Low 5-minute Apgar Score Research Articles

Adverse neonatal outcome and veno-arterial differences in umbilical cord blood pH (ΔpH) at birth: a population-based study of 108,629 newborns

BackgroundUmbilical cord blood gases are routinely used by midwives and obstetricians for quality assurance of birth management and in clinical research. They can form the basis for solving medicolegal issues in the identification of severe intrapartum hypoxia at birth. However, the scientific value of veno-arterial differences in cord blood pH, also known as ΔpH, is largely unknown. By tradition, the Apgar score is frequently used to predict perinatal morbidity and mortality, however significant inter-observer and regional variations decrease its reliability and there is a need to identify more accurate markers of perinatal asphyxia. The aim of our study was to investigate the association of small and large veno-arterial differences in umbilical cord pH, ΔpH, with adverse neonatal outcome.MethodsThis retrospective, population-based study collected obstetric and neonatal data from women giving birth in nine maternity units from Southern Sweden from 1995 to 2015. Data was extracted from the Perinatal South Revision Register, a quality regional health database. Newborns at ≥37 gestational weeks with a complete and validated set of umbilical cord blood samples from both cord artery and vein were included. Outcome measures included: ΔpH percentiles, ‘Small ΔpH’ (10th percentile), ‘Large ΔpH’ (90th percentile), Apgar score (0–6), need for continuous positive airway pressure (CPAP) and admission to neonatal intensive care unit (NICU). Relative risks (RR) were calculated with modified Poisson regression model.ResultsThe study population comprised of 108,629 newborns with complete and validated data. Mean and median ΔpH was 0.08 ± 0.05. Analyses of RR showed that ‘Large ΔpH’ was associated with a decreased RR of adverse perinatal outcome with increasing UApH (at UApH ≥7.20: RR for low Apgar 0.29, P = 0.01; CPAP 0.55, P = 0.02; NICU admission 0.81, P = 0.01). ‘Small ΔpH’ was associated with an increased RR for low Apgar score and NICU admission only at higher UApH values (at UApH 7.15–7.199: RR for low Apgar 1.96, P = 0.01; at UApH ≥7.20: RR for low Apgar 1.65, P = 0.00, RR for NICU admission 1.13, P = 0.01).ConclusionLarge differences between cord venous and arterial pH (ΔpH) at birth were associated with a lower risk for perinatal morbidity including low 5-minute Apgar Score, the need for continuous positive airway pressure and NICU admission when UApH was above 7.15. Clinically, ΔpH may be a useful tool in the assessment of the newborn’s metabolic condition at birth. Our findings may stem from the ability of the placenta to adequately replenish acid-base balance in fetal blood. ‘Large ΔpH’ may therefore be a marker of effective gas exchange in the placenta during birth.

The association between maternal malaria infection and poor birth outcomes in a remote community in Papua, Indonesia

Background Sikari is a remote district in Papua, Indonesia, which is malaria-endemic. Malaria infection during pregnancy has been linked to poor birth outcomes.
 Objective To evaluate for an association between malaria infection in pregnancy and birth outcome.
 Methods This cohort study compared the outcomes of newborns from mothers infected with malaria during pregnancy vs. uninfected controls. We included clinical data of 82 pregnant women from January to December 2020 at the Batavia Public Health Center, Sikari District, Mamberamo Raya, Papua. Malaria diagnosis was established based on the World Health Organization (WHO) criteria and positive rapid diagnostic tests. The maternal and infant characteristics analyzed were years of formal education, antenatal care (ANC) visits, gestational age, obstetric history, diagnosis of malaria, birth weight, APGAR score, and newborn mortality.
 Results Forty-six mothers (56.1%) were diagnosed with malaria during pregnancy, of whom 33 (71.7%) had tropical malaria, 7 (15.2%) had tertian malaria, and 6 (13.0%) had mixed malaria. Malaria infections of any type were associated with an increased risk of preterm birth (OR 5.34; 95%CI 1.10 to 25.91; P=0.04), low birth weight (LBW) (OR 49.00; 95%CI 28.62 to 838.89; P=0.00), newborn mortality (OR 13.86; 95%CI 0.76 to 251.37; P=0.04), and low 5-minute APGAR score (OR 23.65; 95%CI 1.34 to 416.61; P=0.03). Tropical malaria was associated with a higher risk of preterm birth (OR 5.44; 95%CI 1.06 to 27.86; P=0.04), LBW (OR 15.22; 95%CI 1.82 to 127.02; P=0.01), newborn mortality (OR 14.09; 95%CI 0.75 to 265.48; P=0.04), and low APGAR (OR 24.33; 95%CI 1.34 to 440.77; P=0.03). Mixed malaria was associated with a higher risk of LBW (OR 35.00; 95%CI 2.73 to 449.10; P=0.01) and low APGAR score (OR 40.56; 95%CI 1.67 to 985.39; P=0.02).
 Conclusion Malaria infections are associated with an increased risk of preterm birth, low birth weight, newborn mortality, and low 5-minute APGAR scores.

