No increase in composite SMM rates from 2008 to 2018.. · Increases in obstetric SMM subtypes and sepsis.. · Risk factor profiles may differ across SMM subtypes.. · Key risk factors: age, comorbidities, prenatal care.. · County socioeconomic status associated with respiratory SMM risk..

Objective:  Significant racial and ethnic disparities in maternal morbidity and mortality as well as gynecologic outcomes persist in the United States. The role of ambulatory care in obstetrics and gynecology (OBGYN), particularly in facilities that separate resident and attending care along payor (and de facto racial) lines, remains unclear. This study examines patient perspectives on payor-segregated health care delivery in an academic medical center (AMC) and opinions on possible integration.

Study design:  This is a qualitative study conducted at a single AMC with payor-segregated resident and attending outpatient sites. Interviews focused on patient perception of experience and value in outpatient OBGYN care, perspectives on the segregated care model, and attitudes about integration. Patients participated in a 30-minute semistructured interview with recruitment continuing until thematic saturation was reached (October 2022-August 2023). Interviews were coded using an integrated approach with grounded theory; 12% of transcripts were double-coded (k = 0.86).

Results:  We interviewed 26 patients (16 from resident, 10 from attending site). Patients prioritized practical aspects such as clinic proximity and quality of clinician interaction. Most were unaware of the payor-segregated clinic system and disapproved upon learning about it. Opinions varied on topics of telehealth and continuity, indicating diverse patient needs. Notably, minoritized patients valued race and class concordance in clinical spaces. Patients generally supported care integration, conditional upon the preservation of aspects of care they valued.

Conclusion:  Successful OBGYN care integration requires meeting individual needs while ensuring diversity, safety, and community-oriented care, alongside access and convenience. Incorporating patient voices is crucial for aligning services with expectations and improving patient experiences.

Key points: · Patients disapprove of payor-segregated care but prioritize practical aspects over care structure.. · Minoritized patients valued race/class concordance. Preferences varied on continuity, residents, and telehealth.. · Clear communication around prior payor segregation and motivations for integration will foster trust..

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis, and invasive pneumococcal disease among adults in the United States, with higher rates of disease occurring among individuals with chronic medical and immunocompromising conditions. Pregnant individuals, especially those with comorbid conditions, are also at increased risk of infection due to S. pneumoniae due to physiological and immunologic changes in pregnancy. Vaccination against pneumococcus is recommended for adults living with HIV aged 19 to 49, congenital or acquired immunodeficiency, asplenia, chronic renal failure, sickle cell disease, alcohol abuse, cerebrospinal fluid leaks, congestive heart failure and cardiomyopathies, chronic lung disease, chronic liver disease, and diabetes mellitus. During pregnancy, the American College of Obstetricians and Gynecologists (ACOG) recommends vaccination against S. pneumoniae for individuals meeting the criteria for immunization outside of pregnancy. Pneumococcal vaccine uptake has been low. There are no data available for vaccine uptake in pregnancy, but we suspect it is lower than nonpregnant populations. Low uptake of immunization rates in pregnancy is likely multifactorial and includes general vaccine hesitancy among pregnant individuals, cost, access to care, and supply shortages. While data in support of pneumococcal vaccines during pregnancy are limited, sufficient evidence exists to support the safety and efficacy of vaccination in the antepartum period. Pregnancy provides an opportunity to continuously engage individuals in care, allowing obstetricians and gynecologists to establish rapport, work to reduce vaccine hesitancy, and to provide pneumococcal immunization to those who are eligible. Medical indications for pneumococcal vaccination will increasingly apply to pregnant persons as the population acquires comorbidities and there is a need for improved education among obstetricians on the topic of antenatal pneumococcal vaccination. KEY POINTS: · Pregnant persons are at risk of S. pneumoniae.. · Adult pneumococcal vaccine uptake has been low.. · Obstetricians and gynecologists can benefit from education on pneumococcal vaccines.. · Encourage pneumococcal vaccines for eligible pregnant people..

Objective:  A single-center randomized trial showed improved latency with use of indomethacin and cefazolin (I/C) during and following exam-indicated cerclage (EIC). The same center recently published a pre/post comparison demonstrating similar results. This research aimed to validate the protocol in a different setting.

