Rates Of Adverse Neonatal Outcomes Research Articles

577: Impact of the '39 week Rule' on adverse neonatal outcomes: a statewide analysis

To quantify the rates of adverse neonatal outcomes in term births in pre- and post-statewide implementation of the 39 week rule. De-identified data from all term (> 37 weeks gestational age) births in the state from 2000-2008 (prior to the 39-week rule) and 2013-2017 (after statewide implication and enforcement of the rule) were obtained from the Revenue and Fiscal Affairs Office. Demographic data and ICD9/10 codes were obtained for each birth. Primary outcome was a composite of the incidence of RDS, TTN, HIE, seizure, sepsis, birth trauma (bone fracture or neurologic injury), hyperbilirubinemia, hypoglycemia, feeding difficulties, and NICU admissions. Propensity score analysis was used to control for maternal age, maternal BMI, maternal race, maternal gestational hypertensive disorders, infection, abruption,and diabetes. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the two groups. 620,121 infants were liveborn at term during the study periods (402,139 pre-, 217,982 post-). There was a significant difference in composite neonatal adverse outcomes between the two study periods. However the direction of the difference varied with propensity score stratification. Stratifications corresponding to lower risk pregnancies experienced an increase in the composite outcome, while stratifications corresponding to higher risk pregnancies experienced a decrease. In adjusted analysis, there were statistically significant reductions in brachial plexus injuries, skeletal injuries, peripheral nervous system injuries, and hyperbilirubinemia between pre and post-implementation periods (p < 0.01 for all comparisons). However, there was a statistically significant increase in respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), hypoglycemia, and NICU admissions between pre-and post-implementation periods (p < 0.01 for all comparisons). At a state level, lower risk pregnancies have experienced an increased risk of composite adverse neonatal outcomes following the statewide implementation of the 39 week rule.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study.

This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia. The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2). The population included 25798 births. Of these, 23201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations. Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Effects of gestational age at delivery and type of labor on neonatal outcomes among infants with gastroschisis†

Objective To investigate the effect of preterm gestational age (GA) on neonatal outcomes of gastroschisis and to compare the neonatal outcomes after spontaneous labor versus iatrogenic delivery both in the preterm and early term gestational periods. Study design A retrospective study of prenatally diagnosed gastroschisis cases born at Loma Linda University Medical Center and Lucile Packard Children’s Hospital (Loma Linda, CA) between January 2009 and October 2016. A total of 194 prenatally diagnosed gastroschisis cases were identified and included in the analysis. We compared infants delivered <37 0/7 to those ≥37 0/7 weeks’ gestation. Adverse neonatal outcome was defined as any of: sepsis, short bowel syndrome, prolonged ventilation, or death. Prolonged length of stay (LOS) was defined as ≥75th percentile value. Outcomes following spontaneous versus iatrogenic delivery were compared. Analyses were performed using chi-squared test or Fisher’s exact test for categorical variables, and Student’s t-test or Wilcoxon’s rank-sum test for continuous variables. Results One hundred and six neonates were born <37 weeks and 88 at ≥37 weeks. Adverse outcome was statistically similar among those born <37 weeks compared to ≥37 weeks (48 versus 34%, p = .07). Prolonged LOS was more frequent among neonates delivered <37 weeks (p = .03). Among neonates born <37 weeks, bowel atresia was more frequent in those with spontaneous versus iatrogenic delivery (p = .04). There was no significant difference in the adverse neonatal composite outcome between those with spontaneous preterm labor versus planned iatrogenic delivery at <37 weeks (n = 30 (58%) versus n = 21 (39%), p = .08). Conclusions Neonates with gastroschisis delivered <37 weeks had prolonged LOS whereas the rate of adverse neonatal outcomes was similar between those delivered preterm versus term. Neonates born after spontaneous preterm labor had a higher rate of bowel atresia compared to those born after planned iatrogenic preterm delivery.

