- Preclosure Fluid Resuscitation Influences Outcome in Gastroschisis
Optimal preclosure fluid resuscitation in gastroschisis (GS) is unknown. The purpose of our study was to evaluate effects of preclosure intravenous fluid resuscitation on GS outcome. Cases were accrued from a national GS database. Risk variables analyzed included gestational age (GA), birth weight (BW), neonatal illness severity score, and bolus fluid administration within 6 hours of neonatal intensive care unit admission. Outcomes analyzed included closure success, days of ventilation/total parenteral nutrition (TPN), and bacteremic episodes. Linear and logistic regression analyses were performed. Four hundred seven live-born GS cases were identified (362 with complete resuscitative fluids data). Mean BW, GA, and Score for Neonatal Acute Physiology-II score were 2562 ± 539 g, 36.17 ± 1.95 weeks, and 9.97 ± 12.65, respectively. One hundred sixty-two patients received no supplemental fluid, and 200 patients received a mean of 21.49 (0.81 to 134.81) mL/kg of intravenous fluid. Multivariate outcomes analyses demonstrated a significant, direct relationship between resuscitative volume and days of postclosure ventilation, TPN, length of hospital stay, and bacteremic episodes; specifically, every 17 mL/kg of fluid predicted one additional ventilation day (p = 0.002), TPN day (p = 0.01), and hospital day (p = 0.01) and 0.02 odds increase of an episode of bacteremia (p = 0.03). Judicious, preclosure fluid resuscitation is essential in early GS management. Excessive fluid is associated with several adverse survival outcomes.
- Blunted Heart Rate Circadian Rhythms in Small for Gestational Age Infants during the Early Neonatal Period
Infants born with intrauterine growth restriction are at increased risk for adverse cardiovascular outcomes in neonatal and later life. Although circadian rhythm is a prognostic marker of cardiovascular health, the concern over the circadian rhythm of these infants is rarely observed. To determine the influence of intrauterine growth retardation on the pattern of circadian rhythm, heart rate (HR) circadian rhythmicity was analyzed in 39 small for gestational age (SGA; birth weight and height below <−2.0 standard deviation score [SDS]) and 117 appropriate for gestational age (AGA; >−1.5 to <1.5 SDS) infants within 72 hours of birth using spectral analysis and cosinor analysis. Amplitude, midline estimating statistic of rhythm, and acrophase calculated from circadian rhythm were analyzed with clinical variables. A significant HR circadian rhythm was observed in 23.1% of the SGA and 24.8% of the AGA group without significant differences; however, SGA infants exhibited remarkable smaller amplitudes compared with AGA in all gestational age (GA) groups (p < 0.001). Amplitudes in AGA infants were positively correlated with the GA or body composition relevant variables (p < 0.001, respectively), but not SGA infants. The blunted HR circadian rhythmicity in SGA infants showed in this study might indicate the vulnerability to pathophysiological condition and could potentially refer to cardiovascular disease in later life.
- Sleep-Disordered Breathing: A Risk Factor for Adverse Pregnancy Outcomes?
In nonpregnant populations, sleep-disordered breathing (SDB) has been associated with cardiovascular and metabolic disease. Few studies have examined the relationship between SDB and adverse pregnancy outcomes (APO). The objective of this study was to examine the association between SDB and APO. Women who had a delivery as well as an in-laboratory polysomnogram (PSG) were identified. Demographics, PSG results, and pregnancy outcomes were abstracted from the medical record. Absence of SDB was defined as an apnea hypopnea index (AHI) of <5, mild SDB as an AHI of 5 to 14.9, and moderate to severe SDB as an AHI of ≥15. The primary outcome was a composite measure of APO: pregnancy-related hypertension, gestational diabetes, or preterm birth ≤34 weeks. We identified 143 women who had undergone a PSG and a delivery. Increasing severity of SDB was associated with an increasing risk of the composite APO: AHI <5, 18.1%; AHI 5 to 14.9, 23.5%; AHI ≥15, 38.5% (p = 0.038). Obese women (body mass index ≥30) with moderate to severe SDB had the highest rate of APO, 41.7%. SDB, especially moderate to severe disease, may be associated with APO. However, it is unclear if SDB is a risk factor for APO independent of obesity.
- Early Fetal Echocardiography: Ready for Prime Time?
