Severe Neonatal Morbidity Research Articles

Perinatal and neonatal outcomes of women with very early preterm premature rupture of membranes treated via serial transabdominal amnioinfusion and expectant management: Experience of a tertiary referral center in Turkey.

We compared the outcomes of serial transabdominal amnioinfusion and expectant management on the perinatal and neonatal outcomes of pregnancies complicated with very early preterm premature rupture of membranes (PPROM). We retrospectively reviewed the records of patients with very early PPROM admitted to the University of Inonu School of Medicine from 2014 to 2019. All such patients received comprehensive counseling on the possible prognoses; all were offered pregnancy termination, expectant management, and serial transabdominal infusion. Sixty-three women met the inclusion criteria; 36 were assigned to the expectant management group and 27 were assigned to the amnioinfusion group. The median delivery latency and the gestational age at delivery were significantly higher in the amnioinfusion than the expectant management group [35 (11-90), 14 (7-48), p < 0.001; 27.6 (22.1-34.0), 22.3 (19.0-26.5), p <0.001, respectively]. Serial transabdominal amnioinfusion was associated with significantly less neonatal mortality than expectant management (29.6 vs 83.3%, p <0.001). Multivariate binary logistic regression showed that the odds of neonatal mortality were 6.12 times higher among neonates in the expectant management group compared to that of the serial transabdominal amnioinfusion group after adjusting for potential confounders. Severe neonatal morbidities were significantly more common in the expectant management group than in the amnioinfusion group (p =0.011). The present study has demonstrated a significant positive effect of serial transabdominal amnioinfusion procedure on latency period and neonatal morbidity and mortality in pregnant women complicated with very early PPROM.

Sensitivity of Broadened Definition of Fetal Growth Restriction in Predicting Adverse Neonatal Outcomes [A342

INTRODUCTION: In 2020 the Society for Maternal-Fetal Medicine suggested broadening the fetal growth restriction (FGR) definition to include fetuses with isolated abdominal circumference (AC) less than 10th percentile. The purpose of this study was to determine if including these fetuses improves prediction of severe neonatal morbidity and mortality. METHODS: This is a retrospective analysis of births over the past 10 years within a hospital system affiliated with the University of Minnesota. A pregnancy was included if prenatal ultrasound data were available after 24 weeks gestation. Excluded were non-singletons and fetuses with diagnosis of structural or genetic abnormalities that could affect biometry measurements. Fetuses were categorized as FGR based on the prior definition (estimated fetal weight [EFW] less than 10th percentile) and on the proposed definition of EFW or AC less than 10th percentile. Institutional review board approval was obtained from the University of Minnesota (ID 00011238). RESULTS: A total of 26,526 births met inclusion criteria. The mean gestational age at birth was 39 weeks (SD 0.2). The rate of severe morbidity (e.g., severe acidosis, hypoxic ischemic encephalopathy, and sepsis) and mortality for those with EFW less than 10th percentile was 9.3% (odds ratio [OR] 3.6, P&lt;.001) and 2.8% (OR 26.1, P&lt;.001), respectively. For those with EFW or AC less than 10th percentile, rates were 6% (OR 2.3, P&lt;.001) and 1.5% (OR 15.0, P&lt;.001), respectively. CONCLUSION: Broadening the definition unsurprisingly increased the frequency of FGR, but frequency of adverse outcomes was lower. Thus, this analysis does not support the addition of isolated AC less than 10th percentile to the FGR definition.

Homeostatic cytokines regulate the emergence of human prenatal effector T cells.