Maternal and Fetal Risk Factors for Neonatal Hypoxic-Ischemic Encephalopathy: A Retrospective Study.

Neonatal hypoxic-ischemic encephalopathy (HIE) leads to different degree of neurological sequelae. The incidence of HIE is relatively high, and the risk factors associated with HIE are still controversial. It is necessary to identify the risk factors associated with HIE. A total of 258 neonates (110 HIE patients and 148 controls) were enrolled in this study. The characteristics of pregnant women and fetuses during pregnancy and delivery were compared between HIE patients and controls, and the risk factors of HIE were analyzed. The proportions of premature infants, low-birth-weight infants and the levels of 1-minute Apgar score, 5-minute Apgar score in HIE group were significantly lower than those in control group, while the proportion of amniotic fluid contamination in the HIE group was significantly higher than those of the controls. When HIE was taken as the end point of 1-minute Apgar score, and 5-minute Apgar score, the cut-off value of 1-minute Apgar score was 3, and 5-minute Apgar score was 7 by receiver operating characteristic (ROC) curve analysis. The results of multivariate logistic regression analysis showed that low birth weight (<2.5 kg) (OR 1.780, 95% CI: 0.124-25.463, P=0.016), amniotic fluid contamination (OR 3.223, 95% CI: 1.049-9.901, P=0.041), low 1-minute Apgar score (≤3) (OR 92.425, 95% CI: 15.522-550.343, P<0.001), and low 5-minute Apgar score (≤7) (OR 12.641, 95% CI: 2.894-55.227, P=0.001) may increase risk of HIE. In addition, amniotic fluid contamination, low 1-minute Apgar score (≤3), and low 5-minute Apgar score (≤7) may increase risk of HIE among newborns born to women without previous childbearing history, but not in newborns born to women with previous childbearing history. Low birth weight (<2.5 kg), amniotic fluid contamination, low 1-minute Apgar score (≤3), and 5-minute Apgar score (≤7) may increase risk of HIE.

Variability for age at successful extubation in infants with congenital diaphragmatic hernia.

The objective of this study was to characterize clinical factors associated with successful extubation in infants with congenital diaphragmatic hernia. Using the Children's Hospitals Neonatal Database, we identified infants with congenital diaphragmatic hernia from 2017 to 2020 at 32 centers. The main outcome was age in days at the time of successful extubation, defined as the patient remaining extubated for 7 consecutive days. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards ratio equations were used to estimate associations between clinical factors and the main outcome. Observations occurred through 180days after birth. There were 840 eligible neonates with a median gestational age of 38weeks and birth weight of 3.0kg. Among survivors (n=693), the median age at successful extubation was 15days (interquartile range [IQR]: 8-29days, 95th percentile: 71days). For nonsurvivors (n=147), the median age at death was 21days (IQR: 11-39days, 95th percentile: 110days). Center (adjusted hazards ratio: 0.22-15, P<.01), low birth weight, intrathoracic liver position, congenital heart disease, lower 5-minute Apgar score, lower pH upon admission to Children's Hospitals Neonatal Database center, and use of extracorporeal support were independently associated with older age at successful extubation. Tracheostomy was associated with multiple failed extubations. Our findings suggest that infants who have not successfully extubated by about 3months of age may be candidates for tracheostomy with chronic mechanical ventilation or palliation. The variability of timing of successful extubation among our centers supports the development of practice guidelines after validating clinical criteria.

Perinatal Outcomes in Women with Chronic Kidney Diseases

To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy. A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups. A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight. This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.

Teenage Pregnancies in Austria - an Epidemiological Study on Prevalence and Perinatal Outcome.