The objective of this study was to examine the performance of early fetal echocardiography as a screening tool for major cardiac defects in a high-risk population. Fetal echocardiograms performed at 12 to 16 weeks were reviewed. Cases that did not undergo a follow-up echocardiogram at 18 to 22 weeks were excluded. Results of the early and follow-up echocardiograms were compared. Over a 4-year period, 119 early fetal echocardiograms were recorded. Of those, 81 (68%) had follow-up fetal echocardiograms. Results of the early echocardiogram were normal in 77 of 81 (95.1%) cases. Of these, the follow-up was normal in 75 of these 77 cases; in the remaining 2, the follow-up raised suspicion for a ventricular septal defect (VSD) in one and persistent left superior vena cava in the other. On the other hand, the early echocardiogram was abnormal in 4 (4.9%) cases: (1) atrioventricular canal defect, with the follow-up demonstrating a VSD; (2) hypoplastic right ventricle and transposition of the great arteries, confirmed on follow-up; (3) VSD and coarctation of the aorta, confirmed on follow-up. In the fourth case, the early echocardiogram suspected a VSD and right-left disproportion, yet the follow-up was normal. In conclusion, early fetal echocardiography appears to be a reasonable screening tool for major cardiac defects.
- The Interaction Effect of Bacterial Vaginosis and Periodontal Disease on the Risk of Preterm Delivery
The objective of this article is to determine if coexistence of periodontal disease (PD) and bacterial vaginosis (BV) is synergistic on the risk of spontaneous preterm delivery (sPTD). The study design was secondary analysis of a prospective cohort study. Women were screened 6 to 20 weeks gestation for PD and BV. Groups were defined by presence of BV and stratified on PD. The primary outcome was sPTD <37 weeks gestation. Univariable, stratified, and multivariable analyses were performed to estimate the main and interaction effects of BV and PD on sPTD. Of 1453 women screened, 792 (54.5%) were diagnosed with BV. Neither women with BV in the first trimester nor PD was at higher risk of sPTD (risk ratio [RR] for BV 1.1; 95% confidence interval (CI), 0.8–1.5, and RR for PD 0.9; 95% CI, 0.7–1.3). The interaction between BV and PD did not statistically significantly impact the odds of sPTD. Coexistence of PD and BV did not have a synergistic effect on sPTD.
- Low HCMV DNA Copies Can Establish Infection and Result in Significant Symptoms in Extremely Preterm Infants: A Prospective Study
Breast milk (BM) is the main source of human cytomegalovirus (HCMV) infection. We examined whether the number of HCMV DNA copies in BM is related to HCMV infection in very low birth weight (VLBW) infants. We identified 11 pairs of VLBW infants and mothers. BM samples were collected every week until 10 weeks postpartum. Urine samples were collected from the infants within 1 week, at 6 to 8 weeks, at discharge, and whenever HCMV infection was suspected. HCMV DNA in BM was positive in 7 of 11 mothers and reached a peak at 4 to 5 weeks postpartum. Of the 11, 5 infants were determined to be infected from positive HCMV DNA in the urine, despite the fact that BM was used after being frozen. Of the five, four infected infants exhibited symptoms between 35 and 60 days of age. Symptomatic infants had longer stays and slower weight gain. The HCMV infection rate is high in very preterm infants. A new strategy to prevent HCMV infection other than freezing should therefore be established.
- Acid-Base Parameters for Predicting Magnetic Resonance Imaging Measures of Neurologic Outcome after Perinatal Hypoxia-Ischemia: Is the Strong Ion Gap Superior to Base Excess and Lactate?
We conducted this study to compare the strong ion gap (SIG) with base excess (BE) and lactate for predicting neurologic outcome measured by magnetic resonance imaging (MRI) in newborns with hypoxic-ischemic encephalopathy (HIE). In a retrospective cohort of 39 newborns with HIE treated with whole-body surface cooling (n = 17) and no cooling (n = 22), we measured blood SIG, BE, and lactate at 4, 24, and 48 hours after birth, and determined cerebral injury severity by T1-, T2-, and diffusion-weighted MRI scores at age 5 days. Lower SIG levels correlated with better neurologic outcome. The highest correlation coefficient (0.63) was in the “no cooling” subcohort between diffusion-weighted scores and SIG levels at 24 hours; the latter also had the highest area under the receiver operating characteristic curve (AUC), 0.90, with positive and negative predictive values of 84 and 90%. SIG outperformed lactate in the “no cooling” subcohort, and vice-versa in the “cooling” subcohort. All BE AUCs were <0.6. Overall, the SIG is similar to lactate as a prognostic parameter. BE levels at 4, 24, and 48 hours after birth do not predict neurologic outcome. While not displacing lactate the SIG is an additional prognostic parameter for newborns in the first 2 days after hypoxia-ischemia.
- Type of Skin Incision and Wound Complications in the Obese Parturient
We examined the relationship between type of skin incision at time of cesarean delivery and postoperative wound complications in the obese parturient. Women with a body mass index (BMI) of greater than 29 who had undergone cesarean delivery at The University of North Carolina were identified from the Pregnancy, Infection and Nutrition study. Inpatient and outpatient medical records were reviewed for maternal demographics as well as intrapartum and intraoperative characteristics. The exposure of interest was type of incision, classified as vertical or transverse. The primary outcome was wound complication, defined as partial or complete wound separation. Logistic regression analysis was used to create a final model of risk factors for wound complications while controlling for potentially confounding variables. From 1998 to 2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a transverse skin incision in 213 (89%). The overall incidence of wound complications in this group was 13%. BMI was associated with wound complications (p < 0.01). After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding. Increased BMI is associated with a higher rate of wound complications.
