Neonatal Intensive Care Admission Research Articles

A Case Report on the Unique Challenges of COVID-19 Infection During Perioperative Anesthesia Care for a Laboring COVID-19-Infected Mother in a Low-Resource Area

BACKGROUND:Recently, the rate of cesarean sections has increased, addressing the concern of anesthesia for cesarean sections in a similar manner. Physiological changes during pregnancy, such as increased cardiac output, heart rate, and oxygen consumption, decreased lung compliance and capacity, immune modulation (an altered response of the cell-mediated immunity), and increased risk of thromboembolic disease reduce maternal compensation during stress and certain pathological conditions like infections. Importantly, the provision of anesthesia for a pregnant mother is perceived as a challenging situation because of the attendant physiological, anatomical, and pharmacological changes in pregnancy. This culminates in the modification and dosage adjustment for certain medications, especially sedative-hypnotics and delivery, as well as the management of anesthetic techniques, to optimize and ensure maternal organ function and fetal well-being.Certain perioperative factors, such as COVID-19 infection, comorbid disease, and obstetric complications, increase the risk of maternal morbidity and mortality with a subsequent fetal compromise during the perioperative state, besides the aforementioned anesthetic challenges. Moreover, COVID-19 infection increases the perils of complicating pregnancy and pregnancy outcomes, including maternal artificial ventilation and intensive care admission, preterm labor, fetal distress, neonatal intensive care admission, and fetal and maternal deaths.CONCLUSION:Preventive strategies toward the spread of the COVID-19 infection, vaccines, and the proper use of personnel protective equipment by healthcare providers reduce the spread and severity of the COVID-19 infection and improve obstetric and pregnancy outcomes.

Gestational diabetes mellitus screening and diagnosis criteria before and during the COVID-19 pandemic: a retrospective pre-post study.

To determine whether perinatal outcomes after excluding gestational diabetes mellitus (GDM) on the basis of fasting venous plasma glucose (FVPG) assessment during the coronavirus disease 2019 (COVID-19) pandemic in 2020 were similar to those during the preceding year after excluding GDM using the standard oral glucose tolerance test (OGTT) procedure. Retrospective pre-post study. All women who gave birth in Queensland during 1 July - 31 December 2019 and 1 July - 31 December 2020. Perinatal (maternal and neonatal) outcomes for pregnant women assessed for GDM, by assessment method (2019: OGTT/glycated haemoglobin [HbA1c ] assessment; 2020: GDM could be excluded by an FVPG value below 4.7 mmol/L). 3968 of 29 113 pregnant women in Queensland during 1 July - 31 December 2019 (13.6%) were diagnosed with GDM, and 4029 of 28 778 during 1 July - 31 December 2020 (14.0%). In 2020, FVPG assessments established GDM in 216 women (1.1%) and excluded it in 1660 (5.8%). The frequencies of most perinatal outcomes were similar for women without GDM in 2019 and those for whom it was excluded in 2020 on the basis of FVPG values; the exception was caesarean delivery, for which the estimated probability increase in 2020 was 3.9 percentage points (95% credibility interval, 2.2-5.6 percentage points), corresponding to an extra 6.5 caesarean deliveries per 1000 births. The probabilities of several outcomes - respiratory distress, neonatal intensive care or special nursery admission, large for gestational age babies - were about one percentage point higher for women without GDM in 2020 (excluding those diagnosed on the basis of FVPG assessment alone) than for women without GDM in 2019. Identifying women at low absolute risk of gestational diabetes-related pregnancy complications on the basis of FVPG assessment as an initial step in GDM screening could reduce the burden for pregnant women and save the health system substantial costs.