The role of umbilical cord gas studies in the prediction of adverse neonatal outcomes in scheduled nonlaboring term singleton cesarean deliveries

Most major societies do not state a specific recommendation against or in favor of routine umbilical cord gas studies sampling. We aimed to study the correlation between abnormal umbilical cord gas studies (using 5 different definitions) and adverse neonatal outcomes in scheduled nonlaboring term singleton cesarean deliveries. The medical charts, surgical records, and neonatal charts of all singleton cesarean deliveries at 370/7-416/7 weeks of gestation between January 2009 and May 2018 from a single tertiary center were reviewed. The cohort of singleton cesarean deliveries was divided into those with "normal" vs "abnormal" umbilical cord gas studies with the 5 different definitions: (1) definition A: pH ≤7.15; (2) definition B: pH ≤7.15 and base excess ≤-12 mmol/L; (3) definition C: pH ≤7.1l (4) definition D: pH ≤7.1 and base excess ≤-12 mmol/L, and (5) definition E: pH <7.0 and base excess ≤-12 mmol/L. Adverse neonatal outcomes included Apgar scores at 5 minutes ≤7, neonatal sepsis, blood transfusion, phototherapy, respiratory morbidity (presence of respiratory distress syndrome, transient tachypnea of the newborn infant, mechanical ventilation, need for respiratory support, or meconium aspiration), cerebral morbidity (presence of intraventricular hemorrhage, seizures, or hypoxic-ischemic encephalopathy), necrotizing enterocolitis, or death. Composite adverse outcome was ≥1 of the aforementioned complications. Overall, 3001 singleton cesarean deliveries were included. The rate of abnormal umbilical cord gas studies with the use of definitions A-E was 2.6%, 0.3%, 1.2%, 0.3%, and 0.1%, respectively. The overall rate of adverse neonatal outcome for the entire cohort was 14.43% (433/3001). There was no correlation between abnormal umbilical cord gas studies and composite adverse neonatal outcome with the use of any of the definitions A-E (P=.2, P=.3, P=.2, P=.3, P=.1, respectively). The sensitivity and specificity of abnormal umbilical cord gas studies as a predictor of composite adverse neonatal outcome were calculated for each of the abnormal umbilical cord gas studies definitions; although the sensitivity was extremely low (0-2.07%), the specificity was high (97.2-99.9%) CONCLUSION: Abnormal umbilical cord gas studies are an uncommon finding in cases of singleton term singleton cesarean deliveries and do not correlate with adverse neonatal outcomes. Therefore, the clinical usefulness and cost-effectiveness of obtaining these studies routinely should be questioned.

538: Outcomes of elective induction of labor at 39 weeks versus expectant management until week 40

This study analyzes differences in maternal and neonatal outcomes from elective induction of labor (eIOL) at 39 weeks versus one additional week of expectant management in nulliparous women at community hospitals. We conducted a retrospective cohort study of singleton, vertex, nonanomalous deliveries in community hospitals in California between 2007 and 2011 using linked hospital discharge and vital statistics data (n=252,107). We compared outcomes from eIOL, defined by the Joint Commission, at 39 weeks against one additional week of expectant management and delivery at 40 weeks. The maternal outcomes of interest were cesarean delivery, operative vaginal delivery, maternal blood transfusion, perineal tear, chorioamnionitis, and endomyometritis. Neonatal outcomes of interest were intrauterine fetal death, 5 minute Apgar less than 7, NICU admission, respiratory distress syndrome (RDS), hypoglycemia, hypoxic ischemic encephalopathy (HIE) and jaundice. Results were compared using chi square analysis and examined using multivariate logistic regression controlling for maternal age, comorbidities, ethnicity, education level, initiation of prenatal care in the first trimester, and insurance status. A p-value of less than 0.05 was used to indicate statistical significance. In our cohort of 252,107 deliveries, there were significant differences in the incidence of cesarean delivery, operative vaginal delivery, maternal transfusion, perineal tear, chorioamnionitis, endomyometritis in women who were electively induced at 39 weeks compared to those who received expectant management and delivered at 40 weeks. Rates of adverse neonatal outcomes of intrauterine fetal death and hypoglycemia were also significantly decreased when women were electively induced at 39 weeks. However, RDS, HIE and jaundice were not significantly different between the two groups. Logistic regression analysis indicated expectant management until 40 weeks significantly increased cesarean deliveries (OR 1.37, 95% CI 1.32-1.42) and operative vaginal deliveries (OR 1.0, 95% CI 1.02-1.15). The maternal and neonatal outcomes following birth are associated with the timing and management prior to delivery. These findings can be used to counsel women regarding the risks of maternal and neonatal complications from elective induction of labor and one additional week of expectant management.

