Neonatal Intensive Care Unit Admission Rate Research Articles

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

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

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

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

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

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

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

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

Admission and mortality at the main neonatal intensive care unit in Guinea-Bissau.

The authors assessed the risk of admission and mortality at the main neonatal intensive care unit (NICU) at the National Hospital Simão Mendes (NHSM) in Guinea-Bissau. The Bandim Health Project (BHP) maintains a health and demographic surveillance system (HDSS) in the capital Bissau, including at the NHSM. Data from January 2008 to August 2013 was used to assess NICU incubator admissions and mortality. The overall NICU admission rate was 4.8% (1575/33,005); the lowest rate in 2012 (4.0% (214/5293)) and the highest rate in 2009 (6.0% (369/6134)). The overall mortality among admitted children was 19.6% (289/1476), declining from 26.7% (68/255) in 2008 to 13.0% (16/123) in 2013. Birth weight <1500 g (OR=353, (95% CI: 244-510) compared with normal birth weight 2500 g-4000 g), Apgar score≤3 (OR=13.2 (9.72-18.0) compared with Apgar score 7-10) and single motherhood (OR=1.44 (1.20-1.74)) were associated with NICU admission. Low Apgar score was a risk factor for NICU mortality (OR=6.21 (2.05-18.81)) and females (OR=0.55 (0.38-0.79) had a lower mortality than males. Approximately 5% of the hospital-born children were admitted to an incubator and among those almost 20% died, although mortality did decline. Male sex, very low birth weight and low Apgar score were strongly associated with NICU admissions and mortality.

Preeclampsia with Severe Features-Assessing the Impact of Headache and Visual Disturbances [25O

INTRODUCTION: In pregnant women with hypertension, the presence of headache or visual symptoms may prompt early delivery due to concern for preeclampsia (PE) and eclampsia. We evaluated subjects with preeclampsia with severe features (PE-SF) to assess the impact of these symptoms on maternal and neonatal outcomes. METHODS: Retrospective cohort study of subjects with PE-SF, ≥23 weeks gestation at a single institution (October 2013-May 2017). Subjects were identified by ICD-9 and ICD-10 codes, with charts reviewed for diagnostic accuracy. Symptoms like headache and visual disturbances were determined by physician documentation. We compared outcomes in three groups: 1. No headache or visual disturbances; 2. Severe headache only; 3. Severe headache and visual disturbances. Significance determined by chi-square or t-test. RESULTS: Among 8,645 deliveries, 318 women (3.7%) delivered with PE-SF; 192 (60.4%) had no headache or visual disturbances, 68 (21.4%) severe headache only, and 39 (12.3%) both headache and visual disturbances. Maternal admission to the intensive care unit, pulmonary edema, kidney injury, or hemolysis, elevated liver enzymes, low platelet count syndrome, were no different between groups. However, those with both headache and visual disturbances had increased risk of eclampsia, p=0.016. Those with headache were delivered earlier (p&lt;0.0001), more likely to have neonates born preterm (p=0.007) or admitted to the Neonatal Intensive Care Unit (NICU), p=0.02. CONCLUSION: We find that headache and visual disturbances contribute disproportionately to preterm delivery and NICU admission rates in PE-SF. However, the increased risk of eclampsia in this setting suggests that such action is justifiable.

Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes

Objective: To compare planned delivery at 34 versus 35 weeks for women with preterm prelabor rupture of membranes (PPROM).Materials and methods: We performed a retrospective cohort study of singleton pregnancies with PPROM after 24 weeks delivered from 2006 to 2014. In 2009, an institutional practice change established 35 weeks as the target gestational age before induction of labor was initiated after PPROM. Demographic and outcome measures were compared for two cohorts: women delivered 2006–2008 – target 34 weeks (T34) and women delivered 2009–2014 – target 35 weeks (T35). The primary outcome was neonatal intensive care unit (NICU) admission.Results: Of the 382 women with PPROM, 153 (40%) comprized the T34 cohort and 229 (60%) comprized the T35 cohort. Demographic characteristics were similar between groups. There were no differences between groups in gestational age at PPROM (31.0 ± 3.3 weeks versus 31.2 ± 3.1 weeks; p = .50) or maternal complications. The mean gestational age at delivery was earlier in the T34 group (31.8 ± 3.2 weeks versus 32.4 ± 2.7 weeks; p = .04). The median predelivery maternal length of stay (LOS) was 1 day longer in the T35 group (p = .03); the total and postpartum LOS were similar between groups (p > .05). There were no differences in the rate of NICU admission (T34 89.5% versus T35 92.1%; p = .38) or median neonatal LOS (T34 14 days versus T35 17 days; p = .15). In those patients who reached their target gestational age, both maternal predelivery LOS and total LOS were longer in the T35 group (p > .05). The frequency of NICU admission in those reaching their target gestational age was similar between groups (T34 83.37% versus T35 76.19%; p = .46).Conclusions: A 35-week target for delivery timing for women with PPROM does not decrease NICU admissions or neonatal LOS. This institutional change increased maternal predelivery LOS, but did not increase maternal or neonatal complications.