A deep sift convolutional neural networks for total brain volume estimation from 3D ultrasound images

Preterm infants are a highly vulnerable population. The total brain volume (TBV) of these infants can be accurately estimated by brain ultrasound (US) imaging which enables a longitudinal study of early brain growth during Neonatal Intensive Care (NICU) admission. Automatic estimation of TBV from 3D images increases the diagnosis speed and evades the necessity for an expert to manually segment 3D images, which is a sophisticated and time consuming task. We develop a deep-learning approach to estimate TBV from 3D ultrasound images. It benefits from deep convolutional neural networks (CNN) with dilated residual connections and an additional layer, inspired by the fuzzy c-Means (FCM), to further separate the features into different regions, i.e. sift layer. Therefore, we call this method deep-sift convolutional neural networks (DSCNN). The proposed method is validated against three state-of-the-art methods including AlexNet-3D, ResNet-3D, and VGG-3D, for TBV estimation using two datasets acquired from two different ultrasound devices. The results highlight a strong correlation between the predictions and the observed TBV values. The regression activation maps are used to interpret DSCNN, allowing TBV estimation by exploring those pixels that are more consistent and plausible from an anatomical standpoint. Therefore, it can be used for direct estimation of TBV from 3D images without needing further image segmentation.

Discrimination of blood metabolomics profiles in neonates with idiopathic polyhydramnios.

This study is the first to investigate metabolomic profiles in newborns with IPH and examine the correlation between IPH and fetal health. Differential metabolites and pathways may affect amino acid synthesis and the nervous system. Continuous attention to the development of the nervous system in children with IPH is necessary. • There is an increased risk of adverse pregnancy outcomes with IPH, such as perinatal death, neonatal asphyxia, neonatal intensive care admission, cesarean section rates, and postpartum hemorrhage. • Children with a history of IPH have a higher proportion of defects than the general population, particularly central nervous system problems, neuromuscular disorders, and other malformations. • In neonates with IPH, six differential metabolites were identified with significant differences and good AUC values using LC-MS/MS analysis: glutamic acid, serine, asparagine, aspartic acid, homocysteine, and phenylalanine, which were mainly enriched in two metabolic pathways: aminoacyl-tRNA biosynthesis and alanine, aspartate, and glutamate metabolism. • These differential metabolites and pathways may affect amino acid synthesis and development of the nervous system in neonates with IPH.

The PURPOSe cause of death study in stillbirths and neonatal deaths in India and Pakistan: A review.

The PURPOSe study was a prospective, observational study conducted in India and Pakistan to determine the cause of death for stillbirths and preterm neonatal deaths, using clinical data together with minimally invasive tissue sampling (MITS) and the histologic and polymerase chain reaction (PCR) evaluation of fetal/neonatal tissues and the placenta. After evaluating all available data, an independent panel chose a maternal, a placental and a fetal/neonatal cause of death. Here, we summarise the major results. Among the most important findings were that most stillbirths were caused by fetal asphyxia, often preceded by placental malperfusion, and clinically associated with pre-eclampsia, placental abruption and a small-for-gestational-age fetus. The preterm neonatal deaths were primarily caused by birth asphyxia, followed by various infections. An important finding was that many of the preterm neonatal deaths were caused by a nosocomial infection acquired after neonatal intensive care (NICU) admission; the most common organisms were Acinetobacter baumannii, followed by Klebsiella pneumoniae, Escherichia coli/Shigella and Haemophilus influenzae. Group B streptococcus was less commonly present in the placentas or internal organs of the neonatal deaths.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes.

Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Development of a Family-Centered Communication Tool for Kidney Health in Premature Infants: Qualitative Focus Group Study Using Human-Centered Design Methodology.