138: Contemporary trends in adverse neonatal outcomes

ACOG published guidelines in 2013 with specific delivery timing recommendations for various medical and fetal conditions in an effort to reduce maternal and neonatal morbidity. We sought to determine how the timing of the release of these guidelines influenced the rate of adverse neonatal outcomes. Using birth certificate records, we conducted a population based retrospective cohort study of all live births in Ohio from the years 2011-2012 (pre-guidelines, Epoch 1) and 2014-2015 (post-guidelines, Epoch 2). We compared frequency of composite adverse neonatal outcome defined as NICU admission, assisted ventilation (>6hrs), meconium, fetal intolerance of labor (FIOL), surfactant, seizure, low Apgar, or neonatal death between Epoch 1 and 2. We also analyzed individual adverse outcomes. We further stratified analyses by pregnancies complicated by the following medical conditions: chronic (CHTN) or gestational hypertension (GHTN), pre- gestational (PGD) or gestational diabetes (GDM), twin gestation, and fetal growth restriction (FGR). Other than twin gestation, analysis of each medical condition was limited to singleton births. 572,010 live births were included: 48.8% in Epoch 1 (2011-2012) and 51.2% in Epoch 2 (2014-2015). Rates of composite adverse outcomes were significantly higher in Epoch 2 compared to Epoch 1 both overall and when stratified by medical condition. Epoch 2 additionally had significantly higher rates of assisted ventilation but significantly lower rates of infant death. Each medical condition was associated with increased rates of composite adverse outcomes in Epoch 2. The risks are increased despite slight increases in preterm births <37 weeks (12.1 v 13.6%, p<0.001) and early preterm births <34 weeks (4.1 v 4.8%, p<0.001) in Epoch 2. However, neonatal and infant death rates decreased significantly in cases of GHTN and twin gestation. Infant death rates also decreased in pregnancies with FGR and GDM. Since the publication of society guidelines for medically indicated delivery timing, the rates of neonatal adverse outcomes have increased, but neonatal and infant death are on a favorable decline. Future studies should aim to elucidate the causal factors linking specific medical conditions to these neonatal outcomes, with efforts to align findings with future delivery timing recommendations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association between insurance type and pregnancy outcomes in women diagnosed with hypertensive disorders of pregnancy

Objective: Hypertension in pregnancy is associated with adverse maternal and neonatal outcomes. Previous studies have demonstrated disparities in the risk of preeclampsia based on race, educational attainment, census tract income level and household income. Yet, data on the association of insurance type, classification of hypertension in pregnancy and outcomes have not been well described. We sought to compare outcomes in women with hypertensive disorders of pregnancy, by private versus public insurance.Study design: This was a retrospective cohort study of subjects with a hypertensive disorder of pregnancy that delivered ≥23-week gestation at Oregon Health & Science University (October 2013–December 2017). The cohort began with the 2013 American College of Obstetricians and Gynecologists Executive Summary on Hypertension in Pregnancy, which advised surveillance for severe features of disease in women with hypertension. Utilizing ICD-9 and ICD-10 discharge codes, followed by individual chart review, subjects were stratified into two groups by insurance status: Medicaid (public insurance), or individual or group health insurance (private insurance). As primary outcomes, we assessed severe features of preeclampsia, adverse maternal or neonatal outcomes (composite), and final hypertensive diagnosis: (i) chronic hypertension; (ii) gestational hypertension; (iii) preeclampsia without severe features and, (iv) preeclampsia with severe features. Differences in demographic and outcome data were analyzed by chi-square, t-test, and logistic regression.Results: Among 10 132 deliveries, 1335 (13.2%) were delivered with a hypertensive disorder of pregnancy. Medicaid covered 54.1% (722) of these deliveries; 44.1% (589) were covered by private insurance, and 1.8% (24) had unknown insurance. There was a similar percentage of subjects with Medicaid or private insurance in each hypertensive group (p = .08). However, compared to subjects with private insurance, those with Medicaid had more severe blood pressure (BP) elevations (systolic BP ≥160 mmHg, p = .001) and more cases of eclampsia (p = .04), while neonates of subjects with Medicaid had more intensive care unit admissions (p = .02), and preterm births (p < .001). The association between Medicaid insurance and severe BP elevation, or adverse neonatal outcomes, persisted after multivariable adjustment.Conclusion: Medicaid was not associated with a particular hypertensive disorder in pregnancy, yet those with Medicaid experienced more severe BP elevations and higher rates of adverse neonatal outcomes. More research is needed to understand potential risk factors and ways to improve outcomes for those with publicly funded insurance.