- Continuous Glucose Monitoring in Diabetic Women Following Antenatal Corticosteroid Therapy: A Pilot Study
To compare the timing, duration, and severity of corticosteroid-associated hyperglycemia in pregnant women with and without diabetes mellitus (DM). An observational study was conducted of pregnant women with DM and controls who received corticosteroids. Median glucose levels were calculated over 4-hour intervals after the first dose of corticosteroid with a continuous glucose monitor. A glucose level increase of at least 15% above baseline was considered significant. Nine pregnant women participated in this study (six with DM and three without DM). Elevations of glucose levels occurred at hour 20, 44, and 68 in both groups and lasted for up to 4 hours. In those with DM, glucose levels increased 33 to 48%, whereas in those without DM, glucose levels rose 16 to 33%. Several, relatively short episodes of glucose elevation occur in response to corticosteroids, and are more pronounced in diabetic women.
- Therapeutic Hypothermia during Neonatal Transport: Current Practices in California
Therapeutic hypothermia initiated at <6 hours of age reduces death and disability in newborns ≥36 weeks’ gestation with moderate to severe hypoxic ischemic encephalopathy. Given the limited therapeutic window, cooling during transport becomes a necessity. Our goal was to describe the current practice of therapeutic hypothermia during transport used in the state of California. All level III neonatal intensive care units (NICUs) were contacted to identify those units providing therapeutic hypothermia. An electronic questionnaire was sent to obtain basic information. Responses were received from 28 (100%) NICUs performing therapeutic hypothermia; 26 NICUs were cooling newborns and two were in the process of program development. Eighteen (64%) centers had cooled a patient in transport, six had not yet cooled in transport, and two do not plan to cool in transport. All 18 centers use passive cooling, except for two that perform both passive and active cooling, and 17 of 18 centers recommend initiation of cooling at the referral hospital. Reported difficulties include overcooling, undercooling, and bradycardia. Cooling on transport is being performed by majority of NICUs providing therapeutic hypothermia. Clinical protocols and devices for cooling in transport are essential to ensure safety and efficacy.
- Hydrographic Magnetic Resonance Imaging of the Fetal Eye
Previous work has shown that fetal hydrographic magnetic resonance imaging (MRI) provided additional information complementary to T2-weighted single-shot fast spin echo (ssFSE) images. The objective of this study was to determine if hydrographic MRI provides better conspicuity of fetal eye structures compared with ssFSE MRI. ssFSE and hydrographic images were retrospectively examined in 82 consecutive fetal studies with normal central nervous system without sensitivity encoding. Relative signal intensity values on ssFSE and hydrographic MRI were obtained for vitreous and sclera. Ratios of the signal intensity of vitreous to the signal intensity of sclera were calculated to determine conspicuity. Similar measurements were obtained in a smaller separate data set (n = 41) using hydrographic imaging with sensitivity encoding techniques. The hydrographic images significantly demonstrated greater conspicuity (ratio of vitreous to sclera) than ssFSE images. This was consistent for both sensitivity encoding and no-sensitivity encoding groups. The difference in conspicuity was on average approximately two times greater in the hydrographic images compared with ssFSE images. Hydrographic MRI of the fetal eye provides on average two times greater conspicuity of fetal eye structures than ssFSE imaging. This enhancement is not affected by gestational age or the use of sensitivity encoding parallel imaging techniques.
- Twenty-four-Hour Ambulatory Blood Pressure Monitor Heart Rate: A Potential Marker for Gestational Hypertension in at-Risk Women
We prospectively correlated the 24-hour ambulatory blood pressure measurements (ABPM) to conventional sphygmomanometer blood pressure measurements (CSM) in women at risk for gestational hypertensive disorders (GHTNDs) and identified predictive factors from ABPM for GHTND. We analyzed 73 women with ≥1 risk factor for developing a GHTND. Using both the CSM and ABPM, the systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), and heart rate (HR) were measured for 24 hours during three periods (14 to 24 weeks; 24 to 32 weeks; and 33 weeks to delivery). Correlation between the CSM and ABPM lessened as pregnancy progressed. Seventeen (25%) of women developed a GHTND. MAP variability increased in the GHTND group versus those without a GHTND. The odds of developing a GHTND increased 1.5 times for every 1 beat per minute increase in the ABPM 24-hour HR at visit 1 and reversed by visit 3. In women at risk for a GHTND, CSM and ABPM correlate less well as pregnancy advances. HR changes in at-risk women may be a marker for the development of a GHTND and may reflect increased sympathetic activity and/or decreased baroreceptor sensitivity.
