American journal of perinatology最新文献

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 of 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, adjusted hazard ratio: 1.18, 95% confidence interval [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.

Key points: · HDP can be diagnosed before and during labor and postpartum.. · The timing of HDP diagnosis may have different implications for postpartum BP outcomes.. · Patients diagnosed with HDP in the peripartum period experienced a 24-hour shorter time to BP resolution.. · Timing of HDP diagnosis may provide an added window of opportunity to augment existing modalities of managing postpartum hypertension and related cardiovascular disease complications..

Objective:  The rising incidence of neonatal abstinence syndrome (NAS) has amplified the importance of nonpharmacological interventions in its management, which include the selection of feedings. With the goal of obtaining an accurate assessment of the effects of current feeding practices in NAS infants in our neonatal intensive care unit, we conducted a retrospective review of NAS infants at our hospital over a 3-year period to determine their nutritional selections and evaluate their length of stay (LOS), length of treatment (LOT), and growth outcomes.

Study design:  Retrospective chart review of term infants (≥37 weeks of gestation) with NAS. Maternal and infant demographics and characteristics were recorded. Infants were grouped based on majority (>50% of total feeding) nutritional selections and LOS, LOT, and growth parameters were evaluated. Linear regression was used to compare group outcomes. Significance was set at a p-value <0.05.

Results:  A total of 70 infants were included and grouped based on majority feeds into maternal breast milk (MBM), standard term formula (STF), low lactose formula (LLF), and extensively hydrolyzed formula (EHF) groups. Feeding selections were provider-dependent and infants were placed on MBM or STF as an initial selection. In all infants included in our review, LLF was selected as the first choice following MBM or STF for increased gastrointestinal (GI) disturbance-related Finnegan Neonatal Abstinence Scoring scores and changed to EHF if LLF failed to improve the GI-related symptoms. The STF-fed infants had the shortest LOS, and none of these infants required pharmacological treatment. The LOT and LOS were similar in the MBM- and LLF-fed groups. Infants who were EHF fed had the longest LOT and LOS. All feeding groups demonstrated appropriate growth.

Conclusion:  Nutritional selections in our NAS infants were modified for the severity of their withdrawal symptoms. All nutritional modifications driven by severity of withdrawal symptoms supported favorable growth outcomes in the infants.

Key points: · Our NAS infants were fed with multiple types of nutrition.. · Infants with severe NAS required more elemental feeds.. · All formula selections supported favorable growth..

Objective:  We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity.

Study design:  This is a secondary analysis of a prospective cohort study conducted 2010 to 2015 that included all term gravidas who reached active labor (6 cm). 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 of labor (IOL) versus spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders.

Results:  In this cohort of 6,509 patients, 51% underwent IOL. A total of 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 (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [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 vs. 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared with those with normal latent phase.

Conclusion:  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 cutoffs that may be incorporated into labor management guidelines.

Key points: · Latent labor ≥90th percentile is associated with increased maternal morbidity in induced and spontaneous labor.. · Latent labor ≥90th percentile in spontaneous but not induced labor is associated with increased neonatal morbidity.. · Cesarean delivery alone does not explain this increased maternal morbidity..

Despite significant efforts over the past two decades, the maternal mortality rate (MMR) in the United States remains at least double that of most other high-income countries (HICs). In addition, substantial racial disparities exist with MMRs among Black and American Indian/Alaska Native women two to three times higher than White, Hispanic, and Asian/Pacific Islander counterparts. Of the three surveillance systems currently in place, Maternal Mortality Review Committees (MMRCs) are widely considered to provide the highest quality data. MMRCs in combination with Perinatal Quality Collaboratives and other successful initiatives provide the best hope of reversing these concerning trends. The state of maternal health in the United States is at a critical juncture. To reach the ultimate goal of rendering the United States as one of the "safest countries in the world to give birth" will require greater coordination and consolidation of national efforts across the entire prenatal, perinatal, and postpartum continuum. The authors make suggestions to create a robust federal infrastructure to finally provide equitable high-quality maternal care and bring U.S. maternal mortality into alignment with other HICs. KEY POINTS: · U.S. MMRs are double that of other HICs.. · Black MMRs are two to three times higher than White MMRs.. · "Maternity care deserts" show a marked increase in maternal mortality.. · Listed strategies have shown success in reversing these trends..

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 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, 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 the 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 with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, 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 with the baseline population.

Key points: · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..

Objective:  This study aimed to describe patient characteristics, satisfaction, and outcome measures for patients undergoing outpatient cervical ripening.

