Rates Of Adverse Neonatal Outcomes Research Articles

Maternal Arrhythmia and Perinatal Outcomes

INTRODUCTION: Maternal cardiac diseases can be severely compromised in the setting of arrhythmias. We compared perinatal outcomes among women with a cardiac arrhythmia with women with other types of cardiac disease. METHODS: This is a retrospective cohort study of pregnant women with cardiac disease who delivered from 2008 to 2013. Perinatal outcomes among women with an arrhythmia were compared with those with other types of maternal cardiac disease (congenital, structural, or cardiomyopathy). RESULTS: A cohort of 143 women was identified; 37 (26%) had a diagnosis of an arrhythmia. Compared with women without arrhythmias, those with an arrhythmia were more likely to have a spontaneous vaginal delivery (62% compared with 43%, P<.05) and required fewer operative vaginal births (11% compared with 26%, P=.05). Pregnancies were more likely to be complicated by intrauterine growth restriction (IUGR) (16% compared with 5%, P<.05) and placental abruption (5% compared with 0%, P<.05). The risk of IUGR remained increased in multivariable model controlling for confounding (adjusted odds ratio 6.9, 95% confidence interval 1.6–30.4, P=.01). There were no differences in rates of other maternal complications including gestational diabetes, postpartum hemorrhage, chorioamnionitis, or intensive care unit admission. Neonatal outcomes including gestational age at delivery, birth weight, 5-minute Apgar, umbilical artery pH less than 7, and neonatal intensive care unit admission were not different. CONCLUSIONS: Patients with arrhythmias were more likely to have a successful vaginal delivery compared with those other maternal cardiac diseases. However, the pregnancy had an increased risk for IUGR and placental abruption. The rates of adverse neonatal outcomes were similar between the groups.

803: Maternal characteristics and neonatal outcomes among preterm deliveries complicated by vaginal bleeding

Bleeding is proposed as one mechanism of preterm birth (PTB). We sought to determine if women who had a spontaneous PTB (sPTB) and antenatal vaginal bleeding (VB) had different maternal risk factors and rates of adverse neonatal outcomes than women without VB.

Acute Histologic Chorioamnionitis Is a Risk Factor for Adverse Neonatal Outcome in Late Preterm Birth after Preterm Premature Rupture of Membranes

BackgroundThe objective of this study was to determine whether acute histologic chorioamnionitis is associated with adverse neonatal outcomes in late preterm infants who were born after preterm PROM.Methodology/Principal FindingsThe relationship between the presence of acute histologic chorioamnionitis and adverse neonatal outcome was examined in patients with preterm PROM who delivered singleton preterm newborns between 34 weeks and 36 6/7 weeks of gestation. Nonparametric statistics were used for data analysis. The frequency of acute histologic chorioamnionitis was 24% in patients with preterm PROM who delivered preterm newborns between 34 weeks and 36 6/7 weeks of gestation. Newborns born to mothers with histologic chorioamnionitis had significantly higher rates of adverse neonatal outcome (74% vs 51%; p<0.005) than those without histologic chorioamnionitis. This relationship remained significant after adjustment for gestational age at preterm PROM, gestational age at delivery, and exposure to antenatal corticosteroids.Conclusions/SignificanceThe presence of acute histologic chorioamnionitis is associated with adverse neonatal outcome in late preterm infants born to mothers with preterm PROM.

Timing of planned repeat cesarean delivery after two or more previous cesarean sections – Risk for unplanned cesarean delivery and pregnancy outcome

