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Background Before the advent of antenatal steroids, early non-invasive respiratory support (NIV), and intratracheal surfactant, antenatal terbutaline was also used to improve lung compliance and reduce the incidence of respiratory distress syndrome (RDS). Objectives The objective of this paper was to study the association between antenatal terbutaline and endotracheal intubation (ET) within the first 24 hours of life, RDS, bronchopulmonary dysplasia (BPD), and intraventricular hemorrhage (IVH) in infants with the gestational age (GA) of <32 weeks, and to study the association between antenatal terbutaline, and ET or NIV within the first 24 hours of life, and RDS in infants with the GA of 32 to 36 weeks. Method This was a retrospective medical record review of preterm infants delivered at a single tertiary care center from October 2016 to December 2020. Multivariable logistic regression was used to explore the association between antenatal terbutaline and neonatal respiratory support. Result 1,794 infants were included, 234 (13.0%) had the GA of <32 weeks and 1,560 (86.9%) had the GA of 32 to 36 weeks. Antenatal terbutaline, corticosteroid, or both agents were administered in 561 (31.3%), 1,461 (81.4%), and 555 (30.9%), respectively. Antenatal terbutaline was significantly associated with a reduction in ET (adjusted odds ratio [aOR] = 0.40, 95% confident interval [CI] 0.19–0.82, p = 0.012) in infants with the GA of <32 weeks, but not in infants with the GA of 32–36 weeks. Antenatal terbutaline was not associated with RDS or BPD but was significantly associated with a reduction in grade III-IV IVH (aOR 0.11, CI 0.01–0.98; p = 0.048), in infants with the GA of <32 weeks. Conclusion In a state-of-the-art neonatal care setting, antenatal terbutaline was associated with a reduction in ET during the first 24 hours in infants with the GA of <32 weeks. The use of antenatal terbutaline to improve acute neonatal respiratory outcomes merits reconsideration. Key Points The neonatal respiratory benefits of antenatal terbutaline in the era of antenatal corticosteroids were uncertain. Terbutaline is associated with a reduction in endotracheal intubation in a modern care setting. The role of terbutaline, and potentially other betamimetics, to improve neonatal respiratory outcomes merits reconsideration. [ABSTRACT FROM AUTHOR]

Objectives Group prenatal care models were initially designed for women with medically low-risk pregnancies, and early outcome data focused on these patient populations. Pregnancy outcome data for women with medically high-risk pregnancies participating in group prenatal care is needed to guide clinical practice. This study compares rates of preterm birth, low birth weight, and neonatal intensive care unit admissions among women with medical risk for poor birth outcomes who receive group versus individual prenatal care. Study Design This retrospective cohort study uses vital statistics data to compare pregnancy outcomes for women from 21 obstetric practices participating in a statewide expansion project of group prenatal care. The study population for this paper included women with pregestational or gestational hypertension, pregestational or gestational diabetes, and high body mass index (BMI > 45 kg/m 2). Patients were matched using propensity scoring, and outcomes were compared using logistic regression. Two levels of treatment exposure based on group visit attendance were evaluated for women in group care: any exposure (one or more groups) or minimum threshold (five or more groups). Results Participation in group prenatal care at either treatment exposure level was associated with a lower risk of neonatal intensive care unit (NICU) admissions (10.2 group vs. 13.8% individual care, odds ratio [OR] = 0.708, p < 0.001). Participating in the minimum threshold of groups (five or more sessions) was associated with reduced risk of preterm birth (11.4% group vs. 18.4% individual care, OR = 0.569, p < 0.001) and NICU admissions (8.4% group vs. 15.9% individual care, OR = 0.483, p < 0.001). No differences in birth weight were observed. Conclusion This study provides preliminary evidence that women who have or develop common medical conditions during pregnancy are not at greater risk for preterm birth, low birth weight, or NICU admissions if they participate in group prenatal care. Practices who routinely exclude patients with these conditions from group participation should reconsider increasing inclusivity of their groups. Key Points This study compares outcomes for women who receive group versus individual prenatal care The study population was limited to women with diabetes, hypertension, and/or high BMI. Group participants did not have higher rates of preterm birth, low birth weight, or NICU admissions. [ABSTRACT FROM AUTHOR]

Objective No available scale, at the time of initial evaluation for necrotizing enterocolitis (NEC), accurately predicts, that is, with an area under the curve (AUC) ≥0.9, which preterm infants will undergo surgery for NEC stage III or die within a week. Study Design This is a retrospective cohort study (n = 261) of preterm infants with <33 weeks' gestation or <1,500 g birth weight with either suspected or with definite NEC born at Parkland Hospital between 2009 and 2021. A prediction model using the new HASOFA score (Hyperglycemia, Hyperkalemia, use of inotropes for Hypotension during the prior week, Acidemia, Neonatal Sequential Organ Failure Assessment [nSOFA] score) was compared with a similar model using the nSOFA score. Results Among 261 infants, 112 infants had NEC stage I, 68 with NEC stage II, and 81 with NEC stage III based on modified Bell's classification. The primary outcome, surgery for NEC stage III or death within a week, occurred in 81 infants (surgery in 66 infants and death in 38 infants). All infants with pneumoperitoneum or abdominal compartment syndrome either died or had surgery. The HASOFA and the nSOFA scores were evaluated in 254 and 253 infants, respectively, at the time of the initial workup for NEC. Both models were internally validated. The HASOFA model was a better predictor of surgery for NEC stage III or death within a week than the nSOFA model, with greater AUC 0.909 versus 0.825, respectively, p < 0.001. Combining HASOFA at initial assessment with concurrent or later presence of abdominal wall erythema or portal gas improved the prediction surgery for NEC stage III or death with AUC 0.942 or 0.956, respectively. Conclusion Using this new internally validated prediction model, surgery for NEC stage III or death within a week can be accurately predicted at the time of initial assessment for NEC. Key Points No available scale, at initial evaluation, accurately predicts which preterm infants will undergo surgery for NEC stage III or die within a week. In this retrospective cohort study of 261 preterm infants with either suspected or definite NEC we developed a new prediction model (HASOFA score). The HASOFA-model had high discrimination (AUC: 0.909) and excellent calibration and was internally validated. [ABSTRACT FROM AUTHOR]

Objective Necrotizing enterocolitis (NEC) primarily affects preterm, especially small for gestational age (SGA), infants. This study was designed to (1) describe frequency and timing of NEC in SGA versus non-SGA infants and (2) assess whether NEC is independently associated with the severity of intrauterine growth failure. Study Design Retrospective cohort study of infants without severe congenital malformations born <33 weeks' gestational age (GA) carried out from 2009 to 2021. The frequency and time of NEC were compared between SGA and non-SGA infants. Multivariate logistic regression was used to assess whether NEC was independently associated with intrauterine growth restriction. Severe growth restriction was defined as birth weight Z -score < −2. Results Among 2,940 infants, the frequency of NEC was higher in SGA than in non-SGA infants (25/268 [9.3%] vs. 110/2,672 [4.1%], respectively, p < 0.001). NEC developed 2 weeks later in SGA than non-SGA infants. In multivariate analysis, the adjusted odds of NEC increased with extreme prematurity (<28 weeks' GA) and with severe but not moderate growth restriction. The adjusted odds of NEC increased with urinary tract infection or sepsis within a week prior to NEC, were lower in infants fed their mother's own milk until discharge, and did not change over five epochs. NEC was independently associated with antenatal steroid (ANS) exposure in infants with birth weight (BW) Z -score < 0. Conclusion NEC was more frequent in SGA than in non-SGA infants and developed 2 weeks later in SGA infants. NEC was independently associated with severe intrauterine growth failure and with ANS exposure in infants with BW Z -score < 0. Key Points We studied 2,940 infants <33 weeks' GA. We assessed NEC. NEC was more frequent in SGA infants. NEC occurred 2 weeks later in SGA infants. NEC was associated with severe growth restriction. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to determine which late-preterm (35–36 weeks' gestational age [GA]) and term neonates with early-onset hypoglycemia in the first 72 hours postnatal required a continuous glucose infusion to achieve and successfully maintain euglycemia. Study Design This is a retrospective cohort study of late preterm and term neonates born in 2010–2014 and admitted to the Mother-Baby Unit at Parkland Hospital who had laboratory-proven blood glucose concentration < 40 mg/dL (2.2 mmol/L) during the first 72 hours of life. Among the subgroup needing intravenous (IV) glucose infusion, we analyzed which factors predicted a maximum glucose infusion rate (GIR) ≥ 10 mg/kg/min. The entire cohort was randomly divided into a derivation cohort (n = 1,288) and a validation cohort (n = 1,298). Results In multivariate analysis, the need for IV glucose infusion was associated with small size for GA, low initial glucose concentration, early-onset infection, and other perinatal variables in both cohorts. A GIR ≥ 10 mg/kg / min was required in 14% of neonates with blood glucose value < 20 mg/dL during the first 3 hours of observation. The likelihood of a GIR ≥ 10 mg/kg/min was associated with lower initial blood glucose value and lower umbilical arterial pH. Conclusion Need for IV glucose infusion was associated with small size for GA, low initial glucose concentration, early-onset infection, and variables associated with perinatal hypoxia–asphyxia. The likelihood of a maximum GIR ≥ 10 mg/kg/min was greater in neonates with lower blood glucose value during the first 3 hours of observation and lower umbilical arterial pH. Key Points We studied 51,973 neonates ≥ 35 weeks' GA. We established a model predicting the need for IV glucose. We also predicted the need for a high rate of IV glucose. [ABSTRACT FROM AUTHOR]

