Adverse neonatal outcomes: examining the risks between preterm, late preterm, and term infants

The Impact of Maternal Risk Factors on Neonatal Morbidity and Mortality in a Tertiary Care Neonatal Intensive Care Unit (NICU): An Observational Study

BACKGROUND

 Neonatal morbidity and mortality continue to be major public health issues globally, especially for infants admitted to neonatal intensive care units (NICUs). This study aims to investigate the incidence of morbidities among neonates born to high-risk mothers and to evaluate the impact of various maternal risk factors on neonatal morbidity and mortality in the NICU setting.

METHODS

 This prospective observational study was conducted on 1,000 newborns up to 28 days of life, all with maternal risk factors, born in our tertiary care center, and admitted to the NICU.

RESULTS

 Most NICU admissions occurred during the 34-36 weeks of gestation, comprising 412 (41.20%) of the total admissions. Additionally, there was a female predominance, with 552 cases, representing 55.20% of the admissions. Most of the NICU patients came from rural background 594 (59.40%) and belonged to socioeconomic status (SES) IV 764 (76.40%). Higher percentages of neonatal morbidities were observed among children of illiterate and primarily educated mothers, amounting to 913 cases (91.30%). After evaluating patients in the NICU, we found that mortality was 172 (17.20%). Mothers with previous bad obstetric histories were at greater risk of poor neonatal outcomes. Cesarean sections were more commonly associated with NICU admissions, accounting for 555 cases (55.50%). The primary risk factors included pregnancy-induced hypertension, previous lower segment cesarean section, fetal distress, and premature rupture of membranes. Significant neonatal morbidities included respiratory distress syndrome (RDS) due to prematurity 79 (45.9%), intrauterine growth retardation 19 (11.0%), meconium aspiration syndrome 16 (9.3%), birth asphyxia, sepsis 29 (16.8%), and congenital anomalies 12 (6.9%). RDS was identified as the leading cause of morbidity.

CONCLUSION

 The present study highlights several critical factors associated with NICU admissions and neonatal morbidities, underscoring the need for targeted interventions to improve neonatal health outcomes.

Is Parity a Risk Factor for Late Preterm Birth? Results from a Large Cohort Study

Most preterm births occur in the late preterm period. While prematurity-related adverse outcomes are significantly diminished when birth occurs during this period, these infants are still at increased risk of complications. Parity affects the incidence of obstetric complications. The purpose of this study was to determine whether parity impacts the risk of spontaneous late preterm birth (SLPTB) and associated complications. A retrospective observational cohort study was conducted. Patients were divided into three study groups according to parity. The primary outcome was the rate of SLPTB in each group. Secondary outcomes were unplanned cesarean delivery (UCD), prolonged third stage of labor respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), intraventricular hemorrhage (IVH), neonatal hypoglycemia, duration of NICU admission, neonatal death, and composite adverse neonatal outcome (CANO). Primiparas were more likely to have SLPTB, UCD, and CANO compared to multiparas (2.6% vs. 1.9% OR 1.5 [1.3-1.7] p < 0.01) (4.1% vs. 1.3% OR 2.7 [1.2, 5.9] p < 0.01) (8.5% vs. 4.2 OR 2.1 [1.3-3.5] p = 0.002) and grandmultiparas (2.6% vs. 1.7% OR 1.4 [1.2-1.5] p < 0.001) 8.5% vs. 4.4% OR 2.0 [1.1, 3.8], p = 0.01) but no difference in UCD compared to grandmultiparas (4.1% vs. 3.3% OR 1.2 [0.6-2.7] p = 0.28). Primiparas are at increased risk of SLPTB and UCD, and this is accompanied by an increased risk of adverse neonatal outcomes.

Morbidities and rehospitalizations during the first year of life in moderate and late preterm infants: more similarities than differences?

BACKGROUND

The aim was to compare neonatal morbidities in moderate and late preterm infants and to analyze rates and causes for rehospitalizations during the first year of life.

METHODS

Prospective follow-up of a group of moderate and late preterm infants at a tertiary care hospital.

RESULTS

The study population comprised 215 infants (58% males; 60% singletons; 99 moderate and 116 late preterm infants) with a median gestational age of 34 weeks and birth weight of 2100 grams; 20% of them were small for gestational age. Moderate preterm infants more often had a diagnosis of mild respiratory distress syndrome (26% vs. 13%, P<0.01) and feeding problems with longer need for nasogastric tube feeding (median 9.5 vs. 4.2 days, P<0.01) and parenteral nutrition (3.5 vs. 2.7 days, P<0.01), and longer duration of stay at either NICU (10.6 vs. 3.7 days; P<0.01) or hospital (13 vs. 11 days; P<0.01). Fifty-two infants (24.3%) were hospitalized at 67 occasions without differences regarding readmission rates and causes between groups. Median age at readmission was 3 months, median stay 4 days. The most common diagnosis was respiratory illness (43.3%).

CONCLUSIONS

Moderate preterm infants had more neonatal morbidities diagnosed, but the same rehospitalization rates than late preterm infants.

Early-Term Neonates Demonstrate a Higher Likelihood of Requiring Phototherapy Compared to Those Born Full-Term

Early-term neonates (with a gestational age (GA) of 37 and 0/7 weeks to 38 and 6/7 weeks) face higher morbidities, including respiratory and neurodevelopmental issues, than full-term (39 and 0/7 weeks to 40 and 6/7 weeks) infants. This study explores whether hyperbilirubinemia necessitating phototherapy also differs between these groups. A retrospective study was conducted on neonates born from January 2021-June 2022, excluding those with specific conditions. Evaluated factors included GA, birth weight, bilirubin levels, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and feeding type, with phototherapy given as per AAP guidelines. Of 1085 neonates, 356 met the criteria. When stratifying the neonates based on the need for phototherapy, a higher proportion of early-term neonates required phototherapy compared to full-term (p < 0.05). After factoring in various risks (GA; birth weight; gender; feeding type; G6PD deficiency; transcutaneous bilirubin levels at 24 h and 24-48 h postpartum; maternal diabetes; and the presence of caput succedaneum or cephalohematoma), early-term neonates were more likely to need phototherapy than full-term babies (OR: 2.15, 95% CI: 1.21 to 3.80). The optimal cut-off for transcutaneous bilirubin levels 24-48 h postpartum that were used to predict phototherapy need was 9.85 mg/dl. In conclusion, early-term neonates are at a greater risk for developing jaundice and requiring phototherapy than full-term neonates. Monitoring bilirubin 24-48 h postpartum enhances early prediction and intervention.

A case series of higher-order multifetal pregnancies managed at a tertiary maternity unit

Delayed childbearing and increased use of assisted reproduction technology (ART) have resulted in a dramatic rise in the incidence of multifetal pregnancies. In 2022, the incidence of twin birth was 1 in 38.2 (932 live births) and triplet birth 1 in 1978 (18 live births) in Singapore.1 Preterm birth and its associated complications remain the most significant risks of multifetal pregnancies—60.5% of twins and 100% of triplets were born <37 weeks in Singapore in 2019. The relative risks of cerebral palsy in triplets and twins compared with singletons are 12.7 and 4.9, respectively.2

Modified lung ultrasound score for bronchopulmonary dysplasia predicts late respiratory outcomes in preterm infants

OBJECTIVE

Lung ultrasound (LUS) is a useful and radiation-free diagnostic tool for predicting bronchopulmonary dysplasia, which is a risk factor for late respiratory disease. However, data on the relationship of LUS with late respiratory disease was scarce. This study aims to determine whether LUS is associated with late respiratory disease during early childhood.

METHODS

This prospective cohort study enrolled preterm infants born before 32 weeks of gestation. LUS was performed at 36 weeks' postmenstrual age. The predictive values of a modified lung ultrasound (mLUS) score based on eight standard sections were assessed to predict late respiratory disease, defined as a physician diagnosis of bronchopulmonary dysplasia deterioration, asthma, reactive airway disease, bronchiolitis, pneumonia, or respiratory-related hospitalization during the first 2 years of life.

RESULTS

A total of 94 infants completed follow-up, of whom 74.5% met the late respiratory disease criteria. The mLUS scores were significantly associated with late respiratory disease (adjusted odds ratio: 1.23, CI: 1.10-1.38, p < 0.001). The mLUS scores also well predicted late respiratory disease (AUC = 0.820, 95% CI: 0.733-0.907). These scores were superior to the classic lung ultrasound score (p = 0.02) and as accurate as the modified NICHD-defined bronchopulmonary dysplasia classification (p = 0.91). A mLUS score ≥14 was the optimal cutoff point for predicting late respiratory disease.

CONCLUSION

The modified lung ultrasound score correlates significantly with late respiratory disease and well predicts it in preterm infants during the first 2 years of life.

Lack of association between the VEGFA gene polymorphisms and preterm birth in Korean women

Preterm birth (PTB), a pregnancy-related disease, is defined as a birth before 37 weeks of gestation. It is a major cause of maternal mortality and morbidity worldwide, and its incidence rate is steadily increasing. Various genetic factors can contribute to the etiology of PTB. Vascular endothelial growth factor A (VEGFA) gene is an important angiogenic gene and its polymorphisms have been reported to be associated with PTB development. Therefore, we conducted a case-control study to evaluate the association between VEGFA rs699947, rs2010963, and rs3025039 polymorphisms and PTB in Korean women. A total of 271 subjects (116 patients with PTB and 155 women at ≥38 weeks of gestation) were analyzed in this study. The genotyping of VEGFA gene polymorphisms was performed using polymerase chain reaction- restriction fragment length polymorphism. No significant association between the patients with PTB and the control groups was confirmed. In the combination analysis, we found a significant association between PTB and VEGFA rs699947 CC-rs2010963 GG-rs3025039 CC combination (odds ratio, 3.77; 95% confidence interval, 1.091 to 13.032; p = 0.031). The VEGFA rs699947, rs2010963, and rs3025039 polymorphisms might have no genetic association with the pathogenesis of PTB in Korean women. However, the combination analysis indicates the possibility that VEGFA acts in PTB pathophysiology. Therefore, larger sample sets and replication studies are required to further elucidate our findings.