The temporal effect of Category II fetal monitoring on neonatal outcomes.

To correlate the duration of Category II cardiotocograms (CTG) with adverse neonatal outcomes associated with perinatal asphyxia and determine the duration before fetal compromise. This retrospective, observational study used electronic medical record data from a cohort of 271 patients, delivered by C-section due to non-reassuring fetal heart rate, at a tertiary medical center, from 2015 through 2017. Duration of Category II CTG, variability, tachycardia and deceleration frequency were analyzed and correlated to immediate postnatal outcomes. including cord pH ≤ 7, cord base excess >12, 1- and 5-min Apgar scores ≤7, need for ventilation, need for chest compressions, NICU admission, hypoglycemia and convulsions. Intrapartum fever and meconium stained amniotic fluid were correlated to the same outcomes. Categorical and continuous variables were analyzed using chi-square and t-tests, respectively. P < 0.05 was considered significant. The mean duration of Category II CTG was 146 min (range 17-553). Longer duration did not result in increased rates of adverse neonatal outcomes. In contrast, reduced fetal heart rate (FHR) variability, fetal tachycardia and intrapartum fever did show increased rates of adverse neonatal outcomes, as follows: patients exhibiting reduced vs. normal (FHR) variability had 12.9% vs. 1.4% cord pH ≤ 7, P = 0.006 and 12.5% vs. 1.3% cord BE > 12, P = 0.004: patients with fetal tachycardia vs. normal baseline FHR exhibited 48% vs. 17.9% 1-minute Apgar score ≤7, P = 0.0004; 8% vs. 0.8% 5-minute Apgar score ≤7, P = 0.04; and 48% vs. 18.7% ventilation support, P < 0.001; patients with intrapartum fever vs. normal temperature, cord BE > 12 was seen in 9.7% vs. 1.7%, P = 0.035; 1-minute Apgar score was ≤7 in 35.5% vs. 18.7%, P = 0.03; 5-minute Apgar score ≤7 in 9.7% vs. 0.4%, P = 0.005; need for ventilation in 35.5% vs. 19.6%, P = 0.042; need for chest compressions in 6.45% vs. none, P = 0.013; and NICU admission in 12.9% vs. 2.5%, P = 0.018. Our results suggest that the duration of Category II CTG alone does not appear to predict perinatal asphyxia. Parameters associated with perinatal asphyxia are reduced FHR variability, fetal tachycardia and intrapartum fever. Therefore, when contemplating intervention during labor to avoid fetal asphyxia, these parameters should be strongly considered.