Objective Coagulase-negative Staphylococcus (CoNS) is the most frequent pathogen causing late-onset sepsis (LOS) in neonatal intensive care units (NICUs). Technical difficulties hinder blood culture (BC) collection and obtaining only one culture before initiating antibiotic therapy is a common practice. We sought to assess specific clinical information and CoNS cultures for the diagnosis of true bacteremia in the NICU. Study Design This historical cohort study was conducted in NICUs at the Hadassah-Hebrew University Medical Center of Jerusalem in Israel. Clinical and laboratory data in every CoNS bacteremia were collected and compared between bacteremia groups as follows: true positive, two positive BCs; contaminant, one positive BC out of two; undefined, one BC obtained and found positive. Results For 3.5 years, CoNS was isolated in 139 episodes. True positive was identified in 44 of 139 (31.7%), contaminant in 42 of 139 (30.2%), and the event was undefined in 53 of 139 (38.1%). Vancomycin treatment was more frequent in the true positive and undefined groups than the contaminant group (100, 90.6, and 73.8% respectively, p = 0.001); treatment was also prolonged in these two groups (p < 0.001). No clinical variables were associated with true bacteremia on multivariable analysis. Conclusion Diagnosis should definitely be based on at least two positive BCs, despite objective difficulties in obtaining BCs in neonates. Key Points CoNS is a frequent pathogen causing LOS in neonates. Due to technical difficulties, often only one culture is collected prior to antibiotic therapy. No clinical/laboratory variables were associated with the diagnosis of true CoNS bacteremia. [ABSTRACT FROM AUTHOR]

Objective To pilot measurement of hair cortisol concentration (HCC) in pregnant women with opioid use disorder and their infants over time and study the potential utility of hair cortisol as a biomarker of chronic stress in this population. Study Design In this pilot prospective cohort study of mother–infant dyads with and without prenatal opioid exposure, we obtained mother–infant HCCs at delivery and again within 1 to 3 months' postpartum. HCCs were compared between the opioid and control groups and between the two time points. Results There were no significant differences between opioid and control group maternal or infant HCCs at either time point. However, within the opioid-exposed group, there was a significant increase in infant HCCs across the two time points. Conclusion This pilot study describes our experience with the measurement of HCCs in opioid-exposed mother–infant dyads. Key Points Maternal stress impacts fetal and child health. Many stressors in pregnant women with opioid use disorder. Hair cortisol may be a useful stress biomarker. [ABSTRACT FROM AUTHOR]

Objective Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births. Methods In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007–2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis. Results Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings. Conclusion Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers. Key Points Opioid prescribing in the postpartum period is common. Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events. > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death. [ABSTRACT FROM AUTHOR]

Objective Pregnancy outcomes of individuals receiving cervical cerclage when the cervix is dilated are not well known. We sought to examine preterm birth rates after ultrasound or physical examination-indicated cerclage placement according to the degree of cervical dilation. Study Design This was a retrospective cohort study of individuals with singleton pregnancies undergoing ultrasound or physical examination-indicated cerclage before 24 0/7 weeks of gestation from 2004 to 2018. Individuals were categorized based on the degree of cervical dilation at the time of cerclage. Our primary outcome was preterm delivery at less than 37 weeks of gestation. Multivariable logistic regression was performed to calculate adjusted odds ratios (aOR) with 95th confidence intervals (95% CI), controlling for predefined covariates. Results Of 147 individuals undergoing ultrasound or physical examination-indicated cerclage, 90/147 (61%) had a closed or 0.5 cm dilated cervix at the time of cerclage placement, 45/147 (31%) had a cervical dilation of 1 to 2.5 cm, and 12/147 (8%) had a cervical dilation of 3 to 4 cm at the time of placement. Individuals with a cervical dilation of 1 to 2.5 cm compared with those who had a closed cervix did not have increased odds of preterm delivery (58 vs. 42%; aOR: 1.95; 95% CI: 0.93–4.07). However, individuals with a cervical dilation of 3 to 4 cm compared with individuals who had a closed cervix had significantly increased odds of preterm delivery (75 vs. 42%; aOR: 4.33; 95% CI: 1.05–17.77). Conclusion The rate of preterm birth increases with increasing cervical dilation at the time of cerclage placement. However, individuals who have a cerclage placed when the cervix is 1 to 2.5 cm can achieve an outcome that is not significantly different from those who had a cerclage placed when the cervix is closed. Key Points Time from cerclage placement to delivery decreases as cervical dilation increases. Individuals 1 to 2.5 cm dilated at the time of cerclage can achieve a favorable outcome. A cervical dilation of ≥3 cm at cerclage placement was associated with extreme prematurity. [ABSTRACT FROM AUTHOR]

Objective Delayed cord clamping (DCC) has been recently adopted in neonatal resuscitation. The immediate cardiac hemodynamic effects related to DCC more than 30 seconds was not studied. We aimed to study the effect of DCC at 120 seconds compared with 30 seconds on multiple hemodynamic variables in full-term infants using an electrical cardiometry (EC) device. Study Design Present study is a randomized clinical trial. The study was conducted with full-term infants who were delivered at the Obstetrics and Gynecology Department in Cairo University Hospital. Sixty-eight full term infants were successfully enrolled in this trial. Cardiac output (CO) and other hemodynamic parameters were evaluated in this study by EC device. Hemoglobin, glucose, and bilirubin concentrations were measured at 24 hours. Newborn infants were assigned randomly into group 1: DCC at 30 seconds, and group 2: DCC at 120 seconds, based on the time of cord clamping. Results Stroke volume (SV) (mL) and CO (L/min) were significantly higher in group 2 compared with group 1 at 5 minutes (6.71 vs. 5.35 and 1.09 vs. 0.75), 10 minutes (6.43 vs. 5.59 and 0.88 vs. 0.77), 15 minutes (6.45 vs. 5.60 and 0.89 vs. 0.76), and 24 hours (6.67 vs. 5.75 and 0.91vs. 0.81), respectively. Index of contractility (ICON; units) was significantly increased in group 2 at 5 minutes compared with group1 (114.2 vs. 83.8). Hematocrit (%) and total bilirubin concentrations (mg/dL) at 24 hours were significantly increased in group 2 compared with group 1 (51.5 vs. 40.5 and 3.8 vs. 2.9, respectively). Conclusion Stroke volume and cardiac output are significantly higher in neonates with DCC at 120 seconds compared with 30 seconds that continues for the first 24 hours. Key Points CO is significantly increased with DCC at 120 seconds. SV is significantly increased with DCC at 120 seconds. Such effects continued during the entire 24 hours of life in full-term infants. [ABSTRACT FROM AUTHOR]

Objective The objectives of this study were to establish days between birth and death for neonates over a 14-year period, determine if days between birth and death have changed over time across gestational age cohorts, and identify diagnoses which may put infants at high risk of prolonged hospitalization leading to death. Study Design This was a single-site, retrospective chart review of inborn infants who died prior to hospital discharge. Results Two hundred and thirty-nine patients born between 1/1/2006 and 12/31/2020 met inclusion criteria. Days until death ranged from 0 to 300 with a median of 6 days (interquartile range = 23). Median days until death increased over time, with a statistically significant increase between epoch 1 and epoch 2 (p = 0.016) but not between epoch 2 and epoch 3 (p = 0.618). Extremely premature infants died earlier than more mature infants (p < 0.001). In addition, infants with complex congenital heart disease or a gastrointestinal (GI) catastrophe died later (p < 0.001 and p < 0.001, respectively) than newborns without cardiac or GI issues. Conclusion Our findings demonstrate an increase in time to death for newborns who did not survive to hospital discharge over a 14-year period. This trend suggests that the dynamics informing Meadows' assertion that "doomed infants die early" may be shifting, with some seriously ill infants who die before hospital discharge surviving longer than previously described. More research is needed to understand how best to care for babies who will not survive to discharge and to explore when supports such as palliative care consultation may be beneficial. Key Points As per W. Meadow, "Doomed infants die early" Pre-death length of stay varies with diagnosis. Some seriously ill infants who die before hospital discharge are no longer dying early. These infants and families may need supports. [ABSTRACT FROM AUTHOR]

