Requiring Neonatal Intensive Care Unit Admission Research Articles

English

BACKGROUND One of the most common complications of pregnancy is preeclampsia, characterized by abnormal placental development, leading to inadequate uteroplacental blood flow. Doppler ultrasonography can pick up these abnormalities; thus, it is a useful tool to assess fetal outcome. Objective is to calculate the role of colour Doppler (umbilical and middle cerebral artery) in predicting the perinatal outcome. We wanted to evaluate the application of Doppler ultrasound in analysing the blood flow velocity waveform. METHODS This was a cross sectional study carried out between May 2010 - November 2012 in Obstetrics Department, Yenepoya Medical College, Karnataka, among 150 pregnant women with preeclampsia. RESULTS 49.3 % of patients belonged to 25 - 30 years, 58.7 % were primigravida, and 73.3 % and 26.7 % had mild and severe preeclampsia respectively. Patients with increased resistance umbilical artery Doppler - 63.8 % had babies < 2.5 Kg birth weight, 60.9 % Apgar < 7 at 5 minutes of birth and 67.5 % neonatal intensive care unit (NICU) admissions; absent end diastolic flow - all had birth weight < 2 Kg, 90 % Apgar < 7 at 5 minutes, 1 neonatal death and all required NICU admissions; reversal end diastolic flow - 1 neonatal death, all had birth weight < 2.5 Kg, an Apgar < 7 at 5 minutes and required NICU admission. Patients with abnormal Doppler in middle cerebral artery, 46.2 % were low birth weight and had Apgar < 7 at 5 minutes, 50 % required NICU admissions, but no perinatal mortality. CONCLUSIONS Doppler analysis helps in early detection of uteroplacental and fetoplacental changes and to take decisions for early interventions, like administration of steroids for fetal lung maturity and transferring preterm pregnancies to higher centres for better NICU facilities. Umbilical artery Doppler findings are slightly better predictors of adverse perinatal outcome than an abnormal middle cerebral artery. KEYWORDS Doppler, Preeclampsia, Perinatal Outcome, Umbilical Artery, Middle Cerebral Artery

1378. Reservoirs of Transmission of Resistant Gram-negative Pathogens Responsible for Neonatal Sepsis among Hospitalized Neonates in Pune, India

BackgroundNeonatal infections with resistant Gram-negative (GN) organisms are associated with high rates of mortality, with limited antibiotic treatment options. The role of maternal colonization and environmental GN organisms as reservoirs for transmission to neonates has not been well described.MethodsWe performed a prospective cohort study from October 12, 2018, until October 31, 2019, to describe the role of maternal and environmental GN colonization in BSI among neonates admitted to the neonatal intensive care unit (NICU) at a tertiary care center in Pune, India. Women admitted to Labor & Delivery with risk factors for neonatal sepsis who provided consent were enrolled and their neonates were followed until hospital discharge. For neonates who developed bloodstream infection (BSI), colonization with resistant GN organisms was assessed in their mothers from frozen vaginal and rectal swabs collected at enrollment and at delivery and in the neonates from frozen skin swabs and peri-rectal swabs collected at day of life (DOL) 0, 3, 7, and weekly until discharge. Environmental colonization was assessed with weekly sampling of unit sinks and the immediate neonatal care environment. Colonization samples were processed to identify organisms that matched neonatal blood culture isolates.Results953 women were enrolled, of whom 741 (78%) received antepartum antibiotics. Among 987 live born neonates, 12 (1%) died in the delivery room and 257 (26%) required NICU admission. Among neonates admitted to the NICU, 143 (56%) had at least one blood culture, of which 28 (20%) were positive; 21 (75%) had a GN BSI. The most common cause of neonatal BSI was Klebsiella pneumoniae, and 8 (38%) GN BSI were due to a carbapenem-resistant organism. No organism isolated from maternal samples matched organism and resistance pattern from neonatal blood culture. Matching strains were found in unit sinks and neonatal rectal and skin samples (Figure 1).Organism recovery from swabs and match to bloodstream isolate by sample source and time of collection from birth ConclusionAmong neonates born to mothers with risk factors for neonatal sepsis, GN organisms were the most common cause of neonatal BSI. Environmental and neonatal colonization may represent important reservoirs of transmission for these pathogens among neonates hospitalized in a tertiary care NICU in Pune, India.Disclosures All Authors: No reported disclosures

Does detection of fetal growth restriction improve neonatal outcomes?