Introduction Even though teenage pregnancy rates have been declining in the last decades, their global prevalence is still high and shows country-specific discrepancies. Insufficient sexual education, poor availability of contraceptives and early marriage are some of the multifactorial causes for adolescent pregnancies. Very often teenage pregnancies are classified as high-risk pregnancies. Studies have found higher rates of peripartal complications, such as preterm birth, low birth weight or low fetal Apgar-Scores. The aim of this retrospective cohort study is to evaluate the prevalence of teenage pregnancies in Austria and to identify principal differences in maternal and neonatal outcome. Material and methods Data were collected from the Austrian Birth Registry between 01/2012 and 12/2020. A total of 751661 deliveries in Austria were documented. Obstetric, maternal and neonatal parameters were descriptively analyzed. Mothers were subclassified into two age groups: teenage mothers of 19 years and younger and adult mothers of 20 to 39 years of age. Results Newborns of teenage mothers were significantly smaller (49.98 ± 3.11 vs. 50.31 ± 3.16 cm, p < 0.001) and had a lower birth weight (3216 ± 564 vs. 3247 ± 576 g, p < 0.001) than newborns of adult mothers. The percentage of caesarean deliveries in the teenage group was significantly lower than in adult mothers (21.1 vs. 31.8%, p < 0.001). Newborns of teenage mothers had significantly higher rates of very low (< 4) and low (< 7) 5-minute Apgar scores (5-minute Apgar < 4: 0.75 vs. 0.54%, p = 0.004) (5-minute Apgar < 7: 1.77 vs. 1.37%, p = 0.001) and significantly lower arterial umbilical-cord pH (7.25 ± 0.08 vs. 7.26 ± 0.08, p < 0.001). Perinatal mortality was higher in the age group below 20 years (0.7 vs. 0.6%, p = 0.043). Conclusion The data of this study show significantly poorer outcomes in pregnancies of teenagers compared to adult women, even though the healthcare system in Austria is considered excellent. Future guideline recommendations should focus on important aspects of obstetric care in teenage mothers.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes

Background Chorioamnionitis is a risk factor for fetal and neonatal outcomes. Therefore, predicting histological chorioamnionitis (HCA) and neonatal outcomes using clinical parameters could be helpful in management and preventing morbidities. Objective To determine if parameters of clinical chorioamnionitis (CCA) would be associated with HCA and neonatal outcomes. Study design In this cohort study using a retrospective design, we analyzed the performance of signs of CCA in predicting HCA, and neonatal outcomes. Data were extracted from the electronic health record for all neonates with documented CCA delivered at our institution from 2011 to 2016. We compared our findings based on the old ACOG definition of CCA and the new definition released in 2017 – maternal fever plus any of fetal tachycardia, maternal leukocytosis, and purulent vaginal discharge. Maternal tachycardia and uterine tenderness were removed from the new criteria. Neonatal laboratory samples on admission, 12 h and 24 h were used to define the three time points of neonatal suspected sepsis. Results There were 530 mothers-infant dyads with chorioamnionitis. Seventy-three were preterm, and 457 were term. Eighty-eight percent of the preterm mothers had CCA, and HCA was present in 62.5% of 72 preterm placentas. Preterm infants with placental HCA significantly had lower birth weight, gestational age, placental weight, and more infants with lower 5-minute Apgar scores, compared to those with no HCA. In preterm infants, maternal urinary tract infection was significantly associated with decreased odds for HCA (OR 0.22, CI 0.10 − 0.71). More preterm babies with suspected sepsis criteria at the 3 time points had HCA (all p ≤ .01). In the term cohort, 95.4% and 65.6% had CCA and HCA, respectively. In term infants (n = 457), maternal leukocytosis (p = .002) and prolonged rupture of membranes (PROM; p = 002) were associated with HCA. Suspected sepsis was associated with PROM (p = .04), HCA (p = .0001), and maternal leukocytosis (p ≤ .05) in at least 1 of the 3 time points. Conclusion Though maternal leukocytosis was significantly associated with the presence of HCA in the term cohort, there were no CCA criteria that accurately predicted presence of HCA in either the preterm or the term infants.

Heart Rate and Pulse Oximetry Dynamics in the First Week after Birth in Neonatal Intensive Care Unit Patients and the Risk of Cerebral Palsy.

Infants in the neonatal intensive care unit (NICU) are at high risk of adverse neuromotor outcomes. Atypical patterns of heart rate (HR) and pulse oximetry (SpO2) may serve as biomarkers for risk assessment for cerebral palsy (CP). The purpose of this study was to determine whether atypical HR and SpO2 patterns in NICU patients add to clinical variables predicting later diagnosis of CP. This was a retrospective study including patients admitted to a level IV NICU from 2009 to 2017 with archived cardiorespiratory data in the first 7 days from birth to follow-up at >2 years of age. The mean, standard deviation (SD), skewness, kurtosis and cross-correlation of HR and SpO2 were calculated. Three predictive models were developed using least absolute shrinkage and selection operator regression (clinical, cardiorespiratory and combined model), and their performance for predicting CP was evaluated. Seventy infants with CP and 1,733 controls met inclusion criteria for a 3.8% population prevalence. Area under the receiver operating characteristic curve for CP prediction was 0.7524 for the clinical model, 0.7419 for the vital sign model, and 0.7725 for the combined model. Variables included in the combined model were lower maternal age, outborn delivery, lower 5-minute Apgar's score, lower SD of HR, and more negative skewness of HR. In this study including NICU patients of all gestational ages, HR but not SpO2 patterns added to clinical variables to predict the eventual diagnosis of CP. Identification of risk of CP within the first few days of life could result in improved therapy resource allocation and risk stratification in clinical trials of new therapeutics. · SD and skewness of HR have some added predictive value of later diagnosis of CP.. · SpO2 measures do not add to CP prediction.. · Combining clinical variables with early HR measures may improve the prediction of later CP..