Neonatal outcomes and long-term neurodevelopmental evaluations of hospitalized early term infants; prospective case-control study

BACKGROUNDS

It was intended to compare early term babies to term babies by reviewing short-term issues and long-term neurodevelopmental evaluations.

METHODS

It was planned as a prospective case-control study. Of the 4263 infants admitted to the neonatal intensive care unit, 109 infants born at early term by elective cesarean section and hospitalized within the first 10 postnatal days were included in the study. As the control group, 109 babies born at term were enrolled. Nutrition status of infants, reasons for hospitalization in the first postnatal week were recorded. When the babies were 18-24 months old, an appointment was made for neurodevelopmental evaluation.

RESULTS

In the early term group, the time of breastfeeding was later than the control group, with a statistically significant difference. Similarly, breastfeeding difficulty, need for formula in the first week postpartum and hospitalization were found to be significantly higher in the early term group. Considering the short-term results; pathological weight loss, hyperbilirubinemia requiring phototherapy and feeding difficulties were statistically significantly higher in the early term group. Neurodevelopmental delay did not statistically differ across the groups, but the early term group's MDI and PDI scores were found to be statistically lower than those of the term group.

CONCLUSION

Early term infants are thought to be like term infants in many ways. Although these babies are similar to term babies, they are still physiologically immature. The short and long-term negative consequences of early term birth are obvious, non-medical elective early term births should be prevented.

Impact of the "39-week rule" on adverse pregnancy outcomes: a statewide analysis

BACKGROUND

The "39-week rule," adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days-38 weeks 6 days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift.

OBJECTIVE

This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule.

STUDY DESIGN

Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the prerule and postrule groups.

RESULTS

A total of 633,985 births were eligible for inclusion-412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively).

CONCLUSION

There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.

Cervical cerclage for prevention of preterm birth: the results from A 20-year cohort

Cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed. We aimed to describe obstetric outcomes after cerclage procedures. We included 156 singleton pregnancies and six multiple pregnancies. In singleton pregnancies with history-indicated, short cervix-indicated and emergency cerclages, respectively 84.6, 76.5 and 43.8% resulted in late preterm or term deliveries. In singletons, the following complications were reported: excessive bleeding in one emergency cerclage procedure and three re-cerclage procedures in the history-indicated cerclage group. No perioperative rupture of membranes occurred in singletons. When comparing results of experienced and less-experienced gynaecologists, a remarkably smaller take home child rate was observed for singletons treated by less-experienced gynaecologists: 90.7% and 94.4% for the two experienced gynaecologist as compared to 85.0% for the group of less-experienced gynaecologists. In conclusion, cerclages in singletons result in few cerclage-associated complications and a high take home child rate, when performed by experienced gynaecologists. Impact statementWhat is already known on this subject? Prematurity is the leading cause of perinatal and neonatal mortality and morbidity worldwide. Cervical cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed.What the results of this study add? In our cohort study, singleton pregnancies with cerclages seem to have satisfactory obstetric outcomes. We found a very low prevalence of cerclage-associated complications in singleton pregnancies, for both history-indicated, short cervix-indicated and emergency cerclages. Additionally, take home child rates in singleton pregnancies were remarkably higher when cerclage procedures were performed by experienced gynaecologists, compared to less experienced gynaecologists.What the implications are of these findings for clinical practice and/or further research? Based on the observed difference in take home child rates, we advise all cerclage procedures to be performed by experienced gynaecologists only. This may mean that women with an indication for cerclage will be referred to a more experienced colleague, either in the same, or in another hospital. To ensure treatment by an experienced gynaecologist, simulation-based training could also provide a solution.

Perinatal outcomes in twin late preterm pregnancies: results from an Italian area-based, prospective cohort study

BACKGROUND

Multiple gestations represent a considerable proportion of pregnancies delivering in the late preterm (LP) period. Only 30% of LP twins are due to spontaneous preterm labor and 70% are medically indicated; among this literature described that 16-50% of indicated LP twin deliveries are non-evidence based. As non-evidence-based delivery indications account for iatrogenic morbidity that could be prevented, the objective of our observational study is to investigate first neonatal outcomes of LP twin pregnancies according to gestational age at delivery, chorionicity and delivery indication, then non evidence-based delivery indications.

METHODS

Prospective cohort study among twins infants born between 34 + 0 and 36 + 6 weeks, in Emilia Romagna, Italy, during 2013-2015. The primary outcome was a composite of adverse perinatal outcomes.

RESULTS

Among 346 LP twins, 84 (23.4%) were monochorionic and 262 (75.7%) were dichorionic; spontaneous preterm labor accounted for 85 (24.6%) deliveries, preterm prelabor rupture of membranes for 66 (19.1%), evidence based indicated deliveries were 117 (33.8%), while non-evidence-based indications were 78 (22.5%). When compared to spontaneous preterm labor or preterm prelabor rupture of membranes, pregnancies delivered due to maternal and/or fetal indications were associated with higher maternal age (p <  0.01), higher gestational age at delivery (p <  0.01), Caucasian race (p 0.04), ART use (p <  0.01), gestational diabetes (p <  0.01), vaginal bleeding (p <  0.01), antenatal corticosteroids (p <  0.01), diagnosis of fetal growth restriction (FGR) (p <  0.01), and monochorionic (p <  0.01). Two hundred twenty-six pregnancies (65.3%) had at least one fetus experiencing one composite of adverse perinatal outcome. Multivariate analysis confirmed that delivery indication did not affect the composite of adverse perinatal outcomes; the only characteristic that affect the outcome after controlling for confounding was gestational age at delivery (p <  0.01). Moreover, there was at least one adverse neonatal outcome for 94% of babies born at 34 weeks, for 73% of those born at 35 weeks and for 46% of those born at 36 weeks (p <  0.01).

CONCLUSION

Our study suggests that the decision to deliver or not twins in LP period should consider gestational age at delivery as the main determinant infants' prognosis. Delivery indications should be accurately considered, to avoid iatrogenic early birth responsible of preventable complications.

Outcome of monochorionic triamniotic triplet pregnancies: Expectant management versus fetal reduction

OBJECTIVE

To compare the outcomes of monochorionic triamniotic (MCTA) triplets managed expectantly with those reduced to twins.

METHOD

This was a retrospective cohort study comparing expectant management (EM) with fetal reduction (FR) to twins in 43 consecutive MCTA triplets with 3 live fetuses at 11-14 weeks between 2012 and 2021.

RESULTS

Nineteen patients managed expectantly and 24 triplets reduced to twins were included. The rate of pregnancy with at least one survivor was 84.2% in the EM group and 66.7% in the FR group (P=0.190). Compared to the EM cases, triplets reduced to twins had a higher median gestational age at delivery (36.0 weeks vs 33.3 weeks; P＜0.001), a higher mean birth weight (2244.3±488.6g vs 1751.1±383.2g; P<0.001) and a lower risk of preterm birth before 34 weeks (11.8% vs 64.7%; P=0.001). There were no significant differences in the risk of miscarriage, pregnancy complications and composite adverse neonatal outcomes.

CONCLUSION

In MCTA triplets, FR to twins could reduce the risk of preterm birth, whereas EM seems to be a reasonable choice when the priority is at least one survivor. However, due to the small sample size of this study, these findings must be interpreted with great caution. This article is protected by copyright. All rights reserved.

Adverse Neonatal Outcomes and Associated Risk Factors: A Case-Control Study

Background

Adverse neonatal outcomes have a significant effect on perinatal and neonatal survival and the risk of developmental disabilities and illnesses throughout future lives. Hence, the objective of this study was to identify adverse neonatal outcomes and associated risk factors.

Method

Institutional based unmatched case-control study was conducted among 206 neonates. Neonates who had adverse outcomes were cases with their index mothers and those neonates who hadn’t had adverse outcomes were controls with their index mothers. Sociodemographic, potential neonatal risk factors, and clinical data were taken from the mothers and medical records. Data were entered into Epi Info v7 and analyzed using SPSS v23. Bivariate and multivariable logistic regression analyses were used to adjust for confounding factors of adverse neonatal outcomes. Frequencies, means, standard deviations, percentages, and cross-tabulations were used to summarize the descriptive statistics of the data.

Results

In this study, low birth weight (61.5%), preterm birth (57.7%), and low Apgar score at fifth minutes (53.9%) were the major identified adverse neonatal outcomes. Based on the multivariable logistic regression analysis, rural place of residence (AOR = 5.992 to 95% CI [1.011-35.809]), low monthly income (AOR = 4.364), middle monthly income (AOR = 4.364), and emergency cesarean section (AOR = 9.969) were the potential risk factors for adverse neonatal outcomes.

Conclusions

The adverse neonatal outcomes & the risk factors identified in this research have the potential to harm the health of the neonates. Thus, it needs emphasis to tackle the problems and save the life of the newborn through better and strengthened ANC follow-up, accesses to health care.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND

Infants who are born at 34°^/7 to 36^6/7weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of the administration of antenatal corticosteroids (ACS) to women at risk for late preterm delivery on the incidence of neonatal outcomes.

METHOD

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34°^/7 and 36^6/7weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. The primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation).

