Maternal Screening Research Articles

Coordinating Care Across the Perinatal Continuum in Hemolytic Disease of the Fetus and Newborn: The Timely Handoff of a Positive Maternal Anti-Erythrocyte Antibody Screen

Antibody-mediated hemolytic disease of the fetus and newborn, henceforth referred to as hemolytic disease, can pose a significant risk for anemia and severe postnatal hyperbilirubinemia. A positive maternal anti-erythrocyte antibody screen is often the first finding to herald the risk of hemolytic disease and prompt further evaluation including fetal surveillance for anemia and, if indicated, in utero red blood cell transfusion. 1 Liley H.G. Gardener G. Lopriore E. Smits-Wintjens V. Immune hemolytic disease. in: Orkin S. Nathan D. Ginsburg D. Look A.T. Fisher D. Lux S. Nathan and Oski's hematology and oncology of infancy and childhood. Elsevier Saunders, Philadelphia2015: 76-100 Google Scholar A positive maternal anti-erythrocyte antibody screen may also signal a risk for severe hyperbilirubinemia in the neonate, even in the absence of fetal anemia. In this regard, hemolytic disease remains an important cause of marked neonatal hyperbilirubinemia, acute bilirubin encephalopathy, and kernicterus. 2 Johnson L. Bhutani V.K. Karp K. Sivieri E.M. Shapiro S.M. Clinical report from the Pilot US Kernicterus Registry (1992 to 2004). J Perinatol. 2009; 29: S25-S45 Crossref Scopus (232) Google Scholar , 3 Christensen R.D. Agarwal A.M. George T.I. Bhutani V.K. Yaish H.M. Acute neonatal bilirubin encephalopathy in the State of Utah 2009-2018. Blood Cells Mol Dis. 2018; 72: 10-13 Crossref PubMed Scopus (24) Google Scholar , 4 Helal N.F. Ghany E.A. Abuelhamd W.A. Alradem A.Y. Characteristics and outcome of newborn admitted with acute bilirubin encephalopathy to a tertiary neonatal intensive care unit. World J Pediatr. 2019; 15: 42-48 Google Scholar , 5 Rennie J.M. Beer J. Upton M. Learning from claims: hyperbilirubinemia and kernicterus. Arch Dis Child Fetal Neonatal Ed. 2019; 104: F202-F204 Google Scholar Whether a positive maternal anti-erythrocyte antibody screen is detected at pregnancy registration, during gestation, or perinatally at the time of delivery hospitalization, it is incumbent on the newborn caretakers to be aware of the result. 6 Watchko J.F. Common hematologic problems in the newborn nursery. Pediatr Clin N Am. 2015; 62: 509-524 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar , 7 Intermountain Healthcare. Prenatal care for maternal anti-erythrocyte antibodies. 2017 Update. Intermountain Healthcare Patient and Provider Publications CPM043 – 07/17. https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=521363279. Accessed December 1, 2018. Google Scholar We review the critical importance of a successful handoff of a positive maternal anti-erythrocyte antibody screen across the perinatal continuum to ensure the timely evaluation and management of the neonate. Although symptomatic ABO hemolytic disease is also an important cause of neonatal hyperbilirubinemia, maternal anti-A and anti-B antibodies are innately produced, that is, immune competent individuals who do not express the A or B protein produce antibody to the antigen. As such, anti-A and anti-B are not included in the maternal anti-erythrocyte antibody screen and ABO hemolytic disease is not addressed. Two case reports underscore the importance of the timely handoff of a positive maternal anti-erythrocyte antibody screen.

Clinical validation of a novel automated cell‐free DNA screening assay for trisomies 21, 13, and 18 in maternal plasma

ObjectiveTo evaluate clinical performance of a new automated cell‐free (cf)DNA assay in maternal plasma screening for trisomies 21, 18, and 13, and to determine fetal sex.MethodMaternal plasma samples from 1200 singleton pregnancies were analyzed with a new non–sequencing cfDNA method, which is based on imaging and counting specific chromosome targets. Reference outcomes were determined by either cytogenetic testing, of amniotic fluid or chorionic villi, or clinical examination of neonates.ResultsThe samples examined included 158 fetal aneuploidies. Sensitivity was 100% (112/112) for trisomy 21, 89% (32/36) for trisomy 18, and 100% (10/10) for trisomy 13. The respective specificities were 100%, 99.5%, and 99.9%. There were five first pass failures (0.4%), all in unaffected pregnancies. Sex classification was performed on 979 of the samples and 99.6% (975/979) provided a concordant result.ConclusionThe new automated cfDNA assay has high sensitivity and specificity for trisomies 21, 18, and 13 and accurate classification of fetal sex, while maintaining a low failure rate. The study demonstrated that cfDNA testing can be simplified and automated to reduce cost and thereby enabling wider population‐based screening.

