Neonatal Intensive Care Unit Admission Rate Research Articles

Does detection of fetal growth restriction improve neonatal outcomes?

Timely delivery of fetal growth restriction (FGR) is a balance between avoiding stillbirth and minimising prematurity. We sought to assess the neonatal outcomes for babies suspected of FGR, both true and false positives. This population cohort study examined all singleton births in Victoria, Australia from 2000 to 2017 (n = 1 231 415). Neonatal morbidities associated with neonatal intensive care unit (NICU) admission were assessed for babies born ≥32 weeks' with severe FGR (<3rd centile) and babies with birthweight ≥10th centile who were iatrogenically delivered for suspected FGR. Babies with severe FGR iatrogenically delivered for suspected FGR were more likely to require NICU admission than babies with severe FGR who were not detected (3.0% vs. 1.1%, P < 0.001). After adjusting for potential confounders, the odds of NICU admission were increased (adjusted odds ratio (aOR) = 3.00, 95% confidence interval = 2.45-3.67; P < 0.001). Rates of NICU admission were also higher in ≥10th centile babies iatrogenically delivered for suspected FGR than for ≥10th centile babies who entered labour spontaneously (1.8% vs. 0.5%, P < 0.001). After adjustments, the odds of NICU admission were increased (aOR = 3.91, 95% confidence interval = 3.40-4.49; P < 0.001). NICU admissions were associated with morbidities related to iatrogenic prematurity. Detection and planned delivery of FGR reduces stillbirth but may be associated with increased neonatal morbidity related to iatrogenic prematurity.

The timing of initiation of pharmacotherapy for women with gestational diabetes mellitus

BackgroundThe decision to initiate pharmacotherapy is integral in the care for pregnant women with gestational diabetes mellitus (GDM). We sought to compare pregnancy outcomes between two threshold percentages of elevated glucose values prior to initiation of pharmacotherapy for GDM. We hypothesized that a lower threshold at pharmacotherapy initiation will be associated with lower rates of adverse perinatal outcomes.MethodsThis was a retrospective cohort study of women with GDM delivering in a single tertiary care center. Pregnancy outcomes were compared using bivariable and multivariable analyses between women who started pharmacotherapy (insulin or oral hypoglycemic agent) after a failed trial of dietary modifications at two different ranges of elevated capillary blood glucose (CBG) values: Group 1 when 20–39% CBG values were above goal; Group 2 when ≥40% CBG values were above goal. The primary outcome was a composite GDM-associated neonatal adverse outcome that included: macrosomia, large for gestational age (LGA), shoulder dystocia, hypoglycemia, hyperbilirubinemia requiring phototherapy, respiratory distress syndrome, stillbirth, and neonatal demise. Secondary outcomes included cesarean delivery, preterm birth (< 37 weeks), neonatal intensive care unit (NICU) admission, and small for gestational age (SGA).ResultsA total of 417 women were included in the study. In univariable analysis, the composite neonatal outcome was statistically significantly higher in Group 2 compared to Group 1 (47.9% vs. 31.4%, p = 0.001). In addition, rates of preterm birth (15.7% vs 7.4%, p = 0.011), NICU admission (11.7% vs 4.0%, p = 0.006), and LGA (21.2% vs 9.1% p = 0.001) were higher in Group 2. In contrast, higher rates of SGA were noted in Group 1 (8.0% vs. 2.9%, p = 0.019). There was no difference in cesarean section rates. These findings persisted in multivariable analysis after adjusting for confounding factors (composite neonatal outcome aOR = 0.50, 95%CI [0.31–0.78]).ConclusionsInitiation of pharmacotherapy for GDM when 20–39% of CBG values are above goal, compared to ≥40%, was associated with decreased rates of adverse neonatal outcomes attributable to GDM. This was accompanied by higher rates of SGA among women receiving pharmacotherapy at the lower threshold. Additional studies are required to identify the optimal threshold of abnormal CBG values to initiate pharmacotherapy for GDM.