RESULTS

During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (aOR 0.63 95% CI 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57 95% CI 0.35-0.94), and transient tachypnea of the newborn (aOR 0.48 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery, and duration of hospitalization.

CONCLUSION

Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Metabolic profiling of maternal serum of women at high-risk of spontaneous preterm birth using NMR and MGWAS approach

Preterm birth (PTB) is a leading global cause of infant mortality. Risk factors include genetics, lifestyle choices and infection. Understanding the mechanism of PTB could aid the development of novel approaches to prevent PTB. This study aimed to investigate the metabolic biomarkers of PTB in early pregnancy and the association of significant metabolites with participant genotypes. Maternal sera collected at 16 and 20 weeks of gestation, from women who previously experienced PTB (high-risk) and women who did not (low-risk controls), were analysed using 1H nuclear magnetic resonance (NMR) metabolomics and genome-wide screening microarray. ANOVA and probabilistic neural network (PNN) modelling were performed on the spectral bins. Metabolomics genome-wide association (MGWAS) of the spectral bins and genotype data from the same participants was applied to determine potential metabolite-gene pathways. Phenylalanine, acetate and lactate metabolite differences between PTB cases and controls were obtained by ANOVA and PNN showed strong prediction at week 20 (AUC = 0.89). MGWAS identified several metabolite bins with strong genetic associations. Cis-eQTL analysis highlighted TRAF1 (involved in the inflammatory pathway) local to a non-coding SNP associated with lactate at week 20 of gestation. MGWAS of a well-defined cohort of participants highlighted a lactate-TRAF1 relationship that could potentially contribute to PTB.

Two-port, exteriorized uterus, fetoscopic meningomyelocele closure has fewer adverse neonatal outcomes than open hysterotomy closure

BACKGROUND

In utero closure of meningomyelocele using an open hysterotomy approach is associated with preterm delivery and adverse neonatal outcomes.

OBJECTIVE

This study compared the neonatal outcomes in in utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach vs the conventional open hysterotomy approach.

STUDY DESIGN

This retrospective cohort study included all consecutive patients who underwent in utero meningomyelocele closure using open hysterotomy (n=44) or a 2-port, exteriorized uterus, fetoscopic approach (n=46) at a single institution between 2012 and 2020. The 2-port, exteriorized uterus, fetoscopic closure was composed of the following 3 layers: a bovine collagen patch, a myofascial layer, and a skin. The frequency of respiratory distress syndrome and a composite of other adverse neonatal outcomes, including retinopathy of prematurity, periventricular leukomalacia, and perinatal death, were compared between the study groups. Regression analyses were performed to determine any association between the fetoscopic closure and adverse neonatal outcomes, adjusted for several confounders, including gestational age of <37 weeks at delivery.

RESULTS

The fetoscopic closure was associated with a lower rate of respiratory distress syndrome than the open hysterotomy closure (11.5% [5 of 45] vs 29.5% [13 of 44]; P=.037). The proportion of neonates with a composite of other adverse neonatal outcomes in the fetoscopic group was half of that observed patients in the open hysterotomy group; however, this difference did not reach statistical significance (4.3% [2 of 46] vs 9.1% [4 of 44]; P=.429). Here, regression analysis has demonstrated that fetoscopic meningomyelocele closure was associated with a lower risk of respiratory distress syndrome (adjusted odds ratio, 0.23; 95% confidence interval, 0.06-0.84; P=.026) than open hysterotomy closure.

CONCLUSION

In utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach was associated with a lower risk of respiratory distress syndrome than the conventional open hysterotomy meningomyelocele closure.

Late preterm births: neonatal mortality and morbidity in twins vs. singletons

OBJECTIVE

To examine the outcomes of twins and singletons in the late preterm period.

MATERIALS AND METHODS

This is a retrospective cohort study of data obtained for 165,894 births in California who delivered between 34 + 0 and 36 + 6 weeks. The primary outcome was neonatal and infant mortality. The secondary outcomes included the following neonatal morbidities: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), seizure, and sepsis. Univariate analysis was performed using chi-square test and multivariable logistic regression was used to adjust for potential confounders.

RESULTS

There were 143,891 singleton and 22,003 twin gestations included in the study. There was no difference in the primary outcome, neonatal and infant mortality between twins and singletons delivered at 34 and 36 weeks. After controlling for multiple potential confounders, significant differences in secondary outcomes of neonatal morbidity were identified. At 34 weeks, twins had significantly higher rates of IVH (aOR 2.47 (95%CI 1.08-5.64)), NEC (aOR 2.46 (95%CI 1.42-4.29)), RDS (aOR 1.60 (95%CI 1.45-1.77)), and sepsis (aOR 1.19 (95%CI 1.05-1.34)) compared to singletons. By 36 weeks, only an increased risk of RDS persisted among twins.

CONCLUSIONS

While there was no difference in mortality among twins and singletons in the late preterm period, twins may have significantly increased neonatal morbidity compared to singletons delivered between 34 + 0 and 36 + 6 weeks.

Neonatal Morbidities in Infants Born Late Preterm at 35-36 Weeks of Gestation: A Swedish Nationwide Population-based Study

OBJECTIVE

To assess risk for neonatal morbidities among infants born late preterm at 35-36 gestational weeks, early term (37-38 weeks), and late-term (41 weeks) infants, compared with full-term (39-40 weeks) infants.

STUDY DESIGN

This nationwide population-based cohort study included 1 650 450 non-malformed liveborn singleton infants born at 35-41 weeks between 1998 and 2016 in Sweden. The relative risks for low Apgar score (0-3) at 5 minutes; respiratory, metabolic, infectious, and neurologic morbidities; and severe neonatal morbidity (composite outcome) were adjusted for maternal, pregnancy, delivery, and infant characteristics.

RESULTS

Compared with infants born at 39-40 weeks, the adjusted relative risks and proportions of infants born at 35-36 weeks were higher for metabolic morbidity 7.79 (95%, 7.61 to 7.97; 33.75% vs 3.11%), respiratory morbidity 5.54 (95% CI, 5.24 to 5.85; 5.49% vs 0.75%), severe neonatal morbidity 2.42 (95% CI, 2.27 to 2.59; 3.40% versus 1.03%), infectious morbidity 1.98 (95% CI, 1.83 to 2.14; 2.53% vs 0.95%), neurologic morbidity 1.74 (95% CI, 1.48 to 2.03; 0.54% vs 0.23%), and low Apgar score 2.07 (95% CI, 1.72 to 2.51; 0.42% vs 0.12%). The risks for respiratory, severe neonatal morbidity, infectious, neurologic morbidities, and low Apgar score were highest at 35 weeks, gradually decreased until 39 weeks, and increased during 39-41 weeks.

CONCLUSIONS

Infants born late preterm at 35-36 weeks of gestation are at increased risk of neonatal morbidities, although the absolute risks for severe neonatal morbidities are low. Our findings reinforce the need of preventing late preterm delivery to decrease the burden of neonatal morbidity and help professionals and families with a better risk assessment.

Race and neonatal respiratory morbidity in the late preterm period

BACKGROUND

Prematurity is one of the leading causes of perinatal morbidity and mortality. Some studies suggest that respiratory disease may differ by race in early preterm infants. However, the role of race in late preterm neonatal morbidity is not yet established.

OBJECTIVE

The objective of our study was to determine whether neonatal respiratory morbidity differs by race in neonates born late preterm.

STUDY DESIGN

This was a secondary analysis of a randomized trial of women at high risk for late preterm delivery (Antenatal Late Preterm Steroids). Our study was limited to women with nonanomalous, singleton gestations, delivering between 34+0 to 36+6 weeks. Women were categorized into 4 groups by race: Black, White, Asian, or other/mixed. The primary outcome was a neonatal composite of treatment in the first 72 hours (continuous positive airway pressure or high-flow nasal cannula >2 hours, oxygen >4 hours, extracorporeal membrane oxygenation or mechanical ventilation) or stillbirth or neonatal death before 72 hours. The secondary outcomes included severe respiratory morbidity (the primary outcome extending continuous positive airway pressure or high-flow nasal cannula to >12 continuous hours and oxygen to at least 24 continuous hours), respiratory distress syndrome, transient tachypnea of the newborn, apnea, neonatal intensive care unit admission, bronchopulmonary dysplasia, and surfactant administration. The primary and secondary outcomes were assessed in the active (steroid) and placebo groups separately. We fit a logistic regression model to adjust for confounders related to respiratory morbidity.

RESULTS

Of a total of 2331 included women, 26.9% (n=627) were Black/African American, 57.1% (n=1333) White, 3.56% (n=83) Asian, and 12.36% (n=288) were other/mixed. In the placebo group, the rate of the primary outcome was significantly higher in Whites (18.6%) and Asians (22.8%) compared with the African American/Black group (12.3%) (P=.03). Adjusting for confounders, the primary outcome was not significant between the groups. The primary predictor for respiratory morbidity was a prior pregnancy with neonatal respiratory morbidity. Findings were similar in the steroid group, but severe respiratory morbidity was less common in Black infants compared with White infants (adjusted odds ratio, 0.45; 95% confidence interval, 0.24-0.83). However, a prior pregnancy with neonatal respiratory complications was no longer associated with respiratory morbidity after receipt of betamethasone.

CONCLUSION

Late preterm respiratory morbidity was similar between racial groups. Although a history of pregnancy with previous neonatal respiratory disease is the strongest risk factor for recurrence, this risk factor is mitigated by the receipt of steroids.

Maternal pre-pregnancy underweight as a risk factor for the offspring: Survey of Neonates in Pomerania

AIM

The aim was to investigate socio-economic risk factors for maternal underweight before pregnancy and then associations of underweight with neonatal outcomes.

