Risk Of Severe Neonatal Morbidity Research Articles

Morbidity and mortality of newborns born to immigrant and nonimmigrant females residing in low-income neighbourhoods.

Living in low-income neighbourhoods and being an immigrant are each independently associated with adverse neonatal outcomes, but it is unknown if disparities exist in the neonatal period for children of immigrant and nonimmigrant females living in low-income areas. We sought to compare the risk of severe neonatal morbidity and mortality (SNMM) between newborns of immigrant and nonimmigrant mothers who resided in low-income neighbourhoods. This population-based cohort study used administrative data for females residing in low-income urban neighbourhoods in Ontario, who had an in-hospital, singleton live birth at 20-42 weeks' gestation, from 2002 to 2019. We defined immigrant status as nonrefugee immigrant or nonimmigrant, further detailed by country of birth and duration of residence in Ontario. The primary outcome was a SNMM composite (with 16 diagnoses, including neonatal death and 7 neonatal procedures as indicators), arising within 0-27 days after birth. We estimated relative risks (RRs) and 95% confidence intervals (CIs) using modified Poisson regression with generalized estimating equations. Our cohort included 148 050 and 266 191 live births among immigrant and nonimmigrant mothers, respectively. Compared with newborns of non-immigrant females, SNMM was less frequent among newborns of immigrant females (49.7 v. 65.6 per 1000 live births), with an adjusted RR of 0.76 (95% CI 0.74 to 0.79). The most frequent SNMM indicator was receipt of ventilatory support. Relative to neonates of nonimmigrant females, the risk of SNMM was highest among those of immigrants from Jamaica (adjusted RR 1.14, 95% CI 1.05 to 1.23) and Ghana (adjusted RR 1.20, 95% CI 1.05 to 1.38), and lowest among those of immigrants from China (adjusted RR 0.44, 95% CI 0.40 to 0.48). Among immigrants, the risk of SNMM declined with shorter duration of residence before the index birth. Within low-income urban areas, newborns of immigrant females had an overall lower risk of SNMM than those of nonimmigrant females, with considerable variation by maternal birthplace and duration of residence. Initiatives should focus on improving preconception health and perinatal care within subgroups of females residing in low-income neighbourhoods.

Neonatal morbidity associated with maternal Group B Streptococcal colonization in individuals undergoing planned cesarean delivery

Objective To examine the association between unknown maternal Group B Streptococcal (GBS) colonization and the risk of severe neonatal morbidity among individuals undergoing planned cesarean delivery. Methods We performed a secondary analysis of a multicenter, prospective observational study of individuals with singleton gestations and planned cesarean delivery ≥37 weeks gestation with cervical dilation ≤3 cm, intact membranes, and no evidence of labor or induction. GBS status was categorized as positive, negative, or unknown. The primary outcome was a composite of severe neonatal morbidity, including clinical or culture-proven sepsis, ventilator support in the first 24 h, respiratory distress syndrome, hypotension requiring treatment, intubation, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, or death. We compared individuals with unknown GBS status to those with positive and negative GBS status. Results In this cohort, 4,963 individuals met inclusion criteria; 72% had unknown GBS status, 25% were GBS negative and 3% were GBS positive. Among individuals with unknown GBS status, 208 (5.9%) had the primary composite neonatal outcome, compared with 75 (6%) of GBS negative individuals and 6 (4%) of GBS positive individuals. There was no difference in composite severe neonatal morbidity among GBS unknown, GBS negative, and GBS positive individuals (5.9% vs 6% vs 4%, p = .61). After adjusting for male sex and intrapartum antibiotic exposure, unknown GBS status was not associated with severe neonatal morbidity (adjusted risk ratio, 0.95; 95% confidence interval, 0.73–1.22). Conclusion GBS status at time of planned cesarean delivery does not appear to be associated with composite severe neonatal morbidity. The cost effectiveness and clinical utility of GBS screening among individuals undergoing planned cesarean delivery requires further investigation.

