American journal of perinatology最新文献

A functional progesterone withdrawal has been thought to contribute to the pathophysiology of spontaneous preterm birth (PTB). The density of the progesterone receptor (PR) in gestational tissues could play a role in functional progesterone withdrawal. We sought to understand the relationship between placental pathology and the density of PR in the basal decidua in the setting of spontaneous preterm delivery.This is a secondary analysis of a retrospective cohort study of 40 patients with spontaneous PTB < 37 weeks from a prior study at NorthShore University HealthSystem previously described. Placental pathology was categorized according to the Amsterdam criteria into acute inflammation (AI), chronic inflammation (CI), maternal vascular malperfusion (MVM), and fetal vascular malperfusion (FVM). Slides containing basal decidua were stained for PR. Ten distinct images were obtained from the basal plate of each placenta. The positive cell detection program in QuPath image analysis software was used to estimate the percentage of cells positive for PR (%PR + ). The mean %PR+ cells were calculated from the ten representative images and were correlated with patterns of placental injury using t-tests. Models were adjusted for gestational age at delivery.The median gestational age at delivery was 32.5 weeks (interquartile range: 30.5, 34.1). There was a lower density of %PR+ cells among those with AI (12.9%PR+ without AI vs. 9.1%PR +  with AI, p = 0.03). There were no differences in the percent of %PR+ cells based on CI, MVM, or FVM. Models adjusted for gestational at delivery demonstrated persistent association with PR density and AI and no difference in the other pathologies.The presence of AI is associated with the lower density of PR expression in the basal decidua by quantitative immunohistochemical analysis. Further research is needed to investigate these findings in the context of spontaneous PTL and the prevention of PTB. · AI is associated with a lower density of PR expression.. · PR is expressed in the basal decidua in the placenta.. · Further research is needed to investigate findings in the context of PTB..

Pregnancy is associated with increased risk for the development of iron deficiency anemia. Pregnant patients with anemia are at increased risk for significant morbidity and mortality. Iron therapies for the correction of anemia during pregnancy are available in intravenous and oral formulations; however, the cost-effectiveness of these therapies in the United States has not been previously evaluated. The objective of this study is to estimate the cost-effectiveness of oral and intravenous iron therapies as treatments for prepartum anemia in the United States.We constructed a Markov decision-analytic model to evaluate the cost-effectiveness of three common therapies for repleting iron in patients with prepartum anemia in the United States: oral iron, intravenous iron sucrose, and intravenous ferric carboxymaltose. Each strategy differentially modified the proportion of patients with anemia at time of delivery by the therapeutic efficacy of each treatment option demonstrated in the literature. Outcomes of interest included net costs, quality-adjusted life-years, and adverse outcomes averted. Costs were considered from the health system and societal perspectives over a lifetime time horizon for a hypothetical cohort of 3.8 million pregnant patients. Deterministic and Monte Carlo probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.All iron therapies were dominant versus the "do nothing" strategy in the majority of simulations, implying that they were simultaneously more effective and cost-saving. Ferric carboxymaltose produced the most favorable results overall, with $696,920,137 in cost-savings and 26,660 postpartum hemorrhage cases, 888 hysterectomies, and 43 postnatal suicides averted per cohort. Threshold analysis suggested that oral iron was cost-saving below a threshold of $14.40 per 325 mg, and iron sucrose and ferric carboxymaltose were cost-saving below thresholds of $1996.86 and $2,893.97 per course, respectively.Our findings suggest that treating prepartum anemia with currently available iron therapies would result in significant cost-savings and reductions in adverse outcomes associated with anemia in this context. Ferric carboxymaltose likely confers the greatest overall benefit among competing options. This conclusion is robust to parameter uncertainty, even when the cost of these therapies is significantly higher than demonstrated in the literature. · Oral and intravenous iron therapies are likely cost-effective for the treatment of antepartum anemia.. · Intravenous ferric carboxymaltose is likely the most clinically and economically favorable treatment.. · This is the first U.S. estimate of the cost-effectiveness of oral and intravenous iron for antepartum anemia..