METHODS

Data of 3401 mother-child dyads from the population-based birth cohort Survey of Neonates in Pomerania (SNiP) were analysed.

RESULTS

Bivariate analysis showed that underweighted mothers were younger, smoked more often, had a lower equivalent income and lower socio-economic status (employment status and/or educational level) compared to women with normal weight. The final prediction model revealed that only younger maternal age (OR = 0.93; 95%-CI = 0.90-0.97) and maternal smoking during pregnancy (OR = 2.52; 95%-CI = 1.74-3.66) were associated with underweight. Compared to women with normal pre-pregnancy BMI, underweight women had an increased chance of premature labour (OR = 1.73; 95% CI: 1.29-2.31) and a reduced placental weight. The offspring of underweight women had an increased risk of late preterm birth (OR = 1.82; 95% CI: 1.21-2.74) and birthweight < 2500 g (OR = 1.91; 95% CI: 1.23-2.95).

CONCLUSION

Smoking during pregnancy and a younger age were identified as risk factors for maternal pre-pregnancy underweight which then was associated with late preterm birth and low birthweight.

The Incidence of Congenital Heart Defects in Offspring Among Women With Diabetes in Saudi Arabia

BACKGROUND

The risk of congenital anomalies is increased in infants of diabetic mothers (IDM). The most frequent cardiac anomalies in IDMs include ventricular septal defect, transposition of great arteries, and aortic stenosis.

OBJECTIVE

Estimating the incidence of infants with congenital heart defects (CHD) whose mothers have diabetes in Saudi Arabia at a tertiary hospital in the National Guard Health Affairs (NGHA) system.

MATERIALS AND METHODS

This study was a retrospective cohort. The population was all births of type 1 and type 2 diabetic mothers and non-diabetic mothers (also mothers with gestational diabetes) in NGHA by following the exclusion criteria, which were mothers over 40 and below 20 years of age, and other risk factors such as drug-induced congenital disease. The data was from deliveries from January 1st 2018 to January 1st 2019. Data were collected by chart review using the Best-Care system at NGHA hospital. Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis.

RESULTS

A total of 1838 diabetic mothers and non-exposure, non-diabetic mothers, with the outcome of whether the infant had CHD, were included in this study. Most of the mothers (544, 30.11%) were aged 30-34 years old. About two-thirds of mothers, 1161 (63.24%), weren't diabetic, 500 (27.23%) had gestational diabetes, 132 (7.19%) were type 2 diabetes (T2DM), and 43 (2.34%) were type 1 diabetes (T1DM). Two hundred eighteen (11.82%) offspring had CHD, and the remaining 1625 (88.17%) did not. The most frequent echocardiographic abnormalities in infants of diabetic mothers were patent ductus arteriosus (PDA) (31.75%), patent foramen ovale (PFO) (31.75%), and atrial septal defect (ASD) (23.64%).

CONCLUSION

The incidence of CHD among infants of included mothers in this cohort study was 11.82%. The most frequent echocardiographic abnormalities in the infants of diabetics were PDA and PFO. The incidence of CHD was higher among mothers who had T1DM followed by T2DM, and whose ages were between 30-34.

Factors Associated with Increased Risk of Early Severe Neonatal Morbidity in Late Preterm and Early Term Infants

Although the risk of neonatal mortality is generally low for late preterm and early term infants, they are still significantly predisposed to severe neonatal morbidity (SNM) despite being born at relatively advanced gestations. In this study, we investigated maternal and intrapartum risk factors for early SNM in late preterm and early term infants. This was a retrospective cohort study of non-anomalous, singleton infants (34⁺⁰-38⁺⁶ gestational weeks) born at the Mater Mother's Hospital in Brisbane, Australia from January 2015 to May 2020. Early SNM was defined as a composite of any of the following severe neonatal outcome indicators: admission to neonatal intensive care unit (NICU) in conjunction with an Apgar score <4 at 5 min, severe respiratory distress, severe neonatal acidosis (cord pH < 7.0 or base excess <-12 mmol/L). Multivariable binomial logistic regression analyses using generalized estimating equations (GEE) were used to identify risk factors. Of the total infants born at 34⁺⁰-38⁺⁶ gestational weeks, 5.7% had at least one component of the composite outcome. For late preterm infants, pre-existing diabetes mellitus, instrumental birth and emergency caesarean birth for non-reassuring fetal status were associated with increased odds for early SNM, whilst for early term infants, pre-existing and gestational diabetes mellitus, antepartum hemorrhage, instrumental, emergency caesarean and elective caesarean birth were significant risk factors. In conclusion, we identified several risk factors contributing to early SNM in late preterm and early term cohort. Our results suggest that predicted probability of early SNM decreased as gestation increased.

Perinatal Outcomes Associated with Latency in Late Preterm Premature Rupture of Membranes

This study aims to evaluate the perinatal outcomes of preterm premature rupture of membrane (PPROM) with latency periods at 33 + 0-36 + 6 weeks of gestation. This retrospective case-control study included women with singleton pregnancies who delivered at 33 + 0-36 + 6 weeks at Korea University Ansan Hospital in South Korea between 2006-2019. The maternal and neonatal characteristics were compared between different latency periods (expectant delivery ≥72 h vs. immediate delivery <72 h). Data were compared among 345 women (expectant, n = 39; immediate delivery, n = 306). There was no significant difference in maternal and neonatal morbidities between the groups, despite the younger gestational age in the expectant delivery group. Stratified by gestational weeks, the 34-week infants showed a statistically significant lower exposure to antenatal steroids (73.4% vs. 20.0%, p < 0.001), while the incidence of respiratory distress syndrome (12.8%) and the use of any respiratory support (36.8%) was higher than those in the 33-week infants, without significance. Our study shows that a prolonged latency period (≥72 h) did not increase maternal and neonatal morbidities, and a considerable number of preterm infants immediately delivered at 34 weeks experienced respiratory complications. Expectant management and antenatal corticosteroids should be considered in late preterm infants with PPROM.

Neurodevelopmental Outcomes at 18 Months of Corrected Age for Late Preterm Infants Born at 34 and 35 Gestational Weeks

To date, the difference in neurodevelopmental outcomes between late preterm infants (LPI) born at 34 and 35 gestational weeks (LPI-34 and LPI-35, respectively) has not been elucidated. This retrospective study aimed to evaluate neurodevelopmental outcomes at 18 months of corrected age for LPI-34 and LPI-35, and to elucidate factors predicting neurodevelopmental impairment (NDI). Records of all LPI-34 (n = 93) and LPI-35 (n = 121) admitted to our facility from 2013 to 2017 were reviewed. Patients with congenital or chromosomal anomalies, severe neonatal asphyxia, and without developmental quotient (DQ) data were excluded. Psychomotor development was assessed as a DQ using the Kyoto Scale of Psychological Development at 18 months of corrected age. NDI was defined as DQ < 80 or when severe neurodevelopmental problems made neurodevelopmental assessment impossible. We compared the clinical characteristics and DQ values between LPI-34 (n = 62) and LPI-35 (n = 73). To elucidate the factors predicting NDI at 18 months of corrected age, we compared clinical factors between the NDI (n = 17) and non-NDI (n = 118) groups. No significant difference was observed in DQ values at 18 months of corrected age between the groups in each area and overall. Among clinical factors, male sex, intraventricular hemorrhage (IVH), hyperbilirubinemia, and severe hyperbilirubinemia had a higher prevalence in the NDI group than in the non-NDI group, and IVH and/or severe hyperbilirubinemia showed the highest Youden Index values for predicting NDI. Based on the results of this study, we can conclude that no significant difference in neurodevelopmental outcomes at 18 months of corrected age was observed between LPI-34 and LPI-35. Patients with severe hyperbilirubinemia and/or IVH should be considered to be at high risk for developing NDI.

Behavioural Problems Amongst Pre-School Children in Chongqing, China: Current Situation and Influencing Factors

Introduction

Behavioural problems in pre-school children are closely related to their mental health. Such problems include attention deficit, personality disorder, overdependency, poor adaptability and conduct problems.

Methods

From December 2018 to January 2019, we conducted a cross-sectional survey of parents of pre-schoolers. The survey covered sixteen kindergartens in six districts of Chongqing, China. A total of 2200 participants participated in the survey, and 1895 questionnaires were returned. After screening, 1496 valid questionnaires were compiled in the data analysis (n=1496).

Results

Analysis of the maximum likelihood estimation revealed that age, preterm birth, household income, amount of daily interaction with parents, and scolding frequency affected behavioural problems in the pre-schoolers. Behavioural problems tend to be attenuated as children grow. Preterm children had a higher probability of developing behavioural problems than did non-preterm children. Children from families with monthly household incomes between $1130-$1695 USD and $1696-$2260 USD were more prone to developing behavioural problems. Children whose parents spent less time interacting with them (39.26% of parents interacted with children less than 1 hour per day) and children who were scolded more often had greater behavioural problems (13.44% of parents often scolded their children).

Discussion

This study was conducted to evaluate the influence of parenting methods on pre-school children and the education provided by parents on their pre-school children's behavioural problems to provide insights for Chinese parents and mental health professionals to improve treatment of behavioural problems.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND

Infants who are born at 34^0/7 to 36^6/7 weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of administration of antenatal corticosteroids (ACSs) to women at risk for late preterm delivery on the incidence of neonatal outcomes.

METHODS

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34^0/7 and 36^6/7 weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. Primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation).

RESULTS

During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57, 95% CI 0.35-0.94) and transient tachypnea of newborn (aOR 0.48, 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64, 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery and duration of hospitalization.