Association between prenatal exposure to antidepressants and neonatal morbidity: An analysis of real-world data from a nationwide claims database in Japan

BackgroundDepression during pregnancy is relatively undertreated; however, the relationship between prenatal exposure to antidepressants and neonatal outcomes remains controversial. MethodsThis retrospective cohort study used a Japanese nationwide claims database. Data of 114,359 singletons born between January 2005 and November 2019 were used to evaluate the relationship between prenatal exposure to antidepressants and neonatal morbidity. ResultsOf 2892 mothers with a history of depression before delivery, 352 (12.1%) received prescriptions within three months before delivery (MP3), and 2540 did not (non-MP3). The participants were propensity score matched (PSM) in a ratio of 1:3 using logistic regression (MP3_PSM [n = 351] vs non-MP3_PSM [n = 1052]), and maternal prescriptions of antidepressants within three months before delivery were associated with neonatal morbidity indicators, including admission to the neonatal intensive care unit (NICU) (15.7 vs. 9.1%, odds ratio (OR) 1.9 [95% confidence interval (CI): 1.3–2.6]), poor neonatal adaptation syndrome (6.0 vs 1.0%, OR 6.6 [95% CI: 3.1–14.2]), transient tachycardia (15.7 vs. 6.7%, OR 2.6 [95% CI: 1.8–3.8]), and meconium aspiration syndrome (3.1 vs 0.7%, OR 4.8 [95% CI, 1.9–12.5]). There were no significant differences in the long-term duration of stay at the NICU (>15 days). LimitationsConfounding factors may remain even after the propensity matching. ConclusionMaternal prescription of antidepressants within three months before delivery was associated with increased admission to the NICU. However, the absolute risk of severe neonatal morbidity was low. Therefore, collaborative care for prenatal depression and the neonatal intensive care is warranted.

Estimating risk of severe neonatal morbidity in preterm births under 32 weeks of gestation

Background: A large recent study analyzed the relationship between multiple factors and neonatal outcome and in preterm births. Study variables included the reason for admission, indication for delivery, optimal steroid use, gestational age, and other potential prognostic factors. Using stepwise multivariable analysis, the only two variables independently associated with serious neonatal morbidity were gestational age and the presence of suspected intrauterine growth restriction as a reason for admission. This finding was surprising given the beneficial effects of antenatal steroids and hazards associated with some causes of preterm birth. Multivariable logistic regression techniques have limitations. Without testing for multiple interactions, linear regression will identify only individual factors with the strongest independent relationship to the outcome for the entire study group. There may not be a single “best set” of risk factors or one set that applies equally well to all subgroups. In contrast, machine learning techniques find the most predictive groupings of factors based on their frequency and strength of association, with no attempt to identify independence and no assumptions about linear relationships.Objective: To determine if machine learning techniques would identify specific clusters of conditions with different probability estimates for severe neonatal morbidity and to compare these findings to those based on the original multivariable analysis.Materials and methods: This was a secondary analysis of data collected in a multicenter, prospective study on all admissions to the neonatal intensive care unit between 2013 and 2015 in 10 hospitals. We included all patients with a singleton, stillborn, or live newborns, with a gestational age between 23 0/7 and 31 6/7 week. The composite endpoint, severe neonatal morbidity, defined by the presence of any of five outcomes: death, grade 3 or 4 intraventricular hemorrhage (IVH), and ≥28 days on ventilator, periventricular leukomalacia (PVL), or stage III necrotizing enterocolitis (NEC), was present in 238 of the 1039 study patients. We studied five explanatory variables: maternal age, parity, gestational age, admission reason, and status with respect to antenatal steroid administration. We concentrated on Classification and Regression Trees because the resulting structure defines clusters of risk factors that often bear resemblance to clinical reasoning. Model performance was measured using area under the receiver–operator characteristic curves (AUC) based on 10 repetitions of 10-fold cross-validation.Results: A hybrid technique using a combination of logistic regression and Classification and Regression Trees had a mean cross-validated AUC of 0.853. A selected point on its receiver–operator characteristic (ROC) curve corresponding to a sensitivity of 81% was associated with a specificity of 76%. Rather than a single curve representing the general relationship between gestational age and severe morbidity, this technique found seven clusters with distinct curves. Abnormal fetal testing as a reason for admission with or without growth restriction and incomplete steroid administration would place a 20-year-old patient on the highest risk curve.Conclusions: Using a relatively small database and a few simple factors known before birth it is possible to produce a more tailored estimate of the risk for severe neonatal morbidity on which clinicians can superimpose their medical judgment, experience, and intuition.

