Rates Of Adverse Neonatal Outcomes Research Articles

Incidence and factors associated with immediate adverse neonatal outcomes among emergency obstetric referrals in labor at a tertiary hospital in Uganda: a prospective cohort study

BackgroundHigh rates of adverse neonatal outcomes in resource-limited settings are multifactorial, varying by country, region, and institution. In sub-Saharan Africa, the majority of adverse neonatal outcomes are intrapartum related, and studies in Uganda have shown that referral in labor is a major determinant of adverse neonatal outcomes. This study aimed to assess the incidence and factors associated with immediate adverse neonatal outcomes among emergency obstetric referrals in labor at a tertiary hospital in Eastern Uganda.Materials and methodsThis was a prospective cohort study involving 265 women who were referred in labor to Jinja Regional Referral Hospital in Uganda with emergency obstetric complications. The exposure of interest was being referred with obstetrical emergency, and the outcome variable was adverse neonatal outcomes. The study was conducted between July 5, 2023, and October 5, 2023. Consecutive sampling was used, and data on sociodemographic and obstetric factors, referral related factors, as well as the primary outcome variable (adverse neonatal outcome) were collected via interviewer-administered questionnaires. The data were then cleaned, coded, and analyzed using STATA version 14. Log-binomial regression determined risk ratios and associations for factors related to adverse neonatal outcomes. Variables with p-values < 0.2 in bivariable analysis were included in the multivariable analysis, where significance was set at p < 0.05.ResultsOf the 265 women exposed to emergency obstetrical referrals, 40% experienced adverse neonatal outcomes, a composite measure including neonatal intensive care admission (27.6%), low Apgar score (23.8%), fresh stillbirth (11.3%), early-onset neonatal infection (6.8%), and early neonatal death (2.3%). Factors significantly associated with adverse neonatal outcomes were; maternal age ≥ 35 years (aRR = 1.72, CI:1.194–2.477, p value = 0.004), APH (aRR = 2.48, CI: 1.859–3.311, p-value < 0.001), and non-reassuring fetal status (aRR = 1.90, CI: 1.394–2.584, p-value < 0.001).ConclusionsThe study found a high rate of adverse neonatal outcomes among emergency obstetric referrals, with 40% of participants facing issues like ICU admissions, low Apgar scores and fresh stillbirth. Key factors included maternal age over 35, antepartum hemorrhage, and non-reassuring fetal status. These results highlight the urgent need for targeted interventions in emergency obstetric care. Strategies should enhance referral systems, improve facility preparedness, train healthcare providers, and educate communities on timely referrals and managing high-risk pregnancies.

Cancer chemotherapy in pregnancy and adverse pediatric outcomes: a population-based cohort study.

Administration of chemotherapy during pregnancy is often delayed, while preterm delivery is common. If in utero exposure to chemotherapy is associated with adverse pediatric outcomes, it is unknown whether that relationship is directly attributable to the chemotherapy or is mediated by preterm birth. Cases were identified from Canadian cancer registries and administrative data in Alberta, British Columbia, and Ontario, 2003-2017, with follow-up until 2018. The primary exposure was receipt of chemotherapy during pregnancy. Severe neonatal morbidity and mortality (SNM-M), neurodevelopmental disorders and disabilities (NDDs) and pediatric complex chronic conditions (PCCC) reflected short- and long-term pediatric outcomes. Modified Poisson and Cox proportional hazard regression models generated adjusted risk ratios (RR) and hazard ratios (HR), respectively. The influence of preterm birth on the association between exposure to chemotherapy in pregnancy and each study outcome was explored using mediation analysis. Of the 1150 incident cases of cancer during pregnancy, 142 (12.3%) received chemotherapy during pregnancy. Exposure to chemotherapy in pregnancy was associated with a higher risk of SNM-M (RR 1.67, 95% CI: 1.13-2.46), but not NDD (HR 0.93, 95% CI: 0.71-1.22) or PCCC (HR 0.96, 95% CI: 0.80-1.16). Preterm birth <34 and <37 weeks mediated 75.8% and 100% of the observed association between chemotherapy and SNM-M, respectively. Most children born to people with cancer during pregnancy appear to have favourable long-term outcomes, even following exposure to chemotherapy in pregnancy. However, preterm birth is quite common, and may contribute to increased rates of adverse neonatal outcomes.

Pregnancy outcomes in correlation with placental histopathology in pregnancies complicated by fetal growth restriction with vs. without reduced fetal movements.