Study design:  Retrospective cohort study of singleton pregnancies undergoing EIC at a single center between 2013 and 2022. EIC was performed for painless cervical dilation between 16 and 23 weeks' gestation with dilation ≥1 cm. Exposure was defined as receipt of I/C during and following EIC. The primary outcome was latency ≥ 28 days after cerclage placement. Secondary outcomes included latency; gestational age at delivery; delivery ≤ 28 weeks; preterm premature rupture of membranes; intra-amniotic infection (IAI); and median birth weight. Bivariate statistics were used to analyze data; multivariable regression analyses were used to control for confounders (progesterone use, cervical dilation at time of cerclage placement, history of preterm birth, and prolapsing membranes).

Results:  EIC was placed in 81 pregnancies and 48 (59%) received I/C. Baseline characteristics did not differ between groups, except that prolapsing membranes were significantly less likely in patients receiving I/C (6.2 vs. 21.2%; p = 0.04). Latency ≥ 28 days occurred in 90% of I/C recipients and 82% of the controls (p = 0.32); this difference remained nonsignificant after controlling for confounders (adjusted relative risk: 1.02 [95% confidence interval: 0.85, 1.21]). I/C recipients had lower rates of IAI (4.2 vs. 24.2%, p = 0.007), even after adjustment (adjusted relative risk: 0.18 [95% confidence interval: 0.04, 0.74]). Other secondary outcomes did not differ.

Conclusion:  Use of I/C at the time of EIC at this center was not associated with increased latency to delivery (albeit in a small cohort) but was associated with lower rates of intra-amniotic infection. Larger-scale validation studies would be helpful to confirm the value of this intervention.

Key points: · Indomethacin/cefazolin (I/C) increased latency for exam-indicated cerclage in a trial.. · We performed an observational comparison to validate these findings.. · I/C use for exam-indicated cerclages was associated with decreased intra-amniotic infection.. · I/C was not associated with change in latency.. · Larger-scale validation studies needed to confirm the value of intervention..

Objective:  Chronic lung disease (CLD) is a complication of prematurity. Studies examining the effects of long-chain polyunsaturated fatty acids (LC-PUFAs) on CLD are conflicting. This study investigated LC-PUFAs in the red blood cell membrane (RBCM) in preterm infants.

Study design:  This prospective observational study included infants with gestational age <32 weeks or birth weight <2 kg and at least one LC-PUFA measurement in the first month of life. Subjects without CLD (CON group) were compared with those with CLD (CLD group) and then by CLD severity.

Results:  Seventy infants were included (CON n = 29; CLD n = 41). Twenty-six infants had Grade 1 CLD; 12 had Grade 2 CLD; 3 had Grade 3 CLD. When the CLD group was compared with the CON group, the overall mean (95% confidence interval) RBCM% for linoleic acid (LA) was similar (CLD vs. CON 12.5% [11.7-13.4%] vs. 11.2% [10.2-12.3%], p = 0.06) but the overall mean arachidonic acid (ARA) was lower (17.6% [17.1-18.0%] vs. 18.6% [18.1-19.2%], p < 0.01). During weeks 1 to 4, LA% was similar, while ARA% was lower in weeks 2 and 3 (18.8 ± 2.2% vs. 20.0 ± 1.5%, p = 0.05, 16.8 ± 2.0% vs. 18.3 ± 1.6%, p = 0.01). A similar trend was noted when groups were compared by CLD severity. The CLD group had a higher overall mean α-linolenic acid (ALA) compared with the CON group (0.4% [0.3-0.4%] vs. 0.2% [0.2-0.3%], p < 0.01) but no difference in docosahexaenoic acid (DHA; 3.8% [3.4-4.1%] vs. 3.8% [3.4-4.3%], p = 0.80). During weeks 1 to 4, ALA% was higher during week 1 only (0.4 ± 0.3% vs. 0.2 ± 0.1%, p < 0.01), and DHA% was similar for weeks 1 to 4. Results were similar when groups were compared by CLD severity.

Conclusion:  In this study, low ARA status was associated with CLD.

Key points: · In this study, infants with CLD had a similar RBCM% of LA, but a lower percentage of its downstream LC-PUFA, ARA, compared with infants without CLD.. · In this study, infants with CLD had a higher RBCM% of α-linolenic acid, but a similar percentage of its downstream LC-PUFA, DHA, compared with infants without CLD.. · In this study, these trends were similiar when groups were compared by CLD severity..

Objective:  We aimed to examine rates of induction of labor at 39 weeks and cesarean delivery before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial stratified by body mass index (BMI; kg/m²) category.