Prophylactic Dextrose Gel Does Not Prevent Neonatal Hypoglycemia: A Quasi-Experimental Pilot Study

To test the hypothesis that prophylactic dextrose gel administered to newborn infants at risk for hypoglycemia will increase the initial blood glucose concentration after the first feeding and decrease neonatal intensive care unit (NICU) admissions for treatment of asymptomatic neonatal hypoglycemia compared with feedings alone. This quasi-experimental study allocated asymptomatic at-risk newborn infants (late preterm, birth weight <2500 or >4000 g, and infants of mothers with diabetes) to receive prophylactic dextrose gel (Insta-Glucose; Valeant Pharmaceuticals North America LLC, Bridgewater, New Jersey); other at-risk infants formed the control group. After the initial feeding, the prophylactic group received dextrose gel (0.5 mL/kg) rubbed into the buccal mucosa. The blood glucose concentration was checked 30 minutes later. Initial glucose concentrations and rate of NICU admissions were compared between the prophylactic group and controls using bivariate analyses. A multivariable linear regression compared first glucose concentrations between groups, adjusting for at-risk categories and age at first glucose concentration. There were 236 subjects (72 prophylactic, 164 controls). The first glucose concentration was not different between the prophylactic and control groups in bivariate analysis (52.1 ± 17.1 vs 50.5 ± 15.3 mg/dL, P = .69) and after adjusting for covariates (P = .18). Rates of NICU admission for treatment of transient neonatal hypoglycemia were 9.7% and 14.6%, respectively (P = .40). Prophylactic dextrose gel did not reduce transient neonatal hypoglycemia or NICU admissions for hypoglycemia. The carbohydrate concentration of Insta-Glucose (77%) may have caused a hyperinsulinemic response, or alternatively, exogenous enteral dextrose influences glucose homeostasis minimally during the first few hours when counter-regulatory mechanisms are especially active. ClinicalTrials.gov: NCT02523222.

Hostile turf: Higher maternal body mass index and neonatal intensive care unit admission risk

Background: Body mass index (BMI) helps in the evaluation of obesity in pregnancy. Objective: The objective of the present study was to determine association between maternal BMI and neonates requiring the neonatal Intensive Care Unit (NICU) admission. Materials and Methods: All obstetric patients who were admitted for obstetric intervention in the third trimester between April 1, 2014, and September 30, 2015, were studied. Patients with singleton pregnancy gestational age more than 35 weeks were included in the study and multifetal gestation a known case of Type 2 diabetes mellitus (DM) and chronic hypertension were excluded from the study. Patients were divided into four groups on the basis of BMI; in all these groups, maternal and fetal outcome was studied. Results: According to BMI, 22.4% of patients were obese and 35.3% of patients were of normal BMI. Gestational DM, pregnancy-induced hypertension (PIH), and preeclampsia remained statistically significant high in obese and overweight group as compared to women with normal BMI. There was no significant association between antepartum hemorrhage, intrauterine growth restriction, malpresentation, and preterm between obese and nonobese groups. NICU admission rate was significantly associated with maternal obesity. For BMI and NICU admissions, relative risk (RR) in underweight versus healthy was 6.00 (P = 0.011, confidence interval 1 [CI1]:.29–27.76). In comparing women with BMI

Improved Regional Disparities in Neonatal Care by Government-led Policies in Korea.