Fetal movements are crucial indicators of fetal well-being, with reduced fetal movements (RFM) suggesting potential fetal compromise. Fetal growth restriction (FGR), often linked to placental insufficiency, is a major cause of perinatal morbidity and mortality. This study aimed to investigate the neonatal, labor, and placental outcomes of FGR pregnancies with and without RFM at term. In this retrospective study, data from all term, singleton deliveries with FGR and concomitant RFM were obtained and compared to an equal control group of FGR without RFM. Maternal characteristics, pregnancy and neonatal outcomes, and placental histology were compared. The primary outcome was a composite of adverse neonatal outcomes. A multivariable regression analysis was performed to identify independent associations with adverse neonatal outcomes. During the study period, 250 FGR neonates with concomitant RFM and an equal control group were identified. The groups did not differ in maternal demographics aside from significantly higher rates of maternal smoking in the RFM group (p < 0.001). Polyhydramnios and oligohydramnios (p = 0.032 and p = 0.007, respectively) and meconium-stained amniotic fluid (p < 0.001) were more prevalent in the FGR+RFM group. Additionally, the RFM group showed higher rates of adverse neonatal outcomes despite having larger neonates (p = 0.047 and p < 0.001, respectively). No significant differences were observed in placental findings. Logistic regression identified RFM as an independent predictor of adverse neonatal outcomes (aOR 2.45, 95% CI 1.27-4.73, p = 0.008). Reduced fetal movements are significant and independent predictors of worse neonatal outcomes in FGR pregnancies, suggesting an additional acute insult on top of underlying placental insufficiency.

Association between Gestational Age and Perinatal Outcomes in Women with Late Preterm Premature Rupture of Membranes.

The American College of Obstetricians and Gynecologists (ACOG) suggests expectant management until 34 weeks for patients with preterm premature rupture of membranes (PPROM). New data suggest extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM. A retrospective cohort study was performed using linked vital statistics and the International Classification of Diseases, Ninth Revision data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include neonatal intensive care unit (NICU) admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons. In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared with 81% at 34 weeks and 22% at 36 weeks (p < 0.001). At 32 weeks, 20% had neonatal sepsis compared with 11% at 34 weeks and 3% at 36 weeks (p < 0.001). At 32 weeks, 67% had respiratory distress syndrome compared with 44% at 34 weeks and 12% at 36 weeks (p < 0.001). In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis. · The ACOG recommends expectant management until 34 weeks for patients with PPROM.. · However, expectant management to 37 weeks might improve neonatal outcomes.. · Later gestational age at delivery was associated with decreased rates of adverse neonatal outcomes.. · Later gestational age at delivery was not associated with an increase in neonatal sepsis.. · The management of PPROM is complex and should be individualized..

Analysis of perinatal outcomes for emergency cervical cerclage in singleton pregnancies at 24–28 weeks of gestation

BackgroundCervical cerclage is the only effective treatment for cervical insufficiency, effectively preventing late miscarriage and preterm birth. The effectiveness and safety of emergency cervical cerclage (ECC) as an emergency treatment when the cervix is already dilated or when there is protrusion of the fetal membranes into the vagina remain controversial, especially in pregnancies at 24–28 weeks when the fetus is viable. There is still no consensus on whether emergency cervical cerclage should be performed in such cases.PurposeTo investigate the effectiveness and safety of emergency cervical cerclage in singleton pregnant women at 24–28 weeks of gestation.MethodsThis study employed a single-center prospective cohort design, enrolling singleton pregnant women at 24–28 weeks of gestation with ultrasound or physical examination indicating cervical dilation or even membrane protrusion. Emergency cervical cerclage was compared with conservative treatment. The primary endpoints included a comprehensive assessment of perinatal pregnancy loss, significant neonatal morbidity, and adverse neonatal outcomes. Secondary endpoints included prolonged gestational age, preterm birth, neonatal hospitalization rate, premature rupture of membranes, and intrauterine infection/chorioamnionitis.ResultsFrom June 2021 to March 2023, a total of 133 pregnant women participated in this study, with 125 completing the trial, and were allocated to either the Emergency Cervical Cerclage (ECC) group (72 cases) or the conservative treatment group (53 cases) based on informed consent from the pregnant women. The rate of adverse neonatal outcomes was 8.33% in the ECC group and 26.42% in the conservative treatment (CT) group, with a statistically significant difference (P = 0.06). There were no significant differences between the two groups in terms of perinatal pregnancy loss and significant neonatal morbidity. The conservative treatment group had a mean prolonged gestational age of 63.0 (23.0, 79.5) days, while the ECC group had 84.0 (72.5, 89.0) days, with a statistically significant difference between the two groups (P < 0.001). Compared with CT group, the ECC group showed a significantly reduced incidence of preterm birth before 28 weeks, 32 weeks, and 34 weeks, with statistical significance (P = 0.046, 0.007, 0.001), as well as a significantly decreased neonatal hospitalization rate (P = 0.013, 0.031). Additionally, ECC treatment did not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis, with no statistically significant differences (P = 0.406, 0.397).ConclusionIn singleton pregnant women with cervical insufficiency at 24–28 weeks of gestation, emergency cervical cerclage can reduce adverse neonatal pregnancy outcomes, effectively prolong gestational age, decrease preterm births before 28 weeks, 32 weeks, and 34 weeks, lower neonatal hospitalization rates, and does not increase the risk of preterm premature rupture of membranes or intrauterine infection/chorioamnionitis.