Objective There has been national strive to decrease the time needed to identify microorganisms in blood culture samples to reduce antibiotic use. This study evaluated rapid molecular polymerase chain reaction (PCR) use in identifying microorganisms in negative culture bottles from neonates with suspected bacterial blood stream infection at 20 to 24 hours of incubation. Study Design All blood specimens from neonates with suspected blood stream infection were included. Specimens were incubated using a standard blood culturing instrument that would flag positive if bacterial growth was detected. If the specimen was flagged positive at <20 hours, it was tested by PCR and plated for identification as per standard protocol. In our design, if specimen was not flagged at 20 hours of incubation, the bottle was sterilely accessed and a sample was obtained for PCR testing. The bottle would be returned for incubation for 120 hours or until flagged positive. Results A total of 192 blood specimens were included. Four specimens flagged positive at <20 hours and were all found to be positive by PCR. All other samples did not flag positive by 20 hours of incubation and were tested by PCR between 20 and 24 hours. One sample tested positive via PCR at 21.6 hours then flagged positive on the culturing instrument at 23.5 hours. All other specimens were negative by PCR and remained culture negative at 120 hours. The positive and negative predictive value of PCR verified by blood culture were both equal to 1.0. Conclusion Using rapid molecular PCR on blood culture specimens at 20 to 24 hours of incubation provides 100% true negative results possibly allowing providers to discontinue antibiotics at 24 hours. Key Points Antibiotic overuse leads to adverse neonatal outcomes. Molecular PCR may have true negative results. Larger study is needed to discontinue antibiotics earlier. [ABSTRACT FROM AUTHOR]

Objective This study aimed to compare the ventilator-free days (VFDs) at day 28 and the short-term outcomes in neonates with and without ventilator-associated pneumonia (VAP and non-VAP groups). Study Design We performed a cohort study in a Thai neonatal intensive care unit between 2014 and 2020 to identify the VFDs in VAP and non-VAP neonates. Univariate and multivariate analyses were performed. Results The incidences of VAP rates were 5.76% (67/1,163 neonates) and 10.86 per 1,000 (92/8,469) ventilator days. The medians (interquartile ranges [IQRs]) of gestational age and birth weight in the VAP versus non-VAP groups were 31 (27–35) versus 34 (30–38) weeks, and 1,495 (813–2,593) versus 2,220 (1,405–2,940) g (p < 0.001, both), respectively. The medians (IQRs) of VFDs at 28 days in the VAP and non-VAP groups were 5 (0–16) and 24 (20–26) days (p < 0.001). From the univariate analysis, the lower VFDs, longer ventilator days, and higher rates of moderate-to-severe bronchopulmonary dysplasia (BPD), postnatal steroids for BPD, length of stay, and daily hospital cost in the VAP group were significantly higher than in the non-VAP group. From the multivariate analysis, the VAP group had significantly lower VFDs (regression coefficient = −10.99, standard error = 1.11, p < 0.001) and higher BPD (adjusted risk ratio = 18.70; 95% confidence interval = 9.17–39.5, p < 0.001) than the non-VAP group. Conclusion Neonatal VAP lead to lower VFDs and a higher frequency of BPD. A multimodal strategy with a VAP prevention bundle care should be used in indicated cases to reduce the occurrence of neonatal VAP. Key Points The VFDs of the neonatal VAP was lower than reported in adult study. There are limited data on VFDs in VAP during the neonatal period. Neonatal VAP reduces VFDs and increases BPD rates compared with non-VAP infants. [ABSTRACT FROM AUTHOR]

Objective Premature infants are at the risk of developing respiratory distress syndrome (RDS). Beractants and poractants are two commonly used natural surfactants. This retrospective cohort study aims to compare the incidence of pulmonary complications between beractant and poractant treatment groups. Study Design This study evaluated 29 patients treated with beractant and 49 patients treated with poractant. The primary outcome was the incidence of air leak syndrome (ALS) and pulmonary hemorrhage. Secondary outcomes included mortality and pulmonary outcomes, such as mechanical ventilation duration, oxygen dependence duration, fraction of inspired oxygen, and mean airway pressure (MAP) requirement. Logistic regression analyses were conducted to identify independent risk factors for significant primary outcomes. Results No significant difference was found in the demographics between the two groups. A significantly higher incidence of pulmonary hemorrhage was observed in the poractant group (14.3 vs. 0.0%, p = 0.038). The difference in the incidence of ALS between the groups was insignificant (p = 0.536). Logistic regression for the incidence of pulmonary hemorrhage identified coagulopathy as the only significant independent risk factor (odds ratio 39.855, 95% confidence interval [2.912–545.537]; p = 0.006). Secondary outcomes in both treatment groups were similar, except that patients in the poractant group had a higher MAP before surfactant therapy (9 vs. 8 cmH 2 O, p < 0.001). Conclusion This study showed a significantly higher incidence of pulmonary hemorrhage in the poractant group. Coagulopathy was identified as an independent risk factor for pulmonary hemorrhage. Future long-term prospective studies are essential to establish the temporal and causal relationships between coagulopathy and pulmonary hemorrhage in premature infants receiving surfactant therapy for RDS; hence, there is the need for a screening protocol before surfactant administration. Key Points A higher incidence of pulmonary hemorrhage was found in the poractant group. Coagulopathy was the only significant risk factor that was related to the incidence of pulmonary hemorrhage. A screening protocol might be useful to avoid pulmonary hemorrhage in infants receiving surfactant. [ABSTRACT FROM AUTHOR]

Objective 17-α-hydroxyprogesterone caproate (17-OHP) has been recommended by professional societies for the prevention of recurrent preterm birth, but subsequent clinical studies have reported conflicting efficacy results. This study aimed to contribute to the evidence base regarding the effectiveness of 17-OHP in clinical practice using real-world data. Study Design A total of 4,422 individuals meeting inclusion criteria representing recurrent spontaneous preterm birth (sPTB) were identified in a database of insurance claims, and 568 (12.8%) received 17-OHP. Crude and propensity score-matched recurrence rates and risk ratios (RRs) for the association of receiving 17-OHP on recurrent sPTB were calculated. Results Raw sPTB recurrence rates were higher among those treated versus not treated; after propensity score matching, no association was detected (26.3 vs. 23.8%, RR = 1.1, 95% CI: 0.9–1.4). Conclusion We failed to identify a beneficial effect of 17-OHP for the prevention of spontaneous recurrent preterm birth in our observational, U.S. based cohort. Key Points We observed higher risk for sPTB in the group receiving 17-OHP in the unmatched analysis After propensity-score matching, we still failed to identify a beneficial effect of 17-OHP on sPTB Sensitivity analyses demonstrated robustness to the inclusion criteria and modeling assumptions. [ABSTRACT FROM AUTHOR]

Objective Pyelonephritis is the most common nonobstetric cause for hospitalization during pregnancy. The maternal and obstetric complications associated with antepartum pyelonephritis are well described. However, it is not clear whether these risks extend into the postpartum period. The primary objective of this study was to describe the morbidity associated with postpartum pyelonephritis, by comparing the morbidity associated with pyelonephritis in the postpartum period to morbidity seen during pregnancy or delivery. Study Design A retrospective cohort study was performed using the Nationwide Readmissions Database (NRD), an all-payor sample of discharges from approximately 60% of U.S. hospitalizations. Discharges between October 2015 and December 2018 were included. Maternity-associated hospitalizations, diagnosis of pyelonephritis, comorbid conditions, and incidence of severe maternal morbidity were identified using International Classification of Disease-10th Revision (ICD-10) diagnosis and procedure codes. Bivariate statistics, weighted to account for the complex survey methods in the NRD, were used to evaluate the association between antepartum, delivery, and postpartum hospital stays associated with pyelonephritis and maternal morbidity. Weighted regression models were used to evaluate the association between admission timing and maternal outcomes. Results A total of 32,850 pyelonephritis admissions were identified, corresponding to a national estimate of 61,837 admissions. Of these, 1,465 (2.4%) were postpartum, 55,056 (89.0%) were antepartum, and 5,317 (8.6%) involved a delivery stay. Rates of severe maternal morbidity were higher in the postpartum group than the antepartum or delivery hospitalization groups (59.5 vs. 12.9 and 15.8%, respectively, p < 0.001); when compared with antepartum hospitalizations, the adjusted relative risk for composite severe maternal morbidity for postpartum hospitalizations was 4.68 (95% confidence interval [CI]: 4.33, 5.05). Most of this difference was driven by rates of sepsis (53.2 vs. 11.0 vs. 10.9%). Conclusion Though relatively uncommon, postpartum hospitalizations for pyelonephritis are associated with higher rates of severe maternal morbidity, driven by differential rates of sepsis, than are antepartum or delivery-associated hospitalizations. [ABSTRACT FROM AUTHOR]

