Annual summary of vital statistics: 2010-2011

The Effect of Shift Timing on Cesarean Delivery Outcomes and Operative Noise Levels

OBJECTIVE

 Intraoperative noise exposure has been associated with an increased risk of complications, communication errors, and stress among surgical team members. This study evaluates intraoperative noise levels in cesarean deliveries during different shift times, for example, night shifts, day shifts, and hand-off times between shifts.

STUDY DESIGN

 This is a secondary analysis of a prospective observational study which measured volume in decibels, percentage of time above safe levels (>60 dB), startle noise events (events with rapid increase of decibel level above baseline noise), and peak levels (>75 dB) for cesarean deliveries during a 3-month preintervention and postintervention study. This secondary analysis of noise data evaluated whether there were differences in noise for cases occurring during day shifts (6:31 a.m.-4:59 p.m.), night shifts (6:01 p.m.-5:29 a.m.), and hand-off times (5:30 a.m.-6:30 a.m. and 5:00 p.m.-6:00 p.m.). Correlates and postoperative complications during the respective shifts were additionally analyzed.

RESULTS

 Noise data were collected for a total of 312 cesarean deliveries; 203 occurred during the day shift, 94 during the night shift, and 15 during hand-off times. Median noise in decibels, median noise at various key intraoperative points, number of startle events, percentage of time above 60 dB, and above 75 dB had no significant differences throughout the various shift times. Significantly larger numbers of postpartum hemorrhages, unscheduled, urgent, and STAT cesarean deliveries occurred at hand-off times and on night shifts.

CONCLUSION

 Noise levels during cesarean deliveries did not significantly vary when comparing night shifts, day shifts, and hand-off times, despite significantly higher numbers of urgent and STAT cases occurring overnight and during hand-off times. However, more than 60% of case time had noise levels exceeding those considered safe. This suggests that ambient background noise may be contributing more to overall noise levels rather than the specific clinical scenario at hand.

KEY POINTS

· Noise in cesarean delivery operating rooms frequently exceeded recommended levels.. · Noise in cesarean delivery operating rooms did not vary with shift type.. · Hand-off times had higher rates of urgent and STAT cesareans.. · Night shifts had higher rates of urgent and STAT cesareans..

Blood volume reduction due to rapid plasma loss after birth in preterm piglets

BACKGROUND

Understanding changes in blood volume after preterm birth is critical to preventing cardiovascular deterioration in preterm infants. The aims were to determine if blood volume is higher in preterm than term piglets and if blood volume changes in the hours after birth.

METHODS

Paired blood volume measurements were conducted in preterm piglets (98/115d gestation, ~28wk gestation infant) at 0.5-5 h (n = 12), 0.5-9 h (n = 44) and 5-11 h (n = 7) after birth, and in a term cohort at 0.5-9 h (n = 40) while under intensive care.

RESULTS

At 30 min after birth, blood volume was significantly lower in preterm piglets compared to term piglets. By 9 h after birth, blood volume had reduced by 18% in preterm piglets and 13% in term piglets. By 5-9 h after birth, preterm piglets had significantly lower blood volumes than at term (61 ± 10 vs. 76 ± 11 mL/kg).

CONCLUSIONS

In contrast to clinical resources, preterm piglets have a lower blood volume than at term. Substantial reductions in blood volume after birth leave some preterm piglets hypovolemic. If this also occurs in preterm infants, this may have important clinical consequences. Modern studies of blood volume changes after birth are essential for improving preterm outcomes.

IMPACT

Preterm piglets do not have a higher blood volume than their term counterparts, in contrast to current clinical estimates. Rapid reduction in blood volume after birth leads to hypovolemia in some preterm piglets. There is a critical need to understand blood volume changes after birth in preterm infants in order to improve clinical management of blood volume.

Hormonal influences on cerebral aneurysms: unraveling the complex connections

INTRODUCTION

Intracranial aneurysms (IAs) occur in 3-5% of the general population and are characterized by localized structural deterioration of the arterial wall with loss of internal elastic lamina and disruption of the media. The risk of incidence and rupture of aneurysms depends on age, sex, ethnicity, and other different factors, indicating the influence of genetic and environmental factors. When an aneurysm ruptures, there is an estimated 20% mortality rate, along with an added 30-40% morbidity in survivors. The alterations in hormonal levels can influence IAs, while the rupture of an aneurysm can have various impacts on endocrine pathways and affect their outcome.

AREA COVERED

This review explores the reciprocal relationship between endocrinological changes (estrogen, growth hormone, and thyroid hormones) and IAs, as well as the effects of aneurysm ruptures on endocrine fluctuations.

EXPERT OPINION

Based on the data presented in this paper, we recommend further exploration into the influence of hormones on aneurysm formation and rupture. Additionally, we propose conducting endocrine assessments for patients who have experienced a rupture of IAs. Monitoring hormonal changes in patients with IAs could serve as a potential risk factor for rupture, leading to interventions in the approach to managing IAs.

Healthcare segregation in orthopedic surgery: A statewide analysis of American Indian and Alaska Native patients

Significant health disparities have been described for American Indian and Alaska Native (AIAN) patients undergoing various surgical procedures, however, research into healthcare segregation within orthopedic surgery has been limited. In this study, our purpose was to assess if AIAN patients were more likely to be treated by lower-volume surgeons and at lower-volume hospitals. AIAN and White patients who underwent one of four common orthopedic procedures (knee or hip arthroplasty, femur or tibia repair) were identified from a Washington state inpatient database. Demographic, socioeconomic, geographic, and procedure data were surveyed, and volumetric thresholds were established for lower versus higher volume surgeons and hospitals. Adjusted odds ratios were calculated for AIAN patients receiving care from a lower volume surgeon or hospital, including covariates for patient demographics, geographic, and socioeconomic status. AIAN patients were more likely to receive care from a lower-volume surgeon for all procedures except tibial repair. Adjusted odds ratios of 1.53 (95% confidence interval [CI]: 1.22, 1.92) and 1.68 (95% CI: 1.26, 2.21) were found for AIAN patients receiving knee or hip arthroplasty from a lower volume surgeon, respectively. There was no strong evidence of AIAN patients being more likely to receive care at a lower-volume hospital. Finally, AIAN patients having knee arthroplasty at a higher volume hospital were more likely to have their surgery performed by a lower volume surgeon. These data suggest that there may be significant healthcare segregation among AIAN patients across common orthopedic surgical procedures.

Early-onset neonatal sepsis as a risk factor for peri-intraventricular hemorrhage in premature infants

OBJECTIVE

To assess early-onset sepsis as a risk factor of peri-intraventricular hemorrhage in premature infants born at less than or equal to 34 weeks' gestation and admitted to a neonatal intensive care unit (NICU).

METHODS

This retrospective cohort study included premature patients born at less than or equal to 34 weeks' gestation who were admitted to the NICU of a tertiary hospital in southern Brazil, and born from January 2017 to July 2021. Data were collected from patients' medical records. Early-onset sepsis was measured according to the presence or absence of diagnosis within the first 72 hours of life, whereas the outcome, peri-intraventricular hemorrhage, was described as the presence or absence of hemorrhage, regardless of its grade.

RESULTS

Hazard ratios were calculated using Cox regression models. A total of 487 patients were included in the study, of which 169 (34.7%) had some degree of peri-intraventricular hemorrhage. Early-onset sepsis was present in 41.6% of the cases of peri-intraventricular hemorrhage, which revealed a significant association between these variables, with increased risk of the outcome in the presence of sepsis. In the final multivariate model, the hazard ratio for early-onset sepsis was 1.52 (95% confidence interval 1.01-2.27).

CONCLUSION

Early-onset sepsis and the use of surfactants showed to increase the occurrence of the outcome in premature children born at less than or equal to 34 weeks' gestation. Meanwhile, factors such as antenatal corticosteroids and gestational age closer to 34 weeks' gestations were found to reduce the risk of peri-intraventricular hemorrhage.

Characteristics of the oral glucose tolerance test in women with different pre-pregnancy body mass index and the effect of gestational diabetes mellitus on twin pregnancy outcomes

OBJECTIVE

This study aimed to investigate the mid-pregnancy blood glucose levels of women with singleton or twin pregnancies.

METHOD

The relationship between blood glucose levels and Gestational Diabetes Mellitus (GDM) was studied in women with different pre-pregnancy Body Mass Index (BMI), and the effect of GDM on twin pregnancy outcomes was analyzed. Women with twin (n = 1,985) and singleton (n = 1,985) pregnancies were categorized into underweight (BMI < 18.5 kg/m2, n = 597), normal weight (BMI: 18.5-23.9 kg/m2, n = 2,575), and overweight/obese (BMI ≥ 24 kg/m2, n = 798) groups.

RESULTS

The incidence of GDM was 21.01% in women with twin pregnancies. Among the women with GDM in twin pregnancies, 38.37% had at least two abnormal blood glucose levels. The incidence of these parameters increased with preconception BMI, and the incidence of twin pregnancies was higher than that of singleton pregnancies (p < 0.001). In the normal weight and overweight/obese group, the oral glucose tolerance test glucose level and incidence of GDM were higher in women with twin than singleton pregnancies (p < 0.05). For twin pregnancies, the prevalence of selective fetal growth restriction was higher and anemia was lower in the GDM group than in the non-GDM group (all p < 0.05).

