Risk Of Composite Neonatal Morbidity Research Articles

Neonatal and Maternal Outcomes of Pregnancies following Stillbirth.

Prior stillbirth increases risk of subsequent stillbirth but has unclear effect on subsequent liveborn pregnancies. We examined associations between prior stillbirth, adverse neonatal outcomes, and maternal morbidity in subsequent liveborn pregnancies. This is a secondary analysis of a large, National Institutes of Health-funded retrospective cohort study of parturients who delivered a singleton infant at a tertiary-care hospital from January 2002 to March 2013 and had a past medical/obstetric history of diabetic, and/or hypertensive disorders, and/or pregnancy with fetal growth restriction. Our analysis included all multiparous patients from the parent study. The primary outcome was a neonatal morbidity composite (neonatal resuscitation, neonatal birth injury, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis). Secondary outcomes included a maternal morbidity composite (venous thromboembolism, intensive care unit admission, disseminated intravascular coagulation, sepsis, hysterectomy, pulmonary edema, renal failure, blood transfusion), other maternal/delivery complications, and neonatal intensive care unit (NICU) admission. Outcomes were compared between those with versus without prior stillbirth. Negative binomial regression controlled for maternal comorbidities and delivery year. Among 171 and 5,245 multiparous parturients with versus without prior stillbirth, respectively, those with prior stillbirth had higher rates of pregestational diabetes, autoimmune disease, and clotting disorders. After controlling for these differences and delivery year, infants of parturients with prior stillbirth had similar risk of composite neonatal morbidity (adjusted relative ratio [aRR] 1.19; 95% confidence interval [CI] 0.99-1.45) but higher risk of NICU admission (aRR 1.42; 95% CI 1.06-1.91) compared with infants of parturients without prior stillbirth, despite delivering at similar gestational ages. Multiparous patients with prior stillbirth had equal maternal morbidity risk but higher risk of developing preeclampsia with severe features (aRR 2.11; 95% CI 1.19-3.72). Compared with high-risk multiparous patients without prior stillbirth, those with prior stillbirth have higher risk of NICU admission and preeclampsia with severe features. · Prior stillbirth increases risk in subsequent livebirth for NICU admission and neonatal morbidity.. · Prior stillbirth increased the risk of severe preeclampsia for mothers in subsequent livebirth.. · Additional monitoring of pregnancies of patients with prior history of demise may be warranted..

Glycemic control and neonatal outcomes in twin pregnancies with gestational diabetes mellitus

Preliminary data suggest that strict glycemic control in twin pregnancies with gestational diabetes mellitus may not improve outcomes but might increase the risk of fetal growth restriction. This study aimed to investigate the association of maternal glycemic control with the risk of gestational diabetes mellitus-related complications and small for gestational age in twin pregnancies complicated by gestational diabetes mellitus. This was a retrospective cohort study of all patients with a twin pregnancy complicated by gestational diabetes mellitus in a single tertiary center between 2011 and 2020, and a matched control group of patients with a twin pregnancy without gestational diabetes mellitus in a 1:3 ratio. The exposure was the level of glycemic control, described as the proportion of fasting, postprandial, and overall glucose values within target. Good glycemic control was defined as a proportion of values within target above the 50th percentile. The first coprimary outcome was a composite variable of neonatal morbidity, defined as at least 1 of the following: birthweight >90th centile for gestational age, hypoglycemia requiring treatment, jaundice requiring phototherapy, birth trauma, or admission to the neonatal intensive care unit at term. A second coprimary outcome was small for gestational age, defined as birthweight <10th centile or <3rd centile for gestational age. Associations between the level of glycemic control and the study outcomes were estimated using logistic regression analysis and were expressed as adjusted odds ratio with 95% confidence interval. A total of 105 patients with gestational diabetes mellitus in a twin pregnancy met the study criteria. The overall rate of the primary outcome was 32.4% (34/105), and the overall proportion of pregnancies with a small for gestational age newborn at birth was 43.8% (46/105). Good glycemic control was not associated with a reduction in the risk of composite neonatal morbidity when compared with suboptimal glycemic control (32.1% vs 32.7%; adjusted odds ratio, 2.06 [95% confidence interval, 0.77-5.49]). However, good glycemic control was associated with higher odds of small for gestational age compared with nongestational diabetes mellitus pregnancies, especially in the subgroup of diet-treated gestational diabetes mellitus (65.5% vs 34.0%, respectively; adjusted odds ratio, 4.17 [95% confidence interval, 1.74-10.01] for small for gestational age <10th centile; and 24.1% vs 7.0%, respectively; adjusted odds ratio, 3.97 [95% confidence interval, 1.42-11.10] for small for gestational age <3rd centile). In contrast, the rate of small for gestational age in gestational diabetes mellitus pregnancies with suboptimal control was not considerably different when compared with non-gestational diabetes mellitus pregnancies. In addition, in cases of diet-treated gestational diabetes mellitus, good glycemic control was associated with a left-shift of the distribution of birthweight centiles, whereas the distribution of birthweight centiles among gestational diabetes mellitus pregnancies with suboptimal control was similar to that of nongestational diabetes mellitus pregnancies. In patients with gestational diabetes mellitus in a twin pregnancy, good glycemic control is not associated with a reduction in the risk of gestational diabetes mellitus-related complications but may increase the risk of a small for gestational age newborn in the subgroup of patients with mild (diet-treated) gestational diabetes mellitus. These findings further question whether the gestational diabetes mellitus glycemic targets used in singleton pregnancies also apply to twin pregnancies and support the concern that applying the same diagnostic criteria and glycemic targets in twin pregnancies may result in overdiagnosis and overtreatment of gestational diabetes mellitus and potential neonatal harm.