Premature infants are at increased risk of kidney-related complications, including acute kidney injury (AKI) and chronic kidney disease (CKD). The risk of CKD in prematurely born infants is underrecognized by health care teams and caregivers. Understanding how to communicate the risk of CKD to caregivers is essential for longitudinal clinical follow-up and adherence. This study aimed to determine family caregiver attitudes toward kidney health and risk communication during a neonatal intensive care admission. We also sought to understand caregiver preferences for the communication of information surrounding the risk of CKD in premature infants. We augmented standard qualitative group sessions with human-centered design methods to assess parent preferences and clinician perspectives. Caregivers recruited had a prematurely born child who spent time in the neonatal intensive care unit at Riley Hospital for Children in Indianapolis, Indiana, and experienced AKI or another kidney complication, which put them at risk for future CKD. We used a variety of specific design methods in these sessions, including card sorting, projective methods, experience mapping, and constructive methods. A total of 7 clinicians and 8 caregivers participated in 3 group sessions. Caregivers and clinicians readily acknowledged barriers to and drivers of long-term kidney monitoring as well as opportunities for communication of the risk of long-term kidney disease. Caregivers' primary concerns were for both the type and depth of information conveyed as well as the time at which it was communicated. Participants emphasized the importance of collaboration between the hospital care team and the primary care provider. Participant input was synthesized into several prototype concepts and, ultimately, into a rough prototype of a website and an informational flyer. Caregivers of premature infants are open to communication about kidney health during their neonatal admission. The next phase of this work will translate caregivers' preferences into family-centered communication tools and test their efficacy in the neonatal intensive care unit.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries.

Comparative data on the potential impact of various forms of labor analgesia on the mode of delivery and neonatal complications in vaginal deliveries of singleton breech and twin fetuses are lacking. The present study aimed to determine the associations between type of labor analgesia (epidural analgesia (EA) vs. remifentanil patient-controlled analgesia (PCA)) and intrapartum cesarean sections (CS), and maternal and neonatal adverse outcomes in breech and twin vaginal births. A retrospective analysis of planned vaginal breech and twin deliveries at the Department of Perinatology, University Medical Centre Ljubljana, was performed for the period 2013-2021, using data obtained from the Slovenian National Perinatal Information System. The pre-specified outcomes studied were the rates of CS in labor, postpartum hemorrhage, obstetric anal sphincter injury (OASI), an Apgar score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. A total of 371 deliveries were analyzed, including 127 term breech and 244 twin births. There were no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in any of the outcomes studied. Our findings suggest that both EA and remifentanil-PCA are safe and comparable in terms of labor outcomes in singleton breech and twin deliveries.

Effect of progesterone on preventing preterm birth and adverse perinatal outcomes in women in the risk group: A prospective clinical trial

Background and Objective: Preterm labor is a significant reason for perinatal mortality and morbidity. This study was conducted to determine the effect of two regimens of progesterone to avoid preterm labor and the adverse perinatal outcomes in the two groups. Methods: A prospective clinical trial was performed in Maternity Teaching Hospital and Hawler Private Hospital in Erbil city, Kurdistan region, Iraq over a one-year period from 1 May 2019 until 1 May 2020. The study sample was 200 pregnant women with a short cervix and a risk of preterm birth; the sample was divided into two groups. Group I of 100 pregnant women received 400 mg progesterone vaginally once daily, and group II of 100 pregnant women received it twice daily, started from 16 weeks of gestation up to the time of delivery in both groups. Results: The rate of term pregnancy (? 37 weeks) was 87% among women in group II and 55% in women in group I. Accordingly, the rate of neonatal intensive care admission was significantly higher in group I than in group II (30% and 11%, respectively). The rate of respiratory distress syndrome was also significantly higher in group I (31%) than in group II (7%). Conclusion: The administration of progesterone 400 mg vaginally twice a day appears to be more effective than progesterone 400 mg vaginally once a day in preventing preterm birth and reducing the risk of adverse neonatal complications.

Effect of inter-pregnancy interval on serum ferritin, haematocrit and pregnancy outcome in Ilorin, Nigeria.