The Application Value of Three-Dimensional Power Doppler Ultrasound in Fetal Growth Restriction.

In this study, the application value of three-dimensional power Doppler ultrasound (3D-PDU) in fetal growth restriction (FGR) is explored. The retrospective cohort study enrolled pregnant women (with a gestational week of 11–13 + 6 weeks) who received routine health care in the obstetrics and gynecology clinic of our hospital from January 2020 to January 2021. The placentae were scanned using 3D-PDU, and the subjects were followed up until delivery. The fetuses were divided into the control group (n = 322) and FGR group (n = 44) according to their birth weight. There was no significant difference in nuchal translucency (NT), crown-rump length (CRL), and placental volume (PV) during the first trimester between the two groups (P > 0.05). Compared with the control group, the FGR group showed significantly lower levels of vascularisation index (VI), flow index (FI), and vascularisation flow index (VFI) and a higher incidence of fetal distress and neonatal asphyxia (P < 0.05). The FGR group showed a longer gestational week at birth, a higher probability of cesarean section, and a lower 5-minute Apgar score than the control group (P < 0.05). The VI, FI, and VFI of the control group were significantly higher than those of the FGR group. Pearson analysis showed that birth weight was positively correlated with VI and FI (P < 0.05). 3D-PDU assesses the blood perfusion of the fetus and placenta in the first trimester and predicts the pregnancy outcome, which shows great potential in the early diagnosis of FGR.

Duration of Exposure to General Endotracheal Anesthesia During Cesarean Deliveries at Term and Perinatal Complications

(Abstracted from Am J Perinatol 2022;39:232–237) General endotracheal anesthesia (GETA) is performed in approximately 6% of cesarean deliveries (CDs). It is less frequently performed than neuraxial anesthesia because of the risk of neonatal complications such as the need for intubation or supplemental oxygen and lower 5-minute Apgar scores.

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

Perinatal arterial ischemic stroke (PAIS) is a focal brain injury in term neonates that is identified postnatally but is presumed to occur near the time of birth. Many pregnancy, delivery, and fetal factors have been associated with PAIS, but early risk detection is lacking; thus, targeted treatment and prevention efforts are currently limited. To develop and validate a diagnostic risk prediction model that uses common clinical factors to predict the probability of PAIS in a term neonate. In this diagnostic study, a prediction model was developed using multivariable logistic regression with registry-based case data collected between January 2003, and March 2020, from the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and Alberta Pregnancy Outcomes and Nutrition study. Criteria for inclusion were term birth and no underlying medical conditions associated with stroke diagnosis. Records with more than 20% missing data were excluded. Variable selection was based on peer-reviewed literature. Data were analyzed in September 2021. Clinical pregnancy, delivery, and neonatal factors associated with PAIS as common data elements across the 4 registries. The primary outcome was the discriminative accuracy of the model predicting PAIS, measured by the concordance statistic (C statistic). Of 2571 term neonates in the initial analysis (527 [20%] case and 2044 [80%] control individuals; gestational age range, 37-42 weeks), 1389 (54%) were male, with a greater proportion of males among cases compared with controls (318 [60%] vs 1071 [52%]). The final model was developed using 1924 neonates, including 321 cases (17%) and 1603 controls (83%), and 9 clinical factors associated with risk of PAIS in term neonates: maternal age, tobacco exposure, recreational drug exposure, preeclampsia, chorioamnionitis, intrapartum maternal fever, emergency cesarean delivery, low 5-minute Apgar score, and male sex. The model demonstrated good discrimination between cases and controls (C statistic, 0.73; 95% CI, 0.69-0.76) and good model fit (Hosmer-Lemeshow P = .20). Internal validation techniques yielded similar C statistics (0.73 [95% CI, 0.69-0.77] with bootstrap resampling, 10-fold cross-validated area under the curve, 0.72 [bootstrap bias-corrected 95% CI, 0.69-0.76]), as did a sensitivity analysis using cases and controls from Alberta, Canada, only (C statistic, 0.71; 95% CI, 0.65-0.77). The findings suggest that clinical variables can be used to develop and internally validate a model to predict the risk of PAIS in term neonates, with good predictive performance and strong internal validity. Identifying neonates with a high probability of PAIS who could then be screened for early diagnosis and treatment may be associated with reductions in lifelong morbidity for affected individuals and their families.