Timing of Elective Cesarean Section and Neonatal Outcomes in Term Singleton Deliveries: A Single-Center Experience.

This study aimed to evaluate the timing of elective cesarean sections at 37 to 41 weeks from a tertiary hospital in Japan. The primary outcome was the rate of adverse neonatal outcomes, especially focusing on neonates delivered at 38 weeks of gestation. The study population was drawn from singleton pregnancies delivered following planned cesarean birth at the Fukuda Hospital from 2012 to 2019. Information on deliveries was obtained from the hospital database, which contains clinical, administrative, laboratory, and operating room databases. After excluding women with chronic conditions, maternal complications, indications for multiple births, or a neonate with an anomaly, 2,208 neonates remained in the analysis. Among adverse neonatal outcomes, the rate was significantly higher in neonates delivered at 37 weeks of gestation (unadjusted odds ratio [OR] = 13.22 [95% confidence interval [CI]: 6.28, 27.86], p < 0.001) or 38 weeks of gestation (unadjusted OR = 1.82 [95% CI: 1.04, 3.19], p = 0.036) compared with neonates delivered at 39 to 41 weeks. The adjusted risk of any adverse outcome was significantly higher at 380-1/7 weeks (adjusted OR = 2.40 [95% CI: 1.35, 4.30], p = 0.003) and 382-3/7 weeks (adjusted OR = 1.89 [95% CI: 1.04, 3.44], p = 0.038) compared with neonates delivered at 39 to 41 weeks, respectively. Our findings suggest that elective cesarean sections might be best scheduled at 39 weeks or later. When considering a cesarean at 38 weeks, it appears that 384/7 weeks of gestation or later could be a preferable timing in the context of reducing neonatal risks. However, as the composite outcome includes mostly minor conditions, the clinical significance of this finding needs to be carefully interpreted. · Timing of elective cesarean sections from 37 to 41 weeks was evaluated in a Japanese tertiary hospital.. · Neonates delivered at 37 and 38 weeks had higher adverse outcome rates compared with 39 to 41 weeks.. · Scheduling elective cesarean sections at least 384/7 weeks or later may reduce neonatal risk..

Management of late-onset fetal growth restriction: pragmatic approach.

There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol. This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise. Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026). Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal Morbidity in Healthy Obese Pregnant Individuals Delivered by Elective Repeat Cesarean at Term.

This study aimed to compare the risks of adverse perinatal outcomes by body mass index (BMI) categories in healthy pregnant individuals delivered by term elective repeat cesarean (ERCD) to describe an optimal timing of delivery in otherwise healthy patients at the highest-risk BMI threshold. A secondary analysis of a prospective cohort of pregnant individuals undergoing ERCD at 19 centers in the Maternal-Fetal Medicine Units Network from 1999 to 2002. Nonanomalous singletons undergoing prelabor ERCD at term were included. The primary outcome was composite neonatal morbidity; secondary outcomes included composite maternal morbidity and individual components of the composites. Patients were stratified by BMI classes and to identify a BMI threshold for which morbidity was the highest. Outcomes were then examined by completed week's gestation, between BMI classes. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI). A total of 12,755 patients were included in analysis. Patient's with BMI ≥ 40 had the highest rates of newborn sepsis, neonatal intensive care unit admissions, and wound complications. While a weight-related response was observed between BMI class and neonatal composite morbidity (p < 0.001), only those with BMI ≥ 40 had significantly higher odds of composite neonatal morbidity (aOR: 1.4, 95% CI: 1.0-1.8). In analyses of patients with BMI ≥ 40 (n = 1,848), there was no difference in the incidence of composite neonatal or maternal morbidity across weeks' gestation at delivery; however, as gestational age approached 39 to 40 weeks, rates of adverse neonatal outcomes decreased, only to increase again at 41 weeks' gestation. Of note, the odds of the primary neonatal composite were the highest at 38 weeks compared with 39 weeks (aOR: 1.5, 95% CI: 1.1-2.0). Neonatal morbidity is significantly higher in pregnant individuals with BMI ≥40 delivering by ERCD. Despite this increased perinatal morbidity, delivery prior to 39 and after 41 weeks in these patients is associated with increased neonatal risks. · Obese patients without additional comorbidities have higher rates of neonatal morbidity.. · Patients with BMI ≥ 40 carry the highest odds of poor perinatal outcomes.. · Earlier timing of delivery does not appear to reduce this risk..