CONCLUSION

Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Does antenatal steroids treatment in twin pregnancies prior to late preterm birth reduce neonatal morbidity? Evidence from a retrospective cohort study

PURPOSE

To evaluate whether antenatal corticosteroids (ACS) administration during the late-preterm (LPT) period in twin pregnancies is associated with decreased rate of neonatal morbidity.

METHODS

A retrospective cohort study including a total of 290 women with twin pregnancies resulting in live births of 580 neonates who delivered during LPT period between 2016 and 2018 at a tertiary medical center. Patients were allocated into two groups according to ACS exposure. Obstetric and neonatal outcomes were compared between the groups. Primary outcome was neonatal composite respiratory morbidity, defined as the occurrence of at least one of the followings: RDS, TTN, O2 requirement, CPAP use or mechanical ventilation.

RESULTS

Patients exposed to ACS were older and more commonly complicated by gestational diabetes compared to the non-exposed group. Moreover, women exposed to ACS delivered earlier (35.6 vs. 36.3 weeks, P < 0.001) and more frequently by cesarean section (76.4% vs. 54.1%, P = 0.002) compared to the non-exposed group. The rate of composite respiratory morbidity did not differ between the groups. Nevertheless, neonates exposed to ACS had higher rates of neonatal intensive care unit (NICU) admission and hypoglycemia compared to neonates without prior ACS exposure (27.8% vs. 11.7%, P = 0.001; 49.3% vs. 27.1%, P < 0.001, respectively). Multivariable logistic regression revealed that gestational age at delivery was the sole independent risk factor for NICU admission, whereas late-preterm ACS exposure was the only risk factor for hypoglycemia.

CONCLUSION

LPT-ACS administration in twin pregnancies complicated by LPT birth in our study did not reduce neonatal respiratory morbidity but was associated with higher rates of hypoglycaemia.

Maternal weight gain and neonatal outcomes in women with class III obesity

Objective: Obesity in the USA continues to be a prominent medical and public health concern. Due to increasing rates of maternal obesity, the current Institute of Medicine (IOM) guidelines recommend 11-20 pounds of total weight gain during pregnancy in women with a BMI ≥30 kg/m². The impact of maternal obesity on adverse perinatal outcomes has been well documented however, there is minimal data on the effect of gestational weight gain on neonatal outcomes. In this study, we assessed the association between gestational weight gain (GWG) and neonatal outcomes at term in women with class III obesity.Study design: A retrospective cohort of women delivering at a tertiary care institution between July 2013 and December 2017 with a first-trimester baseline BMI ≥40 kg/m² was studied. Pregnancies complicated by multiple gestations, preterm delivery, fetal anomalies, intrauterine fetal demise or with missing data were excluded. The primary outcome was a composite of adverse neonatal outcomes including 5 min Apgar <7, neonatal intubation, grade 3 or 4 intraventricular hemorrhage (IVH), confirmed neonatal sepsis or Neonatal Intensive Care Unit (NICU) admission. Secondary outcomes included individual components of composite and NICU admission for >7 days. Demographic, pregnancy complications & delivery characteristics of women who gained more than IOM guidelines (>20 lbs.) were compared to women who gained at or less than IOM guidelines (≤20 lbs.) using bivariate statistics. Stepwise backward regression was used to estimate the odds of outcomes as appropriate.Results: Of 374 women included, 144 (39.5%) gained more than guidelines. Women who gained above IOM recommendations were less likely to be multiparous and use tobacco. Additional demographic, obstetric and delivery characteristics, including BMI at the entry to care, did not differ. The neonatal composite occurred in 30 (8.0%) of all neonates; corresponding to 11.1% of women who gained more than IOM recommendations and 6.1% of those who gained at or below recommendations (p = .12, OR = 1.71, 95%CI 0.74-3.96). Additionally, neonates born to women gaining more than IOM recommendations were more likely to be admitted to the NICU (10.4 vs. 4.3%, p = .03) and have a NICU length of stay >7 days (6.9 vs. 2.2%, p = .03). When adjusted for mode of delivery, delivery BMI, tobacco use, and chorioamnionitis, women who gained more were not more likely to have an adverse neonatal outcome (1.54, 95%CI 0.62-3.80), they were 3.6 times more likely to have a neonate admitted to the NICU for more than 7 days (95%CI 1.00-13.42).Conclusions: In women with class III obesity, excess gestational weight gain was associated with increased odds of NICU stay >7 days, with trends toward increased NICU admission risk, further emphasizing the importance of appropriate weight gain counseling in this population at risk.

Maternal and family factors differentiate profiles of psychiatric impairments in very preterm children at age 5-years

BACKGROUND

Very preterm (VPT; <30 weeks gestation) children are a heterogeneous group, yet the co-occurrence of psychiatric and neurodevelopmental impairments remains unclear. Moreover, the clinical and socio-environmental factors that promote resilient developmental outcomes among VPT children are poorly understood.

METHODS

One hundred and twenty five children (85 VPT and 40 full-term) underwent neurodevelopmental evaluation at age 5-years. Parents and teachers completed measures of internalizing, externalizing, attention-deficit/hyperactivity (ADHD), and autism symptoms. Psychiatric and neurodevelopmental measures were analyzed using Latent Profile Analysis. Multinomial regression examined the extent that infant, sociodemographic, and family factors, collected prospectively from birth to follow-up, independently differentiated resilient and impaired children.

RESULTS

Four latent profiles were identified, including a Typically Developing Group which represented 27.1% of the VPT group and 65.0% of the full-term group, an At-Risk Group with mild psychiatric and neurodevelopmental problems (VPT 44.7%, full-term 22.5%), a Psychiatric Group with moderate-to-severe psychiatric ratings (VPT 12.9%, full-term 10.0%), and a school-based Inattentive/Hyperactive Group (VPT 15.3%, full-term 2.5%). Clinical diagnoses were highest among the Psychiatric Group (80%). Factors that differentiated resilient and impaired subgroups of VPT children included prolonged exposure to maternal psychosocial distress (p ≤ .04), current family dysfunction (p ≤ .05), and maternal ADHD symptoms (p ≤ .02), whereas social risk index scores differentiated resilient and impaired full-term children (p < .03).

CONCLUSIONS

Lower levels of maternal distress, family dysfunction, and maternal ADHD symptoms were associated with resilience among VPT children. Maternal distress and family dysfunction are modifiable factors to be targeted as part of psychiatric interventions embedded in the long-term care of VPT children.

Early Pulmonary Vascular Disease in Preterm Infants Is Associated with Late Respiratory Outcomes in Childhood

RATIONALE

Early pulmonary vascular disease (PVD) after preterm birth is associated with a high risk for developing bronchopulmonary dysplasia (BPD), but its relationship with late respiratory outcomes during early childhood remains uncertain.

OBJECTIVES

To determine whether PVD at 7 days after preterm birth is associated with late respiratory disease (LRD) during early childhood.

METHODS

This was a prospective study of preterm infants born before 34 weeks postmenstrual age (PMA). Echocardiograms were performed at 7 days and 36 weeks PMA. Prenatal and early postnatal factors and postdischarge follow-up survey data obtained at 6, 12, 18, and 24 months of age were analyzed in logistic regression models to identify early risk factors for LRD, defined as a physician diagnosis of asthma, reactive airways disease, BPD exacerbation, bronchiolitis, or pneumonia, or a respiratory-related hospitalization during follow-up.

MEASUREMENTS AND MAIN RESULTS

Of the 221 subjects (median, 27 wk PMA; interquartile range, 25-28 and 920 g; interquartile range, 770-1090 g) completing follow-up, 61% met LRD criteria. Gestational diabetes and both mechanical ventilator support and PVD at 7 days were associated with LRD. The combination of PVD and mechanical ventilator support at 7 days was among the strongest prognosticators of LRD (odds ratio, 8.1; confidence interval, 3.1-21.9; P < 0.001). Modeled prenatal and early postnatal factors accurately informed LRD (area under the curve, 0.764). Adding BPD status at 36 weeks PMA to the model did not change the accuracy (area under the curve, 0.771).

CONCLUSIONS

Early echocardiographic evidence of PVD after preterm birth in combination with other perinatal factors is a strong risk factor for LRD, suggesting that early PVD may contribute to the pathobiology of BPD.

Impaired Fetal Environment and Gestational Age: What Is Driving Mortality in Neonates With Critical Congenital Heart Disease?

Background

Infants with critical congenital heart disease (CCHD) are more likely to be small for gestational age (SGA) or born to mothers with maternal placental syndrome. The objective of this study was to investigate the relationship between maternal placental syndrome, SGA, and gestational age (GA) on 1‐year mortality in infants with CCHD.

Methods and Results

In a population‐based administrative database of all live‐born infants in California (2007–2012) we identified all infants with CCHD without chromosomal anomalies. Our primary predictor was an impaired fetal environment (IFE), defined as presence of maternal placental syndrome or SGA. We calculated hazard ratios to quantify the association between different components of IFE and 1‐year mortality and conducted a causal mediation analysis to assess GA at birth as a mediator. We identified 6863 infants with CCHD. IFE was present in 25.1%. Infants with IFE were more likely to die than infants without IFE (16.6% versus 11.1%; hazard ratios 1.55, 95% CI 1.34–1.78). Only SGA (hazard ratios 1.76, 95% CI 1.50–2.05) and placental abruption (hazard ratios 1.70, 95% CI 1.17–2.48) were significantly associated with mortality; preeclampsia and gestational hypertension had no significant association with mortality. The mediation analysis showed that 32.8% (95% CI 24.9–47.0%) of the relationship between IFE and mortality is mediated through GA.

Conclusions

IFE is a significant contributor to outcomes in the CCHD population. SGA and placental abruption are the main drivers of postnatal mortality while other maternal placental syndrome components had much less of an impact. Only one third of the effect between IFE and mortality is mediated through GA.