Abstract In a healthy pregnancy, prenatal immunity promotes tolerance in utero and transitions to provide protective immunity after birth. In pathologic pregnancies, in utero immune activation and the ensuing fetal inflammatory response are predictive of severe neonatal morbidity and mortality. We previously demonstrated that the majority of prenatal intestinal memory CD4 T cells express the transcription factor PLZF and possess a heightened Th1 effector potential. These PLZF+ CD4+ T cells specifically accumulate in the intestine, are absent from the adult, and are enriched in the cord blood of infants exposed to in utero inflammatory pathology. However, the signals that drive their intestinal accumulation and maturation are not well understood. We show that PLZF+ CD4+ T cells are MHC Class II restricted and display tissue specific functional heterogeneity, including Th2-, Th22- and Th17-like capacities. We provide evidence that differences in homeostatic cytokines between the small intestine and mesenteric lymph node support the preferential accumulation and functional compartmentalization of prenatal PLZF+ CD4+ T cells. Specifically, we show that IL-7 and TGFβ reciprocally modulate the preferential expansion and functional maturation of PLZF+ CD4+ T cells. We provide evidence for the generation of both virtual memory T cells as well as classic antigen driven differentiation of Th1- and Th17-like effector PLZF+ CD4+ T cells. This work identifies critical mechanisms of human prenatal immune maturation and regulation and could inform the development of novel therapeutic strategies to address perinatal inflammatory pathologies. Supported by K08 Mentored Clinical Scientist Development Award (AI128007) to Joanna Halkias and the Burroughs Wellcome Fund Preterm Birth Initiative (1019828)

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.

Neonatal morbidity and mortality for preterm in breech presentation regarding the onset mode of labor.

To assess severe neonatal morbidity and mortality in induced labor in preterm breech deliveries, compared to spontaneous labor. This is a retrospective study conducted in a tertiary university center in France. Women with single live breech pregnancy between 28 + 0 and 36 + 6weeks gestation were included. We excluded situations with medical contraindication to vaginal delivery and fetal malformations. We compared women with an unfavorable cervix, who had an indication for deliver and could receive cervical ripening to induce labor, to women in spontaneous labor. The primary outcome was a composite criterion of severe neonatal morbidity and mortality including perinatal death, traumatic event during delivery, Apgar score at 5-min < 4, moderate or severe encephalopathy, seizures within the first 24h, Intra-Ventricular Hemorrhage grade 3 or 4, necrotizing enterocolitis grade 2 or 3. We included 212 patients: 64 in the induced labor group and 136 in the spontaneous labor group. In the induced labor group, 45.3% of patients delivered vaginally, and 86% in spontaneous labor group. The neonatal morbidity and mortality rate were similar in both groups: 4.7% in the induced labor group, and 5.2% in the spontaneous labor group, p = 0.889, aOR = 1.5 (0.28-8.28). Nearly half of the patient who received induction of labor delivered vaginally. The onset mode of labor does not appear to have an effect on severe neonatal morbidity and mortality in preterm breech fetuses. Induction of labor could be an option for patients in this setting.

National cohort of infants born before 24 gestational weeks showed increased survival rates but no improvement in neonatal morbidity.

Aim:To describe survival and neonatal morbidities in infants born before 24 weeks of gestation during a 12-year period.Methods:Data were retrieved from national registries and validated in medical files of infants born before 24 weeks of gestation 2007–2018 in Sweden. Temporal changes were evaluated.Results:In 2007–2018, 282 live births were recorded at 22 weeks and 460 at 23 weeks of gestation. Survival to discharge from hospital of infants born alive at 22 and 23 weeks increased from 20% to 38% (p = 0.006) and from 45% to 67% (p < 0.001) respectively. Caesarean section increased from 12% to 22% (p = 0.038) for infants born at 22 weeks. Neonatal morbidity rates in infants alive at 40 weeks of postmenstrual age (n = 399) were unchanged except for an increase in necrotising enterocolitis from 0 to 33% (p = 0.017) in infants born at 22 weeks of gestation. Bronchopulmonary dysplasia was more common in boys than girls, 90% versus 82% (p = 0.044). The number of infants surviving to 40 weeks doubled over time.Conclusion:Increased survival of infants born before 24 weeks of gestation resulted in increasing numbers of very immature infants with severe neonatal morbidities likely to have a negative impact on long-term outcome.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery.

