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Objective To assess the association between use of an oxytocin decision support checklist with oxytocin usage and clinical outcomes. Study Design We conducted a retrospective cohort study of patients with singleton gestations at 37 0/7 weeks or greater who received oxytocin during labor from October 2012 to February 2017 at an integrated community health care system during three exposure periods: (1) prechecklist; (2) after paper checklist implementation; and (3) after checklist integration into the electronic medical record (EMR). The checklist was a clinical decision support tool to standardize the dosing and management of oxytocin. Thus, our primary outcomes included oxytocin infusion rates and cumulative dose. Secondary outcomes included maternal and neonatal outcomes. We controlled for maternal risk factors with multivariable regression analysis and stratified by mode of delivery. Results A total of 34,269 deliveries were included. Unadjusted analyses showed that compared with prechecklist, deliveries during the paper and EMR-integrated periods had a lower cumulative dose (4,670 ± 6,174 vs. 4,318 ± 5,719 and 4,286 ± 5,579 mU, p < 0.001 for both), lower maximal infusion rate (9.9 ± 6.8 vs. 8.7 ± 5.8 and 8.4 ± 5.6 mU/min, p < 0.001 for both), and longer duration of oxytocin use (576 ± 442 vs. 609 ± 476 and 627 ± 488 minutes, p < 0.001 and p = 0.01, respectively). The unadjusted rates of cesarean, 5-minute Apgar <7, mechanical ventilation, and neonatal hospital length of stay were similar between periods. The adjusted mean difference in time from admission to delivery was longer during the EMR-integrated period compared with prechecklist (3.0 [95% confidence interval: 2.7–3.3] hours, p < 0.001). Conclusion Oxytocin checklist use was associated with decreased oxytocin use patterns at the expense of longer labor times. Findings were more pronounced with EMR integration. Key Points An oxytocin decision support checklist is associated with reduced amounts of oxytocin used. However, checklists were associated with longer duration of oxytocin use and of labor. Results were more pronounced in the EMR-integrated checklist compared with paper checklist. [ABSTRACT FROM AUTHOR]

Objective The objective of this paper was to describe peri-procedural events and complications of infants requiring laser photocoagulation for retinopathy of prematurity (ROP) in a level IV neonatal intensive care unit. Study Design A retrospective chart review was performed of neonates requiring ROP exams from January 2017 to August 2020. Baseline maternal and neonatal characteristics, ROP exam findings, and associated treatment were analyzed. Group characteristics were compared based on the need for laser photocoagulation. Subgroup analysis of the laser group including respiratory outcomes, cardiorespiratory index (CRI) scores, and pain scores was also performed. Results Neonatal and maternal characteristics in the laser (n = 27) and non-laser (n = 172) groups were assessed. Of the 81.5% (22/27) that required re-intubation for laser, 36% (8/22) had >1 intubation and 18% (4/22) had >1 extubation attempt. The average duration of intubation following laser was 2.46 ± 7.13 days, with 40% (9/22) needing peri-extubation steroids and 18% (4/22) racemic epinephrine to facilitate extubation. Mean total respiratory support time post-laser was 8.65 ± 15.23 days. Mean neonatal pain, agitation, and sedation scores after laser were zero immediately after the procedure, 0.09 ± 0.33 at 12 hours, 0.11 ± 0.47 at 24 hours, and 0.11 ± 0.51 at 48 hours. The mean CRI scores were 1 ± 0 immediately after the procedure, 1.17 ± 0.4 at 12 hours, 1.41 ± 0.20 at 24 hours, and 1 ± 0 at 48 hours. Conclusion Nearly all infants undergoing laser photocoagulation for ROP in our cohort required intubation and continued respiratory support. Despite stability during the procedure, complications from intubation were common. Key Points Routine intubation for laser is associated with complications. Need for post-procedural respiratory support is common. Avoiding intubation may mitigate these neonatal complications. [ABSTRACT FROM AUTHOR]