Short term outcomes in term and late preterm neonates admitted to the well-baby nursery after resuscitation in the delivery room

OBJECTIVE

To determine the risk for deterioration in well-baby nursery (WBN) admissions after resuscitation.

STUDY DESIGN

A single center retrospective study (2015-2016) of 370 resuscitated WBN admissions.

RESULTS

Of the 11,307 admissions, 3.27% received resuscitation with 183 receiving continuous positive airway pressure (CPAP) alone and 187 receiving positive pressure ventilation (PPV) ± CPAP. Resuscitated neonates were more frequently transferred to the NICU (11.6 versus 3.9%, p < 0.001) compared to those without resuscitation. More neonates requiring CPAP alone were transferred to the NICU compared to those requiring PPV ± CPAP (15.85 versus 7.49%, p = 0.01). Univariate risk ratios for transfer were elevated for CPAP alone and lower gestational age categories. Multivariate regression analyses demonstrated increased transfer risk across gestational age categories only.

CONCLUSIONS

Neonates admitted to the WBN after delivery room resuscitation are at increased risk for NICU transfer compared to those without resuscitation. This study supports the recommendation for post-resuscitation care.

Respiratory morbidity in late preterm twin infants

PURPOSE

Antenatal corticosteroids have been shown to decrease neonatal respiratory morbidity in singleton pregnancies when given during the late-preterm period (34^0/7-36^6/7 weeks). Whether these findings also apply to late-preterm twins, who account for approximately one-third of infants born at 34^0/7-35^6/7 weeks, is currently unclear. The answer to this question depends, in part, on whether the risk of respiratory morbidity among late-preterm twin infants is similar to that observed in late-preterm singletons. We aimed to assess the rate of respiratory morbidity among late-preterm twin infants using a secondary analysis of prospectively collected data from a large international multicenter trial, and to compare that rate with previous studies that used the same definition of respiratory morbidity.

STUDY DESIGN

This was a secondary analysis of the twin birth study. In the current study, we limited the analysis to women who gave birth during the late preterm period. The primary outcomes were the same primary composite respiratory morbidity variables that were used in the randomized controlled trial of Gyamfi-Bannerman et al., on the administration of betamethasone during the late preterm period in singletons (ALPS trial). The risk of respiratory morbidity among late preterm twins was stratified by gestational week at birth.

RESULTS

A total of 1163 women who gave birth to 2324 late preterm twin infants met the inclusion criteria. The rates of respiratory morbidity and severe respiratory morbidity were 16.5% and 8.9%, respectively. The risk of respiratory morbidity was highly dependent on gestational week at birth, being more than fourfold for infants born at 34^0/7-34^6/7 weeks (aOR 4.30, 95%-CI 3.01-6.14) and more than twofold for infants born at 35^0/7-35^6/7 weeks (aOR 2.12, 95%-CI 1.51-2.98) compared with infants born at 36^0/7-36^6/7 weeks. The rate of respiratory morbidity and the theoretical number of women needed to be treated with betamethasone to prevent a single case of respiratory morbidity in the current study were similar to those reported in the APLS trial (16.5% vs. 14.4%, p = 0.103, and NNT 31 vs. 34, respectively).

CONCLUSIONS

The risk-benefit ratio of betamethasone with regard to neonatal respiratory morbidity in women with twins at risk of late-preterm birth is expected to be similar to that observed in singletons.

Evaluation of neurological behaviour in late-preterm newborn infants using the Hammersmith Neonatal Neurological Examination

AIM

We hypothesise that clinically well late-preterm infants (LPI) (34⁺⁰ -36⁺⁶ weeks) are neurologically more immature than their term counterparts, and this immaturity persists even when these infants reach term-corrected age (TCA). The primary aim of our study was to characterise and contrast the neurodevelopmental profile of well LPI with full-term infants (FTI) (39⁺⁰ -41⁺⁶ weeks) using the Hammersmith Neonatal Neurological Examination (HNNE). Our secondary aim was to obtain local reference ranges for the 34 items in the HNNE in an Asian-dominant population.

METHODS

LPI were assessed at two time points: 12-72 h of life and at TCA of 39⁺⁰ -41⁺⁶ weeks, while FTI were assessed at 12-72 h of life using the HNNE. Each of the 34 items on the HNNE was assigned an optimality score (OS) of 0, 0.5 or 1, totalling up to 34. A quantitative comparison of the neurobehavioral patterns was made using two-sample t-tests.

RESULTS

A total of 212 infants (79 LPI and 133 FTI) were recruited. Mean OSs for LPI and FTI at birth were (25.11 ± 3.36)/34 and (31.19 ± 1.50)/34, respectively, with a mean difference of 6.08 (P value <0.0001). The mean OS for LPI on reaching TCA was (28.91 ± 2.30)/34, with a mean difference of 2.28 (P value <0.0001). Reference OSs for the 34 items on the HNNE were also obtained.

CONCLUSION

LPI are more immature than their term counterparts even on reaching TCA, with discrepancies most apparent in 'tone' and 'movement'. We provide reference OSs of 34 items in the HNNE for infants in an Asian-dominant population.

Impact of cancer in the management of delivery: 10 years of variations

Importance: The active-during-pregnancy-cancer (ADPC) is a condition that complicates the 0.1% of pregnancies. Abortion, preterm delivery and cesarean section (CS) are common attitudes for these patients, because of scarcity of evidence-based studies. Not-active-during-pregnancy-cancer (NADPC) is an increasing medical problem. The fertility of young girls survived to neoplasia is significantly lower compared to general population and there are increased rates of low birth weight and preterm birth.Objective: To analyze the impact that the pregnancy-related neoplastic disease has on management of deliveries in the decade 2006-2015.Material and methods: In this observational study, we collected obstetric and oncological data about 205 patients bearing a history of cancer related to pregnancy between January 2006 and September 2016 from Sant'Anna Hospital database archive in Turin. The entire population was divided in 59 patients with ADPC and 146 patients with NADPC because it was cured before starting the gestation. Three ADPC and three NADPC patients who completed their pregnancy in the year 2016 were excluded from the 10 years 2006-2015 trends realization. All in situ and invasive cancers were considered.Results: In ADPC patients, we registered 3.4% miscarriage and 15.3% iatrogenic abortion. The type of delivery was vaginal (22%) and CS (59.3%). Induction of labor was 14.6%, elective CS was 68.8%: the indication for these procedures was 78.6% oncological. The average gestational age was 35.5 weeks. In NADPC patients, we registered 9.6% miscarriage and 8.2% iatrogenic abortion. The type of delivery was vaginal (43.2%) and CS (39%). Induction of labor was 11.7%, elective CS was 36.7%: the indication for these procedures was 77.5% obstetrical. The average gestational age was 38.3 weeks.Conclusions: Ten-year trends in ADPC and NADPC patients showed an increase of induced deliveries and a decrease in elective CS. We observed not significant reduction of gestational age and birth weight. A contemporary decrease of oncological indications for CS in the two populations was reported.

Effect of Antenatal Steroids on Respiratory Morbidity of Late Preterm Newborns: A Randomized Controlled Trial

OBJECTIVE

The objective of this article was to study the effect of antenatal dexamethasone on the respiratory morbidity of late preterm newborns.

STUDY DESIGN

A randomized controlled trial, conducted in Obstetrics and Gynecology Department in collaboration with Neonatology department at JIPMER, India. In total, 155 women were studied in each group. Intention to treat analysis and per protocol analysis were done.

RESULTS

Overall 31 (10%) newborns were admitted to intensive care unit. The composite respiratory morbidity (defined as respiratory distress syndrome and/or transient tachypnea of newborn) was observed in 64 (41.6%) infants in the study and 56 (36.2%) infants in the control group. On multivariable-adjusted analysis, use of steroids was not found to be associated with decrease in composite respiratory morbidity [adjusted relative risk 0.91 (95% confidence interval: 0.7-1.2)].

CONCLUSIONS

Antenatal dexamethasone does not reduce the composite respiratory morbidity of babies born vaginally or by emergency cesarean to women with late preterm labor.

The effects of birth order on neonatal outcomes in early-preterm, late-preterm and term twin infants

Objectives: Birth order is one of the main factors that influences the neonatal outcome of twins. However, there is little prior data regarding the effect of birth order under different clinical circumstances. This study investigates the effect of birth order on the neonatal outcomes of twins delivered during early-preterm, late-preterm and term gestations according to chorionicity, delivery mode and indication for delivery.Methods: This is a retrospective cohort study of women with twin pregnancies delivered at 24-40 weeks of gestation between 1995 and 2014. We excluded twin pregnancies with the following complications: twin-to-twin transfusion syndrome, monoamnionic twins, delayed interval delivery and fetal death, chromosomal anomalies or major congenital malformation in one or more of the twins. The neonatal outcomes, including death, admission to neonatal intensive care unit (NICU), mechanical ventilator support, and respiratory distress syndrome (RDS) was compared between the first and second twin born at early-preterm (24-33 weeks of gestation), late-preterm (34-36 weeks of gestation) and term (≥37 weeks of gestation) gestations. These outcomes were further analyzed according to chorionicity, mode of delivery and indication for delivery by multivariable analysis (after adjusting for sex, presentation, and birth weight).Results: Among a total of 1,614 women with twin pregnancies who met the selection criteria, 423, 674 and 517 women delivered at early-preterm, late-preterm and term gestation, respectively. Overall, the second-born twins were lighter and had higher rates of NICU admission, mechanical ventilator support, and RDS than did first-born twins. Second twins born at early-preterm gestation had higher rates of RDS and mechanical ventilator support than did first twins. Second twins born at late-preterm gestation had higher rates of NICU admission and mechanical ventilator support than did first twins. Second twins born at term gestation also had a higher NICU admission rate than did first twins. However, in the multivariable analysis of the subgroups, the rates of NICU admission, mechanical ventilator support and RDS were not significantly different between most twin pairs. However, there were several significant differences. There was a higher risk of RDS in the second twins in the early-preterm premature rupture of membranes (PROM) subgroup, and a higher risk of mechanical ventilator support in the late-preterm PROM subgroup. Low birth weight was the only significant factor independently associated with a higher risk of adverse neonatal outcome in the second twins compared with the first twins in all subgroups.Conclusions: Second twins born at early-preterm, late-preterm and term were at higher risk of adverse neonatal outcome than were their respective first twins. However, this finding was mainly represented lower birth weight of the second twin. Still, second twins delivered due to early-preterm and late-preterm PROM had a higher risk of RDS and mechanical ventilator support, respectively, than did the first twin after adjusting for birth weight.