To assess severe short-term maternal and neonatal morbidity and pelvic floor disorders at 6 months postpartum after attempted operative vaginal delivery according to the instrument used. We conducted a prospective study of women with live, singleton, term fetuses in vertex presentation. Patients attempted operative vaginal delivery in a French tertiary care university hospital from December 2008 through October 2013. We used multivariable logistic regression and propensity score methods to control for indication bias and compare outcomes associated with vacuum-assisted or forceps- or spatula-assisted delivery. Severe maternal and neonatal morbidity were composite primary endpoints. Symptoms of urinary incontinence (UI) and anal incontinence (AI) were assessed 6 months after delivery by validated self-administered questionnaires. Among 2,128 attempted operative vaginal deliveries, 30.7% (n=654) used vacuum and 69.3% (n=1,474) used forceps or spatulas. Severe maternal morbidity occurred in 5.4% (n=35; 95% CI 3.8-7.4) of vacuum attempts and 10.5% (n=154; 95% CI 8.3-12.1) of forceps or spatula attempts (P<.001); severe neonatal morbidity occurred in 8.4% (n=55; 95% CI 6.4-10.8) and 10.2% (n=155; 95% CI 8.7-11.8), respectively (P=.2). Although attempted operative vaginal deliveries with forceps or spatula were significantly associated with more frequent severe maternal morbidity (adjusted odds ratio [aOR] 1.99 95% CI 1.27-3.10) in the multivariable logistic regression analysis, this association was no longer significant after propensity score matching (aOR 1.46 95% CI 0.72-2.95). Attempted operative vaginal deliveries with forceps or spatula were not significantly associated with more frequent severe neonatal morbidity after multivariable logistic regression or propensity score matching. Among the 934 women (43.9%) who responded to questionnaires at 6 months, the prevalence of symptoms of UI and AI were 22.7% and 22.0%, respectively, with no significant differences between the groups. In singleton term pregnancies, neither severe short-term maternal or neonatal morbidity nor UI or AI were more frequent after attempted operative vaginal delivery by forceps or spatulas than by vacuum after controlling for indication bias with a propensity score analysis.

Association Between Residential Proximity to Hydraulic Fracturing Sites and Adverse Birth Outcomes

The association between hydraulic fracturing and human development is not well understood. Several studies have identified significant associations between unconventional natural gas development and adverse birth outcomes; however, geology and legislation vary between regions. To examine the overall association between residential proximity to hydraulic fracturing sites and adverse birth outcomes, and investigate whether well density influenced this association. This population-based retrospective cohort study of pregnant individuals in rural Alberta, Canada, took place from 2013 to 2018. Participants included reproductive-aged individuals (18-50 years) who had a pregnancy from January 1, 2013, to December 31, 2018, and lived in rural areas. Individuals were excluded if they lived in an urban setting, were outside of the age range, or were missing data on infant sex, postal code, or area-level socioeconomic status. Oil and gas wells that underwent hydraulic fracturing between 2013 to 2018 were identified through the Alberta Energy Regulator (n = 4871). Individuals were considered exposed if their postal delivery point was located within 10 km of 1 or more wells that was hydraulically fractured during 1 year preconception or during pregnancy. Outcomes investigated were spontaneous and indicated preterm birth, small for gestational age, major congenital anomalies, and severe neonatal morbidity or mortality. After exclusions, the sample included 26 193 individuals with 34 873 unique pregnancies, and a mean (SD) parental age of 28.2 (5.2) years. Small for gestational age and major congenital anomalies were significantly higher for individuals who lived within 10 km of at least 1 hydraulically fractured well after adjusting for parental age at delivery, multiple births, fetal sex, obstetric comorbidities, and area-level socioeconomic status. Risk of spontaneous preterm birth and small for gestational age were significantly increased in those with 100 or more wells within 10 km. Results suggest that individuals who were exposed to hydraulic fracturing within pregnancy may be at higher risk of several adverse birth outcomes. These results may be relevant to health policy regarding legislation of unconventional oil and gas development in Canada and internationally.

Model for severe intracranial hemorrhage and role of early indomethacin in extreme preterm infants.

To develop a model for prediction of severe intracranial hemorrhage (ICH) or death based on variables from the first 12 h of age and to compare mortality and morbidities with and without exposure to early indomethacin. This retrospective cohort study included extreme preterm (220/7-266/7 weeks) infants born at National Institute of Child Health and Human Development Neonatal Research Network sites. Primary outcome was a composite of severe ICH and/or death. Of 4624 infants, 1827 received early indomethacin. Lower gestation, lack of antenatal steroids exposure, lower 1-min Apgar, male sex, and receipt of epinephrine were associated with severe ICH or death. Early indomethacin was associated with a lower risk of patent ductus arteriosus, bronchopulmonary dysplasia, and higher risk of spontaneous intestinal perforation. A model for early prediction of severe ICH/death was developed and validated. Early indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of spontaneous intestinal perforation. Not applicable. Modern data on severe ICH and neonatal morbidities in relation to prophylactic indomethacin are scarce in the published literature. Prophylactic indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of intestinal perforation. A risk estimator for severe intracranial hemorrhage/death was developed in a large cohort of extremely preterm infants. The risk estimator developed based on a large cohort of patients provides an estimate of severe intracranial bleeding for an individual infant.