Complications of antenatal corticosteroids in infants born by early term scheduled cesarean section

OBJECTIVE To compare neonatal hypoglycemia and respiratory morbidity rates in pregnancies complicated by diabetes following early term scheduled cesarean section (ETSCS) with and without maternal corticosteroid administration. RESEARCH DESIGN AND METHODS A retrospective cohort study of women with any form of diabetes in pregnancy undergoing ETSCS were included. Primary outcomes were admission rates to the neonatal intensive care unit (NICU) for Respiratory Distress Syndrome (RDS)/Transient Tachypnea of the Newborn (TTN) and/or neonatal hypoglycemia. RESULTS NICU admission rates for neonatal hypoglycemia were significantly higher (24.2% vs. 4.4%, P = 0.003), and RDS/TTN rates were nonsignificantly higher (15.2% vs. 7.2%, P = 0.209) following corticosteroid administration. CONCLUSIONS Corticosteroids were not beneficial among women with any form of diabetes in pregnancy undergoing ETSCS and, indeed, may be harmful. In our hospital, we have ceased the use of corticosteroids for women under these circumstances.

Timing of Repeat Cesarean Delivery for Women with a Prior Classical Incision.

This study aimed to compare neonatal outcomes for delivery at 36 weeks compared with 37 weeks in women with prior classical cesarean delivery (CCD). This was a secondary analysis of the prospective observational cohort of the Eunice Kennedy National Institute for Child and Human Development's Maternal-Fetal Medicine Unit Network Cesarean Registry. Data on cases of repeat cesarean delivery (RCD) in the setting of a prior CCD were abstracted and used for analysis. This study compared outcomes of women who delivered at 360/7 to 366/7 versus 370/7 to 376/7 weeks. The primary outcome was a composite of adverse neonatal outcomes that included neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), hypoglycemia, mechanical ventilation, sepsis, length of stay ≥5 days, and neonatal death. A composite of maternal outcomes that included uterine rupture, blood transfusion, general anesthesia, cesarean hysterectomy, venous thromboembolism, maternal sepsis, intensive care unit admission, and surgical complications was also evaluated. There were 436 patients included in the analysis. Women who delivered at 36 weeks (n = 176) were compared those who delivered at 37 weeks (n = 260). There were no differences in baseline characteristics. Delivery at 37 weeks was associated with a reduction in composite neonatal morbidity (24 vs. 34%, adjusted odds ratio [aOR] = 0.61 [0.31-0.94]), including a decrease in NICU admission rates (20 vs. 29%, aOR = 0.63 [0.40-0.99]), hospitalization ≥5 days (13 vs. 24%, aOR = 0.48 [0.29-0.8]), and RDS or TTN (9 vs. 19%, aOR = 0.43 [0.24-0.77]). There was no difference in adverse maternal outcomes (7 vs. 7%, aOR = 0.98 [0.46-2.09]). Delivery at 37 weeks for women with a history of prior CCD is associated with a decrease in adverse neonatal outcomes, compared with delivery at 36 weeks. · Classical cesarean section may have increased risk of uterine rupture in future pregnancies.. · This study compares outcomes of delivery at 370/7 to 376/7 versus 360/7 to 366/7 weeks.. · Delivery at 370/7 to 376/7 weeks was associated with decreased neonatal morbidity..

Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with nonsevere male infertility

To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes compared with conventional invitro fertilization (IVF) for patients with nonsevere male factor infertility. Retrospective cohort. University-affiliated reproductive endocrinology unit. Couples who received their first-cycle embryo transfer without severe oligoasthenozoospermia (OA) between January 2012 and December 2016 were included in this study. Six subgroup analyses were performed according to the proposed indications for the use of ICSI as follows: non-male factor infertility, advanced maternal age (≥38 years), unexplained infertility, low oocyte yield (≤6), mild OA, and moderate OA. Live birth rates and selected perinatal outcomes. ICSI resulted in live birth rates similar to those achieved with IVF (41.68% vs. 44.31%). There were no significant differences in the incidences of gestational diabetes mellitus, hypertension disorder of pregnancy, placental previa, postpartum hemorrhage, cesarean delivery, fetal macrosomia, small for gestational age, large for gestational age, neonatal intensive care unit (NICU) admission, and congenital anomalies between the two groups. Subgroup analyses showed that ICSI resulted in a lower rate of NICU admission in couples with moderate OA. Our results suggested that routine use of ICSI for all causes of infertility did not result in better pregnancy and perinatal outcomes compared with conventional IVF in the first cycle. ICSI might be associated with a lower risk of NICU admission when used in couples with moderate OA. Large prospective studies are required to validate our current findings.

Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System

There are few population-based studies addressing trends in neonatal intensive care unit (NICU) admission and NICU patient-days, especially in the subpopulation that, by gestational age (GA) and birth weight (BW), might otherwise be able to stay in the room with their mothers. To describe population-based trends in NICU admissions, NICU patient-days, readmissions, and mortality in the birth population of a large integrated health care system. This cohort study was conducted using data extracted from electronic medical records at Kaiser Permanente Southern California (KPSC) health care system. Participants included all women who gave birth at KPSC hospitals and their newborns from January 1, 2010, through December 31, 2018. Data extraction was limited to data entry fields whose contents were either numbers or fixed categorical choices. Rates of NICU admission, NICU patient-days, readmission rates, and mortality rates were measured in the total population, in newborns with GA 35 weeks or greater and BW 2000 g or more (high GA and BW group), and in the remaining newborns (low GA and BW group). Admissions to the NICU and NICU patient-days were risk adjusted with a machine learning model based on demographic and clinical characteristics before NICU admission. Changes in the trends were assessed with 2-sided correlated seasonal Mann-Kendall test. Data analysis was performed in August 2019. Admission to the NICU and NICU patient-days among the birth cohort. The primary outcomes were NICU admission and NICU patient-days in the total neonatal population and GA and BW subgroups. The secondary outcomes were readmission and mortality rates. Over the study period there were 320 340 births (mean [SD] age of mothers, 30.1 [5.7] years; mean [SD] gestational age, 38.6 [1.97] weeks; mean [SD] birth weight, 3302 [573] g). The risk-adjusted NICU admission rate decreased from a mean of 14.5% (95% CI, 14.2%-14.7%) to 10.9% (95% CI, 10.7%-11.7%) (P for trend = .002); 92% of the change was associated with changes in the care of newborns in the high GA and BW group. The number of risk-adjusted NICU patient-days per birth decreased from a mean of 1.50 patient-days (95% CI, 1.43-1.54 patient-days) to 1.40 patient-days (95% CI, 1.36-1.48 patient-days) (P for trend = .03); 70% of the change was associated with newborns in the high GA and BW group. The unadjusted 30-day readmission rates and mortality rates did not change. Admission rates to the NICU and numbers of NICU patient-days decreased over the study period without an increase in readmissions or mortality. The observed decrease was associated with the high GA and BW newborn population. How much of this decrease is attributable to intercurrent health care systemwide quality improvement initiatives would require further investigation. The remaining unexplained variation suggests that further changes are also possible.

Outcome of late preterm newborns in Upper Egypt

BackgroundThe incidence of preterm births is increasing and has become a global health concern. This study aimed to compare the outcome of late preterm (LPT) to full term (FT) neonates at two large hospitals in Upper Egypt.ResultsOut of 250 newborns included in the study, 180 (72%) were FT and 70 (28%) were LPT. More than half of the LPT newborns (52.9%) were admitted to the neonatal intensive care unit (NICU), compared with 26.7% of FT newborns. Delivery of LPT was associated with an increased risk of neonatal morbidity, including jaundice requiring phototherapy (34.3% vs. 7.8%), respiratory morbidities (32.9% vs. 13.9%), hypoglycemia (8.6% vs. 1.7 %), and convulsions (4.3% vs. 0.6%).ConclusionsLPT neonates were more susceptible to suffer from jaundice and respiratory distress among other morbidities. They also had a higher rate of NICU admission, longer duration of NICU stay, as well as a higher mortality rate. The best treatment of late prematurity is to prevent it. Public and professional awareness of the problems associated with late prematurity should be highlighted. Follow-up programs for early detection and intervention for long term complications are recommended.

Complications of Antenatal Corticosteroids in Infants Born by Early Term Scheduled Cesarean Section.

To compare neonatal hypoglycemia and respiratory morbidity rates in pregnancies complicated by diabetes following early term scheduled cesarean section (ETSCS) with and without maternal corticosteroid administration. In a retrospective cohort study, women with any form of diabetes in pregnancy undergoing ETSCS were included. Primary outcomes were admission rates to the neonatal intensive care unit (NICU) for respiratory distress syndrome (RDS)/transient tachypnea of the newborn (TTN) and/or neonatal hypoglycemia. NICU admission rates for neonatal hypoglycemia were significantly higher (24.2% vs. 4.4%, P = 0.003) and RDS/TTN rates were nonsignificantly higher (15.2% vs. 7.2%, P = 0.209) following corticosteroid administration. Corticosteroids were not beneficial among women with any form of diabetes in pregnancy undergoing ETSCS and, indeed, may be harmful. In our hospital, we have ceased the use of corticosteroids for women under these circumstances.

