The causes of preterm neonatal deaths in India and Pakistan (PURPOSe): a prospective cohort study

Anaphylaxis-induced premature uterine contractions: a case report and literature review

BACKGROUND

Preterm labor is caused by multiple etiologies, including intra-amniotic infection and/or intra-amniotic inflammation, vascular disorders, cervical disease, decidual senescence, and breakdown of maternal-fetal tolerance. Accumulating evidence in vivo and in vitro has shown that an allergic reaction, including anaphylaxis, can induce preterm uterine contractions. This report describes a case of a pregnant woman who developed anaphylaxis and regular uterine contractions after the ingestion of a strawberry-coated biscuit. We also review the mechanism of allergic reaction (hypersensitivity)-induced preterm labor. Case presentation A 31-year-old woman (gravida 1, para 0) at 30+2 weeks of gestation was admitted to the labor and delivery unit with regular uterine contractions and anaphylactic symptoms after she ingested a strawberry-coated biscuit as a snack. The uterine contractions resolved after the treatment of anaphylaxis by administering antihistamines and epinephrine. The patient subsequently delivered at 39+3 weeks of gestation. The amniotic fluid profile showed no infection or inflammation. A postpartum skin-prick test confirmed a positive type 1 hypersensitivity reaction to the strawberry-coated biscuit.

CONCLUSIONS

We report a case of anaphylaxis-induced uterine contractility in which uterine contractions subsided after the treatment of anaphylaxis. The absence of intra-amniotic infection and/or intra-amniotic inflammation and the cause of the anaphylaxis were confirmed. Our findings indicate that maternal allergic reactions may be one of the mechanisms of preterm labor.

Bann C, Bozdar MH, Raza J, Dhaded SM, Goudar SS, Gowdar G, Yasmin H, McClure EM, Goldenberg RL. Predictors of Preterm Neonatal Mortality in India and Pakistan: A Secondary Analysis of Data from PURPOSe Study

Objective. To create a prediction model for preterm neonatal mortality. Methods. A secondary analysis was conducted using data from a prospective cohort study, the Project to Understand and Research Preterm Pregnancy Outcome South Asia. The Cox proportional hazard model was used and adjusted hazard ratios (AHR) with 95% confidence intervals (95% CI) were reported. Results. Overall, 3446 preterm neonates were included. The mean age of preterm neonates was 0.65 (1.25) hours and 52% were female. The preterm neonatal mortality rate was 23.3%. The maternal factors predicting preterm neonatal death was any antepartum hemorrhage, AHR 1.99 (1.60-2.47), while neonatal predictors were preterm who received positive pressure ventilation AHR 1.30 (1.08-1.57), temperature <35.5°C AHR 1.18 (1.00-1.39), and congenital malformations AHR 3.31 (2.64-4.16). Conclusion. This study identified key maternal and neonatal predictors of preterm neonatal mortality, emphasizing the need for targeted interventions and collaborative public health efforts to address disparities and regional variations.

Gut microbiota of preterm infants in the neonatal intensive care unit: a study from a tertiary care center in northern India

Introduction

Disruptions of the gut microbiota of preterm infants admitted to the neonatal intensive care unit (NICU) during the first 2 weeks of life are of critical importance. These infants are prone to various complications, including necrotizing enterocolitis (NEC) and sepsis. Studying the gut microbiota will improve outcomes in preterm infants. In the present study, we examined the gut microbiota of preterm infants admitted to the NICU in the first month of life.

Methods

Neonates admitted to the NICU were recruited, and stool samples were collected weekly from the seventh day of the infant's life until the 30th day of life. DNA was extracted using a DNeasy Powersoil DNA isolation kit. 16S rRNA gene sequencing targeting the V3-V4 region was performed using the MiSeq platform. Sequenced reads were processed on DADA2 pipeline to obtain an amplicon sequence variant (ASV) table. All bioinformatic and statistical analyses were performed using different packages in the R statistical framework.