CONCLUSION

Therefore, a greater emphasis should be placed on BMI before conception, and well-controlled GDM does not increase adverse pregnancy outcomes for twin pregnancies.

Clinical and demographic features with outcome predictors of adult patients with acute intoxication admitted to a medical intensive care unit in the Mediterranean part of Croatia

Background

The objective of the study was to assess the demographics, clinical parameters, and outcome of acute intoxications among adult patients admitted to a medical intensive care unit in southern Croatia.

Materials and Methods

An observational retrospective study was conducted over a 1-year period. The subjects were patients admitted to the intensive care unit for acute poisoning.

Results

In all, 81 subjects (32.1% females) aged 43.16 ± 14.77 years were admitted to the intensive care unit because of poisoning (14.97% of the total annual intensive care unit admissions). Psychiatric disorders were previously established in 76.5% participants, and 69.1% of all acute intoxications were classified as suicidal. Non-suicidal subjects differed from suicidal subjects in age (37.36 ± 9.71 vs. 45.75 ± 15.93 years; P = 0.009), in pCO2 (6.38 ± 1.78 vs. 5.50 ± 1.26 kPa; P = 0.020), in length-of-stay in intensive care unit (median 1.00, interquartile range 1.00 vs. median 2.00, interquartile range 2.00 days; P = 0.022), and in length-of-stay in hospital (median 2.00, interquartile range 2.00 vs. median 10.50, interquartile range 15.25 days; P < 0.001). Three (3.7%) patients died. Pharmaceutical psychoactive drug intoxications were the most common poisoning cases; of these, diazepam was the most frequent (16.8%), followed by ethanol (9.0%) and alprazolam (7.8%). Benzodiazepines/hypnotics were the most common group (28.7%), followed by antipsychotics (13.2%). Intoxications with more than 1 poison accounted for the largest number of cases (67.9%). The number of toxins was significantly correlated with length-of-stay in the hospital (rho = -0.265; P = 0.008), systolic blood pressure (rho = -0.318; P = 0.002), and diastolic blood pressure (rho = -0.262; P = 0.009). The electrocardiogram was considered abnormal in 50.62% of the cases.

Conclusion

Acute intoxicants were most commonly caused by psychiatric pharmaceutical drugs. Multidrug exposure was a typical pattern of acute intoxication.

Effect of vaginal microbiota on pregnancy outcomes of women from Northern China who conceived after IVF

Objective

This study aimed to investigate the correlation between vaginal microbiota and pregnancy outcomes of women who achieved pregnancy via in vitro fertilization (IVF) in Northern China, and to determine a biomarker for evaluation of the risk of preterm births in these women.

Methods

In total, 19 women from Northern China women who conceived after IVF and 6 women who conceived naturally were recruited in this study. The vaginal samples of the healthy participants were collected throughout pregnancy, that is, during the first, second, and third trimesters. The V3-V4 region of 16S rRNA was used to analyze the vaginal microbiome, and the bioinformatic analysis was performed using QIIME Alpha and Beta diversity analysis.

Results

Either IVF group or Natural conception group, bacterial community diversities and total species number of vagnal samples from who delivered at term were significantly higher than those who delivered before term. Low abundance of vaginal bacteria indicates an increased risk of preterm delivery. Further, more abundant vaginal bacteria was found in first trimesters instead of the next two trimesters. Vignal samples collected during first trimester showed richer differences and more predictive value for pregnancy outcoes. In addition, the diversity of the vaginal bacterial community decreased as the gestational age increased, in all samples. Alloscardovia was only found in participants who conceived after IVF, and the percentage of Alloscardovia in viginal samples of normal delivery group is much higher than the samples from preterm delivery group.Vobrio specifically colonized in vagina of pregnant woman in AFT group (those who conceived after IVF (A), first trimester (F), and delivered at term (T)) and Sporosarcina was detected only in women with AFT and AST (those who conceived after IVF (A), second trimester (S), and delivered at term (T)). These data indicates that Alloscardovia, Vobrio and Sporosarcina have great potential in predicting pregnancy outcomes who pregnanted by vitro fertilization.

Conclusions

Vaginal microbiota were more stable in women who conceived naturally and those who carried pregnancy to term. Oceanobacillus might act as a positive biomarker, whereas Sulfurospirillum and Propionispira may act as negative biomarkers for the risk of preterm birth.

Is High-intensity Focused Ultrasound Superior to Uterine Artery Embolization in Cesarean Scar Pregnancy and Subsequent Pregnancy Outcomes? A Meta-analysis of the Chinese Population

OBJECTIVE

High-intensity focused ultrasound (HIFU) followed by curettage or uterine artery embolization (UAE) followed by curettage are relatively effective methods for cesarean scar pregnancy (CSP), which can provide a high success rate and repregnancy while reducing blood loss and adverse events. Therefore, we conducted this meta-analysis to evaluate the efficacy, safety, and pregnancy outcomes of HIFU groups versus UAE groups with CSP.

DATA SOURCES

The PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure, and Wanfang databases were systematically searched to find studies that compared the therapeutic effects of HIFU groups versus UAE groups.

METHODS OF STUDY SELECTION

Our primary end points were blood loss, adverse events, success rate, and repregnancy. We implemented random-effects models or fixed-effects models to evaluate the pooled data.

TABULATION, INTEGRATION, AND RESULTS

Thirty-four eligible items were included in studies. The blood loss was significantly reduced in HIFU groups compared with UAE groups (standardized mean difference = -1.45, 95% confidence interval [CI], 2.21 to -0.68; p <.001). Significantly fewer adverse events occurred in the HIFU groups than in UAE groups (odds ratio [OR] = 0.36, 95% CI, 0.23-0.57; p <.001). The success rate of HIFU groups was higher than that of UAE groups (OR = 1.56, 95% CI, 1.05-2.32; p = .03). There were more pregnancies in HIFU groups than in UAE groups (OR = 1.64, 95% CI, 1.28-2.11; p <.001).

CONCLUSION

In the CSP, the effect of HIFU groups was better than that of UAE groups: less blood loss, high success rate, fewer adverse events, and favorable fertility protection. Thus, it is a promising therapeutic method for patients.

Brain Damage in Preterm and Full-Term Neonates: Serum Biomarkers for the Early Diagnosis and Intervention

The Brain is vulnerable to numerous insults that can act in the pre-, peri-, and post-natal period. There is growing evidence that demonstrate how oxidative stress (OS) could represent the final common pathway of all these insults. Fetuses and newborns are particularly vulnerable to OS due to their inability to active the antioxidant defenses. Specific molecules involved in OS could be measured in biologic fluids as early biomarkers of neonatal brain injury with an essential role in neuroprotection. Although S-100B seems to be the most studied biomarker, its use in clinical practice is limited by the complexity of brain damage etiopathogenesis and the time of blood sampling in relation to the brain injury. Reliable early specific serum markers are currently lacking in clinical practice. It is essential to determine if there are specific biomarkers that can help caregivers to monitor the progression of the disease in order to active an early neuroprotective strategy. We aimed to describe, in an educational review, the actual evidence on serum biomarkers for the early identification of newborns at a high risk of neurological diseases. To move the biomarkers from the bench to the bedside, the assays must be not only be of a high sensitivity but suitable for the very rapid processing and return of the results for the clinical practice to act on. For the best prognosis, more studies should focus on the association of these biomarkers to the type and severity of perinatal brain damage.

Maternal and neonatal characteristics associated with clinical outcomes of TOLAC from 2012-20 in the USA: Evidence from a retrospective cohort study

Background

The risks of a few maternal and/or neonatal morbidities are higher with the trial of labour after caesarean (TOLAC) owing to unplanned caesarean delivery. Thus, it is imperative to consider the trade-off between the risk of side effects and the potential benefits before TOLAC utilisation and whether TOLAC should be provided to women with specific characteristics related to previous caesarean delivery. We aimed to investigate maternal and neonatal characteristics associated with TOLAC utilisation, compare maternal and/or neonatal morbidities in TOLAC women with women who chose planned caesarean deliveries, and assess specific characteristics related to maternal and/or neonatal morbidities in women with TOLAC utilisation.

Methods

In this retrospective cohort study, we used nationwide, linked birth and infant death data in the United States between 2012 and 2020, which covers all 50 states in the US. Poisson regression models using generalised estimating equations yielded adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) of TOLAC utilisation and unsuccessful TOLAC by maternal and neonatal characteristics. Logistic regression models using generalised estimating equations yielded adjusted odds ratios (aORs) with 95% CIs of maternal and neonatal morbidities. Statistical analysis was performed from February 2022 to July 2022.

Findings

The sample included 4,898,441 women with mean (SD) maternal age years (5.4 years; range 13-50). Several specific maternal and neonatal characteristics were significantly associated with unsuccessful TOLAC, although women with TOLAC utilisation were associated with significantly lower risks of maternal unplanned hysterectomy (aOR, 0.60; 95% CI, 0.60-0.61), admission to intensive care (aOR, 0.84; 95% CI, 0.84-0.85), and neonatal seizures (aOR, 0.80; 95% CI, 0.74-0.84). In women who attempted TOLAC, advanced maternal age, higher maternal body mass index, more than 2 previous caesarean deliveries, having maternal co-morbidities and fetal malpresentation increased the likelihood of maternal and neonatal morbidities.