Maternal and neonatal morbidities associated with cesarean delivery without labor compared with induction of labor around term.

We aimed to compare the maternal and neonatal morbidities associated with elective cesarean delivery (CD) without labor and those associated with induction of labor (IOL) at ≥38 weeks of gestation. This retrospective observational study from 2013 to 2020 included singleton pregnancies in nulliparous women at ≥38 weeks of gestation. Maternal and neonatal morbidities associated with elective CD without labor were compared with those associated with IOL. Altogether, 395 women were recruited. Among these, 326 underwent delivery through IOL, while 69 underwent elective CD. The elective CD group exhibited higher maternal age, lower gestational age at birth, and lower neonatal birth weight than the IOL group (P<0.001). Moreover, the elective CD group exhibited longer hospital stay, higher rate of uterotonic agent usage, and lower rate of antibiotic usage after discharge. However, no differences were observed in postpartum bleeding, readmission, or number of outpatient visits (>3) after discharge between the groups. Perinatal morbidities were similar between the groups except the incidence of meconium-stained amniotic fluid. Elective CD exhibited similar rates of complications related to composite maternal morbidity when compared with IOL, but had a lower risk of complications related to composite neonatal morbidity (relative risk, 0.45; 95% confidence interval, 0.24-0.85). Elective CD and IOL had similar rates of composite maternal morbidity but the former exhibited some benefits against obstetric wound infection. The elective CD group exhibited a decreased risk of composite neonatal morbidity despite lower gestational age at birth and higher maternal age.

Maternal and neonatal outcomes of women with gestational diabetes and without specific medical conditions: an Australian population-based study comparing induction of labor with expectant management.

Background/aimsTo evaluate maternal birth and neonatal outcomes among women with gestational diabetes mellitus (GDM), but without specific medical conditions and eligible for vaginal birth who underwent induction of labour (IOL) at term compared with those who were expectantly managed.Materials and methodsPopulation‐based cohort study of women with GDM, but without medical conditions, who had a singleton, cephalic birth at 38–41 completed weeks gestation, in New South Wales, Australia between January 2010 and December 2016. Women who underwent IOL at 38, 39, 40 weeks gestation (38‐, 39‐, 40‐induction groups) were compared with those who were managed expectantly and gave birth at and/or beyond the respective gestational age group (38‐, 39‐, 40‐expectant groups). Multivariable logistic regression analysis was used to assess the association between IOL and adverse maternal birth and neonatal outcomes taking into account potential confounding by maternal age, country of birth, smoking, residential location, residential area of socioeconomic disadvantage and birth year.ResultsOf 676 762 women who gave birth during the study period, 66 606 (10%) had GDM; of these, 34799 met the inclusion criteria. Compared with expectant management, those in 38‐ (adjusted odds ratio (aOR) 1.11; 95% CI, 1.04–1.18), 39‐ (aOR 1.21; 95% CI, 1.14–1.28) and 40‐ (aOR 1.50; 95% CI, 1.40–1.60) induction groups had increased risk of caesarean section. Women in the 38‐induction group also had an increased risk of composite neonatal morbidity (aOR 1.10; 95% CI, 1.01–1.21), which was not observed at 39‐ and 40‐induction groups. We found no difference between groups in perinatal death or neonatal intensive care unit admission for births at any gestational age.ConclusionIn women with GDM but without specific medical conditions and eligible for vaginal birth, IOL at 38, 39, 40 weeks gestation is associated with an increased risk of caesarean section.

Idiopathic Polyhydramnios and Neonatal Morbidity at Term.