Objective The primary objective was to estimate the initiation and adherence rates of 17 α-hydroxyprogesterone caproate (17OHPC) among eligible mothers in a statewide population-based cohort of Medicaid enrollees. The secondary objectives were to (1) determine the association of maternal sociodemographic and clinical characteristics with 17OHPC utilization and (2) assess the real-world effectiveness of 17OHPC on recurrent preterm birth prevention and admission to neonatal intensive care unit (NICU). Study Design This is a retrospective cohort study using a linked, longitudinal administrative dataset of birth certificates and medical assistance claims. Medicaid-enrolled mothers in Pennsylvania were included in this study if they had at least one singleton live birth from 2014 to 2016 following at least one spontaneous preterm birth. Maternal Medicaid claims were used to ascertain the use of 17OHPC from various manufacturers, including compounded formulations. Propensity score matching was used to create a covariate balance between 17OHPC treatment and comparison groups. Results We identified 4,781 Medicaid-covered 17OHPC-eligible pregnancies from 2014 to 2016 in Pennsylvania, 3.4% of all Medicaid-covered singleton live births. The population-based initiation rate was 28.5% among eligible pregnancies. Among initiators, 50% received ≥16 doses as recommended, while 10% received a single dose only. The severity of previous spontaneous preterm birth was the strongest predictor for the initiation and adherence of 17OHPC. In the matched treatment (n = 1,210) and comparison groups (n = 1,210), we found no evidence of 17OHPC effectiveness. The risks of recurrent preterm birth (relative risk [RR] 1.10, 95% confidence interval [CI] 0.97–1.24) and births admitted to NICU (RR 1.00, 95% CI 0.84–1.18) were similar in treated and comparison mothers. Conclusion The 17OHPC-eligible population represented 3.4% of singleton live births. Less than one-third of eligible mothers initiated treatment. Among initiators, 50% were treatment adherent. We found no difference in the risk of recurrent preterm birth or admission to NICU between treatment and comparison groups. Key Points About 3.4% of singleton live births were eligible for 17OHPC. About 30% of eligible mothers initiated treatment. We found no association of 17OHPC with recurrent preterm birth. [ABSTRACT FROM AUTHOR]

Objective To determine if women who newly met criteria for stage 1 hypertension in early pregnancy were at increased risk for adverse perinatal outcomes compared with normotensive women. Study Design We conducted a retrospective cohort study of women who had prenatal care at a single institution and subsequently delivered a live infant between December 2017 and August 2019. Women with a singleton gestation who had at least two prenatal visits prior to 20 weeks of gestation were included. We excluded women with known chronic hypertension or other major maternal illness. Two groups were identified: (1) women newly diagnosed with stage 1 hypertension before 20 weeks of gestation (blood pressure [BP]: 130–139/80–89 on at least two occasions) and (2) women with no known history of hypertension and normal BP (<130/80 mm Hg) before 20 weeks of gestation. The primary outcome was any hypertensive disorder of pregnancy; secondary outcomes were indicated preterm birth and small for gestational age. Generalized linear models were used to compare risk of adverse outcomes between the groups. Results Of the 1,630 women included in the analysis, 1,443 women were normotensive prior to 20 weeks of gestation and 187 women (11.5%) identified with stage 1 hypertension. Women with stage 1 hypertension were at significantly increased risk for any hypertensive disorder of pregnancy (adjusted risk ratio [aRR]: 1.86, 95% confidence interval [CI]: 1.12–3.04) and indicated preterm birth (aRR: 1.83, 95% CI: 1.12–3.02). Black women and obese women with stage 1 hypertension were at increased for hypertensive disorder of pregnancy compared with white women and nonobese women, respectively (aRR: 1.32, 95% CI: 1.11–1.57; aRR: 1.69, 95% CI: 1.39–2.06). Conclusion These results provide insight about the prevalence of stage 1 hypertension and inform future guidelines for diagnosis and management of hypertension in pregnancy. Future research is needed to assess potential interventions to mitigate risk. Key Points Stage 1 hypertension increased risk for hypertensive disorders of pregnancy and indicated preterm birth. Among women with stage 1 hypertension, risk of severe preeclampsia was 2.6 times higher than normotensive women. Black and obese women with stage 1 hypertension were at additional risk for adverse outcomes. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to compare the frequency and timing of laboratory abnormalities and evaluate optimal laboratory testing strategies in women with preeclampsia (PE) undergoing expectant management. Study Design Retrospective cohort study of women with inpatient expectant management of PE at ≥23 weeks at a tertiary center from 2015 to 2018 was conducted. Women ineligible for expectant management or with less than two laboratory sets (platelets, aspartate aminotransferase, and serum creatinine) before the decision to deliver were excluded. Women were categorized as per the American College of Obstetricians and Gynecologists' definitions by initial diagnosis: PE without severe features, superimposed preeclampsia (SiPE) without severe features, and their forms with severe features. The frequency and timing of laboratory abnormalities were compared across the four PE categories. Kaplan–Meier curves modeled time to a laboratory abnormality (event) with censoring for delivery and were compared using log-rank tests. Logistic regression analysis modeled the development of a laboratory abnormality as a function of testing time intervals (days) for each PE type. Receiver operating characteristic curves and areas under the curve (AUC) were calculated; optimal cut points were determined using the Liu method. Results Among 636 women who met inclusion criteria, laboratory abnormalities were uncommon (6.3%). The median time to a laboratory abnormality among all women was ≤10 days, time being shortest in women with PE with severe features. Time to laboratory abnormality development did not differ significantly between the four PE groups (p = 0.36). Laboratory assessment intervals were most predictive for PE and SiPE with severe features (AUC = 0.87, AUC = 0.72). Optimal cutoffs were every 4 days for PE without severe features, 2 days for PE with severe features, 8 days for SiPE without severe features, and 3 days for SiPE with severe features. Conclusion Most laboratory abnormalities in PE occur earlier and more frequently in those with severe features. Individual phenotypes should undergo serial evaluation based on this risk stratification. Key Points Most laboratory abnormalities occur within 10 days of diagnosis. Laboratory abnormalities occur more often with severe features. Laboratory testing should occur according to disease severity. [ABSTRACT FROM AUTHOR]

Objective Urinary tract infections are among the most common infections during pregnancy. The association between symptomatic lower urinary tract infections during pregnancy and fetal and maternal complications such as preterm birth and low birthweight remains unclear. The aim of this research is to evaluate the association between urinary tract infections during pregnancy and maternal and neonatal outcomes, especially preterm birth. Study Design This study is a secondary analysis of a multicenter prospective cohort study, which included patients between October 2011 and June 2013. The population consists of women with low risk singleton pregnancies. We divided the cohort into women with and without a symptomatic lower urinary tract infection after 20 weeks of gestation. Baseline characteristics and maternal and neonatal outcomes were compared between the two groups. Multivariable logistic regression analysis was used to correct for confounders. The main outcome was spontaneous preterm birth at <37 weeks. Results We identified 4,918 pregnant women eligible for enrollment, of whom 9.4% had a symptomatic lower urinary tract infection during their pregnancy. Women with symptomatic lower urinary tract infections were at increased risk for both preterm birth in general (12 vs. 5.1%, adjusted OR 2.5; 95% CI 1.7–3.5) as well as a spontaneous preterm birth at <37 weeks (8.2 vs. 3.7%, adjusted OR 2.3; 95% CI 1.5–3.5). This association was also present for early preterm birth at <34 weeks. Women with symptomatic lower urinary tract infections during pregnancy are also at increased risk of endometritis (8.9 vs. 1.8%, adjusted OR 5.3; 95% CI 1.4–20) and mastitis (7.8 vs. 1.8%, adjusted OR 4.0; 95% CI 1.6–10) postpartum. Conclusion Low risk women with symptomatic lower urinary tract infections during pregnancy are at increased risk of spontaneous preterm birth. In addition, an increased risk for endometritis and mastitis postpartum was found in women with symptomatic lower urinary tract infection during pregnancy. Key Points UTIs increase the risk of preterm birth. UTIs increase the risk of endometritis postpartum. UTIs increase the risk of mastitis postpartum. [ABSTRACT FROM AUTHOR]

Objective This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. Study Design Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. Results A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). Conclusion Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. Key Points Maternal morbidity increase with each CD. Absolute adverse outcomes remains low in highest order CDs. In women without placenta previa, there is no added morbidity with additional CDs. [ABSTRACT FROM AUTHOR]

