Fluid and Electrolyte Management of the Neonate

Despite the fact that hundreds of thousands of preterm infants receive parenteral fluids each year, study of optimal fluid and electrolyte management in this population is limited. Compared to older children and adults, preterm infants have an impaired capacity to regulate water and electrolyte balance. Appropriate fluid and electrolyte management is critical for optimal care of low birth weight or sick infants, as fluid overload and electrolyte abnormalities pose significant morbidity. This review highlights basic physiological principles which need to be applied when prescribing parenteral fluids and builds upon published literature to outline a rational approach to initial fluid and electrolyte management of the preterm infant.

Severe maternal morbidity is associated with substantially increased risks of adverse neonatal outcomes. However, few studies have assessed the association between severe maternal morbidity and adverse pregnancy, delivery, and perinatal outcomes in the subsequent delivery. We aimed to investigate the association between severe maternal morbidity and its specific types in the first delivery and the risk of adverse pregnancy, delivery, and neonatal outcomes in the second delivery. We examined 2 population-based cohorts in Sweden and British Columbia, Canada, of mothers with both their first and second delivery recorded. The primary exposure was severe maternal morbidity in the first delivery (recorded during pregnancy, delivery or within 42 days postpartum). The outcomes were pregnancy and delivery complications, and offspring composite severe neonatal morbidity, and perinatal mortality (ie, stillbirths or neonatal deaths) within the first 28 days after birth, in the second delivery. We used multivariable generalized linear models to obtain adjusted risk ratios and 95% confidence intervals, adjusted for confounders. In both Sweden and British Columbia, women who experienced severe maternal morbidity in their first delivery had an increased risk of composite perinatal death/severe neonatal morbidity in the second delivery (Sweden: adjusted risk ratio, 1.88; 95% confidence interval, 1.75-2.02, British Columbia: adjusted risk ratio, 1.49; 95% confidence interval, 1.24-1.79), compared with mothers without severe maternal morbidity in the first delivery. In Sweden, second deliveries to women who had severe maternal morbidity in their first delivery were associated with a 1.59-times higher risk of stillbirth, a 1.65-times higher risk of neonatal mortality, a 1.95-times higher risk of composite severe neonatal morbidity, and 1.69-fold higher risk of infant mortality. In Sweden, compared with unaffected first delivery, severe maternal morbidity in the first delivery was associated with a 4.77-fold higher risk of severe maternal morbidity, 6.20-fold higher risk of preeclampsia, and an approximately 2-fold increased risk of placental abruption, maternal infection, antepartum hemorrhage, and postpartum hemorrhage in the second delivery. While in British Columbia, the adjusted estimates were in the same direction as in Sweden, statistical significance was reached for several outcomes, specifically, infant mortality, severe maternal morbidity, preeclampsia, gestational diabetes, placental abruption, antepartum hemorrhage, postpartum hemorrhage, and both elective and cesarean delivery in the second delivery. In both Sweden and British Columbia, Canada, severe maternal morbidity in the first delivery was associated with an increased risk of adverse pregnancy, delivery, and offspring outcomes in the subsequent delivery. Our findings can guide clinical and reproductive counseling for women with a history of severe maternal morbidity.