692: Association of cerclage removal with maternal and neonatal outcomes in pregnancies complicated by preterm premature rupture of membranes

To compare pregnancy outcomes between women with pPROM in the presence of cervical cerclage in whom the cerclage was removed within <48h and those in whom the cerclage was retained in situ. We conducted a retrospective cohort study of all women with a singleton pregnancy admitted with pPROM in the presence of cerclage to one of two tertiary referral centers in Toronto, Ontario between 2012-2016. The two centers differ in their approach with regard to the management of cerclage in the context of PPROM: in one center (SB) the common practice is to retain cerclage while in the second center (MSH) the common practice is to remove cerclage. Outcomes were compared between women in whom cerclage was removed within 48 hours and those in whom cerclage was retained until the onset of delivery. 1) Of a total of 79 women who met the study inclusion criteria, cerclage was removed in 44 (55.7%) and retained in 35 (44.3%). 2) There were no differences between the removal and retention groups in baseline characteristics, gestational age at cerclage placement (19.3±3.3 vs.18.0±4.1 weeks, p=0.1), cervical dilatation at cerclage, and gestational age at pPROM (28.3±2.9 vs. 28.0±2.6 weeks, p=0.7). 3) Women in the cerclage removal group had a lower pPROM to delivery interval (2.0±6.5 vs. 7.9±7.5 days, respectively, p<0.001) and were less likely to have a latency period of >7 days (4.5% vs. 37.1%, respectively, p<0.001) compared with women in whom cerclage was retained (Figure 1). 4) After adjustment for confounding factors, retention of cerclage was associated with higher odds for latency >7 days and lower odds for composite neonatal outcome (Figure 2). There were no differences between the groups in the odds for clinical chorioamnionitis and neonatal sepsis (Figure 2). In this multi-center retrospective study of women with pPROM and cervical cerclage, retention of cerclage was associated with longer latency period and lower rate of adverse neonatal outcome without increasing the risk of infection in the mother and newborn.

640: Impact of insurance status on outcomes in women with hypertensive disorders in pregnancy

Hypertension in pregnancy is associated with adverse maternal and neonatal outcomes. Yet, data on the association of insurance status, classification of hypertension in pregnancy and outcomes have not been well described. We sought to compare outcomes in women with hypertensive disorders of pregnancy by private versus public insurance. This is a retrospective cohort study of subjects with a hypertensive disorder of pregnancy that delivered ≥23 weeks gestation at a single institution in Oregon (October ‘13 - May ’17). The cohort began with the 2013 American College of Obstetricians and Gynecologists Executive Summary on Hypertension in Pregnancy, which advised surveillance for severe features of disease in women with hypertension. Utilizing ICD-9 and ICD-10 discharge codes, followed by individual chart review, we abstracted data on severe features into four groups: i) chronic hypertension; ii) gestational hypertension; iii) preeclampsia (PE) without severe features and, iv) PE with severe features. We then stratified subjects into two groups by insurance status: i) Medicaid (public insurance) or ii) individual or group health insurance (private insurance). Demographic and outcome data were abstracted, with analysis by chi-square, t-test, and logistic regression. Among 8,645 deliveries, 1,188 (13.7%) were delivered with a hypertensive disorder of pregnancy. Medicaid covered 54.97% (653) of these deliveries; 43.18% (513) were covered by private insurance, and 1.85% (22) were unknown. There were a similar percentage of Medicaid patients in each hypertensive group (p=0.17). Compared to subjects with private insurance, those with Medicaid had more severe features of preeclampsia, primarily severe systolic BP ≥160 mmHg. Neonates of subjects with Medicaid had more preterm births, intensive care unit admissions and respiratory distress syndrome (Table 1). The association between Medicaid, severe features of preeclampsia and adverse neonatal outcomes persisted after multivariable adjustment (Table 2). Medicaid insurance did not associate with a particular hypertensive disorder, yet those with Medicaid experienced more severe features of preeclampsia and higher rates of adverse neonatal outcomes. More research is needed to understand potential risk factors and ways to improve outcomes for those with publicly funded insurance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Choice of scheduled cesarean delivery versus trial of labor for advanced maternal age primiparous women