Results

Fourteen preterm infants were recruited, and 48 samples were collected. Alpha diversity metrics, observed ASV count, and Shannon index were found to have no differences in any clinical variables. Permutational multivariate analysis of variance (PERMANOVA) showed discrimination of neonates by gestational age and administration of probiotics. Differential abundance analysis showed a decreased abundance of Bifidobacterium Breve in extremely preterm infants (gestational age <28 weeks) compared to moderate preterm infants (gestational age 29-32 weeks). Supplementation with probiotics decreased Acinetobacter and increased Bifidobacterium in the gut of preterm neonates regardless of gestational age.

Conclusion

Gestational age and probiotic supplementation alter the gut microbiota of preterm infants admitted to the NICU.

Neonatal death audits at Kgapane Hospital, Limpopo province

BACKGROUND

 Neonatal deaths (NNDs) are a global public health challenge, predominantly affecting low- and middle-income countries. The causes of most NNDs are preventable. Therefore, this study reviewed perinatal clinical audit data at Kgapane Hospital over a 4-year period with a special focus on the factors associated with NNDs.

METHODS

 File audits were performed for all NNDs occurring at Kgapane Hospital and its catchment area from 2018 to 2021. The data from these audits were analysed to identify factors associated with NNDs.

RESULTS

 The NND rate for the study period was 12.6/1000 live births. In this study (n = 236), 90% of the deaths could be associated with four factors, namely prematurity (44%); intrapartum complications (19%) including asphyxia, meconium aspiration and breech deliveries; neonatal infections (16%) of which human immunodeficiency virus (HIV) positivity was the most prevalent; and foetal congenital abnormalities (11%). The modifiable factors included inadequate intrapartum foetal monitoring; delays in management interventions; instances where no attempts were made to refer patients for specialised care, or where no beds were available at the next level of care; patient-related factors; and inadequate adherence to management protocols, such as for the management of prematurity and HIV.

CONCLUSION

 Understanding factors associated with NNDs can guide health worker training and improvement strategies to reduce this heart-breaking complication of pregnancy.Contribution: Family physicians working in rural hospitals are also responsible for newborn care. Understanding the factors associated with NNDs will guide them to focus training and develop improvement strategies to reduce these preventable deaths.

Care During Labour, Childbirth, and Immediate Newborn Care in India: A Review

India is committed to achieve a single-digit neonatal mortality rate (NMR) and stillbirth rate (SBR) by 2030 through India Newborn Action Plan (INAP) 2014. However, the current rate of decline is not enough to achieve the target neonatal mortality rate. Course correction and renewed efforts are required. This review outlines the current scenario and proposed scale-up of services included during labour, childbirth, and the immediate newborn period. The article summarises the challenges and bottlenecks in achieving a reduction in neonatal mortality rate and INAP targets. India has achieved over 80% coverage of three of the four ENAP coverage targets, but antenatal care coverage is still poor. There are concerns about the quality and completeness of antenatal care visits and other program interventions. The ongoing quality assurance should be strengthened through continuous supportive supervision by involving the medical colleges in a hub and spoke model and other key stakeholders. There is a need for effective and strategic engagement of the private sector in these initiatives. The states need to systematically assess the gaps as per population requirements and find effective solutions to overcome them quickly. The state and district-wise data maps show immense variations in coverage between states and within states, mirroring the variations in NMR. This indicates the need to ensure contextual micro-plans and provides an opportunity for the districts and states to learn from each other. The recent initiatives to strengthen primary healthcare should be used as a platform for all stillbirth and neonatal mortality prevention interventions in India.

Pregnancy outcomes in preterm multiple gestations: Results from a prospective study in India and Pakistan (PURPOSe)

OBJECTIVE

To evaluate perinatal outcomes in preterm multiple compared with singleton pregnancies in India and Pakistan.

DESIGN

Prospective, observational study.

SETTINGS

Study hospitals in India and Pakistan.

POPULATION

We evaluated 3897 preterm pregnancies. These mothers gave birth to 3615 (92.8%) singleton infants, 267 (6.8%) sets of twins, 14 (0.4%) sets of triplets and one set of quadruplets.