571: Predictors of failed operative vaginal delivery: A prospective population-based cohort study

To identify factors associated with failed attempted OVD (aOVD) in a prospective population-based cohort study, evaluate whether these factors can be used to accurately predict failed OVD, and build a predictive score for failed aOVD. This was a planned secondary analysis of data collected for a prospective population-based cohort study of 2,138 deliveries with an aOVD at term from 2008-2013. Its design was to estimate severe composite maternal and neonatal morbidity after aOVD according to the fetal head station [mid- (391/2,138; 18.3%), low- (1,550/2,138; 72.5%), and outlet-pelvic (197/2,138; 9.2%)]. Women in the case group were defined as women who had aOVD but required ultimately cesarean delivery, and women who delivered vaginally after aOVD were defined as controls. A risk score for failed aOVD was derived using univariate and multivariate logistic regression analyses. Ability of the tool to predict failed aOVD was assessed using the area under the receiver operating characteristic curve (AUC). Failed aOVD occurred in 39 women (1.8%): 35 (8.9%) mid-, and 4 (0.3%) low-pelvic aOVD (P<.0001). Women with failed aOVD had more often gestational age (GA)≥40 weeks (P=.003), fetal occiput-posterior position (P<.0001), mid station at application (P<.0001), aOVD performed by senior obstetrician (P<.0001), vacuum (P<.0001), and less often with active phase of second stage longer than 30 min (P=.005). Failed aOVD was associated with severe maternal morbidity (P=.0008) without increasing risk of severe neonatal morbidity (P=.07). The risk score for failed aOVD included the following predictors: vacuum (+1), fetal occiput-posterior position (+1), and aOVD for arrested progress (+1), active phase of second stage longer than 30 min (-1), GA≥40 weeks with midpelvic aOVD (+1). The AUC was 0.83 (95% CI 0.75-0.91) (Fig.1). A cut-off point of 2 had Se of 66.7%, Sp of 93.6%, and PPV of 93.2% for cesarean delivery after failed aOVD. If failed aOVD was considered as women who had aOVD but required sequential use of 2 instruments or ultimately cesarean delivery (n=117; 5.5%), the AUC was 0.77 (95%CI 0.73-0.80) (Fig.2). Using a cut-off point of 2, failed aOVD was predicted with Se, Sp, and PPV of 35.3%, 94.2%, and 90.9%, respectively. Risk factors identified before an aOVD should be easily used to accurately predict whether an aOVD will fail.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Birthweight Extremes and Neonatal and Childhood Outcomes after Preterm Premature Rupture of Membranes.

Objective To determine the association between birthweight extremes and risk of adverse neonatal and childhood outcomes following preterm premature rupture of membranes (PPROM). Study Design This is a secondary analysis of data from the Beneficial Effects of Antenatal Magnesium Sulfate Trial. Women with nonanomalous singletons and PPROM delivering ≥24.0 weeks were included. Birthweight was classified as small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA). Composite severe neonatal morbidity and childhood outcomes at age 2, were compared between these groups. Results One thousand five hundred and ninety-eight infants were included (58 SGA, 1,354 AGA, and 186 LGA). There was an inverse relationship between birthweight and rate of composite major neonatal morbidity (55.2% of SGA, 31.5% of AGA, 18.3% of LGA, p < 0.001). Former-SGA children were more likely to be diagnosed with major composite childhood morbidity at age 2 (25.9% of SGA, 8.3% of AGA, 5.9% of LGA, p < 0.001). In multivariate models, LGA infants had improved initial neonatal outcomes compared with AGA infants (adjusted odds ratio [aOR], 0.44; 95% confidence interval [CI], 0.28-0.71; p = 0.001). Conclusion Among infants delivered following PPROM, those who were LGA at delivery had improved composite adverse neonatal outcomes. SGA increases the risk of severe neonatal morbidity, early childhood death, and moderate/severe cerebral palsy at age 2.

