Peripartum Risk Research Articles

The newborn at risk of hypoxic-ischemic encephalopathy: a large Italian multicentre retrospective study on antepartum and peripartum risk factors

The newborn at risk of hypoxic-ischemic encephalopathy: a large Italian multicentre retrospective study on antepartum and peripartum risk factors

Biopsychosocial Predictors of Postpartum Depression: Protocol for Systematic Review and Meta-Analysis.

During the postpartum period, psychological disorders may emerge. Aims and objectives: With the current study, we aim to explore the biological determinants that act on women during labor and incur the risk for postpartum depression (PPD). To reach the aim, we will perform the following tasks: (i) identify biological peripartum risk factors and calculate pooled prevalence of PPD for each of them; (ii) explore the strength of the relationship between peripartum risk factors and PPD; (iii) rank the predictors by their prevalence and magnitude of association with PPD. The knowledge obtained will support the development and implementation of early diagnostic and preventive strategies. Methods and analysis: We will systematically go through peer-reviewed publications available in the PubMed search engine and online databases: Scopus, Web of Science, EMBASE. The scope of the review will include articles published any time in English, Arabic, or Polish. We will deduplicate literature sources with the Covidence software, evaluate heterogeneity between the study results, and critically assess credibility of selected articles with the Joanna Briggs Institute's bias evaluation tool. The information to extract is the incidence rate, prevalence, and odds ratio between each risk factor and PPD. A comprehensive analysis of the extracted data will allow us to achieve the objectives. The study findings will contribute to risk stratification and more effective management of PPD in women.

987 Prospective validation of an automated Peripartum Risk Score Model to predict severe maternal morbidity (SMM)

987 Prospective validation of an automated Peripartum Risk Score Model to predict severe maternal morbidity (SMM)

Pregnancy complications and their association with postpartum depression symptoms: a retrospective study

ABSTRACT Objective Postpartum depression affects around 17% of the women worldwide and has considerable implications for maternal and child health. While some risk factors have been identified, the association between pregnancy and delivery complications and postpartum depression is less well understood. This study aims to determine whether specific pregnancy complications are associated with risk of postpartum depression symptoms (PPDS). Method This study analysed a subset of variables collected as part of a larger study exploring pregnancy circumstances and maternal-foetal health outcomes. Mothers residing in Australia provided information on their biological children aged 3–13 years. Pregnancy complications were analysed using bivariate analyses and binary logistic regression. Results Mothers (N = 1,926) reported on N = 3,210 pregnancies (mean number of pregnancies = 1.27, SD = 0.97). At the time of childbirth, mothers were on average 30.1 years old (SD = 5.14). Experiencing a pregnancy complication increased the risk of PPDS (X2 = 16.45, df = 1, p < 0.001) However, logistic regression analyses indicated an increased risk of PPDS was associated with the specific pregnancy complications of cytomegalovirus (AOR = 7.06, 95% CI[1.51,32.98]), emergency caesarean (AOR = 1.67, 95% CI[1.31,2.12]), foetal distress before birth (AOR = 1.49, 95% CI[1.16,1.91]), induced labour (AOR = 1.55, 95% CI[1.25,1.91]) and placenta previa (AOR = 2.60, 95% CI[1.44,4.71]). Conclusion Specific pregnancy complications were associated with PPDS, suggesting that some complications may pose a greater risk for PPDS than others. This study contributes to the growing understanding of peripartum risk factors for postpartum depression, and suggests that early clinical identification of at-risk mothers and early prophylactic and supportive care may be warranted to reduce that risk.

Maternal and peripartum risk factors for acute funisitis among term deliveries complicated by intraamniotic infection

