Interaction of chorioamnionitis at term with maternal, fetal and obstetrical factors as predictors of neonatal mortality: a population-based cohort study

Epidemiology, causes, and morbidities of stroke in the young

PURPOSE OF REVIEW

The purpose is to describe the latest research on epidemiology, causes, and morbidities of stroke in neonates and children.

RECENT FINDINGS

The global incidence of childhood stroke is approximately 2 per 100 000 person-years, which is significantly lower compared to neonates (20-40 per 100 000 live births) and adults (80-90 per 100 000 person-years). Placental abnormalities are a risk factor for perinatal stroke, although cause is usually multifactorial. In children, nonatherosclerotic arteriopathies and arteriovenous malformations are major causes of ischemic and hemorrhagic strokes, respectively. The perinatal period confers a high risk of stroke and can lead to long-term disability, including motor delay, cognitive or speech impairment, and epilepsy. Recent studies suggest that at least 50% of survivors of perinatal stroke have abnormal neurodevelopmental scores in long-term follow up. Childhood stroke is associated with significant morbidity, including epilepsy, motor impairments, and behavioral disability. Recent studies have also identified an association between pediatric stroke and behavioral disorders, such as attention deficit hyperactivity disorder and autism.

SUMMARY

Perinatal and childhood strokes are important causes of neurological morbidity. Given the low incidence of childhood stroke, prospective research studies on epidemiology, causes, and outcomes remain limited, highlighting the need for continued multisite collaborations.

Chorioamnionitis: An Update on Diagnostic Evaluation

Chorioamnionitis remains a major cause of preterm birth and maternal and neonatal morbidity. We reviewed the current evidence for the diagnostic tests of chorioamnionitis and how this relates to clinical practice today. A comprehensive literature search and review was conducted on chorioamnionitis and intra-uterine inflammation. Data from randomized control trials and systematic reviews were prioritized. This review highlights that sterile inflammation plays an important role in chorioamnionitis and that the current tests for chorioamnionitis including clinical criteria, maternal plasma and vaginal biomarkers lack diagnostic accuracy. Concerningly, these tests often rely on detecting an inflammatory response after damage has occurred to the fetus. Care should be taken when interpreting current investigations for the diagnosis of chorioamnionitis and how they guide obstetric/neonatal management. There is an urgent need for further validation of current diagnostic tests and the development of novel, accurate, minimally invasive tests that detect subclinical intra-uterine inflammation.

[Establishment of a nomogram model for predicting the risk of early-onset sepsis in very preterm infants]

OBJECTIVES

To identify risk factors associated with early-onset sepsis (EOS) in very preterm infants and develop a nomogram model for predicting the risk of EOS.

METHODS

A retrospective analysis was conducted on 344 very preterm infants delivered at the First Affiliated Hospital of Zhengzhou University and admitted to the Department of Neonatology between January 2020 and December 2022. These infants were randomly divided into a training set (241 infants) and a validating set (103 infants) in a 7:3 ratio. The training set was further divided into two groups based on the presence or absence of EOS: EOS (n=64) and non-EOS (n=177). Multivariate logistic regression analysis was performed to identify risk factors for EOS in the very preterm infants. The nomogram model was developed using R language and validated using the validating set. The discriminative ability, calibration, and clinical utility of the model were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis, respectively.

RESULTS

The multivariate logistic regression analysis revealed that gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis were risk factors for EOS in very preterm infants (P<0.05). The area under the ROC curve for the training set was 0.925 (95%CI: 0.888-0.963), and that for the validating set was 0.796 (95%CI: 0.694-0.898), confirming the model's good discrimination. The Hosmer-Lemeshow goodness-of-fit test suggested that the model was well-fitting (P=0.621). The calibration curve analysis and decision curve analysis demonstrated that the model had high predictive efficacy and clinical applicability.

CONCLUSIONS

Gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis are significantly associated with the development of EOS in very preterm infants.The nomogram model for predicting the risk of EOS in very preterm infants, constructed based on these factors, has high predictive efficacy and clinical applicability.