Timely delivery of fetal growth restriction (FGR) is a balance between avoiding stillbirth and minimising prematurity. We sought to assess the neonatal outcomes for babies suspected of FGR, both true and false positives. This population cohort study examined all singleton births in Victoria, Australia from 2000 to 2017 (n = 1 231 415). Neonatal morbidities associated with neonatal intensive care unit (NICU) admission were assessed for babies born ≥32 weeks' with severe FGR (<3rd centile) and babies with birthweight ≥10th centile who were iatrogenically delivered for suspected FGR. Babies with severe FGR iatrogenically delivered for suspected FGR were more likely to require NICU admission than babies with severe FGR who were not detected (3.0% vs. 1.1%, P < 0.001). After adjusting for potential confounders, the odds of NICU admission were increased (adjusted odds ratio (aOR) = 3.00, 95% confidence interval = 2.45-3.67; P < 0.001). Rates of NICU admission were also higher in ≥10th centile babies iatrogenically delivered for suspected FGR than for ≥10th centile babies who entered labour spontaneously (1.8% vs. 0.5%, P < 0.001). After adjustments, the odds of NICU admission were increased (aOR = 3.91, 95% confidence interval = 3.40-4.49; P < 0.001). NICU admissions were associated with morbidities related to iatrogenic prematurity. Detection and planned delivery of FGR reduces stillbirth but may be associated with increased neonatal morbidity related to iatrogenic prematurity.

Lung ultrasound features predict admission to the neonatal intensive care unit in infants with transient neonatal tachypnoea or respiratory distress syndrome born by caesarean section

We aimed to evaluate the reliability of lung ultrasound (LU) to predict admission to the neonatal intensive care unit (NICU) for transient neonatal tachypnoea or respiratory distress syndrome in infants born by caesarean section (CS). A prospective, observational, single-centre study was performed in the delivery room and NICU of Sant’Orsola-Malpighi Hospital in Bologna, Italy. Term and late-preterm infants born by CS were included. LU was performed at 30’ and 4 h after birth. LU appearance was graded according to a previously validated three-point scoring system (3P-LUS: type-1, white lung; type-2, black/white lung; type-3, normal lung). Full LUS was also calculated. One hundred infants were enrolled, and seven were admitted to the NICU. The 5 infants with bilateral type-1 lung at birth were all admitted to the NICU. Infants with type-2 and/or type-3 lung were unlikely to be admitted to the NICU. Mean full-LUS was 17 in infants admitted to the NICU, and 8 in infants not admitted. In two separate binary logistic regression models, both the 3P- and the full LUS proved to be independently associated with NICU admission (OR [95% CI] 0.001 [0.000–0.058], P = .001, and 2.890 [1.472–5.672], P = .002, respectively). The ROC analysis for the 3P-LUS yielded an AUC of 0.942 (95%CI, 0.876–0.979; P<.001), while ROC analysis for the full LUS yielded an AUC of 0.978 (95%CI, 0.926–0.997; P<.001). The AUCs for the two LU scores were not significantly different (p = .261).Conclusion: the 3P-LUS performed 30 min after birth proved to be a reliable tool to identify, among term and late preterm infants born to CS, those who will require NICU admission for transient neonatal tachypnoea or respiratory distress syndrome.What is known• Lung ultrasound (LU) has become an attractive diagnostic tool in neonatal settings, and guidelines on point-of-care LU in the neonatal intensive care unit (NICU) have been recently issued.• LU is currently used for diagnosing several neonatal respiratory morbidities and has been also proposed for predicting further intervention, such as NICU admission, need for surfactant treatment or mechanical ventilation in preterm infants.What is new• LU performed 30′ after birth and evaluated through a simple three-point scoring system represents a reliable tool to identify, among term and late preterm infants born to caesarean section, those with transient neonatal tachypnoea or respiratory distress syndrome who will require NICU admission.• LU performed in the neonatal period confirms its potential role in ameliorating routine neonatal clinical management.