Association of the previous history of maternal depression with post-partum depression, anxiety, and stress in the neonatal intensive care unit

Background A history of depression in post-partum women who have infants admitted to the neonatal intensive care unit (NICU), is associated with higher risk for anxiety and stress. These conditions, which can be harmful to neonates, may be missed if maternal mental health screening is confined to depression. Objective To determine if the history of a previously diagnosed depression would be associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress) among mothers with infants in the NICU. Design Prospective survey questionnaire-based study conducted over a period of 9 months. Setting Urban inpatient hospital-based setting, serving mainly low-income population. Participants A total of 118 mothers of newborns who had been in the NICU for 7–29 days were approached for enrollment. Out of 118, 96 mothers consented to be screened and were asked to fill out the 21-item Depression Anxiety and Stress Scale-21 (DASS-21) questionnaire. Outcome Primary outcome was to determine whether the history of a previously diagnosed depression is associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress). Results Out of the 96 subjects, 36 (37.5%) had a previous history of depression before delivery (Group A) while 60/96 (62.5%) did not (Group B) and 46/96 (48%) of the mothers were positive for either depression, anxiety, or stress. This included 22/96 (22.9%) mothers who screened positive for depression; 37/96 (38.5%) who screened positive for anxiety; and 32/96 (33.3%) who screened positive for stress. After adjusting for maternal drug abuse, birth weight and maternal gravidity, the association between a previous history of depression and current depression scores were statistically significant (p = .04), as were the associations between previous depression and current anxiety and stress scores (p = .02 and p = .003, respectively). Conclusions and relevance A history of depression, documented in the antepartum medical record, identifies post-partum women who are at higher risk for anxiety and stress. Screening for depression alone may lead to missing these mental health issues.

Hepatitis C Screening in Mothers and Infants Exposed to Opioids

Hepatitis C virus (HCV) is the most common blood-borne pathogen in the United States. In the context of the opioid epidemic, there has been a dramatic rise in perinatal opioid use and the prevalence of HCV infection, which can be transmitted to infants. One national guideline recommends HCV screening for all pregnant women and screening for HCV-exposed newborns after 18 months of age. In this study, we aimed to identify the trends in HCV prevalence and screening among mothers using opioids during pregnancy and infants exposed to HCV infection in utero. Infants with International Classification of Diseases, Ninth Revision (779.5) or International Classification of Diseases, 10th Revision codes (P96.1) for neonatal abstinence syndrome and in-utero exposure to methadone, buprenorphine, or other opioid medications were identified for this retrospective cohort analysis. Information regarding maternal and infant HCV screening, demographics, and follow-up care was also extracted from the electronic medical record and HealthInfoNet, a statewide database of laboratory results. Between 2013 and 2018, 769 infants with in-utero opiate exposure were identified. The maternal HCV screening rate increased from 58.1% in 2013 to 90% in 2018. Of the mothers tested for HCV during pregnancy, 257 (47.9%) were HCV-positive. Of the 177 infants eligible for testing by age criteria, 94 (53%) were tested for HCV, and 7 (7.4%) were HCV-positive. We estimate that an additional 10 infants were HCV-positive and undiagnosed. Despite the high prevalence of HCV, rates of maternal and infant screening remain suboptimal. This study highlights the need for improved care for this high-risk population of infants born to mothers with opiate use disorder.

Prevalence and specificity of clinically significant red cell alloantibodies in pregnant women - a study from a tertiary care hospital in Southeast Michigan.