Idiopathic polyhydramnios is among the most common etiologies of polyhydramnios. However, conflicting evidence exists regarding the relationship between polyhydramnios and neonatal morbidity. We investigated the association between pregnancies with and without idiopathic polyhydramnios and neonatal morbidity at term. This is a retrospective cohort study of singleton, term (i.e., ≥370/7 weeks) pregnancies from 2014 to 2018. Pregnancies complicated by fetal anomalies, pregestational diabetes, and multifetal gestation were excluded. Pregnancies complicated by idiopathic polyhydramnios were defined by the deepest vertical pocket (DVP) ≥8 cm or amniotic fluid index (AFI) ≥24 cm after 20 weeks' gestation and were compared with women without polyhydramnios at time of delivery. These groups were matched 1:2 by gestational age within 7 days at delivery and maternal race. The primary outcome was a composite neonatal morbidity (neonatal death, respiratory morbidity, hypoxic-ischemic encephalopathy, therapeutic hypothermia, seizures, and umbilical artery pH < 7.10). Outcomes were compared between pregnancies with and without idiopathic polyhydramnios. Unadjusted and adjusted risk ratios were estimated using multivariable logistic regression. Idiopathic polyhydramnios was diagnosed in 192 pregnancies and were matched to 384 pregnancies without polyhydramnios. After adjustment for obesity, women with pregnancies complicated by idiopathic polyhydramnios had an increased risk of composite neonatal morbidity 21.4 versus 5.5% (adjusted risk ratio [aRR] = 4.0, 95% confidence interval [CI]: 2.3-6.7). Term neonatal respiratory morbidity was the primary driver 20.3 versus 4.2%, (aRR = 4.8, 95% CI: 2.7-8.7) and included higher use of continuous positive airway pressure 19.8 versus 3.4%, p <0.01 and the need for supplemental oxygen at >12 hours of newborn life 6.8 versus 1.8%, p <0.01. Idiopathic polyhydramnios is associated with term neonatal respiratory morbidity at delivery and during the subsequent hours of newborn life, compared with pregnancies without idiopathic polyhydramnios. Further studies are needed to minimize neonatal morbidity at term. · Idiopathic polyhydramnios is associated with increased risk of neonatal morbidity at term.. · Increasing idiopathic polyhydramnios severity was associated with a trend toward worsening morbidity at term.. · Idiopathic polyhydramnios at term requires respiratory support at delivery and during neonatal care..

Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad

Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported. This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia. This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia. Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors. Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.

670 Neonatal outcomes after cesarean for non-reassuring fetal status in the first stage of labor

Non-reassuring fetal status (NRFS) is the second most common indication for cesarean delivery (CD) accounting for 1 in 4 cesareans. We sought to evaluate neonatal outcomes following CD for NRFS. This was a secondary analysis of a prospective cohort study. We included singleton term pregnancies admitted for labor or induction of labor between 2010-2014. The primary outcome was fetal acidemia defined as umbilical artery (UA) pH < 7.1. Secondary outcomes were UA base excess, lactate, and neonatal composite morbidity (hypoxic-ischemic encephalopathy, meconium aspiration syndrome, hypothermia treatment, intubation, mechanical ventilation, neonatal seizure, death). The exposure was first stage CD for any indication that included NRFS and the control group was all other deliveries. Multivariable logistic regression and the Zhang method was used to estimate relative risk and adjust for confounders. We also performed a sensitivity analysis of patients who underwent CD for the sole indication of NRFS. Of the 8580 patients in the cohort, 721 (8.4%) had a first stage CD for NRFS. Among these, 476 (66.0%) were for the sole indication of NRFS. The risk of fetal acidemia was 5 times higher among patients undergoing CD for NRFS compared to all other deliveries (7.3% vs 1.2%, aRR 5.45[95% CI 3.35-8.68]). UA base excess and lactate were higher among patients with CD for NRFS. CD for NRFS was associated with an increased risk of composite neonatal morbidity (4.0% vs 1.0%, aRR 2.52 [95% CI 1.30-4.78]). After restricting the analysis to patients who had CD for the sole indication of NRFS, the risk of fetal acidemia and neonatal morbidity remained significantly higher in the CD for NRFS group than control deliveries. CD for NRFS is associated with an increased risk of fetal acidemia and composite neonatal morbidity. Although the vast majority of infants delivered for NRFS have normal outcomes, these results suggest that the diagnosis of NRFS using continuous fetal monitoring in labor is predictive of adverse outcomes.

642 How does elevated intrauterine resting tone affect the fetus?

More than a third of laboring patients receive an intrauterine pressure catheter (IUPC) for contraction monitoring in labor. Elevated resting intrauterine tone has been hypothesized to decrease uterine perfusion with unknown fetal affect. We assessed the effect of elevated uterine resting tone on neonatal outcomes. This was a secondary analysis of a prospective cohort study of singleton term deliveries between 2010-2014. We included patients with at least 30 minutes of IUPC data prior to delivery. The primary outcome was composite neonatal morbidity (hypoxic ischemic encephalopathy, hypothermia treatment, meconium aspiration syndrome, intubation, mechanical ventilation, seizures, or death). The secondary outcome was umbilical arterial (UA) pH<7.2, lactate ≥ 4 mmol/l, NICU admission, and 5 min APGAR <7. We defined resting tone as the average baseline tone between contractions. Elevated intrauterine tone was ≥ 75th percentile. Multivariable logistic regression and the Zhang method was used to estimate relative risk while adjusting for potential confounders. Of the 8580 patients in the cohort, 2210 (25.8%) had an IUPC and at least 30 mins of pressure data prior to delivery. The majority (98%) of IUPC data were from the second stage. 567 patients had resting intrauterine tone ≥ 12.3 mmHg (≥75th percentile). After adjusting for obesity and chorioamnionitis, elevated resting tone was not associated with increased risk of composite neonatal morbidity (3.5% vs 2.0%, [aRR 1.71 (0.98-2.94)]. However, in a sensitivity analysis of patients in the second stage, elevated resting tone was significantly associated with composite neonatal morbidity [aRR 1.83 (95% CI 1.03-3.15)]. Elevated resting tone was associated with an increased risk of UA pH < 7.2 and UA lactate ≥ 4 [aRR 1.66 (95% CI 1.32-2.07) and 1.32 (95% CI 1.13-1.52)]. Low APGAR scores and NICU admission was similar between groups. The risk of composite neonatal morbidity and acidosis was increased among patients with higher uterine resting tone in the second stage, though the absolute risk was low.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1085 Maternal and neonatal outcomes of a subsequent pregnancy after stillbirth