ABSTRACTObjectiveTo evaluate the use of twin vs singleton growth charts for detecting small‐for‐gestational‐age (SGA) twins at risk of adverse neonatal outcomes.MethodsMEDLINE, EMBASE, CINAHL, Cochrane and Scopus databases were searched electronically from inception to May 2024. The primary outcome of this meta‐analysis was the risk of composite adverse neonatal outcome in SGA fetuses in a twin pregnancy diagnosed using twin or singleton charts. The secondary outcomes included: neonatal intensive care unit (NICU) admission, oxygen supplementation or continuous positive airway pressure, mechanical ventilation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, neonatal sepsis and neonatal mortality. Prospective and retrospective studies on neonatal outcomes of monochorionic or diamniotic twins diagnosed with SGA using both singleton and twin charts based on estimated fetal weight or birth weight were considered suitable for inclusion. Quality assessment of the included studies was performed using the Newcastle–Ottawa Scale for cohort studies. Random‐effects head‐to‐head meta‐analyses were used to analyze the data.ResultsSix studies were included in the systematic review and five studies, including 10 554 twin pregnancies, were included in the meta‐analysis. The risk of composite adverse neonatal outcome (OR, 3.11 (95% CI, 1.83–5.26)) and that of most secondary outcomes was significantly higher in SGA fetuses diagnosed using twin charts compared with those diagnosed using singleton charts. Conversely, the risk of composite adverse neonatal outcome (OR, 1.22 (95% CI, 0.73–2.04)) and most secondary outcomes was similar when comparing SGA fetuses diagnosed using singleton charts vs non‐SGA fetuses diagnosed using twin charts, except for the risk of NICU admission, which was significantly higher in SGA fetuses diagnosed using singleton charts. When comparing non‐SGA fetuses diagnosed using twin charts vs non‐SGA fetuses diagnosed using singleton charts, the risk of composite adverse neonatal outcome was significantly lower when using twin charts (OR, 0.90 (95% CI, 0.83–0.97)). Finally, when comparing SGA vs non‐SGA fetuses diagnosed using singleton charts, there was no significant difference for the primary or secondary outcomes, except for a higher risk of NICU admission in the SGA group (OR, 1.54 (95% CI, 1.11–2.12)). Twin charts had lower sensitivity than singleton charts in predicting adverse neonatal outcome (14% (95% CI, 7–26%) vs 32% (95% CI, 24–41%)), but higher specificity (95% (95% CI, 86–98%) vs 71% (95% CI, 63–77%)).ConclusionsTwin charts increase the specificity but reduce the sensitivity for the detection of SGA compared with singleton charts. Nevertheless, twin charts detect cases at higher risk of adverse neonatal outcome, which may be the cases that require intervention. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Preeclampsia affects between 2 to 8% of pregnancies worldwide and is associated with significant adverse outcomes for both mothers and their offspring. The present study aims to investigate whether there is a correlation between early age at menarche and an increased risk of developing preeclampsia and experiencing adverse neonatal outcomes. The study involved a review of medical records of 4227 pregnant women who gave birth at The First Affiliated Hospital of Chengdu Medical College between January 2017 and December 2022. The collected data included demographic characteristics, clinical manifestations of preeclampsia, laboratory indicators, gestational complications, and neonatal outcomes. Pregnant women were categorized into four groups based on their age at menarche (≤ 12, 13, 14, and ≥ 15years). Logistic regression analysis was conducted to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between different menarche age groups and the risk of preeclampsia and adverse neonatal outcomes. Pregnant women who had an age at menarche of ≤ 12years had a higher risk of preeclampsia than women who had their menarche at 13, 14, and ≥ 15years of age, with adjusted ORs (95% CIs) for preeclampsia of 1.00 (reference), 0.78 (0.45-0.91), 0.76 (0.59-0.88), and 0.73 (0.56-0.94), respectively. The predictive efficacy of age at menarche for preeclampsia was assessed with a sensitivity and specificity of 85.2% and 76.4%, respectively, and an AUC of 0.82. Moreover, infants born to women with an age at menarche of ≤ 12years had a higher risk of adverse neonatal outcomes, including small for gestational age, preterm birth, low birth weight, neonatal respiratory distress syndrome, and neonatal intensive care unit admission. Our findings suggest that an early age at menarche is associated with an increased risk of preeclampsia and adverse neonatal outcomes. This information could be useful for obstetricians to identify women at risk for preeclampsia early on and implement timely interventions to reduce the incidence of preeclampsia and associated adverse neonatal outcomes.