Neonatal Intensive Care Unit Admission Temperatures of Infants 1500 g or More: The Cold Truth.

Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants. The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU). Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017. In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (<36.5°C), 54.4% with a normothermic temperature, and 2.8% were hyperthermic. Of those infants admitted hypothermic, 30.4% had an admission temperature ranging from 36°C to 36.4°C and 12.1% had an admission temperature of less than 36°C. When compared with infants weighing less than 1500 g, who were born at the same institution and received extra thermal support interventions, there was a statistically significant difference (P < .001) between admission temperatures where infants less than 1500 g were slightly warmer (36.8°C vs 36.5°C). Ongoing admission temperature monitoring of all infants requiring NICU admission regardless of birth weight or admission diagnosis is important if we are going to provide the best support to decrease mortality and morbidity for this high-risk population. While this study examined short-term outcomes, effects on long-term outcomes were not addressed. Findings could be used to design targeted interventions to support thermal regulation for all high-risk infants. Neonates admitted to the NICU weighing 1500 g or more are at high risk for developing hypothermia, similar to smaller preterm infants.

Neonatal Admission and Its Relationship to Maternal Pain: Pain Scores and Analgesia.

The aim of this study was to determine whether postnatal women whose babies required neonatal intensive care unit (NICU) admission self-reported lower pain scores and required less analgesia than women whose babies remained with them. A prospective matched audit comparing pain scores and analgesia requirements where every woman with a baby admitted to the NICU was matched to 2 women whose babies remained on the ward was undertaken. Matches were based on age, number of previous births, type of birth, episiotomy, and epidural or spinal analgesia use. Data were collected on pain scores and analgesia administered in the first 72 hours postbirth. A total of 150 women were recruited and matched from November 2015 to May 2017. No statistically significant differences were found between the 2 groups for opiate analgesia use (P = .91) or pain scores (P = .89). Regardless of NICU admission, significantly higher pain scores were reported in participants who had episiotomies (P = .03). Birth via cesarean birth resulted in significantly higher pain scores (P < .01) and greater opiate administration (P < .01). This study found no statistically significant difference between pain scores or analgesia use of mothers whose babies required NICU admission and mothers whose babies remained with them.

Cystatin C as a biomarker of acute kidney injury in sick neonates

Objective: This study was planned to study serum cystatin C (CysC) levels in sick neonates admitted in neonatal intensive care unit (NICU) with predisposing risk factor(s) for development of acute kidney injury (AKI). We evaluated serum levels of CysC and creatinine in sick neonates. Methods: Ninety-four sick neonates with prematurity, sepsis, respiratory distress, and/or perinatal asphyxia requiring NICU admission were enrolled. Serum levels of creatinine and CysC were measured on day 3 of life. Results: Serum levels of both cystatin C and creatinine were significantly elevated in neonates who developed AKI versus those who did not (CysC: 2.18 ± 0.59 vs. 1.91 ± 0.47 mg/dl, P = 0.04; creatinine: 1.68 ± 0.75 vs. 0.89 ± 0.40, P

Prevalence and Outcome of Preterm Births in the National Referral Hospital in Bhutan: An Observational Study.

Preterm birth-related complications are the leading cause of under-5 mortality globally. Bhutan does not have a reliable preterm birth rate or data regarding outcome of preterm babies. To determine the preterm birth rate at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, Bhutan, and assess their outcomes. All live preterm births at JDWNRH from 1 January 2017 to 31 December 2017 were followed from birth till hospital discharge. Maternal demographic data, pregnancy details and delivery details were collected. Morbidity and mortality information as well as discharge outcome were collected on babies admitted to neonatal intensive care unit (NICU). Preterm birth rate among live births was 6.4%. Most mothers were younger than 30 years, housewives and had secondary education. Pregnancy registration rate and adequacy of antenatal visits were high. Most preterm births were singleton and the predominant mode of delivery was cesarean section. More than half of the births were initiated spontaneously, and the male:female ratio was 1.2:1. Most babies were late preterm and low birth weight. Half of them required NICU admission. Overall mortality rate was 11% and 21.6% for admitted preterm neonates. Preterm small-for-gestational-age neonates, and those born after provider-initiated preterm birth had significantly increased risk of mortality. Most preterm neonates were discharged without complications. The rate of extrauterine growth restriction was high. This is the first study on the prevalence of preterm births and their outcomes in the largest tertiary-care hospital in Bhutan.