Neonatal outcome in vaginal breech labor at 32\u2009+\u20090\u201436\u2009+\u20090 weeks of gestation: a nationwide, population-based record linkage study

BackgroundIn many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries.DesignA retrospective register-based study.SettingMaternity hospitals in Finland, 2004–2017.ParticipantsThe study population included 762 preterm breech deliveries at 32 + 0—36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section.MethodsThe study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes.Outcome measuresNeonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes.ResultsA five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08–5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40–0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33–0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19–0.48).ConclusionVaginal breech labor at 32 + 0—36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.

Latent class analysis of placental histopathology: a novel approach to classifying early and late preterm births

Neonatal morbidity attributable to prematurity predominantly occurs among early preterm births (<32 weeks) rather than late preterm births (32 to <37 weeks). Methods to distinguish early and late preterm births are lacking given the heterogeneity in pathophysiology and risk factors, including maternal obesity. Although preterm births are often characterized by clinical presentation (spontaneous or clinically indicated), classifying deliveries by placental features detected on histopathology reports may help identify subgroups of preterm births with similar etiology and risk factors. Latent class analysis is an empirical approach to characterize preterm births on the basis of observed combinations of placental features. To identify histopathologic markers that can distinguish early (<32 weeks) and late preterm births (32 to <37 weeks) that are also associated with maternal obesity and neonatal outcomes. Women with a singleton preterm birth at University of Pittsburgh Medical Center Magee-Womens Hospital (Pittsburgh, PA) from 2008 to 2012 and a placental evaluation (89% of preterm births) were stratified into early (n=900, 61% spontaneous) and late preterm births (n=3362, 57% spontaneous). Prepregnancy body mass index was self-reported at first prenatal visit and 16 abstracted placental features were analyzed. Placental subgroups (ie, latent classes) of early and late preterm births were determined separately by latent class analysis of placental features. The optimal number of latent classes was selected by comparing fit statistics. The probability of latent class membership across prepregnancy body mass indexes was estimated in early preterm births and in late preterm births by an extension of multinomial regression called pseudo-class regression, adjusting for race, smoking, education, and parity. The frequencies of severe neonatal morbidity (composite outcome: respiratory distress, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, patent ductus arteriosus, and retinopathy of prematurity), small-for-gestational-age, and length of neonatal intensive care unit stay were compared across latent classes by chi-square and Kruskal-Wallis tests. Early preterm births were grouped into 4 latent classes based on placental histopathologic features: acute inflammation (38% of cases), maternal vascular malperfusion with inflammation (29%), maternal vascular malperfusion (25%), and fetal vascular thrombosis with hemorrhage (8%). As body mass index increased from 20 to 50kg/m2, the probability of maternal vascular malperfusion and fetal vascular thrombosis with hemorrhage increased, whereas the probability of maternal vascular malperfusion with inflammation decreased. There was minimal change in the probability of acute inflammation with increasing body mass index. Late preterm births also had 4 latent classes: maternal vascular malperfusion (22%), acute inflammation (12%), fetal vascular thrombosis with hemorrhage (9%), and low-risk pathology (58%). Body mass index was not associated with major changes in likelihood of the latent classes in late preterm births. Associations between body mass index and likelihood of the latent classes were not modified by type of delivery (spontaneous or indicated) in early or late preterm births. Maternal malperfusion and fetal vascular thrombosis with hemorrhage were associated with greater neonatal morbidity than the other latent classes in early and late preterm births. Obesity may predispose women to early but not late preterm birth through placental vascular impairment. Latent class analysis of placental histopathologic data provides an evidence-based approach to group preterm births with shared underlying etiology and risk factors.

