Perinatal risk factors and mode of delivery associated with mortality in very low birth weight infants

Objective: To investigate the association of perinatal risk factors including delivery mode with mortality in very low birthweight (VLBW) in a tertiary hospital setting.

Methods: Medical records of 241 live-born VLBW infants (≤1500?g) were retrospectively reviewed. Details of maternal, obstetrical, perinatal risk factors and their associations with infant mortality were evaluated.

Results: The overall infant mortality rate was 23.2%. Mortality was significantly higher for infants born at ≤27 gestational weeks and with a birthweight of ≤750?g (p?=?0.000 and p?=?0.000, respectively), showing a steep decrease thereafter. On ROC analysis, a cut off of 26.5 weeks was determined for mortality with a sensitivity of 57.1% and a specificity of 90.3% (area under the curve?=?0.792, 95% CI: 0.719–0.866). On multivariate regression analysis, gestational week at birth, birthweight, antenatal steroid treatment and pathologic Doppler ultrasound findings were found as independent risk factors for mortality.

Conclusions: Gestational week at birth, birthweight and antenatal steroid treatment remain the most important perinatal risk factors for infant mortality in VLBW infants. Mode of delivery does not seem to be associated with mortality when adjusted for other perinatal risk factors.     

Transcervical Foley’s catheter versus Cook balloon for cervical ripening in stillbirth with a scarred uterus: a randomized controlled trial

Objective: To compare the efficacy and safety of the use of transcervical Foley’s catheter versus Cook cervical ripening balloon in pregnant women with stillbirth, unfavorable cervix and scarred uterus.

Design: Randomized controlled study.

Setting: El Minia University Hospital, El Minia, Egypt.

Patients and methods: Two-hundred pregnant women with stillbirth, unfavorable cervix and scarred uterus were recruited into this study. They were randomized into two groups. In group I (n?=?100), cervical ripening was done using Foley’s catheter. In group II (n?=?100), cervical ripening was done using Cook cervical ripening balloon.

Main outcome measures: Balloon insertion to delivery interval, successful ripening rate, cesarean delivery rate, maternal adverse events and maternal satisfaction.

Results: Time from balloon insertion to expulsion and from balloon insertion to delivery was significantly shorter in Foley’s catheter group. However, the difference between the two groups regarding time from balloon insertion to active labor, time from balloon expulsion to delivery, cervical ripening, cesarean section, instrumental delivery, pain score, need for analgesia, hospital stay and maternal satisfaction was not statistically significant.

Conclusions: Foley’s catheter and Cook cervical ripening balloon are comparable regarding efficacy and safety profile when used to ripen the cervix in pregnant women with stillbirth, unfavorable cervix and scarred uterus. However, Foley’s catheter has a shorter induction to delivery interval and is relatively cheaper device.     

Pregnancy outcome after induction of labor in women with previous cesarean section

Objective: As conflicting data exist concerning the safety of induction of labor (IoL) in women with previous single lower segment cesarean section (CS), we aimed to assess pregnancy outcome following IoL in such patient population.

Methods: All singleton pregnancies with previous single CS which underwent IoL during 2008–2012 were included (study group). Their pregnancy outcome was compared to those pregnancies with previous single CS that admitted with spontaneous onset of labor (control group).

Results: Overall, 1898 pregnancies were eligible, of them, 259 underwent IoL, and 1639 were admitted with spontaneous onset of labor. Parity, gestational age at delivery and birthweight were similar. Women in the study group were more likely to undergo CS mainly due to labor dystocia (8.1 versus 3.7%, p?<?0.01). The rate of CS due to non-reassuring fetal heart rate was similar. No difference was found in the rate of uterine rupture/dehiscence. Short-term neonatal outcome was similar between the groups. On multivariable logistic regression analysis, IoL was not independently associated with uterine rupture (OR 1.33, 95% C.I 0.46–3.84, p?=?0.59).

Conclusion: Our data suggest that IoL in women with one previous low segment CS neither increases the risk of uterine rupture nor adversely affects immediate neonatal outcome.     