Acute funisitis (AF), the histologic diagnosis of inflammation within the umbilical cord, represents a fetal inflammatory response and has been associated with adverse neonatal outcomes. There is little known regarding the maternal and intrapartum risk factors associated with the development AF among term deliveries complicated by intraamniotic infection (IAI). To identify maternal and intrapartum risk factors associated with developing AF among term deliveries complicated by IAI. After IRB approval, we conducted a retrospective cohort study of term deliveries affected by clinical IAI at a single tertiary center between 2013-2017 with placental pathology consistent with histologic chorioamnionitis. Exclusion criteria included intrauterine fetal demise, missing delivery information or placental pathology, and documented congenital fetal abnormalities. Maternal sociodemographic, antepartum, and intrapartum factors were compared among patients with AF on pathology to those without AF using bivariate statistics. Regression models developed to estimate adjusted odds ratios (aOR). Of 123 patients meeting inclusion criteria, 75 (61%) had AF on placental pathology. Compared to placental specimens without AF, AF was observed more frequently among patients with maternal body-mass-index (BMI) ≥ 30kg/m2 (58.7% vs, 39.6%, p=0.04) and labor courses with increased rupture of membrane (ROM) duration (17.3 vs, 9.6 hours, p=0.001). Use of fetal scalp electrode (FSE) was observed less frequently in AF (5.3% vs, 16.7%, p=0.04) compared to cases without AF. In regression models, maternal BMI≥30kg/m2 (aOR 2.67, 95% CI 1.21,5.90) and ROM >18 hours (aOR 2.48, 95% CI 1.07,5.75) were significantly associated with AF. FSE use (aOR 0.18, 95% CI 0.04,0.71) was negatively associated with AF. In term deliveries with IAI and histologic chorioamnionitis, maternal BMI≥30kg/m2, and ROM>18 hours were associated with AF on placental pathology. As insight into the clinical impact of AF grows, the ability to predict which pregnancies are at greatest risk for its development may allow for a tailored approach to predicting neonatal risk for sepsis and related comorbidity.

The peripartum period involvement in the development of post-partum depression. A prospective cohort study

PurposeThis study explores postpartum depression (PPD) in women who screened negative in mid-pregnancy to assess the impact of the peripartum period on the development of depressive symptoms. MethodsA prospective cohort study was carried out in two facilities in Argentina. The Edinburgh postnatal depression scale (EPDS) scale was applied to pregnant women between weeks 20–24 gestation, and those screening negative (<10) were included in the cohort. Participants were followed up until the 4th week postpartum, when the EPDS was repeated. If positive, a semi-structured clinical interview was applied (MINI) to define the diagnosis. ResultsA total of 112 pregnant women were eligible for the follow-up. At the 4th week postpartum, 14 women (12.5%, CI 95% 7.0; 20.1) screened positive using a cutoff point of 10 or more in the EPDS. Of those screened positive in the EPDS, two participants (1.8%, CI 95% 0.2–6.3) had a Major Depressive Disorder. Newborn admission to the Intensive Care Unit, hospitalization of the newborn after discharge, abuse during childbirth, and lack of company during labor were identified as peripartum risk factors. ConclusionsThis study reinforces the relevance of women and newborn mental health care during the hospitalization process surrounding peripartum. The women and newborn hospitalization process should be better explored to understand the contribution to PPD and design and test strategies to alleviate the impact of maternal depression.

Hypoxic ischemic encephalopathy: Do peripartum risk factors account for observed changes in incidence?

Hypoxic ischemic encephalopathy: Do peripartum risk factors account for observed changes in incidence?

Performance of the early-onset-sepsis calculator in Israeli newborns

Riskin et al report a 2-year single-center prospective surveillance of performance of the early-onset-sepsis (EOS) calculator in Israeli infants born at 34 weeks' gestational age with one or more peripartum risk factors for EOS. The impact of use of the calculator in Israel compared with use in the US where it was invented and validated is of special interest because currently there is no recommendation for screening or intrapartum antibiotic prophylaxis (IAP) for group B Streptococcus (GBS) in Israel. The EOS calculator performed in Israeli infants with peripartum risk factor(s) similarly to its performance in this cohort of US infants and was associated with the expected decrease in laboratory testing and use of empiric antibiotics. However, during this surveillance period, GBS was the most common cause of EOS at this Israeli center, where GBS cases primarily were in infants without peripartum risk factors and who were asymptomatic at birth (which also was the case in the US prior to universal screening and IAP). It should be noted that approximately one-half of GBS EOS in the US currently occur in infants whose mothers' screening during pregnancy was negative. The bottom line is that although sepsis calculators appropriately applied can provide a level of confidence that permits providers to forego laboratory testing and excessive use of empiric antibiotic therapy, the critical element of optimal care of the neonate throughout the first day of life is repeated, templated clinical examinations with protocols in place for rapid response should abnormalities arise. Article page 71 ▸ Evaluation of Implementation of Early-Onset Sepsis Calculator in Newborns in IsraelThe Journal of PediatricsVol. 234PreviewTo evaluate the recommendations based on the early-onset sepsis (EOS) calculator in the first 2 years of its implementation in Israel. Full-Text PDF