Objective Retosiban, an oxytocin receptor antagonist, was developed for treating spontaneous preterm labor (sPTL) in women with intact membranes. This ARIOS follow-up study aimed to characterize clinical safety, morbidity, and mortality of infants exposed to retosiban or comparator over 2 years. Study Design ARIOS prospectively assessed outcomes in infants whose mothers received at least one dose of retosiban or comparator (placebo/atosiban) in two Phase 3 sPTL trials. Both trials were terminated prematurely owing to poor enrolment. Infants could be enrolled into ARIOS from 28 days after estimated due date until hospital discharge or up to 9 months (corrected age). An internally developed questionnaire detailing medical conditions, mortality and resource use (Child Health Inventory; CHI), Ages and Stages Questionnaire-3 (ASQ-3), Modified Checklist for Autism in Toddlers–Revised with Follow-Up, and Child Behavior Checklist for Ages 1.5 to 5 were completed remotely by parents or legal guardians at prespecified intervals. Serious adverse events (SAEs) were primarily captured via CHI. No comparative statistical analysis was conducted between treatment arms. Results A total of 49 (86%) infants who had received retosiban and 49 (78%) infants who had received a comparator were enrolled in ARIOS. No deaths occurred during the study. Nine infants experienced SAEs: 6/49 (12.2%) infants in the comparators group and 3/49 (6.1%) in the retosiban group. Of the nine SAEs, seven were due to infections, three, and four in the retosiban and comparators groups, respectively. Based on ASQ-3 score, the incidence of neurodevelopmental delay at 18 and 24 months were 0/18 (0%) and 2/25 (8%) with retosiban and 7/22 (31.8%) and 3/21 (14.3%) with comparator, respectively. Conclusion The current study showed no unexpected adverse outcome or impairment with retosiban based on safety monitoring and neurodevelopment assessments. No further follow-up is intended owing to the discontinuation of clinical development of retosiban. Key Points There is a need for an effective and safe treatment for sPTL. ARIOS was a follow-up study of two Phase 3 trials in sPTL. There were no safety concerns with retosiban treatment. Slow recruitment led to termination of the Phase 3 trials. [ABSTRACT FROM AUTHOR]

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points ERAS after cesarean reduces inpatient opioid consumption. ERAS after cesarean increases the proportion of women not consuming any opioids. This pathway can be feasibly adopted elsewhere. [ABSTRACT FROM AUTHOR]

Objective The goal of this study was to investigate whether preexisting cardiac arrhythmias are associated with adverse obstetrical outcomes in women with a history of open cardiac surgery. Study Design This was a retrospective cohort study of women with a history of open cardiac surgery who delivered at MedStar Washington Hospital Center (Washington, DC) from January 2007 through December 2018. Women with the isolated percutaneous cardiac surgical repair were excluded. Maternal and neonatal outcomes were compared between patients with preexisting cardiac arrhythmias and patients without preexisting cardiac arrhythmias. Maternal outcomes studied were intensive care unit admission, postpartum blood loss greater than 1,000 mL, congestive heart failure development, preeclampsia with severe features, postpartum readmission, postpartum cardiac events, and postpartum length of stay >5 days. Neonatal outcomes investigated were low birth weight <2,500 g, Apgar's scores <7 at 5 minutes, and neonatal intensive care unit admission. Multivariate logistic regression model was used to calculate the adjusted odds ratio (aOR) and 95% confidence intervals. Results The outcomes for 69 deliveries from 56 women with a history of open cardiac surgery were examined. Thirty-three women (48%) had arrhythmias after cardiac surgery with fourteen (20%) requiring implantable cardioverted defibrillators. Two women (6%) with preexisting arrhythmias after cardiac surgery developed postpartum volume overload requiring readmission (p = 0.06). After controlling for age, gestational age at delivery, and BMI, preeclampsia with severe features (p = 0.02) and low birth weight neonates (p = 0.02, aOR = 2.26 [0.56–9.03]) remained statistically more like to occur in patients with preexisting cardiac arrhythmias than in patients without preexisting arrhythmias. Conclusion Women with a history of open cardiac surgery and preexisting cardiac arrhythmias prior to pregnancy are more likely to develop preeclampsia with severe features and have low birth weight neonates compared with women with a history of open cardiac surgery without preexisting cardiac arrhythmias. Key Points Preexisting arrhythmias after cardiac surgery was associated with a risk of preeclampsia. Neonates of women with preexisting cardiac arrhythmias are more likely to be low birth weight. Forty-seven percent of women with open cardiac surgery developed subsequent arrhythmias. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. Study Design This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < − 1, −1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m 2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. Results Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m 2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23–2.41) Women who lost 1 kg/m 2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04–2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m 2 or more and weight gain of ≥4 kg/m 2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. Conclusion Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. Key Points Significant weight gain between deliveries increases the risk of neonatal death. Modest weight loss between deliveries increases the risk of neonatal death. This risk may be partially explained by increased risk of congenital malformations. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to determine whether stage 1 hypertension is a risk factor for cesarean at ≥39 0/7 weeks. Study Design This is a retrospective cohort study of nulliparas delivering at ≥39 0/7 weeks. Exposure was defined as stage 1 hypertension and compared with normotension. The primary outcome was unplanned cesarean. Statistical analysis was performed using SPSS 27. Results Two hundred and fifty patients had stage 1 hypertension and 250 had normotension. Thirty-eight percent of the patients with stage 1 hypertension required cesarean as did 22% of controls (risk ratio [RR]=1.55, 95% confidence interval [CI]: 1.23–1.96, p <0.001). This remained significant after controlling for confounders in a logistic regression (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.02–2.55, p <0.040). Upon secondary analysis, these results were statistically significant for gestational age ≥39 5/7 weeks (adjusted odds ratio [AOR]=1.89, 95% CI: 1.05–3.39, p =0.033) but not from 39 0/7 to 39 4/7 weeks (AOR=0.68, 95% CI: 0.31–1.50, p =0.34). Conclusion In nulliparas, stage 1 hypertension is an independent risk factor for unplanned cesarean. Key Points Stage 1 hypertension correlates with more cesareans. Unplanned cesarean for nonreassuring fetal status correlates with impaired placental function. Stages 1 and 2 hypertension carry similar risks. [ABSTRACT FROM AUTHOR]

Objective Our objective was to assess whether variables from an index pregnancy (PG1) can be used to guide testing for gestational diabetes mellitus (GDM) in a subsequent pregnancy (PG2) and to create a risk calculator for GDM in PG2. Study Design This was a retrospective cohort study of patients delivering ≥2 singleton gestations at >24 weeks' gestation from June 2009 to December 2018, for whom results of a 1-hour glucose challenge test (GCT) were available from PG1. Univariable and multivariable analyses were performed to evaluate factors associated with GDM in PG2. Results In total, 4,278 patients met the inclusion criteria. Among patients with a normal 1-hour GCT (<140 mg/dL) in PG1 (n = 3,719), 3.9% were diagnosed with GDM in PG2. In multivariable analysis of this group, GDM in PG2 was associated with higher GCT in PG1 (adjusted odds ratio [aOR]: 1.05, 95% confidence interval [CI]: 1.04–1.06), large for gestational age neonate in PG1 (aOR: 1.97, 95% CI: 1.24–3.13), and higher BMI (aOR: 1.08, 95% CI: 1.05–1.11). A novel risk calculator for GDM in PG2 was developed based on these associations. Using a risk cut-off of 15%, the calculator had a positive predictive value of 26% and a negative predictive value of 97%, with 3.2% of patients identified as "at risk". Among patients with abnormal 1-hour GCT in PG1, 38.3% (n = 214/559) had an abnormal 1-hour GCT in PG2 and 34.5% (n = 74/214) of these patients received a diagnosis of GDM. Conclusion A normal 1-hour GCT in an PG1 is followed by GDM in a subsequent pregnancy in only 3.9% of cases. A novel calculator supports replacing universal screening with targeted testing in subsequent pregnancies in this population. Among patients with an abnormal 1-hour GCT in PG1, nearly 40% have an abnormal 1-hour GCT in a subsequent pregnancy. Direct diagnostic testing can be considered in such patients. Key Points Normal GCT in a first pregnancy is associated with normal GCT in subsequent pregnancy. A risk calculator can target diabetes testing in a subsequent pregnancy. Abnormal GCT in a first pregnancy is associated with abnormal GCT in subsequent pregnancy. [ABSTRACT FROM AUTHOR]

Objective This study aimed to evaluate if supraumbilical midline vertical incision performed in patients with a hanging pannus (umbilicus at the level of the pubic bone) is a reasonable alternative to the Pfannenstiel in patients with body mass index (BMI) ≥ 50 kg/m 2 undergoing cesarean delivery. Study Design Retrospective cohort study in patients with BMI ≥ 50 kg/m 2 undergoing cesarean delivery at a single center from 2016 to 2020. Study groups were Pfannenstiel's versus supraumbilical vertical skin incision. If patients had a hanging pannus (umbilicus at the level of the pubic bone), vertical incisions were performed. Otherwise, Pfannenstiel's incision was performed. Decision for the incision was made prospectively. Primary outcome was a composite of need for blood transfusion, presence of immediate surgical complications, and presence of delayed surgical complications. Secondary outcomes included the individual components of the primary outcome, the median surgical blood loss, total operative time, time from skin incision to delivery of neonate, hysterotomy type, and neonatal outcomes. MedCalc 19.5.1 was used for analysis. Results A total of 103 patients with BMI ≥50 kg/m 2 were included. Of those, 68 (66%) had Pfannenstiel's and 35 (34%) had supraumbilical vertical incisions. There was no statistically significant difference in the incidence of the primary outcome (12 vs. 11%, p = 0.96). There was neither significant difference in immediate or delayed postoperative complications nor in neonatal outcomes. However, patients in the vertical midline incision group were more likely to have a classical hysterotomy (52%) compared with the Pfannenstiel group (6%; p < 0.05), increased overall median surgical blood loss (1,000 vs. 835 mL, p < 0.05), and increased total surgical time by a median of 30 minutes (p < 0.05). Conclusion In patients with super obesity and hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and implications in future pregnancies. Key Points Patients with BMI >50 kg/m 2 were allocated to different incision types based on subcutaneous fat distribution pattern. If umbilicus was at level of pubic bone, supraumbilical vertical skin incision was made There were no significant differences between Pfannenstiel's and supraumbilical vertical incisions in terms of the composite outcome and immediate or delayed postoperative complications and neonatal outcomes. In patients with a hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and subsequent implications in future pregnancies. [ABSTRACT FROM AUTHOR]