BackgroundMaternal red cell IgG antibodies can cross the placenta and cause hemolysis of fetal red cells in case of antigenic differences between maternal and fetal RBCs, leading to hemolytic disease of the fetus and newborn (HDFN). Although the incidence of anti-D associated HDFN has drastically reduced with Rh immune globulin prophylaxis, HDFN due to other maternal red cell alloantibodies still remains a concern. Prevalence and specificities of clinically significant red cell alloantibodies in pregnant females have rarely been reported in the USA.MethodsA retrospective chart review was conducted to determine the prevalence and specificity of clinically significant red cell alloantibodies in pregnant females who delivered at Beaumont Hospital Royal Oak between May 1, 2017 and December 31, 2017. A total of 4548 pregnant females were screened using electronic medical records. One female above 50 years age and two females with invalid ABO type were excluded from the study per IRB approved protocol. The remaining 4545 pregnant females with a valid ABO/RhD type and valid red cell antibody screen were included.ResultsOut of the 4545 included females, 440 had a positive red cell antibody screen. Of these 440 females, 34 had clinically significant alloantibodies, giving an overall prevalence of 0.74%. Anti-E was the most frequently identified significant alloantibody followed by anti-K. The most prevalent significant alloantibodies in RhD positive and RhD negative females were anti-E and anti-K, respectively. Significant association (p-value <0.001) was found between RhD type and the presence of clinically significant alloantibodies amongst females with positive antibody screen.ConclusionOur study aims to reiterate the importance of maternal red cell antibody screening during early pregnancy to help identify and manage high-risk pregnancies. Minimizing the exposure of childbearing age females to incompatible red cell antigens through unnecessary transfusions can help reduce the incidence of red cell alloimmunization and the risk of HDFN.

108. HEPATITIS B VACCINATION IN DUKE UNIVERSITY AND DUKE REGIONAL HOSPITAL NEWBORN NURSERIES

Background Vertical transmission continues to be a mode of Hepatitis B virus (HBV) infection despite implementation of prenatal maternal screening. HBV vaccination induces seroprotection in 98% of term infants. The CDC recommends that all infants should receive the first dose of hepatitis B vaccine at birth or within the first 12- 24 hours of life before they leave the hospital. Nevertheless, HBV vaccination rates prior to discharge were sub-optimal in the Duke newborn nurseries, which consist of the main Duke University Hospital (DUH) nursery and the community-based Duke Regional Hospital (DRH) nursery. Aim Statement We aimed to increase all HBV vaccination rates from a baseline of 94% to 96% at the DUH and from 88% to 90% at the DRH nurseries within 1 year. Interventions Baseline HBV vaccination rates were obtained from the electronic medical record (EMR) by using the 12 months preceding first intervention. The first intervention educated clinicians and nurses on the updated CDC guidelines by displaying posters in work areas. The second intervention aimed to increase project awareness among nursing staff in the nursing newsletter. The third intervention was an interdisciplinary effort among the nursing, physician, and pharmacy teams to coordinate administration of the HBV vaccine with the routine administration of vitamin K injection and erythromycin eye ointment at delivery. Measures After each intervention, a PDSA cycle was completed, assessing vaccination rates over the next three months on average. We assessed the effect on nursing workflow through a survey as a balancing measure. Results At both DUH and DRH nurseries respectively, we saw the rates of HBV vaccination increase slightly from baseline rates of 88% and 94% to 92% and 95% after the first two cycles. The third intervention at DUH resulted in a robust response in vaccination rates (up-trending to 95.8% in the month of November). Rates have been above the means for 7 and 10 consecutive months for DUH and DRH since the project began. Conclusions and Next Steps We have demonstrated a trend in improvements in HBV vaccination rates in the DUH and DRH newborn nurseries over several PDSA cycles. Most notably, the multi-disciplinary intervention of administering HBV with the vitamin K injection and erythromycin eye ointment at DUH had a marked impact. Continued multi-disciplinary efforts to improve HBV vaccination in the newborn nursery at both hospitals will optimize the care of newborn infants in prevention of HBV.

Down syndrome among primiparae at older maternal age: A test of the relaxed filter hypothesis.