Interpretation

When utilising TOLAC, specific maternal and neonatal characteristics in pregnant women should be considered in conjunction with the potential benefits of TOLAC in preventing maternal and neonatal morbidities.

Funding

This study is funded by the Clinical Medicine Plus X - Young Scholars Project, Peking University, the Fundamental Research Funds for the Central Universities (No: PKU2022LCXQ008).

Hospital variation in extremely preterm birth

OBJECTIVE

Given that regionalization of extremely preterm births (EPTBs) is associated with improved infant outcomes, we assessed between-hospital variation in EPTB stratified by hospital level of neonatal care, and determined the proportion of variance explained by differences in maternal and hospital factors.

STUDY DESIGN

We assessed 7,046,253 births in California from 1997 to 2011, using hospital discharge, birth, and death certificate data. We estimated the association between maternal and hospital factors and EPTB using multivariable regression, calculated hospital-specific EPTB frequencies, and estimated between-hospital variances and median odds ratios, stratified by hospital level of care.

RESULT

Hospital frequencies of EPTB ranged from 0% to 2.5%. Between-hospital EPTB frequencies varied substantially, despite stratifying by hospital level of care and accounting for confounding factors.

CONCLUSION

Our results demonstrate differences in EPTBs among hospitals with level 1 and 2 neonatal care, an area to target for future research and quality improvement.

Adverse outcomes associated with twin pregnancies conceived via in vitro fertilization

OBJECTIVE

To compare adverse pregnancy and neonatal outcomes in twin pregnancies conceived by in vitro fertilization (IVF) to those conceived spontaneously.

METHODS

Retrospective analysis of the Centers for Disease Control and Prevention, Natality Live Birth database for the years 2016-2019. All twin live births were included and stratified into two groups: those from pregnancies conceived via IVF and those from pregnancies conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes were compared between the two groups. Statistical analysis included multivariable logistic regression to adjust for the following potential confounders: maternal age, race/ethnicity, body mass index, education level, type of medical insurance, chronic hypertension, pregestational diabetes, and prior preterm birth. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Twin live births from pregnancies conceived via IVF comprised 9.5% of the study cohort (39,356 of 415,560). Baseline characteristics varied significantly between IVF and spontaneously conceived twins. After adjusting for these variables, IVF in twins was associated with an increased risk of multiple adverse outcomes including gestational diabetes (aOR = 1.35, 95% CI = 1.30-1.39), hypertensive disorders of pregnancy (aOR = 1.70, 95% CI = 1.65-1.75), preterm birth prior to 28 weeks (aOR = 1.53, 95% CI = 1.43-1.63), maternal intensive care unit admission (aOR = 2.03, 95% CI = 1.79-2.31), maternal blood transfusion (aOR = 2.97, 95% CI = 2.75-3.20), unplanned hysterectomy (aOR = 3.37, 95% CI = 2.73-4.16), and prolonged ventilation in newborns (aOR = 1.76, 95% CI = 1.69-1.82), compared to spontaneously conceived twin pregnancies.

CONCLUSIONS

Based on this large United States population-based cohort, twin pregnancies conceived via IVF represent a subgroup of twins that have an increased risk for several adverse pregnancy and neonatal outcomes, compared to those conceived spontaneously. With increased contemporary utilization of IVF, obstetricians should consider these risks while caring for patients with twin pregnancies conceived via IVF.

Antenatal corticosteroids and neonatal outcomes in preterm birth in the United States

OBJECTIVES

To determine the impact of antenatal corticosteroids (ACS) on neonatal outcomes in a large United States population of preterm births.

METHODS

Retrospective cohort study utilizing the United States Natality Live Birth database from the Centers for Disease Control and Prevention (2016-2017). Women with singleton preterm births were eligible for inclusion. Out-of-hospital births, fetal anomalies, and cases where ACS exposure was unknown were excluded. Neonates from reported live births were divided into two groups based on whether the mother received ACS before delivery or not. The incidence of several reported neonatal outcomes were compared between the two groups at each gestational week. Subsequently, comparisons between three gestational age groups (23 0/7 to 27 6/7, 28 0/7 to 33 6/7, and 34 to 36 6/7 weeks) were performed. Statistical analysis included use of Chi-squared test and multivariate logistic regression.

RESULTS

Of the 588,077 live births included, 121,151 (20.6%) had been exposed to ACS. ACS use was associated with a significantly decreased odds of neonatal mortality and 5-min Apgar score <7, but an increased rate of several neonatal outcomes such as surfactant replacement therapy, prolonged ventilation, antibiotics for suspected neonatal sepsis, and neonatal intensive care unit (NICU) admissions.

CONCLUSIONS

ACS administration prior to preterm birth is associated with a decrease in neonatal mortality and low Apgar scores, and increased odds of several adverse neonatal outcomes.

The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States

ABSTRACT

Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.

Neonatal Acute Kidney Injury

Acute kidney injury (AKI) is a common occurrence in the neonatal intensive care unit (NICU). In recent years, our knowledge of the incidence and impact of neonatal AKI on outcomes has expanded exponentially. Neonatal AKI has been shown to be associated with adverse outcomes including increased length of mechanical ventilation, prolonged length of stay, and rise in mortality. There has also been increasing work suggesting that neonates with AKI are at higher risk of chronic kidney disease (CKD). In the past, AKI had been defined multiple ways. The utilization of the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria as the standard definition for neonatal AKI in research and clinical care has driven the advances in our understanding of neonatal AKI over the last 10 years. This definition has allowed researchers and clinicians to better understand the incidence, risk factors, and outcomes associated with neonatal AKI across populations through a multitude of single-center studies and the seminal, multicenter Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. As the impacts of neonatal AKI have become clear, a shift in efforts toward identifying those at highest risk, protocolizing AKI surveillance, improving prevention and diagnosis, and expanding kidney support therapy (KST) for neonates has occurred. These efforts also include improving risk stratification (identifying high risk populations, including those with nephrotoxic medication exposure) and diagnostics (novel biomarkers and diagnostic tools). Recent work has also shown that the targeted use of methylxanthines may prevent AKI in a variety of high-risk populations. One of the most exciting developments in neonatal AKI is the advancement in technology to provide KST to neonates with severe AKI. In this comprehensive review we will provide an overview of recent work and advances in the field of neonatal AKI. This will include a detailed review of (1) the definition of neonatal AKI, (2) the epidemiology, risk factors, and outcomes associated with neonatal AKI, (3) improvements in risk stratification and diagnostics, (4) mitigation and treatment, (5) advancements in the provision of KST to neonates, and (6) the incidence and risk of subsequent CKD.

Erythropoietin as a Neuroprotective Drug for Newborn Infants: Ten Years after the First Use

Protective strategies against perinatal brain injury represent a major challenge for modern neonatology. Erythropoietin (Epo) enhances endogenous mechanisms of repair and angiogenesis. In order to analyse the newest evidence on the role of Epo in prematurity, hypoxic ischemic encephalopathy (HIE) and perinatal stroke, a critical review using 2020 PRISMA statement guidelines was conducted. This review uncovered 26 clinical trials examining the use of Epo for prematurity and brain injury-related outcomes. The effects of Epo on prematurity were analysed in 16 clinical trials. Erythropoietin was provided until 32–35 weeks of corrected postnatal age with a dosage between 500–3000 UI/kg/dose. Eight trials reported the Epo effects on HIE term newborn infants: Erythropoietin was administered in the first weeks of life, at different multiple doses between 250–2500 UI/kg/dose, as either an adjuvant therapy with hypothermia or a substitute for hypothermia. Two trials investigated Epo effects in perinatal stroke. Erythropoietin was administered at a dose of 1000 IU/kg for three days. No beneficial effect in improving morbidity was observed after Epo administration in perinatal stroke. A positive effect on neurodevelopmental outcome seems to occur when Epo is used as an adjuvant therapy with hypothermia in the HIE newborns. Administration of Epo in preterm infants still presents inconsistencies with regard to neurodevelopmental outcome. Clinical trials show significant differences mainly in target population and intervention scheme. The identification of specific markers and their temporal expression at different time of recovery after hypoxia-ischemia in neonates might be implemented to optimize the therapeutic scheme after hypoxic-ischemic injury in the developing brain. Additional studies on tailored regimes, accounting for the risk stratification of brain damage in newborns, are required.

Duration of the second stage of labour and risk of subsequent spontaneous preterm birth

OBJECTIVES

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

POPULATION

Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded.

METHODS

Charts from 2007 to 2019 were reviewed.

MAIN OUTCOME MEASURES

Rate of sPTB (<37 weeks of gestation) in the second delivery.

RESULTS

Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p < 0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p < 0.001).

CONCLUSION

Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage.

Pediatric Trauma

Musculoskeletal injuries of the lower limb are frequent in pediatric patients and represent the most common cause of emergency department admissions. Acute sports-related injuries commonly involve the lower extremity, as the knee and ankle are the most frequently injured parts. Physeal fractures are common injuries in children and adolescents participating in contact sports, which may lead to growth disturbances and cause limb length discrepancy. It is imperative for pediatric trauma centers to implement evidence-based multispecialty protocols for the perimanagement of the injured child, especially through the postdischarge and rehabilitation phases, in order for the child to resume active daily living.