Objective: To assess the effect of the scheduled gestational age for a repeat planned cesarean section (CS) on the risk for adverse pregnancy outcome in women with two or more previous CS.Methods: A retrospective cohort study of all women after ≥2 previous CS who were scheduled for a repeat planned CS. Women were divided into two groups at which the planned CS was scheduled: 38-week group or 39-week group.Results: Overall, 377 were enrolled, 264 (70.0%) and 113 (30.0%) in the 38-week and the 39-week groups, respectively. The rate of an unplanned CS was significantly higher in the 39-week versus the 38-week group (23.0% versus 13.3%, p = 0.02). A repeat planned CS scheduled to week 39 was associated with an increased risk of maternal adverse outcome (31.9% versus 21.6%, p = 0.03). There was no significant difference in the rate of adverse neonatal outcome between the two groups (20.8% versus 23.0%, p = 0.5). The lowest rate of any adverse outcome (maternal and/or neonatal) was observed when CS was scheduled to 38 + 1 weeks of gestation.Conclusions: In women after two cesarean sections, scheduling a planned CS at around 39 weeks compared with at around 38 weeks is associated with an increased risk for maternal adverse outcome with no apparent advantage in terms of neonatal outcome.

The effect of time of day on outcome of unscheduled cesarean deliveries

Objective. To assess the association between time of day and characteristics and complications rate of cesarean sections.Methods. We conducted a retrospective cohort study of all women who underwent an unscheduled (non-elective) cesarean section (CS) between 1997 and 2007 in a single tertiary medical center. Maternal and neonatal outcome and duration of CS were analyzed according to the work shift. Multivariable logistic regression analysis was used to determine whether shift number is an independent risk factor for maternal or neonatal adverse outcome.Results. There were overall 9944 unscheduled CS during the study period, of them 2995 (30.1%) were operated on the morning shift, 4618 (46.4%) on the evening shift, and 2331 (23.5%) on the night shift. The characteristics of the women in each of the shifts were overall similar. Women who underwent CS during night shift had a higher rate of endometritis and wound infection, postpartum hemorrhage requiring hemotransfusion, and prolonged postoperative hospitalization. The rate of adverse neonatal outcome was similar in the three working shifts. After adjustment for potential confounders by multivariable logistic regression analysis, maternal morbidity was significantly higher for women operated on night shift. The risk of neonatal morbidity was unrelated to the working shift. Overall duration of CS, time required for induction of anesthesia, and net operation time were all significantly higher during the night shift compared with the morning and evening shift.Conclusion. CSs performed during night shift are associated with longer operative time and an increased risk for maternal, but not neonatal, morbidity.

Rates of labor induction and primary cesarean delivery do not correlate with rates of adverse neonatal outcome in level I hospitals

Objective. To determine whether variation in rates of labor induction (IOL) and primary cesarean delivery (PCD) among level I hospitals is associated with differences in neonatal outcomes.Methods. A birth certificate database was used to calculate crude and adjusted rates of IOL and PCD among 10 regional hospitals. Adjustment via logistic regression controlled for differences in medical and demographic factors. Linear regression assessed the relationship of crude and adjusted IOL and PCD rates to rates of three neonatal outcomes.Results. IOL and PCD rates varied widely among hospitals (1.79- and 1.72-fold, respectively); variation increased following adjustment (1.93- and 1.86-fold, respectively). Rates of adverse neonatal outcomes varied by year and hospital, but not by IOL or PCD rates (p ≥ 0.05).Conclusions. Crude and adjusted rates of labor induction and PCD vary among level I hospitals, but with no consistent effect on neonatal outcome.