A Novel Care Model for Neonatal Intestinal Failure Patients Is Associated With Cost Savings and Improved Outcomes.

BackgroundNeonates with intestinal failure (IF) have prolonged admissions in the neonatal intensive care unit (NICU) and require lifelong follow-up with gastroenterology (GE) as outpatients. Inpatient management of these patients typically relies on many rotating practitioners and currently discharge criteria do not exist. We sought to create standardized discharge criteria with a continuity care model for neonatal IF patients.MethodsInpatient care was streamlined to two GE physicians with weekly consultations. We implemented standardized discharge goals for both enteral and total parental nutrition (TPN) by: 1) Enteral feedings of at least 5 mL/h were tolerated; 2) Stable central venous access was intact; 3) TPN was cycled to 20 h/day or less; and 4) No other medical issues required NICU admission. Patient records were reviewed after 18 months of implementing standardized discharge criteria and we compared their outcomes to a historical cohort of IF patients.ResultsOptimal discharge criteria were met in 12 patients and a cohort of 26 historical patients was used for comparison. Patients in optimal versus historical groups had similar baseline characteristics (medians, all P values = non-significant (NS)): gestational age (36 vs. 35 weeks), birth weight (1,990 vs. 2,076 g), birth length (45 vs. 44 cm), and small bowel length after definitive surgery (63 vs. 55 cm). Compared to the historical group, the optimal cohort was discharged earlier (median length of stay 69 vs. 126 days, P < 0.01), with a reduced total stay of 684 NICU days, fewer central line-associated bloodstream infections (CLABSIs) (4 vs. 10 per 1,000 patient days, P = 0.04), and had fewer readmissions (7 vs. 17 per 1,000 patient days, P < 0.01), respectively.ConclusionsConcentrating the care of IF patients to a GE team invested in long-term care, while implementing safe discharge criteria, resulted in a dramatic length of stay reduction with fewer CLABSIs and readmissions compared to historical management. At approximately 4,000 dollars per day in NICU hospital charges, this program saved over 2.7 million dollars in care costs while allowing families and their infants more time at home. The safety and applicability of the optimal discharge criteria presented here should be studied further. Similar programs may be effective at other large NICUs.

Prenatal predictors of neonatal intensive care unit admission due to respiratory distress.

Admission to the neonatal intensive care unit (NICU) due to respiratory distress is determined according to subjective clinician judgement. We investigated prenatal factors predictive of NICU admission in neonates with respiratory distress. This case-control study was conducted at Nara Prefecture General Medical Center, Nara, Japan, from February 2013 to April 2017 and included neonates with birthweight ≥2,000g, ≥36weeks of gestational age, who required oxygen due to respiratory distress at birth. The cases consisted of neonates admitted to the NICU, and the control group consisted of neonates who did not require NICU admission. Perinatal factors between the groups were compared, and multivariate logistic regression analysis carried out to evaluate predictive factors. The NICU group consisted of 94 neonates, and the control group, 417 neonates during the period reviewed. On multivariate analysis, maternal anemia (OR, 2.97; 95%CI: 1.42-6.21), infertility treatment (OR, 2.79; 95%CI: 1.36-5.71), threatened preterm labor (OR, 2.16; 95%CI: 1.10-4.23), premature rupture of membranes (OR, 5.30, 95%CI: 2.52-11.17), fibroids (OR, 6.06; 95%CI: 1.57-23.41), history of uterine surgery (OR, 3.53, 95%CI: 1.13-11.06), abruptio placentae (OR, 10.21; 95%CI: 1.83-57.17), intrauterine growth restriction (OR, 6.69; 95%CI: 1.96-22.85), and having twins (OR, 0.23; 95%CI: 0.09-0.58) were significant prenatal predictors of NICU admission. Factors that potentially predict NICU admission were identified. Clinicians may wish to consider these factors when treating neonates with respiratory distress.