- The Timing of Antibiotics at Cesarean: A Randomized Controlled Trial
We compared maternal and neonatal outcomes in women who received prophylactic antibiotics prior to skin incision to those who received antibiotics at cord clamp. We performed a randomized clinical trial at two sites. Eligible women included those undergoing nonemergency cesarean at 36 weeks’ gestation or greater. Subjects were randomized (permuted blocks) into one of two treatments: “preoperative antibiotics” (cefazolin 1 g given <30 minutes prior to skin incision) or “intraoperative antibiotics” (cefazolin 1 g at cord clamping). Patients who reported an allergy to penicillin received clindamycin 900 mg. The trial primary outcome was a composite of maternal infectious morbidities, defined as having any one of the following: (1) postoperative fever (defined as oral temperature >38°C on two separate occasions more than 6 hours apart, after the initial 24-hour postoperative period); (2) wound infection (defined as purulent discharge from the incision); (3) endomyometritis (defined as fundal tenderness and fever malodorous lochia, fever); (4) urinary tract infection (defined as fever, positive urine culture). We enrolled a total of 434 subjects in this study, with 217 in each group. Overall, we found no difference in composite maternal infectious morbidity between those who received antibiotics preoperatively and those who received antibiotics at cord clamp (relative risk = 1.2, 95% confidence interval 0.7 to 1.5). Neonatal outcomes were also similar between the two intervention arms. The rate of suspected sepsis was similar between the two groups. There were no cases of antibiotic resistance in the neonates. Either preoperative antibiotic therapy or antibiotic administration after cord clamp is a reasonable clinical method for reducing the risk of postcesarean infectious morbidity.
- Ovarian Tumors in Pregnancy: Diagnosis and Management
Ovarian tumors first diagnosed during pregnancy often present a challenge for both the obstetrician and gynecologists providing pregnancy care and for the consulting subspecialists. Although the vast majority of these tumors is benign, on rare occasions, patients present with tumors that turn out to be malignant requiring more comprehensive and extensive surgical procedures that are more likely to lead to pregnancy loss. Hence accurate knowledge of tumor characteristics, especially the ultrasound appearance and gestational age at diagnosis, are key prerequisite for establishing the most effective management plan not just for the index but also for future pregnancies. The primary objective of the current review is to provide practical guidelines for the evaluation and management of ovarian tumors first diagnosed during pregnancy.
- Acceptance of 2009 H1N1 Influenza Vaccine among Pregnant Women in Delaware
Due to disproportionately high mortality from 2009 H1N1 influenza, pregnant women were given highest priority for H1N1 vaccination. We surveyed postpartum women to determine vaccine uptake and reasons for lack of vaccination. We performed a cross-sectional survey of postpartum women delivering at our institution from February 1 to April 15, 2010. The 12-question survey ascertained maternal characteristics and vaccination concerns. Among 307 postpartum women, 191 (62%) had received H1N1 vaccination and 98 (32%) had declined. Factors associated with H1N1 vaccination included older age (relative risk [RR] 1.3, 95% confidence interval [CI] 1.1 to 1.5 for age ≥35 years compared with 20 to 34 years), at least college education (RR 1.5, 95% CI 1.3 to 1.8), prior influenza vaccination (RR 1.6, 95% CI 1.3 to 2.0), provider recommendation (RR 3.9, 95% CI 2.1 to 7.4), vaccination of family members (RR 1.6, 95% CI 1.3 to 1.9), and receipt of seasonal influenza vaccination (RR 2.2, 95% CI 1.7 to 2.9). Non-Hispanic black women were less likely to have been vaccinated (RR 0.6, 95% CI 0.5 to 0.8) than non-Hispanic white women. Safety concerns were cited by the majority (66%) of nonvaccinated women. H1N1 vaccine uptake among pregnant women was substantially higher than reported influenza vaccination rates during previous seasons. Safety concerns were the major barrier to vaccination.
- The Effect of Breech Presentation on the Accuracy of Estimated Fetal Weight
To determine whether fetal presentation affects the accuracy of ultrasonographic estimated fetal weight (EFW). This is a retrospective cohort study of singleton pregnancies that underwent ultrasonographic EFW within 3 weeks of delivery at a single institution from 1993 to 2008. Breech presenting fetuses were compared with those presenting cephalic. EFW using the Hadlock formula was compared with actual birth weight (ABW) and reported as mean difference and mean percentage difference. Differences were also considered categorically. Subgroup analyses were performed of women who delivered within 4 days of scan and excluding women with comorbidities. Ability to detect small and large for gestational age infants was compared. Evaluation of 3770 patients, 183 (4.9%) breech presenting and 3587 (95.1%) cephalic presenting revealed no difference in mean gram difference (−222.1 g ± 312.6 vs. −210.7 g ± 793.2, p = 0.084), respectively, or ability to accurately predict within 10% of ABW (adjusted odds ratio [AOR] 1.23; 95% CI, 0.89,1.69; p = 0.208). Subgroup analyses revealed similar results. There was no difference in the ability to detect small and large for gestational age infants. Presentation does not demonstrably affect the accuracy of ultrasonographic EFW when utilizing the Hadlock formula.