108: Trial of labor after cesarean: Maternal and neonatal outcomes from the Consortium on Safe Labor

To evaluate maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean (TOLAC) using a more contemporary data set. This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study from 2002 to 2008. Women met inclusion criteria for our study if they had a history of any prior cesarean delivery (CD). Perinatal outcomes such as uterine rupture, uterine dehiscence, blood transfusion, hemorrhage, hysterectomy, endometritis, maternal death, neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome, neonatal seizure, and neonatal death were evaluated based on desired delivery mode (planned elective CD or TOLAC). Multivariate logistic regression was used to describe the association between TOLAC and markers of maternal and neonatal morbidity and mortality. Of 9,858 patients who had a prior CD, our study population had 4,400 patients (44.6%) who desired TOLAC and 5,458 patients (55.4%) who underwent elective repeat CD. Of 4,400 patients who desired trial of labor, 3,162 (72%) achieved a vaginal birth. Women who attempted TOLAC compared to those who had an elective CD were more likely to have uterine rupture (OR 3.11; 95% CI 1.21 – 8.02), hemorrhage (OR 2.24; 95% CI 1.86 – 2.70), and blood transfusion (OR 2.33; 95% CI 1.70 – 3.19) (Table 1). Rate of uterine rupture was higher in patients undergoing TOLAC (0.34%), however it was still described in patients undergoing elective CD (0.11%). Rate of NICU admission was higher in patients undergoing TOLAC compared to elective CD, 12.9% and 11.3% respectively (OR 1.17; 95% CI 1.03 – 1.32). Patients undergoing TOLAC are two-times more likely to have a hemorrhage or require blood transfusion compared to women with elective repeat cesarean delivery. Compared to the Cesarean Registry data, women have half the rate of uterine rupture and a 30% higher risk for blood transfusion.

Correlation of short-term variation and Doppler parameters with adverse perinatal outcome in small-for-gestational age fetuses at term.

To evaluate the association of short-term variation (STV) and Doppler parameters with adverse perinatal outcome in small-for-gestational-age (SGA) fetuses at term. In this retrospective single-center study 97 patients with singleton SGA fetuses at term (≥ 37 + 0weeks' gestation) were examined. Inclusion criteria were a birth weight < 10th centile, cephalic presentation and planned vaginal birth. Only cases with available Doppler measurements of umbilical artery (UA) and middle cerebral artery (MCA) with calculated cerebroplacental ratio (CPR) in combination with a computerized CTG (cCTG) and STV 72h prior to delivery were eligible for analysis. Pulsatility indices (PI) were converted into multiples of median (MoM), adjusted for gestational age. The association between Doppler indices and STV values with mode of delivery [secondary cesarean delivery (CD), operative vaginal delivery (OVD), as well as secondary CD and OVD due to fetal distress] and neonatal outcome [UA blood pH ≤ 7.15 and the need of admission to the neonatal intensive care unit (NICU)] was analyzed using logistic regression analysis. There was a significant association between UA PI MoM and the rate of CD. CD due to fetal distress, OVD and OVD due to fetal distress did not show a correlation with the evaluated Doppler parameters. Furthermore, we did not find an association between low UA birth pH and Doppler parameters while neonates with the need of admission to NICU had significant higher UA PI MoM and significant lower MCA PI MoM and CPR MoM. Regarding STV, a significant effect of low STV on NICU admission was found while none of the other assessed outcome parameters were significantly associated with STV. STV and Doppler parameters in SGA fetuses at term are significantly associated to the rate of NICU admission.

Perinatal outcome in gestational diabetes according to different diagnostic criteria.