Descriptive population-based birthweight standards possess low sensitivity in detecting infants with growth impairment. A prescriptive birthweight standard based on a 'healthy' subpopulation without risk factors for intrauterine growth restriction might be superior. We created two birthweight standards based on live born, singleton infants with gestational age 24-42weeks and born in The Netherlands between 2000 and 2007. Inclusion criteria for the prescriptive birthweight standard were restricted to infants without congenital malformations, born to healthy mothers after uncomplicated pregnancies. We defined small-for-gestational-age (SGA) as birthweight <10th percentile and assessed the ability of both standards to predict adverse neonatal outcomes. The prescriptive birthweight standard identified significantly more infants as SGA, up to 38.0% at 29weeks gestation. SGA infants classified according to both standards as well as those classified according to the prescriptive birthweight standard only, were at increased risk of both major and minor adverse neonatal outcomes. The prescriptive birthweight standard was both more sensitive and less specific, with a maximum increase in sensitivity predicting bronchopulmonary dysplasia (+42.6%) and a maximum decrease in specificity predicting intraventricular haemorrhage (-26.9%) in infants aged 28-31weeks. Prescriptive birthweight standards could improve identification of infants born SGA and at risk of adverse neonatal outcomes. • Descriptive birthweight standards possess low sensitivity in detecting growth restricted infants at risk of adverse neonatal outcomes. • Prescriptive standards could improve identification of very preterm small-for-gestational-age (SGA) infants at risk of intraventricular haemorrhage. What is New: • Prescriptive standards identify more preterm and term SGA infants at risk of major adverse neonatal outcomes. • Late preterm and term SGA infants classified according to the prescriptive standard are at increased risk of minor adverse neonatal outcomes with potentially harmful implications.

Type-III selective intrauterine growth restriction (sIUGR) is associated with a high and unpredictable risk of fetal death and fetal brain injury. The objective of this study was to describe the prospective risk of fetal death and the risk of adverse neonatal outcome in a cohort of twin pregnancies complicated by Type-III sIUGR and treated according to up-to-date guidelines. We reviewed retrospectively all monochorionic diamniotic twin pregnancies complicated by Type-III sIUGR managed at nine fetal centers over a 12-year period. Higher-order multiple gestations and pregnancies with major fetal anomalies or other monochorionicity-related complications at initial presentation were excluded. Data on fetal and neonatal outcomes were collected and management strategies reviewed. Composite adverse neonatal outcome was defined as neonatal death, invasive ventilation beyond the resuscitation period, culture-proven sepsis, necrotizing enterocolitis requiring treatment, intraventricular hemorrhage Grade > I, retinopathy of prematurity Stage > II or cystic periventricular leukomalacia. The prospective risk of intrauterine death (IUD) and the risk of neonatal complications according to gestational age were evaluated. We collected data on 328 pregnancies (656 fetuses). After exclusion of pregnancies that underwent selective reduction (n=18 (5.5%)), there were 51/620 (8.2%) non-iatrogenic IUDs in 35/310 (11.3%) pregnancies. Single IUD occurred in 19/328 (5.8%) pregnancies and double IUD in 16/328 (4.9%). The prospective risk of non-iatrogenic IUD per fetus declined from 8.1% (95% CI, 5.95-10.26%) at 16 weeks, to less than 2% (95% CI, 0.59-2.79%) after 28.4 weeks and to less than 1% (95% CI, -0.30 to 1.89%) beyond 32.6 weeks. In otherwise uncomplicated pregnancies with Type-III sIUGR, delivery was generally planned at 32 weeks, at which time the risk of composite adverse neonatal outcome was 29.0% (31/107 neonates). In twin pregnancies that continued to 34 weeks, there was a very low risk of IUD (0.7%) and a low risk of composite adverse neonatal outcome (11%). In this cohort of twin pregnancies complicated by Type-III sIUGR and treated at several tertiary fetal centers, the risk of fetal death was lower than that reported previously. Further efforts should be directed at identifying predictors of fetal death and optimal antenatal surveillance strategies to select a cohort of pregnancies that can continue safely beyond 33 weeks' gestation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