Prior stillbirth is associated with increased risk of future stillbirth, but risks of adverse neonatal outcomes in a subsequent liveborn pregnancy are unknown. This is a secondary analysis of a large NIH-funded retrospective cohort study of women with diabetes, hypertensive disorders, and/or fetal growth restriction who delivered at a tertiary-care hospital from January 2002 to March 2013, excluding women with only severe preeclampsia or multifetal gestations. All women in the parent study were included in this analysis, comparing women with and without a history of stillbirth >20 weeks. The primary outcome is a neonatal morbidity composite: neonatal resuscitation (oxygen, CPAP, intubation, CPR), neonatal injury, RDS, TTN, hypoglycemia, sepsis. Secondary outcomes include a maternal morbidity composite (DVT/PE, ICU admission, DIC, sepsis, hysterectomy, pulmonary edema, renal failure, blood transfusion), neonatal death, and less severe neonatal and maternal outcomes. Log binomial and linear regression were performed controlling for maternal comorbidities. 191 women with and 11,725 women without prior stillbirth were included. Women with prior stillbirth were older (p<0.001), had higher BMI (p=0.001), and higher rates of chronic hypertension (p=0.007), autoimmune disease (p=0.02), and clotting disorder needing anticoagulation (p=0.03). After controlling for these factors, women with prior stillbirth had nearly 25% increased risk of composite neonatal morbidity (aRR 1.23; 95% CI 1.02-1.48), more than 50% increased risk of NICU admission (aRR 1.53; 95% CI 1.14-2.05), and nearly seven-fold increased risk of neonatal death (aRR 6.95; 95% CI 1.37-35.3), despite delivery at similar gestational age. Women with prior stillbirth were equally likely to have the maternal morbidity composite but nearly twice as likely to develop severe pre-eclampsia (aRR 1.88; 95% CI 1.09-3.31). Women with common obstetric comorbidities who have a prior stillbirth are at higher risk for severe neonatal complications, NICU admission and neonatal death when compared to women without prior stillbirth.

609 The association between toxicology-confirmed marijuana use close to delivery and neonatal outcomes and placental pathology

Marijuana use is increasing in women of reproductive age. Prior studies on marijuana's association with obstetric and neonatal outcomes were mainly based on self-reported use remote from delivery. We aim to evaluate the association between toxicology-confirmed marijuana use, within 72 hours of delivery and adverse neonatal outcomes. We also aim to examine placental pathology in women exposed to marijuana during pregnancy. This is a retrospective study of patients delivered between January 2016 and December 2019. Singleton pregnancies with urine drug screen performed within 72 hours of delivery and placenta sent to pathology at the time of delivery were included. Women who tested positive for polysubstance use and current tobacco and alcohol users were excluded. Neonatal outcomes and placental pathology (PP) findings were compared between the women that tested negative for drugs (NDS) and positive for marijuana use (MU). PP findings were categorized into vascular malperfusion and inflammatory findings. 466 patients (NDS) and 32 (MU) were identified. MU are likely to be younger (p=0.002), black and non- Hispanic (p=0.005) and have a psychiatric history (p= 0.01). There is no difference in BMI, parity and preexisting conditions among the groups. Gestational age at delivery and antepartum complications were similar among the groups except for gestational diabetes, which was higher in NDS group (p=0.01). The mean birth weight (BW) is lower in MU group. However, low BW, defined as <2500 grams, is similar among the groups (Table-1). NICU admissions and length of stay did not differ among the groups (Table 1). MU are likely to have higher composite neonatal morbidity (p=0.09). PP did not differ among the groups (Table 2). In contrast to prior studies, MU is not associated with increased risk of low BW, when smoking is excluded. This is also demonstrated in PP, as placental vascular insufficiency is similar in both the groups. Our study also showed increased risk of composite neonatal morbidity which has not been previously reported.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