Treatment of Respiratory Distress Syndrome with Single Recombinant Polypeptides that Combine Features of SP-B and SP-C

Treatment of respiratory distress syndrome (RDS) with surfactant replacement therapy in prematurely born infants was introduced more than 30 years ago; however, the surfactant preparations currently in clinical use are extracts from animal lungs. A synthetic surfactant that matches the currently used nature-derived surfactant preparations and can be produced in a cost-efficient manner would enable worldwide treatment of neonatal RDS and could also be tested against lung diseases in adults. The major challenge in developing fully functional synthetic surfactant preparations is to recapitulate the properties of the hydrophobic lung surfactant proteins B (SP-B) and SP-C. Here, we have designed single polypeptides that combine properties of SP-B and SP-C and produced them recombinantly using a novel solubility tag based on spider silk production. These Combo peptides mixed with phospholipids are as efficient as nature-derived surfactant preparations against neonatal RDS in premature rabbit fetuses.

Factors associated with the development of neonatal hypoglycemia after antenatal corticosteroid administration: It's all about timing

OBJECTIVE

To determine the factors associated with neonatal hypoglycemia among neonates exposed to antenatal corticosteroid (ACS).

METHODS

A retrospective study conducted during 2017-2019 at a tertiary-care center including all neonates delivered between 24 and 34 weeks of gestation after ACS administration. The primary outcome was neonatal hypoglycemia (<40 mg/dl).

RESULTS

Overall, 362 early preterm neonates, including 205 singletons and 157 twins, were exposed to ACS before delivery and constituted the study group. Of them, 275 (76.0%) were exposed to a single ACS course and 87 (24.0%) to an additional rescue ACS course. Neonatal hypoglycemia occurred in 84 (23.2%) neonates. The incidence of neonatal hypoglycemia was significantly higher in those delivered between 24 and 48 h after ACS administration compared with those delivered outside this time interval (10/25, 40.0% vs 74/337, 21.9%; P = 0.049). In multivariate analysis, after adjusting for neonatal birth weight and gestational age, delivery within 24-48 h after ACS administration was the only independent risk factor associated with neonatal hypoglycemia (adjusted odds ratio 2.41, 95% confidence interval 1.03-5.68; P = 0.044).

CONCLUSION

Neonatal hypoglycemia occurred in over one-fifth of those exposed to ACS, and was independently associated with delivery between 24 and 48 h after ACS administration.

The screening performance of glucose challenge test for gestational diabetes in twin pregnancies: a systematic review and meta-analysis

BACKGROUND

The screening accuracy of the 50 g-glucose challenge test (50 g-GCT) for gestational diabetes (GDM) has been described in singleton pregnancies. Given the physiologic differences and greater increase in insulin resistance in twin compared with singleton pregnancies, the performance of the 50 g-GCT in twin pregnancies may differ.

OBJECTIVES

To perform a systematic review on the screening performance of the 50 g-GCT for gestational diabetes in twin pregnancies.

DATA SOURCES

Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included randomized controlled trials or cohort studies that evaluated the screening accuracy of the 50 g-GCT for GDM in twin pregnancies using the two-step approach. The primary outcome was the positive predictive value of the 50 g-GCT for GDM using the 140 mg/dL (7.8 mmol/L) threshold.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality of included studies was assessed using the QUADAS-2 tool. The positive predictive value (PPV) was pooled for studies that used similar test characteristics.

RESULTS

From 2044 citations, 7 retrospective cohort studies with a total of 55,597 participants were included (6.5% twins and 93.5% singletons). The majority of studies evaluated a 50-g GCT cutoff point of 140 mg/dL. The pooled PPV for a threshold of 140 mg/dL (7.8 mmol/L) for twins was 22.58% (95% CI: 0.1912-0.2647, I²=34.1%). The 50-g GCT screen positive rate in twin pregnancies was higher than that in singleton pregnancies. None of the studies performed routine OGTT.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The PPV of 50 g-GCT for GDM in twin pregnancies when using a threshold of 140 mg/dL (7.8 mmol/L) is approximately 23%. There is currently no data on the sensitivity and specificity of the 50 g-GCT in twins.

Is the type of neuraxial anesthesia associated with adverse neonatal outcomes among patients with preeclampsia?

OBJECTIVE

Both preeclampsia and neuraxial anesthesia can alter placental perfusion, potentially affecting the neonatal status. The objective of our study is to quantify the association between type of neuraxial anesthetic and short-term neonatal morbidity among preeclamptic patients undergoing cesarean delivery.

METHODS

We performed a secondary analysis of a prospective observational cohort study. Women with singleton gestations and a diagnosis of preeclampsia who underwent cesarean delivery with neuraxial anesthesia were included in the analysis. Short-term neonatal morbidities, defined as neonatal intensive care unit (NICU) admission, arterial cord gas pH ≤7.2 and 5-minute Apgar <7, were compared based on type of neuraxial anesthetic.

RESULTS

A total of 4100 patients were included in the analysis, 1696 (41.4%) received spinal anesthesia 1848 (45.1%) received epidural anesthesia and 556 (13.5%) received a combined spinal-epidural (CSE). Antepartum and intrapartum characteristics significantly differed between the groups (p≤0.02). After adjusted analysis, spinal anesthesia was associated with reduced odds of NICU admission, compared with epidural or CSE (OR; 95% CI: 0.79; 0.63-0.98, 0.71; 0.53-0.94, respectively). Spinal anesthesia was also associated with lower odds of a 5-minute Apgar <7 compared with epidural anesthesia (OR 0.59; 95% CI; 0.43-0.83). We found no association between type of anesthesia and arterial cord pH ≤7.2. In stratiifed analysis by gestational age, no association between the type of neuraxial anesthesia and neonatal outcomes was noted among term infants, but associations persisted in preterm infants.

CONCLUSIONS

Among women with preeclampsia undergoing cesarean delivery, spinal anesthesia may be associated with reduced short-term neonatal morbidity in preterm infants, compared with epidural or CSE.

Rescue antenatal corticosteroids and neonatal outcomes in twin gestation

OBJECTIVE

Although repeated antenatal corticosteroids (ACS) courses are not recommended, a single rescue ACS course has been shown to decrease neonatal morbidity among preterm singletons. However, little is known regarding the effects of rescue ACS course in twin pregnancies.

METHODS

A retrospective cohort study conducted during 2015-2017 at a tertiary-care center including all twins delivered between 24-34 weeks of gestation who received at least one course of ACS.

RESULTS

Overall, 162 (70.4%) twins were exposed to a single ACS course and 68 (29.6%) to an additional rescue ACS course. Rescue ACS course was associated with lower rates of respiratory distress syndrome (7.4% vs. 19.1%, p = .03), surfactant use (7.4% vs 18.5%, p = .04) and bronchopulmonary dysplasia (0 vs 8.6%, p = .01) as compared to a single ACS course. In the rescue ACS group, compared to the single ACS group, the rates of composite respiratory adverse outcome (10.3% vs 22.2%, OR [95% CI]: 0.40 (0.17-0.95), p = .04) and any adverse neonatal outcome (13.2% vs 26.5%, OR [95% CI]: 0.42 (0.19-0.92), p = .04) were significantly lower. Hospital stay was also shorter among neonates born to mothers receiving a rescue ACS course (median 23 vs. 30 days, p = .01). No differences were noted in neonatal birthweight, head circumference and the rate of neonatal hypoglycemia.

CONCLUSION

Rescue ACS course was associated with improved respiratory and neonatal outcomes in twin gestations. Further studies are warranted to confirm our findings and better delineate the optimal regimen of rescue ACS in this setting.

Usability Evaluation of a Tablet-Based Intervention to Prevent Intradialytic Hypotension in Dialysis Patients During In-Clinic Dialysis: Mixed Methods Study

Background

Patients on hemodialysis receive dialysis thrice weekly for about 4 hours per session. Intradialytic hypotension (IDH)—low blood pressure during hemodialysis—is a serious but common complication of hemodialysis. Although patients on dialysis already participate in their care, activating patients toward IDH prevention may reduce their risk of IDH. Interactive, technology-based interventions hold promise as a platform for patient activation. However, little is known about the usability challenges that patients undergoing hemodialysis may face when using tablet-based informatics interventions, especially while dialyzing.

Objective

This study aims to test the usability of a patient-facing, tablet-based intervention that includes theory-informed educational modules and motivational interviewing–based mentoring from patient peers via videoconferencing.

Methods

We conducted a cross-sectional, mixed methods usability evaluation of the tablet-based intervention by using think-aloud methods, field notes, and structured observations. These qualitative data were evaluated by trained researchers using a structured data collection instrument to capture objective observational data. We calculated descriptive statistics for the quantitative data and conducted inductive content analysis using the qualitative data.

Results

Findings from 14 patients cluster around general constraints such as the use of one arm, dexterity issues, impaired vision, and lack of experience with touch screen devices. Our task-by-task usability results showed that specific sections with the greatest difficulty for users were logging into the intervention (difficulty score: 2.08), interacting with the quizzes (difficulty score: 1.92), goal setting (difficulty score: 2.28), and entering and exiting videoconference rooms (difficulty score: 2.07) that are used to engage with peers during motivational interviewing sessions.