Evaluation of Implementation of Early-Onset Sepsis Calculator in Newborns in Israel

To evaluate the recommendations based on the early-onset sepsis (EOS) calculator in the first 2years of its implementation in Israel. Prospective 2-year surveillance of a cohort of infants born at gestational age of ≥34weeks in Bnai Zion Medical Center, who were evaluated using the EOS calculator because of peripartum risk factors. We evaluate 1146 newborns with peripartum risk factors using the EOS calculator. The percentage of infants who had laboratory evaluation decreased to 4.6%, and the EOS calculator recommended empiric antibiotic therapy in only 2.2%. During the study period, there were 4 early-onset infections (EOS incidence of 0.6 in 1000 live births). Three had group B streptococcus (GBS) and one had Escherichia coli infection. Only 2 of these infants had perinatal risk factors and the EOS calculator identified them and recommended laboratory evaluation and empiric antibiotics. However, 2 infants with GBS EOS had no perinatal risk factors or clinical symptoms at delivery, and were discovered clinically at older ages. The Israeli EOS calculator-based guidelines seem to be appropriate and are associated with less laboratory evaluations, and little use of empiric antibiotics. Concerns are related to the current recommendation of no GBS universal screening in Israel, and the inability of the calculator-based approach to identify GBS EOS in infants born to mothers with unknown GBS who have no peripartum risk factors before presentation of clinical symptoms.

Factors Associated With High Inpatient Utilization of Oxycodone After Cesarean Delivery [14E

INTRODUCTION: Few large studies have comprehensively evaluated which factors are associated with increased inpatient opioid analgesia after cesarean delivery. Our objective was to determine if specific maternal and peripartum risk factors are associated with high inpatient utilization of oxycodone after cesarean section. METHODS: IRB approved, retrospective case-control study of live singleton cesarean deliveries at 37 weeks of gestation or greater at a tertiary university hospital from 2013–2016. Patients were excluded for NSAID or opioid allergies, and incomplete medical records. Cases were patients with high oxycodone utilization (&gt;90th percentile) and controls were those with normal oxycodone utilization (≤90th percentile). Patient demographics and clinical characteristics were examined to determine if they were associated with high oxycodone utilization. Statistical significance P&lt;.05. RESULTS: A total of 7,415 deliveries were included. In this population, high utilization of oxycodone equated to greater than 42 mg/day (n=742). Maternal demographic factors associated with high utilization included advanced maternal age, Caucasian race, pre-pregnancy obesity, and multiparity. Peripartum factors associated with high utilization included prolonged postpartum hospitalization, repeat cesarean delivery, and increased birth weight. Among the social factors evaluated, smoking was associated with increased oxycodone use but prior drug use was not. Maternal comorbidities such as diabetes and hypertension, and pregnancy complications such as preeclampsia and obstetrical hemorrhage were not significantly associated with increased oxycodone use. CONCLUSION: After term cesarean deliveries, a number of maternal and peripartum factors are associated with increased inpatient oxycodone utilization. Our findings may help identify patient subgroups that necessitate interventions to prevent development of prolonged postoperative opioid use.

673 The Peripartum Risk of Deep Vein Thrombosis and Pulmonary Embolism in Women With Inflammatory Bowel Disease: A Population-Based Cohort Analysis