Down syndrome (DS) ranks as one of the most common birth defects in the United States. The relaxed filter hypothesis (RFH) asserts that mothers with no previous children but nearing reproductive senescence reduce fetal selectivity against DS pregnancies in the first trimester given the high probability of having no offspring at all if the DS pregnancy is not carried to term. We test the parity prediction of RFH-specifically, that pregnancies to older mothers with no previous live births show an elevated prevalence of DS above values expected from the separate contributions of older maternal age and primiparity. We retrieved maternal age and parity information on 2,748 DS cases (live, stillborn, or terminated due to anomaly) from the Paris Birth Defects Registry, 1983-2015. We used two waves of the Enquête Fertility Survey (n = 5,460) and counts of stillbirths to calculate total prevalence of DS by maternal age and parity. Primiparous mothers 35+ years show the greatest prevalence of any parity group (9.78 cases per 1,000 deliveries). Tests for additive interaction of primiparity and older maternal age reject the null (relative excess risk due to interaction = 1.01; 95% confidence interval: 0.33, 1.69; null value on additive scale is 0). Relaxed selection may account for 10% of the increase in the prevalence, among older primiparous mothers, of DS detected during or after the 11th week. Future work may hold implications for understanding, among older mothers, the strength of this maternal screen against other defects.

Neonatal Group B Streptococcal Infection in a Tertiary Care Hospital in Saudi Arabia: A 13-year Experience.

Group B streptococcus (GBS) is a leading cause of neonatal bacterial sepsis and meningitis globally. Studies concerning the incidence and burden of neonatal GBS disease in Saudi Arabia are lacking. This study determined the incidence and burden of GBS infection among neonates in association with maternal GBS screening. A retrospective cohort chart review study included all neonatal GBS disease cases identified through microbiology lab records within the first 90 days of life in the hospital from January 2004 to December 2016. Charts were reviewed to collect maternal and neonatal characteristics using a standardized form. Over 13 years, of 108,609 live births, 55 GBS disease cases were identified (overall incidence, 0.51/1000 live births), 69.1% (n = 38) of those had early onset disease (EOD). The annual incidence in 2015 and 2016 was significantly higher than in any previous year (P < 0.0001), coinciding with the discontinuation of routine universal maternal GBS screening. Median age at presentation was 1 day (range, 0-54 days). We found that 67.3% (n = 37) of mothers were not screened antenatally, 72.9% (n = 27) of whom had neonates present with EOD. Neonates of unscreened mothers were more likely to have GBS disease (P = 0.01) and to present with EOD (P = 0.005). Urinary tract infection was the most common manifestation (47.3%, n = 26), followed by sepsis (43.6%, n = 24). Mortality rate was 3.6% (n = 2). The incidence of neonatal GBS infection in Saudi Arabia is similar to the worldwide incidence. Universal antenatal screening discontinuation was significantly associated with an increase in EOD incidence.

Serological screening of immunoglobulin M and immunoglobulin G during pregnancy for predicting congenital cytomegalovirus infection

BackgroundCytomegalovirus (CMV) is one of the most frequent pathogens for congenital infections. Most cases of congenital CMV infection (cCMV) are asymptomatic at birth, but sensorineural hearing loss (SNHL) or neurodevelopmental delay can appear later in childhood. This prospective study examined the practicability of serological screening for anti-CMV immunoglobulin (Ig) G and anti-CMV IgM in pregnant women.MethodsA total of 11,753 pregnant women were examined for CMV IgG and CMV IgM during the first or second trimester. When IgM was positive, IgG was reevaluated more than two weeks later. When IgG was negative, IgG was reevaluated in the second or third trimester. All neonates from mothers with positive/borderline IgM or IgG seroconversion underwent polymerase chain reaction assay for CMV using urine samples to diagnose cCMV. Levels of IgG and IgM were compared between mothers with and without cCMV. Receiver operating characteristic (ROC) curves for IgM titers were analyzed.ResultsEight of 500 neonates (1.6%) born from mothers with positive IgG and positive IgM, and 3 of 13 neonates (23.1%) born from mothers with IgG seroconversion were diagnosed with cCMV. Neither IgM titers nor IgG titers differed significantly between cCMV and non-cCMV groups. The area under the ROC curve was 0.716 and the optimal cut-off for IgM was 7.28 index (sensitivity = 0.625, specificity = 0.965, positive predictive value = 0.238, negative predictive value = 0.993). Titers of IgG were not frequently elevated in pregnant women with positive IgM during the observation period, including in those with cCMV. All 11 cCMV cases were asymptomatic at birth and none had shown SNHL or developmental delay as of the last regular visit (mean age, 40 months).ConclusionsSeroconversion of CMV IgG and high-titer IgM during early pregnancy are predictors of cCMV. High IgM titer (> 7.28 index) is a predictor despite relatively low sensitivity. Levels of IgG had already plateaued at first evaluation in mothers with cCMV. Maternal screening offered insufficient positive predictive value for diagnosing cCMV, but allowed identifying asymptomatic cCMV cases in an early stage.