Conclusions

In this paper, we present implications for designing informatics interventions for patients on dialysis and detail resulting changes to be implemented in the next version of this intervention. We frame these implications first through the context of the role the patients’ physical body plays when interacting with the intervention and then through the digital considerations for software and interface interaction.

Delivery Mode Preference and Associated Factors among Pregnant Mothers in Harar Regional State, Eastern Ethiopia: A Cross-Sectional Study

Background

The right to prefer mode of delivery is a crucial component of compassionate and respectful care that fosters both maternal and neonatal well-being as the failure to respect the mother's interest increases to the risk of maternal depression and posttraumatic stress. Thus, the aim of the study was to assess delivery mode preference and associated factors among pregnant women.

Methods and Materials

The study was conducted in two hospitals and two health centers. We used a cross-sectional study design incorporating 398 pregnant mothers attending an antenatal care follow-up from February to May 2018. The study excluded pregnant mothers with any previous uterine surgery including caesarean delivery from participation due to their restricted chance to prefer their mode of delivery. Data were collected by using a pretested questionnaire. Data were entered to EpiData Manager version 3.1 and exported to Statistical Package for the Social Sciences version 22 for analysis. Besides, the analysis included both the bivariate and multivariable analyses to check the association between dependent and independent variables. Finally, level of statistical significance was declared at P value < 0.05.

Result

The participant's level of response was 100% (398). The age of the mothers ranges from 15 to 45 years old. The delivery mode preference of the caesarean section (C/S) and spontaneous vertex delivery (SVD) was 115 (28.9%) and 283 (71.1%), respectively. The study revealed that planned 47 pregnancy [AOR, 1.76; CI: 0.89-3.47], young age [AOR, 12.9; CI: 0.23-7.1], and primigravida [AOR, 1.24; CI: 0.29-5.2] were among the variables associated with maternal preference of caesarean section. Conclusion and Recommendation. Nearly one-third of the mothers preferred caesarean delivery as their mode of delivery due to fear of labor pain and repeated vaginal examination by the care providers. This is particularly seen in women who had received higher education level, claim their pregnancy as planned, their choice of delivery at hospital, young aged, pregnant for the first time, and those who had visited antenatal care repeatedly. This implies that policy makers and stakeholders should exert due emphasis to ongoing desire of caesarean delivery as the procedure is not without risk, if it is done without indication. For researchers, we recommend to investigate the preference of mode of delivery in a much broader aspect.

NF-κB and Its Regulators During Pregnancy

The transcriptional factor NF-κB is a nuclear factor involved in both physiological and pathological processes. This factor can control the transcription of more than 400 genes, including cytokines, chemokines, and their modulators, immune and non-immune receptors, proteins involved in antigen presentation and cell adhesion, acute phase and stress response proteins, regulators of apoptosis, growth factors, other transcription factors and their regulators, as well as different enzymes; all these molecules control several biological processes. NF-κB is a tightly regulated molecule that has also been related to apoptosis, cell proliferation, inflammation, and the control of innate and adaptive immune responses during onset of labor, in which it has a crucial role; thus, early activation of this factor may have an adverse effect, by inducing premature termination of pregnancy, with bad outcomes for the mother and the fetus, including product loss. Reviews compiling the different activities of NF-κB have been reported. However, an update regarding NF-κB regulation during pregnancy is lacking. In this work, we aimed to describe the state of the art around NF-κB activity, its regulatory role in pregnancy, and the effect of its dysregulation due to invasion by pathogens like Trichomonas vaginalis and Toxoplasma gondii as examples.

Is increasing paternal age negatively associated with donor oocyte recipient success? A paired analysis using sibling oocytes

OBJECTIVE

To determine if increasing paternal age has an adverse effect on pregnancy outcomes in paired donor egg recipients who received oocytes from the same donor in the same stimulation cycle.

DESIGN

Retrospective cohort study.

SETTING

Reproductive Medicine Center.

PATIENT(S)

The study included 154 recipients who received oocytes from a split donor oocyte cycle and received sperm from men in discrepant age groups (group A: <45 years old; group B: ≥45 years old).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Implantation rate, pregnancy loss rate, pregnancy rate, and live birth rate.

RESULT(S)

The median paternal age was 41 years old for group A and 48 years old for group B. The pregnancy rate was 81% in group A compared with 69% in group B. The live birth rate was 65% in group A compared with 53% in group B. The rate of pregnancy loss was 19% in group A and 23% in group B. The implantation rate was 69% in group A compared with 66% in group B. The adjusted odds of pregnancy were found to be 65% lower for patients in the older partner age group (95% confidence interval [CI], 0.13, 0.95). The adjusted odds of live birth rate (odds ratio [OR], 0.45; 95% CI, 0.20, 1.00), implantation rate (OR, 0.91; 95% CI, 0.43, 1.92), and rate of pregnancy loss (OR, 1.5; 95% CI, 0.5, 4.5) favored the younger partner age group; however, these results were not statistically significant.

CONCLUSION(S)

In this model that controlled for oocyte quality to the greatest degree possible by using paired recipients from the same donor from the same stimulation cycle, we found that increased paternal age had a negative effect on pregnancy rates.

Timing of active phase labor arrest diagnosis in nulliparous women: a cost-effectiveness analysis

BACKGROUND

Recommendations from the American College of Obstetricians and Gynecologists for the safe prevention of primary cesarean deliveries propose that cesarean delivery for active phase arrest in the first stage of labor should be performed only if women fail to progress despite four hours of adequate uterine activity and no cervical change. This is a change in recommendation from a two-hour threshold.

OBJECTIVE

To determine the economic and clinical implications of waiting four hours compared to two hours for cervical progression before diagnosing active phase labor arrest.

STUDY DESIGN

We designed a cost-effectiveness analysis using TreeAge Pro 2020 software with model inputs derived from the literature. We used a theoretical cohort of 1.4 million women, the approximate number of nulliparous U.S. women reaching four centimeters in spontaneous labor. We compared maternal and neonatal outcomes and costs associated with defining active phase arrest after four hours of no cervical progression versus two hours. As a baseline assumption, active labor was defined at four centimeters. It was assumed that women with active phase arrest were delivered via cesarean delivery. In addition to cost and maternal quality-adjusted life years (QALY), outcomes included mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and maternal deaths. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. The willingness-to-pay threshold was set at $100,000/QALY.

RESULTS

In a theoretical cohort of 1.4 million women, waiting four hours instead of two hours led to 322,253 fewer cesarean deliveries, 6 fewer maternal deaths, 123 fewer postpartum hemorrhages requiring transfusions, and 28,615 fewer episodes of endometritis. There were 418 more instances of neonatal shoulder dystocia and 14 more cases of permanent brachial plexus injuries with a four-hour threshold. A four-hour threshold leads to 56% more women having a vaginal delivery in our theoretical cohort. Results from our model show that waiting four hours versus two hours to diagnose active phase labor arrest led to increased total QALYs with increased costs, with an incremental cost effectiveness ratio (ICER) below our willingness-to-pay threshold of $100,000 per QALY. Thus, it was cost effective to wait for at least four hours in the diagnosis of active phase arrest. Multivariable sensitivity analysis demonstrated the model was robust over a wide range of assumptions.

CONCLUSIONS

Increasing the time threshold from two to four hours for diagnosing active phase labor arrest beyond four centimeters is a cost-effective strategy, resulting in fewer primary cesarean deliveries and improved maternal outcomes, despite a small increase in adverse neonatal outcomes.

Vegetarian diets during pregnancy, and maternal and neonatal outcomes

BACKGROUND

Vegetarian diets are becoming increasingly popular in the USA. Limited research has examined the health consequences of vegetarian diets during pregnancy. We comprehensively examined associations of vegetarianism during pregnancy with maternal and neonatal outcomes.

METHODS

We used data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Fetal Growth Studies-Singletons, a prospective multi-site cohort of 1948 low-risk pregnant women of four races/ethnicities (White, Black, Hispanic, Asian/Pacific Islander) in the USA (2009-2013). Vegetarianism was self-reported and also defined based on dietary patterns measured using a self-administered first-trimester food-frequency questionnaire (full [lacto-ovo and vegan], pesco-, semi- and non-vegetarians). Neonatal outcomes included birthweight and neonatal anthropometric measures, small for gestational age, small for gestational age with neonatal morbidity and preterm delivery. Maternal outcomes included gestational weight gain, gestational diabetes, hypertensive disorders of pregnancy and gestational anaemia.

RESULTS

Ninety-nine (6.2%) women self-reported being vegetarian. The diet-based definition identified 32 (2.0%) full vegetarians, 7 (0.6%) pesco-vegetarians and 301 (17.6%) semi-vegetarians. Neonates of diet-based full vegetarians had higher odds of being small for gestational age [adjusted odds ratio (ORadj) = 2.51, 95% confidence interval: 1.01, 6.21], but not of being small for gestational age with a postnatal morbidity. Full vegetarians had marginally increased the odds of inadequate second-trimester gestational weight gain (ORadj = 2.24, 95% confidence interval: 0.95, 5.27).

CONCLUSION

Vegetarian diets during pregnancy were associated with constitutionally smaller neonatal size, potentially via the mothers' reduced gestational weight gain. Notably, vegetarianism was not associated with small-for-gestational-age-related morbidities or other adverse maternal outcomes.

Objectively assessed sleep-disordered breathing during pregnancy and infant birthweight

BACKGROUND

Sleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight.