Intrahepatic cholestasis of pregnancy and timing of delivery

Objective: We examined the morbidities from delivery at earlier gestational ages versus intrauterine fetal demise (IUFD) for women with intrahepatic cholestasis of pregnancy (ICP) to determine the optimal gestational age for delivery.

Methods: A decision-analytic model was created to compare delivery at 35 through 38 weeks gestation for different delivery strategies: (1) empiric steroids; (2) steroids if fetal lung maturity (FLM) negative; (3) wait a week and retest if FLM negative; or (4) deliver immediately. Literature review identified 18 studies that estimated IUFD in ICP; we used the mean rate, 1.74%, and assumed a uniform distribution from 34 to 40 weeks gestation. Large cohort data was used to calculate neonatal morbidity rates at each gestational age. Maternal and neonatal quality-adjusted life years (QALYs) were combined. Univariate sensitivity and Monte Carlo analyses were performed to test for robustness.

Results: Immediate delivery at 36 weeks without FLM testing and steroid administration was the optimal strategy as compared to delivery at 36 weeks with steroids (+47 QALYs) and as compared to immediate delivery at 35 weeks (+210 QALYs). Our results were robust up to a 30% increase in the rate of IUFD.

Conclusion: Immediate delivery at 36 weeks in women with ICP is the optimal delivery strategy.     

Ultrasound assessment of fetal head circumference at the onset of labor as a predictor of operative delivery

Objective: This study sought to determine whether ultrasound assessment of fetal head circumference (FHC) at the onset of labor can predict the likelihood of operative delivery.

Methods: We performed a prospective cohort study of 200 nulliparous women with singleton, cephalic, term pregnancies in an Irish Maternity Hospital. Transabdominal ultrasound assessment of FHC was performed when spontaneous labor was diagnosed or immediately prior to induction. Odds ratios for operative delivery (instrumental delivery or cesarean section) and maternal and neonatal morbidity were calculated using logistic regression with FHC categorized at a ≥350-mm cut-off (90th percentile).

Results: Ultrasound assessment of FHC at the onset of labor was highly correlated with post-delivery neonatal head circumference (NHC) (Pearson’s correlation coefficient 0.74), suggesting that it can be measured reliably. FHC ≥350?mm was associated with more than twice the risk of any operative delivery (OR 2.5, 95% CI 1.0–6.2) and a two-fold increased risk of cesarean section for dystocia (OR 2.0, 95% CI 1.0–4.3). Differences in maternal and neonatal morbidity were not statistically significant.

Conclusion: These preliminary data suggest that ultrasound assessment of FHC at the onset of labor may be useful in identifying women at greater risk of intrapartum intervention and warrant further research.     

Prognostic value of funisitis and/or chorionic vasculitis compared to histologic chorioamnionitis in full-term infants

Aim: To compare pathological findings in the placenta and cord with the prognosis of full-term infants in cases of neonatal infection and microbial analyses.

Methods: The pathological findings in the placenta and cord and microbial analyses of amniotic fluid and neonatal samples based on culture or polymerase chain reaction (PCR) were observed in 1208 full-term mother–infant pairs at our center. We also collected neonatal clinical infection data, such as the occurrence of septicemia and other infectious diseases.

Results: Neonatal infection and positive identification of microorganisms were more common in the funisitis and/or chorionic vasculitis group than in the histologic chorioamnionitis group.

Conclusion: Funisitis and/or chorionic vasculitis is a valuable pathological marker for assessing the comparison between intrauterine infection and neonatal inflammatory conditions in infants delivered at full-term.     

Do the first,second and third trimester maternal serum hepcidin concentrations clarify obstetric complications?

Objective: To evaluate whether first, second, and third-trimester maternal serum hepcidin levels are different in pregnancies with and without adverse pregnancy outcomes (APO).

Methods: A 165 nullipar pregnant women were included in this prospective cohort study. Serum hepcidin, ferritin, IL-6, C-reactive protein (CRP) and Hb values were measured at 11–14, 24–28, and 30–34 weeks of gestation. The relation between these parameters and APO and neonatal outcomes were investigated. Preterm delivery, intrauterine growth restriction, pre-eclampsia, gestational hypertension and placental abruption were determined as adverse pregnancy outcomes.