The fetal inflammatory response syndrome is a risk factor for morbidity in preterm neonates

The aim of this study was to show and discuss an association between fetal inflammatory response syndrome (FIRS) and an adverse neonatal outcome defined as combined severe neonatal morbidity and mortality in preterm neonates hospitalized in our neonatal intensive care unit. This was an observational study including all preterm neonates hospitalized in our neonatal intensive care unit over a 21 month period. FIRS was defined as cord blood interleukin (IL)-6 greater than 11 pg/mL. Main outcome parameter was an adverse neonatal outcome defined as hospital mortality and/or the presence of any of 5 prespecified morbidities (bronchopulmonary dysplasia, periventricular leukomalacia, intraventricular hemorrhage, and early- or late-onset sepsis). Fifty-seven of 176 preterm infants hospitalized during the study period (32%) had an adverse neonatal outcome and 62 of these 176 infants (35%) had FIRS with median IL-6 values of 51.8 pg/mL (range, 11.2 to >1000 pg/mL). In a regression analysis, FIRS was significantly associated with adverse neonatal outcome (P < .001) and with the single outcome parameters, intraventricular hemorrhage and early-onset sepsis (P = .006 and P = .018, respectively). In the bivariate analysis, FIRS was associated with death and bronchopulmonary dysplasia (P = .004 and P < .001, respectively). IL-6 correlated with adverse neonatal outcome (r = 0.411, P < .001). When comparing the correlation in neonates less than 32 weeks' gestational age (r = 0.481, P < .001) with neonates 32 weeks or longer (r = 0.233, P = .019), the difference was nearly significant (P = .065). FIRS is a risk factor for adverse neonatal outcome in preterm infants. In particular, the combination of IL-6 greater than 11 pg/mL and low gestational age increased the risk for severe neonatal morbidity or death.

Neonatal Morbidity in Growth-Discordant Monochorionic Twins: Comparison Between the Larger and the Smaller Twin

Fetal growth restriction in singletons has been shown to enhance fetal lung maturation and reduce the risk of respiratory distress syndrome due to increased endogenous steroid production. However, data on lung maturation in growth-discordant monochorionic (thus, identical) twins are lacking. Our objective was to compare the risk of severe neonatal morbidity between the larger and the smaller twin in monochorionic twins with birth weight discordance (BWD). We included in the study all consecutive monochorionic diamniotic pregnancies with severe BWD (≥25%) and two live-born twins delivered at our center (n=47 twin pairs). We compared the incidence of neonatal morbidity, particularly respiratory distress syndrome (RDS), and cerebral lesions between the larger and the smaller co-twin. The incidence of severe neonatal morbidity in the larger and smaller twin was 38% (18/47) and 19% (9/47), respectively (odds ratio (OR) 2.66, 95% confidence interval (CI) 0.94-7.44) and was due primarily to the higher incidence of RDS, 32% (15/47) and 6% (3/47), respectively (OR 6.88, 95% CI 1.66-32.83). In conclusion, this study shows that the larger twin in monochorionic twin pairs with BWD is at increased risk of severe neonatal morbidity, particularly RDS, compared to the smaller twin.