Outcomes After Internal Versus External Tocodynamometry for Monitoring Labor

Professional societies in obstetrics and gynecology have recommended the use of internal tocodynamometry to monitor uterine contractions during induction or augmentation of labor. This recommendation is based on the hypothesis that internal tocodynamometry in comparison to external monitoring provides a more accurate assessment of contractions and may quantify the frequency, duration, and magnitude of uterine activity more accurately. Monitoring with internal tocodynamometry may improve maternal and fetal outcomes by allowing better adjustment of oxytocin, thereby preventing uterine hyperstimulation and fetal hypoxia. Because limited clinical data support such hypotheses, the recommendations are based on expert opinion. This randomized, multicenter, controlled clinical trial was designed to evaluate whether the use of internal tocodynamometry during labor, in a population of women with an indication for induced or augmented labor, provides superior outcomes compared to use of external monitoring. The study subjects were 1456 singleton women at >36 weeks' gestation, who required either induction or augmented labor with intravenous oxytocin. The women were randomly assigned to either an internal tocodynamometry group (n = 734) or an external monitoring group (n = 722). The trial was performed at 6 hospitals in the Netherlands between 2004 and 2007. The composite primary outcome was the rate of operative delivery, including cesarean section or instrumented vaginal delivery. Secondary outcomes evaluated were the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes defined as a 5-minute Apgar score below 7, an umbilical artery pH below 7.05, or a neonatal admission longer than 48 hours. Operative delivery was performed in 230 (31.3%) of the women in the internal-tocodynamometry group and in 214 (29.6%) of those in the external-monitoring group (relative risk with internal monitoring = 1.1; 95% confidence interval = 0.91-1.2). No significant difference was found between the 2 groups in the frequencies of secondary outcomes. The rate of adverse neonatal outcomes was also similar (14.3% with internal monitoring vs. 15.0% with external monitoring; relative risk = 0.95, 95% confidence interval = 0.74-1.2). The use of the intrauterine pressure catheter was not associated with serious adverse events. These findings show no significant difference in the rates of operative delivery or adverse neonatal outcomes between internal tocodynamometry and external monitoring of uterine contractions in a population of women with an indication for induction or labor augmentation with oxytocin. The data do not support the routine use of internal tocodynamometry for monitoring contractions in women with induced or augmented labor.

Time of Delivery and Perinatal Outcome

The purpose of this study was to examine the association between time of delivery and perinatal outcomes in singleton deliveries at Japanese Red Cross Katsushika Maternity Hospital. We performed a retrospective cohort study of all singleton deliveries at ≥ 22 weeks' gestation from 2002 through 2009 at our hospital. During the nighttime period (12 midnight to 8 am), although the rate of delivery of high-risk pregnancies was low, the rate of low umbilical artery pH (< 7) was higher than that during the daytime periods (8 am to 4 pm) (odds ratio 1.9, 95% confidence interval 1.1-3.4, p = 0.02). During the nighttime period, in addition, the rate of low umbilical artery pH in patients with emergent cesarean delivery was significantly higher than that during the daytime period (odds ratio 6.9; 95% confidence interval 2.5-19, p < 0.01). In our hospital, the rate of adverse neonatal outcomes associated with cesarean birth was increased at nighttime period.

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

The use of Kjelland's forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjelland's rotational delivery in the 'modern era' of high caesarean section rates is unclear. To compare the results of attempted Kjelland's forceps rotational delivery with other methods of instrumental delivery in a tertiary hospital. Retrospective review of all instrumental deliveries for singleton pregnancies 34 or more weeks gestation in a four-year birth cohort, with reference to adverse maternal and neonatal outcomes. The outcomes of 1067 attempted instrumental deliveries were analysed. Kjelland's forceps were successful in 95% of attempts. Kjelland's forceps deliveries had a rate of adverse maternal outcomes indistinguishable from non-rotational ventouse, and lower than all other forms of instrumental delivery. Kjelland's forceps also had a lower rate of adverse neonatal outcomes than all other forms of instrumental delivery. Prudent use of Kjelland's forceps by experienced operators is associated with a very low rate of adverse maternal and neonatal outcomes. Training in this important obstetric skill should be reconsidered urgently, before it is lost forever.

Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study

BackgroundAnaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections.MethodsCohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.ResultsThe risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.ConclusionThe infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.