Association between Endotype of Prematurity and Mortality: A Systematic Review, Meta-Analysis, and Meta-Regression

INTRODUCTION

Preterm birth represents the leading cause of neonatal mortality. Pathophysiological pathways, or endotypes, leading to prematurity can be clustered into infection/inflammation and dysfunctional placentation. We aimed to perform a systematic review and meta-analysis exploring the association between these endotypes and risk of mortality during first hospital admission Methods: PROSPERO ID: CRD42020184843. PubMed and Embase were searched for observational studies examining infants with gestational age (GA) ≤34 weeks. Chorioamnionitis represented the infectious-inflammatory endotype, while dysfunctional placentation proxies were hypertensive disorders of pregnancy (HDP) and small for GA (SGA)/intrauterine growth restriction (IUGR). A random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals. Heterogeneity was studied using random-effects meta-regression analysis.

RESULTS

Of 4,322 potentially relevant studies, 150 (612,580 infants) were included. Meta-analysis showed positive mortality odds for chorioamnionitis (OR: 1.43, 95% confidence interval: 1.25-1.62) and SGA/IUGR (OR: 1.68, 95% confidence interval: 1.38-2.04) but negative mortality odds for HDP (OR 0.74, 95% confidence interval: 0.64-0.86). Chorioamnionitis was associated with a lower GA, while HDP and SGA/IUGR were associated with a higher GA. Meta-regression showed a significant correlation between these differences in GA and mortality odds.

CONCLUSION

Our data suggest that the infectious/inflammatory endotype of prematurity has a greater overall impact on mortality risk as it is the most frequent endotype in the lower GAs. However, when the endotype of placental dysfunction is severe enough to induce growth restriction, it is strongly associated with higher mortality rates even though newborns are more mature.

Clinical characteristics and predictors of neonatal outcomes in chorioamnionitis at term gestation: A cohort study

OBJECTIVE

To investigate the association between clinical and laboratory characteristics of chorioamnionitis in deliveries at term gestation with adverse neonatal outcomes.

DESIGN

Retrospective cohort study.

SETTING

The study is based on data from the Swedish Pregnancy Register, enriched with clinical data extracted from medical charts.

SAMPLE

A cohort of 500 term singleton deliveries in Stockholm County with registered diagnosis of chorioamnionitis (based on the assessment of the responsible obstetrician) in the Swedish Pregnancy Register between 2014 and 2020.

METHODS

Logistic regression was used to estimate odds ratios (ORs) as a measurement of the association between clinical and laboratory characteristics and neonatal complications.

MAIN OUTCOME MEASURES

Neonatal infection and asphyxia-related complications.

RESULTS

The prevalence of neonatal infection and asphyxia-related complications was 10% and 22%, respectively. First leukocyte count in the second tertile (OR 2.14, 95% CI 1.02-4.49), maximum C-reactive protein (CRP) level in the third tertile (OR 4.01, 95% Cl 1.66-9.68) and positive cervical culture (OR 2.22, 95% Cl 1.10-4.48) were associated with an increased risk of neonatal infection. Maximum level of CRP in the third tertile (OR 1.93, 95% Cl 1.09-3.41) and fetal tachycardia (OR 1.63, 95% Cl 1.01-2.65) were associated with an increased risk of asphyxia-related complications.

CONCLUSIONS

Elevated inflammatory laboratory markers were associated with both neonatal infection and asphyxia-related complications, and fetal tachycardia was associated with asphyxia-related complications. Based on these findings, the incorporation of maternal CRP in the management of chorioamnionitis should be considered, and a continuous communication between obstetric and neonatal care extending past the delivery time point endorsed.

Development and Validation of a Prediction Model for Perinatal Arterial Ischemic Stroke in Term Neonates

IMPORTANCE

Perinatal arterial ischemic stroke (PAIS) is a focal brain injury in term neonates that is identified postnatally but is presumed to occur near the time of birth. Many pregnancy, delivery, and fetal factors have been associated with PAIS, but early risk detection is lacking; thus, targeted treatment and prevention efforts are currently limited.

OBJECTIVE

To develop and validate a diagnostic risk prediction model that uses common clinical factors to predict the probability of PAIS in a term neonate.

