Neonatal Outcomes In Women Research Articles

The Arabin pessary to prevent preterm birth in women with a twin pregnancy and a short cervix: the STOPPIT 2 RCT.

Preterm birth is common in twins and accounts for significant mortality and morbidity. There are no effective preventative treatments. Some studies have suggested that, in twin pregnancy complicated by a short cervix, the Arabin pessary, which fits around the cervix and can be inserted as an outpatient procedure, reduces preterm birth and prevents neonatal morbidity. STOPPIT 2 aimed to evaluate the clinical utility of the Arabin cervical pessary in preventing preterm birth in women with a twin pregnancy and a short cervix. STOPPIT 2 was a pragmatic, open label, multicentre randomised controlled trial with two treatment group - the Arabin pessary plus standard care (intervention) and standard care alone (control). Participants were initially recruited into the screening phase of the study, when cervical length was measured. Women with a measured cervical length of ≤ 35 mm were then recruited into the treatment phase of the study. An economic evaluation considered cost-effectiveness and a qualitative substudy explored the experiences of participants and clinicians. Antenatal clinics in the UK and elsewhere in Europe. Women with twin pregnancy at < 21 weeks' gestation with known chorionicity and gestation established by scan at ≤ 16 weeks' gestation. Ultrasound scan to establish cervical length. Women with a cervical length of ≤ 35 mm at 18+ 0-20+ 6 weeks' gestation were randomised to standard care or Arabin pessary plus standard care. Randomisation was performed by computer and accessed through a web-based browser. Obstetric - all births before 34+ 0 weeks' gestation following the spontaneous onset of labour; and neonatal - composite of adverse outcomes, including stillbirth or neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis or proven sepsis, all measured up to 28 days after the expected date of delivery. A total of 2228 participants were recruited to the screening phase, of whom 2170 received a scan and 503 were randomised: 250 to Arabin pessary and 253 to standard care alone. The rate of the primary obstetric outcome was 18.4% (46/250) in the intervention group and 20.6% (52/253) in the control group (adjusted odds ratio 0.87, 95% confidence interval 0.55 to 1.38; p = 0.54). The rate of the primary neonatal outcome was 13.4% (67/500) and 15.0% (76/506) in the intervention group and control group, respectively (adjusted odds ratio 0.86, 95% confidence interval 0.54 to 1.36; p = 0.52). The pessary was largely well tolerated and clinicians found insertion and removal 'easy' or 'fairly easy' in the majority of instances. The simple costs analysis showed that pessary treatment is no more costly than standard care. There was the possibility of a type II error around smaller than anticipated benefit. In this study, the Arabin pessary did not reduce preterm birth or adverse neonatal outcomes in women with a twin pregnancy and a short cervix. The pessary either is ineffective at reducing preterm birth or has an effect size of < 0.4. Women with twin pregnancy remain at risk of preterm birth; work is required to find treatments for this. Current Controlled Trials ISRCTN98835694 and ClinicalTrials.gov NCT02235181. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 44. See the NIHR Journals Library website for further project information.

Maternal and neonatal outcomes in women with disorders of lipid metabolism.

The effects of lipid metabolism disorders (LMD) on pregnancy outcomes is not well known. The purpose of this study is to evaluate the impact of LMD on maternal and fetal outcomes. Using the Healthcare Cost and Utilization Project- National Inpatient Sample from the United States, we carried out a retrospective cohort study of all births between 1999 and 2015 to determine the risks of complications in pregnant women known to have LMDs. All pregnant patients diagnosed with LMDs between 1999 and 2015 were identified using the International Classification of Disease-9 coding, which included all patients with pure hypercholesterolemia, pure hyperglyceridemia, mixed hyperlipidemia, hyperchylomicronemia, and other lipid metabolism disorders. Adjusted effects of LMDs on maternal and newborn outcomes were estimated using unconditional logistic regression analysis. A total of 13,792,544 births were included, 9,666 of which had an underlying diagnosis of LMDs for an overall prevalence of 7.0 per 10,000 births. Women with LMDs were more likely to have pregnancies complicated by diabetes, hypertension, and premature births, and to experience myocardial infarctions, venous thromboembolisms, postpartum hemorrhage, and maternal death. Their infants were at increased risk of congenital anomalies, fetal growth restriction, and fetal demise. Women with LMDs are at significantly higher risk of adverse maternal and newborn outcomes. Prenatal counselling should take into consideration these risks and antenatal care in specialized centres should be considered.