Delivery mode and severe maternal and neonatal morbidity among singleton term breech births: A population-based cohort study

ObjectiveThe aim of this study was to examine the association between delivery mode and severe maternal and neonatal morbidity in singleton term breech births. Study designThis nationwide population-based cohort study includes 41 319 singleton term and post-term breech births (37 + 0–42 + 6 gestational weeks) in Sweden from 1998 to 2016. Data was retrieved from the Swedish Medical Birth Register. The primary outcomes were two separate composite outcomes, maternal and neonatal severe morbidity. Secondary outcomes were separate severe maternal and neonatal morbidity outcomes. Hospitalization and out-patient visits during childhood were also analyzed in ages 0–5 years. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI) of severe maternal and neonatal morbidity in women with vaginal breech birth or intrapartum cesarean section. Women with a prelabor breech cesarean section was used as the reference group. ResultsNo difference between vaginal delivery and prelabor cesarean section was seen regarding maternal morbidity. Intrapartum cesarean section was associated with elevated odds for maternal morbidity (aOR 1.27, 95% CI 1.10–1.47) compared with prelabor cesarean section. A similar result was observed for vaginal delivery and intrapartum cesarean section combined (aOR 1.29, 95% CI 1.11–1.50). Vaginal delivery was associated with higher odds for composite neonatal morbidity (aOR 1.85, CI 1.54–2.21) and most separate outcomes, as well as increased number of hospital nights and out-patient visits during first year of life, compared with prelabor cesarean section. ConclusionsPrelabor cesarean section in breech births improved short-term neonatal health without increasing risks for severe maternal short-term complications.

Individualized treatment of preterm premature rupture of membranes to prolong the latency period, reduce the rate of preterm birth, and improve neonatal outcomes

Preterm premature rupture of membranes complicates approximately 3% of pregnancies. Currently, in the absence of chorioamnionitis or placental abruption, expectant management, including antenatal steroids for lung maturation and prophylactic antibiotic treatment, is recommended. The benefits of individualized management have not been adequately explored. This study aimed to compare the impact of 2 different management strategies of preterm premature rupture of membranes in 2 tertiary obstetrical centers on latency of >7 days, latency to birth, chorioamnionitis, funisitis, and short-term adverse maternal and neonatal outcomes. This was a multicenter retrospective study of women with singleton pregnancies with preterm premature rupture of membranes from 23 0/7 to 33 6/7 weeks of gestation between 2014 and 2018 and undelivered within 24 hours after hospital admission managed at Sunnybrook Health Sciences Center, Toronto, Canada (standard management group), and BCNatal (Hospital Clínic of Barcelona and Hospital Sant Joan de Déu Barcelona), Barcelona, Spain (individualized management group), following local protocols. The standard management group received similar management for all patients, which included a standard antibiotic regimen and routine maternal and fetal surveillance, whereas the individualized management group received personalized management on the basis of amniocentesis at hospital admission (if possible), to rule out microbial invasion of the amniotic cavity and targeted treatment. The exclusion criteria were cervical dilatation >2 cm, active labor, contraindications to expectant management (acute chorioamnionitis, placental abruption, or abnormal fetal tracing), and major fetal anomalies. The primary outcome was latency of >7 days, and the secondary outcomes included latency to birth, chorioamnionitis, and short-term adverse maternal and neonatal outcomes. Statistical comparisons between groups were conducted with propensity score weighting. A total of 513 pregnancies with preterm premature rupture of membranes were included in this study: 324 patients received standard management, and 189 patients received individualized management, wherein amniocentesis was performed in 112 cases (59.3%). After propensity score weighting, patients receiving individualized management had a higher latency of >7 days (76.0% vs 41.6%; P<.001) and latency to birth (18.1±14.7 vs 9.7±9.7 days; P<.001). Although a higher rate of clinical chorioamnionitis was suspected in the individualized management group than the standard group (34.5% vs 22.0%; P<.01), there was no difference between the groups in terms of histologic chorioamnionitis (67.2% vs 73.4%; P=.16), funisitis (57.6% vs 58.1%; P=.92), or composite infectious maternal outcomes (9.1% vs 7.9%; P=.64). Prolonged latency in the individualized management group was associated with a significant reduction of preterm birth at <32 weeks of gestation (72.1% vs 90.5%; P<.001), neonatal intensive care unit admission (75.6% vs 83.0%; P=.046), and neonatal respiratory support at 28 days of life (16.1% vs 26.1%; P<.01) compared with that in the standard management group. Moreover, prolonged latency was not associated with neonatal severe morbidity at discharge (survival without severe morbidity, 80.4% vs 73.5%; P=.09). Individualized management of preterm premature rupture of membranes may prolong pregnancy and reduce preterm birth at <32 weeks of gestation, the need for neonatal support, and neonatal intensive care unit admissions, without an increase in histologic chorioamnionitis, funisitis, neonatal infection-related morbidity, and short-term adverse maternal and neonatal outcomes.