This study aimed to identify unmet health and childcare needs and associations with infant characteristics, parent characteristics, and parent self-efficacy after neonatal intensive care unit (NICU) discharge.We conducted a secondary mixed-methods analysis of data from a single-center randomized control trial. Twelve months after discharge, parents reported if their child did not need, need and received, or needed but did not receive seven health and childcare services. Associations with infant characteristics, parent characteristics, and parent self-efficacy were assessed using logistic regression. Open-ended responses were analyzed for themes.A total of 241 families completed assessments 12 months after discharge. Thirty-three respondents (14%) reported at least one unmet need. Increasing gestational age decreased the odds of unmet needs (odds ratio [OR]: 0.91; 95% confidence interval [CI]: 0.84-0.97), while longer length of stay and moderate or severe infant functional status increased odds (OR: 1.01; 95% CI: 1.01-1.02; OR: 2.93; 95% CI: 1.14-8.17). Greater self-efficacy was associated with lower odds of unmet needs (OR: 0.91; 95% CI: 0.85-0.97). Black parents had 2.8 times the odds of unmet needs compared to White parents after adjusting for length of stay (95% CI: 1.15-7.54). Self-efficacy may have a moderating effect on this racial disparity. Parents reported needing childcare, psychosocial support, and financial assistance in open-ended responses.We found families experienced unmet health and childcare needs with evident racial disparities in the year after NICU discharge. Greater parental self-efficacy may reduce this racial gap. Pediatric practices and health care systems, especially NICU follow-up programs, should continue to screen and connect this high-risk population to support and resources. · Greater unmet needs after NICU discharge were associated with greater infant illness severity.. · Black parents had greater odds of reporting unmet needs compared to White parents.. · Greater parent self-efficacy was associated with lower odds of unmet needs..

Presently, societal guidelines differ regarding evaluation and management of variations in placental cord insertion (PCI). This variation may in part be secondary to inconsistency in reported risk associated with marginal and velamentous cord insertion (VCI). The objective of this study is to compare perinatal outcomes based on PCI site in pregnancies at risks for fetal growth disorders.This was a secondary analysis of singletons with growth assessment between 26 and 36 weeks of gestation. Fetuses with chromosomal or congenital malformations were excluded. The primary outcomes studied were neonatal small for gestational age (SGA), birth weight, and gestational age (GA) at delivery. Other outcomes included a composite of adverse neonatal outcomes, a composite score of obstetrical outcomes, and hypoglycemia. Categorical data were analyzed with χ² and continuous data with Kruskal-Wallis tests. Pairwise comparisons and Bonferroni corrections were utilized. Logistic regression model was applied to assess the association of hypoglycemia with VCI.Of the 1,054 fetuses, 660 had confirmed PCI site by pathology review. Of those, 609 (92%) had central cord insertion, 37 (5.6%) had marginal, and 14 (2.1%) had velamentous. There was no difference in SGA or preterm birth. Those with a VCI had lower GA at delivery than placentas with central cord insertion (37.6 vs. 38.6, p = 0.032) and higher rates of hypoglycemia than those with other types of PCIs, 26.2% for central cord insertion, 20% for marginal cord insertion, and 71.4% for VCI (p < 0.001). After controlling for confounders, VCI remained significantly associated with hypoglycemia (adjusted odds ratio = 5.52; 95% confidence interval: 1.54-19.82).VCI was associated with lower GA at delivery and higher rates of neonatal hypoglycemia compared with other PCIs. Additional studies are needed to assess the association of marginal cord insertion and VCI and adverse perinatal outcomes. · VCI was associated with neonatal hypoglycemia.. · VCI is associated with earlier gestational age at delivery.. · The rate of VCI is 2.1% in this cohort..

All children, including infants admitted to the neonatal intensive care unit (NICU) require health insurance. However, despite eligibility for Medicaid, many children are uninsured due to barriers in the enrollment process. Therefore, we studied the prevalence of and reasons for delayed insurance enrollment among families with Medicaid-eligible infants admitted to the NICU.This was a single-center, prospective survey study conducted in a seventy-one-bed level IV NICU. All neonates eligible for Medicaid enrollment and hospitalized for at least 21 days were eligible for the study. The primary outcome variable was enrollment in public insurance by the time of survey completion. We also examined the reported barriers to insurance enrollment.We enrolled 102 infants in this study, 76% of whom were already enrolled in Medicaid at survey completion. Common barriers to Medicaid enrollment reported by infants' parents were difficulty understanding the application process and the Medicaid application forms.Although most Medicaid-eligible neonates in the NICU had obtained insurance coverage prior to the fourth week of life, simplifying the application process (including the application forms) can remove the remaining barriers to coverage enrollment. · Health insurance coverage is vital for all children.. · Medicaid is the largest insurer of children.. · Identifying barriers to insurance enrollment is critical..