Objectives The aim of the study was to: (1) Identify (early in pregnancy) psychosocial and stress-related factors that predict risk of spontaneous preterm birth (PTB, gestational age <37 weeks); (2) Investigate whether "protective" factors (e.g., happiness/social support) decrease risk; (3) Use the Dhabhar Quick-Assessment Questionnaire for Stress and Psychosocial Factors (DQAQ-SPF) to rapidly quantify harmful or protective factors that predict increased or decreased risk respectively, of PTB. Study Design This is a prospective cohort study. Relative risk (RR) analyses investigated association between individual factors and PTB. Machine learning-based interdependency analysis (IDPA) identified factor clusters, strength, and direction of association with PTB. A nonlinear model based on support vector machines was built for predicting PTB and identifying factors that most strongly predicted PTB. Results Higher levels of deleterious factors were associated with increased RR for PTB: General anxiety (RR = 8.9; 95% confidence interval [CI] = 2.0,39.6), pain (RR = 5.7; CI = 1.7,17.0); tiredness/fatigue (RR = 3.7; CI = 1.09,13.5); perceived risk of birth complications (RR = 4; CI = 1.6,10.01); self-rated health current (RR = 2.6; CI = 1.0,6.7) and previous 3 years (RR = 2.9; CI = 1.1,7.7); and divorce (RR = 2.9; CI = 1.1,7.8). Lower levels of protective factors were also associated with increased RR for PTB: low happiness (RR = 9.1; CI = 1.25,71.5); low support from parents/siblings (RR = 3.5; CI = 0.9,12.9), and father-of-baby (RR = 3; CI = 1.1,9.9). These factors were also components of the clusters identified by the IDPA: perceived risk of birth complications (p < 0.05 after FDR correction), and general anxiety, happiness, tiredness/fatigue, self-rated health, social support, pain, and sleep (p < 0.05 without FDR correction). Supervised analysis of all factors, subject to cross-validation, produced a model highly predictive of PTB (AUROC or area under the receiver operating characteristic = 0.73). Model reduction through forward selection revealed that even a small set of factors (including those identified by RR and IDPA) predicted PTB. Conclusion These findings represent an important step toward identifying key factors, which can be assessed rapidly before/after conception, to predict risk of PTB, and perhaps other adverse pregnancy outcomes. Quantifying these factors, before, or early in pregnancy, could identify women at risk of delivering preterm, pinpoint mechanisms/targets for intervention, and facilitate the development of interventions to prevent PTB. Key Points Newly designed questionnaire used for rapid quantification of stress and psychosocial factors early during pregnancy. Deleterious factors predict increased preterm birth (PTB) risk. Protective factors predict decreased PTB risk. [ABSTRACT FROM AUTHOR]

Objective  Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and screening via fundal height or ultrasound is routinely performed. During the novel coronavirus disease 2019 (COVID-19) pandemic, we developed a hybrid model of prenatal care which decreased the frequency of in-person visits and incorporated telemedicine visits. We sought to determine if prenatal FGR diagnoses decreased with this hybrid model compared with routine prenatal care. Study Design  This was a retrospective cohort study of singleton nonanomalous neonates with birth weights <10th percentile at term. The "routine care" group was consisted of those who born between April and July 2019 with in-person prenatal care, and the "hybrid care" group was consisted of those who born between April and July 2020 with both in-person and telemedicine prenatal cares at a collaborative academic practice. The primary outcome was the rate of diagnosis of small for gestational age (SGA) as defined as infant birth weight <10th percentile without a prenatal diagnosis of FGR. The secondary outcome was timing of diagnosis of FGR. Results  Overall, 1,345 and 1,296 women gave birth in the routine and hybrid groups, respectively. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7,727 in the hybrid period; 3,265 telemedicine visits occurred during the hybrid period. The total number of prenatal patients remained relatively stable at 3,993 and 3,753 between periods. Third trimester ultrasounds decreased from 2,929 to 2,014 between periods. Birth weights <10 percentile occurred in 115 (8.6%) births during the routine period and 79 (6.1%) births during the hybrid period. Of 115, 44 (38.3%) cases were prenatally diagnosed with FGR in the routine versus 28 of 79 (35.4%) in the hybrid group (p  = 0.76). Median gestational age at diagnosis did not vary between groups (36 vs. 37 weeks, p  = 0.44). Conclusion  A hybrid prenatal care model did not alter the detection of FGR. Future efforts should further explore the benefits of incorporating telemedicine into prenatal care. Key Points Telemedicine visits can provide comprehensive prenatal care. FGR was diagnosed equally with hybrid versus routine prenatal care. FGR diagnosis was not delayed with hybrid care. [ABSTRACT FROM AUTHOR]

Objective  Management of delivery at periviable gestation requires complex counseling and decision making, including difficult choices about monitoring and potential cesarean delivery (CD) for fetal benefit. Our objective was to characterize decisions that patients make regarding fetal monitoring and potential CD for fetal benefit when delivering in the periviable period, and associations with perinatal and obstetric outcomes. We hypothesize that a significant number of patients forgo monitoring and potential CD for fetal benefit in the periviable period when offered the opportunity to do so. Study Design  Retrospective cohort study of nonanomalous singleton pregnancies delivering between 23 0/7 and 25 6/7 weeks at a tertiary care center from 2015 to 2020 as based on our institutional clinical practice. Since 2015, these patients are offered the ability to accept or decline fetal monitoring, potential CD for fetal benefit, and active resuscitation of a liveborn neonate. The frequency of patients desiring potential CD for fetal benefit was identified, and associations with CD and intrapartum demise were analyzed. Results  Fifty subjects were included. Seventy-eight percent (n  = 39) desired monitoring and potential CD for fetal benefit, and 84% (n  = 42) desired resuscitation if the neonate was born alive. This varied by gestational age: 55% (6/11) of patients delivering between 23 0/7 and 23 6/7 weeks desired fetal monitoring and potential CD for fetal benefit, while 90% (19/21) of patients delivering between 25 0/7 and 25 6/7 weeks desired fetal monitoring and potential CD for fetal benefit (p  = 0.02). Sixty-nine percent of pregnancies in which potential CD for fetal benefit was desired resulted in CD (27/39), of which 85% were classical (23/27). Intrapartum fetal demise occurred in 45% (5/11) of pregnancies in which monitoring was not performed. Conclusion  While a majority of patients delivering between 23 0/7 and 25 6/7 weeks desired monitoring and potential CD for fetal benefit, this varied significantly by gestational age. The decision to perform monitoring and potential CD for fetal benefit was associated with a high frequency of CD, while the decision to forgo monitoring was associated with high frequency of intrapartum demise. Key Points Patients desires vary in the setting of periviable delivery. Periviable monitoring is associated with cesarean delivery. Forgoing monitoring is associated with intrapartum demise. [ABSTRACT FROM AUTHOR]