METHODS

We measured SDB objectively in early (6-15 weeks' gestation) and mid (22-31 weeks' gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA: <10th percentile for gestational age) birthweights.

RESULTS

The prevalence of early-pregnancy SDB was nearly 4%. The incidence of mid-pregnancy SDB was nearly 6.0%. The prevalence of LGA and SGA was 7.4% and 11.9%, respectively. Early-pregnancy SDB was associated with a higher risk of LGA in unadjusted models (RR 2.2, 95% CI 1.3-3.5) but not BMI-adjusted models (aRR 1.0, 95% CI 0.6-1.8). Mid-pregnancy SDB was not associated with SGA or LGA. Mid-pregnancy nocturnal hypoxemia (% of sleep time <90% oxygen saturation) and increasing nocturnal hypoxemia from early to mid-pregnancy were associated with a higher risk of LGA in BMI-adjusted models. SDB and nocturnal hypoxemia were not associated with SGA.

CONCLUSIONS

SDB in pregnancy was not associated with an increased risk of LGA or SGA birthweight, independent of BMI. Some measures nocturnal hypoxemia were associated with an increase in LGA risk, independent of BMI. ClinicalTrials.gov Registration number NCT02231398.

Impact of Probiotic B. infantis EVC001 Feeding in Premature Infants on the Gut Microbiome, Nosocomially Acquired Antibiotic Resistance, and Enteric Inflammation

Background: Preterm birth is a major determinant of neonatal survival and morbidity, but the gut microbiome and associated enteric inflammation are also key factors in neonatal development and the risk of associated morbidities. We prospectively and longitudinally followed two cohorts of preterm infants, one of which was fed activated Bifidobacterium longum subsp. infantis (B. infantis) EVC001 8 × 109 CFU daily, and the other was not fed a probiotic. Hospital feeding protocol assigned all infants born at <1500 g and/or < 32 weeks corrected gestational age to the probiotic feeding protocol, whereas infants born at >1500 g and/or >32 weeks corrected gestational age were not fed a probiotic. Fecal samples were opportunistically collected from 77 infants throughout the hospital stay, and subjected to shotgun metagenomic sequencing and quantification of enteric inflammation. De-identified metadata was collected from patient medical records. Results: The gut microbiome of preterm infants was typified by a high abundance of Enterobacteriaceae and/or Staphylococcaceae, and multivariate modeling identified the probiotic intervention, rather than degree of prematurity, day of life, or other clinical interventions, as the primary source of change in the gut microbiome. Among infants fed B. infantis EVC001, a high abundance of total Bifidobacteriaceae developed rapidly, the majority of which was B. infantis confirmed via subspecies-specific qPCR. Associated with this higher abundance of Bifidobacteriaceae, we found increased functional capacity for utilization of human milk oligosaccharides (HMOs), as well as reduced abundance of antibiotic resistance genes (ARGs) and the taxa that harbored them. Importantly, we found that infants fed B. infantis EVC001 exhibited diminished enteric inflammation, even when other clinical variables were accounted for using multivariate modeling. Conclusion: These results provide an important observational background for probiotic use in a NICU setting, and describe the clinical, physiological, and microbiome-associated improvements in preterm infants associated with B. infantis EVC001 feeding.

Is real-time dynamic cervical shortening predictive of preterm birth?- A case control study

OBJECTIVES

We aimed to assess the risk of preterm birth in those with real-time dynamic cervical shortening.

METHODS

A retrospective matched case-control study. The study group comprised all women with dynamic cervical shortening (≥4 mm) noted from 24 to 34 weeks of gestation during 2010-2017 at a university hospital. Two control groups of women were established by matching the minimal and maximal cervical length measured, as well as age, parity, gestational age, history of spontaneous preterm birth, symptoms of preterm labor, and delivery year.

RESULTS

Data from 339 women were analyzed, 113 with dynamic cervical shortening comprised the study group, and two groups with 113 women each, matched for the minimal and maximal cervical lengths measured comprised the control groups. Rates of spontaneous preterm birth rate at <37 weeks (32.7% vs. 15.9%; OR [95% CI]: 2.60 (1.36, 4.87), p = .004) and <35 weeks (15.9% vs. 5.3%; OR [95% CI]: 3.38 (1.29, 8.86), p = .013) were significantly higher among those with dynamic cervix than among the control group matched for the maximal cervical length, and comparable to the control group matched for the minimal cervical length. The negative predictive values of cervical length for preterm birth occurrence at various cutoff values were lower in those with dynamic cervix.

CONCLUSIONS

The minimal cervical length measured should be used to guide patient management when dynamic cervix is noted. In the setting of dynamic cervical change, the value of cervical length as a negative predictor of preterm birth is limited.

Delta Shock Index Predicts Outcomes in Pediatric Trauma Patients Regardless of Age

INTRODUCTION

Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients.

METHODS

We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed.

RESULTS

We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01).

CONCLUSIONS

Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients.

LEVEL OF EVIDENCE

Level III Prognostic.

Adaptation of the parent readiness for hospital discharge scale with mothers of preterm infants discharged from the neonatal intensive care unit

AIMS AND OBJECTIVES

To evaluate the psychometric properties of a new Persian translation of the Readiness for Hospital Discharge Scale.

BACKGROUND

Globally, one in 10 newborns are born preterm and many require care in a neonatal intensive care unit (NICU). A primary role of NICU nurses is to assure parents are well prepared to take their newborns home from the hospital. Assessment of parent perception of discharge readiness provides important input into discharge decisions. The availability of reliable and valid instruments tested within the geographical and cultural context is needed for a comprehensive assessment of predischarge readiness, so that parent needs can be identified and the necessary interventions designed and implemented.

DESIGN

This psychometrics study included a convenience sample of 200 mothers with preterm infants being discharged from the NICU of Shahid Sadoughi Hospital in Yazd, Iran. The original 29-item version of the Readiness for Hospital Discharge Scale-Parent questionnaire was translated into Persian using the standard forward-backward method. Face, content and construct validity (principal components analysis), and reliability (internal consistency-Cronbach's alpha) were assessed. Methods followed STROBE criteria as applicable (see Appendix S1).

RESULTS

The content validity index and content validity ratio were both 0.93. Construct validity testing identified 6 factors (mother and infant physical-psychological readiness, expected support, knowledge of future events and care, knowledge of infant personal care, pain and therapeutic interventions). Using Cronbach's alpha coefficient, the reliability of the whole instrument was estimated to be 0.87.

CONCLUSION

The Persian Readiness for Hospital Discharge-Parental Form for use with mothers of preterm infants being discharged from an Iranian NICU has acceptable validity and reliability.

RELEVANCE TO PRACTICE

This tool can be used before discharge to determine the needs of mothers and design the necessary measures to improve quality of discharge care.

Clinical Implications of SARS-CoV-2 Infection in the Viable Preterm Period

OBJECTIVE

This study aimed to determine the rate of preterm birth (PTB) during hospitalization among women diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between 23 and 37 weeks of gestation and whether this rate differs by gestational age at diagnosis of infection.

STUDY DESIGN

Retrospective, cross-sectional study of all women diagnosed with SARS-CoV-2 infection between 23 and 37 weeks of gestation within a large integrated health system from March 13 to April 24, 2020. Cases with severe fetal structural malformations detected prior to infection were excluded. Women were stratified into two groups based on gestational age at diagnosis: early preterm (230/7 to 336/7 weeks) versus late preterm (34 to 366/7 weeks). We compared the rate of PTB during hospitalization with infection between the two groups. Statistical analysis included use of Wilcoxon rank sum and Fisher exact tests, as well as a multivariable logistic regression. Statistical significance was defined as a p-value <0.05.

RESULTS

Of the 65 patients included, 36 (53.7%) were diagnosed in the early preterm period and 29 (46.3%) were diagnosed in the late preterm period. Baseline demographics were similar between groups. The rate of PTB during hospitalization with infection was significantly lower among women diagnosed in the early preterm period compared with late preterm (7/36 [19.4%] vs. 18/29 [62%], p-value = 0.001). Of the 25 patients who delivered during hospitalization with infection, the majority were indicated deliveries (64%, 16/25). There were no deliveries <33 weeks of gestation for worsening coronavirus disease 2019 and severity of disease did not alter the likelihood of delivery during hospitalization with SARS-CoV-2 infection (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.24-1.59). Increased maternal age was associated with a lower likelihood of delivery during hospitalization with SARS-CoV-2 infection (aOR: 0.77; 95% CI: 0.58-0.96), while later gestational age at diagnosis of infection was associated with a higher likelihood of delivery during hospitalization (aOR: 2.9; 95% CI: 1.67-8.09).

CONCLUSION

The likelihood of PTB during hospitalization with SARS-CoV-2 infection is significantly lower among women diagnosed in the early preterm period compared with late preterm. Most women with SARS-CoV-2 infection in the early preterm period recovered and were discharged home. The majority of PTB were indicated and not due to spontaneous preterm labor.

KEY POINTS

· Preterm delivery is less likely among women diagnosed in the early preterm compared with late preterm.. · Most women infected in the early preterm period recovered and were discharged home undelivered.. · The majority of preterm birth were indicated and not due to spontaneous preterm labor..

Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial

OBJECTIVE

Examination of postoperative analgesia with intravenous and oral acetaminophen.