Can prenatal ultrasound predict adverse neonatal outcomes in SARS-CoV-2–affected pregnancies?

On the basis of available data, at least 1 ultrasound assessment of pregnancies recovering from SARS-CoV-2 infection is recommended. However, reports on prenatal imaging findings and potential associations with neonatal outcomes following SARS-CoV-2 infection in pregnancy have been inconclusive. This study aimed to describe the sonographic characteristics of pregnancies after confirmed SARS-CoV-2 infection and assess the association of prenatal ultrasound findings with adverse neonatal outcomes. This was an observational prospective cohort study of pregnancies diagnosed with SARS-CoV-2 by reverse transcription polymerase chain reaction between March 2020 and May 2021. Prenatal ultrasound evaluation was performed at least once after diagnosis of infection, with the following parameters measured: standard fetal biometric measurements, umbilical and middle cerebral artery Dopplers, placental thickness, amniotic fluid volume, and anatomic survey for infection-associated findings. The primary outcome was the composite adverse neonatal outcome, defined as ≥1 of the following: preterm birth, neonatal intensive care unit admission, small for gestational age, respiratory distress, intrauterine fetal demise, neonatal demise, or other neonatal complications. Secondary outcomes were sonographic findings stratified by trimester of infection and severity of SARS-CoV-2 infection. Prenatal ultrasound findings were compared with neonatal outcomes, severity of infection, and trimester of infection. A total of 103 SARS-CoV-2-affected mother-infant pairs with prenatal ultrasound evaluation were identified; 3 cases were excluded because of known major fetal anomalies. Of the 100 included cases, neonatal outcomes were available in 92 pregnancies (97 infants); of these, 28 (29%) had the composite adverse neonatal outcome, and 23 (23%) had at least 1 abnormal prenatal ultrasound finding. The most common abnormalities seen on ultrasound were placentomegaly (11/23; 47.8%) and fetal growth restriction (8/23; 34.8%). The latter was associated with a higher rate of the composite adverse neonatal outcome (25% vs 1.5%; adjusted odds ratio, 22.67; 95% confidence interval, 2.63-194.91; P<.001), even when small for gestational age was removed from this composite outcome. The Cochran Mantel-Haenszel test controlling for possible fetal growth restriction confounders continued to show this association (relative risk, 3.7; 95% confidence interval, 2.6-5.9; P<.001). Median estimated fetal weight and birthweight were lower in patients with the composite adverse neonatal outcome (P<.001). Infection in the third trimester was associated with lower median percentile of estimated fetal weight (P=.019). An association between placentomegaly and third-trimester SARS-CoV-2 infection was noted (P=.045). In our study of SARS-CoV-2-affected maternal-infant pairs, rates of fetal growth restriction were comparable to those found in the general population. However, composite adverse neonatal outcome rates were high. Pregnancies with fetal growth restriction after SARS-CoV-2 infection were associated with an increased risk for the adverse neonatal outcome and may require close surveillance.