225 Idiopathic polyhydramnios and neonatal morbidity at term: respiratory support at delivery?

Idiopathic polyhydramnios (IP) is the most common etiology of polyhydramnios. Yet, conflicting evidence exists regarding the relationship between IP and neonatal morbidity. We investigated the association between IP and neonatal morbidity at term. This is a retrospective cohort of singleton, term pregnancies from 2014-2018. Pregnancies complicated by IP were defined by a deepest vertical pocket (DVP) > 8 cm or amniotic fluid index (AFI) > 24 cm after the 20th week of gestation and were compared to women without polyhydramnios at time of delivery. These groups were matched 1:2 by gestational age within seven days at delivery and maternal race. The primary outcome was a composite neonatal morbidity (neonatal death, respiratory morbidity, hypoxic-ischemic encephalopathy, therapeutic hypothermia, seizures, and umbilical artery pH < 7.10). Outcomes were compared between pregnancies with and without IP. The trend with neonatal morbidity by polyhydramnios severity category (mild, moderate, and severe) was assessed using the Cochrane-Armitage test. Unadjusted and adjusted relative risk were estimated using multivariable logistic regression using the Zhang method. IP was diagnosed in 192 pregnancies that were matched to 384 pregnancies without polyhydramnios. After adjustment for obesity, women with pregnancies complicated by IP had an increased risk of composite neonatal morbidity 21.4% vs 5.5% adjusted risk ratio aRR [95%CI] 4.0 [2.3-6.7], driven primarily by respiratory morbidity 20.3% vs 4.2%, aRR [95% CI] 4.8 [2.7-8.7]. Increasing polyhydramnios severity category was associated with a trend towards increased neonatal morbidity (mild 31/166 (18.7%), moderate 8/20 (40%), and severe polyhydramnios 2/2 (100%), p-value <0.01). IP is associated with increased risk of neonatal morbidity at term, driven primarily by respiratory morbidity. Pregnancies complicated by polyhydramnios should have neonatal respiratory support at the time of delivery.

Association of abnormal first stage of labor duration and maternal and neonatal morbidity

Contemporary guidelines for labor management do not characterize abnormal labor on the basis of maternal and/or neonatal morbidity. In this study, we aimed to evaluate the association of abnormal duration of the first stage of term labor and the risk of maternal and neonatal morbidity. We conducted a retrospective analysis of prospectively collected data of all consecutive women admitted for delivery at a single center at ≥37 weeks and 0 to 7 days of gestation with singleton, nonanomalous, vertex infants from 2010 to 2015, who reached 10 cm cervical dilation. Multivariable logistic regression compared odds ratios for maternal and neonatal outcomes among women above and below the 90th, 95th, and 97th percentiles for first stage of labor duration. Receiver operating characteristic curves estimated the association between first stage of labor duration and maternal morbidity. Maternal morbidity was a composite of maternal fever, hemorrhage, transfusion, or endomyometritis; prolonged second stage of labor duration; and third- or fourth-degree perineal laceration. Neonatal morbidity was a composite of hypothermic therapy, need for mechanical ventilation, respiratory distress syndrome, meconium aspiration syndrome, birth injury or trauma, and neonatal seizure or sepsis. Of 6823 women included in this study, 682 were anticipated to have first stage of labor duration above the 90th percentile cutoff point, which was associated with an increased risk of composite maternal morbidity, maternal fever, postpartum transfusion, prolonged second stage of labor duration, third- or fourth-degree perineal laceration, and cesarean or operative vaginal delivery (P≤.02) and an increased risk of composite neonatal morbidity, respiratory distress syndrome, need for mechanical ventilation, and neonatal sepsis (P≤.03). Composite maternal morbidity was 2.2 (95% confidence interval, 1.8-2.7), 1.9 (95% confidence interval, 1.4-2.4), and 1.8 (95% confidence interval, 1.3-2.5) times more likely to occur among women above the 90th, 95th, and 97th percentile, respectively, for first stage of labor duration from 4 to 10 cm. Composite neonatal morbidity was 2.6 (95% confidence interval, 2.1-3.2), 2.2 (95% confidence interval, 1.7-2.9), and 1.9 (95% confidence interval, 1.3-2.8) times more likely to occur among infants delivered by women above the 90th, 95th, and 97th percentiles for first stage of labor duration from 4 to 10 cm. Receiver operating characteristic curves among all women from 4 to 10 cm and 6 to 10 cm, including when stratified by parity and type of labor onset, had an area under the curve of 0.51 to 0.62 and 0.53 to 0.71 for maternal and neonatal morbidity, respectively. Thus, duration of labor has moderate predictive ability, at best, for composite maternal or neonatal morbidity. No curve demonstrated a clear point at which adverse maternal or neonatal outcomes increased that could be used to define abnormal labor. The benefit of expectantly managing a prolonged first stage of labor with duration above the 90th percentile in anticipation of vaginal delivery must be weighed against the increased risk of composite maternal and neonatal morbidity. Risks associated with performing cesarean delivery as an alternative management for women with prolonged first stage of labor duration must also be considered.

Neonatal Morbidity of Monoamniotic Twin Pregnancies: A Systematic Review and Meta-analysis.