Trends in maternal characteristics, and maternal and neonatal outcomes of women with gestational diabetes: A study from Jordan

BackgroundGestational diabetes mellitus (GDM) is a major health issue that poses its risk on pregnancy. It is prevalence has been globally increasing. AimThis study aimed to examine trends in demographic and socioeconomic characteristics, maternal BMI, behavioral factors, obstetric interventions, pregnancy complications, and maternal pre-existing medical conditions and maternal and neonatal outcomes in women with GDM in Jordan. We also aimed to equate the occurrence of emergency cesarean delivery with GDM. MethodsThe study is a part of a comprehensive national study of perinatal mortality that was conducted in Jordan. This study included all women who gave birth in the selected hospitals during the study period. Maternal and medical conditions during pregnancy and neonatal outcomes were compared among women who did not develop gestational diabetes mellitus and those who developed gestational diabetes mellitus. ResultsThe overall incidence rate of gestational diabetes mellitus (GDM) was 1.2%. Women with gestational diabetes had a higher weight, and BMI, more likely to be overweight, obese, or morbidly obese and less likelihood to be underweight. A significant association was detected between previous spontaneous abortions/miscarriages, previous preterm, previous stillbirths, previous children born with birth weight less than 2500 g, and previous children born alive and died before 28 days, and the incidence of GDM. Women with GDM were at high risk for complications in pregnancy such as hypertension, preeclampsia, premature delivery and labor induction. The offspring of GDM patients were at high risk of complications such as macrosomia, stillbirth, neonatal hypoglycemia, and neonatal jaundice and admittance to the NICU. ConclusionsThe incidence of GDM was linked to several clinical factors. Women with GDM are at high risk for complications of pregnancy and at higher risk of neonatal complications.

Effect of pre-pregnancy body mass index on neonatal outcomes in women undergoing autologous frozen-thawed embryo transfer

To investigate the associations between pre-pregnancy body mass index (BMI) and neonatal outcomes in women undergoing autologous frozen-thawed embryo transfer (FET). Retrospective cohort study. University-affiliated reproductive medical center. A total of 16,240 women with singleton deliveries achieved by autologous FET. None. Neonatal outcomes included preterm birth (PTB), low birth weight (LBW), small-for-gestational age (SGA), large-for-gestational age (LGA), fetal macrosomia, and birth defects. After adjusting for confounding factors, our study showed that in autologous FET cycles, the overweight women (23 kg/m2≤ BMI <27.5 kg/m2) were associated with increased rates of PTB (adjusted odds ratio [aOR], 1.226; 95% confidence interval [CI], 1.060-1.418), macrosomia (aOR, 1.692; 95% CI, 1.491-1.921), and LGA (aOR, 1.980; 95% CI, 1.715-2.286); and the obese women (BMI ≥27.5 kg/m2) were significantly associated with increased PTB (aOR, 1.503; 95% CI, 1.167-1.936), early PTB (aOR, 2.829; 95% CI, 1.679-4.765), very LBW (aOR, 3.087; 95% CI, 1.720-5.542), macrosomia (aOR, 2.325; 95% CI, 1.862-2.904), and LGA (aOR, 3.235; 95% CI, 2.561-4.085). The rate of SGA infants was higher in the underweight women (BMI <18.5 kg/m2) (aOR, 1.687; 95% CI, 1.375-2.071) than that in the normal-weight women (18.5 kg/m2≤ BMI ≤23 kg/m2). No significant difference was observed in the risk of birth defects between normal-weight cases and other BMI categories. Among women undergoing FET, pre-pregnancy BMI affected neonatal outcomes of singletons. BMI in Asian categories for overweight and obese showed significant increases in PTB, macrosomia, and LGA; early PTB and very LBW only increased in obese cases. In addition, underweight status was associated with increased risk of SGA. In contrast, there was no association between pre-pregnancy BMI and birth defects in FET cycles.

Adverse Maternal and Neonatal Outcomes in Women With Elevated Intrapartum Temperature Complicated by Histological Chorioamnionitis at Term: A Propensity-Score Matched Study.