Hypertensive disorders of pregnancy are a leading cause of pregnancy-related deaths in the United States and approximately 70% occur after birth. We estimated the crude and adjusted association between elevated postnatal blood pressure (BP) and acute care utilization (visits to the Emergency Department, obstetric triage, urgent care facility, or hospital readmission) in the first 12 weeks after discharge from the birth hospitalization.We constructed a retrospective cohort of birthing people aged ≥18 years who gave birth to ≥1 liveborn infant at >20 weeks of gestation from July 1, 2021, to December 31, 2022, at a quaternary maternity hospital in the Southeastern United States using electronic health records. Elevated BP was defined as ≥3 values of systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg between birth and discharge from the birth hospitalization. Crude and adjusted multivariable binomial regression models estimated risk differences comparing the 12-week risk of the postpartum acute care utilization (PACU) outcomes among birthing people with elevated postnatal BP to those without.In this cohort of 6,041 birthing people, 13.3% (n = 804) had any PACU within 12 weeks of discharge from the birth hospitalization. The unadjusted 12-week risk of PACU was 6.5 percentage points higher among those with elevated postnatal BP compared to those without (95% confidence interval [CI]: 4.7 and 8.4). After adjusting for potential confounders, the 12-week risk of PACU was 6.0 percentage points higher among those with elevated postnatal BP compared to those without (95% CI: 4.2 and 7.8).Postnatal BP is a simple indicator of postpartum health status that may be used to flag individuals in need of more intensive postpartum counseling and follow-up. · Elevated postnatal BP is associated with postpartum acute care use.. · People used acute care for BP-related reasons and reasons not related to BP.. · Tracking postnatal BPs may be a simple way to find people who need extra support..

This study aimed to examine whether newborns with orofacial clefts are at increased prevalence of poor birth health outcomes.This is a population-based cross-sectional study, conducted with information from 25,879,282 live births registered in the U.S. Vital Statistics Natality Birth Data from 2017 to 2023. The prevalence ratios and logistic regression models between orofacial cleft status (all, isolated, or nonisolated) and each child's birth health variables (delivery method, maternal morbidity, 5-minute Apgar score, gestational age, birth weight, abnormal conditions, infant breastfed at discharge) were calculated, assuming a p ≤ 0.05 as statistically significant.The prevalence ratios showed that newborns with orofacial clefts were more susceptible to being born by cesarean section (prevalence ratio [PR] = 1.18, p = 0.000, 95% confidence interval [CI] = 1.16-1.21), having lower birth weight (PR = 2.18, p = 0.000, 95% CI = 2.11-2.25), lower Apgar 5 score (PR = 4.08, p = 0.000, 95% CI = 4.08-4.50), prematurity (PR = 1.55, p = 0.000, 95% CI = 1.50-1.60), experiencing more abnormal conditions at birth (PR = 3.72, p = 0.000, 95% CI = 3.64-3.80), and having more difficulty to be breastfed (PR = 2.16, p = 0.000, 95% CI = 2.11-2.22) than newborns without clefts. These ratios were even higher among those with nonisolated orofacial clefts. Associations were statistic significant even after adjustments.This study provides evidence that newborns with orofacial clefts are at increased prevalence of poor birth health outcomes. · Orofacial clefts are associated to higher prevalence of birth outcomes.. · Newborns with orofacial clefts were more susceptible to have low birth weight.. · Newborns with orofacial clefts were more susceptible to preterm birth..