Study design:  This was a repeated cross-sectional analysis of publicly available U.S. birth certificate data from 2015 to 2021. We limited analyses to nulliparous individuals with a singleton pregnancy, cephalic presentation, without chronic hypertension, diabetes (gestational or pregestational), and fetal anomaly who delivered between 39 and 42 weeks' gestation. The pre-ARRIVE period spanned from August 2016 to July 2018 and the post-ARRIVE period spanned from January 2019 to December 2020. The dissemination period of the ARRIVE trial was from August 2018 to December 2018. Our co-primary outcomes were induction at 39 weeks and cesarean delivery. Our secondary outcomes were overall induction of labor and preeclampsia. We conducted an interrupted time series analysis after stratifying by prepregnancy BMI (<40 or ≥40). Negative binomial regression was used to calculate adjusted incident rate ratios with 95% confidence intervals.

Results:  Of 2,122,267 individuals that were included, 2,051,050 had BMI <40 and 71,217 had BMI ≥40. In individuals with BMI <40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, a decreased rate of cesarean delivery, and an increased rate of overall induction of labor. In individuals with BMI ≥40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, an increased rate of overall induction of labor and a decreased rate of preeclampsia; however, the decrease in the rate of cesarean delivery was not significant.

Conclusion:  An increase in induction of labor at 39 weeks' gestation in individuals with BMI ≥40 was not associated with a decrease in the cesarean delivery rate.

Key points: · The ARRIVE trial increased 39-week labor inductions in BMI <40 and ≥40.. · BMI <40 had fewer cesareans; BMI ≥40 showed no significant decrease.. · Offering labor induction is reasonable as cesarean rates didn't increase..

Objective:  This study aimed to describe scholarly activity training during neonatal-perinatal medicine (NPM) fellowship and factors associated with scholarship productivity.

Study design:  NPM fellowship program directors (FPDs) were surveyed between March and October 2019, as part of a larger study of all pediatric subspecialty programs, to define barriers, resources, and productivity for fellow scholarly activity. High productivity was defined as >75% of fellows in a program in the last 5 years having a manuscript accepted for publication based on fellowship scholarly work.

Results:  Fifty-four percent (54/100) of NPM FPDs completed the survey. Nineteen fellowship programs (35%, 19/54) met the definition for high productivity. High productivity in scholarly activity was associated with a greater likelihood of having funds to conduct scholarship (p = 0.011), more protected months dedicated to scholarly activity (p = 0.03), and fellow extramural grant applications (submitted or accepted, p = 0.047). FPDs of productive programs were less likely to report lack of an adequate core research curriculum (p = 0.018), lack of adequate expertise on the fellowship scholarly oversight committee (p = 0.048), and lack of sufficient divisional mentorship (p = 0.048) as barriers to completion of scholarly activity during fellowship.

Conclusion:  Research funding, protected research time, established research mentors, and a research curriculum are associated with higher scholarly activity productivity among NPM fellowship programs. Further investment in these resources may improve scholarly activity productivity during fellowship training.

Key points: · Fellow productivity depends on protected time.. · Inadequate funding impacts fellow productivity.. · Mentorship is important for fellow scholarship.. · A research curriculum impacts research outcomes..

Objective:  Noninvasive respiratory support (NRS) failure is common in preterm infants with respiratory distress syndrome (RDS). We evaluated the utility of respiratory severity score (RSS) and oxygen saturation index (OSI) during the first 2 hours of life (HOL) as predictors for NRS failure in moderate preterm infants.

Study design:  We conducted a retrospective cohort study of infants born between 28^0/7 and 33^6/7 weeks with RDS. Univariate and multivariable logistic regression analyses were used to assess whether the RSS and OSI summary measures were associated with NRS failure.

Results:  A total of 282 infants were included in the study. Median gestational age and birth weights were 32 weeks and 1.7 kg, respectively. Fifty-eight infants (21%) developed NRS failure at the median age of 10.5 hours. RSS and OSI summary measures in the first 2 HOL were associated with NRS failure within 72 HOL.

Conclusion:  RSS and OSI during the first 2 HOL can predict NRS failure. Optimal RSS and OSI cutoffs for the prediction of NRS failure need to be determined in large cohort studies.

Key points: · Nearly one in five moderate preterm infants on NRS at 2 hours of life developed NRS failure.. · RSS and OSI during the first 2 HOL can predict NRS failure.. · Optimal RSS and OSI cutoffs for the prediction of NRS failure need to be determined..