Background: Elevated intrapartum temperature has been widely proven to be associated with adverse clinical outcomes in both mothers and neonates. Histological chorioamnionitis (HCA), the inflammation of chorion and amniotic membranes, is commonly observed in those with elevated intrapartum temperature. Thus, we aimed to explore whether the combination of HCA would further affect the pregnancy outcomes in those with intrapartum temperature ≥ 37.5°C.Methods: This retrospective cohort study was conducted at the International Peace Maternity and Child Health Hospital (IPMCH), including all full-term women with intrapartum temperature ≥ 37.5°C from Jan 2017 to Jan 2019. Patients were divided in to HCA group or control group according to placental pathology results, and we used 1:1 propensity score matching (PSM) to reduce the effects of potential confounding factors between the two groups. Univariate and multivariable logistic regression were used to identify the association between HCA and different adverse maternal and neonatal outcomes.Results: We formed a propensity-score matched cohort containing 464 women in each group. Higher positive rate of mycoplasma (14.01% vs. 7.33%, p = 0.001) was found in the vaginal secretion culture of women in the HCA group. After adjusting for various baseline clinical characteristics, women with HCA were more likely to end their delivery by cesarean section (AOR = 1.55, 95% CI: 1.05–2.28), and puerperal morbidity (AOR = 2.77, 95% CI: 1.44–5.33) as well as prolonged hospitalization (AOR = 1.56, 95% CI: 1.12–2.17) were more likely to be observed in the HCA group. The existence of HCA might also be associated with neonatal sepsis (AOR = 2.83, 95% CI: 1.14–7.04) and NICU admission (AOR = 1.40, 95% CI: 1.04–1.87) in newborns. In the study on the impact of different stages of HCA, we found that both maternal and neonatal outcomes would not be affected by mild HCA (stage I), while HCA of stage III was associated with increased need for neonatal respiratory support and elevated likelihood of prolonged hospitalization in neonates.Conclusions: Elevated intrapartum temperature complicated by HCA might be related to the elevated occurrence of several adverse maternal and neonatal outcomes, except those with HCA of stage I. Advanced HCA stage correlated with a worse prognosis.

Oxytocin Administration in Low-Risk Women, a Retrospective Analysis of Birth and Neonatal Outcomes.

Background: In recent years, higher than the recommended rate of oxytocin use has been observed among low-risk women. This study examines the relationship between oxytocin administration and birth outcomes in women and neonates. Methods: A retrospective analysis of birth and neonatal outcomes for women who received oxytocin versus those who did not. The sample included 322 women with a low-risk pregnancy. Results: Oxytocin administration was associated with cesarean section (aOR 4.81, 95% CI: 1.80–12.81), instrumental birth (aOR 3.34, 95% CI: 1.45–7.67), episiotomy (aOR 3.79, 95% CI: 2.20–6.52) and length of the second stage (aOR 00:18, 95% CI: 00:04–00:31). In neonatal outcomes, oxytocin in labor was associated with umbilical artery pH ≤ 7.20 (OR 3.29, 95% CI: 1.33–8.14). Admission to neonatal intensive care unit (OR 0.56, 95% CI: 0.22–1.42), neonatal resuscitation (OR 1.04, 95% CI: 0.22–1.42), and Apgar score <7 (OR 0.48, 95% CI: 0.17–1.33) were not associated with oxytocin administration during labor. Conclusions: Oxytocin administration during labor for low-risk women may lead to worse birth outcomes with an increased risk of instrumental birth and cesarean, episiotomy and the use of epidural analgesia for pain relief. Neonatal results may be also worse with an increased proportion of neonates displaying an umbilical arterial pH ≤ 7.20.

Betamethasone as a potential treatment for preterm birth associated with sterile intra-amniotic inflammation: a murine study

Preterm birth remains the leading cause of perinatal morbidity and mortality worldwide. Preterm birth is preceded by spontaneous preterm labor, which is commonly associated with sterile intra-amniotic inflammation; yet, no approved treatment exists for this clinical condition. Corticosteroids are the standard of care to improve neonatal outcomes in women at risk of preterm birth. Herein, we first validated our model of alarmin-induced preterm birth. Next, we investigated whether treatment with betamethasone could prevent preterm birth resulting from sterile intra-amniotic inflammation in mice. Under ultrasound guidance, the first cohort of dams received an intra-amniotic injection of the alarmin high-mobility group box-1 (HMGB1, n=10) or phosphate-buffered saline (PBS, n=9) as controls. A second cohort of dams received HMGB1 intra-amniotically and were subcutaneously treated with betamethasone (n=15) or vehicle (n=15). Dams were observed until delivery, and perinatal outcomes were observed. Intra-amniotic HMGB1 reduced gestational length (p=0.04), inducing preterm birth in 40% (4/10) of cases, of which 100% (4/4) were categorized as late preterm births. Importantly, treatment with betamethasone extended the gestational length (p=0.02), thereby reducing the rate of preterm birth by 26.6% (from 33.3% [5/15] to 6.7% [1/15]). Treatment with betamethasone did not worsen the rate of neonatal mortality induced by HMGB1 or alter weight gain in the first three weeks of life. Treatment with betamethasone prevents preterm birth induced by the alarmin HMGB1. This study supports the potential utility of betamethasone for treating women with sterile intra-amniotic inflammation.