BackgroundAlthough the number of high-risk neonates has increased in Korea, hospitals were reluctant to open or maintain neonatal intensive care unit (NICU) due to the low medical cost. Consequently, there were regional disparities in facilities, equipment, and neonatal health outcomes. For these reasons, the Korean government began to invest in neonatal care during the last decade. We identified the status of NICUs in Korea and assessed changes after the government-driven policies.MethodsWe surveyed 87 of 89 hospitals that operated NICUs in 2015. The questionnaire assessed the number of NICU beds, admission and mortality rates of very low birthweight infants (VLBWIs), personnel status, equipment and facilities, and available multidisciplinary approach. Current data was compared with the previous studies and changes in the status and function of the nationwide NICU from 2009 and 2011.ResultsDuring the last 7 years, there was an increase of 462 NICU beds, which met the required number estimated by the number of births and covered about 90% of regional VLBWI births. Status of facilities and equipment improved in all regions in Korea but there were still regional differences in multidisciplinary approach and human resources. The difference in odds ratios for mortality of VLBWI between regions decreased compared to 2009.ConclusionThere was improvement in regional disparities of neonatal care and mortality of premature babies with the government investment in Korea. Further supports are required for human resources and referral system.

Is it the baby or the beds?

Since the 1960s, reductions in neonatal mortality in the United States track closely with the increased availability of neonatal intensive care unit beds. Not surprisingly, as the number of intensive care unit beds have increased, the number of babies admitted to these units to fill these beds has increased. While there is no doubt that the large proportion of these admissions are necessary and result in improved outcomes, there is also the possibility that the mere prospect of bed availability drives NICU admission. In this volume of The Journal, Harrison et al use large national data sets to determine the relationship between NICU admission and regional bed supply. Importantly, the authors have uncovered regional variation in NICU bed availability that is not explained by validated markers of need. Furthermore, it appears that bed availability may drive NICU admission rates, especially for larger (potentially “less sick”) babies. The implications for resource allocation and utilization are staggering. These results scratch the surface of a complex set of issues and reveal important questions that we must begin to answer in order to provide responsible, appropriate, and effective health care. We must do better in deciding where to provide services, and work hard and continually re-evaluate whether the services we provide are safe, necessary, beneficial, and cost-effective. Article page 73 ▶ Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed SupplyThe Journal of PediatricsVol. 192PreviewTo characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. Full-Text PDF

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity

Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Live birth at GA of 34 weeks or more. Inborn NICU admission rate. Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41). Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease.

Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease.

Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply

To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.

Prenatal Care Adherence and Neonatal Intensive Care Unit Admission or Stillbirth among Women with Gestational and Preexisting Diabetes Mellitus.

To determine if there was an association between prenatal care adherence and neonatal intensive care unit (NICU) admission or stillbirth, and adverse perinatal outcomes in women with preexisting diabetes mellitus (DM) and gestational DM (GDM). This is a retrospective cohort study among women with DM and GDM at a Diabetes in Pregnancy Program at an academic institution between 2006 and 2014. Adherence with prenatal care was the percentage of prenatal appointments attended divided by those scheduled. Adherence was divided into quartiles, with the first quartile defined as lower adherence and compared with the other quartiles. There were 443 women with DM and 499 with GDM. Neonates of women with DM and lower adherence had higher rates of NICU admission or stillbirth (55 vs. 39%; p = 0.003). A multivariable logistic regression showed that the lower adherence group had higher likelihood of NICU admission (adjusted odds ratio: 1.61 [1.03-2.5]; p = 0.035). Those with lower adherence had worse glycemic monitoring and more hospitalizations. Among those with GDM, most outcomes were similar between groups including NICU admission or stillbirth. Women with DM with lower adherence had higher rates of NICU admission and worse glycemic control. Most outcomes among women with GDM with lower adherence were similar.

Third trimester preterm and term premature rupture of membranes: Is there any difference in maternal characteristics and pregnancy outcomes?

BackgroundThe clinical significance and management of preterm premature rupture of membranes (PPROM) remains a topic of a controversy. Although PROM is associated with a low rate of complications, PPROM may lead to significant neonatal and maternal morbidity. MethodsWe performed a retrospective study of 714 women who presented to Jiangsu Province Hospital with third trimester PPROM or PROM between January and December 2015. The data were analyzed by SPSS; the significance of maternal characteristics, and maternal and neonatal outcomes were tested using Student’s t test and the χ2 test. A two-sided p value < 0.05 was considered statistically significant. ResultsThere were 714 women included in this analysis. We identified 577 (80.8%) women with PROM and 137 (19.2%) with PPROM. In the PPROM group, we further divided the women into 28+0–31+6 weeks (n = 21) and 32+0–36+6 weeks (n = 116) of gestational age. PPROM was associated with a significantly lower gestational age, and patients in this group showed higher C-reactive protein and body temperature when admitted to the hospital (p < 0.05). Breech presentation and history of previous cesarean section were associated with occurrence of PPROM compared with PROM (p < 0.05). The PPROM group showed a significantly longer latency period compared with the PROM group, in which the latency period increased with the lower gestational age (28+0–31+6 weeks). Significantly higher neonatal intensive care unit (NICU) admission rate was shown in the PPROM group as compared with the PROM group, and gestational age 28+0–31+6 weeks yielded a significantly higher rate of NICU admission than 32+0–36+6 weeks did (p < 0.05). ConclusionHigher C-reactive protein and body temperature in the PPROM group suggest an asymptomatic infection that requires close monitoring to prevent any adverse effect on pregnancy outcome. Longer latency period in PPROM group is predictable in order to minimize perinatal morbidity and mortality because of prematurity itself. Therefore, an increase in gestational age plays an important role that can affect a clinician’s decision making regarding whether to transfer to the NICU.