The clinical utility of fetal fibronectin in the prediction of pre-term birth in a low socio-economic setting hospital in Ecuador

Background. Pre-term birth is a world wide health problem, and although fetal fibronectin (fFN) testing has proven its clinical utility in developed countries, this remains to be determined in the developing world.Objective. To evaluate the clinical utility of fFN in predicting pre-term birth in a low socio-economic, non-profit hospital setting.Study Design. In this observational study, pregnant women < 37 completed weeks with symptoms suggestive of threatened pre-term labour (painful regular contractions and cervical modifications) were tested with the fFN test, admitted for management and subsequently followed up every 2 weeks until the end of gestation. Delivery rates <35 and <37 weeks and within 7, 14 and 21 days were compared among women with positive and negative results.Results. During the study period, 180 gravids were tested for fFN [52 positives (28.9%) and 128 negatives (71.1%)]. In the positive fFN group, the admission-to-delivery interval was significantly shorter, whereas delivery rates before 35 and 37 weeks and within 7, 14 and 21 days were found to be higher. Neonates delivered from positive fFN women had lower weight and gestational age as well as higher rates of adverse neonatal outcomes and admissions to the intensive care unit. Finally, fFN testing was useful in predicting delivery at less than 37 and 35 weeks (sensitivity: 76, 100%; specificity: 89.2, 76.2%; positive predictive value: 73.1, 23.1%; negative predictive value: 90.6, 100%, respectively) and within 7, 14 and 21 days (sensitivity: 75, 66 and 65.6%; specificity: 78.2, 86.6 and 91.4%; positive predictive value: 34.6, 67.3 and 80.8%; negative predictive value 95.3, 85.9 and 82.8%, respectively).Conclusions. In this low-income healthcare scenario, testing for fFN was effective in assessing the risk of pre-term birth; we propose that testing be implemented as a hospital policy suggesting that negative resulting women be managed in an ambulatory fashion.

Cesarean Section in Term Breech Presentations: Do Rates of Adverse Neonatal Outcomes Differ by Hospital Birth Volume?

In the United States, the majority (86%) of infants in breech presentation is delivered by cesarean, but some still have adverse neonatal outcomes. This study asked whether adverse outcomes after cesarean delivery at term differ according to the volume of such births at a given hospital. This population-based cohort study used Missouri birth certificate data from 10,106 singleton term infants (37 or more weeks gestation) born from 1993 to 1999 who had birth weights from 2500 to 3999 g and were in breech presentation. Infants with congenital abnormalities, growth restriction, or macrosomia, and all multiple gestations and preterm births were excluded. Participating hospitals were divided into low-, medium-, and high-volume terciles based on the median number of yearly deliveries over the period of study (<1034, 1035-2236, and 2237-6474 deliveries per year, respectively). The proportions of study infants born at low-, medium-, and high-volume hospitals were 38%, 28%, and 33%, respectively. The rates of any adverse outcome during the period under review were, respectively, 18, 15, and 6 cases per 1000 deliveries at low-, medium-, and high-volume hospitals. Neonatal deaths were relatively rare in all groups. After adjusting for maternal educational level, adverse outcomes were collectively more frequent in low- and medium-volume hospitals that at high-volume institutions. The respective odds ratios for low- and medium-volume hospitals compared with high-volume centers were 2.7 (95% confidence interval [CI], 1.6-4.5) and 2.4 (95% CI, 1.4-4.1). The odds ratios for adverse outcomes were significantly higher for parous women having a repeat cesarean section at a medium-volume hospital and for nulliparous mothers having primary cesareans at low- and medium-volume hospitals. These findings suggest that parturients whose fetuses are in breech presentation incur an increased risk of an adverse outcome after cesarean delivery at hospitals where there are fewer than 2200 births per year. Not enough is known about the factors affecting this finding to recommend transferring prospective mothers to large-volume hospitals.

Cesarean section in term breech presentations: do rates of adverse neonatal outcomes differ by hospital birth volume?

To determine if risk of adverse neonatal outcomes among term breech infants delivered by cesarean section differs by volume of such births at the delivering hospital. We conducted a population-based cohort study using Missouri linked birth and death certificate files. The study population included 10,106 singleton, term, normal birth weight infants in breech presentation delivered by cesarean section. Infants were linked to hospitals where delivered. These hospitals were divided into terciles (low, medium, and high volume) based on the median number of annual deliveries during 1993-1999. The primary outcome was presentation of at least one adverse neonatal outcome. Adjusted odds ratios and 95% confidence intervals (CI) were calculated using logistic regression analysis. The rate of any adverse outcome was 17.8, 15.0, and 5.9 cases per 1,000 deliveries at low-, medium-, and high-volume hospitals, respectively. All component adverse outcomes occurred more frequently in low- or medium-volume hospitals than in high-volume hospitals. Compared to breech infants delivered at high-volume hospitals, those delivered at low-volume and medium-volume hospitals were 2.7 (CI 1.6, 4.5) and 2.4 (CI 1.4, 4.1) times, respectively, more likely to experience an adverse outcome after adjusting for significant confounders. Prospective studies should explore the source of these risk differences.