After completing this article, readers should be able to: 1. Describe the epidemiology and pathophysiology of gastroesophageal reflux (GER) in preterm neonates. 2. Delineate the associations of GER with apnea, chronic lung disease, behavior, and growth of preterm infants. 3. Review the investigations used to evaluate GER in preterm infants. 4. Describe nonpharmacologic and pharmacologic therapies for GER. Gastroesophageal reflux (GER) is a normal physiologic event occurring across the age spectrum. It may contribute to a variety of disorders, including esophagitis, feeding problems, and airway disease in all age groups. (1) A large number of symptoms and signs have been purported to be caused by GER despite a lack of data showing a clear association between a specific symptom and GER. In preterm infants, empiric therapy often is administered using agents of unproven efficacy and safety to treat symptoms that likely are unrelated to GER. In a survey on management practices for GER in preterm infants, common treatment strategies included positioning (98%) and slopes (96%), histamine 2 (H 2) receptor antagonists (100%), feed thickeners (98%), antacids (96%), prokinetics (79%), proton pump inhibitors (PPIs) (65%), and dopamine receptor antagonists (53%). (2)(3) The safety, efficacy, and appropriate dosing recommendations for most medical therapies remain uncertain in neonates. In this review, we attempt to summarize the current literature regarding physiology, pathophysiology, and diagnostic and management strategies for GER pertinent to the neonate, with an emphasis on the preterm infant. GER describes the retrograde movement of stomach contents (air or feeding, liquid or semisolid, acid or alkaline, enzymes or bile salts) into the esophagus. GER disease (GERD) occurs when GER causes symptoms or signs such as pain, poor weight gain, esophagitis, hematemesis, and airway symptoms, including apnea, aspiration, recurrent pneumonia, chronic lung disease (CLD), or large airway inflammation. However, any of these symptoms or signs …

Emerging data regarding the encouraging outcomes of extremely preterm infants from centers taking active approaches to the care of these infants have prompted dialogue regarding optimal medical management. Among the multitude of decisions providers make in caring for extremely premature infants is the prescribing of parenteral fluids. Surprisingly, there are limited data to guide evidenced-based approaches to fluid and electrolyte management in this population. Immaturity of renal function and skin barriers contribute to the impaired capacity of the preterm infant to maintain salt and water homeostasis. This perspective paper highlights developmental physiological properties of the kidney and skin, which the provider needs to understand to provide parenteral fluid therapy. Additionally, we provide recommendations for initial fluid and electrolyte management of the preterm infant based on novel data as well as the published literature.

INTERGROWTH-21st vs customized birthweight standards for identification of perinatal mortality and morbidity

A comparison of criteria for defining metabolic acidemia in live-born neonates and its effect on predicting serious adverse neonatal outcomes

786 Neonatal outcomes in pregnant women with diagnosis of COVID-19

To describe ethnic disparities in the risk of spontaneous preterm birth and related adverse neonatal outcome. Nationwide prospective cohort study. The Netherlands, 1999-2007. Nine hundred and sixty-nine thousand, four hundred and ninety-one singleton pregnancies with a spontaneous onset of labor. We investigated ethnic disparities in perinatal outcome for European white, African, South-Asian, Mediterranean and East-Asian women. We performed multivariate logistic regression analyses to calculate the adjusted odds ratio (aOR) and confidence intervals (CIs) of spontaneous preterm birth and the risk of subsequent neonatal morbidity and mortality. The primary outcome measure was spontaneous preterm birth before 37 completed weeks of gestation. Secondarily, we investigated subsequent adverse neonatal outcome, which was a composite outcome of intraventricular hemorrhage, bronchopulmonary dysplasia, infant respiratory distress syndrome, neonatal sepsis or neonatal mortality within 28 days after birth. Compared with European whites, the aOR of delivering preterm was 1.33 (95% CI 1.26-1.41) for African women, 1.58 (95% CI 1.47-1.69) for South-Asians, 0.88 (95% CI 0.84-0.91) for Mediterraneans and 1.04 (95% CI 0.98-1.11) for East-Asians. Subsequent odds of adverse neonatal outcome were significantly lower for African (aOR 0.51; 95% CI 0.41-0.64) and Mediterranean women (aOR 0.86; 95% CI 0.75-0.99) when compared with European whites. African and South-Asian women are at higher risk for preterm birth than European white women. However, the harmful effect of preterm birth on neonatal outcome is less severe for these women.