- The Freeze–Thaw Process and Long Intervals after Fortification Denature Human Milk Fat Globules
Although mother’s milk is the optimal nutrition for preterm infants, the amount of protein, calcium, and phosphorus become inadequate for the growth of preterm infants, such that fortification is recommended when enteral feeding is established. Recently, intestinal obstruction due to calcium soap formation has been reported. All the reported cases were fed fortified thawed human milk. It has not been elucidated how human milk fortifier reacts with milk fat globules (MFGs) in thawed human milk. Therefore, we investigated whether freezing durations and time between fortification and enteral feeding denatured MFGs. Six samples of preterm mothers’ milk of each type (fresh unfrozen, 1-month frozen, and 12-month frozen) were analyzed. Fortifier was not added to the control. The samples were measured at 1, 12, and 24 hours after fortification. The MFG size distribution of each milk sample was measured. The freezing process enlarged the mode diameter (4.0 ± 0.4, 4.3 ± 0.7, and 4.5 ± 0.9 in fresh unfrozen milk, 1-month frozen, and 12-month frozen milk, respectively, p < 0.001). Fortification itself did not significantly alter the MFG size in thawed mother’s milk. However, a time lag of 12 hours after fortification enlarged the MFG size and resulted in smaller surface area per unit (3.6 ± 0.2, 3.3 ± 0.1, and 3.3 ± 0.1 m2/g, fresh unfrozen, 1-month frozen, and 12-month frozen, respectively) compared with 0 hours of time lag (3.8 ± 0.2, 3.5 ± 0.1, and 3.4 ± 0.2 m2/g, fresh unfrozen, 1-month frozen, and 12-month frozen, respectively). Not only the freeze–thaw procedure but also time lag after fortification affected MFG size. We recommend using fortified thawed human milk within 12 hours.
- The Significance of a Positive Fetal Fibronectin in the Setting of a Normal Cervical Length in Twin Pregnancies
To estimate the risk of preterm birth in asymptomatic women with twin pregnancies with a normal cervical length (CL) and a positive fetal fibronectin (fFN), we reviewed a retrospective cohort of twin pregnancies delivered in our practice from 2005 to 2010. Patients were screened from 22 to 32 weeks with CL and fFN at 2- to 4-week intervals. We examined 244 patients with twin pregnancies and a normal CL (>25 mm) between 22 and 32 weeks and compared outcomes based on the fFN result. Fourteen (5.7%) patients had a positive fFN and 230 (94.3%) patients had a negative fFN. Positive fFN was associated with an increased the risk of spontaneous preterm birth <37 weeks (85.7% versus 38.3%, p = 0.001), <35 weeks (50% versus 11.8%, p < 0.001), <34 weeks (35.7% versus 6.9%, p < 0.001), and <32 weeks (21.4% versus 2.2%, p < 0.001). On adjusted analysis, a positive fFN was independently associated with preterm birth <32 weeks (odds ratio 6.8, 95% confidence interval 1.42, 32.2) and gestational age at delivery (p = 0.001). In the setting of a normal CL, a positive fFN is significantly associated with preterm birth in asymptomatic twin pregnancies. Contingency model screening of fFN in asymptomatic twin pregnancies solely based on CL evaluation may fail to identify a cohort of at-risk patients.
- The Effects of Prenatal Methamphetamine Exposure on Childhood Growth Patterns from Birth to 3 Years of Age
We examined the effects of prenatal methamphetamine (MA) exposure on growth parameters from birth to age 3 years. The 412 subjects included (n = 204 exposed) were enrolled at birth in the Infant Development, Environment and Lifestyle study, a longitudinal study assessing the effects of prenatal MA exposure on childhood outcomes. Individual models were used to examine the effects of prenatal MA exposure on weight, head circumference, height, and weight-for-length growth trajectories. After adjusting for covariates, height trajectory was lower in the exposed versus the comparison children (p = 0.021) over the first 3 years of life. Both groups increased height on average by 2.27 cm per month by age 3 years. In term subjects, MA exposure was also associated with a lower height trajectory (p = 0.034), with both the exposed and comparison groups gaining 2.25 cm per month by age 3 years. There was no difference in weight, head circumference, or weight-for-length growth trajectories between the comparison and the exposed groups. Children exposed prenatally to MA have a modest decrease in height growth trajectory during the first 3 years of life with no observed difference in weight, head circumference, or weight-for-length trajectories.