Exploration of the process of prenatal screening and diagnosis for women with advanced maternal age based on results of 351 cases of fetal chromosomal abnormalities

To explore the suitable process for prenatal screening and diagnosis for women with advanced maternal age. From January 2014 to November 2017, the indications and distributions of prenatal diagnosis for women with advanced maternal age only or accompanying with positive maternal serum test screening and non-invasive prenatal testing (NIPT), abnormal fetal ultrasound, one harboring chromosomal abnormalities or anomalous reproductive history were analyzed. The rate of fetal chromosomal abnormalities was compared between different groups. The 351 pregnant women with fetal chromosomal abnormalities have included 196 cases with advanced maternal age, 26 with positive maternal serum test, 96 with high-risk by NIPT, 14 with abnormal fetal ultrasound, 15 with one partner harboring chromosomal abnormalities, and 4 with anomalous reproductive history. Assuming that all pregnant women had undergone maternal serum test screening or NIPT without amniocentesis, the detection rate of fetal chromosome abnormality would be 51.0% and 69.2%, respectively. However, should these women have received both tests, the detection rate would be as high as 84.6%. Should those with one partner harboring chromosomal abnormalities undergone maternal serum test screening or NIPT without amniocentesis, the detection rate of fetal chromosomal abnormality would only be 6.7%. Should pregnant women with advanced maternal age undergo both maternal serum test and NIPT, the detection rate of fetal chromosomal abnormality will be higher than those receiving only maternal serum test screening or NIPT. Couples with one partner harboring chromosomal abnormalities should undergo prenatal diagnosis by amniocentesis.

Diagnostic Point-of-Care Ultrasound: Applications in Obstetric Anaesthetic Management

(Anaesthesia. 2018;73:1265–1279) Even in low-risk centers, pregnancies can become complicated seriously and quickly, without time to obtain diagnostic help from specialists. While ultrasound has been routinely used in fetal monitoring, it can also be a useful tool in maternal bedside diagnosis and screening. This report reviews the use of ultrasound in assessing patients’ gastric contents and airways, managing breathless patients, diagnosing shock, and predicting fluid responsiveness.

Incidence and outcome of group B streptococcal invasive disease in Omani infants.

ObjectivesGroup B streptococcus (GBS) infection is a serious disease that continues to cause high morbidity and mortality. It is one of the leading cause of sepsis; particularly meningitis, in infants and young children all around the world. In this study, we aim to identify the incidence of GBS sepsis in Omani infants less than 3 months of age who were born at Royal Hospital and who presented with clinical sepsis and positive culture. In addition, we aim to describe the clinical presentation and complications noted on admission and then on follow-up visit.MethodsThis is an observational retrospective chart review study. It included all Omani infants (0–3 months) who were diagnosed to have GBS sepsis/meningitis from 2006 to 2016 at the Royal Hospital, Muscat, Sultanate of Oman.ResultsThere were 83,000 live births in the Royal Hospital over a period of 10 years. Thirty-eight babies had culture proven GBS infection, with an overall incidence rate of neonatal GBS of 0.46 per 1000 live births with 95% confidence intervals. There were no significant variations in the annual rates of infection during the study period, ranging from around 1–7 cases per year. Additional 5 cases of GBS sepsis presented to Royal Hospital are either through Emergency Department or as referrals from other hospitals, giving us a total of 43 cases of proven GBS infections. Out of the 43 cases, 8 were born prematurely (19%), either before (<34 weeks, n = 2) or during (34–36 weeks, n = 6). Term babies were 35 out of 43 with percentage of 81% of the total. Three died, resulting in a case mortality of 7.0%.ConclusionOur GBS incidence is comparable to that of screened population internationally. At the time being, with the best available results, maternal screening might not seem cost effective in our current settings. A cost effective study is required before implemented a national screening programme in the Country. However, this research will definitely help in the process of any future plans of implantation of new guidelines, as it can be used as leading point for future prospective studies.