Results: The risk of APO was three times higher in women with high IL-6 levels in the second trimester. High hepcidin levels in the second trimester were associated with a 1.6 times increased risk of APO. Newborns of women with high IL-6 levels in the third trimester had a 1.6-fold increased risk of neonatal complications. High ferritin levels in the third trimester were associated with minimally increased risk of neonatal complications.

Conclusions: Mean serum hepcidin levels were similar in all pregnant women, however, elevated second trimester serum hepcidin and IL-6 levels were associated with a higher risk of APO and high third trimester hepcidin, ferritin and IL-6 levels were associated with higher risk of neonatal complications.     

Computational model for timing of delivery in an obese population

Objective: To estimate the impact on stillbirth risk, cesarean deliveries, and delivery-related healthcare cost associated with induction of labor compared to expectant management of term pregnancies in an obese population.

Methods: A decision analysis model was designed to compare the delivery and cost outcomes associated with a hypothetical cohort of 100,000 term pregnancies, complicated by obesity, that were planning a vaginal delivery. The model predicted stillbirths, cesarean deliveries, and total delivery-related health care cost from routine induction at 39 weeks compared to expectant management and routine induction each week from 40 to 42 weeks.

Results: There were 387 stillbirths avoided by routine induction at 39 weeks compared to the worst-case model of expectant management with induction at 42 weeks. 9234 cesarean deliveries were avoided by routine induction at 39 weeks compared to the worst-case model of expectant management and induction at 41 weeks (30,888 vs. 40,122) . Routine induction at 39 weeks showed a savings in delivery-related health care cost of 30 million dollars compared to the worst-case model of expectant management and induction at 41 weeks (536 million vs. 566 million).

Conclusion: Utilizing this computational model, routine induction at 39 weeks minimizes stillbirths, cesarean deliveries, and delivery-related health care cost.     

Polycystic ovary syndrome and low-grade inflammation with special reference to YKL-40

Objective: To evaluate the plasma level of YKL-40 in a Danish polycystic ovary syndrome (PCOS) population and to investigate whether YKL-40 is associated with CVD risk factors such as waist circumference, body mass index (BMI), insulin resistance (IR), fasting glucose, fasting insulin, blood lipids and CRP.

Design: Cross-sectional study.

Setting: Gynecological clinics at three Danish University Hospitals.

Patients: One hundred seventy-one premenopausal women with PCOS recruited consecutively from April 2010 to February 2012. PCOS was diagnosed according to the Rotterdam criteria.

Main outcome measures: Plasma level of YKL-40 in four phenotypes of PCOS defined by BMI and IR.

Results: No statistically significant difference was observed in the plasma level of YKL-40 across the four BMI/IR-phenotypes. Positive associations were observed between YKL-40 and BMI, total and free testosterone, triglycerides, and CRP. Total and free testosterone were independent predictors of YKL-40.

Conclusion: YKL-40, the marker of low-grade inflammation is not increased in women with PCOS.     

Medical improvisation training to enhance the antenatal counseling skills of neonatologists and neonatal fellows: a pilot study

Introduction: Neonatologists must be skilled at providing antenatal counseling to expectant parents of premature infants at the limits of viability. We conducted a medical improvisation workshop with the objective of enhancing antenatal counseling skills.

Methods: Pre- and postworkshop questionnaires were collected to examine the impact of the training. A follow-up survey was distributed 3 months after the workshop to examine the impact of the training on antenatal counseling skills.

Results: Nine neonatologists and three neonatal fellows participated in the workshop. Participants reported the skills learned in the workshop could enhance the quality of antenatal counseling. On follow-up survey, 90% of subjects reported improvements in the quality of their antenatal counseling.

Discussion: Participation in a medical improvisation workshop resulted in enhancements of self-perceived antenatal counseling skills. Medical improvisation training may provide a feasible and effective method of communication training for neonatologists. Further research into this innovative method are needed.     

Pre-pregnancy body mass index (BMI) and macrosomia in a Canadian birth cohort

Objective: To compare demographic characteristics and maternal, fetal, neonatal, and pregnancy outcomes of term macrosomic infants of obese and non-obese mothers.