Available information remains limited on inter-pregnancy interval (IPI) and its effect on maternal health and pregnancy outcome. To determine the effect of IPI on maternal serum ferritin, haematocrit and pregnancy outcome. A prospective cohort study of 316 women categorized into WHO recommended IPI of ≥24 months (group I) and IPI <24 months i.e. short IPI (SIPI) as group II after matching for gestational age and social status. Serum ferritin and haematocrit levels were assayed in first and second trimesters; primary outcome measures were maternal serum ferritin, haematocrit and pregnancy outcome gestational age at delivery, birth and placental weights, APGAR scores and neonatal intensive admission). Participants were followed up until six-week post-delivery. Data analysis was with SPSS version 21.0; p<0.05 was significant. Women in group I had higher mean serum ferritin (37.40±3.15 vs. 32.61±2.68; P<0.001), booking haematocrit (33.24±3.59 vs. 27.92±2.67; P<0.001) and mean birth weight (3100±310 vs. 2700±350; P<0.001). Antenatal hospital admission (P0.002), preterm delivery (P<0.001) and neonatal intensive care admission (P<0.001) were higher for group II. There was no maternal mortality; perinatal mortality was zero (group I) and 95/1000 livebirth (group II). Low serum ferritin, haematocrit and adverse neonatal outcomes were associated with SIPI.

Cervical dilatation at diagnosis of active phase of labour determines the mode of delivery and peripartum outcomes: a retrospective study in a single tertiary centre in Malaysia

BackgroundThere is an increasing trend of Caesarean section rate in Malaysia. Limited evidence demonstrated the benefits of changing the demarcation of the active phase of labour.MethodsThis was a retrospective study of 3980 singletons, term pregnancy, spontaneous labouring women between 2015 and 2019 comparing outcomes between those with cervical dilation of 4 versus 6 cm at diagnosis of the active phase of labour.ResultsA total of 3403 (85.5%) women had cervical dilatation of 4 cm, and 577 (14.5%) at 6 cm upon diagnosis of the active phase of labour. Women in 4 cm group were significantly heavier at delivery (p = 0.015) but significantly more multiparous women were in 6 cm group (p < 0.001). There were significantly fewer women in the 6 cm group who needed oxytocin infusion (p < 0.001) and epidural analgesia (p < 0.001) with significantly lower caesarean section rate (p < 0.001) done for fetal distress and poor progress (p < 0.001 both). The mean duration from diagnosis of the active phase of labour until delivery was significantly shorter in the 6 cm group (p < 0.001) with lighter mean birth weight (p = 0.019) and fewer neonates with arterial cord pH < 7.20 (p = 0.047) requiring neonatal intensive care unit admissions (p = 0.01). Multiparity (AOR = 0.488, p < 0.001), oxytocin augmentation (AOR = 0.487, p < 0.001) and active phase of labour diagnosed at 6 cm (AOR = 0.337, p < 0.001) reduced the risk of caesarean delivery. Caesarean delivery increased the risk of neonatal intensive care admission by 27% (AOR = 1.73, p < 0.001).ConclusionsActive phase of labour at 6 cm cervical dilatation is associated with reduced primary caesarean delivery rate, labour intervention, shorter labour duration and fewer neonatal complications.

Neonatal intensive care admission for term neonates and subsequent childhood mortality: a retrospective linkage study

BackgroundNeonatal intensive care unit (NICU) admission among term neonates is a rare event. The aim of this study was to study the association of the NICU admission of term neonates on the risk of long-term childhood mortality.MethodsA single-center case–control retrospective study between 2005 and 2019, including all in-hospital ≥ 37 weeks’ gestation singleton live-born neonates. The center perinatal database was linked with the birth and death certificate registries of the Israeli Ministry of Internal Affairs. The primary aim of the study was to study the association between NICU admission and childhood mortality throughout a 15-year follow-up period.ResultsDuring the study period, 206,509 births were registered; 192,527 (93.22%) term neonates were included in the study; 5292 (2.75%) were admitted to NICU. Throughout the follow-up period, the mortality risk for term neonates admitted to the NICU remained elevated; hazard ratio (HR), 19.72 [14.66, 26.53], (p < 0.001). For all term neonates, the mortality rate was 0.16% (n = 311); 47.9% (n = 149) of those had records of a NICU admission. The mortality rate by time points (ratio1:10,0000 births) related to the age at death during the follow-up period was as follows: 29, up to 7 days; 20, 7–28 days; 37, 28 days to 6 months; 21, 6 months to 1 year; 19, 1–2 years; 9, 2–3 years; 10, 3–4 years; and 27, 4 years and more. Following the exclusion of congenital malformations and chromosomal abnormalities, NICU admission remained the most significant risk factor associated with mortality of the study population, HRs, 364.4 [145.3; 913.3] for mortality in the first 7 days of life; 19.6 [12.1; 32.0] for mortality from 28 days through 6 months of life and remained markedly elevated after age 4 years; HR, 7.1 [3.0; 17.0]. The mortality risk related to the NICU admission event, adjusted for admission diagnoses remained significant; HR = 8.21 [5.43; 12.4].ConclusionsNICU admission for term neonates is a pondering event for the risk of long-term childhood mortality. This group of term neonates may benefit from focused health care.