Maternal and Neonatal Outcomes After Monoclonal Antibody Use [ID: 1376620

INTRODUCTION: The study aimed to evaluate whether the administration of monoclonal antibodies (MABs) in mildly symptomatic unvaccinated COVID-19-positive pregnant patients reduced the need for maternal hospitalization and to evaluate whether this medication affected the rate of adverse neonatal outcomes and severe maternal disease. We hypothesized that MAB use would reduce the need for hospitalization. METHODS: This retrospective cohort study was completed by obtaining electronic medical record data of all pregnant patients between August 2020 and January 2022 who met criteria for MAB therapy. The two comparison groups were patients who received outpatient MAB therapy during pregnancy and those who were eligible for therapy but declined. Demographic and hospitalization data were obtained. Exclusion criteria included severe illness upon diagnosis requiring hospitalization, or patients for whom delivery and neonatal data were not available. RESULTS: During the study period, 49 patients qualified for MAB therapy, of which delivery data were available for 39 patients. Twenty patients (51%) elected to receive MAB therapy and 19 (49%) declined. Among those who received MAB therapy, 10 (26% of the population) were vaccinated, and among those who declined, 6 (15% of the population) were vaccinated. The two groups were similar in gestational age at delivery (38 weeks 4 days versus 37 weeks 5 days) and gestational age at diagnosis (19 weeks 0 days versus 22 weeks 6 days). Among patients who did not receive MABs, both absolute and relative maternal hospitalization rate was higher (26.3% versus 5%, 12.8% versus 3%, P&gt;.05). When stratified by vaccination status, those who were vaccinated had a 5% probability of hospitalization regardless of MAB therapy. The probability of hospitalization was highest among unvaccinated women who did not receive MAB therapy (67%) and lowest among unvaccinated women who received MAB therapy (0%). CONCLUSION: Unvaccinated patients who declined MAB therapy had a higher rate of hospitalization, although not statistically significant. These preliminary findings warrant further study with a larger cohort.

Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment.

This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..

Evaluation of Low-Dose Aspirin to Prevent Preeclampsia in Pregnant People with Chronic Hypertension.

Our objective was to evaluate if the use of low-dose aspirin (LDA) among pregnant individuals with chronic hypertension (CHTN) reduces the rate of superimposed preeclampsia or other adverse maternal and neonatal outcomes. Our study included single-center cohort of pregnant individuals with CHTN who had a live birth after 23 weeks' gestation, between 2013 and 2018. The primary exposure was the use of LDA in pregnancy and the primary outcome was superimposed preeclampsia. LDA use was also evaluated by the timing of initiation, before or after 16 weeks' gestation. Secondary outcomes included preeclampsia subtypes (e.g., preeclampsia with severe features, early-onset disease), as well as adverse maternal and neonatal outcomes. Differences were analyzed by χ 2, Fisher's exact, or t tests, with logistic regression to adjust for confounders. Of 11,825 deliveries during the study period, 494 (4.2%) occurred in women with CHTN. Among those with CHTN, 174 (35%) were prescribed LDA, most often 81 mg daily (173 out of 174, 99%). Baseline characteristics were similar between groups, but the history of preeclampsia was more common in those prescribed LDA. The rate of superimposed preeclampsia was no different among those with CHTN-prescribed LDA compared with those who were not (36% vs. 30%, p = 0.2), even when restricting the analysis to those prescribed LDA before 16 weeks' gestation (33 vs. 30%, p = 0.2). In addition, LDA did not lead to a reduction in the rate of preeclampsia with severe features, early-onset preeclampsia, or other adverse maternal outcomes. However, the composite rate of adverse neonatal outcomes was lower in LDA users versus nonusers (4.0 vs. 13%, p = 0.002), which persisted after multivariable adjustment (adjusted odds ratio: 0.28, 95% confidence interval: 0.12-0.67). Among pregnant individuals with CHTN, LDA did not decrease the rate of superimposed preeclampsia. Further studies are warranted to validate our observed reduction in adverse neonatal outcomes and to determine if aspirin is more beneficial at dosages greater than 81 mg daily. · Superimposed preeclampsia rates are the same regardless of LDA.. · Decreased rate of adverse neonatal outcomes is seen with LDA.. · No decrease in adverse maternal outcomes is seen with LDA..

Perinatal outcomes of twin pregnancies complicated with preeclampsia at a tertiary hospital in Ethiopia: A case‐control study

AbstractBackgroundPreeclampsia accounts for 10–15% maternal deaths globally, corresponding to 50,000 annual maternal deaths. Twin pregnancy is a known risk factor for preeclampsia; however, there is inadequate data on the clinical characteristics and perinatal outcomes of twin pregnancies complicated with preeclampsia. This paper studied the perinatal outcomes of twin pregnancies complicated with preeclampsia at a tertiary hospital in Ethiopia.MethodsA case‐control study was conducted at St. Paul's Hospital Millennium Medical College (Addis Ababa, Ethiopia) from September 1, 2016 till August 31, 2018. A total of 173 twin deliveries (63 preeclampsia cases and 110 normotensive controls) were included in the study and the primary outcome was the frequency of preterm delivery. Data were analyzed using SPSS version 23 and statistical test of association was done using chi‐square test for categorical data. Variables with p value of &lt;0.2 on bivariate analysis were entered into multivariable logistic regression analysis. p value &lt;0.05 were considered significant.ResultsThe frequency of preterm birth was 61.9% in the preeclampsia group and 33.6% in the normotensive group, p &lt; 0.001. Preeclampsia group were 2.58 times more likely to have preterm delivery compared to matched normotensive controls [adjusted OR = 2.58, 95% CI (1.24 – 5.35), p = 0.01]. There was no difference in the rate of adverse neonatal outcome (respiratory distress syndrome, early neonatal death, and Low Apgar score) between the groups.ConclusionsIn this study, twin pregnancies complicated with preeclampsia were found to have an increased rate of preterm birth compared to matched controls without hypertension.