Methods: A sample of 1996 singleton, term deliveries was drawn from the All Our Babies Cohort, a prospective, community-based pregnancy cohort. Maternal self-reported socio-demographic and anthropometric information was linked to the clinical data on pregnancy and birth events abstracted from electronic health records. Demographic, obstetrical characteristics and maternal, fetal, neonatal, and pregnancy outcomes of macrosomic infants in obese, overweight, and normal weight women were compared. Multinomial regression analysis assessed the risk factors of macrosomia in primiparous and multiparous women stratified by maternal pre-pregnancy BMI, controlling for confounding variables.

Results: Macrosomia affected 10% of pregnancies in the study. Mothers whose infants were macrosomic were more likely to be Caucasian, obese, have had previous deliveries, undergo induction of labour and delivery by emergency C-section, particularly for labour abnormalities. Macrosomic infants were more likely to be delivered postdates, have meconium stained liquor and require resuscitation at birth. There were no significant differences in birth and neonatal outcomes of macrosomic pregnancies between obese, overweight and normal weight women. Pre-pregnancy BMI and gestational age at delivery were risk factors for macrosomia in all women. Ethnicity and history of delivery of a macrosomic infant were additional independent risk factors in multiparas.

Conclusions: Obesity in pregnancy increases the risk of delivery of a macrosomic infant in both primiparous and multiparous women. The maternal, fetal and neonatal outcomes of macrosomic pregnancies are similar in obese and normal weight women.     

Prenatal diagnosis of congenital malformations for the better and for the worse

Background: Prenatal detection of congenital malformations gives an opportunity to positively influence prenatal and postnatal management, survival and morbidity, as well as to allow parental choice and psychological preparation.

Objective: To examine the available evidence regarding the impact of detection and underdetection of fetal anomalies as well as that of fetal therapy on neonatal outcome, parental psychological wellness and neonatal care organization.

Methods: Literature search of PubMed.

Results and conclusions: The impact of prenatal diagnosis on neonatal survival and morbidity is dependent upon the type and severity of the anomalies inasmuch as upon the evaluation criteria chosen. We discuss the various pitfalls in the design of trials explaining why only few studies, targeting selected anomalies, have shown improved outcomes associated with prenatal diagnosis of congenital malformations. Fetal therapy applies mainly to conditions that are lethal either in utero or at birth if untreated before birth. It has rarely been evaluated with the highest level of evidence; this may be explained by a poor acceptability of randomization between prenatal intervention and expectancy up until delivery.     

Perinatal outcomes from the use of antiepileptic drugs during pregnancy: a case-control study

Objective: To evaluate the perinatal results from epileptic women using antiepileptic drugs during prenatal care.

Methods: This was a retrospective longitudinal study assessing the perinatal results of women exposed to antiepileptic drugs during pregnancy, and we compared these results with those of pregnant women who were not exposed. The development of pregnancy, gestational age at delivery, Apgar scores, biometric data, morbidity, stillbirths and neonatal mortality were analyzed. The chi-square test and Fisher’s exact test were used for the categorical variables, while Student’s t-test was used for independent numerical variables.

Results: Over a 10-year period, 12?790 singleton gestations were analyzed, among which 104 (0.8%) consisted of epileptic pregnant women. From this total, 82 evolved to childbirth and their neonatal data were compared with those of 316 newborns from non-epileptic women. The most-used antiepileptic drug was phenobarbital in 70% of the cases. There was greater neonatal mortality (p?=?0.006), occurrence of neonatal hemorrhagic disorders (p?=?0.005), and occurrence of minor congenital anomalies (p?=?0.03) among the children of women exposed to antiepileptic drugs.

Conclusion: The antenatal exposure to antiepileptic drugs is associated mainly with occurrences of hemorrhagic complications during the neonatal period; furthermore, great prevalence of newborns presenting minor congenital anomalies and elevated risk of neonatal mortality.     

Neonatal morbidities among full-term infants born to obese mothers

Introduction: Impact of maternal obesity on full-term neonates is not known.