Impact of a Sepsis Screening Tool on the Assessment of Maternal Sepsis

Maternal sepsis screening tool in the labor and delivery unit. To study how a sepsis screening tool will impact nurses on the labor and delivery unit and their awareness and recognition regarding sepsis. Sepsis accounts for up to 28% of all maternal deaths and 15% of maternal admissions to the intensive care unit. Although some sepsis screening tools exist, sepsis in pregnant women has not been researched extensively and can resemble the normal pathophysiology of pregnancy. The evidence shows that early recognition and treatment of maternal sepsis increase the chance of survival. To measure our outcome, we surveyed labor and delivery unit nurses before implementation to assess their current knowledge of the sepsis screening tool and their comfort level caring for a patient who has sepsis. After 3 months of implementation, we reassessed nurses’ knowledge regarding sepsis. According to our preimplementation data, 47% of nurses (14/30) stated that they were comfortable caring for a patient with sepsis and 57% of nurses (17/30) stated that they currently assessed for sepsis every shift. However, when asked to select the symptoms of sepsis, only 3% of nurses (1/30) were able to correctly select all of the symptoms. Ninety-three percent (28/30) of the nurses agreed that a sepsis screening tool would be helpful to them in their role as a nurse. According to our postimplementation data, 48% of nurses (10/21) were able to correctly identify all of the symptoms of sepsis and 76% of nurses (16/21) reported that their knowledge had increased. After using the screening tool, 100% of nurses thought that a screening tool in the EPIC documentation be helpful in their role as nurse. Use of the sepsis screening tool increased nurses’ awareness and recognition regarding sepsis. Nurses reported that they felt empowered to notify the physicians and make appropriate recommendations regarding patient care. All nurses agreed that having a sepsis screening tool in EPIC would benefit their practice and help promote patient safety and successful outcomes. Since this hospital does not have a sepsis protocol in place, our recommendation is to create a sepsis protocol that includes bundles that nurses can initiate independently.

Performance of first trimester maternal screening biomarkers pregnancy-associated plasma protein a (PAPP-A) and free beta human chorionic gonadotropin (FBHCG) on the Atellica® IM Analyzer

Metabolic syndrome (MetS) has been associated with a procoagulant and hypofibrinolytic state. Current data exploring the role of MetS in venous thromboembolism (VTE) are limited. The objective was to measure the prevalence of MetS in patients with acute PE receiving catheter-directed thrombolysis (CDT) and to investigate its effect on mean pulmonary arterial pressure and overall treatment success.We used a 3-year prospective registry of ED patients with acute PE with severity qualifying for activation of a PE response team (PERT). All patients had CDT with catheter-measured mPAP and angiography. The presence or absence of MetS components were extracted from chart review based on the following criteria: 1. body mass index (BMI) > 30 kg/m2; 2. diagnosed hypertension; 3. diabetes mellitus (including HbA1c > 6.5%) and; 4. dyslipidemia (including triglycerides > 150 mg/dL or high-density lipoprotein < 40 mg/dL).Of the 134 patients, 85% met the criteria for at least one of four MetS components, with obesity being most common, present in 71%. Results demonstrated a positive concordance between the number of criteria for MetS and MPAP, both pre- and post-fibrinolysis, as pressures tended to increase with each additional MetS criterion. Multivariate regression analysis determined age (-), BMI (+) and hypertension (+) to be significant independent predictor variables for mPAP.MetS was common in patients with more severe manifestations of PE and was associated with higher mPAP values both at diagnosis and following treatment with CDT.

Influence of the level of maternal education on the long-term neurodevelopmental outcome of Saudi infants with birth weight of 1000-1500 grams at the age of 21-24 months