MATERNAL VIRTUAL INFANT NUTRITION SUPPORT CLINIC FOR THE NEONATAL INTENSIVE CARE UNIT (MAVINS-NICU) - A QUALITATIVE STUDY

Abstract BACKGROUND Canadian exclusive breastfeeding rates at 6 months of age are only 24.2%, and are even lower in mothers of infants requiring Neonatal Intensive Care Unit (NICU) admission. An interactive website was developed that provides professional (articles, videos) and peer (discussion forum for peers, access to a lactation consultant) breastfeeding support to mothers of infants requiring NICU admission. OBJECTIVES The objective of the study is to outline maternal perceptions of the breastfeeding support website (MAVINS-NICU) in a level-III NICU setting. DESIGN/METHODS This study represents the qualitative research component of the MAVINS-NICU project. Semi-structured interviews were conducted antenatally with women at risk of delivering an infant requiring NICU admission (n=6), and postnatally with mothers of infants admitted to the NICU (n=7), regarding their experiences with the MAVINS-NICU website. Interviews were audio-recorded and transcribed by a professional transcriptionist. Analysis occurred in an iterative fashion using open and axial coding strategies to identify majors themes. RESULTS Several themes were identified: 1) Women seemed comforted that a reliable hospital-provided resource would be available to them after birth, “…I’m very happy that I’m going to have lots of support”; 2) Women felt overwhelmed after birth, but often accessed the website on their phone or read newly posted comments on the discussion forum in response to automatically generated weekly emails from the website, “I’m just, overwhelmed… because I’m [in the NICU a lot], I only have my phone and it’s just easier to look at the emails… [they] just pop up”; 3) Mothers felt extremely comforted by the peer support component of the website, “to see what other moms are going through … similar emotions or issues … to see that I’m not the only one [helps]”; 4) Mothers enjoyed remote access and quick online lactation consultant response times, “ … [you can] get help even when there’s no one around”, “I was really surprised … by how quickly I got responses”; 5) Majority of mothers expressed a sense of empowerment to provide breast milk with the help of MAVINS support, “…being able to breastfeed eventually is a big deal for me… [it made me feel] like I was accomplishing something”. CONCLUSION Mothers of infants admitted to the NICU found the MAVINS-NICU website very helpful and considered it part of their success in providing breast milk for their babies.

998: Association between labor and neonatal respiratory morbidity in pregnancies complicated by gestational diabetes mellitus

Neonates born to women with gestational diabetes mellitus (GDM) have historically been thought to be at increased risk of respiratory morbidity but it is uncertain whether or how exposure to labor affects this association. Therefore, we sought to assess the risk of respiratory complications in neonates who were delivered after labor compared to those who did not experience labor among a cohort of neonates born to women with GDM. A prospective cohort study of singleton pregnancies complicated by GDM in which the infants were live born at ≥34 weeks. The primary outcome for this analysis was respiratory distress syndrome (RDS) or transient tachypnea of the newborn (TTN) which resulted in neonatal intensive care unit (NICU) admission. Neonates who experienced labor (either spontaneous or induced) were compared to those who delivered by cesarean without labor. Covariates, including gestational age, were investigated and adjusted for if the p-value was <0.05. Of the 292 neonates meeting study inclusion criteria, 25 (8.6%) developed RDS or TTN and required NICU admission (median length of stay = 7 days). Seventy four delivered without labor (25 by primary cesarean delivery [CD] and 49 by repeat CD) and 218 delivered after labor (46 by CD and 172 vaginally). Those who delivered without labor and those who labored delivered at similar gestational ages (38.4 v. 38.6 weeks), but differed with regard to age and race. Not laboring, compared to laboring, was associated with a significantly higher risk of the primary outcome, 13.5% v. 4.1% (OR 3.6; 95% CI 1.4-9.3). Even after adjusting for age and race, those who did not labor had a higher risk of the primary outcome (aOR 4.2; 95% CI 1.2-14.9). Exposure to labor is associated with a decreased risk of respiratory morbidity in neonates born in the late preterm or term period to mothers with GDM.