Objective: We hypothesized increased incidence of neonatal morbidities requiring NICU admission in full-term neonates of obese women compared to neonates of normal-weight women.

Methods: Data from full-term pregnancies collected in the Consortium of Safe Labor study were analyzed. Maternal BMI was classified using the WHO criteria. Incidence of neonatal outcomes including sepsis, PDA, NEC, respiratory distress, or their combination were compared between newborns of obese and normal-weight women.

Results: Of the 109?488 women included in the study, 17.7% were obese. Maternal co-morbidities (diabetes, gestational diabetes, hypertension, and preeclampsia) increased with increasing maternal BMI. Both maternal obesity and its related co-morbidities were associated with higher incidence of neonatal morbidities. After adjusting for maternal comorbidities, there was a higher incidence of sepsis (AOR 1.91(1.45–2.50)), and combination of any of the neonatal outcomes (AOR 1.66(1.32–2.09)) among newborns of obese women than those of normal-weight women, along with an increased trend for incidence of PDA (Cochran-Armitage Test (CA)?=?23.1, p?<?0.0001) and NEC (CA?=?7.2, p?=?0.007).

Conclusion: Maternal obesity is independently associated with increased incidence of neonatal sepsis and a combination of neonatal morbidities in full-term newborns with an increased trend for PDA and NEC.     

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate,results from a prospective observational study

Objective: To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP).

Design: Five-year prospective observational study.

Setting: Prenatal Diagnosis Unit, Vall d'Hebron University Hospital – Barcelona.

Patients: TEP cases fulfilling criteria for medical treatment with Methotrexate.

Interventions: ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated.

Main outcome measure: Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment.

Results: 126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0–7 and 4–7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0–7 (25%) and 4–7 (20%), respectively.

Conclusion: ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.     

Small for gestational age newborns – does pre-recognition make a difference in pregnancy outcome?

Objective: We aimed to evaluate whether pre-recognition of small for gestational age (SGA) at late preterm or term pregnancies, has an impact on pregnancy outcome.

Methods: Retrospective analysis of SGA newborns, stratified to those with suspected or unsuspected IUGR according the sonographic estimated fetal weight (EFW), below the 10th percentile for gestational age (n?=?619), with fetuses not suspected as SGA (EFW ≥10th percentile) preformed up to 7 days prior to delivery (n?=?1770).

Results: SGA was correctly diagnosed prior to delivery in 26% of the fetuses. Women with suspected SGA were delivered earlier (37.9?±?1.7 versus 38.8?±?1.4 weeks, p?<?0.001) and at a lower birth weight (2280?±?321 versus 2454?±?263 grams, p?<?0.001). They also had higher rates of induction of labor (19.1% versus 6.2%, p?<?0.001) and cesarean delivery (29.1% versus 19.8%, p?<?0.001). Fetuses suspected for SGA had higher rate of neonatal adverse outcome, but on multivariate analysis suspected SGA (aOR 0.41, 95% CI 0.20–0.86), birthweight (aOR 0.67, 95% CI 0.5 to ?0.77 for each additional 50?g), gestational age at delivery (aOR 0.63, 95% CI 0.56–0.71 for each additional week) and spontaneous vaginal delivery (aOR 0.88, 95% CI 0.19–3.89) were independently associated with an improved neonatal composite outcome.

Conclusion: Identification of SGA may improve neonatal outcome. However, by itself, it is not an indication for intervention, which may lead to adverse outcome.     

Immediate postpartum glycemic control and risk of surgical site infection

Objective: Nearly one-third of all births in the United States in 2013 were by cesarean delivery, with 6% complicated by diabetes. The purpose of this study was to correlate immediate postoperative hyperglycemia with wound morbidity in diabetic women who underwent cesarean delivery.

Methods: This retrospective case–control study was performed at UC Irvine Health and Miller Women’s & Children’s Hospital Long Beach between 2009 and 2015. Subjects included women with at least Class B diabetes mellitus who underwent cesarean birth. Fasting and postprandial blood glucose levels (BGL) were recorded daily during postoperative days one through four. Outcomes included abscess formation, cellulitis, wound separation, fascial dehiscence, hospital readmission, secondary wound closure, antibiotic treatment, and a composite of the above.