Objective: We aimed to evaluate perinatal outcomes of advanced maternal age (AMA) primiparous women seeking scheduled cesarean delivery (CD) versus a trial of labor (TOL).Materials and methods: This was a retrospective cohort study of primiparous women ≥40 years of age carrying a single fetus, who delivered at a tertiary, university-affiliated medical center (2007–2014). We compared perinatal outcomes of women who chose a scheduled CD with those who chose TOL. Subsequently, we compared women who had successful TOL (sTOL) with those who had a failed TOL (fTOL).Results: Out of 62 102 deliveries during the study period, inclusion criteria were met by 374 women. Of them, 83 (22.2%) women had a scheduled CD, and 291 (77.8%) had TOL. Of the TOL group, 118 women (40.5%) had fTOL and 173 (59.5%) had sTOL. Women in the fTOL had higher rates of 1-min Apgar score <7, neonatal asphyxia and adverse neonatal composite outcome compared with women in the sTOL group (p < .05). After adjusting for potential confounders, compared with sTOL, fTOL was not associated with adverse neonatal composite outcome. Compared with scheduled CD, fTOL was associated with an increased risk for adverse neonatal composite outcome (aOR 2.65, 95% CI 1.13–6.19, p = .03).Conclusion: AMA primiparous women attempting TOL have comparable outcome to those seeking scheduled CD, however, women with fTOL have higher rates of adverse neonatal outcome.

Cup detachment during vacuum-assisted vaginal delivery and birth outcome.

To determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD). A retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012-2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb's palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders. Overall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, p<0.05). This remained significant after adjustment to potential confounders (subarachnoid hematoma aOR=45.44, 95% CI 6.42-321.62 and neonatal birth trauma aOR=2.62, 95% CI 1.1-6.22, p<0.05 for all). Other neonatal and maternal morbidities were similar between groups. Cup detachment is associated with a higher rate of adverse neonatal outcome. Cup reapplication should be considered carefully.

Cesarean Section Rates and Adverse Neonatal Outcomes After Induction of Labour Versus Expectant Management in Women With an Unripe Cervix: A Secondary Analysis of the HYPITAT and DIGITAT Trials

(BJOG. 2016;123(9):1501–1508) Between 20% and 25% of pregnancies involve induction of labor (IOL), with the intervention indicated when conditions exist where a better outcome for mother and/or child would be expected if the pregnancy is not further prolonged. However, the effectiveness of IOL is debatable, especially in the setting of an unripe cervix, with studies indicating an associated high rate of cesarean section (CS). The objective of this study was to evaluate CS and adverse neonatal outcome rates for IOL versus expectant management in women with an unripe cervix at or near term, using a secondary analysis of data from 2 previously completed randomized trials.

Adverse Neonatal Outcomes Among Women With Hypertensive Disorders of Pregnancy [28C

INTRODUCTION: The American College of Obstetricians and Gynecologists (the College) provided new guidance for diagnosis and management of hypertensive disorders of pregnancy. The impact of these changes is unclear; so we sought to compare adverse neonatal outcomes among women with hypertensive disorders of pregnancy. METHODS: Retrospective cohort study of singleton deliveries occurring greater than or equal to 23 weeks gestational age from September 2015 to March 2016 in a single institution. Subjects were screened for hypertension in pregnancy utilizing hospital discharge codes, and diagnoses confirmed by individual chart review. Subjects were placed into 4 groups by College criteria: chronic hypertension (CHTN), gestational hypertension (GHTN), preeclampsia (PE) without severe features (SF), and PE with SF. RESULTS: In our cohort of 1,399 consecutive deliveries, 193 women (13.8%) with hypertensive disease met inclusion criteria; CHTN (3.1%), GHTN (3.2%), PE without SF (3.6%) and PE with SF (4.1%). Women with CHTN had higher BMI and were less often nulliparous compared to those with GHTN or PE (BMI p &lt; 0.001; nulliparous p=0.001). Subjects with CHTN delivered earlier than those with GHTN or PE without SF (p=0.003). Rates of adverse neonatal outcomes were increased with CHTN compared to GHTN (preterm birth p=0.040; NICU admission p=0.021; RDS p=0.026), but adverse outcomes were similar between CHTN and PE without SF. CONCLUSION: We find that women with CHTN have rates of adverse neonatal outcomes similar to women with PE without SF, but higher than GHTN. Our findings reinforce the College’s recommendation to maintain vigilance in pregnancies complicated by CHTN.