Pregnancy in women with osteogenesis imperfecta: pregnancy characteristics, maternal, and neonatal outcomes

Women with rare diseases, such as osteogenesis imperfecta, may consider pregnancy, although data regarding outcomes, specific risks, and management strategies are lacking. The Brittle Bone Disorders Consortium of the National Institute of Health Rare Diseases Clinical Research Network established an Osteogenesis Imperfecta Pregnancy Registry to collect and evaluate pregnancy, maternal, and neonatal outcomes in women with osteogenesis imperfecta. This was a cross-sectional, survey-based study. Appropriate participants of the Brittle Bone Disorders Consortium Contact Registry were invited to participate in the study. Self-reported information regarding pregnancy characteristics and maternal and neonatal outcomes of women with osteogenesis imperfecta was compared with that of the general population, referenced by literature-based standards. Furthermore, compared with the general population, cohorts of women and fetuses with osteogenesis imperfecta were evaluated to determine whether the presence of osteogenesis imperfecta conveyed an increase in antepartum, intrapartum, and postpartum complications and an increase in adverse neonatal outcomes. Here, a total 132 participants completed the survey. Compared with the general population, women with osteogenesis imperfecta had higher rates of diabetes in pregnancy (13.3% vs 7%; 95% confidence interval, 7.0-19.6; P=.049), cesarean delivery (68.5% vs 32.7%; 95% confidence interval, 59.9-77.1; P<.001), need for blood transfusion (8.3% vs 1.5%; 95% confidence interval, 3.9-12.8; P=.019), and antepartum and postpartum fractures (relative risk, 221; 95% confidence interval, 59.3-823; P<.001). Maternal hospitalization and cesarean delivery rates were higher in individuals with moderate or severe osteogenesis imperfecta than women who reported mild osteogenesis imperfecta. Neonates born to women with osteogenesis imperfecta had higher risk of being low (26.2% vs 6.8%; P<.001) or very low birthweight (13.8% vs 1.4%; P<.001) infants than the general population. Neonates born to women with osteogenesis imperfecta had a higher rate of neonatal intensive care unit admissions (19% vs 5.68%; P<.001) and higher neonatal mortality at 28 days of life (4.8% vs 0.4%; P=.026), regardless of neonatal osteogenesis imperfecta status. Pregnancies for women with osteogenesis imperfecta are at an increased risk of complications, including hemorrhage, fractures, diabetes mellitus, and increased neonatal morbidity.

Weight gain after diagnosis of gestational diabetes mellitus and its association with adverse pregnancy outcomes: a cohort study

BackgroundGestational diabetes mellitus (GDM) and excessive body weight are two key risk factors for adverse perinatal outcomes. However, it is not clear whether restricted gestational weight gain (GWG) is favorable to reduce the risk for adverse pregnancy and neonatal outcomes in women with GDM. Therefore, this study aimed to assess the association of GWG after an oral glucose tolerance test with maternal and neonatal outcomes.MethodsThis prospective cohort study assessed the association of GWG after an oral glucose tolerance test (OGTT) with pregnancy and neonatal outcomes in 3126 women with GDM, adjusted for age, pre-pregnancy body mass index, height, gravidity, parity, adverse history of pregnancy, GWG before OGTT, blood glucose level at OGTT and late pregnancy. The outcomes included the prevalence of pregnancy-induced hypertension (PIH) and preeclampsia, large for gestational age (LGA), small for gestational age, macrosomia, low birth weight, preterm birth, and birth by cesarean section. GDM was diagnosed according to the criteria established by the International Association of Diabetes and Pregnancy Study Groups.ResultsGWG after OGTT was positively associated with risk for overall adverse pregnancy outcomes (adjusted odds ratio [aOR] = 1.72, 95% confidence interval [CI] = 1.50–1.97), LGA (aOR = 1.29, 95%CI = 1.13–1.47), macrosomia (aOR = 1.24, 95%CI = 1.06–1.46) and birth by cesarean section (aOR = 1.91, 95%CI = 1.67–2.19) in women with GDM. Further analyses revealed that a combination of excessive GWG before OGTT and after OGTT increased the risk of PIH and preeclampsia, LGA, macrosomia, and birth by cesarean section compared with adequate GWG throughout pregnancy. In contrast, GWG below the Institute of Medicine guideline after OGTT did not increase the risk of adverse perinatal outcomes despite GWG before OGTT.ConclusionExcessive GWG after OGTT was associated with an elevated risk of adverse pregnancy outcomes, while insufficient GWG after OGTT did not increase the risk of LBW. Restricting GWG after diagnosis of GDM in women with excessive GWG in the first half of pregnancy may be beneficial to prevent PIH and preeclampsia, LGA, macrosomia, and birth by cesarean section.