INTRODUCTION: Population-based adverse outcomes in the peripartum period are limited. Both Inflammatory Bowel Disease (IBD) and pregnancy are known risk factors for venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). The aim of our study was to determine whether the odds of VTE are higher in women with Ulcerative Colitis (UC) and Crohn's disease (CD) at the time of delivery, compared to pregnant patients without IBD. METHODS: We performed a population-based retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP)'s Nationwide Inpatient Sample (NIS) between 2005 and 2014. ICD-9-CM diagnosis and procedure codes were used to identify unique obstetric hospitalizations associated with delivery of an infant, and VTE. We created national estimates using appropriate weights for each NIS admission. Multivariable logistic regression was used to evaluate the association of UC and CD with VTE, while adjusting for age, race, smoking, obesity, Charlson Comorbidity Index, chronic steroid use, income, primary insurance, hospital region, and hospital bed size. RESULTS: The cohort comprised of 39.8 million deliveries, including 19,167 in women with UC and 31,083 in women with CD. Table 1 depicts baseline characteristics of the cohort. Overall, IBD patients were more likely to be white, have private insurance, receive care at larger hospitals, have a cesarean section and use chronic steroids compared to non-IBD patients. There were 19 (0.1%) cases of VTE in UC patients, 18 (0.06%) in CD patients versus 11,935 (0.03%) in non-IBD patients. Unadjusted odds ratios [OR] were 4.0 for UC; 95% confidence interval [CI] 1.5-10.5, and 2.5 (95% CI, 0.9-6.8) for CD. After adjusting for confounders, the OR for developing VTE was 1.63 (95% CI 0.41-6.55) among UC patients and 2.11 (95% CI, 0.79-5.64) in CD patients. As seen in Table 2, the following variables were associated independently with an increased risk for VTE: age, higher comorbidity scores, inpatient cesarean delivery, obesity and smoking. CONCLUSION: Our study showed that patients with IBD were not at greater risk for VTE at the time of delivery compared with non-IBD, perhaps due to the lower absolute risk of VTE over time (0.06-0.1% in our study vs 1.5-2.1% in the 2005 NIS database). Improved awareness and practices surrounding DVT prophylaxis may also be contributing. This study was not able to differentiate between active versus quiescent disease.

Ophthalmological and obstetric management in pregnant women with retinal disorders.

To analyze the clinical significance of ophthalmological assessment in pregnant women affected with degenerative retinal lesions, and the lesions' clinical relevance in determining the obstetric management and delivery method. 69 pregnant women affected with retinal degenerative lesions were included in our study. In each patient, the risk of ophthalmological complications during vaginal delivery was evaluated. After the woman's delivery, alignment between the ophthalmological recommendations and the obstetric management were analyzed. Each case where the management plan differed from the clinical proceedings was thoroughly investigated to determine the cause. In 69 pregnant women the risk of ophthalmological complications was evaluated, and in 24 cases (35%) assessed as low, as medium in 37 cases (54%) and as high in 8 cases (11%). Among the 69 patients, 42 of women delivered vaginally and the remaining 27 underwent caesarean section. In the high-risk group, the rate of caesarean section was 87%, while in both the low- and medium-risk groups the rate of vaginal births was 75%. Two years of postnatal ophthalmological follow-up did not reveal any complications that could have been associated with the delivery. Every pregnant woman should undergo ophtalmological examination to assess peripartum risk of complications and determine the method of delivery.

Mode of Anaesthesia for Preterm Caesarean Delivery

Background Preterm delivery is often performed by Caesarean section. We investigated modes of anaesthesia and risk factors for general anaesthesia among women undergoing preterm Caesarean delivery. Methods Women undergoing Caesarean delivery between 24+0 and 36+6 weeks’ gestation were identified from a multicentre US registry. The mode of anaesthesia was classified as neuraxial anaesthesia (spinal, epidural, or combined spinal and epidural) or general anaesthesia. Logistic regression was used to identify patient characteristic, obstetric, and peripartum risk factors associated with general anaesthesia. Results Within the study cohort, 11 539 women had preterm Caesarean delivery; 9510 (82.4%) underwent neuraxial anaesthesia and 2029 (17.6%) general anaesthesia. In our multivariate model, African-American race [adjusted odds ratio (aOR)=1.9; 95% confidence interval (CI)=1.7–2.2], Hispanic ethnicity (aOR=1.5; 95% CI=1.2–1.8), other race (aOR=1.4; 95% CI=1.1–1.9), and haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or eclampsia (aOR=2.8; 95% CI=2.2–3.5) were independently associated with receiving general anaesthesia for preterm Caesarean delivery. Women with an emergency Caesarean delivery indication had the highest odds for general anaesthesia (aOR=3.5; 95% CI=3.1–3.9). For every 1 week decrease in gestational age at delivery, the adjusted odds of general anaesthesia increased by 13%. Conclusions In our study cohort, nearly one in five women received general anaesthesia for preterm Caesarean delivery. Although potential confounding by unmeasured factors cannot be excluded, our findings suggest that early gestational age at delivery, emergent Caesarean delivery indications, hypertensive disease, and non-Caucasian race or ethnicity are associated with general anaesthesia for preterm Caesarean delivery.