Caesarean Section for Placenta Previa: A Retrospective Cohort Study of Anaesthesia Techniques.

Placenta previa is associated with maternal and neonatal morbidity and mortality. This study aims to add to the limited literature from the developing world on the association of different anaesthetic techniques with blood loss, the need for blood transfusion, and maternal/ neonatal outcomes among women undergoing caesarean section with placenta previa.This retrospective study was conducted at Aga University Hospital, Karachi, Pakistan. The patient population included parturients undergoing caesarean section for placenta previa from January 1, 2006, through December 31, 2019.Out of 276 consecutive cases of placenta previa progressing to caesarean section during the study period, 36.24% were performed under regional anaesthesia and 63.76% under general anaesthesia. When compared to general anaesthesia, significantly less regional anaesthesia was used for emergency caesarean section (26% vs. 38.6%, P = .033) and for grade IV placenta previa (50% vs. 68.8%, P = .013). Blood loss was found to be significantly low with regional anaesthesia (P = .005) and posterior placenta (P = .042), while it was found to be high in grade IV placenta previa (P = .024). The odds of requiring blood transfusion were low in regional anaesthesia (odds ratio = 0.122; 95% CI = 0.041-0.36, P = .0005) and posterior placenta (odds ratio = 0.402; 95% CI = 0.201-0.804, P = .010), while they were high in grade IV placenta previa (odds ratio: 4.13; 95% CI = 0.90-19.80, P = .0681). The rate of neonatal deaths and intensive care admission was significantly lower in regional anaesthesia than in general anaesthesia (7% vs. 3% and 9% vs. 3%). The maternal mortality was zero; however, intensive care admission was less in regional anaesthesia compared to general anaesthesia (<1% vs. 4%).Our data demonstrated less blood loss, need for blood transfusion, and better maternal and neonatal outcomes with regional anaesthesia for caesarean section in women with placenta previa.

Multiple congenital anomalies and adverse developmental outcomes are associated with neonatal intensive care admission and unilateral hearing loss.

To determine congenital and developmental outcomes of children with Unilateral Hearing Loss (UHL) who were admitted to the Neonatal Intensive Care Unit (NICU). Retrospective, single-site study that followed 25 children with permanent congenital UHL and a NICU admission to a NICU of Nottingham University Hospital. Birth and two-year developmental follow-up data were collected. They were compared to matched control group who had a NICU admission but no hearing loss (matched on gestational age, weight and sex). The median birthweights, gestational ages and number of days spent on the NICU for the UHL population were 2510 g, 36 weeks, and 12 days respectively. Most children (20/25; 80%) with UHL and a NICU admission were diagnosed with a congenital anomaly within the first two years of life. Only half (13/25) of these children were diagnosed with a congenital anomaly at discharge. Children with UHL and a NICU admission were more likely than the matched group (NICU admission only; p < .001) to have multiple congenital anomalies. We found a positive association between multiple congenital anomalies and developmental impairment for the NICU graduates with UHL (p = .019). This UHL-NICU group were also more likely than the matched NICU children to have developmental impairment (7/25 vs. 0/25; p = .01), speech and language therapy (13/25 vs. 1/25; p < .001), inner ear malformations (14/25 vs. 0/25, p < .001) or craniofacial anomalies (12/25 vs. 2/25; p = .004). Children with UHL and a NICU admission were at high risk of congenital anomalies and certain adverse developmental outcomes. Improved congenital anomaly screening is needed at birth for this population. Having multiple congenital anomalies suggests closer developmental monitoring is needed. This study contributes towards producing clinical screening and management guidelines to ensure consistent high-quality care for this unique population.