Objectives To evaluate whether gestational diabetes mellitus (GDM) diagnosed by different criteria impacts perinatal outcome. Methods This was a retrospective study of deliveries with a diagnosis of GDM (2014-2016). Perinatal outcomes were compared between patients with: (1) GDM diagnosed according to a single abnormal value on the 100-g oral glucose tolerance test (OGTT); (2) two or more abnormal OGTT values; and (3) a 50-g glucose challenge test (GCT) value ≥200 mg/dL. Results A total of 1163 women met the inclusion criteria, of whom 441 (37.9%) were diagnosed according to a single abnormal OGTT value, 627 (53.9%) had two or more abnormal OGTT values and 95 (8.17%) had a GCT value ≥200 mg/dL. Diet-only treatment was significantly higher in the single abnormal value group (70.3% vs. 65.1% vs. 50.5%) and rates of medical treatment were significantly higher in the GCT ≥ 200 mg/dL group (P < 0.05). Women in the GCT ≥ 200 mg/dL group had higher rates of neonatal intensive care unit (NICU) admission (10.5% vs. 2.7% vs. 2.8%, P < 0.001) and neonatal hypoglycemia (5.3% vs. 0.5% vs. 0.8%, P < 0.001). On multivariate logistic regression, GCT ≥ 200 mg/dL was no longer associated with higher rates of NICU admission and neonatal hypoglycemia (P > 0.05). Conclusion No difference was noted in the perinatal outcome amongst the different methods used for diagnosing GDM.

Increase in the number of patients diagnosed using the new classification of hypertensive disorders of pregnancy in Japan.

This study aimed to examine how the number of patients diagnosed with pre-eclampsia increased according to the Japanese classification of hypertensive disorders of pregnancy (HDP) that was revised in 2018. The effect of new classification on perinatal outcomes was also analyzed. We enrolled 181 women with HDP who delivered at Hokkaido University Hospital between February 2011 and December 2017. All women were reclassified on the basis of the new classification, in which proteinuria was not required to diagnose pre-eclampsia in patients with maternal organ damage. The number and reasons of reclassification and the admission rate to the neonatal intensive care unit (NICU) and gestational age (GA) at the onset of HDP and at delivery were analyzed. In this cohort, 17 (9.4%) of 181 women with HDP were reclassified. Low platelet count (41.2%) and uteroplacental dysfunction (41.2%) were the two main causes for reclassification. GA at the onset of HDP (33.6 [29.9-36.1] weeks vs 37.4 [35.7-38.4] weeks; P < 0.001) and at delivery (35.9 [32.4-37.3] weeks vs 38.1 [37.3-39.6] weeks; P < 0.001) were significantly earlier in women with reclassification than women without reclassification. The NICU admission rate was higher in women with reclassification than women without reclassification (70.6% vs 20.4%; P < 0.001). Almost 10% of pregnant women were newly diagnosed with pre-eclampsia as per the new Japanese classification of HDP. Women with reclassification as pre-eclampsia had a greater risk of preterm delivery and NICU admission than those who were not reclassified.

The Association of Respiratory Morbidity and Assisted Ventilation Rates in Late Preterm Births after Premature Rupture of Membranes: A Retrospective Cohort Study in a Tertiary Center

Objective: The aim of this study was to determine the association of respiratory morbidity and assisted ventilation rates in late preterm births after premature rupture of membranes (PROM). Methods: This retrospective cohort study included 584 consecutive women admitting due to PROM and delivered between 34+0 and 36+6 weeks of gestation at Seoul National University Bundang Hospital from August 2008 to July 2018. Multifetal pregnancies and intrauterine fetal demise were excluded. Primary outcome included the use of assisted ventilation and neonatal respiratory complications and a multivariable analysis was also performed. Results: 1) The proportions of neonates receiving assisted ventilation were significantly decreased as the gestational age at delivery advanced (P-trend <0.05 for all) in late preterm births after PROM. 2) The incidences of respiratory distress syndrome were 14%, 7%, and 3% for preterm births in the 34th, 35th, and 36th week of gestation (trend=0.007), respectively. 3) The gestational age at delivery was associated with the rates of positive pressure ventilation immediately after birth, neonatal intensive care unit (NICU) admission, minor assisted ventilators in preterm births with PROM after 34 weeks of gestation when analyzed by multivariate logistic regression. 4) The interval from PROM to delivery was independently associated with the rate of NICU admission (odds ratio, 1.04; 95% confidence interval, 1.01-1.06). Conclusion: Although late preterm births seem to be less severe than earlier gestation, gestational age at delivery is still an important factor for neonatal respiratory complications and for the use of assisted ventilation, even when the pregnancy is complicated with PROM.

Perinatal outcome of twin pregnancies according to maternal age.