Delivery of Monochorionic Twins in the Absence of Complications

Objective We sought to estimate the optimal time to deliver uncomplicated monochorionic-diamnionic (MCDA) twins. Study Design Data were retrospectively obtained from twin pregnancies from 2000 through 2009. The gestational week–specific prospective perinatal mortality risk was calculated. A cohort of MCDA twins with nonindicated deliveries was analyzed separately. Neonatal outcomes and costs were compared between MCDA twins with nonindicated deliveries born at specific weeks of gestation, and those born the subsequent week. Results There were 5894 dichorionic-diamnionic twins and 1704 MCDA twins. After 28 weeks, the gestational week–specific prospective risk of perinatal mortality did not differ between groups. There were 948 MCDA twins with nonindicated deliveries. Until 37 weeks, the risk of severe neonatal morbidity, perinatal mortality, and hospital costs were greater for fetuses delivered compared to fetuses born in a subsequent week. Conclusion To optimize neonatal outcome and decrease hospital costs, MCDA twins should not be delivered

Delivery of monochorionic twins in the absence of complications: analysis of neonatal outcomes and costs

We sought to estimate the optimal time to deliver uncomplicated monochorionic-diamnionic (MCDA) twins. Data were retrospectively obtained from twin pregnancies from 2000 through 2009. The gestational week-specific prospective perinatal mortality risk was calculated. A cohort of MCDA twins with nonindicated deliveries was analyzed separately. Neonatal outcomes and costs were compared between MCDA twins with nonindicated deliveries born at specific weeks of gestation, and those born the subsequent week. There were 5894 dichorionic-diamnionic twins and 1704 MCDA twins. After 28 weeks, the gestational week-specific prospective risk of perinatal mortality did not differ between groups. There were 948 MCDA twins with nonindicated deliveries. Until 37 weeks, the risk of severe neonatal morbidity, perinatal mortality, and hospital costs were greater for fetuses delivered compared to fetuses born in a subsequent week. To optimize neonatal outcome and decrease hospital costs, MCDA twins should not be delivered <37 weeks unless medically indicated.

Quel risque néonatal pour les grossesses à bas risque : implications pédiatriques pour l'organisation des maisons de naissance ?

Aim This study was designed to identify pregnant women at low risk for severe neonatal morbidity. This population should apply for delivery in birth centers. Population and methods This study was retrospective and included all livebirths in Burgundy over a 4-year period. Fifteen obstetric criteria recorded in the regional perinatal database were used to select pregnant women at low risk for severe neonatal morbidity. Incidence of severe neonatal morbidity in the low and high risk groups was assessed from the following markers: postnatal death; severe neurological conditions (ischemic encephalopathy, seizures, meningitis, intraventricular hemorrhage stage 3–4 and cystic periventricular leukomalacia in preterm infants) ; tracheal intubation ; hospitalization in neonatal intensive care unit. Results The incidence of severe neonatal morbidity was significantly different ( P < 0.0001) in the low risk group (0.34% [IC 95%: 0.29–0.40]; N = 46 345) as compared with the high risk group (5.6% [IC 95%: 5.3–5.9]; N = 24 961). The main neonatal diseases in the low risk group were: respiratory diseases (29.8%); congenital heart diseases (17.9%) and perinatal asphyxia (15.3%). Conclusion Even though the low risk criteria were associated with a low incidence of severe neonatal morbidity, residual morbidity should be considered in organization of birth centers in France.

The Need to Go Beyond: Evaluating Antenatal Corticosteroid Trials With Long-Term Outcomes

A single course of antenatal corticosteroids (ACS) reduces the risk of severe neonatal morbidity and is associated with a strong trend towards a reduced risk of abnormal neurodevelopmental outcome. However, because 50% of women given ACS remain undelivered and continue to be at risk for preterm delivery, the question remains: would these women benefit from repeated courses of ACS, and, if so, how do repeated courses of ACS affect the fetus and long-term neurodevelopmental outcome? The serious consequences of this effect on the developing brain justify the need for long-term outcome studies (beyond two years of age) before repeat courses of ACS become standard care in the management of pregnant women who are at risk of preterm delivery throughout pregnancy.