Outcomes of history indicated cerclage compared with cervical length screening in patients with cervical insufficiency

To evaluate pregnancy outcomes of history-indicated cerclage compared with ultrasound cervical length screening in patients with a history of cervical insufficiency defined as prior spontaneous preterm delivery from 14 0/7 to 23 6/7 weeks’ of gestation. This was a retrospective cohort study of patients with singleton gestations with a history of cervical insufficiency. We excluded patients who started prenatal care after 24 weeks, who delivered before 24 weeks, and who declined both a history-indicated cerclage or cervical length screening. The primary outcome was preterm delivery < 37 weeks’ gestation. Secondary outcomes included gestational age at delivery, spontaneous preterm birth < 37 weeks, spontaneous preterm birth < 34 weeks, preterm premature rupture of membranes, cesarean delivery, birthweight, and neonatal intensive care (NICU) admissions. Adjusted odds ratios (aOR) with 95th confidence intervals (95%CI) were calculated, controlling for confounders. Of 376 singleton gestations included, 177 (47.1%) underwent history-indicated cerclage and 199 (52.9%) underwent cervical length screening. Of 199 who underwent cervical length screening, 92 (46%) underwent ultrasound-indicated or physical exam-indicated cerclage. Compared to cervical length screening, history-indicated cerclage was not associated with increased odds of preterm delivery less than 37 weeks (37.7% vs. 29.4%; aOR 0.75 [95%CI 0.48-1.18]). However, compared to cervical length screening, history-indicated cerclage was associated with decreased odds of spontaneous preterm delivery less than 34 weeks (18.1% vs. 9.0%; aOR 0.47 [95%CI 0.23-0.97]). History-indicated cerclage compared with cervical length screening was associated with decreased odds of spontaneous preterm delivery less than 34 weeks. Given that approximately half of the patients undergoing cervical length screening required cerclage, history-indicated cerclage should be considered for patients with a history of cervical insufficiency.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Panniculus retractor use during scheduled cesarean section: potential neonatal impact

Use of a disposable panniculus retractor (DPR) during cesarean section (CS) improves surgical site visualization in obese women. However, whether this redistribution of weight onto the uterus and abdominal vasculature just prior to delivery impacts neonatal outcomes is unclear. To assess the potential downstream effect of DPR, we investigated neonatal outcomes after scheduled CS for deliveries using DPR. A retrospective cohort study of term pregnant patients with body mass index (BMI) ≥ 40.00 kg/m2 who underwent a scheduled CS at a tertiary care center from June, 2018 to May, 2019. CS using a DPR were compared to those without. Exclusion criteria included multiple gestation, fetal anomalies and general anesthesia. Universal umbilical artery (UA) cord gas collection is performed at our institution. The primary outcome was UA pH. Secondary outcomes were UA pH< 7.1, APGAR scores at 1 min and 5 min, neonatal intensive care (NICU) admission, and other UA gas parameters. Descriptive statistics and univariate analysis were performed. Multivariable logistic regression was used to adjust for potential confounders. 91 patients met inclusion criteria, including 23 (25.3%) with intraoperative DPR use and 68 (74.7%) without. Patients in the DPR group had a higher BMI (49.4 kg/m2 ±7.8 vs 45.9 kg/m2±6.1 [p=0.03]), and higher rates of drug use (47.8% vs 16.2% [p< 0.01]). UA pH was similar between groups (7.21±0.09 vs 7.24±0.06 [p=0.13]) as was UA pH < 7.1 (4.3% vs 1.5% [p=0.56]). UA lactate was significantly higher in the DPR group (4.0mmol/l±1.9 vs 3.2mmol/l±1.2 [p=0.02]). However, the risk of UA lactate > 4 mmol/l and NICU admission were similar between groups (aRR 2.52 [0.81, 3.53] and aRR 1.92 [0.31, 8.59], respectively). Intraoperative use of DPR did not significantly impact rates of neonatal acidemia at time of delivery. However, as elevated UA lactate represents early hypoxemia, more research is needed to assess the impact of increased lactate and whether this indicates an emerging trend.