- Circulating Blasts and Associated Hematologic Disorders in Neonates with Down Syndrome
We analyzed complete blood count (CBC) data obtained from neonates with Down syndrome (DS) in a primarily Hispanic population over a 10-year period to determine the incidence of hematologic abnormalities and the relationship of abnormalities to the presence of circulating blasts (CB). Hematologic values obtained during the first 10 days were analyzed. Definitions were: CB, ≥ 1% blasts manually counted on peripheral smear; elevated white blood cell count (WBC), >30,000 cells/mm3; thrombocytopenia, platelet count <150,000/mm3; polycythemia, hematocrit >65%. Two hundred thirty-two neonates (88% Hispanic) with DS had 692 CBCs available for analysis. The presence of CB (11.6%) and the incidence of thrombocytopenia (60.2%) were significantly higher in DS neonates than in the reference group. Elevated WBC (33.3%) and thrombocytopenia (84.6%) were more common in DS neonates with CB versus those with no CB. No relationship between thrombocytopenia and polycythemia was observed. Unlike previous reports, we did not observe a male predominance in those DS neonates with CB. Thrombocytopenia occurred frequently in DS neonates and was significantly more likely in those with CB than in those with no CB. CBC screening should be performed routinely in DS neonates.
- External Validation of a Prediction Model for Successful External Cephalic Version
We sought external validation of a prediction model for the probability of a successful external cephalic version (ECV). We evaluated the performance of the prediction model with calibration and discrimination. For clinical practice, we developed a score chart to calculate the probability of a successful ECV. We studied 320 women undergoing ECV, of which 117 (37%) were successful. The model underestimated the success rate by 4 to 14%. The area under the receiver operating characteristic curve was moderate (0.66; 95% confidence interval: 0.60 to 0.72), but the model was able to make good distinction between women with a higher predicted probability of a successful ECV (more than 50%) compared with women with a lower predicted probability of a successful ECV (less than 20%). Our model to predict the outcome of ECV holds in external validation. It can be used to support patient counseling and decision making for ECV in singleton term breech presentations.
- Pregnancy after Age 50: Defining Risks for Mother and Child
Assisted reproductive technology using donor-egg in vitro fertilization (D-IVF) has enabled women 50 years and above to successfully achieve pregnancy. We examine the safety profile of these pregnancies through a large, single-center case series and retrospective cohort analysis in which all participants were carefully screened medically prior to conception. Consecutive women aged ≥ 50 years (n = 101) who achieved a viable pregnancy via D-IVF were identified and their perinatal outcomes were recorded. These data were compared with control data from younger (≤ 42 years) recipients of D-IVF (n = 41) who also achieved a viable pregnancy at our center during the same period. Compared with the younger women, older recipients had statistically similar rates of hypertensive disorders of pregnancy (23% versus 14%, odds ratio [OR] 1.9 [0.65 to 5.4]), gestational diabetes (4.0% versus 3.0%, OR 1.4 [0.15 to 113.0]), preterm premature rupture of membranes/preterm labor (8.9% versus 14%, OR 0.59 [0.18 to 1.9]), and abnormal placentation (2.1% versus 0%). Cesarean delivery was high in women ≥ 50 (81% of singletons, 100% of multiples). There was one maternal death, which occurred before delivery in a 49-year-old woman who would have been 50 at term had she survived, presumably secondary to myocardial infarction. Primary neonatal outcomes of gestational age and birth weight were excellent and similar between groups. Women ≥ 50 years who achieve pregnancy via D-IVF are at high risk for maternal complications, particularly hypertensive disorders and cesarean section, but at rates similar to those seen in younger recipients.
- Role of Gender in Morbidity and Mortality of Extremely Premature Neonates
We investigated the effect of gender on survival and short-term outcomes of extremely premature infants (≤27 weeks) born in Canada. The records of infants admitted between 2000 and 2005 to a neonatal intensive care unit participating in the Canadian Neonatal Network were reviewed for infant gender, birth weight, gestational age, outborn status, Score for Neonatal Acute Physiology II, and antenatal corticosteroid exposure. The following outcomes were recorded: survival at final discharge, necrotizing enterocolitis, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage grade ≥3, retinopathy grade ≥3, days on ventilation, and length of hospital stay. Among 2744 extremely premature infants, 1480 (54%) were male and 1264 (46%) were female. Mean birth weight of female neonates was significantly lower at each week of gestational age. Although no significant difference in survival at discharge was found between genders overall, the prevalence of BPD, combined adverse outcomes, and mortality for infants born between 24 and 26 weeks were significantly higher in males. This study suggests that, in the postsurfactant era, males remain at higher risk of respiratory complications and may have higher mortality when born between 24 and 26 weeks of gestation.