Reduced fetal urine production rate-An early marker of fetal inflammatory response syndrome in preterm premature rupture of membranes: Prospective cohort study.

To find association between fetal urine production rate (FUPR) and fetal inflammatory response syndrome (FIRS) in preterm premature rupture of membranes (PPROM). A prospective cohort study of 70 pregnant women with PPROM at 28-34weeks of pregnancy was conducted. FUPR was calculated by performing serial fetal bladder volume measurements ultrasonographically and was repeated weekly until delivery. After delivery, cord blood interleukin-6 (IL-6) levels were measured. Placental tissue histopathology was performed and neonatal outcomes were noted. Out of 70 recruited patients with PPROM, 44 had evidence of FIRS (62.86%). Mean FUPR at the time of delivery was significantly reduced in neonates with evidence of FIRS compared with the Non-FIRS group (13.89±8.06ml/h vs. 25.89±4.94ml/h). Out of 41 patients with reduced FUPR, 39 neonates had FIRS whereas only five out of 29 neonates with normal FUPR had FIRS (P<0.001). Severe neonatal morbidity was found in 24 out of 41 (58.54%) neonates with reduced FUPR prenatally. The occurrence of respiratory distress syndrome, necrotizing enterocolitis, and sepsis was significantly high in neonates with reduced FUPR. Reduced FUPR is strongly associated with FIRS in cases of PPROM and hence can be used as an early predictor of adverse neonatal outcomes.

Outcome of subsequent pregnancies in women with complete uterine rupture: A population-based case-control study.

In the attempt of a trial of labor after a cesarean section approximately one in 200 women experience a complete uterine rupture. As a complete uterine rupture is associated with an adverse perinatal outcome, data regarding subsequent pregnancies are needed to provide proper care and guidance to women with a complete uterine rupture when informing them of future possibilities. The objective of this study was to investigate the fetal and maternal outcomes in subsequent pregnancies after a complete uterine rupture. Retrospective population-based case-control study. Denmark 1997-2017. A total of 175 women with complete uterine rupture during an attempted trial of labor after cesarean (TOLAC) at term (cases) and a corresponding group of 272 women with no uterine rupture during an attempted TOLAC at term (controls) were labeled as index deliveries. Index deliveries were included from January 1, 1997 to December 31, 2008. From the date of the index delivery to December 31, 2017 the information on subsequent pregnancies and deliveries, and on referral to hospital with any obstetric or gynecological diagnosis were retrieved from the Danish Medical Birth Registry and National Patient Registry. Main outcome measures were miscarriage, perinatal death, neonatal morbidity, preterm birth, and recurrence of uterine rupture. Outcome measures were compared between cases and controls. After the index deliveries; there were 109 pregnancies and 70 deliveries after gestational age 22+0 weeks in the population of cases. In the population of controls, there were 183 pregnancies and 126 deliveries after 22+0 weeks. Cases had a significantly higher risk of miscarriage (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.36-13.17). The incidence of uterine rupture was 8.6% among cases and 0.8% among controls (OR 11.7; 95% CI 1.36-543.1). Among cases, 98.6% had live-born infants, and none of these had severe neonatal morbidity. No significant association was found between previous complete uterine rupture and preterm delivery, placenta previa, hysterectomy in relation to subsequent births, diagnosis such as meno/metrorrhagia, dysmenorrhea, or procedures such as hysteroscopy or hysterectomy. In pregnancies following complete uterine rupture continuing after 22+0 weeks, maternal and fetal outcomes are good when managed promptly with cesarean delivery.