Trial of labor of vertex-nonvertex twins following a previous cesarean delivery

Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. Our data show thattrial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery.Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.

Association of COVID-19 Vaccination in Pregnancy With Adverse Peripartum Outcomes

There is limited comparative epidemiological evidence on outcomes associated with COVID-19 vaccination during pregnancy; monitoring pregnancy outcomes in large populations is required. To evaluate peripartum outcomes following COVID-19 vaccination during pregnancy. Population-based retrospective cohort study in Ontario, Canada, using a birth registry linked with the provincial COVID-19 immunization database. All births between December 14, 2020, and September 30, 2021, were included. COVID-19 vaccination during pregnancy, COVID-19 vaccination after pregnancy, and no vaccination. Postpartum hemorrhage, chorioamnionitis, cesarean delivery (overall and emergency cesarean delivery), admission to neonatal intensive care unit (NICU), and low newborn 5-minute Apgar score (<7). Linear and robust Poisson regression was used to generate adjusted risk differences (aRDs) and risk ratios (aRRs), respectively, comparing cumulative incidence of outcomes in those who received COVID-19 vaccination during pregnancy with those vaccinated after pregnancy and those with no record of COVID-19 vaccination at any point. Inverse probability of treatment weights were used to adjust for confounding. Among 97 590 individuals (mean [SD] age, 31.9 [4.9] years), 22 660 (23%) received at least 1 dose of COVID-19 vaccine during pregnancy (63.6% received dose 1 in the third trimester; 99.8% received an mRNA vaccine). Comparing those vaccinated during vs after pregnancy (n = 44 815), there were no significantly increased risks of postpartum hemorrhage (incidence: 3.0% vs 3.0%; aRD, -0.28 per 100 individuals [95% CI, -0.59 to 0.03]; aRR, 0.91 [95% CI, 0.82-1.02]), chorioamnionitis (0.5% vs 0.5%; aRD, -0.04 per 100 individuals [95% CI, -0.17 to 0.09]; aRR, 0.92 [95% CI, 0.70-1.21]), cesarean delivery (30.8% vs 32.2%; aRD, -2.73 per 100 individuals [95% CI, -3.59 to -1.88]; aRR, 0.92 [95% CI, 0.89-0.95]), NICU admission (11.0% vs 13.3%; aRD, -1.89 per 100 newborns [95% CI, -2.49 to -1.30]; aRR, 0.85 [95% CI, 0.80-0.90]), or low Apgar score (1.8% vs 2.0%; aRD, -0.31 per 100 newborns [95% CI, -0.56 to -0.06]; aRR, 0.84 [95% CI, 0.73-0.97]). Findings were qualitatively similar when compared with individuals who did not receive COVID-19 vaccination at any point (n = 30 115). In this population-based cohort study in Ontario, Canada, COVID-19 vaccination during pregnancy, compared with vaccination after pregnancy and with no vaccination, was not significantly associated with increased risk of adverse peripartum outcomes. Study interpretation should consider that the vaccinations received during pregnancy were primarily mRNA vaccines administered in the second and third trimester.

Maternal and Neonatal Complications in Teen Pregnancies: A Comprehensive Study of 661,062 Patients

PurposeTo provide a comprehensive assessment of maternal and neonatal complications associated with teen pregnancies in the United States. MethodsRetrospective analysis of the Centers for Disease Control and Prevention natality live births database (2016-2019). Singleton births to women younger than 35 years from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. The risks of various complications were compared between teen patients (<20 years old) and nonteen patients (20–35 years old) using Pearson's chi-square test with the Bonferroni correction. Multivariate logistic regressions were used to adjust outcomes for potential confounders, including body mass index, race/ethnicity, payment method, prenatal care, parity, and the presence of chronic comorbidities. ResultsTeen pregnancies comprised approximately 6% of the study population (661,062 of 11,038,489). Teen pregnancies were associated with increased odds of several maternal complications, such as hypertensive disorders of pregnancy, eclampsia, preterm birth, blood transfusion, and chlamydial and gonorrheal infections. Teen pregnancies were also associated with increased odds of several neonatal complications, including congenital birth defects, low 5-minute Apgar score, suspected neonatal sepsis, and assisted ventilation. Conversely, teen pregnancies were associated with decreased odds of gestational diabetes, unplanned hysterectomy, macrosomia, low birth weight, and neonatal intensive care unit admission. DiscussionTeen pregnancies in the United States are associated with increased risks of multiple adverse outcomes. This information should inform clinicians and policy makers about the unique risks of this highly vulnerable patient population and provide further knowledge for the important efforts to reduce teen birth rates in the United States.

Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial

The ARRIVE trial demonstrated the benefit of induction of labor at 39 weeks gestation. Obstetrics departments across the United States faced the challenge of adapting clinical practice in light of these data while managing logistical constraints. To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication. This was a population-based retrospective cohort study of low-risk, nulliparous women who initiated prenatal care by 12 weeks gestation with singleton, nonanomalous pregnancies delivering at ≥39 weeks. Data were obtained from the US Natality database. The pre-ARRIVE group were women who delivered between January 1, 2015 and December 31, 2017. The post-ARRIVE group consisted of women who delivered between January 1, 2019 and December 31, 2019. Births that occurred in 2018 were excluded. Practice outcomes were rates of induction of labor, timing of delivery, and cesarean delivery rate. Adverse maternal outcomes were blood transfusion and admission to medical intensive care unit. Adverse neonatal outcomes were need for assisted ventilation (immediate and >6 hours), 5-minute APGAR score <3, neonatal intensive care unit admission, seizures, and surfactant use. Univariate and multivariate analyses were performed. Trends were tested across the time period represented by the pre-ARRIVE group using Cochran-Armitage trend test. There were 1,966,870 births in the pre-ARRIVE group and 609,322 in the post-ARRIVE group. The groups differed in age, race, body mass index, marital status, infertility treatment, and smoking history (P<.001). After adjusting for these differences, the post-ARRIVE group was more likely to undergo induction (36.1% vs 30.2%; adjusted odds ratio, 1.36 [1.36-1.37]) and deliver by 39+6 weeks of pregnancy (42.8% vs 39.9%; adjusted odds ratio, 1.14 [1.14-1.15]). The post-ARRIVE group had a significantly lower rate of cesarean delivery than the pre-ARRIVE group (27.3 % vs 27.9%; adjusted odds ratio, 0.94 [0.93-0.94]). Patients in the post-ARRIVE group were more likely to receive a blood transfusion (0.4% vs 0.3%; adjusted odds ratio, 1.43 [1.36-1.50]) and be admitted to medical intensive care unit (0.09% vs 0.08%; adjusted odds ratio, 1.20 [1.09-1.33]). Neonates in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs 2.8%; adjusted odds ratio, 1.28 [1.26-1.30]) and >6 hours (0.6% vs 0.5%; adjusted odds ratio, 1.36 [1.31-1.41]). The neonates in the post-ARRIVE group were more likely to have low 5-minute APGAR scores (0.4% vs 0.3%; adjusted odds ratio, 0.91 [0.86-0.95]). Neonatal intensive care unit admission did not differ between the 2 groups (4.9% vs 4.9%; adjusted odds ratio, 1.01 [0.99-1.03]). There were no differences in neonatal seizures (0.04% vs 0.04%; adjusted odds ratio, 0.97 [0.84-1.13]), and surfactant use (0.08% vs 0.07%; adjusted odds ratio, 1.05 [0.94-1.17]) between the 2 groups. There were more inductions of labor, more deliveries at 39 weeks' gestation, and fewer cesarean deliveries in the year after the ARRIVE trial publication. The small but statistically significant increase in some adverse maternal and neonatal outcomes should be explored to determine if they are related with concurrent changes in obstetrical practices.

Impact of the COVID-19 pandemic on perinatal care and outcomes in the United States: An interrupted time series analysis.

Hospitals quickly adapted perinatal care to mitigate SARS-CoV-2 transmission at the onset of the COVID-19 pandemic. The objective of this study was to estimate the impact of pandemic-related hospital policy changes on perinatal care and outcomes in one region of the United States. This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic-related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48hours after cesarean and <24hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5-minute Apgar score, neonatal intensive care unit (NICU) admission, and 30-day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5-minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study.