Adverse perinatal outcomes in pregnancies affected by severe COVID-19 infection

BackgroundSevere COVID-19 infection in pregnancy has been associated with an increase in adverse perinatal outcomes, though studies differ regarding which outcomes are affected. Increased characterization of obstetric and neonatal outcomes are needed including details on indications for preterm delivery and additional neonatal adverse outcomes.ObjectiveTo determine whether there is a higher rate of adverse perinatal outcomes amongst severe-critical COVID-19 infection compared to non-severe COVID-19 infection diagnosed during pregnancy.Study DesignThis was a retrospective observational cohort study that compared rates of adverse perinatal outcomes amongst singleton pregnancies identified as having a positive laboratory PCR diagnosis of COVID-19 infection with severe-critical COVID-19 infection versus non-severe (asymptomatic, mild or moderate). Primary outcomes included hypertensive disorders of pregnancy, cesarean delivery, fetal growth restriction, preterm birth, and neonatal intensive care unit (NICU) admission. Additional neonatal outcomes analyzed include need for CPR, low birthweight (<2500g), 1 or 5 min Apgar <7, need for supplemental oxygen, need for intubation, interventricular hemorrhage, sepsis, respiratory distress syndrome, bronchopulmonary dysplasia, blood transfusion, necrotizing enterocolitis, hypoxic ischemic encephalopathy, birth trauma or neonatal death. Appropriate bivariate analyses were used to compare groups. Logistic regression was used to examine primary outcomes adjusting for confounders.ResultsA total of 441 participants were identified and confirmed via detailed chart review to be pregnant with a singleton pregnancy while diagnosed with COVID-19. Of these, 44 (10%) met NIH criteria for severe-critical COVID-19 infection. The median gestational age at the time of maternal COVID-19 diagnosis was 36.4 weeks (IQR 29.6 – 38.6). Severe-critical COVID-19 infection had a higher risk of a composite adverse neonatal outcome (36.4% vs 21.4%, p=0.03). There was a high incidence of hypertensive disorders of pregnancy overall (20.6%) but this outcome was not higher in the severe-critical vs non-severe group. There were no maternal deaths. There was a low incidence of neonatal COVID-19 test positivity amongst those tested (1.8%). When adjusting for presence of heart disease and gestational age at COVID-19 diagnosis, severe-critical COVID-19 was strongly associated with fetal growth restriction (aOR 2.73, 1.03 – 7.25) and NICU admission (aOR 3.50, CI 1.56 – 7.87). Preterm delivery was more common but was no longer significant after adjustment (aOR 2.23, CI 0.99 – 5.05).ConclusionSevere-critical COVID-19 infection during pregnancy is associated with higher rates of adverse neonatal outcomes and strongly associated with NICU admission and fetal growth restriction compared to non-severe disease. There is a high rate of hypertensive disorders of pregnancy overall in all those affected by COVID-19, regardless of severity. Pregnant persons should be counseled on these risks to encourage vaccination, and those with infection during pregnancy should be monitored for fetal growth disorders.

Correlation between Pregnancy Outcome and Placental Pathology in COVID-19 Pregnant Women.