Neonatal Outcome in Twin-to-Twin Transfusion Syndrome Not Treated with Fetoscopic Laser Surgery

AbstractThe aim of this study was to describe the neonatal management and outcome in monochorionic twins with twin-to-twin transfusion syndrome (TTTS) not treated with fetoscopic laser surgery. All consecutive live-born neonates with TTTS managed at our center between 2002 and 2021 were included in this retrospective study. Neonatal outcome was assessed in 44 twin pairs with TTTS not treated with laser (nonlaser group) compared to a control group of 88 twin pairs with TTTS successfully treated with laser (laser group), matched for gestational age at birth. Primary outcome was adverse neonatal outcome, a composite outcome including neonatal mortality or severe neonatal morbidity. The incidence of adverse neonatal outcome in the nonlaser group and laser group was 30% (26/88) and 11% (19/176), respectively (relative risk = 3.46, 95% CI [1.79, 6.71]). In the nonlaser group, 11% had necrotizing enterocolitis (vs. 2% in the laser group) and 24% had hypotension (vs. 10% in the laser group). Recipients in the nonlaser group had, compared to recipients in the laser group, significantly more severe cerebral injury (18% vs. 5%) and more polycythemia at birth (21% vs. 1%). Donors in the nonlaser group had, compared to donors in the laser group, more severe growth restriction (71% vs 42%), renal failure (11% vs 1%), and anemia at birth (25% vs. 7%). Thus, the risk for neonatal mortality and/or severe morbidity is three-fold higher in TTTS not treated with laser than in TTTS treated with laser, which highlights the fact that these neonates with TTTS are very sick at birth, requiring accurate and prompt intensive treatment.

Impact of COVID-19-Related Lockdown on Delivery and Perinatal Outcomes: A Retrospective Cohort Study.

Objective: The magnitude and direction of effects on pregnancy outcomes of the lockdown imposed during COVID-19 have been uncertain and debated. Therefore, we aimed to quantify delivery and perinatal outcomes during the first nationwide lockdown due to the COVID-19 pandemic compared with the same durations of time for the pre- and post-lockdown periods. Study design: This was a retrospective cohort study of six university hospital maternity units distributed across France, each of which serves as the obstetric care referral unit within its respective perinatal network. Maternal and perinatal outcomes were compared between the lockdown period and same-duration (i.e., 55-day) periods before and after the 2020 lockdown (pre-lockdown: 22 January–16 March; lockdown: 17 March–10 May; post-lockdown: 11 May–4 July). We compared the overall rates of Caesarean delivery (CD), pre-labor CD, labor induction, operative vaginal delivery, severe postpartum hemorrhage (≥1 L), severe perineal tear, maternal transfusion, and neonatal mortality and morbidity (1- and 5-min Apgar scores < 7), hypoxia and anoxia (umbilical arterial pH < 7.20 or <7.10, respectively), and admission to a neonatal intensive care unit before discharge. Adjusted odds ratios were estimated using logistic regression, controlling for region of birth, maternal age category, multiparity, multiple pregnancies, diabetes, and hypertensive disorders. Results: The study sample consisted of 11,929 women who delivered consecutively at one of the six maternity units studied (4093 pre-lockdown, 3829 during lockdown, and 4007 post-lockdown) and their 12,179 neonates (4169 pre-lockdown, 3905 during lockdown, and 4105 post-lockdown). The maternal and obstetric characteristics of the women delivering during the lockdown period were alike those delivering pre- and post-lockdown on maternal age, parity, body mass index, rate of complication by hypertensive disorders or insulin-treated diabetes, and gestational age at delivery. Overall CD rates were similar during the three periods (23.6%, 24.8%, and 24.3% pre-lockdown, lockdown, and post-lockdown, respectively) and no outcome differed significantly during lockdown compared to pre- and post-lockdown. These findings were consistent across maternity units. Conclusion: The maternal and perinatal outcomes are reassuring regarding the performance of the health-care system during the COVID-19 lockdown studied. Such information is crucial, because additional COVID-19-related lockdowns might still be needed. They are also instructive regarding potential future pandemics.

Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31weeks' gestation: Perinatal and 2-year outcomes in the EPIPAGE-2 cohort.