696: Cigarette smoking and its association with adverse fetal outcomes: looking beyond SGA

619: A history of prior preeclampsia is a major risk factor for preterm birth

Gestational hypertension/preeclampsia is the most common obstetric complication of pregnancy. Management in the near term and early term periods remains controversial; the 2 options are induction of labor versus expectant management. Induction at an earlier gestational age presents risks of cesarean delivery (CD) and increased rates of neonatal morbidities. Maternal risks of expectant management include progression to severe gestational hypertension, eclampsia, or placental abruption. The Hypertension and Pre-eclampsia Intervention Trial at Term (HYPITAT) compared labor induction with expectant management and showed that induction reduced the occurrence of high-risk situations and was not associated with an increase in CDs or adverse neonatal outcomes. This post hoc analysis of the HYPITAT trial data was performed to evaluate the association between ripeness of the cervix and outcomes of labor induction and expectant management. The HYPITAT trial included 756 women with a singleton pregnancy at 36 to 41 weeks’ gestation and complicated by gestational hypertension or mild preeclampsia; they were allocated to either labor induction or expectant management. In the induction group, labor was induced within 48 hours of randomization. Women in the expectant management group were monitored until the onset of spontaneous labor. The primary outcome was a composite of high-risk situations (ie, maternal mortality, maternal morbidity, progression to severe disease, and major postpartum hemorrhage). Secondary outcomes were CD and a composite of adverse neonatal outcomes. Before labor, the cervix was assessed by cervical length measurement and Bishop score calculation. The predictors in each model were treatment, cervical length, and an interaction between these factors. The HYPITAT trial found that labor induction reduced the occurrence of high-risk situations without increasing the risk of CD or adverse neonatal outcomes. The median cervical length was 30 mm (range, 0–64 mm), and median Bishop score was 3 (range, 0–9). For the expectant management group, each centimeter of increase in cervical length was associated with a 32% increase in the likelihood of high-risk situations. For the induced women, each centimeter increase in baseline cervical length carried a 3% risk reduction for maternal high-risk situations (P = 0.03 for interaction between the treatment options). Fifty-one (13.5%) of 377 women who were induced developed an indication for CD compared with 68 (17.9%) of 379 women monitored expectantly. In both groups, the probability of CD was lower when the cervix was more favorable. For each centimeter increase in the length of cervix, the risk of CD was 31% and 14% higher for expectant management and labor induction, respectively (P = 0.48 for interaction). No association was found between cervical length and risk of adverse neonatal outcomes. Analyses using the Bishop score found similar, but not statistically significant, associations between cervical favorability and high-risk maternal situations, CD, and adverse neonatal outcomes. The women were categorized into those with a favorable or unfavorable cervix at baseline. In the induction group, the average times to delivery with a favorable or unfavorable cervix were 1.9 and 2.6 days, respectively. In women managed expectantly, the respective times to delivery were 7.7 and 9.1 days. In the induction group, 33% and 32% of women with a favorable or unfavorable cervix, respectively, had high-risk situations. In the expectant management group, 39% and 49%, respectively, experienced high-risk situations. The risk of CD was comparable after induction for women with (14.6%) and without (14.8%) a favorable cervix. In women managed expectantly, the risks of CD were 18.2% and 21.1%, respectively, for women with a favorable or unfavorable cervix. No increase was found in risks of adverse neonatal outcomes when women with and without a favorable cervix in each treatment group were compared. This post hoc analysis showed that the likelihood of developing high-risk situations depends on the level of cervical ripeness only when women are managed expectantly. If labor is induced, the development of high-risk situations is not associated with cervical ripeness. A comparable risk of CD after labor induction occurs in women with a favorable or unfavorable cervix. Women with an unripe cervix are at increased risk for CD with expectant management. Despite more monitoring and earlier detection of deterioration in the induction of labor group, more women developed high-risk situations in the expectant management group.