Background: Advancements in perinatal-neonatal care in the last decades has led to improved survival rates of very-low birth weight (VLBW) infants. An association between the level of maternal education and neurodevelopmental outcome has been demonstrated in many European studies. This study evaluates the influence of maternal education level and socio-demographic status on the long-term development of Saudi VLBW infants with birth weight of 1000-1500 grams at a corrected gestational age of 21-24 months. Method: This retrospective cohort study examined prospectively collected data from the period of 2005 to 2016 from the Neonatal Follow-up Program (NFP) at King Khalid University Hospital in Riyadh, Saudi Arabia. Results: A total of 122 VLBW infants with a mean gestational age of 29.57 weeks and mean birth weight 1265 grams were enrolled. There was no statistically significant association between the level of maternal education and neurodevelopmental screening outcome at the age of 21-24 months according to the Bayley Infant Neurodevelopmental Screener (BINS) (p=0.149). Bronchopulmonary dysplasia (BPD) was highly associated with cerebral palsy (p=0.001) and an abnormal BINS score (p=0.010). Conclusion: There was no significant influence of the level of maternal education on the neurodevelopmental screening outcome of VLBW infants at the corrected age of 21-24 months. BPD was the strongest predictor of adverse neurodevelopmental outcome. Keywords: Bayley Infant Neurodevelopmental Screener (BINS), Neurodevelopmental Outcome, Maternal educational level, Neonatal follow-up program (NFP), Very Low Birth Weight (VLBW) infant.

Hepatitis B virus infection: Prevention of mother-to-child transmission and exacerbation during pregnancy

The aims of this study were to assess the effect of maternal screening for hepatitis B (HB) virus and a perinatal prevention program of mother-to-child transmission, and to identify clinical characteristics and findings associated with HB exacerbation during pregnancy. This prospective cohort study enrolled 3796 pregnant women and their neonates with informed consent. Pregnant women underwent maternal universal screening for HBs antigen (Ag) in the first trimester. If HBs Ag was positive, serum levels of HBe Ag, alanine transaminase (AST), aspartate aminotransferase (ALT), and HB virus (HBV) DNA were measured. All neonates delivered from HBs Ag-positive women were given HB immune globulin and HB vaccine based on the guidelines of the perinatal prevention program. Of the 3796 pregnant women, 40 (1.05%) tested positive for HBs Ag. Three (7.5%) of the 40 HBs Ag-positive women experienced exacerbation of HBV infection during pregnancy. Serum levels of AST (median 776 vs. 22 mIU/ml, p < 0.01), ALT (median 325 vs. 15 mIU/ml, p < 0.01), and HBV-DNA (median 9.1 vs. 5.4 log copies/ml, p < 0.05), and frequencies of HBe Ag-positive (100% vs. 29.7%, p < 0.05) and symptoms of itching or general fatigue (66.7% vs. 0%, p < 0.01) in three women with exacerbation of HBV infection were significantly higher than those in 37 women without exacerbation. There was no case of mother-to-child transmission, suggesting the perinatal HBV prevention program was effective. Levels of HBe Ag, liver enzymes, and HBV-DNA as well as symptoms of itching and general fatigue should be carefully monitored for HBs Ag-positive women during pregnancy and the postpartum period.

Group B streptococcal screening, intrapartum antibiotic prophylaxis, and neonatal early-onset infection rates in an Australian local health district: 2006-2016.

BackgroundIntrapartum antibiotic prophylaxis (IAP) to reduce the likelihood of neonatal early-onset group B streptococcal infection (EOGBS) has coincided with major reductions in incidence. While the decline has been largely ascribed to IAP following either universal screening or a risk-based approach to identify mothers whose babies may most benefit from IAP, there is lack of high quality evidence to support this view.AimsTo describe management of maternal GBS colonisation in one local health district using universal screening and assess rates of EOGBS over time.MethodsA retrospective cohort study was undertaken to describe compliance with GBS management, to determine the incidence of EOGBS and association between rates and maternal screening. Linking routinely collected maternity and pathology data, we explored temporal trends using logistic regression and covariates for potential effect modifiers.ResultsOur cohort included 62,281 women who had 92,055 pregnancies resulting in 93,584 live born babies. Screening occurred in 76% of pregnancies; 69% had a result recorded, 21.5% of those were positive for GBS. Prophylaxis was used by 79% of this group. Eighteen babies developed EOGBS, estimated incidence/1000 live births in 2006 and 2016 was 0.35 (95% CI, 0.07 to 0.63) and 0.1 (95% CI, 0 to 0.2) respectively. Seven of 10 term babies with EOGBS were born to mothers who screened negative. Data were unable to provide evidence of difference in rates of EOGBS between screened and unscreened pregnancies. We estimated the difference in EOGBS incidence from crude and weighted models to be 0 (95% CI, -0. 2 to 0.17) and -0.01 (95% CI, -0.13 to 0.10) /1000 live births respectively.ConclusionNo change was detected in rates of EOGBS over time and no difference in EOGBS in babies of screened and unscreened populations. Screening and prophylaxis rates were modest. Limitations of universal screening suggest alternatives be considered.