Are women with small endometriomas who undergo intracytoplasmic sperm injection at an elevated risk for adverse pregnancy, obstetric, and neonatal outcomes?

ObjectiveThe aim of the study was to investigate pregnancy, obstetric, and neonatal outcomes in women with small (<4 cm) unilateral endometriomas.MethodsThis retrospective study included 177 patients: 91 patients with small endometriomas and 86 controls with unexplained or tubal factor infertility who were treated at the Süleymaniye Gynecology and Maternity Training and Research Hospital Infertility Unit between January 2010 and July 2015. The groups were matched with regards to demographic characteristics such as age, body mass index, and infertility duration. All of the women in this study conceived via intracytoplasmic sperm injection. We compared pregnancy, obstetric, and neonatal outcomes between these groups.ResultsWomen with endometriomas had a higher biochemical pregnancy rate, but lower clinical pregnancy and live birth rates than women with unexplained and tubal factor infertility (p<0.05 for all). However no significant differences were found in terms of obstetric and neonatal complications between the two groups (p>0.05 for all).ConclusionIn this study, we found that women with endometriomas less than 4 cm were more prone to early pregnancy complications. We also showed that this group did not have any increased risks of late pregnancy, obstetric, and neonatal complications.

Outcomes following medical termination versus prolonged pregnancy in women with severe preeclampsia before 26 weeks.

ObjectiveTo compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France).MethodsWe conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student’s t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables.ResultsThere was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision.ConclusionWhen comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up.

771 Impact of antenatal fetal surveillance on obstetric and neonatal outcomes in women with diabetes

To explore the impact of common antenatal fetal surveillance (AFS) methods, including non-stress tests and biophysical profiles, on obstetric and neonatal outcomes in women with diabetes. A chart review was conducted on a cohort of pregnant women with diabetes (type 1, type 2, or gestational) who received prenatal care at a tertiary care academic center between 2012 and 2019. We identified interventions performed after abnormal AFS testing, either further testing or delivery, and then examined pregnancy outcomes. Descriptive statistics were reported in SPSS (IBM, Armonk, NY). We identified 586 diabetic pregnancies and AFS was performed on 449 (76.6%). A total of 2367 tests (1424 NSTs and 943 BPPs) were performed. Overall, 70% (n=314) had normal AFS, while 30% (n=135) had at least one abnormal AFS. The total number of AFS tests that resulted in delivery was 33/2387 (1.4%), or 33/449 (7.3%) total pregnancies. The positive predictive value of abnormal AFS was 24.4. Of AFS resulting in delivery, 13/33 (39.4%) were preterm (prior to 37 weeks) and 3 had T1DM, 7 had T2DM, and 3 had GDM. Of these preterm deliveries, 2 (15.4%) had APGAR scores < 7 and 12 (92.3%) had significant maternal comorbidities that warranted further testing and consideration of delivery. One fetal death occurred with no AFS, one neonatal death occurred despite normal AFS, and one neonatal death occurred after abnormal AFS. One woman with abnormal AFS had no interventions and resulted in an uncomplicated scheduled repeat cesarean section. AFS rarely led to delivery as an obstetric intervention, and perinatal outcomes were overall favorable. There is no clear correlation between an abnormal AFS test and perinatal mortality due to its low incidence, but a normal AFS test is overall reassuring. Most preterm deliveries associated with abnormal AFS were complicated by other comorbidities that necessitated delivery. New AFS techniques with improved ability to identify the fetus most at risk are needed to improve perinatal outcomes and decrease unnecessary interventions.