DESIGN, SETTING, AND PARTICIPANTS

In this diagnostic study, a prediction model was developed using multivariable logistic regression with registry-based case data collected between January 2003, and March 2020, from the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and Alberta Pregnancy Outcomes and Nutrition study. Criteria for inclusion were term birth and no underlying medical conditions associated with stroke diagnosis. Records with more than 20% missing data were excluded. Variable selection was based on peer-reviewed literature. Data were analyzed in September 2021.

EXPOSURES

Clinical pregnancy, delivery, and neonatal factors associated with PAIS as common data elements across the 4 registries.

MAIN OUTCOMES AND MEASURES

The primary outcome was the discriminative accuracy of the model predicting PAIS, measured by the concordance statistic (C statistic).

RESULTS

Of 2571 term neonates in the initial analysis (527 [20%] case and 2044 [80%] control individuals; gestational age range, 37-42 weeks), 1389 (54%) were male, with a greater proportion of males among cases compared with controls (318 [60%] vs 1071 [52%]). The final model was developed using 1924 neonates, including 321 cases (17%) and 1603 controls (83%), and 9 clinical factors associated with risk of PAIS in term neonates: maternal age, tobacco exposure, recreational drug exposure, preeclampsia, chorioamnionitis, intrapartum maternal fever, emergency cesarean delivery, low 5-minute Apgar score, and male sex. The model demonstrated good discrimination between cases and controls (C statistic, 0.73; 95% CI, 0.69-0.76) and good model fit (Hosmer-Lemeshow P = .20). Internal validation techniques yielded similar C statistics (0.73 [95% CI, 0.69-0.77] with bootstrap resampling, 10-fold cross-validated area under the curve, 0.72 [bootstrap bias-corrected 95% CI, 0.69-0.76]), as did a sensitivity analysis using cases and controls from Alberta, Canada, only (C statistic, 0.71; 95% CI, 0.65-0.77).

CONCLUSIONS AND RELEVANCE

The findings suggest that clinical variables can be used to develop and internally validate a model to predict the risk of PAIS in term neonates, with good predictive performance and strong internal validity. Identifying neonates with a high probability of PAIS who could then be screened for early diagnosis and treatment may be associated with reductions in lifelong morbidity for affected individuals and their families.

The relation between cigarette smoking with delivery outcomes. An evaluation of a database of more than nine million deliveries

OBJECTIVES

Smoking in pregnancy is associated with an increased risk of preterm birth (PTB), intrauterine growth restriction, placental abruption and perinatal death. The association between smoking and other delivery outcomes, such as chorioamnionitis, mode of delivery or postpartum hemorrhage (PPH), however, is insufficient as only few studies addressed these issues. The aim of the study was to evaluate the association between prenatal smoking and delivery outcomes in a large database, while controlling for confounding effects.

METHODS

A retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). A dataset of all deliveries between 2004 and 2014 (inclusively) was created. Our control group included all pregnant women who did not smoke during pregnancy, which was compared to pregnant women who smoked. A multivariate logistic analysis was conducted, adjusting for any statistically significant confounding effects.

RESULTS

Our study identified 9,096,788 births between 2004 and 2014. Of which, 443,590 (4.8%) had a documented diagnosis of smoking. A significantly higher risk was found for PTB (odds ratio 1.39, CI 1.35-1.43), preterm premature rupture of membranes (odds ratio 1.52, CI 1.43-1.62) and small for gestational age (SGA) neonates (odds ratio 2.27, CI 2.19-2.35). The risks of preeclampsia (odds ratio 0.82, CI 0.78-0.85), chorioamnionitis (odds ratio 0.88, CI 0.83-0.4), PPH (odds ratio 0.94 CI 0.9-0.98) and operative vaginal delivery (odds ratio 0.9, CI 0.87-0.94) were lower among smokers.

CONCLUSIONS

This large database confirms the findings of previous smaller studies, according to which smoking decreases the risk of preeclampsia while increasing the risk of PTB and SGA neonates. The current study also revealed a decreased risk for PPH as well as for chorioamnionitis among pregnant smokers.