MAIN OUTCOME MEASURES

Neonatal mortality, stillbirth, cause of death.

RESULTS

Of the singleton infants, 691 (19.1%) were stillborn and 2924 (80.9%) live born. Of the 534 infants from twin pregnancies, 41 (7.7%) were stillborn and 493 (92.3%) were live born. Of the 267 sets of twins, in 14 cases (5.2%) both were stillborn, in 13 cases (4.8%) one was stillborn and one live born, and in 240 cases (90.0%) both were live born. In both preterm twins and preterm singletons, the three most common causes of death were intrauterine hypoxia, infections acquired prior to birth and infections acquired at or after birth. The preterm twins appeared less likely to have died from intrauterine hypoxia but more likely to have died from infections acquired at or after birth. Respiratory distress syndrome (RDS) was less likely considered by the panel to be the primary cause of death in either the twins (9.6%) or singletons (9.7%). Congenital anomalies were also not often judged to be the cause of death in either the preterm twins 2 (2.4%) or singletons 27 (5.3%).

CONCLUSION

In the PURPOSe study, neonatal mortality rates in preterm twins compared with singletons when evaluated by sex, GA, birthweight and SGA, were generally similar to rates of preterm singleton neonatal mortality in those groups. Thus, the higher rate of mortality in live-born twin infants is related to the fact that these infants were more likely to be born earlier rather than to any inherent characteristics of the babies themselves.

Data usefulness in determining cause of stillbirth in South Asia

OBJECTIVE

To evaluate the usefulness of data to determine cause of stillbirth in India and Pakistan.

DESIGN

Prospective, observational study.

SETTINGS

Study hospitals in India and Pakistan.

POPULATION

200 fetal deaths with placental evaluation and minimally invasive tissue sampling (MITS) of internal organs and polymerase chain reaction (PCR) test for 75 pathogens.

MAIN OUTCOME MEASURES

Data defined as useful to determine stillbirth causes.

RESULTS

Placental pathology was the most useful to determine cause of stillbirth. Comparing placental and fetal weight with standard weights was useful in 44.5% and 48.5%, respectively. Lung histology was useful in 42.5%. Most of the other findings of internal organ histology were only occasionally useful. Signs of abruption, by maternal history or placental evaluation, were always deemed useful. Placenta, brain and cord blood PCR were also useful, but less often than histology.

CONCLUSION

Based on this analysis, maternal clinical history, placental histology and fetal examination were most informative. Comparing the placental and fetal weights with recognised standards was useful in nearly half the cases. Fetal tissue histology and PCR were also informative. Of all the potential tests of MITS-obtained specimens, we would first recommend histological evaluation of the lungs, and using a multiplex PCR platform would determine pathogens in blood and brain/CSF. We recognise that this approach will not identify some causes, including some genetic and internal organ anomalies, but will confirm most common causes of stillbirth and most of the preventable causes of stillbirth in low- and middle-income countries.

Analysis of an Association between Preterm Birth and Parental Educational Level in Japan Using National Data

Preterm birth rate depending on parental educational level in recent years has not been surveyed in Japan. In this study, we showed the trend in preterm birth rate depending on parental educational level from 2000 to 2020 by linking data from the Census regarding individuals' educational level and parents in birth data of the vital statistics. Four types of parental educational level, namely junior high school, high school, technical school or junior college, and university or graduate school, were compared. Slope and relative indexes of inequality for preterm birth by educational level were computed by binomial models. Data on 3,148,711 births and 381,129,294 people were used in the analysis, and data on 782,536 singleton births were used after data linkage. The preterm birth rate (%) for junior high school graduate mothers and fathers was 5.09 and 5.20 in 2020, respectively. Contrarily, the preterm birth rate (%) for parents who graduated from a university or graduate school was 4.24 for mothers and 4.39 for fathers, and the rate tended to increase as educational level decreased, irrespective of parental gender. Results of inequality indexes showed that a statistically significant inequality by parental educational level persisted from 2000 to 2020.