511 Choosing the optimal skin incision for cesarean delivery in patients with morbid obesity

Although there have been studies comparing Pfannenstiel incision (PI) with supraumbilical vertical skin incision (SVI) in obese women, the optimal skin incision for cesarean delivery (CD) in patients with class III obesity has not been determined. Our objective was to evaluate if PI vs SVI had any significant differences in maternal or neonatal outcomes in women with body mass index (BMI) ≥50 undergoing CD. We conducted a retrospective cohort study in pregnant women with BMI ≥50 undergoing CD at a single tertiary care center from 2016 to 2020. Electronic medical records and operative reports were used to collect study variables and identify the study groups: PI vs SVI. SVI incisions were performed on patients with hanging pannus (umbilicus at the level of the pubic bone) following evaluation by a multi-disciplinary team. Primary outcome was surgical blood loss. Secondary outcomes were hysterotomy type, surgical time, negative pressure wound therapy use, neonatal outcomes, and surgical complications. Mann-Whitney U test and chi-squared test were used to compare continuous and categorical data, respectively. During our study period, 70 women with BMI ≥50 were delivered by CD. Of those, 40 (57%) women had PI, and 30 (43%) women had SVI. Surgical blood loss was significantly lower in the PI group compared to the SVI group (832ml vs. 1000ml, p=0.024); however, there was no difference in postpartum hemorrhage rates. Patients with SVI were more likely to undergo classical hysterotomy and had significantly longer operating times (Table). There was no significant difference in either immediate or delayed post-operative complications (Table), nor in neonatal outcomes between the two groups. Although morbidly obese patients undergoing CD via SVI had significantly increased surgical blood loss, this difference was not clinically significant. In morbidly obese women with a hanging pannus, performing a SVI is safe in terms of immediate and delayed surgical complications when compared with PI, despite a longer surgical time and an increased rate of classical hysterotomy.

636 Prenatal methadone exposure is associated with smaller fetal and neonatal cranial measurements compared to buprenorphine

Limited information about differential effects of methadone (mthdn) vs. buprenorphine (bup) on fetal and neonatal outcomes exists. Objectives of this study were to compare fetal measurements, including unique ultrasound measures of fetal brain, and neonatal outcomes in women who receive mthdn or bup in pregnancy. Data were obtained from the ENRICH prospective cohort study; 60 women receiving mthdn and 86 receiving bup. Ultrasound measurements were obtained for 127 women in the 2nd trimester (18-22 weeks) and 132 in the 3rd trimester (28-32 weeks). Fetal measurements included standard biometric parameters as well as frontal lobe width and length, fronto-thalamic distance, and caval-calvarial distance (CCD). Neonatal measurements included birth weight, length, and head circumference (HC). Group comparisons used Wilcoxon rank sum, Fisher’s exact, or Chi-square tests as appropriate. Ultrasound measures were compared using analysis of variance models (non-percentile measures adjusted for gestational age). Least-square means±standard error are reported. Methadone-exposure was associated with smaller cranial measurements beginning in the 2nd trimester and persisting to birth compared to buprenorphine-exposure. Second trimester ultrasound demonstrated significantly lower HC percentile (29.2±2.7 vs. 38.6±2.3), CCD (21.8±0.3 vs. 23.1±0.3mm), and occipitofrontal diameter (OFD) (63.4±0.3 vs. 65.0±0.3mm) in the mthdn compared to bup group (all p’s<0.05). These differences persisted in the 3rd trimester (HC percentile 27.3±4.2 vs. 42.1±3.6; OFD 95.3±1.5 vs. 101.3±1.3mm). Differences were also observed at birth between mthdn and bup treated groups (HC percentile: 28.3±2.9 vs. 49.5±3.5; p<0.01; length percentile: 34.0±3.5 vs. 45.6±3.4; p=0.04). Buprenorphine-exposed infants had shorter hospital stays (14.5±5.2 vs 18.6±1.8 days; p<0.01) and were less likely to require withdrawal treatment (31.4% vs 58.3%; p<0.01). Prenatal methadone exposure was associated with smaller head circumference and body length measurements and longer neonatal hospital stays due to withdrawal treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

997 The impact of anemia on neonatal outcomes in women with pre-existing diabetes

Anemia affects 25% of all pregnancies and increases the risk for poor pregnancy and chronic disease outcomes, but its impact on women with diabetes in pregnancy remains unknown. We sought to determine the prevalence of anemia among women with pre-existing diabetes and the association with adverse pregnancy outcomes. We conducted a retrospective cohort study of pregnant patients with type 1 or 2 diabetes who received care at a tertiary referral center from 2007-2017. Exclusion criteria included a known hemoglobinopathy. Patients who ever had microcytic or normocytic anemia during pregnancy were compared to those who never had anemia in pregnancy. The primary outcome was a neonatal composite morbidity index including polyhydramnios, preterm birth, neonatal hypoglycemia, Neonatal Intensive Care Unit admission, and respiratory distress syndrome. Secondary outcomes included individual components of the composite. Logistic regression was used to adjust for potential confounding variables including race, nulliparity, and diabetes type. Of 447 patients who met inclusion criteria, 285 (64%) had anemia at some point during pregnancy while 162 (36%) did not. Demographic characteristics were similar between groups except those with anemia were more likely to be Black and multiparous. Compared with no anemia, anemia during pregnancy was associated with a higher risk of the neonatal composite index (43% anemia vs. 29% aRR 1.49; 95% CI 1.13-1.96) and early preterm birth <34 weeks (17% vs. 10%, aRR 3.75; 95% CI 1.18-11.93). Other secondary outcomes were not significantly different between groups. Anemia is more prevalent among women with pre-existing diabetes. It is associated with an increased risk of adverse neonatal outcomes and may be a modifiable risk factor to improve pregnancy outcomes in this population.