DESIGN

Prospective, three-arm, nonblinded, randomized clinical trial.

SETTING

A single academic medical center.

SUBJECTS

Parturients scheduled for elective cesarean delivery.

METHODS

This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects.

RESULTS

Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group.

CONCLUSIONS

Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.

Effect of Antenatal Exercises, Including Yoga, on the Course of Labor, Delivery and Pregnancy: A Retrospective Study

Background: Delivering a child is a very stressful experience for women. Pregnancy and labor entail complex events that are unique to each individual female. The management of labor pain is often done using analgesics and anesthesia, which have been shown to have some side effects. More comprehensive data are needed to provide clinically significant evidence for clinicians to confidently prescribe exercises to patients. This study was done to evaluate the effect of antenatal exercises, including yoga, on the course of labor, delivery, and pregnancy outcomes. Methods: A retrospective study was conducted among 200 primiparous subjects (aged 20-40). A questionnaire was provided to the subjects to obtain their demographic and obstetrical information 6 weeks after delivery, and their hospital records were also assessed for further details. Based on the nature and details obtained for the antenatal exercises, subjects were divided into two groups: control and exercise. Outcome measures included the need for labor induction, self-perceived pain and perceived exertion during labor, duration and nature of the delivery, newborn infant weight, maternal weight gain, history of back pain, and post-partum recovery. The total maternal weight gain (in kilograms) was calculated from weight at 6 weeks after delivery minus the weight at 12-14 weeks of gestation. Back pain during pregnancy and self-perceived labor pain were measured using a visual analog scale (VAS). The overall perceived exertion during labor was measured using an adapted Borg scale for perceived effort. Results: The subjects who followed regular antenatal exercises, including yoga, had significantly lower rates of cesarean section, lower weight gain, higher newborn infant weight, lower pain and overall discomfort during labor, lower back pain throughout pregnancy, and earlier post-partum recovery compared to those who did no specific exercises or only walked during pregnancy. Conclusions: This retrospective study showed that regular antenatal exercises, including yoga, result in better outcomes related to the course of labor, delivery, and pregnancy. These results notably indicated that pregnant women should be active throughout pregnancy and follow a supervised exercise program that includes yoga unless contraindicated. We require further large-scale prospective studies and quasi-experimental trials to confirm the observed findings.

Endoscopic Treatment of Previous Cesarean Scar Defect in Women with Postmenstrual Bleeding: A Retrospective Cohort Study

OBJECTIVE

To compare the incidence of postmenstrual bleeding after hysteroscopic resection versus laparoscopic repair of previous cesarean scar defect (PCSD).

MATERIALS AND METHODS

Retrospective analysis of computerized patient records. For the diagnosis of PCSD, patients underwent transvaginal ultrasound first without and then with saline-assisted sonohysterography. Hysteroscopic PCSD resection was performed under sonographic guidance, while laparoscopic repair was guided by hysteroscopy for the confirmation of scar margins.

RESULTS

Records of 62 patients presenting with PCSD-related postmenstrual bleeding were included in analysis. Hysteroscopic surgery had significantly shorter operative time compared to the laparoscopic approach (Mean =30.9 vs 71.0 minutes; p < 0.001). Blood loss and hospital stay were significantly less (p < 0.001) in hysteroscopic resection (10.4 ± 4.6 ml and 2.1 ± 0.4 days) than in laparoscopic repair (36.6 ± 4 ml, and 4.6 ± 1 days). After surgical interventions, the postmenstrual bleeding was resolved or improved. The effectiveness rates of hysteroscopic resection and laparoscopic repair were 91.4% and 96.3%, respectively. Incidence of post-treatment postmenstrual bleeding was not significantly different between hysteroscopy and laparoscopy (OR= 1.29 [95% confidence interval 0.367, 4.86]; p = 0.662). Pretreatment postmenstrual bleeding was associated with time since cesarean section (B= -0.091 [-0.158, -0.023]; p = 0.01) and PCSD length (B = 0.502 [0.085, 0.919]; p = 0.019).

CONCLUSION

Both hysteroscopic resection and laparoscopic repair of PCSD yield comparable efficacy in reducing postmenstrual bleeding. However, hysteoroscopic resection of PCSD is associated with comparatively shorter operative time, less blood loss, and shorter hospital stay.

Does epidural analgesia influence labor progress in women aged 35 or more?

Background: During the last decades, the age of pregnant women significantly increased. The incidence of maternal and labor complications is higher among older women, but conclusive data have not been delivered whether labor epidural analgesia (EA) may affect the duration of labor and delivery outcomes in this population of patients. The aim of this study is to evaluate the effect of EA among women aged over 35 years.Methods: We retrospectively reviewed medical records of all, singleton, at term deliveries, laboring with EA, between December 2011 and October 2017. Women aged ≥35 years (study group) were compared with women aged <35 years (control group) to evaluate EA effects on the duration of labor and neonatal outcome.Results: The study enrolled 459 women with EA: 122 women were included in the study group and 337 in the control group. The multiple regression analysis showed that parity was an independent variable for a shorter dilation period (p = .002), second stage length (p = .0001) and for the total labor duration (p = .0001); neonatal weight was significant for a shorter dilation period (p = .005) and for the total labor duration (p = .002); maternal age and cervical dilatation at the beginning of EA did not influence neither the period of the labor stages nor the total labor duration (p > .05).Conclusions: Results of this study indicate that women aged ≥35 with EA may have labor duration and neonatal short-term outcomes similar to younger women with EA.

Lung ultrasound for detecting pneumothorax in injured children: preliminary experience at a community-based Level II pediatric trauma center

BACKGROUND

Ultrasound (US) has been used in the adult trauma population with reported moderate to high sensitivities, but data are scarce in the pediatric trauma population.

OBJECTIVE

The purpose of this study was to specifically examine the sensitivity and specificity of one lung US methodology (single-point anterior exam) in the pediatric trauma population when compared to chest radiography or CT.

MATERIALS AND METHODS

We conducted a retrospective review of pediatric trauma patients who received lung US as an extension of the focused assessment with sonography for trauma (FAST) exam. We compared lung US findings with chest radiography and CT scans.

RESULTS

Two hundred twenty-six pediatric trauma patients underwent lung US exam with confirmatory exams; 11 pneumothoraces (4.8%) were observed. Of those 11, 6 were evaluated as false negatives on the lung US. Analyses resulted in 45.5% sensitivity, 98.6% specificity and 96.0% accuracy. Pneumothoraces undetected by lung US were small and apical and were likely not observed because of their size and location. None of the false negatives required intervention. All true positives were associated with lung contusions.

CONCLUSION

Pneumothorax is less common in the pediatric than the adult trauma population, and when encountered in children pneumothorax is often occult and might be associated with lung contusions. Existing evidence supports the usefulness of chest US in detecting pneumothorax in adults and suggests that it can be translated to injured children. However, our findings suggest that the sensitivity of lung US as a single-point anterior exam extension of the FAST exam might not be as reliable in the pediatric trauma population as in adults. Other methodologies using lung US might improve sensitivity.

Trophic factors are essential for the survival of grafted oligodendrocyte progenitors and for neuroprotection after perinatal excitotoxicity

The consequences of neonatal white matter injury are devastating and represent a major societal problem as currently there is no cure. Prematurity, low weight birth and maternal pre-natal infection are the most frequent causes of acquired myelin deficiency in the human neonate leading to cerebral palsy and cognitive impairment. In the developing brain, oligodendrocyte (OL) maturation occurs perinatally, and immature OLs are particularly vulnerable. Cell replacement therapy is often considered a viable option to replace progenitors that die due to glutamate excitotoxicity. We previously reported directed specification and mobilization of endogenous committed and uncommitted neural progenitors by the combination of transferrin and insulin growth factor 1 (TSC1). Here, considering cell replacement and integration as therapeutic goals, we examined if OL progenitors (OLPs) grafted into the brain parenchyma of mice that were subjected to an excitotoxic insult could rescue white matter injury. For that purpose, we used a well-established model of glutamate excitotoxic injury. Four-day-old mice received a single intraparenchymal injection of the glutamate receptor agonist N-methyl-D-aspartate alone or in conjunction with TSC1 in the presence or absence of OLPs grafted into the brain parenchyma. Energetics and expression of stress proteins and OL developmental specific markers were examined. A comparison of the proteomic profile per treatment was also ascertained. We found that OLPs did not survive in the excitotoxic environment when grafted alone. In contrast, when combined with TSC1, survival and integration of grafted OLPs was observed. Further, energy metabolism in OLPs was significantly increased by N-methyl-D-aspartate and modulated by TSC1. The proteomic profile after the various treatments showed elevated ubiquitination and stress/heat shock protein 90 in response to N-methyl-D-aspartate. These changes were reversed in the presence of TSC1 and ubiquitination was decreased. The results obtained in this pre-clinical study indicate that the use of a combinatorial intervention including both trophic support and healthy OLPs constitutes a promising approach for long-term survival and successful graft integration. We established optimal conditioning of the host brain environment to promote long-term survival and integration of grafted OLPs into an inflamed neonate host brain. Experimental procedures were performed under the United States Public Health Service Guide for the Care and Use of Laboratory Animals and were approved by the Institutional Animal Care Committee at (UCLA) (ARC #1992-034-61) on July 1, 2010.