Pregnancy Outcomes in Women With Autoimmune Hepatitis – A Nationwide Population-based Cohort Study With Histopathology

Autoimmune hepatitis (AIH) is a chronic inflammatory liver condition that predominantly affects women. However, pregnancy risks remain unclear. A nationwide population-based cohort study (ESPRESSO) in Sweden from 1992 to 2016 including 309 singleton births in women with AIH and 1532 matched births in women from the general population was performed. AIH was diagnosed as a combination of administrative coding from medical diagnosis of AIH and liver biopsy data from Sweden's 28 pathology departments. Using conditional logistic regression, odds ratios (ORs) for adverse pregnancy outcomes were determined. Among 306 live births to women with AIH, 51 (16.7%) were preterm, compared with 70 of 1524 (4.6%) reference births. This corresponded to an OR of 5.10 for preterm birth (95% confidence interval [CI], 3.29-7.92), with similar odds using sibling comparators. Women with AIH with and without cirrhosis had similar odds for preterm birth. The AIH association was particularly strong with medically indicated preterm birth (OR, 13.01; 95% CI, 5.50-30.79). AIH was associated with low birth weight (OR, 5.31; 95% CI, 2.82-9.99) and low 5-minute Apgar score (OR, 3.46; 95% CI, 1.14-10.49) offspring, but we found no association with congenital malformations (OR, 1.14; 95% CI, 0.68-1.91), small for gestational age (OR, 1.04; 95% CI, 0.38-2.85), stillbirth (OR, 0.59; 95% CI, 0.02-18.88), or neonatal death (OR, 7.42; 95% CI, 0.65-84.25). Maternal AIH was linked to an increased odds of cesarean section (OR, 1.44; 95% CI, 1.04-2.00) and preeclampsia (OR, 3.65; 95% CI, 2.01-6.64), but not to gestational diabetes. Maternal AIH was associated with a 5-fold higher odds of preterm birth, and cirrhosis at diagnosis did not add to the impact of AIH on preterm birth. Future studies are needed to understand how to reduce this risk.

The implications for advanced maternal age on pregnancy complications and adverse neonatal outcomes

Objective This study aimed to determine the effect of advanced maternal age (AMA) on maternal and neonatal outcomes in pregnant women aged ≥35 years compared with patients aged 30–34 years. Also, we aimed to analyze the risk estimates of potential confounders to identify whether these variables contributed to the development of adverse pregnancy outcomes or not. Methods This retrospective cohort study included 2284 pregnant women aged ≥35 years at the time of delivery who was delivered in a tertiary referral hospital from January 1, 2016, to December 31, 2020. We further classified these women into two subgroups: 35–39 years as early AMA (EAMA), and ≥40 years as very AMA (VAMA). Pregnancy complications and adverse neonatal outcomes were recorded. Results Compared to younger women, pregnant AMA women had significantly higher risks of complicated pregnancies, including a higher risk of gestational diabetes mellitus (GDM, p&lt;0.001), polyhydramnios (p&lt;0.001), cesarean section (p&lt;0.001), stillbirths (p&lt;0.001), major fetal abnormality (p&lt;0.001), preterm delivery (p&lt;0.001), lower birth weight (p&lt;0.001), lower 5-minute Apgar scores (p&lt;0.001), lower umbilical artery blood pH values (p&lt;0.001), neonatal intensive care unit (NICU) admission (p&lt;0.001), and length of NICU stay (p&lt;0.001). Conclusion We found a strong and significant association between VAMA and adverse pregnancy outcomes, including an increased risk of GDM, polyhydramnios, cesarean section, and adverse neonatal outcomes, including a higher risk of stillbirths, preterm delivery, lower birth weight, lower 5-minute Apgar scores, and NICU admission.