117 Clinically defined active phase arrest of labor in nulliparous women

We sought to examine maternal and neonatal outcomes in women who achieved the active phase of labor and evaluated the duration of time to progress at least 1 cm. This was a retrospective cohort study of nulliparous women with term singleton in a cephalic presentation who presented with spontaneous labor and achieved active labor. Women were categorized based on the time interval it took to make at least 1 cm of cervical change (less than 4 hours, 4-5.9 hours, 6 hours or greater). Analyses were performed at cervical dilation of 6, 7, 8, and 9 cm. Outcomes that were examined included cesarean delivery, chorioamnionitis, and a composite of neonatal outcomes including intensive care unit admission, seizure, ventilator use, birth injury, or asphyxia. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) were calculated, controlling for predefined covariates. Of 31,505 nulliparous women, there were 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) who had documented cervical dilation of 6, 7, 8, and 9 cm, respectively (Figure). Rates of women who took 6 hours or greater to make at least 1 cm cervical change decreased as cervical dilation progressed. Overall, results were similar regardless of cervical dilation. For example, if we look at the time interval for women to make cervical change starting at 8 cm; women who took less than 4 hours to make cervical change from 8 cm compared to those who took 4-5.9 hours had lower rates of cesarean delivery (aOR 0.40; 95%CI 0.28-0.55), chorioamnionitis (aOR 0.42; 95%CI 0.29-0.60), and the neonatal composite outcome (aOR 0.51; 95%CI 0.36-0.72). However, women who took 6 hours or greater had similar rates of cesarean delivery (aOR 1.14; 95%CI 0.78-1.69), chorioamnionitis (aOR 1.30; 95%CI 0.83-2.03), and the neonatal composite outcome (aOR 1.18; 95%CI 0.70-2.00). While women who took less than 4 hours to make cervical change had lower rates of maternal and neonatal outcomes compared to those who took 4-5.9 hours, those who took 6 hours or greater did not have increased rates of maternal and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1124 Maternal and neonatal outcomes in women with opioid use disorder treated with buprenorphine versus buprenorphine/naloxone

This study specifically assessed whether the formulation of buprenorphine impacts maternal and neonatal complications. This retrospective cohort study evaluated all women enrolled in our treatment program between 2015-2020. Inclusion criteria included those prescribed a buprenorphine product and delivery outcome. Women on methadone in this program were excluded. The primary outcome was the rate of NAS requiring medical treatment in those treated with and without naloxone. Secondary outcomes included gestational age at delivery, rates of NOWS, and neonatal length of stay. 310 patients were included with 129 (41.6%) receiving the mono-product and 181 treated with the combination product (58.4%). No significant differences were identified in GA at program start, total daily dose, educational, or housing, as seen in Table 1. Maternal outcomes did not differ between groups for the gestational age at delivery, birthweight, or frequency of preterm birth. Neonatal outcomes were also similar between groups for the frequency of medication treatment for NOWS, neonatal length of stay, and frequency of anomalies observed between these subpopulations. No cases of fetal death or acute withdrawal related to misuse with IV injection were reported. This large cohort study did not identify a difference in obstetric or neonatal outcomes with combination products versus mono-buprenorphine products. Neonatal outcomes were similar and no safety concerns were observed. Both formulations of buprenorphine should be considered as appropriate for use in obstetric populations.

931 Maternal and neonatal outcomes associated with vasa previa resolution during the antepartum period

In recent years, the phenomenon of “resolved” vasa previa has been increasingly described when vasa previa (VP) is detected on ultrasound in the midtrimester with a resolution rate as high as 20-26%. There is little information on the obstetrical outcomes associated with resolved VP. Our objective was to describe obstetrical and neonatal outcomes in women with resolved VP and compare them to women who have persistent VP. This was a multi-center descriptive and retrospective cohort study of patients diagnosed prenatally with VP on transvaginal ultrasound in the NYC MFM Research Consortium centers between 2012 and 2018. The primary outcome was gestational age (GA) at delivery. Other outcomes evaluated included mode of delivery, birthweight, NICU admission, and preterm birth. Data were analyzed using Mann-Whitney U test and Fisher exact test with p<0.05 defined as significance. 165 pregnancies with VP were included, of which 16 were twin gestations. 43 VP cases (26.1%) including one twin gestation were noted to resolve on subsequent ultrasound, of which 6 were lost to follow up. Pregnancies with resolved VP had a higher median GA at delivery, lower rate of preterm birth <37 weeks, and lower rate of cesarean delivery. There was no difference in rate of preterm birth <32 weeks (Table 1). Neonatal data was available on 131 newborns. In cases of resolved VP, neonates had a higher median birthweight and lower rate of NICU admission. There were no significant differences in rates of neonatal blood transfusion or neonatal death (Table 2). Resolved VP is associated with later GA at delivery, lower rate of cesarean delivery, and improved neonatal outcomes. However, it is not associated with a reduction in preterm birth prior to 32 weeks. The observed preterm birth rate in the resolved group of 16% raises concern that resolved VP may be a risk factor for preterm birth and merits further investigation. Once VP is diagnosed, surveillance for VP resolution should be performed as resolution has important implications for obstetrical and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