This study was aimed to report the incidence of neonatal morbidity in monochorionic monoamniotic (MCMA) twin pregnancies according to gestational age at birth and type of management adopted (inpatient or outpatient). Medline and Embase databases were searched. Inclusion criteria were nonanomalous MCMA twins. The primary outcome was a composite score of neonatal morbidity, defined as the occurrence of at least one of the following outcomes: respiratory morbidity, overall neurological morbidity, severe neurological morbidity, and infectious morbidity, necrotizing enterocolitis at different gestational age windows (24-30, 31-32, 33-34, and 35-36 weeks). Secondary outcomes were the individual components of the primary outcome and admission to neonatal intensive care unit (NICU). Subanalysis according to the type of surveillance strategy (inpatient compared with outpatient) was also performed. Random effect meta-analyses were used to analyze the data. A total of 14 studies including 685 MCMA twin pregnancies without fetal anomalies were included. At 24 to 30, 31 to 32, 33 to 34, and 35 to 36 weeks of gestation, the rate of composite morbidity was 75.4, 65.5, 37.6, and 18.5%, respectively, the rate of respiratory morbidity was 74.2, 59.1, 35.5, and 12.2%, respectively, while overall neurological morbidity occurred in 15.3, 10.2, 4.3, and 0% of the cases, respectively. Infectious morbidity complicated 13, 4.2, 3.1, and 0% of newborns while 92.1, 81.6, 58.7, and 0% of cases required admission to NICU. Morbidity in pregnancies delivered between 35 and 36 weeks of gestation was affected by the very small sample size of cases included. When comparing the occurrence of overall morbidity according to the type of management (inpatient or outpatient), there was no difference between the two surveillance strategies (p = 0.114). MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity that gradually decreases with increasing gestational age at delivery with a significant reduction for pregnancies delivered between 33 and 34 weeks. We found no difference in the occurrence of neonatal morbidity between pregnancies managed as inpatient or outpatient. · MCMA pregnancies are at high risk of composite neonatal morbidity, mainly respiratory morbidity.. · Neonatal morbidity gradually decreases with increasing GA at delivery, mostly between 33 and 34 weeks.. · There is no difference in the occurrence of neonatal morbidity between in- or outpatient management..

Association of Prior Cesarean Delivery With Early Term Delivery and Neonatal Morbidity

To assess whether a history of prior cesarean delivery is associated with an increased risk of earlier delivery timing and resultant neonatal morbidity. We performed a population-based retrospective cohort study using U.S. birth certificate data, 2012-2016. The study population included women with one or more prior cesarean deliveries compared with a referent group of parous women without prior cesarean delivery. To enrich for a population with minimized risk factors for early delivery, we excluded women with history of preterm birth, pregnancies complicated by multifetal gestation, pregnancy-induced hypertension, anomaly, small for gestational age, or malpresentation. Analyses were limited to births from 35 to 42 weeks of gestation. Women with a vaginal birth after cesarean delivery were excluded. The primary outcome was the risk of birth at each week of gestational age. Secondary outcomes included adverse neonatal and maternal outcomes. Patients were stratified by number of prior cesarean deliveries (one, two, three, or four or more) compared with parous patients without prior cesarean delivery. The adjusted relative risk (aRR) of delivery at 35 weeks of gestation was highest in women with four or more prior cesarean deliveries (aRR 2.79, 95% CI 2.74-2.82). Prior cesarean delivery also had a significant influence on neonatal morbidity. As the number of prior cesarean deliveries increased, the risk of composite neonatal morbidity increased, from 8.0% (aRR 1.5, 95% CI 1.48-1.51) with one prior cesarean delivery up to 21.0% (aRR 4.9, 95% CI 4.76-5.04) with four or more prior cesarean deliveries compared with a baseline risk of 5.5% in parous women without prior cesarean delivery. Prior cesarean delivery is correlated with earlier delivery and increased neonatal morbidity. Advocating trial of labor after cesarean delivery may provide maternal and neonatal benefit.

Sex-Specific Differences in Neonatal Morbidity at Term [34O

INTRODUCTION: Male sex is associated with worse outcomes among preterm neonates, but it is unclear if such sex discordant morbidity occurs in term infants. The aim of this study was to investigate the relationship between fetal sex and neonatal morbidity at term gestation. METHODS: This is a secondary analysis of a prospective cohort of women admitted for labor at term within a single institution from 2010 to 2015. The primary outcome was composite neonatal morbidity that included death, respiratory distress, mechanical ventilation, meconium aspiration syndrome, suspected sepsis, hypoxic-ischemic encephalopathy, therapeutic hypothermia, and seizure. Multivariable logistic regression was used to estimate the association between infant sex and neonatal morbidity. RESULTS: Of the 8578 participants, 51% delivered a male fetus. Birthweight was higher in male infants (3304 g vs 3177 g, P&lt;.01), as were the rates of prostaglandin administration (19.0 vs 11%, P&lt;.01), operative vaginal (4.0 vs 5.6%, P&lt;.01), and cesarean delivery (15.4 vs 18.6%, P&lt;.01). After adjusting for birthweight, male infants had a significantly higher risk of composite neonatal morbidity (aOR 1.21 [95% CI 1.04, 1.40]). This association was driven primarily by a higher rate of respiratory distress in male infants (1.34 [1.07, 1.68]). CONCLUSION: Term male infants appear to be at increased risk for neonatal morbidity compared to females even after adjustment for birthweight. This association was partly driven by a higher rate of respiratory morbidity in male infants. Our findings reinforce the current notion that neonatal outcomes can be sex-dependent, and call for further investigation into the physiologic mechanisms driving this association.

Mild Neonatal Acidemia is Associated with Neonatal Morbidity at Term.