Results: Outcomes were evaluated for 176 subjects. Twenty-nine experienced wound complications. Women readmitted for wound complications and those with composite morbidity experienced significantly higher mean fasting BGL, however, BGL during the immediate postoperative setting were not predictive of wound morbidity.

Conclusion: In our cohort of diabetic women who underwent cesarean delivery, immediate postoperative hyperglycemia was not associated with wound morbidity.     

A comparison of maternal and perinatal outcome between in vitro fertilization and spontaneous dichorionic-diamniotic twin pregnancies

Objective: To compare the maternal and neonatal outcome of dichorionic diamniotic in vitro fertilization (IVF) twin and spontaneous twin pregnancies.

Material and methods: Maternal and fetal data of all consecutive dichorionic-diamniotic twin pregnancies delivered in our institution between January 2009 and May 2015 were abstracted from medical records and pregnancy outcome of IVF twin was compared to spontaneous twin.

Results: Overall 708 twin pregnancies (449 IVF and 259 spontaneous) were included. Women in the IVF group were 2 years older and more frequently nulliparous. The rate of pregnancy induced hypertension and preeclampsia (PIH/PET) was three times higher in the IVF group than in the spontaneous group. The rate of preterm births, before 37 weeks of gestation and the rate of cesarean section were higher in the IVF group. These results were confirmed by multivariate analysis. The neonatal outcome was similar in both the groups except for a lower mean newborn birthweight in the IVF group.

Conclusion: Women with IVF twins are at a significantly higher risk of having preterm births, PIH/PET and cesarean section but there was no significant adverse effect on neonatal outcome except for a lower mean newborn birth weight.     

Selective uterine fundal pressure maneuver during the second stage of the first twin delivery at near term

Objective: We examined the perinatal outcomes of twin deliveries following selective uterine fundal pressure maneuver (UFPM) during the second stage of the first twin delivery.

Methods: At our institute, if non-reassuring fetal heart rate and/or maternal exhaustion were observed during the second stage of the first twin, selective UFPM was performed following making sure of the position of the first twin’s buttocks by ultrasonography. We reviewed the obstetric records of all cases of trial of vaginal delivery of twins between 2002 and 2012.

Results: A total of 64 cases were evaluated for the statistical analyses. Of these, selective UFPM for the first twin was performed in 15 cases (24%). Although the cases requiring selective UFPM for the first twin was associated with an increased postpartum hemorrhage, there were no significant differences in neonatal outcomes between the two groups.

Conclusion: There was no evidence that the selective UFPM is unsafe for both mother and two babies during the second stage of the first twin delivery.     

Oxidative stress in preeclamptic mother – newborn dyads and its correlation with early neonatal outcome – a case control study

Background: Preeclamptic mothers are likely to have increased oxidative stress during pregnancy which can adversely affect the outcome in their neonates.

Objectives: To measure the oxidative stress in preeclamptic mother- newborn dyads and correlate it with the immediate neonatal outcome.

Methods: This case control study conducted in a tertiary care teaching hospital, South India included 71 preeclamptic mothers – newborn dyads (cases) and 72 normal mothers – newborn dyads (controls). Biochemical parameters including total antioxidant status (TAS), protein carbonyls and malondialdehyde levels (MDA) were measured in both maternal and cord blood. Association between these oxidative stress parameters and early neonatal outcome was studied.

Results: All oxidative stress markers were higher in the preeclampsia group compared to the controls. Cord blood protein carbonyl levels had significant correlation with maternal levels. Prematurity, low-birth weight, respiratory distress syndrome (RDS), early onset sepsis (EOS) and intra-uterine growth restriction (IUGR) were more among cases. Early neonatal outcomes like death, IUGR, EOS, and RDS had significant correlation with protein carbonyl levels among the cases.

Conclusions: Oxidative stress is increased in preeclamptic mother – newborn dyads. Increased protein carbonyl levels in preeclampsia correlate with adverse early neonatal outcome.