Background Vertical transmission of several viruses during pregnancy has been shown to cause adverse fetal outcomes. The question about the possibility of a similar outcome in association with SARS-CoV-2 has been raised in recently published articles. Indeed, the rate of transmission through the placenta to the fetus reported in women with COVID-19 has been shown to form a minority. The aim of this study was to explore the possible histopathological changes in the placenta of pregnant women with COVID-19 after delivery and those changes in the umbilical cord. Methods A case-control study including a total of 50 full-term pregnant women with COVID-19 and 60 control pregnant females. Histopathological evaluation of placental tissues and umbilical cords were reported. Results The main findings in the umbilical cord were increased thickness of vessels, thrombus formation, endothelins, and narrow lumen; except for the increased thickness of blood vessels, these findings were more frequently seen in women with COVID-19, in comparison with control women in a significant manner (p < 0.05). Increased thickness of blood vessels was more significantly observed in the control group compared to the COVID-19 group (p < 0.01). Findings of the placenta included avascular villi, fibrin, thrombosis, and meconium macrophage in various combinations. Except for fibrin as the sole findings, all other findings including combinations were more frequently encountered in the study group in comparison to the control group (p < 0.05). Conclusion Pregnant women with COVID-19 have significant pathological alterations in the placenta and umbilical cord. These findings reflect the capability of SARS-CoV-2 in causing immunological reactions to the placenta, either directly or indirectly, and these pathologies may be linked to the higher rate of adverse neonatal outcomes and maternal admission to the intensive care unit.

Antenatal maternal hypoglycemia in women with gestational diabetes mellitus and neonatal outcomes.

To examine the prevalence of antenatal maternal hypoglycemia after initiation of pharmacotherapy for gestational diabetes mellitus (GDMA2) and its association with pregnancy outcomes. Retrospective cohort of GDMA2 women receiving either insulin or oral hypoglycemic agents. Composite neonatal outcome included macrosomia, jaundice, respiratory distress syndrome, large for gestational age, shoulder dystocia, birth trauma, 5-minute Apgar < 7, and neonatal hypoglycemia, and was compared between women with and without hypoglycemia using bivariate and multivariate analyses. Of 489 women included in the study, 95 (19.4%) had at least one episode of hypoglycemia, most often in the setting of glyburide. Newborns exposed to maternal hypoglycemia had higher rates of the composite neonatal outcome (54.7% vs. 38.3%, p = 0.004). After controlling for confounding factors, maternal hypoglycemia remained independently associated with the composite neonatal outcome (aOR = 1.69, 95% CI 1.04-2.72). Maternal hypoglycemia in GDMA2 was associated with higher rates of adverse neonatal outcomes.

Gestational diabetes mellitus in in-vitro fertilization pregnancies – Clinical and placental histological characteristics

We aimed to investigate obstetric and neonatal outcomes and placental histological findings in in vitro fertilization (IVF) pregnancies complicated by gestational diabetes mellitus (GDM) as compared to unassisted pregnancies. This was a retrospective cohort of deliveries at a single university affiliated center between 12/2008 and 01/2020. Included were singleton pregnancies complicated by GDM, for which placental histopathological examination was performed. Obstetric, neonatal and placental outcomes were compared between pregnancies following IVF and unassisted pregnancies. Placental lesions were categorized according to the "Amsterdam" criteria. Included were 688 deliveries with a diagnosis of GDM with placental examination - 69 IVF pregnancies (IVF group) and 619 unassisted pregnancies (control group). The IVF group was characterized by a significantly higher maternal age and higher rate of nulliparous women - 60.8% vs. 32.9%, p<0.001. There were no differences in GDM type between the study groups - about two thirds of cases were GDMA1 and on third GDMA2. A higher incidence of preeclampsia was noted in the IVF group - 17.3% vs. 9.3%, p=0.03, with no difference in cesarean deliveries and birthweight. IVF deliveries were characterized by a significantly higher rate of adverse neonatal outcomes - 18.8% vs. 8.8%, p=0.008, although this did not attain significance after adjustment to gestational age. No differences were noted in placental histology between the groups. GDM in IVF is associated with a significantly higher rate of adverse neonatal outcomes, as compared with non-assisted pregnancies complicated by GDM. Placental histology does not shed light on these clinical associations.

Management of pregnancies with suspected preeclampsia based on 6-hour vs 24-hour urine protein collection—a randomized double-blind controlled pilot trial