ObjectiveTo investigate the perinatal outcomes of twin pregnancies according to maternal age.MethodsThis is a retrospective cohort study of twin pregnancies delivered ≥24 weeks' gestation at a tertiary academic hospital from 1995 to 2016. Subjects were categorized into 5 groups according to maternal age: <25, 25–29, 30–34, 35–39, and ≥40 years. Maternal and neonatal outcomes of each maternal age group were analyzed using the Jonckheere-Terpstra test and the linear-by-linear association test.ResultsA total of 1,936 twin pregnant women were included, of which 47 (2.4%), 470 (24.3%), 948 (49.0%), 417 (21.5%), and 54 (2.7%) women were aged <25, 25–29, 30–34, 35–39, and ≥40 years, respectively. Higher maternal age was significantly associated with a higher rate of dichorionic twins and a higher risk of gestational diabetes and placenta previa. However, rates of preterm labor, preterm premature rupture of membranes, cervical incompetence, preterm delivery, preeclampsia, placenta abruption, and cesarean section were not associated with maternal age. Birth weight increased and the rate of admission to the neonatal intensive care unit (NICU) decreased with older maternal age, but other neonatal outcomes did not change with age. Maternal age was significantly associated with a lower rate of NICU admission after controlling for potential confounding factors in multivariable analysis.ConclusionAdvanced maternal age in twin pregnancies was associated with increased risk of gestational diabetes, placenta previa, and higher birth weight but a lower rate of NICU admission. However, other outcomes were not significantly associated with maternal age.

Utilization of a Neonatal Early-Onset Sepsis Calculator to Guide Initial Newborn Management.

Introduction:Within our hospital system, all infants born to mothers with chorioamnionitis were directly admitted to the neonatal intensive care unit (NICU) for evaluation and treatment of presumed sepsis for a minimum of 48 hours, regardless of clinical appearance. Implementation of a risk-stratification system for thesWe high-risk infants based on the early onset sepsis (EOS) calculator may decrease NICU admissions and antibiotics exposure in well-appearing neonates.Methods:We used The Model for Improvement as a framework for designing this initiative. Participants were inborn infants 35 weeks and older born to mothers with chorioamnionitis and/or fever. Plan Do Study Act (PDSA) cycles were utilized to educate staff, monitor for sepsis, and follow adherence to the calculator in the newborn nursery.Results:From June 2015 to June 2016, there were 312 at-risk infants identified and evaluated on the EOS calculator. Of these 312 infants, 228 did not require admission to the NICU based on their risk assessment using the online calculator. Implementation of the Kaiser EOS calculator protocol for at-risk infants decreased NICU admission rates, decreased practitioner practice variability, decreased the number of painful procedures, promoted family bonding, resulted in higher breastfeeding rates at hospital discharge, diminished financial burden, and promoted antibiotic stewardship.Conclusion:This study demonstrates that the implementation of the sepsis risk calculator at an academic medical center can decrease the number of asymptomatic infants transferred to the NICU for empiric antibiotic treatment.

50: Hospital-level variation in term nicu admission rates

Neonatal intensive care unit (NICU) admissions are known to vary by hospital, and NICU admission rates among term, non-anomalous infants have been proposed as a metric of obstetric quality. The objective of this study was to determine what percentage of the variation was attributed to systemic differences between hospitals and their practices after accounting for a hospital’s patient case mix. This is a retrospective cohort study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), vertex-presenting, singleton, non-anomalous, liveborn infants in hospitals with a NICU were included. The primary outcome was NICU admission. Multilevel mixed effect models were used and included a hospital-specific random effect. The total variance and the proportion of the variance attributed to the hospital was calculated before and after adjustment for maternal demographics (age, race, insurance status) and pregnancy characteristics (parity, gestational age, diabetes, hypertension, tobacco use, drug use, HIV, abruption, and birth weight). Adjusted odds ratios were obtained, controlling for demographics, pregnancy characteristics, and the random-effect of the hospital. 146,714 infants from 9 hospitals were included. Figure 1 shows the variation in NICU admission rates (range 3.0 – 9.8%). Prior to adjustment for patient case mix, 11.4% of the variation was attributed to the hospital. With the addition of maternal demographics, the hospital-level variation was slightly decreased at 10.7%. However, the majority of the variation was explained by the pregnancy characteristics of patients at each hospital. When these characteristics were added to the model, the residual hospital variation was only 2.0%. The adjusted odds ratios for the pregnancy characteristics associated with NICU admission are shown in Table 1. The term, non-anomalous NICU admission rate varied three-fold across the nine, geographically diverse hospitals that participated in the Consortium for Safe Labor. However, the residual variation attributed to hospital-specific practices was minimal (2.0%) after accounting for each hospital’s case mix. The lack of variation attributed to hospital-specific practices argues against this rate being used as a quality metric in obstetrics. Further research is needed to study NICU admission variation in more diverse settings to assess the generalizability of these findings.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