Predicting Failure of Conservative Airway Management in Robin Sequence

PURPOSE: While initial management of upper airway obstruction in Robin sequence is traditionally conservative, early identification of patients who failed in this approach would avoid the deleterious effects of prolonged upper airway obstruction and hospitalization. The purpose of the current study was to evaluate patient factors, clinical data, and polysomnographic (PSG) results in hospitalized infants with Robin sequence who were either discharged after successful conservative airway measures (Group 1) or required surgical airway intervention after a protracted hospital course (Group 2). We hypothesized that differences between these two groups may expedite early operative airway procedures in appropriate patients without an initial prolonged and, ultimately, unsuccessful period of conservative management. METHODS: A retrospective review was conducted among infants diagnosed with RS who underwent primary airway management at a single institution from 1994 to 2020. Patient demographics, nutritional and respiratory status, laboratory values, and PSG results were recorded. Airway management was classified as conservative or surgical, and recorded variables were compared between the groups. Unpaired t-test/Wilcoxon-Mann-Whitney test was used to compare continuous data and Chi square test/Fisher exact test for categorical data. To assess the ability of PSG variables to predict failure of conservative management, we performed receiver operator characteristic (ROC) curve analysis. Accuracy was graded based on the area under the curve (AUC) defined as “poor” (AUC 0.60–0.70), “fair” (AUC 0.70–0.80), “good” (AUC 0.80–0.90), and “excellent” (AUC 0.90–1.00). Optimal cut-points were calculated using the Youden index (J) method. RESULTS: In total, 122 infants with Robin sequence were analyzed. Conservative airway measures were successful in 61 patients (Group 1), while 61 infants failed this approach after a mean period of 23 days and required a surgical airway procedure (Group 2). Lower 5-minute Apgar scores and associated pulmonary, CNS, and reflux disease were seen more frequently in Group 2 patients. A significantly smaller proportion of patients in Group 2 also demonstrated adequate oral intake compared with Group 1 patients (5% versus 28%, P < 0.001). The surgically managed patients required greater respiratory support or intubation, as well as higher levels of maximum CO2 (67.8 versus 51.4 mm Hg, P < 0.001) and maximum HCO3 (32.7 versus 28 mmol/L, P = 0.001). PSG results in Group 2 patients documented a higher percentage of time with O2 saturation < 90% (10.4% versus 1.1%, P = 0.005) and overall higher apnea-hypopnea index (AHI) (59.7 versus 20.6 events/hour, P < 0.001). Good predictors for failure of conservative airway management (AUC range: 0.80–0.85) included AHI, obstructive AHI (OAHI) REM, OAHI non-REM, and maximum ETCO2 (asleep). Cut points most predictive for failure of conservative management by ROC curve analysis included: AHI > 16.9, OAHI REM > 25.9, OAHI non-REM > 23.6, and maximum ETCO2 > 49 mm Hg. CONCLUSIONS: The current study identified patient factors and PSG results in infants with RS that were associated with persistent upper airway obstruction despite weeks of conservative airway management. Our data may expedite earlier definitive treatment of these critical patients that is essential to reducing risk for known complications such as hypertension, metabolic syndrome, and neurocognitive dysfunction.

The burden of severe hypertensive disorders of pregnancy on perinatal outcomes: a nationwide case-control study in Suriname

BACKGROUNDLatin America and the Caribbean is the region with the highest prevalence of hypertensive disorders of pregnancy worldwide. In Suriname, where the stillbirth rate is the second highest in the region, it is not yet known which maternal factors contribute most substantially.OBJECTIVEThe aims of this study in Suriname were to (1) study the impact of different types of maternal morbidity on adverse perinatal outcomes and (2) study perinatal birth outcomes among women with severe hypertensive disorders of pregnancy.STUDY DESIGNA case-control study was conducted between March 2017 and February 2018 during which time all hospital births (86% of total) in Suriname were included. We identified babies with adverse perinatal outcomes (perinatal death or neonatal near miss) and women with severe maternal morbidity (according to the World Health Organization Near Miss tool). Stillbirths and early neonatal deaths (<7 days) were considered perinatal death. We defined a neonatal near miss as a birthweight below 1750 g, gestational age <33 weeks, 5-minute Apgar score <7, and preterm intrauterine growth restriction <p3. Descriptive statistics and multivariate binary logistic regression analyses were conducted.RESULTSIn the 1-year study period, adverse perinatal outcomes were reported for 638 singleton births of which 120 (18.8%) involved women with severe maternal morbidity. In most of these cases, the mother suffered severe hypertensive disorders of pregnancy (n=95/120, 79.2%). Severe hypertensive disorders of pregnancy were strongly associated with adverse perinatal outcomes (adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9). The prevalence of severe hypertensive disorders of pregnancy in Suriname was 2.5% (234/9197). Of the 215 singleton pregnancies complicated by severe hypertensive disorders, adverse perinatal outcomes were reported for 44.2% of them (n=95/215; adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9); perinatal death accounted for 18.1% of these cases (n=39/215; adjusted odds ratio, 8.6; 95% confidence interval, 5.8–12.7) and neonatal near miss accounted for another 26.0% (n=56/215). Women with severe hypertensive disorders of pregnancy had a preterm birth (<37 weeks) in 67.1% of the cases (n=143/215; adjusted odds ratio, 14.1; 95% confidence interval, 10.5–19.0), a baby with a low birthweight (<2500 g) in 62.2% of the cases (n=130/215; adjusted odds ratio, 10.8; 95% confidence interval, 8.1–14.5), and a baby with a low 5-minute Apgar score in 20.5% of the cases (n=43/215; adjusted odds ratio, 6.9; 95% confidence interval, 4.8–10.0).CONCLUSIONIn Suriname, severe hypertensive disorders of pregnancy are strongly associated with adverse perinatal outcomes, with an increased risk for preterm birth, low birthweight, low Apgar score, and perinatal mortality. Prevention, early diagnosis, and management of hypertensive disorders of pregnancy are expected to reduce perinatal deaths substantially. Recommendations to reduce perinatal deaths in Suriname include the establishment of a national health plan for the management of severe hypertensive disorders of pregnancy and the introduction of perinatal death and neonatal near miss reviews.