ObjectiveTo compare different antibiotic prophylaxis administered after preterm premature rupture of membranes to determine whether any were associated with differences in obstetric and/or neonatal outcomes and/or neurodevelopmental outcomes at 2 years of corrected age.DesignProspective, nationwide, population‐based EPIPAGE‐2 cohort study of preterm infants.SettingFrance, 2011.SampleWe included 492 women with a singleton pregnancy and a diagnosis of preterm premature rupture of membranes at 24–31 weeks. Exclusion criteria were contraindication to expectant management or indication for antibiotic therapy other than preterm premature rupture of membranes. Antibiotic prophylaxis was categorised as amoxicillin (n = 345), macrolide (n = 30), third‐generation cephalosporin (n = 45) or any combinations covering Streptococcus agalactiae and >90% of Escherichia coli (n = 72), initiated within 24 hours after preterm premature rupture of membranes.MethodsPopulation‐averaged robust Poisson models.Main Outcome MeasuresSurvival at discharge without severe neonatal morbidity, 2‐year neurodevelopment.ResultsWith amoxicillin, macrolide, third‐generation cephalosporin and combinations, 78.5%, 83.9%, 93.6% and 86.0% of neonates were discharged alive without severe morbidity. The administration of third‐generation cephalosporin or any E. coli‐targeting combinations was associated with improved survival without severe morbidity (adjusted risk ratio 1.25 [95% confidence interval 1.08–1.45] and 1.10 [95 % confidence interval 1.01–1.20], respectively) compared with amoxicillin. We evidenced no increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen.ConclusionIn preterm premature rupture of membranes at 24–31 weeks, antibiotic prophylaxis based on third‐generation cephalosporin may be associated with improved survival without severe neonatal morbidity when compared with amoxicillin, with no evidence of increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen.Tweetable Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes.

Survival Without Severe Neonatal Morbidity in Very Preterm Twins According to Planned Mode of Delivery.

To assess survival to discharge without severe neonatal morbidity by planned mode of delivery for twins born before 32 weeks of gestation. The JUMODA (JUmeaux MODe d'Accouchement) study was a French national prospective, population-based, cohort study of twin deliveries conducted from February 2014 to March 2015. This planned secondary analysis included diamniotic twin pregnancies from 26 0/7 through 31 6/7 weeks of gestation. Exclusion criteria included contraindications to vaginal delivery and situations for which planned cesarean delivery is favored, and neonatal prognosis depends largely on the underlying pathology rather than the planned mode of delivery. The primary outcome was survival to discharge without severe neonatal morbidity (bronchopulmonary dysplasia, grade 3 or grade 4 intraventricular hemorrhage, periventricular leukomalacia, stage 2 or stage 3 necrotizing enterocolitis). The association between planned mode of delivery and primary outcome was assessed by multivariate Poisson regression model. A propensity-score approach with inverse probability of treatment weighting also was performed to control for indication bias. Subgroup analyses according to birth order and sensitivity analyses limited to spontaneous preterm births only were performed. Among 424 very preterm twin pregnancies, 192 (45.3%) had a planned cesarean delivery and 232 (54.7%) had a planned vaginal delivery. Survival to discharge without severe morbidity did not differ in the two groups: 308 of 384 (80.2%) after planned cesarean and 375 of 464 (80.8%) after planned vaginal delivery (crude relative risk 0.99; 95% CI 0.91-1.15; adjusted relative risk 1.02; 95% CI 0.93-1.11). After applying inverse probability of treatment weighting, planned cesarean delivery still was not associated with higher survival to discharge without severe neonatal morbidity than planned vaginal birth (relative risk 1.11; 95% CI 0.84-1.46). Subgroup and sensitivity analyses showed similar results. Planned cesarean delivery for very preterm twins is not associated with higher survival to discharge without severe neonatal morbidity than planned vaginal delivery. These results suggest that very preterm delivery should not be considered a per se indication for planned cesarean in twin pregnancies.

Impact of daily oral anti-hypertensives on neonatal outcomes in superimposed severe pre-eclampsia before 34 weeks

In patients with chronic hypertension (cHTN) subsequently diagnosed with superimposed severe preeclampsia by blood pressure (sPreBP) before 34 weeks, the association of preceding daily oral antihypertensive (OAH) use with severe neonatal morbidity is unclear. The objective of this study was to investigate this further