Objective  This study was aimed to develop models using multiple cytokine/chemokine levels in cervicovaginal fluid (CVF) and plasma and widely used noninvasive parameters that have better accuracy for predicting intra-amniotic infection and/or inflammation (IAI) and imminent spontaneous preterm delivery (SPTD, ≤48 hours) in women with preterm labor (PTL). Study Design  This was a retrospective cohort study of 95 singleton pregnant women with PTL (23–34 weeks) who underwent amniocentesis. Both CVF and plasma samples were obtained at the time of amniocentesis, and serum C-reactive protein (CRP) levels were measured. The amniotic fluid (AF), CVF, and plasma samples were assayed for interleukin (IL)-6, IL-8, IL-10, monocyte chemotactic protein-1 (MCP-1), and macrophage inflammatory protein-1β (MIP-1β) levels using a multiplex immunoassay kit. Results  The levels of most cytokines/chemokines measured in the AF and CVF were significantly higher in the women with than in those without IAI and imminent SPTD, whereas only high-plasma IL-10 level showed a significant association with imminent SPTD. In predicting IAI, proteins in AF had significantly higher areas under the curves (AUCs) than those in CVF and plasma. However, for predicting imminent SPTD, no significant differences in the AUCs of the outcome-associated proteins were observed among the measurements in AF, CVF, and maternal plasma. By using stepwise regression analyses, noninvasive models (using protein levels in CVF and baseline clinical parameters) were developed for the prediction of IAI and imminent SPTD. The AUC of these noninvasive models were similar to those of the invasive models (using AF protein levels and baseline clinical parameters). Conclusion  Noninvasive models based on CVF cytokine/chemokine levels and widely used noninvasive parameters (especially CRP) act as good indicators for predicting the risk of IAI and imminent SPTD in women with PTL. Evaluation of cytokine/chemokine levels in plasma samples did not add valuable information regarding the two outcome measures in the PTL setting. Key Points Markers in either CVF or plasma alone did not have sufficient accuracy for predicting IAI and SPTD. Noninvasive models using CVF cytokine and CRP act as effective tools for predicting two outcomes. Evaluation of cytokine level in plasma did not add valuable information regarding two outcomes. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to describe the overall quantity and type of supplements and medications used during pregnancy in a low-risk cohort and to examine any racial/ethnic differences in intake. Study Design  We used data from 2,164 racially/ethnically diverse, nonobese, and low-risk pregnant women participating without pre-pregnancy chronic conditions in a prospective cohort study at 12 sites across the United States. Medication data were self-reported as free text in enrollment, follow-up visit questionnaires, and abstracted from medical records at delivery. Supplements and medications data were mapped to their active ingredients and categorized into corresponding classes using the Slone Drug Dictionary. The total number and classes of supplements and medications consumed during pregnancy were calculated. Modified Poisson regression models were used to estimate the racial/ethnic differences in supplements and medications intake. All models were adjusted for maternal sociodemographic factors and study site. Results  98% of women took at least one supplement during pregnancy, with prenatal vitamins/multivitamins being most common. While only 31% reported taking no medications during pregnancy, 23% took one, 18% took two, and 28% took three or more. The percentage of women taking at least one medication during pregnancy was highest among non-Hispanic white women and lowest among Asians (84 vs. 55%, p  < 0.001). All racial/ethnic groups reported taking the same top four medication classes including central nervous system agents, gastrointestinal drugs, anti-infective agents, and antihistamines. Compared with non-Hispanic white women, Hispanic (adjusted relative risk [aRR]: 0.84, 95% confidence interval [CI]: 0.71–0.98), and Asian women (aRR: 0.83, 95% CI: 0.70–0.98) were less likely to take central nervous system agents, as well as gastrointestinal drugs (Hispanics aRR: 0.79, 95% CI: 0.66–0.94; Asians aRR = 0.75, 95% CI: 0.63–0.90), and antihistamines (Hispanics aRR: 0.65, 95% CI: 0.47–0.92). Conclusion  Supplement intake was nearly universal. Medication use was also common among this low-risk pregnancy cohort and differed by race/ethnicity. ClinicalTrials.gov Identifier  NCT00912132. Key Points In women without chronic conditions, medication use is common. Racial/ethnic differences exist in prenatal medications use. Almost all women use supplements during pregnancy. [ABSTRACT FROM AUTHOR]

Objective  Outside of pregnancy, urinary pathogens such as Proteus and Klebsiella are considered more pathogenic than E. coli. During pregnancy, the implications of lower urinary tract infection (LUTI) with more pathogenic bacteria are unclear. Thus, we sought to compare the risk of progression from LUTI to pyelonephritis among women infected with these more pathogenic urinary bacteria to those infected with E. coli. Study Design  Retrospective cohort of pregnant women with LUTI at single tertiary center from July 2013 to May 2019. Pathogenic infections (PI) were defined as asymptomatic bacteriuria or acute cystitis urinary cultures positive for Proteus , Klebsiella , Enterobacter , Citrobacter , Acinetobacter , Staphylococcus , or Raoultella species. Demographic, infectious, antepartum, and postpartum data abstracted. Pregnant women with PI compared with those with E. coli. Primary outcome was progression to pyelonephritis. Secondary outcomes included pyelonephritis length of stay (LOS) >6 days, preterm birth (PTB), low birthweight (LBW), and measures of pyelonephritis-related morbidity. Results  Of 686 pregnant women with LUTIs, 313 had urine culture growing out either PI or E. coli , with 59 (12%) growing PI and 254 (54%) growing E. coli. Women with PI were more likely to be African American, have chronic hypertension, and have history of preeclampsia. The primary species causing PI were Klebsiella (n  = 29) and Proteus (n  = 11). PI were not more likely to progress to pyelonephritis than E. coli LUTIs (10.9 vs. 14.5%; p  = 0.67). Median LOS for pyelonephritis and other measures of pyelonephritis-related morbidity did not differ nor did PTB or LBW rates. After controlling for race, body mass index, history of preeclampsia, and history of pyelonephritis, PI were not associated with increased odds of progression to pyelonephritis (adjusted odds ratio: 0.69, 95% confidence interval: 0.27–1.80). Conclusion  Bacteria traditionally considered to be more pathogenic outside of pregnancy do not progress to pyelonephritis at higher rates than E. coli in pregnancy, and are associated with similar pyelonephritis-related morbidity. Larger studies are needed to confirm these findings. Key Points Little is known about impact of uropathogen on progression to pyelonephritis and obstetric outcomes. Rates of progression to pyelonephritis from UTI did not vary by uropathogen. Pyelonephritis-related morbidities and preterm birth rates were also similar among uropathogens. [ABSTRACT FROM AUTHOR]

Objective  The aim of this study is to evaluate formal bereavement debriefing sessions after infant death on neonatal intensive care unit (NICU) staff. Study Design  Prospective mixed methods study. Pre- and postbereavement debriefing intervention surveys were sent to clinical staff. Evaluation surveys were distributed to participants after each debriefing session. Notes on themes were taken during each session. Results  More staff attended sessions (p  < 0.0001) and attended more sessions (p  < 0.0001) during the postdebriefing intervention epoch compared with the predebriefing epoch. Stress levels associated with the death of a patient whose family the care provider have developed a close relationship with decreased (p  = 0.0123). An increased number of debriefing session participants was associated with infant age at the time of death (p  = 0.03). Themes were (1) family and provider relationships, (2) evaluation of the death, (3) team cohesion, (4) caring for one another, and (5) emotional impact. Conclusion  Bereavement debriefings for NICU staff reduced the stress of caring for dying infants and contributed to staff well-being. Key Points Providing end-of-life care in NICU is challenging. Debriefings assist staff in coping with grief. Staff well-being impacts patient care. [ABSTRACT FROM AUTHOR]

Objective  Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM. Study Design  A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process. Results  There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p  = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p  = 0.005). Conclusion  We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes. Key Points Benefit to routine review of SMM has not been demonstrated. Routine review of SMM is associated with 36% reduction in potentially preventable SMM. This is the first study to demonstrate the benefit of routine review of SMM. [ABSTRACT FROM AUTHOR]

Objective  Short-term morbidity of placenta accreta spectrum (PAS) is well described, but few data are available regarding long-term outcomes and quality of life. We aimed to evaluate patient-reported outcomes after hysterectomy for PAS. Study Design  This is a prospective cohort study of women with risk factors for PAS who were enrolled antenatally. Exposed women were defined as those who underwent cesarean hysterectomy due to PAS. Unexposed women were those with three or more prior cesareans or placenta previa, but no PAS, who underwent cesarean delivery without hysterectomy. Two surveys were sent to patients at 6, 12, 24, and 36 months postpartum: (1) a general health questionnaire and (2) the SF-36, a validated quality of life survey. Aggregate scores for each questionnaire were calculated and responses were analyzed. Results  At 6 months postpartum, women with PAS were more likely to report rehospitalization (odds ratio [OR] 5.83, 95% confidence interval [CI] 1.40–24.3), painful intercourse (OR 2.50, 95% CI 1.04–6.02), and anxiety/worry (OR 3.77, 95% CI 1.43–9.93), but were not statistically more likely to report additional surgeries (OR 3.39, 95% CI 0.99–11.7) or grief and depression (OR 2.45, 95% CI 0.87–6.95). At 12 months, women with PAS were more likely to report painful intercourse, grief/depression, and anxiety/worry. At 36 months, women with PAS were more likely to report grief/depression, anxiety/worry, and additional surgeries. Women with PAS reported significantly lower quality of life in physical functioning, role functioning, social functioning, and pain at 6 months postpartum, but not in other quality of life domains. Decreased quality of life was also reported at 12 and 36 months in the PAS group. Conclusion  Women with PAS are more likely to report ongoing long-term health issues and decreased quality of life for up to 3 years following surgery than those undergoing cesarean for other indications. Key Points Long-term placenta accreta spectrum data to guide peripartum patient education. This study addresses a critical knowledge gap. Women affected by PAS report long-term morbidity. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS). Study Design  This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center. Results  Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 34 4/7  ± 1 1/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta. Conclusion  Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140–254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500–5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS. Key Points PAS is associated with severe maternal morbidity. Decreased operative time and blood loss have many clinical benefits. Reloadable stapler use for PAS decreases operative time. Reloadable stapler use for PAS decreases operative blood loss. [ABSTRACT FROM AUTHOR]