775: Timing of induction of labor in women with term PROM and maternal and neonatal outcomes

BACKGROUND: Based on data from a large randomized controlled trial on the management of women with prelabor rupture of membranes (PROM) at term (the TermPROM Study), planned induction of labor (IOL) with oxytocin, when compared to planned expectant management, may decrease the rate of maternal infection but does not affect the risk of neonatal infection and cesarean delivery (CD). However, the original analysis did not assess the PROM-to-induction interval in a continuous manner. Therefore, the optimal timing of IOL remains to be determined. To investigate the association between PROM-to-induction interval and maternal and neonatal outcomes in women with term PROM. METHODS: A cohort study design based on data from the TermPROM trial. At each interval from onset of PROM, maternal and neonatal outcomes were compared between women who underwent IOL and those managed expectantly at this interval. Neonatal outcomes included a composite of probable or definite neonatal infection and admission to neonatal intensive care unit (NICU). Maternal outcomes included a composite of maternal infection (chorioamnionitis or postpartum fever) and CD. A total of 4,564 of the 5,041 women included in the original trial met study criteria. The rate of neonatal infection was low overall (3.3±1.1%), increased with the interval from PROM but was not different between IOL vs. expectant management at any interval (Figure 1). The rate of NICU admission increased with the interval from PROM and was significantly lower among women undergoing IOL compared with expectant management at any given interval within the first 13 hours from PROM (Figure 1). Among women who underwent IOL within the first 15 hours after PROM the rate of maternal infection remained stable at approximately 6% and was significantly lower than in women managed expectantly during this time period (Figure 1). The rate of CD was not affected by the interval from PROM or by IOL (Figure 1). The proportion of women who experienced spontaneous labor increased with the interval from PROM increasing to 40% at 15 hours after PROM (Figure 2). CONCLUSIONS: In women with term PROM, immediate IOL can minimize the risk of maternal infection and NICU admission. However, delaying induction by up to 15 hours may allow for up to 40% of women to go into spontaneous labor without increasing the risk of infection or CD, but at the price of increased risk of NICU admission.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The effects of birth order on neonatal outcomes in early-preterm, late-preterm and term twin infants*

Objectives: Birth order is one of the main factors that influences the neonatal outcome of twins. However, there is little prior data regarding the effect of birth order under different clinical circumstances. This study investigates the effect of birth order on the neonatal outcomes of twins delivered during early-preterm, late-preterm and term gestations according to chorionicity, delivery mode and indication for delivery.Methods: This is a retrospective cohort study of women with twin pregnancies delivered at 24–40 weeks of gestation between 1995 and 2014. We excluded twin pregnancies with the following complications: twin-to-twin transfusion syndrome, monoamnionic twins, delayed interval delivery and fetal death, chromosomal anomalies or major congenital malformation in one or more of the twins. The neonatal outcomes, including death, admission to neonatal intensive care unit (NICU), mechanical ventilator support, and respiratory distress syndrome (RDS) was compared between the first and second twin born at early-preterm (24–33 weeks of gestation), late-preterm (34–36 weeks of gestation) and term (≥37 weeks of gestation) gestations. These outcomes were further analyzed according to chorionicity, mode of delivery and indication for delivery by multivariable analysis (after adjusting for sex, presentation, and birth weight).Results: Among a total of 1,614 women with twin pregnancies who met the selection criteria, 423, 674 and 517 women delivered at early-preterm, late-preterm and term gestation, respectively. Overall, the second-born twins were lighter and had higher rates of NICU admission, mechanical ventilator support, and RDS than did first-born twins. Second twins born at early-preterm gestation had higher rates of RDS and mechanical ventilator support than did first twins. Second twins born at late-preterm gestation had higher rates of NICU admission and mechanical ventilator support than did first twins. Second twins born at term gestation also had a higher NICU admission rate than did first twins. However, in the multivariable analysis of the subgroups, the rates of NICU admission, mechanical ventilator support and RDS were not significantly different between most twin pairs. However, there were several significant differences. There was a higher risk of RDS in the second twins in the early-preterm premature rupture of membranes (PROM) subgroup, and a higher risk of mechanical ventilator support in the late-preterm PROM subgroup. Low birth weight was the only significant factor independently associated with a higher risk of adverse neonatal outcome in the second twins compared with the first twins in all subgroups.Conclusions: Second twins born at early-preterm, late-preterm and term were at higher risk of adverse neonatal outcome than were their respective first twins. However, this finding was mainly represented lower birth weight of the second twin. Still, second twins delivered due to early-preterm and late-preterm PROM had a higher risk of RDS and mechanical ventilator support, respectively, than did the first twin after adjusting for birth weight.