Prophylactic Oral Dextrose Gel for Newborn Babies at Risk of Neonatal Hypoglycaemia: A Randomised Controlled Dose-Finding Trial (the Pre-hPOD Study).

BackgroundNeonatal hypoglycaemia is common, affecting up to 15% of newborns, and can cause brain damage. Currently, there are no strategies, beyond early feeding, to prevent neonatal hypoglycaemia. Our aim was to determine a dose of 40% oral dextrose gel that will prevent neonatal hypoglycaemia in newborn babies at risk.Methods and FindingsWe conducted a randomised, double-blind, placebo-controlled dose-finding trial of buccal dextrose gel to prevent neonatal hypoglycaemia at two hospitals in New Zealand. Babies at risk of hypoglycaemia (infant of a mother with diabetes, late preterm delivery, small or large birthweight, or other risk factors) but without indication for admission to a neonatal intensive care unit (NICU) were randomly allocated either to one of four treatment groups: 40% dextrose at one of two doses (0.5 ml/kg = 200 mg/kg, or 1 ml/kg = 400 mg/kg), either once at 1 h of age or followed by three additional doses of dextrose (0.5 ml/kg before feeds in the first 12 h); or to one of four corresponding placebo groups. Treatments were administered by massaging gel into the buccal mucosa. The primary outcome was hypoglycaemia (<2.6 mM) in the first 48 h. Secondary outcomes included admission to a NICU, admission for hypoglycaemia, and breastfeeding at discharge and at 6 wk. Prespecified potential dose limitations were tolerance of gel, time taken to administer, messiness, and acceptability to parents. From August 2013 to November 2014, 416 babies were randomised. Compared to babies randomised to placebo, the risk of hypoglycaemia was lowest in babies randomised to a single dose of 200 mg/kg dextrose gel (relative risk [RR] 0.68; 95% confidence interval [CI] 0.47–0.99, p = 0.04) but was not significantly different between dose groups (p = 0.21). Compared to multiple doses, single doses of gel were better tolerated, quicker to administer, and less messy, but these limitations were not different between dextrose and placebo gel groups. Babies who received any dose of dextrose gel were less likely to develop hypoglycaemia than those who received placebo (RR 0.79; 95% CI 0.64–0.98, p = 0.03; number needed to treat = 10, 95% CI 5–115). Rates of NICU admission were similar (RR 0.64; 95% CI 0.33–1.25, p = 0.19), but admission for hypoglycaemia was less common in babies randomised to dextrose gel (RR 0.46; 95% CI 0.21–1.01, p = 0.05). Rates of breastfeeding were similar in both groups. Adverse effects were uncommon and not different between groups. A limitation of this study was that most of the babies in the trial were infants of mothers with diabetes (73%), which may reduce the applicability of the results to babies from other risk groups.ConclusionsThe incidence of neonatal hypoglycaemia can be reduced with a single dose of buccal 40% dextrose gel 200 mg/kg. A large randomised trial (Hypoglycaemia Prevention with Oral Dextrose [hPOD]) is under way to determine the effects on NICU admission and later outcomes.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12613000322730

Gestational hypertensive disease in twin pregnancy: Influence on outcomes in a large national prospective cohort.