Republication de : Évaluation prospective des connaissances des couples concernant l’échographie de dépistage prénatal

ObjectivesEvaluation of the knowledge of couples concerning the prenatal screening ultrasound in order to improve information. MethodsThis prospective, observational and comparative study was carried out in three maternal centers: a level III maternity, a level II private maternity, and a private gynecologist's office where prenatal screening ultrasounds were performed between the first of March 2018 and the 31th of April 2018. A questionnaire was given to all pregnant women coming to consult for a prenatal screening ultrasound. It included items on maternal characteristics, pregnancy characteristics, and screening ultrasound. ResultsOne hundred and sixty-nine women answered the questionnaire. On the 138 participants who had consulted in the level III maternity, 42 % expected them to study fetal well-being, 38 % growth, and 13 % malformation. Forty-six percent attested to have received a request for consent, as well as information about these ultrasounds. The same is true for the 120 spouses in thelevel III maternity where only 7 % expected a malformation search to be carried out. The number of participants in the type II private maternity and the private gynecologist's office was insufficient. ConclusionThe information given and received, and the knowledge of couples in this level III maternity about the prenatal screening ultrasound seem to be insufficient. It is therefore important to inform the pregnant women and their spouse by giving consent before the first ultrasound and by a verbal message, simple and clear about what the professional is looking for in order to reduce this discrepancy, and thus prepare the couple in case of announcement of an anomaly.

Improving obstetric hemorrhage morbidity by a checklist-based management protocol; a quality improvement initiative

ObjectivePostpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide. Institutions are encouraged to have a standardized approach to the management of obstetric hemorrhage. The purpose of this quality improvement project was to investigate postpartum hemorrhage associated morbidity before and after implementing an obstetric hemorrhage checklist-based protocol. Study designIn 2015, a resident-driven initiative for obstetric hemorrhage was initiated at a single institution using a checklist-based protocol for postpartum hemorrhage. The project included development of the obstetric hemorrhage checklist by a multidisciplinary team and implementation using low cost education and training strategies. Following implementation, a pre-and post-protocol retrospective analysis was performed measuring maternal morbidity surrogates and protocol compliance. During the 18 month study period, 422 women were identified for review and 147 met criteria in the pre-protocol group and 150 met criteria in the post-protocol group. ResultsThere was a significant decrease in severe postpartum hemorrhage rates in the post-protocol group (p = 0.04) and all other surrogates for maternal morbidity decreased in the post-protocol group. Protocol compliance was 62.2% and compliance with screening using an assessment of hemorrhage risk was 75.7%. ConclusionThe implementation of a checklist-based management protocol for postpartum hemorrhage has shown a promising trend in improving maternal morbidity, screening, early diagnosis, and healthcare delivery for obstetric hemorrhage at our institution and has been approved for larger scale implementation within our health system.

A cohort study of maternal screening for congenital Toxoplasma gondii infection: 12 years' experience

Primary infection with Toxoplasma gondii (T. gondii) during pregnancy may cause congenital infection of the infant. This study evaluated whether screening using IgG avidity and multiplex-nested polymerase chain reaction (PCR) methods was effective for detecting a high-risk pregnancy for congenital T. gondii infection. In a prospective cohort study serum T. gondii IgG avidity was measured in 469 pregnant women who had a positive test for T. gondii antibody plus a positive or equivocal test for IgM. Multiplex-nested PCR for T. gondii DNA on amniotic fluid, maternal blood, and neonatal blood was performed with informed consent. Low (<30%), borderline (30–35%), and high (>35%) IgG avidity indices were found in 104 (22.2%), 30 (6.4%), and 305 (71.4%), respectively. A total of 12 cases had a positive PCR test for amniotic fluids of the prenatal amniocentesis or at birth, or neonatal blood. Seven of the 12 cases were diagnosed as having congenital T. gondii infection, and they had low IgG avidity indices. Congenital T. gondii infection screening using of IgG avidity and multiplex-nested PCR methods for pregnant women with a positive test for T. gondii antibody plus a positive or equivocal test for T. gondii IgM was useful for detecting a high-risk pregnancy and diagnosing congenital T. gondii infection.