Outcomes of Implementation of a NICU-Based Late Preterm Infant Feeding Guideline

BACKGROUND AND OBJECTIVES

Late preterm (LPT) infants are at risk for feeding difficulties. Our objectives were to reduce the use of intravenous (IV) fluids and increase breastfeeding at discharge among LPT infants admitted to our NICU.

METHODS

We implemented a feeding guideline and evaluated its effect using a pre-post design. We examined rates of our main outcomes, IV fluid use, and any or exclusive breastfeeding at discharge, as well as several secondary outcomes, including hypoglycemia (glucose <50 mg/dL) at >8 hours of life, by using χ² and t tests. We excluded infants that were <2000 g, admitted to the NICU at >8 hours of life, or needed IV fluids at ≤8 hours of life for a medical reason. We used multivariable logistic regression to examine odds ratios and 95% confidence intervals of our main outcomes.

RESULTS

Fifty percent of infants were eligible. Of those eligible, 18 of 52 (35%) vs 14 of 65 (22%) received IV fluids at >8 hours of life (P = .06). In the 24 hours before discharge, 35 of 52 (75%) vs 46 of 65 (78%) received any breast milk (P = .67), and 10 of 52 (30%) vs 10 of 65 (21%) received exclusive breast milk (P = .43). More infants had hypoglycemia in the posttime period (16 of 65 [25%]) compared with the pretime period (3 of 52 [6%]; P = .01).

CONCLUSIONS

After implementation of a LPT feeding guideline in our NICU that defined specific expected feeding volumes, we did not find changes in IV fluid use or breastfeeding.

Outcomes of Care for 1,892 Doula-Supported Adolescent Births in the United States: The DONA International Data Project, 2000 to 2013

This is the largest study to-date to report on outcomes of care for a national sample of doula-supported adolescent births (n = 1,892, birth years 2000 to 2013). Descriptive statistics were calculated for maternal demographics, risk profiles, labor/birth interventions and occurrences, and birth outcomes. In this national sample, childbearing adolescents and their neonates experienced improved health outcomes and lower rates of intervention relative to national statistics for adolescent deliveries in the United States. Key findings are consistent with previous studies on the effects of doula care for marginalized and medically underserved communities. Results strengthen the case for doulas as a perinatal care strategy for improving maternal and infant health outcomes and decreasing inequities among childbearing adolescents.

Examining Early Childhood Health Outcomes of Children Born Late Preterm in Urban Manitoba

Objective The late preterm population [34-36 weeks gestational age (GA)] is known to incur increased morbidity in the infancy stage compared to the population born at term (39-41 weeks GA). This study aimed to examine the health of these children during their early childhood years, with specific attention to the role of socioeconomic status. Methods A retrospective cohort study was conducted using data from the Manitoba Centre for Health Policy, including all live-born children born at 34-36 and 39-41 weeks GA in urban Manitoba between 2000 and 2005 (n = 28,100). Multivariable logistic regression was used to examine the association of GA with early childhood morbidity after controlling for maternal, child and family level variables. Results The late preterm population was found to have significantly greater adjusted odds of lower respiratory tract infections in the preschool years (aOR = 1.59 [1.24, 2.04]) and asthma at school age (aOR = 1.33 [1.18, 1.47]) compared to the population born at term. The groups also differed in health care utilization at ages 4 (aOR = 1.19 [1.06,1.34]) and 7 years (aOR = 1.24 [1.09, 1.42]). Additional variables associated with poor outcomes suggest that social deprivation and GA simultaneously have a negative impact on early childhood development. Conclusions for Practice Adjustment for predictors of poor early childhood development, including socioeconomic status, were found to attenuate but not eliminate health differences between children born late preterm and children born at term. Poorer health outcomes that extend into childhood have implications for practice at the population level and suggest a need for further follow-up post discharge.

Amniocentesis compared with antenatal corticosteroids prior to early term scheduled cesarean delivery

Objective: There are a variety of maternal or fetal conditions that require late preterm or early term delivery. In cases where early delivery is indicated, optimal management is not always clear. Historically, obstetricians used amniocentesis to document fetal lung maturity, but recently, many have transitioned to administration of antenatal corticosteroids (ACS). The objective of this study was to compare neonatal outcomes between women undergoing amniocentesis or receiving ACS prior to scheduled cesarean delivery (CD) less than 39 weeks. Methods: This was a retrospective cohort study of women undergoing scheduled CD by one maternal-fetal medicine practice between 36 and 38 6/7 weeks, from 2005 to 2017. We identified women who underwent amniocentesis or received ACS within 2 weeks prior to delivery. Neonatal outcomes were compared between the two groups, with the primary outcome being neonatal intensive care unit (NICU) admission. Results: A total of 502 women were included, of whom 313 (62.4%) underwent amniocentesis and 189 (37.6%) received ACS. Overall, 55 (11.0%) of neonates were admitted to the NICU. NICU admission was not significantly different between groups (11.8 versus 9.5%, p=.46). This held true after adjusting for gestational age and other differences in baseline characteristics. There were no significant differences between groups for all other neonatal outcomes, including NICU admission for respiratory indications, respiratory support, neonatal greater than maternal length of stay, low Apgar scores, and neonatal death. Rates of hypoglycemia were low and not significantly different between groups (2.2% in the amniocentesis group versus 0.5% in the ACS group, p=.27). Diabetes was the only covariate significantly associated with NICU admission (aOR 3.19, 95% CI 1.35, 7.54). Conclusions: In women undergoing scheduled CD between 36 and 38 6/7 weeks, administration of ACS is associated with similar neonatal outcomes compared to amniocentesis. This supports the current notion that outcomes are similar with ACS compared to amniocentesis for late preterm and early term deliveries. Brief rationale: The objective of this study was to compare neonatal outcomes between women undergoing amniocentesis or receiving antenatal corticosteroids (ACS) prior to scheduled cesarean delivery (CD) less than 39 weeks. We found that in women undergoing scheduled cesarean delivery between 36 and 38 6/7 weeks, administration of antenatal corticosteroids is associated with similar neonatal outcomes compared to amniocentesis.

Late-preterm infants, early-term infants, and timing of elective deliveries; current status in a Korean medical center

OBJECTIVE

The aim of this study was to examine the current perinatal outcomes among infants born late-preterm and early-term compared to those born full-term and evaluate the optimal gestational age for delivery.

METHODS

We performed a retrospective cohort study for births occurred at Seoul St. Mary's Hospital over the past 7 years. Statistical comparison was performed using χ² test and multivariable logistic regression models.

RESULTS

A total of 7580 women met the study criteria. Compared to 39 weeks, delivery at late-preterm and early-term had higher risk of composite morbidity, including respiratory morbidities, intracranial hemorrhage (ICH), and admission to neonatal intensive care unit (NICU) (34 weeks adjusted odds ratio [aOR]: 132.54; 95% confidence interval (CI): 74.00-240.10; 37 weeks aOR: 2.14; 95%CI: 1.65-2.77). The risks of sepsis and necrotizing enterocolitis in deliveries before 36 weeks and the risk of feeding difficulty in deliveries before 37 weeks were significantly higher than those of 39 weeks. Neonatal morbidity at deliveries was not significantly different between 38 and 39 weeks.

CONCLUSIONS

Neonatal morbidities at late-preterm births are significant and surveillance for them seems increasing. Obstetricians should recognize the risk of respiratory morbidity, ICH, and NICU admission for deliveries before 38 weeks' gestation.

Gestational Age and Outcomes in Critical Congenital Heart Disease

BACKGROUND AND OBJECTIVES

It is unknown how gestational age (GA) impacts neonatal morbidities in infants with critical congenital heart disease (CCHD). We aim to quantify GA-specific mortality and neonatal morbidity in infants with CCHD.

METHODS

Cohort study using a database linking birth certificate, infant hospital discharge, readmission, and death records, including infants 22 to 42 weeks' GA without chromosomal anomalies (2005-2012, 2 988 925 live births). The International Classification of Diseases, Ninth Revision diagnostic and procedure codes were used to define CCHD and neonatal morbidities (intraventricular hemorrhage, retinopathy, periventricular leukomalacia, chronic lung disease, necrotizing enterocolitis). Adjusted absolute risk differences (ARDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

We identified 6903 out of 2 968 566 (0.23%) infants with CCHD. The incidence of CCHD was highest at 29 to 31 weeks' GA (0.9%) and lowest at 39 to 42 weeks (0.2%). Combined neonatal morbidity or mortality in infants with and without CCHD was 82.8% and 57.9% at <29 weeks and declined to 10.9% and 0.1% at 39 to 42 weeks' GA. In infants with CCHD, being born at 34 to 36 weeks was associated with a higher risk of death or morbidity than being born at 37 to 38 weeks (adjusted ARD 9.1%, 95% CI 5.5% to 12.7%), and being born at 37 to 38 weeks was associated with a higher risk of death or morbidity than 39 to 42 weeks (adjusted ARD 3.2%, 95% CI 1.6% to 4.9%).