Gestational hypertensive disease (GHD) is associated with pregnancy-related complications and poor maternal and fetal outcomes in singleton pregnancies. We sought to examine the influence of GHD in a large prospective cohort of twin pregnancies. The ESPRIT study was a national multicenter observational cohort study of 1028 structurally normal twin pregnancies. Each pregnancy underwent sonographic surveillance with two-week ultrasound from 24 weeks for dichorionic and from 16 weeks for monochorionic gestations. Characteristics and demographics as well as labour and delivery outcome data were prospectively recorded. Perinatal mortality, admission to the neonatal intensive care unit (NICU) and a composite of morbidity of respiratory distress syndrome, hypoxic ischaemic encephalopathy, periventricular leukomalacia, necrotising enterocolitis and sepsis were documented for all cases. Outcomes for patients with documented GHD (pre-eclampsia and gestational hypertension) were compared with those without GHD. Perinatal outcome data were recorded for 977 patients. Women with GHD had a higher body mass index (27.1 ± 6.4 vs 25.2 ± 4.5, P < 0.0001) than those without and were more likely to be nulliparous (65% (59/92) vs 46% (407/885), P = 0.001). Both groups had similar mean birthweights, but those with GHD were more likely to have a birthweight discordance ≥18% (35% (32/92) vs 20% (179/885), P = 0.001). Rates of caesarean delivery were higher in those twin pregnancies affected by GHD, and while the rate of composite morbidity was similar in both groups, twins in the GHD group had higher rates of NICU admission. In twin gestations, gestational hypertension independently confers an increased risk for emergency caesarean delivery, birthweight discordance and NICU admission, such that intensive maternal-fetal monitoring is justified when hypertension develops in a twin pregnancy.

Neonatal outcomes of twin pregnancies delivered at late-preterm versus term gestation based on chorionicity and indication for delivery.

To investigate the neonatal outcomes of twin pregnancies delivered at late-preterm versus term gestation based on chorionicity and indication for delivery. This is a retrospective cohort study of women with twin pregnancies delivered at ≥34 weeks of gestation from 1995 to 2014. Subjects were categorized into two groups according to gestational age at delivery: late-preterm group (34-36 weeks) and term group (≥37 weeks). Neonatal outcome measures including neonatal intensive care unit (NICU) admission, mechanical ventilator support, and respiratory distress syndrome (RDS) were compared between the late-preterm and term group based on chorionicity (monochorionic or dichorionic) and delivery indication (elective or non-elective). A total of 1198 twin pregnancies were included in the study: 679 in the late-preterm group and 519 in the term group. Late-preterm twin infants had higher rates of NICU admission, mechanical ventilator support, and RDS than did term twin infants, regardless of the chorionicity and indication for delivery. In the multivariable analysis, late-preterm birth, monochorionicity, and non-elective delivery were independently associated with a significantly higher risk of NICU admission and mechanical ventilator support. The late-preterm birth was associated with a higher risk of adverse neonatal outcome regardless of chorionicity and indication for delivery, and showed significantly increased risk by monochorionicity and non-elective delivery.

Increasing maternal body mass index during pregnancy increases neonatal intensive care unit admission in near and full-term infants

Background: Obesity is becoming an increasingly commonplace health problem. Obesity during pregnancy is important because the condition adversely affects not only the mother, but also the developing fetus and the newborn.Objective: The primary objective of this study was to evaluate the association between maternal body mass index (mBMI) at the time of delivery and neonatal intensive care unit (NICU) admission of offspring and to analyze the role of possible confounding variables that are often associated with obesity. Comorbidities, such as gestational diabetes mellitus (DM), hypertension (HT) and/or pre-eclampsia (PEC), are more common in more obese mothers, as is a higher association of obesity among non-Caucasian patients.Methods: Using a retrospective cohort design, 1736 mothers and their singleton live-born at ≥35 weeks’ gestation were analyzed for mBMI, maternal conditions of DM, HT and/or PEC, and whether NICU care was required and the reason for NICU admission.Results: NICU admission rate was significantly associated with maternal obesity. In comparing women with mBMI < 30 versus mBMI ≥ 30, OR was 1.39 (p = 0.045); OR increased to 1.76 (p = 0.006) in comparing patients with mBMI ≥ 35. mBMI was significantly associated with an increased rate of maternal DM, HT and PEC (p < 0.05 each); however, NICU admission rate was not correlated with DM, HT or PEC. The relationship between NICU admission and mBMI was significant in Caucasian mothers versus a borderline significance in African-American mothers (p = 0.035 versus p = 0.05). After controlling for neonatal hypoglycemia (NH) as the reason for admission to the NICU, no mBMI-NICU association persisted. The rate of infants with NH increased in higher mBMI groups, independent of maternal DM diagnosis.Conclusion: This study demonstrated a significant association between higher mBMI groups and NICU admissions independent of diagnosis of maternal comorbidities. However, accounting for NH eliminating this association suggests a pre-clinical diabetic pathology in obese women that affects newborn outcome. Despite increased percentage of nonwhite mothers in higher mBMI groups, African–American race does not seem to be a significant contributing factor in the increased rate of NICU admission in our population.