- Using Improvement Science to Increase Accuracy and Reliability of Gestational Age Documentation
Our aim was to improve the reliability of recording gestational age (GA) in the mother's obstetric record, as this record is used for clinical management, research databases, and eventual transmission to the Ohio Department of Health birth certificates. We performed a prospective cohort study, including all hospital births. We began quality improvement interventions in October 2009. Improvement test cycles were targeted to four working groups, including nursing staff, community obstetric providers, and the process itself. Test cycle results were evaluated to determine which successful interventions could spread further. Rates of process outcome measurements were compared by statistical process control and univariate analysis pre- and postintervention. During the preintervention period, the median daily GA reliability was 25%. To date, over 30 small sample size tests of change have been completed. Of 8795 births studied, significant improvement in GA accuracy/completeness was detected (median postintervention = 78%, p < 0.01). Increased communication of and completion of the prenatal record, in addition to GA recording in high-risk groups, such as premature infants, were also achieved (all p < 0.01). GA reliability can be increased using standardized improvement science methods. Better communication of GA will enable better clinical decisions and foster population-based perinatal research.
- Impact of Smoking during Pregnancy on Functional Coagulation Testing
Compounds that are systemically absorbed during the course of cigarette smoking, and their metabolites, affect the coagulation system and cause endothelial dysfunction, dyslipidemia, and platelet activation leading to a prothrombotic state. In addition, smoking increases the activity of fibrinogen, homocysteine, and C-reactive protein. We hypothesize that smoking may affect functional coagulation testing during pregnancy. A secondary analysis of 371 women pregnant with a singleton pregnancy and enrolled in a multicenter, prospective observational study of complications of factor V Leiden mutation subsequently underwent functional coagulation testing for antithrombin III, protein C antigen and activity, and protein S antigen and activity. Smoking was assessed by self-report at time of enrollment (<14 weeks). None of the functional coagulation testing results was altered by maternal smoking during pregnancy. Smoking does not affect the aforementioned functional coagulation testing results during pregnancy.
- False-Negative Results in Routine Combined First-Trimester Screening for Down Syndrome in Finland
We analyzed the frequency and possible causes of false-negative (Fn) screening results in first-trimester combined Down syndrome screening in Finland. During the study period (May 1, 2002, to December 31, 2008), 76,949 voluntary women with singleton pregnancies participated in screening. Maternal age at screening, week of gestation, levels of pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (fβ-hCG), and nuchal translucency (NT) measurement were compared and statistically analyzed between true-positive (Tp) and Fn cases. There were a total of 188 Down syndrome cases (1:409) in the screened population; 154 confirmed Tp and 34 Fn cases. Most Fn cases (n = 25) occurred at 12 + 0 to 13 + 6 weeks' gestation and only nine Fn cases presented between 10 and 11 weeks' gestation. According to the logistic regression analysis, the NT measurement was the most powerful discriminating factor in Fn screening results and accounted for 37.2% of Fn results. The second most important factor was fβ-hCG, adding 14.0% to R2, followed by PAPP-A, which contributed a further 14.3%. The chosen parameters explain 83.9% of Fn results, but 16.1% remain due to unknown factor(s). All investigated parameters contributed to Fn screening results, but fetal NT was the most discriminating factor leading to an Fn screening result.
- Prediction of Neonatal Metabolic Acidosis in Women with a Singleton Term Pregnancy in Cephalic Presentation
We sought to predict neonatal metabolic acidosis at birth using antepartum obstetric characteristics (model 1) and additional characteristics available during labor (model 2). In 5667 laboring women from a multicenter randomized trial that had a high-risk singleton pregnancy in cephalic presentation beyond 36 weeks of gestation, we predicted neonatal metabolic acidosis. Based on literature and clinical reasoning, we selected both antepartum characteristics and characteristics that became available during labor. After univariable analyses, the predictors of the multivariable models were identified by backward stepwise selection in a logistic regression analysis. Model performance was assessed by discrimination and calibration. To correct for potential overfitting, we (internally) validated the models with bootstrapping techniques. Of 5667 neonates born alive, 107 (1.9%) had metabolic acidosis. Antepartum predictors of metabolic acidosis were gestational age, nulliparity, previous cesarean delivery, and maternal diabetes. Additional intrapartum predictors were spontaneous onset of labor and meconium-stained amniotic fluid. Calibration and discrimination were acceptable for both models (c-statistic 0.64 and 0.66, respectively). In women with a high-risk singleton term pregnancy in cephalic presentation, we identified antepartum and intrapartum factors that predict neonatal metabolic acidosis at birth.