Traditionally, the diagnosis of preeclampsia requires elevated blood pressure measurements and proteinuria demonstrated in a 24-hour urine collection. This prolonged urine collection is associated with patient discomfort, a delay in diagnosis, and in some cases, hospitalization for further management of outcomes. We aimed to assess the feasibility, reliability, and association between maternal and neonatal outcomes of pregnancies managed according to a 6-hour vs 24-hour urine protein collection for suspected preeclampsia. This was a randomized controlled trial conducted at a tertiary university hospital between January 2019 and January 2021 (ClinicalTrials.gov Identifier: NCT03724786). Patients who were hospitalized for preeclampsia workup were asked to participate and randomized at a 1:1 ratio to 6- and 24-hour urine protein collection groups. Both groups collected urine for 24 hours, during which the collection was also tested after 6-hours. After 24 hours, both results were reviewed by one of the research staff, and either the 6- or 24-hour collection result was reported to the patient's managing physician and was documented in the patient's medical record. Both patient and the managing physician were blinded to group allocation. Unblinding was undertaken in cases of a discrepancy between the results (1 of 2 results of >300 mg protein), and the results were analyzed by intention to treat. The primary study outcome was defined as a composite of adverse maternal outcomes. The sample size was set empirically as per proof on concept design. During the study period, 115 patients participated in the trial, 101 of whom completed the follow-up and were analyzed-51 in the 6-hour group and 50 in the 24-hour group. Patient demographics were similar between the study groups. Unblinding occurred in 7 cases in the 6-hour group, in which the initial 6-hour result ranged from 168 to 475 mg. The rates of composite adverse maternal outcomes were 15.6% and 12.0% in the 6- and 24-hour groups, respectively (P=.59). No significant difference was demonstrated in the rate of adverse neonatal outcomes, cesarean delivery, induction of labor, gestational age at delivery, betamethasone treatment, or neonatal birthweight. Managing pregnancies suspected of preeclampsia with a 6-hour urine protein collection is feasible and associated with similar maternal and neonatal outcomes. In cases where the 6-hour result is in the 168 to 475 mg range, we propose completing a 24-hour collection.

Preeclampsia Prevalence, Risk Factors, and Pregnancy Outcomes in Sweden and China

Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality worldwide. Within-country studies have reported racial differences in the presentation and outcome, but little is known about differences between countries. To compare preeclampsia prevalence, risk factors, and pregnancy outcomes between the Swedish and Chinese populations. This cross-sectional study compared deliveries from the Swedish national Medical Birth Register (2007-2012) and the China Labor and Delivery Survey (2015-2016). The Swedish Medical Birth Register records maternal, pregnancy, and neonatal information for nearly all deliveries in Sweden. The China Labor and Delivery Survey was conducted throughout China, and these data were reweighted to enable national comparisons. Participants included 555 446 deliveries from Sweden and 79 243 deliveries from China. Data management and analysis was conducted from November 2018 to August 2020 and revised in February to March 2021. Maternal characteristics, parity, multiple gestation, chronic and gestational diabetes, cesarean delivery. Preeclampsia prevalence and risk factors, overall and for mild and severe forms and rates of adverse neonatal outcomes compared with pregnancies with no gestational hypertension. The 555 446 Swedish pregnancies and 79 243 Chinese pregnancies had mean (SD) maternal age of 30.9 (5.3) years and 28.6 (4.6) years, respectively. The overall prevalence of preeclampsia was similar in Sweden and China, 16 068 (2.9%) and 1803 (2.3%), respectively, but with 5222 cases (32.5%) considered severe in Sweden and 1228 cases (68.1%) considered severe in China. Obesity (defined as BMI ≥28 in China and BMI ≥30 in Sweden) was a stronger risk factor in China compared with Sweden (China: odds ratio [OR], 5.12; 95% CI, 3.82-6.86; Sweden: OR, 3.49; 95% CI, 3.31-3.67). Nulliparity had a much stronger association with severe preeclampsia in Sweden compared with China (Sweden: OR, 3.91; 95% CI, 3.65-4.18; China: OR, 1.65; 95% CI, 1.20-2.25). The overall stillbirth rate for singleton in China was more than 3-fold higher than in Sweden (846/77 512[1.1%] vs 1753/547 219 [0.3%], P < .001), and 10-fold higher among women with preeclampsia (66/1652 [4.6%] vs 60/14 499[0.4%], P < .001). In this study, the prevalence rates of preeclampsia in Sweden and China were similar, but women in China had more severe disease and worse pregnancy outcomes than women in Sweden. The associations of obesity and nulliparity with preeclampsia suggest a role for lifestyle and health care factors but may reflect some differences in pathophysiology. These findings have relevance for current efforts to identify high-risk pregnancies and early serum markers because the value of risk prediction models and biomarkers may be population specific.

Considering Criteria for Active Phase Labor Management of Nulliparous Women: A Cost-Effectiveness Analysis.

The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective. A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis. In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions. In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes. · Cervical dilation of 6 cm should be considered the threshold for the active phase of labor. This is a change from the prior definition of 4 cm.. · We built a theoretical model to compare outcomes and costs associated with the new active phase definition of 6 cm.. · Using a 6-cm threshold is a cost-effective strategy for decreasing primary cesarean deliveries..