CONCLUSIONS

Infants born with CCHD are at high risk of neonatal morbidity. Morbidity remains increased across all GA groups in comparison with infants born at 39 to 42 weeks. This substantial risk of neonatal morbidity is important to consider when caring for this patient population.

Prematurity and neonatal outcome including congenital malformations after maternal malignancy within six months prior to or during pregnancy

INTRODUCTION

The proportion of women who postpone childbearing is increasing. As malignancy risk increases with age, pregnancy in connection with malignancy will become more common.

MATERIAL AND METHODS

We compared infants born 1994-2011 to women with a malignancy within six months prior to the last menstrual period or during pregnancy with offspring of women without a previous malignancy. Five national registers were used.

RESULTS

A total of 790 women with a malignancy diagnosis from six months prior to the last menstrual period up to delivery were identified. Their 802 infants were compared with 1 742 757 infants of women without a malignancy. A high rate of prematurity was found, especially when the malignancy was diagnosed during the second or third trimesters (33%). Most of these premature births were the result of induced delivery before 35 weeks (91%). The most remarkable finding is the observation that these premature infants had a significantly higher risk for neonatal morbidity than premature infants in the control group with an adjusted odds ratio of 2.67 (95% confidence interval; 1.86-3.84). We found a significantly increased risk of mainly relatively mild malformations among infants of women with a malignancy diagnosis within six months prior to the last menstrual period or during the first trimester with a risk ratio of 1.81 (95% confidence interval; 1.20-2.61).

CONCLUSIONS

A high incidence of prematurity, mostly due to induced delivery, was found, including an increased risk for neonatal morbidity among these infants. An increased risk for relatively mild malformations was also found.

Parental Perception of Risk Associated With Their Premature Infant

BACKGROUND

Preterm birth has been linked to increased parental stress, depression, and anxiety. Although the rate of neonatal morbidity and mortality decreases with increasing gestational age, recent research has revealed that there is no threshold age for risk or parental concern.

PURPOSE

This study examines parental concern about medical and developmental outcomes of their premature infant.

METHODS

Parents of 60 premature infants were surveyed in a follow-up clinic regarding their level of concern about 11 morbidities and their child's gestation-adjusted age; these were compared with the infant's inpatient chart. "Concern scores" were tallied and compared across gestational age groups and knowledge of gestation-adjusted age using Chi-square tests of independence.

FINDINGS

Many parents reported concerns about morbidities that were unsupported by their child's diagnoses. Across parents of extremely, very, and moderate-late preterm children, the mean concern scores were 13.9, 15.7, and 19.7, respectively. Overall, 62% of parents incorrectly reported the gestation-adjusted age of their child. Parents who were correct were significantly more likely to correctly anticipate abnormal developmental patterns (70%) and growth patterns (65%) than those who were incorrect (33% and 31%, respectively).

IMPLICATIONS FOR RESEARCH

Future research should focus on whether NICU graduate parental stress levels are directly linked to the severity of their child's condition, and how physicians can help decrease NICU graduate parental stress.

IMPLICATIONS FOR PRACTICE

Parental anxiety regarding all gestational age neonatal intensive care unit infant outcomes can be decreased by a thorough explanation of gestation-adjusted age and a discussion of expected prematurity-related issues.

Surfactant reduced the mortality of neonates with birth weight ⩾1500 g and hypoxemic respiratory failure: a survey from an emerging NICU network

OBJECTIVE

We evaluated the efficacy of surfactant therapy and assisted ventilation on morbidity and mortality of neonates with birth weight (BW) ⩾1500 g and hypoxemic respiratory failure (HRF).

STUDY DESIGN

We retrospectively analyzed 5650 patients with BW ⩾1500 g for incidence, management and outcome of HRF, defined as acute hypoxemia requiring mechanical ventilation and/or nasal continuous positive airway pressure ⩾24 h. The patients were allocated into groups of moderate preterm (1735, 30.7%), late preterm (1431, 25.4%), early term (ETM, 986, 17.5%), full term (1390, 24.6%) and post term (79, 1.4%), with gestational age ⩽33, 34 to 36, 37 to 38, 39 to 41 and ⩾42 weeks, respectively.

RESULTS

In the five groups, 66.9, 42, 21.6, 12.8 and 5.1% had respiratory distress syndrome (RDS). For pneumonia/sepsis and meconium aspiration syndrome (MAS), the proportion was 13.8%, 25.4%, 38.0%, 52.5% and 76.0%, respectively. Surfactant was given to 21.9% (n=1238) of HRF and 51.2% (n=1108) of RDS. Survival rates of RDS were 82.2%, 87.8%, 84.5%, 77.1% and 75.0%, respectively (numbers needed to treat was 8 to 11 for surfactant benefit). Overall mortality rate of HRF was 21%, or 17.9%, 14.7%, 25.6%, 28.9% and 39.2%, respectively. Mortalities of MAS and pneumonia/sepsis were 29.4 and 27.6%. Relative risk of death was associated with initial disease severity, female gender, mechanical ventilation and congenital anomalies by multivariate logistic regression analysis.

CONCLUSION

Surfactant was effective for infants with RDS and BW ⩾1500 g, and different incidences and outcome of HRF among GA groups reflected standard of perinatal and respiratory care in emerging neonatal intensive care unit network.

Multifetal pregnancy reduction of triplets to twins compared with non-reduced triplets: a meta-analysis

The current systematic review and meta-analysis evaluate the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced triplet pregnancies. All studies comparing perinatal outcome of twin pregnancies following MPR to non-reduced triplet pregnancies were considered. MEDLINE, non-indexed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant published articles up to August 2016. The search yielded 653 publications of which 92 were assessed for eligibility. A total of 24 studies met the inclusion criteria. Overall, the outcomes of pregnancies following MPR were better compared with expectantly managed triplets. The MPR group delivered at a later gestational age and was less likely to be delivered before 32 or 28 weeks' gestation. Newborns in the MPR group had significantly higher birthweight at delivery (mean difference 500 g [95% CI 439.95, 560.04]). Rates of pregnancy loss before 24 weeks' gestation and overall infant survival were comparable between the groups. This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with improved perinatal outcome compared with non-reduced triplets. Should primary prevention of high order multiple pregnancy fail, MPR is an appropriate alternative to minimize the perinatal morbidity and mortality of triplet pregnancies.

Early-onset preeclampsia appears to discourage subsequent pregnancy but the risks may be overestimated

BACKGROUND

Early-onset preeclampsia is associated with adverse maternal and perinatal outcomes. For women who consider another pregnancy after one complicated by early-onset preeclampsia, the likelihood of recurrence and the subsequent pregnancy outcome for themselves and their babies are pertinent considerations.

OBJECTIVES

The purpose of this study was to determine the subsequent pregnancy rate after a nulliparous pregnancy that was complicated by early-onset preeclampsia and among those who have a subsequent pregnancy, the risk of recurrence by gestational week, and adverse pregnancy outcomes.

STUDY DESIGN

This was a population-based record linkage cohort study. The study population included nulliparous women with a singleton pregnancy and early-onset preeclampsia (<34 weeks gestation) who gave birth in New South Wales Australia from 2001-2010 (the index birth), with follow-up data for a subsequent birth through 2012. Early-onset in the index birth was further categorized as <28 vs 28-33 weeks gestation. Subsequent pregnancy outcomes that were assessed included the pregnancy rate, preeclampsia recurrence, and maternal and perinatal morbidity and mortality rates. The risk of preeclampsia necessitating delivery at each gestational week for women who were at risk was plotted, and the net gain or loss of gestational age when comparing the index with the subsequent pregnancy was calculated.

RESULTS

Among 361,031 nulliparous women with singleton pregnancies, 1473 (0.4%) had early-onset preeclampsia. Women with early-onset preeclampsia in their first pregnancy had a lower subsequent pregnancy rate (59.7%) than women without preeclampsia (67.7%). Of the 758 women with a subsequent singleton birth, 256 (33.8%) experienced preeclampsia in the next pregnancy; 57 women (7.5%) with recurrent early-onset preeclampsia were included. Cumulative rates of preeclampsia in the subsequent pregnancy were higher at every gestation from 23 weeks gestation when the index birth was <28 weeks compared with 28-33 weeks gestation. The cumulative rate and gestation-specific risk of recurrent preeclampsia rose most steeply at 32-38 weeks gestation. Most women (94.6%) progressed to a later gestational age in their subsequent pregnancy. The median overall increase in gestational age at delivery was 6 weeks (interquartile range, 4-8); among women with recurrent preeclampsia, the median increase was 5 weeks (interquartile range, 2-7). Women with index birth <28 weeks gestation compared with 28-33 weeks gestation were more likely to deliver preterm (38.8% vs 28.7%; relative risk, 1.35; 95% confidence interval, 1.04-1.75) and have a perinatal death (4.3% vs 1.2%; relative risk, 3.46; 95% confidence interval, 1.15-10.39) at the subsequent birth, but live born infants had similar rates of severe morbidity (17.1% vs 15.0%; relative risk, 1.14; 95% confidence interval, 0.73-1.79).

CONCLUSION

Women with early-onset preeclampsia in a first pregnancy appear less likely than women without preeclampsia to have a subsequent pregnancy. Maternal and perinatal outcomes in the subsequent pregnancy are generally better than in the first; most women will not have recurrent preeclampsia, and those who do usually will give birth at a greater gestational age compared with their index birth.