Does severe vitamin D deficiency impact obstetric outcomes in pregnant women with thyroid autoimmunity?

Purpose: Vitamin D plays an important role in the modulation of the immune system and anti-autoimmune activities. Autoimmune thyroid diseases related to endocrine disorders are associated with poor obstetric outcomes in pregnancy. Herein, we aimed to investigate the contribution of vitamin D hypovitaminosis to poor pregnancy outcomes in pregnant women with the positive autoimmune antibody.Materials and methods: This was a prospective case–control study that enrolled pregnant women at their first trimester. The pregnant women were divided based on thyroid antibody (TA) status (TA-positive pregnant group (TAs (+)) and negative group (TAs (−)). Vitamin D status was categorized as sufficient, insufficient, and deficient (severe and moderate).Results: A total of 283 pregnant women were enrolled in this study. A total of 219 pregnant women were assigned to the TAs (−) group and 64 to the TAs (+) group. The rate of vitamin D insufficiency was 8.7, and 7.8% in the pregnant with TAs (−), and the pregnant with TAs (+) groups, respectively. Vitamin D deficiency was highly prevalent in all groups. Specifically, the prevalence rate was 91 and 92% in the pregnant with TAs (−) and the pregnant with TAs (+) groups, respectively. Admission to the neonatal intensive care unit (NICU) was more prevalent in the pregnant with TAs (+) group than in the pregnant with TAs (−) group (40.6 versus 25%; p = .0187; effect size (ES) = 0.134). The rate of gestational diabetes mellitus (GDM) was significantly higher in the pregnant women with TAs (+) group than that in the pregnant women with TAs (−) group (12.5 versus 4.1%; p = .03; ES =0.13). The rate of NICU admission and GDM was significantly higher in the severe vitamin D-deficient pregnant group with TAs (+) than that in the severe vitamin D-deficient pregnant group with TAs (−) (47 versus 23%; p = .007; ES =0.207 and 19.4% versus 4.1%; p = .006; ES =0.214, respectively).Conclusions: Severe vitamin D deficiency may contribute to increase the prevalence of GDM and need for NICU admission in pregnant women with positive TA.

Decreasing NICU admissions of asymptomatic infants of women with pregestational diabetes mellitus improves breastfeeding initiation rates.

Asymptomatic infants born to women with pregestational diabetes mellitus (PGDM) are usually admitted to the well baby nursery (WBN) while those who are symptomatic or in need of specialized care are admitted to the neonatal intensive care unit (NICU). To determine if changes in the NICU admission rate of asymptomatic infants born to women with PGDM during two different epochs affected breastfeeding (BF) initiation rates. Retrospective cohort investigation of 386 women with PGDM and their infants who delivered in 2008-11 (epoch 1) and 457 who delivered in 2013-16 (epoch 2) at a single institution. NICU admissions: Comparison between epoch 1 and epoch 2 showed a decrease in the number of admissions from 243 (63%) to 175 (38%) *(chi square *p < 0.05). Respiratory distress (39 and 43%) and prematurity (28 and 23%) as admission diagnoses remained unchanged. Admissions for prevention of hypoglycemia declined (32% to 21%)*. At discharge from the NICU, exclusive BF (12 to 19%)* and any BF increased (41 to 55%)* while formula feeding (FF) decreased (59 to 45%)*. Admission to the NICU remained a strong predictor of BF initiation failure (a OR 0.6, 95% , CI 0.4-0.9, p 0.005).WBN admissions: Comparison between epoch 1 and epoch 2 showed an increase in the number of admissions from 143 (37%) to 282 (62%)*. The incidence of hypoglycemia (31% and 38%) and its correction with oral feedings (76% and 71%) remained unchanged. At discharge from the WBN, exclusive BF (15 to 27%)* and any BF (52 to 62%)* increased while FF decreased (48 to 38%)*. A decrease in the number of NICU admissions of asymptomatic infants born to women with PGDM is associated with improvements in BF initiation rates.