- The Changing Epidemiology of Preterm Twins and Triplets Admitted to Neonatal Intensive Care Units in Canada, 2003 to 2008
We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets <33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p = 0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p = 0.04). These trends were significant in mothers ≥ 35 years of age. Neonatal outcomes improved for preterm twins (mortality, p < 0.01; survival without any major morbidity, p < 0.01; severe neurological injury, p = 0.02; and severe retinopathy of prematurity, p = 0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at <33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period.
- Implementation of Health Information Technology to Maximize Efficiency of Resource Utilization in a Geographically Dispersed Prenatal Care Delivery System
This study investigated the utilization of health information technology (HIT) to enhance resource utilization in a geographically dispersed tertiary care system with extensive outpatient and delivery services. It was initiated as a result of a systems change implemented after Hurricane Ike devastated southeast Texas. A retrospective database and electronic medical record review was performed, which included data collection from all patients evaluated 18 months prior (epoch I) and 18 months following (epoch II) the landfall of Hurricane Ike. The months immediately following the storm were omitted from the analysis, allowing time to establish a new baseline. We analyzed a total of 21,201 patients evaluated in triage at the University of Texas Medical Branch. Epoch I consisted of 11,280 patients and epoch II consisted of 9922 patients. Using HIT, we were able to decrease the number of visits to triage while simultaneously managing more complex patients in the outpatient setting with no clinically significant change in maternal or fetal outcome. This study developed an innovated model of care using constrained resources while providing quality and safety to our patients without additional cost to the health care delivery system.
- The Stillbirth Collaborative Research Network Postmortem Examination Protocol
After reviewing the state of knowledge about the scope and causes of stillbirth (SB) in a special workshop sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the participants determined that there is little guidance regarding the best use of postmortem examination (PM) to address the pathogenesis of stillbirth. In this report, we describe the PM procedure designed and used in the NICHD-supported Stillbirth Cooperative Research Network (SCRN). Perinatal pathologists, clinicians, epidemiologists, and biostatisticians at four tertiary care centers, a data coordinating center, and NICHD developed a standardized approach to perinatal PM, which was applied to a population-based study of stillbirth as part of the SCRN. The SCRN PM protocol was successfully instituted and used at the four medical centers. A total of 663 women with stillbirth were included: 620 delivered a single stillborn infant, 42 delivered twins, and one delivered triplets for a total of 676 stillborn infants. Of these women, 560 (84.5%) consented to PM (572 stillborn infants) that was conducted according to the SCRN protocol. A standardized PM protocol was developed to evaluate stillbirth consistently across centers in the United States. Novel testing and approaches that increase the yield of the PM can be developed using this model.
- Indomethacin in Pregnancy: Applications and Safety
Preterm labor (PTL) is a major cause of neonatal morbidity and mortality worldwide. Among the available tocolytics, indomethacin, a prostaglandin synthetase inhibitor, has been in use since the 1970s. Recent studies have suggested that prostaglandin synthetase inhibitors are superior to other tocolytics in delaying delivery for 48 hours and 7 days. However, increased neonatal complications including oligohydramnios, renal failure, necrotizing enterocolitis, intraventricular hemorrhage, and closure of the patent ductus arteriosus have been reported with the use of indomethacin. Indomethacin has been also used in women with short cervices as well as in those with idiopathic polyhydramnios. This article describes the mechanism of action of indomethacin and its clinical applications as a tocolytic agent in women with PTL and cerclage and its use in the context of polyhydramnios. The fetal and neonatal side effects of this drug are also summarized and guidelines for its use are proposed.
- The Relationship between Maternal Body Mass Index and Tobacco Use on Small-for-Gestational-Age Infants
We sought to estimate the association between prepregnancy body mass index (BMI) and small-for-gestational-age (SGA) neonates and to determine if there is a synergistic effect of tobacco use on SGA across all BMI strata. We performed a retrospective cohort study of 65,104 patients seen for second-trimester ultrasound. BMI was categorized into underweight, normal weight, overweight, and obese. SGA was defined as birth weight <10th percentile and <5th percentile. Univariable and multivariable logistic regression analyses were used to evaluate the association between BMI and SGA. Stratified analyses and tests for effect modification were performed to evaluate for a potential synergistic effect between tobacco use and abnormal prepregnancy BMI on SGA. After controlling for potential confounders, underweight BMI was associated with an increased risk for SGA <10th percentile (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.5 to 2.1), while overweight (aOR 0.7, 95% CI 0.7 to 0.8) and obese BMIs (aOR 0.6, 95% CI 0.5 to 0.7) were associated with a decreased risk of SGA. There was no effect modification of tobacco use on the risk of SGA across all BMI categories. Although both tobacco and underweight BMI are independently associated with SGA, there was no evidence of synergism. Continued emphasis on both smoking cessation and maintenance of normal prepregnancy BMI remains paramount to decreasing the incidence of SGA.
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