The aim of this study is to determine the association between mild acidemia (umbilical artery [UA] pH: 7.11-7.19) and neonatal morbidity in neonates at term. This is a secondary analysis of a prospective cohort of women admitted for labor at ≥37 weeks of gestation within a single institution from 2010 to 2015. Universal umbilical cord blood gas assessment was performed and validated. A composite neonatal morbidity index was created including respiratory distress, mechanical ventilation, meconium aspiration syndrome, suspected or confirmed sepsis, hypoxic-ischemic encephalopathy, need for therapeutic hypothermia, seizures and death. The cohort was stratified by UA pH into normal (≥7.20), mild acidemia (7.11-7.19), acidemia (7.00-7.10), and severe acidemia (≤7.00). A subanalysis was also performed where neonates with UA pH between 7.11 and 7.19 were further stratified into two groups (7.11-7.14 and 7.15-7.19) to determine if mildly acidotic infants at the lower end of the pH range were at increased risk of morbidity. Multivariable logistic regression was used to estimate the association between UA pH and neonatal morbidity. Among 6,341 participants, 614 (9.7%) had mild acidemia. These infants were more likely to experience morbidity compared with those with normal UA pH (adjusted odds ratio [aOR]: 2.14; [1.68-2.73]). Among neonates with mild acidemia, UA pH 7.11 to 7.14 was associated with increased risk of composite neonatal morbidity (aOR: 3.02; [1.89-4.82]), as well as respiratory distress and suspected or confirmed sepsis when compared with UA pH 7.15 to 7.19. These data demonstrate that term neonates with mild acidemia at birth are at higher odds for short-term morbidity compared with neonates with normal UA pH. Furthermore, among neonates with mild acidemia, those with lower UA pH had worse neonatal outcomes than those with higher UA pH. This suggests that closer evaluation of neonates with UA pH higher than traditionally used could allow for earlier detection of morbidity and possible intervention. · Neonates with mild acidemia (umbilical artery [UA] pH: 7.11-7.19) demonstrated an increased risk of composite morbidity compared with those with normal UA pH (≥7.20).. · Among neonates with mild acidemia, those with lower UA pH (7.11-7.14) had a greater risk of morbidity compared with those with higher UA pH (7.15-7.19), suggesting a progression of risk of morbidity as UA pH decreases.. · The majority of prior research has focused on severe acidemia (UA pH ≤ 7.00) using outcomes of severe neurologic morbidity and mortality. These data suggest that an increased risk of morbidity exists at higher pH values when more proximal and less severe outcomes are included, such as respiratory distress and neonatal sepsis..

Birthweight discordance and neonatal morbidity in twin pregnancies: A systematic review and meta-analysis.

The aim of this systematic review was to quantify the association between birthweight discordance and neonatal morbidity in twin pregnancies. MEDLINE, Embase and Cinahl databases were searched. Studies reporting the occurrence of morbidity in twins affected compared with those not affected by birthweight discordance were included. The primary outcome was composite neonatal morbidity (including neurological, respiratory, infectious morbidities, abnormal acid-base status and necrotizing enterocolitis). The secondary outcomes were the individual morbidities. Sub-group analysis according to chorionicity, gestational age at birth and fetal weight (smaller vs larger twin) was also performed. Random-effect head-to-head meta-analyses were used to analyze the data. Twenty studies (10851 twin pregnancies) were included. The risk of composite morbidity was significantly higher in the pregnancies with birthweight discordance ≥15% (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.0-1.9), ≥20% (OR 2.2, 95% CI 1.40-3.45), ≥25% (OR 2.5, 95% CI 1.8-3.6), and ≥30% (OR 3.4, 95% CI 2.2-3.2). In dichorionic twins, birthweight discordance ≥15% (OR 2.4, 95% CI 1.65-3.46), ≥20% (OR 2.2, 95% CI 1.3-3.8), ≥25% (OR 2.7, 95% CI 1.4-5.1) and ≥30% (OR 3.6, 95% CI 2.3-5.7) were all significantly associated with composite neonatal morbidity. Analysis of monochorionic twins was hampered by the very small number of included studies, which precluded adequate statistical power. Monochorionic twins with a birthweight discordance ≥20% were at significantly higher risk of composite neonatal morbidity (OR 2.2, 95% CI 1.1-4.9) compared with those presenting with lesser degree of discordance. When stratifying the analysis according to gestational age at birth and fetal size, twins with birthweight discordance ≥15%, 20%, 25% and 30% delivered at ≥34weeks were at higher risk of neonatal morbidity compared with controls, but there was no difference in the risk of morbidity between the larger and the smaller twin in the discordant pair. Birthweight discordance is associated with neonatal morbidity in twin pregnancies. The strength of this association persists for dichorionic twins. It was not possible to extrapolate robust evidence on monochorionic twins due to the low power of the analysis due to the small number of included studies.

758: Marked variability-cause for concern?