Morbidity and mortality among very preterm singletons following fertility treatment in Australia and New Zealand, a population cohort study

BackgroundDue to high rates of multiple birth and preterm birth following fertility treatment, the rates of mortality and morbidity among births following fertility treatment were higher than those conceived spontaneously. However, it is unclear whether the rates of adverse neonatal outcomes remain higher for very preterm (<32 weeks gestational age) singletons born after fertility treatment. This study aims to compare adverse neonatal outcomes among very preterm singletons born after fertility treatment including assisted reproductive technology (ART) hyper-ovulution (HO) and artificial insemination (AI) to those following spontaneous conception.MethodsThe population cohort study included 24069 liveborn very preterm singletons who were admitted to Neonatal Intensive Care Unit (NICU) in Australia and New Zealand from 2000 to 2010. The in-hospital neonatal mortality and morbidity among 21753 liveborn very preterm singletons were compared by maternal mode of conceptions: spontaneous conception, HO, ART and AI. Univariate and multivariate binary logistic regression analysis was used to examine the association between mode of conception and various outcome factors. Odds ratio (OR) and adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated.ResultsThe rate of small for gestational age was significantly higher in HO group (AOR 1.52, 95% CI 1.02–2.67) and AI group (AOR 2.98, 95% CI 1.53–5.81) than spontaneous group. The rate of birth defect was significantly higher in ART group (AOR 1.71, 95% CI 1.36–2.16) and AI group (AOR 3.01, 95% CI 1.47–6.19) compared to spontaneous group. Singletons following ART had 43% increased odds of necrotizing enterocolitis (AOR 1.43, 95% CI 1.04–1.97) and 71% increased odds of major surgery (AOR 1.71, 95% CI 1.37–2.13) compared to singletons conceived spontaneously. Other birth and NICU outcomes were not different among the comparison groups.ConclusionsCompared to the spontaneous conception group, risk of congenital abnormality significantly increases after ART and AI; the risk of morbidities increases after ART, HO and AI. Preconception planning should include comprehensive information about the benefits and risks of fertility treatment on the neonatal outcomes.

Small for Gestational Age: The Differential Mortality When Detected versus Undetected Antenatally.

Background Antenatal detection of fetal growth restriction (FGR) prompts antepartum surveillance to reduce perinatal mortality, yet most cases of FGR are undetected. Objective This study aims to compare rates of adverse neonatal outcomes when FGR is detected versus undetected. Study Design Small-for-gestational-age (SGA) newborns (birth weight < 10% for gestational age) delivered at the Magee-Women's Hospital in Pittsburgh, PA from 2003 to 2010 were divided into three groups: those whom did not undergo third-trimester fetal growth ultrasound (SGA-no US), were appropriate for gestational age (AGA) by ultrasound (SGA-undetected), or were FGR by ultrasound (SGA-detected). We then compared rates of 5-minute Apgar < 4 and neonatal death (ND), with AGA newborns as the referent. Results Out of 29,885 neonates, 2,475 (8.3%) were SGA. Out of the 826 (33%) SGA neonates who underwent growth ultrasound, 185 (22%) were considered FGR. In the SGA-no US group, the adjusted odds ratio (aOR) for Apgar < 4 was 2.84 (95% confidence interval (CI): 1.28-6.29) and 3.87 (95% CI: 2.09-7.18) for ND. The risk of Apgar < 4 (aOR: 3.10, 95% CI: 0.93-10.28) and ND (aOR: 2.16, 95% CI: 0.66-7.14) were not significantly elevated for SGA-undetected neonates, while SGA-detected neonates were most at risk, with an aOR of 18.20 (95% CI: 6.82-48.60) for Apgar < 4 and 18.24 (95% CI: 7.90-42.13) for ND. Conclusion Fetal growth ultrasound effectively stratifies risk amongst SGA neonates.