Infants Born with Down Syndrome: Burden of Disease in the Early Neonatal Period

To evaluate the incidence of direct admission of infants with Down syndrome to the postnatal ward (well newborn nursery) vs the neonatal intensive care unit (NICU), and to describe the incidence of congenital heart disease (CHD) and pulmonary hypertension (PH). This retrospective cohort study of Down syndrome used the maternal/infant database (2011-2016) at the Rotunda Hospital in Dublin, Ireland. Admission location, early neonatal morbidities, outcomes, and duration of stay were evaluated and regression analyses were conducted to identify risk factors associated with morbidity and mortality. Of the 121 infants with Down syndrome, 54 (45%) were initially admitted to the postnatal ward, but 38 (70%) were later admitted to the NICU. Low oxygen saturation profile was the most common cause for the initial and subsequent admission to the NICU. Sixty-six percent of the infants (80/121) had CHD, 34% (41/121) had PH, and 6% died. Risk factors independently associated with primary NICU admission included antenatal diagnosis of Down syndrome, presence of CHD, PH, and the need for ventilation. Infants with Down syndrome initially admitted to the postnatal ward have a high likelihood of requiring NICU admission. Overall, high rates of neonatal morbidity were noted, including rates of PH that were higher than previously reported. Proper screening of all infants with Down syndrome for CHD and PH is recommended to facilitate timely diagnoses and potentially shorten the duration of the hospital stay.

Perinatal Backgrounds and NICU Bed Occupancy of Multiple-Birth Infants in Japan.

Multiple pregnancies (twin, triplet, and higher-order pregnancy) are associated with an increased risk of resultant preterm and low birth weight infants. The increase of multiple pregnancies for several decades in Japan has been an important consideration in bed allocation planning for neonatal intensive care unit (NICU). The guideline of the Japan Society of Obstetrics and Gynecology (JSOG) in 2008 recommended that embryo transfer be limited to one. The epidemiological data of Japanese regional multiple pregnancies before the JSOG recommendation are valuable in assessing the perinatal effects after this recommendation. The aim of this study was to investigate regional backgrounds of multiple pregnancies and neonatal outcomes of multiple births including NICU admission before the JSOG recommendation. This is a retrospective population-based study for 20 months (January, 2007 through August, 2008) in Shiga Prefecture, Japan. Sending questionnaires to institutions treating multiple births in Shiga, we extracted relevant data from the responses of respective obstetricians and neonatologists. There were 245 multiple births including 241 twins and 4 triplets. We found more twin deliveries with higher risks such as monochorionic diamniotic twins or preterm twins less than 34 weeks in hospitals including perinatal centers than in primary obstetrics clinics. More than half of multiple-birth infants (57%) required NICU admission, and nearly 20% of NICU beds in Shiga are occupied with multiple-birth infants. Furthermore, half of multiple-birth infants were conceived with medical assistance. We conclude that multiple pregnancies resulting from medically assisted conception could have a significant impact upon the NICU bed occupancy in Japan.

Effect of Delayed Cord Clamping Above Versus Below the Perineum on Neonatal Hematocrit: A Randomized Controlled Trial.

The purpose of this study was to determine if there is a difference in neonatal hematocrit at 24 hours of life in full-term newborns for which delayed cord clamping is performed above versus below the perineum. One hundred one patients with singleton pregnancies >37 weeks of gestation presenting for delivery were randomized to delayed cord clamping above or below the perineum. At 24 hours of life, neonatal hematocrit was determined, and the difference was compared using statistical analysis. Secondary outcomes measured were need for phototherapy, transfusion, and neonatal intensive care unit (NICU) admission. Of 101 patients recruited for the study, 53 were randomized to the above group, and 48 were randomized to the below group. Twenty-seven patients in the above group and 26 patients in the below group completed the study. The above group had an average neonatal hematocrit of 52.7% (± 2.58%). The below group had an average neonatal hematocrit of 55.8% (± 2.42%). There was no statistical difference between groups (p = 0.10). Similarly, differences in secondary outcomes did not reach statistical significance. Three infants in the above group and one infant in the below group required phototherapy. None of the infants required blood transfusion. Three infants in the above group and one infant in the below group required NICU admission. When comparing delayed cord clamping above versus below the perineum, there is no difference in the neonatal hematocrit at 24 hours of life.