Continuous electronic fetal monitoring (EFM) is widely used to assess intrapartum fetal well-being during labor. However, little guidance is available regarding the frequency and interpretation of marked variability. We investigated the incidence of marked variability before delivery and its association with neonatal morbidity. This is a secondary analysis of a prospective cohort of 8,580 singleton deliveries from 2010-2015 at 37 weeks or beyond. EFM patterns during the 120 minutes prior to delivery were interpreted in 10-minute epochs. The primary outcomes were 1) a composite neonatal morbidity (death, respiratory distress, mechanical ventilation, suspected sepsis, meconium aspiration syndrome, therapeutic hypothermia, hypoxic-ischemic encephalopathy, & seizure) and 2) a composite adverse acid-base status (umbilical artery acidemia pH<7.10, elevated lactate ≥4 mmol/L, elevated base excess < -12). Outcomes were compared between women with and without marked variability defined as fluctuations in EFM amplitude of greater than 25 beats per minute ever in last 120 minutes. Adjusted risk ratios were estimated using multivariable logistic regression. Of the 8,580 women, 390 (4.5%) had marked variability before delivery. 757 (8.8%) of neonates had composite neonatal morbidity and 2,212 (26%) had composite adverse acid-base status. After adjusting for maternal age & obesity, women who had marked variability did not have increased risk of the composite neonatal morbidity 11% vs 8.7% aRR, [95% CI] 1.22 [0.91 1.63], though there was an increase in the risk of respiratory distress 7.2% vs 3.7% 1.85 [1.25, 2.70]. In contrast, there was an increased risk of composite adverse acid-base status 41.5% vs 25% 1.66 [1.47, 1.88]. This finding was driven by an increased risk of elevated lactate 42% vs 25% 1.66 [1.47, 1.88]. Marked variability occurred rarely before delivery and was not associated with increased risk of composite neonatal morbidity. However, marked variability was significantly associated with an increased risk of respiratory distress and elevated cord blood lactate.

200: Mild neonatal acidemia is associated with neonatal morbidity at term

Neonatal acidemia is associated with neonatal morbidity. Umbilical artery pH of 7.0 or 7.1 is often used as a threshold for assessing risk of neonatal morbidity and mortality. However, the relevance of mild acidemia above this threshold has not been adequately assessed. This study was designed to determine the association of incremental increases in pH and neonatal morbidity among neonates with mild academia, defined as pH between 7.11 and 7.19. This is a secondary analysis of a prospective cohort study of 8580 women who were admitted for labor at ≥ 37 weeks gestation within a single institution from 2010 to 2015. Umbilical cord blood gas assessment was performed during the study time. A composite neonatal morbidity index was created including death, respiratory distress, mechanical ventilation, meconium aspiration syndrome, suspected sepsis, hypoxic-ischemic encephalopathy, therapeutic hypothermia and seizures. Neonates with mild acidosis were divided into those with umbilical artery pH 7.11-7.14 and those with pH 7.15-7.19. Multivariable logistic regression was used to estimate the association between lower pH and neonatal morbidity while adjusting for confounders. Of the 8,580 participants, 669 (7.8%) had mild acidosis. Lower umbilical artery pH (7.11-7.14) was associated with increased risk of composite neonatal morbidity when compared to pH 7.15-7.19 (aOR 2.53 [1.59,4.03]; Table 1). Among individual components, lower pH was associated with increased neonatal respiratory distress and treatment for suspected sepsis although respiratory distress was no longer significant after adjustment. These data demonstrate that term neonates with mild acidemia at birth are at increased risk for immediate morbidity. Long term risks of mild acidemia at birth will need to be assessed, and the utility of potential interventions that benefit infants with moderate and severe acidemia should be explored among this population.

246: Are intermittently elevated UA Doppler Pulsatility Indices associated with increased risk of neonatal morbidity in pregnancies with intrauterine growth restriction?

Intrauterine growth restriction (IUGR) with persistently elevated umbilical artery Doppler Pulsatility Index (UA PI) (>95%) is associated with an increased risk of perinatal morbidity compared to IUGR with normal UA PI (≤95%). Clinically, intermittently elevated UA PI is observed, but the clinical significance is unknown. We aimed to estimate the risk of neonatal morbidity with intermittently elevated UA PI. This retrospective cohort study included all non-anomalous singleton, IUGR pregnancies receiving UA PI testing at a tertiary care prenatal diagnostic center from 01/2010-09/2016. Intrauterine growth restriction was defined as an estimated fetal weight ≤ 10% for gestational age. Women with consistently elevated UA PI or absent or reversed flow were excluded. Intermittently elevated UA PI was defined as having ≥1 UA PI >95% and ≥1 UA PI ≤95%. Women with intermittently elevated UA PI were matched 1:3 by gestational age at IUGR diagnosis to those with consistently normal UA PI. The primary outcome was a composite neonatal morbidity including ventilation, phototherapy, intraventricular hemorrhage, and necrotizing enterocolitis. Secondary outcomes included individual components of the composite, 5-minute APGAR score, umbilical cord artery pH, type of delivery, and interval from diagnosis of IUGR to delivery. 1893 women were included; of these, 143 (7.6%) had intermittently elevated UA PI and were matched to 452 controls. The risk of composite neonatal morbidity was not significantly different among IUGR pregnancies with intermittently elevated versus normal UA PI. Similarly, the individual components of the composite neonatal morbidity were not significantly different between the two groups. Intermittently elevated UA PI was not associated with differences in 5-minute APGAR scores, umbilical artery pH, rates of cesarean delivery (CD) or CD for fetal distress, or interval from diagnosis of IUGR to delivery. Intermittently elevated UA PI is not uncommon among IUGR pregnancies but is not associated with an increased risk of neonatal morbidity or CD. These data suggest intermittently elevated UA PI should be managed clinically as normal UA PI.