Study design:  A retrospective cohort study using electronic health record data from March 2020 to March 2022 from a large health system. The sample included patients with a low-risk singleton pregnancy undergoing outpatient cervical ripening with either an osmotic dilator or Foley balloon catheter. A subset of patients completed satisfaction surveys. Frequencies and means were used to describe the population and conduct comparisons by device type. Inverse probability of treatment weighted estimates were generated to address baseline differences between patients in the two device groups.

Results:  Outpatient cervical ripening was completed by 120 patients (80 osmotic dilators and 40 Foley balloon catheters). The mean time from insertion to inpatient admission was 16.2 ± 4.8 hours. The mean change in simplified Bishop score (SBS) was 1.8 ± 1.4 and the mean change in dilation was 1.8 ± 1.1 cm. There were no differences in the amount of cervical change by device type. Patients returned earlier than planned 16.7% of the time, primarily for contractions or rupture of membranes. Following outpatient cervical ripening, the time from admission to delivery was 19.9 ± 10.3 hours, with no difference by device type. Vaginal delivery occurred for 74.8% of patients. Patients reported overall satisfaction with the outpatient cervical ripening experience, with the highest satisfaction among those with osmotic dilators. Patients with both device types stated they would recommend outpatient cervical ripening to others, and experienced low levels of stress and discomfort at home prior to hospital admission.

Conclusion:  Patients participating in outpatient cervical ripening with osmotic dilators or Foley balloon catheters experienced clinically meaningful changes in dilation and SBSs while at home and reported general satisfaction with the outpatient program experience.

Key points: · Outpatient use of osmotic dilators or Foley balloon catheters improved Bishop scores.. · Patient and device complications were comparable to other research findings.. · Patients reported overall satisfaction with outpatient cervical ripening..

Objective:  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 U.S.

Cohort:

Study design:  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 ID anemia (IDA). Four participants with anemia but normal ferritin were excluded. Receiver operating curve analysis, including the area under the curve (AUC), was performed to assess the accuracy of Ret-He in detecting ID. A one-way ANOVA (analysis of variance) with post-hoc analysis was used to compare differences in Ret-He between the three groups of ID severity.

Results:  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).

Conclusion:  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 only.

Key points: · The prevalence of ID in our cohort was 82%.. · Ret-He has low accuracy in diagnosing ID in pregnancy.. · Ferritin is preferable when readily available..

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin-Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management. KEY POINTS: · Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.. · There is a variation in the BP threshold for antihypertensive treatment initiation.. · Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring..

Objective:  Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery 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 in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [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:  A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with 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.

Key points: · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay..

Objective:  Whether clusters exist within severe maternal morbidity (SMM), a set of life-threatening heterogeneous conditions, is not known. Our primary objective was to identify SMM clusters using a data-driven clustering technique, their associated predictors and outcomes.

Study design:  From 2008 to 2017, we used a delivery database supplemented by state data and medical record abstraction from a single institution in Pennsylvania. To identify SMM clusters, we applied latent class modeling that included 23 conditions defined by 21 Centers for Disease Control SMM indicators, intensive care unit (ICU) admission, or prolonged postpartum length of stay. Logistic regression models estimated risk for SMM clusters and associations between clusters and maternal and neonatal outcomes.

Results:  Among 97,492 deliveries, 2.7% (N = 2,666) experienced SMM by any of the 23 conditions. Four clusters were identified as archetypes of SMM. Deliveries labeled as Hemorrhage (37.7%, N = 1,004) were characterized by blood transfusions and sickle cell anemia; Critical Care (28.1%, N = 748) by ICU admission and amniotic embolism; Vascular (24.5%, N = 654) by cerebrovascular conditions; and Shock (9.8%, N = 260) by ventilatory support and shock. Hypertensive disorders of pregnancy, depression, and Medicaid insurance were associated with Shock cluster. People in all clusters had a high risk of maternal death within 1 year (odds ratio: 12.0, 95% confidence interval: 6.2-23). Infants born to those in the shock cluster had the highest odds of neonatal death, low Apgar scores, and neonatal ICU admission.

Conclusion:  We identified four novel SMM clusters that may help understand the collection of conditions defining SMM, underlying pathways and the importance of comorbidities such as depression and social determinants of health markers that amplify the well-established risk factors for SMM such as hypertensive disorders of pregnancy.

Key points: · A total of 2.7% of deliveries experienced SMM events.. · There are four distinct SMM clusters: Hemorrhage, Critical Care, Vascular, and Shock.. · Not all SMM clusters bear the same risk for adverse perinatal outcomes..