Mode of anaesthesia for preterm Caesarean delivery: secondary analysis from the Maternal–Fetal Medicine Units Network Caesarean Registry

Preterm delivery is often performed by Caesarean section. We investigated modes of anaesthesia and risk factors for general anaesthesia among women undergoing preterm Caesarean delivery. Women undergoing Caesarean delivery between 24(+0) and 36(+6) weeks' gestation were identified from a multicentre US registry. The mode of anaesthesia was classified as neuraxial anaesthesia (spinal, epidural, or combined spinal and epidural) or general anaesthesia. Logistic regression was used to identify patient characteristic, obstetric, and peripartum risk factors associated with general anaesthesia. Within the study cohort, 11 539 women had preterm Caesarean delivery; 9510 (82.4%) underwent neuraxial anaesthesia and 2029 (17.6%) general anaesthesia. In our multivariate model, African-American race [adjusted odds ratio (aOR)=1.9; 95% confidence interval (CI)=1.7-2.2], Hispanic ethnicity (aOR=1.5; 95% CI=1.2-1.8), other race (aOR=1.4; 95% CI=1.1-1.9), and haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or eclampsia (aOR=2.8; 95% CI=2.2-3.5) were independently associated with receiving general anaesthesia for preterm Caesarean delivery. Women with an emergency Caesarean delivery indication had the highest odds for general anaesthesia (aOR=3.5; 95% CI=3.1-3.9). For every 1 week decrease in gestational age at delivery, the adjusted odds of general anaesthesia increased by 13%. In our study cohort, nearly one in five women received general anaesthesia for preterm Caesarean delivery. Although potential confounding by unmeasured factors cannot be excluded, our findings suggest that early gestational age at delivery, emergent Caesarean delivery indications, hypertensive disease, and non-Caucasian race or ethnicity are associated with general anaesthesia for preterm Caesarean delivery.

Group B Streptococcal Infections

1. Laura Sass, MD* 1. *Division of Infectious Diseases, Children's Specialty Group, Children's Hospital of The King's Daughters, Norfolk, VA; Pediatrics, Eastern Virginia Medical School, Norfolk, VA. * Abbreviations: CDC: : Centers for Disease Control and Prevention CPS: : capsular polysaccharides CSF: : cerebrospinal fluid EOD: : early onset disease GBS: : group B Streptococcus IAP: : intrapartum antibiotic prophylaxis NAAT: : nucleic acid amplification test UTI: : urinary tract infection In 2010, revised guidelines were published with updated algorithms for group B Streptococcus screening, intrapartum prophylaxis, antibiotic doses, and revised management for newborns. After completing this article, readers should be able to: 1. Know the mode of transmission of group B Streptococcus (GBS) and the peripartum risk factors associated with a high risk of infection. 2. Know the major clinical manifestations of GBS and be able to differentiate the epidemiology and clinical presentation of early onset GBS disease from that of late-onset disease. 3. Know the laboratory testing for GBS: isolation, antigen detection, and susceptibility tests. 4. Know the treatment of GBS infections: drugs of choice, alternative drugs, and ineffective drugs. 5. Review the most recent guidelines for the prevention of perinatal GBS disease. 1. Understand the importance of maternal screening tests for GBS. 2. Know the criteria for the treatment of mothers known to be GBS carriers at the time of delivery. 3. Differentiate the prevention of early onset disease from that of late onset. Group B Streptococcus (GBS), or Streptococcus agalactiae , is an encapsulated gram-positive diplococcus that produces a narrow zone of β-hemolysis on blood agar and generally is resistant to bacitracin. GBS can be further differentiated by type-specific capsular polysaccharides (CPS) and protein antigens. Current circulating serotypes include Ia, Ib, Ia/c, II, III, IV, V, VI, VII, VIII, and IX. GBS initially was believed to be a bovine mastitis pathogen, but cases of puerperal sepsis in humans were described in the 1930s. The organism then became more prominent in the 1970s as a cause of maternal and neonatal disease. The most common maternal manifestations are asymptomatic bacteriuria, urinary tract infection (UTI), bacteremia, chorioamnionitis, and endometritis. In …

Management of Acquired Cardiac Disease in the Obstetric Patient

Physiologic changes incurred by pregnancy can cause severe decompensation in the parturient with underlying cardiac disease. The result is increased morbidity and mortality for both mother and child. Appropriate anesthetic management can significantly impact these outcomes. This review systematically presents the pathophysiology, peripartum risk, and anesthetic management in the puerperium of specific acquired cardiac abnormalities including: valvular disease, pulmonary hypertension, cardiomyopathy, cardiac transplantation, ischemia, arrhythmias, and cardiac arrest.