Assessment of the Relationship between Recurrent High-risk Pregnancy and Mothers’ Previous Experience of Having an Infant Admitted to a Neonatal Intensive Care Unit

Background: High-risk pregnancies increase the risk of Intensive Care Unit (ICU) and Neonatal Intensive Care Unit (NICU) admission in mothers and their newborns. In this study, we aimed to identify the association between the recurrence of high-risk pregnancy and mothers’ previous experience of having an infant admitted to NICU. Methods:We performed a cohort, retrospective study to compare subsequent pregnancy outcomes among 232 control subjects and 200 female cases with a previous experience of having a newborn requiring NICU admission due to intrauterine growth retardation, preeclampsia, preterm birth, premature rupture of membranes, and asphyxia. The information about the prevalence of subsequent high-risk pregnancies was gathered via phone calls. Results: As the results indicated, heparin, progesterone, and aspirin were more frequently administered in the case group during subsequent pregnancies, compared to the control group (p <0.001). Also, pregnancy-induced hypertension, preeclampsia, preterm labor, and gestational diabetes mellitus were more frequent in the case group, compared to the control group (p <0.05). Conclusion: There was a positive correlation between recurrent high-risk pregnancy and previous experience of having a newborn requiring NICU admission. As the results indicated, mothers in the case group were at a higher risk for preeclampsia, preterm labor, and gestational diabetes mellitus, compared to the control group. Therefore, earlier diagnosis, prompt treatment, and prevention should be taken into account by physicians.

Risk Factors for Neonatal Intensive Care Unit Admission After Term Twin Deliveries

INTRODUCTION: The rate of twin delivery has increased by 76% since the 1980s and is associated with risk of neonatal intensive care unit (NICU) admission. Research on twin outcomes at term is limited. Our objective was to profile twin term pregnancies at increased risk of NICU admission. METHODS: The U.S. Natality database of birth certificate data from all births in the nation from 2007 to 2010 was reviewed. Inclusion criteria were twin delivery, term gestational age (37–42 weeks of gestation), and admission compared with no admission to a NICU. Congenital anomalies and missing data were excluded. Variables considered were demographics (maternal race, live birth order, fetal gender), obstetric complications (hypertension and diabetes-related disorders), labor complications (fetal distress, chorioamnionitis, meconium), labor outcomes (induction of labor, delivery method), and newborn status (Apgar score). Adjusted odds ratios for NICU admission were obtained from logistic regression. RESULTS: From 2007 to 2010, NICU admission rates for term twin deliveries increased from 19.9% to 30.2%. Table 1 shows NICU admission was higher for African American, male newborns delivered by cesarean of primiparas with premature rupture of membranes and chorioamnionitis as well as preeclampsia, chronic hypertension, diabetes mellitus, and meconium (P=.000).CONCLUSIONS: In term twins, the profile of neonates requiring NICU admission includes medical complications of pregnancy with evidence of infection during labor. Although these neonates tend to be African American males born to primiparas, the major warning signs for adverse perinatal outcome are premature rupture of membranes, chorioamnionitis, and low 5-minute Apgar scores. Recognition of this high-risk profile may allow for timely assessment and early intervention to improve outcomes for these high-risk perinates.