Objective  The objective of this study was to create three point-of-care predictive models for very preterm birth using variables available at three different time points: prior to pregnancy, at the end of the first trimester, and mid-pregnancy. Study Design  This is a retrospective cohort study of 359,396 Ohio Medicaid mothers from 2008 to 2015. The last baby for each mother was included in the final dataset. Births prior to 22 weeks were excluded. Multivariable logistic regression was used to create three models. These models were validated on a cohort that was set aside and not part of the model development. The main outcome measure was birth prior to 32 weeks. Results  The final dataset contained 359,396 live births with 6,516 (1.81%) very preterm births. All models had excellent calibration. Goodness-of-fit tests suggested strong agreement between the probabilities estimated by the model and the actual outcome experience in the data. The mid-pregnancy model had acceptable discrimination with an area under the receiver operator characteristic curve of approximately 0.75 in both the developmental and validation datasets. Conclusion  Using data from a large Ohio Medicaid cohort we developed point-of-care predictive models that could be used before pregnancy, after the first trimester, and in mid-pregnancy to estimate the probability of very preterm birth. Future work is needed to determine how the calculator could be used to target interventions to prevent very preterm birth. Key Points We developed predictive models for very preterm birth. All models showed excellent calibration. The models were integrated into a risk calculator. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to determine the accuracy of neonatal lung ultrasound (LUS) in predicting the need for surfactant therapy compared with chest X-ray (CXR) in preterm infants. Study Design  A prospective double-blind study was conducted in infants with a gestational age <34 weeks with respiratory distress syndrome (RDS) by evaluation with LUS and CXR on admission. Results  Among 45 preterm infants, the median (interquartile range [IQR]) LUS score was 4 (2–8) in the mild RDS group, whereas it was 10 (IQR: 9–12) in the severe RDS group (p  < 0.01). The LUS score showed a significant correlation with the need for total surfactant doses (ρ  = 0.855; 95% confidence interval [CI]: 0.801–0.902; p  < 0.001). A cut-off LUS score of four predicted the need for surfactant with 96% sensitivity and 100% specificity (area under the curve [AUC]: 1.00; 95% CI: 0.97–1.00; p  < 0.01). LUS scores predicted continuous positive airway pressure (CPAP) failure accurately (AUC: 0.804; 95% CI: 0.673–0.935; p  = 0.001). A significant correlation was observed between LUS scores and positive end-expiratory pressure levels (ρ  = 0.782; p  < 0.001). During the study period, the CXR number per infant with RDS decreased significantly when compared with preceding months (p  < 0.001). The LUS score in the first day of life did not predict the development of bronchopulmonary dysplasia (AUC: 0.274; 95% CI: 0.053–0.495; p  = 0.065). Conclusion  The LUS score in preterm infants accurately predicts the severity of RDS, the need for surfactant and CPAP failure. The routine use of LUS can decrease the frequency of CXRs in the neonatal intensive care units. Key Points LUS is a nonhazardous bedside technique. LUS predicts the need for surfactant in preterm infants. LUS predicts the severity of RDS better than CXR. [ABSTRACT FROM AUTHOR]

Objective  The optimal noninvasive ventilation (NIV) modality in the treatment of transient tachypnea of the newborn (TTN) is still unknown. The aim of this study was to compare nasal continuous positive airway pressure (NCPAP) versus bi-level CPAP in the treatment of TTN. Study Design  This was a prospective randomized study that was conducted in a tertiary level neonatal intensive care unit of Zekai Tahir Burak Women's Health Education and Research Hospital during the 1-year period between April 2017 and March 2018. The study included infants at ≥34 gestational weeks and birth weight ≥2,000 g who were diagnosed with TTN. The patients were randomized to either NCPAP or bi-level CPAP groups as initial respiratory support. The primary outcome was the rate of NIV failure. Results  A total of 151 infants were incorporated into the study. The intubation rate was significantly higher in the NCPAP group (15/75) compared with the bi-level CPAP group (6/76) (p  = 0.032). There was a significant decrease in the level of pCO 2 at the 12 (60.7 ± 6.7 vs. 66.3 ± 8.8, p  = 0.017) and 24 (50 ± 8 vs. 53 ± 10, p  = 0.028) hours of NIV in the bi-level CPAP group compared with the NCPAP group. Duration of NIV, total respiratory support, hospital stay, and the incidence of pneumothorax were similar between the groups. Conclusion  Bi-level CPAP reduced the rate of NIV failure and pCO 2 levels at the 12 and 24 hours in late preterm and term infants with a diagnosis of TTN. Key Points Bi-level CPAP seems to be a safe and effective method in TTN. Bi-level CPAP may reduce the rate of NIV failure in late preterm and term infants with TTN. Future studies are warranted to answer the question whether bi-level CPAP might be used as a standard treatment in babies with TTN. [ABSTRACT FROM AUTHOR]

Objective  The study aimed to evaluate the association between hemoglobin A1c values and likelihood of fetal anomalies in women with pregestational diabetes. Study Design  Women with pregestational diabetes who delivered at a single institution that serves a nonreferred population from May 1, 2009 to December 31, 2018 were ascertained. Hemoglobin A1c values were obtained at the first prenatal visit. Women who delivered a singleton live- or stillborn infant with a major malformation as defined by European Surveillance of Congenital Anomalies criteria were identified. In infants with multiple system anomalies, each malformation was considered separately. Hemoglobin A1c values were analyzed categorically by using Mantel–Haenszel method and continuously with linear regression for trend for fetal anomalies. Results  A total of 1,676 deliveries to women with pregestational diabetes were delivered at our institution, and hemoglobin A1c was assessed in 1,573 deliveries (94%). There were 129 deliveries of an infant with at least one major malformation, an overall anomaly rate of approximately 8%. Mean hemoglobin A1c concentration was significantly higher in pregnancies with anomalous infants, 9.3 ± 2.1% versus 8.0 ± 2.1%, and p <0.001. There was no difference in gestational age at the time hemoglobin A1c was obtained, 13 ± 8.3 versus 14 ± 8.7 weeks. Hemoglobin A1c was associated with increased probability of a congenital malformation. This reached 10% with a hemoglobin A1c concentration of 10%, and 20% with a hemoglobin A1c of 13%. Similar trends were seen when examining risk of anomalies by organ system with increasing hemoglobin A1c levels, with the greatest increase in probability for both cardiac and genitourinary anomalies. Conclusion  In women with pregestational diabetes, hemoglobin A1c is strongly associated with fetal anomaly risk. Data from a contemporary cohort may facilitate counseling and also highlight the need for preconceptual care and glycemic optimization prior to entry to obstetric care. Key Points Infants of diabetic mothers had an 8% major anomaly rate. HbA1c of 10% in pregnancy associated with 10% anomaly rate. HbA1c of 13% in pregnancy associated with 20% anomaly rate. Preconceptual care is important to reduce prevalence. [ABSTRACT FROM AUTHOR]

Objective  Despite the Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force (USPSTF) recommending universal hepatitis C virus (HCV) screening in pregnancy Society for Maternal-Fetal Medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG) continue to endorse risk-based screening for HCV in pregnancy. We hypothesized that universal screening is associated with increased HCV diagnosis and postpartum linkage to HCV care compared with risk-based screening. Study Design  This retrospective cohort study included pregnant women screened for HCV at a single tertiary-care center. We defined two cohorts: women managed with risk-based (January 2014–October 2016) or universal HCV screening (November 2016–December 2018). Screening was performed with ELISA antibody testing and viremia confirmed with HCV ribonucleic acid (RNA) polymerase chain reaction (PCR). Primary outcomes were the rate of HCV screen positivity and postpartum linkage to care. Results  From 2014 to 2018, 16,489 women delivered at our institution, of whom 166 screened positive for HCV. A total of 7,039 pregnant women were screened for HCV: 266 with risk-based and 6,773 with universal screening; 29% (76/266) were positive HCV antibody screening (HCVAb + ) in the risk-based cohort and 1.3% (90/6,773) in the universal cohort. HCVAb+ women in the risk-based cohort were more likely to have a positive drug screen. Only 69% (62/90) of HCVAb+ women in the universal cohort met the criteria for risk-based testing. Of the remaining 28 women, 6 (21%) had active viremia (HCV RNA +). Of the 166 HCVAb+ women, 64% (103/166) were HCV RNA + —51 of 266 (19%) in the risk-based and 52 of 6,773 (0.8%) in the universal cohort. Of HCVAb+ women, 75% (125/166) were referred postpartum for HCV evaluation and 27% (34/125) were linked to care. Only 9% (10/103) of women with viremia initiated treatment within 1 year of delivery. Conclusion  Universal HCV screening in pregnancy identified an additional 31% of HCVAb+ women compared with risk-based screening. Given low rates of HCV follow-up and treatment regardless of screening modality, further studies are needed to address barriers to postpartum linkage to care. Key Points Ideal screening for HCV in pregnancy is unknown. We explore screening strategies in pregnancy to linkage to HCV care. Regardless of screening strategy there is low rates of postpartum linkage to HCV care. [ABSTRACT FROM AUTHOR]