701 Elevated liver enzymes and adverse outcomes among women with preeclampsia with severe features

To evaluate the association between elevated liver enzymes and maternal and neonatal outcomes among women with preeclampsia with severe features. Retrospective cohort study among hypertensive women who delivered ≥23 weeks’ gestation at a single academic hospital (Oct 2013 – Sep 2018). Those with preeclampsia with severe features (including chronic hypertension with superimposed preeclampsia meeting criteria for severe features) were included after screening of ICD-9 and ICD-10 codes and chart validation. The primary exposure was elevated liver enzymes prior to delivery, according to the American College of Obstetricians and Gynecologists’ criteria for severe features of preeclampsia: aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥2x the upper limit of normal (above threshold liver function tests [LFTs]). Primary outcomes included adverse maternal and neonatal outcomes. Differences were analyzed by Chi-squared, Fisher’s exact, t-test, and logistic regression, with α=0.05. Of 11,825 deliveries, 333 (2.8%) met inclusion criteria and had preeclampsia with severe features. Of these, 46 (13.8%) had above threshold LFTs. Adverse maternal outcomes were no different in those with above threshold LFTs compared to those with below threshold LFTs. The unadjusted odds of an adverse neonatal outcome was 1.95x greater in women with above threshold LFTs (95% CI: 0.99-3.80), and 2.3x greater when adjusting for maternal characteristics (95% CI: 1.12-4.60). However, the association between above threshold LFTs and adverse neonatal outcomes became non-significant after adjustment for gestational age at delivery (OR: 1.51, 95% CI: 0.63-3.62). Among women with preeclampsia with severe features, above threshold LFTs are not independently associated with an increased risk of adverse maternal or neonatal outcomes. Adverse neonatal outcomes in women with preeclampsia with severe features and above threshold LFTs are driven by earlier gestational age at delivery. Prospective studies are needed to guide delivery timing in women with preeclampsia and elevated liver enzymes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1153 Influence of race on adverse perinatal outcomes in women undergoing TOLAC

To examine the association between race and adverse maternal and neonatal outcomes in women who undergo Trial of Labor after Cesarean (TOLAC). This is a retrospective cohort study of singleton non-anomalous pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of adverse outcomes for women who underwent TOLAC categorized by race. Multivariable logistic regression was used to control for several factors including race. Race was categorized into six categories of White (Non-Hispanic), Black, Hispanic, Asian, American Native, and Other. The adverse maternal outcomes examined were postpartum hemorrhage (PPH), perineal lacerations, chorioamnionitis, maternal blood transfusion, placental abruption, severe maternal morbidity (SMM), and endomyometritis. The neonatal outcomes examined were infant death, neonatal death (NND), intrauterine fetal death (IUFD), Neonatal Intensive Care Unit (NICU) admission, birth injuries, brachial plexus injury (BPI), hypoxic ischemic encephalopathy (HIE), clavicle fracture, and skull fracture. The cohort consisted of 362,270 pregnancies with a prior CD, 29,628 pregnancies resulted in TOLAC. The cohort of 2,699,312 women consisted of 36,195 TOLAC, 29,638 of which were singleton non-anomalous pregnancies. After controlling for several confounders of interest there was a statistically significant increase in PPH, lacerations, chorioamnionitis, maternal blood transfusions, SMM, endomyometritis, infant death and birth injuries in Asian Women. There was a statistically significant increase in chorioamnionitis and HIE as well as a decrease in lacerations in Black Women. There was a statistically significant increase in chorioamnionitis and endomyometritis in Hispanic women as well as a decrease in infant death (Table 1). Different racial backgrounds increase the risk of maternal and neonatal complications in the settings TOLAC. Practitioners should exercise heightened awareness of the effect of race on these potential adverse outcomes when managing TOLAC.