Isolated elevated blood neutrophil concentration at altitude does not require NICU admission if appropriate reference ranges are used

The Intermountain Healthcare hospitals use a clinical pathway algorithm for early-onset infection, which is based on the 2002 Centers for Disease Control and Prevention (CDC) guidelines for perinatal group B streptococcal disease. As part of this pathway, neonates in the well baby nursery, who seem to be well but have risk factors for infection, receive a 'limited laboratory evaluation including a CBC', and if the complete blood cell count (CBC) is abnormal, antibiotic treatment and neonatal intensive care unit (NICU) monitoring are initiated. We recently found that reference ranges for absolute neutrophil counts (ANCs) are much wider at our altitude (4800 to 5000 ft) than at sea level. On this basis, we speculated that some well babies with risk factors for infection are mistakenly judged as having an abnormal CBC, and are unnecessarily admitted to the NICU. This was a retrospective observational cohort study of neonates of >37 weeks gestation admitted to either of two Intermountain Healthcare NICUs for intravenous antibiotic treatment during a recent 36-month period. During the study period 3217 patients were admitted to the two NICUs, 1049 (32.6%) of which were born at>37 weeks gestation. Of these, 14 (1.3%) were found to have been admitted to the NICU on the basis of an abnormal CBC (elevated ANC), when in retrospect, using the appropriate ANC chart, their CBCs were completely normal. None of the 14 neonates had a leukocyte left shift (immature to total neutrophil ratio >0.3) or thrombocytopenia. None were treated with supplemental oxygen or mechanical ventilation in the NICU. All 14 had sterile blood cultures. All had antibiotics stopped in 48 to 72 h, and all were discharged home as well babies. We identified 14 neonates who, while in the well baby nursery, were found to have risk factors for early-onset infection, but did not seem to be infected, and were subsequently admitted to a NICU for intravenous antibiotic treatment and monitoring under the mistaken impression that they had an abnormal CBC. We maintain that use of an appropriate neutrophil reference range chart can reduce NICU admissions and can limit unnecessary antibiotic exposure.

Watchful waiting: A management protocol for maternal glycaemia in the peripartum period

It is accepted that tight glycaemic control is necessary during labour in women with pregestational or gestational diabetes mellitus (GDM). Although policies vary, routine use of intravenous glucose and insulin remains a standard practice in some institutions. We present a retrospective review of a more conservative approach. Briefly, regardless of planned delivery method, maternal blood sugar level (BSL) is monitored during delivery and only if outside 4-7 mmol/L is action taken. We report the results of an audit of this practice. A retrospective (August 2001-July 2004) review of 137 singleton, term deliveries of women with diabetes (23 pregestational, 114 GDM). Predetermined outcomes reported were BSL achieved prior to delivery, first neonatal BSL and/or admission to neonatal intensive care unit (NICU) for hypoglycaemia. With our management practice, most women had a BSL between 4 and 8 mmol/L prior to delivery (17 (74%) diabetes mellitus (DM), 37 (93%) diet-controlled GDM, 55 (89%) insulin-requiring GDM). Neonatal hypoglycaemia (< 2.6 mmol/L) was common (n = 30 (22%)). However, most neonatal hypoglycaemia occurred in infants born to mothers with BSL 4-8 mmol/L (n = 26 (87%)). Neonatal hypoglycaemia requiring NICU admission (n = 13) was predominantly in infants born to mothers with BSL < 8mmol/L prior to delivery (n = 10 (77%)). Three of eight maternal BSLs > 8 mmol/L occurred prior to emergency caesarean section in women with pregestational diabetes. These results suggest that our current practice, particularly in women with GDM, may offer an alternative to more aggressive regimes.

Infants admitted to a neonatal intensive care unit: parental psychological status at 9 months

This paper reports on the 9-month follow-up of parents who had an infant admitted to neonatal intensive care unit (NICU) compared to parents of full-term health infants. The psychological status of the parent groups is compared and factors associated with status change are examined. Prospective longitudinal study of random sample of 447 parents (mother and father with an infant admitted to the NICU and 189 parents (mother and father) with term infant not requiring NICU admission. Parents' depression and anxiety symptoms were assessed at infant birth and 9 months later. The increased levels of depression and anxiety symptoms evident in NICU parents after their infant's birth were no longer apparent by 9 months. Higher initial symptom severity and perceived quality of the couple relationship were most commonly associated with improvement. Other factors related to symptoms change were number of baby hospitalizations for fathers and being in the NICU, age and living with the infant's father or mother. For the majority of parents having an infant admitted to the NICU does not result in ongoing psychological distress.