Tracheostomy in the Extremely Premature Neonate: A Multi-Institutional Study

OBJECTIVE

(1) To describe characteristics associated with tracheostomy placement and (2) to describe associated in-hospital morbidity in extremely premature infants.

STUDY DESIGN

Pooled retrospective analysis of charts.

SETTING

Academic children's hospitals.

SUBJECTS AND METHODS

The patient records of premature infants (23-28 weeks gestational age) who underwent tracheostomy between January 1, 2012, and December 31, 2017, were reviewed from 4 academic children's hospitals. Demographics, procedural morbidity, feeding, respiratory, and neurodevelopmental outcomes at the time of transfer from the neonatal intensive care unit (NICU) were obtained. The contribution of baseline characteristics to mortality, neurodevelopmental, and feeding outcomes was also assessed.

RESULTS

The charts of 119 infants were included. The mean gestational age was 25.5 (95% confidence interval, 25.2-25.7) weeks. The mean birth weight was 712 (671-752) g. Approximately 50% was African American. The principal comorbidity was chronic lung disease (92.4%). Overall, 60.5% of the infants had at least 1 complication. At the time of transfer, most remained mechanically ventilated (94%) and dependent on a feeding tube (90%). Necrotizing enterocolitis increased the risk of feeding impairment (P = .002) and death (P = .03).

CONCLUSIONS

Tracheostomy in the extremely premature neonate is primarily performed for chronic lung disease. Complications occur frequently, with skin breakdown being the most common. Placement of a tracheostomy does not seem to mitigate the systemic morbidity associated with extreme prematurity.

Differential Secretion of Angiopoietic Factors and Expression of MicroRNA in Umbilical Cord Blood from Healthy Appropriate-For-Gestational-Age Preterm and Term Newborns-in Search of Biomarkers of Angiogenesis-Related Processes in Preterm Birth

Objectives: Premature birth, defined as less than 37 weeks gestation, affects approximately 12% of all live births around the world. Advances in neonatal care have resulted in the increased survival of infants born prematurely. Although prematurity is a known risk factor for different cardiovascular diseases, little is known about the pathophysiology of vasculature during premature gestation and angiopoietic factors network during premature birth. Aims: The objective of this study was to determine whether the profile of several pro-angiogenic and anti-angiogenic factors in umbilical cord blood (UCB) is different in healthy appropriate-for-gestational-age preterm newborns and normal term babies. The second aim of this study was to investigate the microRNA (miRNAs) expression profile in UCB from preterm labor and to detect miRNAs potentially taking part in control of angogenesis-related processes (Angio-MiRs). Methods: Using an immunobead Luminex assay, we simultaneously measured the concentration of Angiogenin, Angiopoietin-1, FGF-acidic, FGF-basic, PDGF-aa, PlGF, VEGF, VEGF-D, Endostatin, Thrombospondin-2, NGF, BDNF, GDNF, and NT-4 in UCB samples collected from the preterm (n = 27) and term (n = 52) delivery. In addition, the global microRNA expression in peripheral blood mononuclear cells (PBMCs) circulating in such UCB samples was examined in this study using microarray MiRNA technique. Results: The concentrations of five from eight measured pro-angiogenic factors (VEGF, Angiopoietin-1, PDGF-AA, FGF-a, and FGF-b) were significantly lower in UCB from preterm newborns. On the contrary, two angiostatic factors (Endostatin and Thrombospondin-2) were significantly up-regulated in preterm UCB. Among analyzed neurotrophins in preterm newborns, the elevated UCB concentration was found only in the case of GDNF, whereas BDNF was significantly reduced. Moreover, two angiopoietic factors, VEGF-D and PlGF, and two neurotrophins, NT4 and NGF, did not differ in concentration in preterm and term babies. We also discovered that among the significantly down-regulated miRNAs, there were several classical Angio-MiRs (inter alia MiR-125, MiR-126, MiR-145, MiR-150, or MiR155), which are involved in angiogenesis regulation in newborn after preterm delivery. Conclusions: This is the first report of simultaneous measurements of several angiopoietic factors in UCB collected from infants during preterm and term labor. Here, we observed that several pro-angiogenic factors were at lower concentration in UCB collected from preterm newborns than term babies. In contrast, the two measured angiostatic factors, Endostatin and Thrombospondin-2, were significantly higher in UCB from preterm babies. This can suggest that distinct pathophysiological contributions from differentially expressed various angiopoietic factors may determine the clinical outcomes after preterm birth. Especially, our angiogenesis-related molecules analysis indicates that preterm birth of healthy, appropriate-for-gestational-age newborns is an “anti-angiogenic state” that may provide an increased risk for improper development and function of cardiovascular system in the adulthood. This work also contributes to a better understanding of the role of miRNAs potentially involved in angiogenesis control in preterm newborns.

Recurrence risk of preterm birth in a subsequent singleton pregnancy after a spontaneous preterm triplet delivery

OBJECTIVE

History of prior preterm birth (PTB) represents one of the strongest risk factors for recurrent PTB. Nevertheless, whether the occurrence of PTB in multifetal gestation is associated with increased risk of PTB in subsequent pregnancies remains unclear. We aimed to determine the recurrence risk of PTB in a subsequent singleton pregnancy after a previous spontaneous preterm triplet delivery.

STUDY DESIGN

A retrospective matched case-control study. The study group comprised all women with spontaneous preterm trichorionic triplet delivery who had a subsequent singleton pregnancy during 2006-2017 at two university hospitals. A control group of women with spontaneous preterm dichorionic twin delivery and a subsequent singleton pregnancy, was established by matching, four-to-one, according to maternal age, parity, gestational age at delivery, and delivery year.

RESULTS

Data from 170 women were analyzed, 34 with preterm triplet delivery and 136 matched control women with preterm twin delivery. Gestational age at the subsequent singleton delivery was higher in those with preterm triplet delivery than in those with preterm twin delivery (median 39 vs 38 weeks, P = 0.02). Women with prior triplet PTB had a significantly lower rate of recurrent PTB as compared with women with prior twin PTB (5.9 % vs. 25.0 %; OR [95 % CI]: 0.19 (0.04, 0.82), P = 0.02) with lower proportions of low-birth weight infants (<2500 g) (0 % vs. 11.8 %, P = 0.04).

CONCLUSIONS

The risk of recurrent PTB following spontaneous PTB in triplet pregnancy was low compared to preterm twin delivery. These data provide reassurance for those who experienced preterm triplet delivery and suggest the need for further studies to understand the mechanisms contributing to PTB in multifetal pregnancies.

Acceptability of an eHealth Intervention to Prevent Alcohol-Exposed Pregnancy Among American Indian/Alaska Native Teens

BACKGROUND

A tribally led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) Program has successfully decreased the risk of alcohol-exposed pregnancies (AEPs) among adult American Indian/Alaska Native (AI/AN) women by either reducing risky drinking or increasing contraception use. However, a community needs assessment revealed a need to implement a similar intervention with AI/AN teens. The goal of the project was to develop and establish the acceptability of CHOICES for AI/AN teens.

METHODS

Key informant interviews were conducted to review the existing OST CHOICES intervention. After modifications to the existing program, focus groups with AI/AN teens were conducted to ensure validity and to finalize the OST CHAT (CHOICES for American Indian Teens) intervention.

RESULTS

Key informant (N = 15) participants suggested that a Web-based intervention may increase teen engagement by making the intervention more interactive and visually stimulating. Based on this formative research, CHAT was developed via Research Electronic Data Capture (REDCap). Feedback on the online CHAT curriculum was given by focus groups comprised of AI/AN adolescents, and participants felt that this type of intervention would be both acceptable and able to implement with a community of reservation-based teens.

CONCLUSIONS

This study outlines the development of a Web-based intervention for an AEP intervention for AI/AN teens and will inform future prevention efforts. Implications include an expansion of the evidence-based CHOICES intervention for AI/AN teens and also development of a Web-based intervention for rural, reservation-based AI/AN communities.

Interventions to reduce the cesarean delivery rate in a tertiary hospital in China

Introduction: High cesarean delivery rate has been a global public health concern. This study assesses the effect of medical interventions and societal changes on cesarean delivery rates in a Chinese tertiary hospital.Material and methods: A retrospective study including all live births ≥34-week gestation between 2008 and 2016 from Guangzhou Women and Children's Medical Center was divided into 5 stages: (1) no interventions; (2) patient-controlled epidural analgesia; (3) episiotomy restriction; (4) new labor management; (5) universal two-child policy. An interrupted time series design was used to measure the effect of interventions on overall cesarean rate, primary cesarean rate, maternal and neonatal outcomes.Results: There were 126,609 deliveries including 49,092 cesarean deliveries and 77,517 vaginal deliveries in this period. Overall cesarean delivery rate declined after implementing patient-controlled epidural analgesia, episiotomy restriction and universal two-child policy. Primary cesarean rate decreased after implementing episiotomy restriction. Cesarean rate with previous cesarean dramatically increased, and maternal request cesarean rate decreased gradually. Low Apgar rate (score ≤7 at 5 min) increased after episiotomy restriction and maternal postpartum hemorrhage rate increased after new labor management.Conclusions: Patient-controlled epidural analgesia, episiotomy restriction and the universal two-child policy showed the most significant effects to reducing the cesarean rate.