Objective:  The objective of this study is to assess whether, among a cohort of placenta accreta spectrum (PAS) patients, antenatal suspicion of PAS was less likely in in vitro fertilization (IVF) compared with non-IVF patients. In addition, we aimed to assess whether IVF patients exhibited similar risk factors for PAS compared with non-IVF patients.

Study design:  This is an international multicenter retrospective study of patients with pathologically confirmed PAS (accreta, increta, percreta) between 1998 and 2021. PAS patients were identified through a central international PAS database. Antenatal and pathological criteria are specific to each institution. Pregnancies that resulted from IVF were compared with non-IVF pregnancies. Comparisons were made using a chi-square or Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables.

Results:  Of the 692 pregnancies included, 44 were in the IVF group and 648 were in the non-IVF group. The IVF group was less likely to have had a prior cesarean delivery (70.5 vs. 91%, p < 0.01) but a similar prevalence of placenta previa (63.6 vs. 68.1%, p = 0.12) compared with the non-IVF group. The IVF group was also less likely to have either a prior cesarean delivery or placenta previa than the non-IVF group (79.5 vs. 95.4%, p < 0.01). Antenatal detection of PAS was less common in the IVF group compared with the non-IVF group (40.9 vs. 60.5%, p < 0.01, respectively), even when adjusted for maternal age, prior cesarean delivery, prior uterine surgery, placenta previa and site (risk ratio: 0.70, 95% confidence interval: 0.62-0.81). The IVF group had less severe pathological disease compared with the non-IVF group (p = 0.02).

Conclusion:  Pregnant people with PAS who underwent IVF are less likely to have an antenatal suspicion compared with non-IVF patients. This finding may be explained by the lower incidence of prior cesarean deliveries and/or placenta previa as well as less severe forms of PAS.

Key points: · IVF group is less likely to have antenatal PAS suspicion.. · IVF group is less likely to have had prior cesarean delivery.. · Risk profile for PAS differs in IVF pregnancies..

Objective:  This study aimed to examine associations of fetal biometric and amniotic fluid measures with intrapartum primary cesarean delivery (PCD) and develop prediction models for PCD based on ultrasound parameters and maternal factors.

Study design:  Secondary analysis of the National Institute of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-singleton cohort (2009-2013) including patients with uncomplicated pregnancies and intent to deliver vaginally at ≥37^0/7 weeks. The estimated fetal weight, individual biometric parameters, fetal asymmetry measurements, and amniotic fluid single deepest vertical pocket assessed at the final scan (mean 37.5 ± 1.9 weeks) were categorized as <10th, 10th to 90th (reference), and >90th percentiles. Logistic regression analyses examined the association between the ultrasound measures and PCD. Fetal and maternal SuperLearner prediction algorithms were constructed for the full and nulliparous cohorts.

Results:  Of the 1,668 patients analyzed, 249 (14.9%) had PCD. The fetal head circumference, occipital-frontal diameter, and transverse abdominal diameter >90th percentile (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [95% CI]: 1.39, 4.51; aOR = 1.86, 95% CI: 1.02, 3.40; and aOR = 2.13, 95% CI: 1.16, 3.89, respectively) were associated with PCD. The fetal model demonstrated poor ability to predict PCD in the full cohort and in nulliparous patients (area under the receiver-operating characteristic curve [AUC] = 0.56, 95% CI: 0.52, 0.61; and AUC = 0.54, 95% CI: 0.49, 0.60, respectively). Conversely, the maternal model had better predictive capability overall (AUC = 0.79, 95% CI: 0.75, 0.82) and in the nulliparous subgroup (AUC = 0.72, 95% CI: 0.67, 0.77). Models combining maternal/fetal factors performed similarly to the maternal model (AUC = 0.78, 95% CI: 0.75, 0.82 in full cohort, and AUC = 0.71, 95% CI: 0.66, 0.76 in nulliparas).

Conclusion:  Although a few fetal biometric parameters were associated with PCD, the fetal prediction model had low performance. In contrast, the maternal model had a fair-to-good ability to predict PCD.

Key points: · Fetal HC >90th percentile was associated with cesarean delivery.. · Fetal parameters did not effectively predict PCD.. · Maternal factors were more predictive of PCD.. · Maternal/fetal and maternal models performed similarly.. · Prediction models had lower performance in nulliparas..