Optimal mode of delivery in pregnancy: Individualized predictions using national vital statistics data.

Child birth via Cesarean section accounts for approximately 32% of all births each year in the United States. A variety of risk factors and complications can lead caregivers and patients to plan for a Cesarean delivery in advance before onset of labor. However, a non-trivial subset of Cesarean sections (∼25%) are unplanned and occur after an initial trial of labor is attempted. Unfortunately, patients who deliver via unplanned Cesarean sections have increased maternal morbidity and mortality rates and higher rates of neonatal intensive care admissions. In an effort to develop models aimed at improving health outcomes in labor and delivery, this work seeks to explore the use of national vital statistics data to quantify the likelihood of an unplanned Cesarean section based on 22 maternal characteristics. Machine learning techniques are used to ascertain influential features, train and evaluate models, and assess accuracy against available test data. Based on cross-validation results from a large training cohort (n = 6,530,467 births), the gradient-boosted tree algorithm was identified as the best performer and was evaluated on a large test cohort (n = 10,613,877 births) for two prediction scenarios. Area under the receiver operating characteristic curves of 0.77 or higher and recall scores of 0.78 or higher were obtained and the resulting models are well calibrated. Combined with feature importance analysis to explain why certain maternal characteristics lead to a specific prediction in individual patients, the developed analysis pipeline provides additional quantitative information to aid in the decision process on whether to plan for a Cesarean section in advance, a substantially safer option among women at a high risk of unplanned Cesarean delivery during labor.

Fetal pulmonary artery Doppler parameters in pregnancies complicated with intrahepatic cholestasis of pregnancy: a prospective case-control study

The primary aim of this study was to determine whether pulmonary artery acceleration time (AT) to ejection time (ET) ratio (PATET) was altered in fetuses of mothers with intrahepatic cholestasis of pregnancy (IHCP). The secondary aim was to investigate the association between fetal pulmonary artery Doppler parameters with neonatal outcomes in pregnancies complicated by IHCP. This prospective case control study was conducted in a tertiary perinatal-neonatal center. A total of 18 fetuses whose mothers’ pregnancies were complicated by IHCP were included as the study group and a total of 37 fetuses of mothers with healthy pregnancies were selected as controls. Fetal pulmonary artery Doppler parameters (AT; ET; AT/ET ratio) were assessed and neonatal outcomes were evaluated. Mean pulmonary artery AT, ET and PATET were significantly different between the groups (p=0.001, p=0.024 and p=0.003, respectively). The mean PATET value in the IHCP group was 0.217±0.029 while in the control group it was 0.180±0.020. While PATET values were correlated with gestational age at birth, respiratory distress and need for neonatal intensive care admission were not correlated with PATET. Higher values of PATET may be a useful biomarker of fetal lung damage, secondary to IHCP.