This study aimed to determine the temporal trends and racial differences in the infant mortality rate (IMR) in preterm infants with birth weight <500 g in the United States from 2005 through 2022.This was a retrospective cross-sectional study of data from the CDC's Wide-ranging Online Data for Epidemiologic Research. Infants with gestational age (GA) 22 to 28 weeks, with birth weight of <500 g, and deaths up to 1 year of age were included. IMR was calculated as deaths per 1,000 live births for each GA and year, and further stratified by maternal race. We evaluated trends with Joinpoint regression and IMR trends were reported using average annual percentage change (AAPC) with 95% confidence intervals (CI). The fetuses-at-risk approach was used to examine racial/ethnic differences in IMR.During the study period, 39,511 out of 50,855 infants born at 22 to 28 weeks GA with birth weight <500 g died within the first year (overall IMR 776.93 per 1,000). The IMR was inversely related to gestational age. The overall IMR decreased significantly from 817.48 to 714.51 (AAPC of -0.8%; CI, -1.0, -0.6) and in all the three racial/ethnic groups. As per the fetuses-at-risk approach, non-Hispanic Black (NHB) infants had the highest IMR of 1.33 per 1,000 fetuses-at-risk compared with 0.39 for non-Hispanic White (NHW) and 0.46 for Hispanic infants (p < 0.01).The IMR in extremely preterm infants weighing <500 g at birth decreased significantly, overall, and in all racial/ethnic groups. However, significant racial/ethnic differences persist. · Infant mortality rate decreased significantly in preterm infants with birth weight <500 g.. · The IMR decreased significantly in the three racial/ethnic groups studied.. · The IMR was significantly higher in non-Hispanic Black infants..

Social determinants of health (SDOH) may impact the incidence of respiratory syncytial virus (RSV) infection and the uptake of vaccinations in pregnancy. The objective of this study is to identify contributors to disparities in RSV vaccination in pregnancy.This is a retrospective cohort study of patients delivering at term within three hospitals during February and March 2024, comparing pregnant patients identified as receiving versus not receiving RSV vaccinations. This period and gestational age were chosen to include patients who would have qualified for RSV vaccination administration. Vaccination status was extracted from standardized admission templates where these variables were recorded as discrete fields. Patients without RSV vaccination information were excluded. Sociodemographic factors, COVID-19 vaccination status, and delivery campus were evaluated. Outcomes were analyzed using chi-squared, t-test, and McNemar test.A total of 2,181 patients met inclusion criteria and RSV vaccination information was available for 1,548 patients (71%) with a 14% vaccination rate. Compared with those not vaccinated (n = 1,332), RSV-vaccinated patients (n = 216) were more likely to be older (30.7 vs. 34.8, p < 0.001), have private insurance (42 vs. 85%, p < 0.001), speak English (82 vs. 95%, p < 0.001), and deliver at our regional perinatal center (26 vs. 77%, p < 0.001). Fifty percent of RSV-vaccinated patients had a history of COVID-19 vaccination compared with 33% of those not vaccinated against RSV (p < 0.001).SDOH was associated with differences in RSV vaccination status. In addition, patients without RSV vaccination were less likely to have had COVID-19 vaccination. These findings highlight the need to address SDOH to increase vaccination rates for vulnerable populations. · The rate of RSV vaccination in pregnant patients is low.. · Patients vaccinated against RSV tended to be older, privately insured, and English-speaking.. · SDOH and COVID-19 vaccination status are associated with RSV vaccination rates..

We aimed to determine if the implementation of teleconsults in the community hospital would decrease the time to initiation of therapeutic hypothermia (TH).We compared neonates treated with TH prior to implementation of the teleconsult program (pretele) to those treated after (posttele) for the outcomes of time to initiation of TH, seizures, and death/severe injury on brain MRI. We controlled for confounders using multivariable linear and logistic regression models.There were 52 pretele neonates and 49 posttele who were all born in community hospitals and treated with TH. Mothers in the posttele group were older and had higher rates of gestational diabetes. Fewer neonates with mild encephalopathy were cooled in the posttele period (13 [25.0%] pretele vs. 2 [4.1%] posttele). After controlling for gestational diabetes, maternal age, and severity of encephalopathy, there was no difference in time to TH initiation (p = 0.445), brain injury or death (p = 0.136), or seizure (p = 0.433) between the pre-and posttele groups. In the sub-analysis of the posttele group, the time to initiation was 4.50 hours (3.75, 5.00) for those with teleconsults versus 3.25 (2.12, 4.00) hours (p = 0.007) for those without.When comparing pre- to posttele groups, teleconsults in the community hospital did not significantly change the time to initiate TH or result in more adverse short-term outcomes of seizures or death/brain injury. In the sub-analysis of the posttele group, teleconsults did result in delayed initiation of TH but also possibly improved patient selection with fewer mildly encephalopathic neonates treated. · Telemedicine did not reduce the time to initiate TH.. · Fewer mild NE neonates received TH posttele.. · Multiple NE exams increased for the posttele group.. · No short-term adverse outcome differences were found..