Placental histopathology lesions and pregnancy outcome in pregnancies complicated with symptomatic vs. non-symptomatic placenta previa

BackgroundThe mechanisms involved in bleeding in cases of placenta previa (PP) and the effect on pregnancy outcome is unclear. ObjectivesWe aimed to compare pregnancy outcome and placental histopathology in pregnancies complicated with symptomatic (bleeding) vs. non-symptomatic PP, and to study the effects of the co-existence of histopathological retro-placental hemorrhage (RPH) in cases of symptomatic PP on neonatal and maternal outcomes. Study designLabor and maternal characteristics, neonatal outcome and placental histopathology lesions of pregnancies with PP, delivered between 24 and 42weeks, during 2009–2015, were reviewed. Results were compared between PP who had elective cesarean delivery (CD) (previa group) and PP with bleeding necessitating emergent CD (symptomatic previa group). Placental lesions were classified to lesions consistent with maternal malperfusion or fetal thrombo-occlusive disease (vascular and villous changes), and inflammatory lesions. ResultsCompared to the previa group (n=63), the symptomatic previa group (n=74) was characterized by older patients (p<0.001), higher rate of smokers (p=0.005), thrombophilia (p=0.038), and preterm deliveries (p<0.001). Placentas within the symptomatic previa group were smaller, with higher rates of weight<10th% (p=0.02), RPH (p<0.001) and villous changes related to maternal malperfusion (p=0.023). As compared to symptomatic PP without RPH, co-existence of RPH was associated with higher rate of adverse neonatal outcome (p<0.001) and maternal blood transfusion (p=0.02). On multivariate regression analysis, composite adverse neonatal outcome was found to be dependent on coexisting RPH (OR=2.8, 95%CI 1.2–11.7, p=0.03), and low gestational age (OR=3.1, 95%CI 1.6–4.9, p=0.02). ConclusionsSymptomatic placenta previa is associated with increased placental malperfusion lesions suggesting an association of maternal malperfusion with abnormal placental separation. The coexisting finding of RPH with symptomatic placenta previa can be seen as a marker for more extensive/severe placental separation, hence the association with maternal transfusion requirements and poorer fetal outcome.

Increased rate of adverse neonatal outcomes among twins following assisted reproductive technology

Increased rate of adverse neonatal outcomes among twins following assisted reproductive technology

The influence of obesity on perinatal outcomes in pregnancies achieved with assisted reproductive technology: A population-based retrospective cohort study.

To determine the influence of obesity on neonatal outcomes of pregnancies resulting from assisted reproductive technology. Population-based retrospective cohort study of all non-anomalous, live births in Ohio from 2007 to 2011, comparing differences in the frequency of adverse neonatal outcomes of women who conceived with assisted reproductive technology versus spontaneously conceived pregnancies and stratified by obesity status. Primary outcome was a composite of neonatal morbidities defined as ≥1 of the following: neonatal death, Apgar score of <7 at 5 min, assisted ventilation, neonatal intensive care unit admission, or transport to a tertiary care facility. Rates of adverse neonatal outcomes were significantly higher for assisted reproductive technology pregnancies than spontaneously conceived neonates; non-obese 25% versus 8% and obese 27% versus 10%, p < 0.001. Assisted reproductive technology was associated with a similar increased risk for adverse outcomes in both obese (adjusted odds ratio (aOR): 1.33, 95% confidence interval (CI): 1.11-1.59) and non-obese women (aOR: 1.34, 95% CI: 1.18-1.51) even after adjustment for coexisting risk factors. This increased risk was driven by higher preterm births in assisted reproductive technology pregnancies; obese (aOR: 1.06, 95% CI: 0.86-1.31) and non-obese (aOR: 1.15, 95% CI: 1.00-1.32). Assisted reproductive technology is associated with a higher risk of adverse neonatal outcomes. Obesity does not appear to adversely modify perinatal risks associated with assisted reproductive technology.

Clinical Value of Maternal Bile Acid Quantification in Intrahepatic Cholestasis of Pregnancy as an Adverse Perinatal Outcome Predictor

Aims: To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made. Methods: A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level). Results: A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02). Conclusions: ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.