Overt diabetes imposes a comparable burden on outcomes as pregestational diabetes: a cohort study

BackgroundWomen with diabetes first diagnosed during pregnancy (overt diabetes) may be at the same risk level of adverse outcomes as those with known pregestational diabetes. We compared pregnancy outcomes between these groups.MethodsWe evaluated pregnant women with type 2 diabetes, pregestational or overt diabetes, attending high risk antenatal care in two public hospitals in Southern Brazil, from May 20, 2005 to June 30, 2021. Outcomes were retrieved from electronic medical records. Risk of adverse outcomes, expressed as relative risk (RR) and 95% confidence interval (CI), were calculated using Poisson regression with robust estimates.ResultsOf 618 women, 33% were labelled as having overt diabetes and 67%, pregestational diabetes. Baseline maternal characteristics were similar: there was a slight, non-clinically relevant, difference in maternal age (33 ± 5.7 years in women with pregestational diabetes vs. 32 ± 6.0 years in women with overt diabetes, p = 0.004); and women with overt diabetes reported smoking almost twice compared to those with pregestational diabetes (12.3% vs. 6.5%, p = 0.024). There were no relevant differences between the groups regarding pregnancy outcomes, although there was a trend of higher neonatal intensive care admission in the group of women with pregestational diabetes (45.2% vs. 36.1%, p = 0.051).ConclusionsOvert diabetes was diagnosed in one third of this cohort of pregnant women with hyperglycemia. Their pregnancy outcomes were similar to those of women with pregestational diabetes and were mostly related to maternal demographic characteristics and metabolic control. A call to action should be made to identify women of childbearing age at risk for pre-pregnancy diabetes; to detect hyperglycemia before conception; and to implement timely preconception care to all women with diabetes.

Induction of labour with misoprostol in premature rupture of membranes after 34 weeks: Which route is better and at what dose a randomized control trial in a tertiary care hospital

Background: The idea of this study was to evaluate the efficacy and safety of different routes of administration of misoprostol - 50µg oral, 25µg vaginal and 50µg sublingual for induction of labour in women with premature rupture of membranes after 34 weeks of gestation.Design: Randomized controlled trial.Sample: A total of 252 women with premature rupture of membranes after 34 weeks of gestation with indications of induction of labour.Methods: Study was conducted from 01/02/2022 to 31/11/2022, Women admitted to ward with premature rupture of membranes (PROM) after 34 weeks of gestation and requiring induction of labour were randomized into three groups. A total of 252 women participated in the study and were assigned to three groups to receive either 50µg oral misoprostol (n=82) or 25µg vaginal misoprostol (n=85) or 50µg sublingual misoprostol (n=85). The doses were repeated 4 hourly till active labour was established or up to a maximum of 4 doses.Major outcomes: 1.Induction to active labour 2.induction to delivery intervals 3.Delivery modes and 4.fetal outcomes were noted.Results: The mean induction to active labour interval was not significantly different in the three groups (oral vs vaginal vs sublingual- 7.54±4.8 vs 7.77±4.1 h vs 7.68±5.1 h; p=0.92). There was no significant difference in the induction to delivery time interval among the three misoprostol groups (oral vs vaginal vs sublingual – 10.7± 5.5 h vs 11.2±5.0 h vs 11.2±6.4 h; p= 0.88). Spontaneous vaginal delivery rate, instrumental delivery rate and lower segment caesarean section rates were comparable among the three groups. The spontaneous vaginal delivery is more in vaginal group and least in the sublingual group. The oral group is almost equal to the sublingual group in spontaneous delivery. The number of neonates with APGAR score <7 (low APGAR) at 1 minute of birth was highest in sublingual group and lowest in vaginal group which was statistically significant (oral vs vaginal vs sublingual, 16.8% vs 9.4% vs 20%; p= 0. 04). APGAR score <7 at 5 minutes was not significantly different among the three groups (oral vs vaginal vs sublingual, 6.02% vs 3.5% vs 7.05%; p=0.2). This implies that the need for immediate resuscitation was more in the sublingual group. Neonatal intensive care admission was least in the vaginal group although the difference was not statistically significant.Conclusion: 50µg oral misoprostol, 25µg vaginal misoprostol or 50µg sublingual misoprostol for induction of labour after 34 weeks of gestation have equal efficacy for induction of labour in women with spontaneous vaginal delivery is highest in vaginal route. The spontaneous vaginal delivery is more in vaginal route. The sublingual route having slightly higher incidence of low APGAR scores at one minute for the neonate.