Twin pregnancy in advanced maternal age (AMA) women is not associated with increased rates of adverse neonatal outcomes

The prevailing opinion is that women who are AMA have pregnancies with poorer outcomes. Our aim is to determine if women of AMA (age ≥ 35) with twin pregnancies have worse neonatal outcomes as compared to a group of younger controls (age < 35).

Hypertensive disorders in twin versus singleton gestations

Objective: This study was undertaken to compare rates and severity of gestational hypertension and preeclampsia, as well as perinatal outcomes when these complications develop, between women with twin gestations and those with singleton gestations. Study Design: This was a secondary analysis of prospective data from women with twin (n = 684) and singleton (n = 2946) gestations enrolled in two separate multicenter trials of low-dose aspirin for prevention of preeclampsia. End points were rates of gestational hypertension, rates of preeclampsia, and perinatal outcomes among women with hypertensive disorders. Results: Women with twin gestations had higher rates of gestational hypertension (relative risk, 2.04; 95% confidence interval, 1.60-2.59) and preeclampsia (relative risk, 2.62; 95% confidence interval, 2.03-3.38). In addition, women with gestational hypertension during twin gestations had higher rates of preterm delivery at both <37 weeks’ gestation (51.1% vs 5.9%; P < .0001) and <35 weeks’ gestation (18.2% vs 1.6%; P < .0001) and also had higher rates of small-for-gestational-age infants (14.8% vs 7.0%; P = .04). Moreover, when outcomes associated with preeclampsia were compared, women with twin gestations had significantly higher rates of preterm delivery at <37 weeks’ gestation (66.7% vs 19.6%; P < .0001), preterm delivery at <35 weeks’ gestation (34.5% vs 6.3%; P < .0001), and abruptio placentae (4.7% vs 0.7%; P = .07). In contrast, among women with twin pregnancies, those who remained normotensive had more adverse neonatal outcomes than did those in whom hypertensive complications developed. Conclusions: Rates for both gestational hypertension and preeclampsia are significantly higher among women with twin gestations than among those with singleton gestations. Moreover, women with twin pregnancies and hypertensive complications have higher rates of adverse neonatal outcomes than do those with singleton pregnancies. (Am J Obstet Gynecol 2000;182:938-42.)

A comparison of neonatal outcomes of age-matched, growth-restricted twins and growth-restricted singletons.

A retrospective cohort study was performed to determine whether growth-restricted fetuses of a twin gestation are at increased risk of adverse neonatal outcome compared with growth-restricted singletons. One cohort was comprised of 48 growth-discordant twin pregnancies in which the birth weight of the smaller twin was less than the tenth percentile. The neonatal outcomes of the 48 growth-restricted twin infants were compared with a cohort of 96 singleton infants matched by gestational age, degree of growth restriction, and gender. Outcomes evaluated included: length of stay, days of assisted ventilation, and diagnoses of morbidities of prematurity, congenital abnormalities, and neonatal death. No significant difference was detected in rates of neonatal morbidity or mortality. The overall neonatal death rate in the twins was 125 of 1000 and in the singletons was 104 of 1000 (Odds ratio 1.2, 95% confidence interval [CI]0.4-3.3). Growth-restricted twins have similar rates of adverse neonatal outcomes as compared with growth-restricted singletons. Both have high rates of morbidity and neonatal death. Twins and singletons should receive comparable diagnostic evaluation and antepartum management for growth restriction.