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 This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m 2) and the presence of previous vaginal delivery (VD). Study Design This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m 2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates. Results Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m 2 , 1,108,278 had BMI 30 to 39.9 kg/m 2 , and 320,031 had BMI 40 to 69.9 kg/m 2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m 2 (5.0 vs. 6.5%; aRR = 1.33 [1.30–1.36]), BMI 30 to 39.9 kg/m 2 (6.1 vs. 7.8%; aRR = 1.29 [1.24–1.34]), and BMI 40 to 69.9 kg/m 2 (8.2 vs. 9.0%; aRR = 1.15 [1.07–1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m 2 (6.2 vs. 5.8%; aRR = 0.98 [0.96–1.00]), BMI 30 to 39.9 kg/m 2 (7.4 vs. 7.1%; aRR = 0.99 [0.95–1.02]), and BMI 40 to 69.9 kg/m 2 (9.4 vs. 8.7%; aRR = 0.96 [0.91–1.02]). Conclusion TOLAC among obese individuals could be offered in selected cases. Key Points TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it. Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC. Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications. [ABSTRACT FROM AUTHOR]

Objective This study aimed to examine the relationship of fetal station in the first stage of labor to labor curves and cesarean delivery rates among women presenting in spontaneous labor. Study Design Labor curves for patients with nonanomalous singletons who presented in spontaneous labor to our hospital's Obstetric Triage Unit with intact membranes from January 1, 2012, to August 31, 2016, were reviewed. Cervical exams and time of exam were obtained for each patient from presentation to triage until delivery. Station for each presentation and cervical dilation was estimated using a random effects model and the slope of cervical station change was calculated to estimate the change in dilation by hour. Perinatal outcomes, including cesarean delivery rates, were examined according to fetal station at initial presentation. Factors known to affect labor curves—epidural analgesia, infant birth weight, maternal habitus, and parity—were also examined. Results There were 8,123 patients presented in spontaneous labor with intact membranes. For patients presenting at 6-cm dilation, the rate of change of labor was significantly different when identified to have a station greater than 0 (+1 and more caudad) when compared with those with −1 and more cephalad station (both p < 0.001). This relationship persisted when analyzed according to epidural analgesia, birth weight, maternal habitus, and parity. The frequency of cesarean delivery was significantly higher for women presenting in spontaneous labor with negative fetal station (p < 0.05). When stratified across all dilation (3–9 cm), this trend remained significant (p < 0.001). Conclusion In the first stage of labor, advanced fetal station was significantly associated with differing rates of labor progression, and positive fetal station was significantly less likely to result in cesarean delivery. Physical examination, including station, remains a critical element in labor management. Key Points Fetal station is important in labor management. Fetal station at initial exam is related to time to delivery. Positive fetal station at initial exam is less likely to result in cesarean delivery. [ABSTRACT FROM AUTHOR]

Objective Resilience is associated with mental and somatic health benefits. Given the social, physical, and mental health toll of the coronavirus disease 2019 (COVID-19) pandemic, we examined whether the COVID-19 pandemic was associated with population-level changes in resilience among pregnant people. Study Design Secondary analysis of a prospective cohort of nulliparous pregnant people <20 weeks' gestation from a single hospital. Participants completed baseline assessments of resilience characteristics, including dispositional optimism (DO), mindfulness, and proactive coping. For this analysis, participants recruited before the COVID-19 pandemic were compared with those recruited during the pandemic. The primary outcome was DO, assessed as a continuous score on the validated Revised Life Orientation Test. Secondary outcomes included continuous scores on mindfulness and proactive coping assessments. Bivariable analyses were completed using chi-squared and Mann–Whitney U tests. Multivariable linear regression compared resilience scores by recruitment time frame, controlling for confounders selected a priori: maternal age, education, and marital status. Results Of the 300 participants, 152 (50.7%) were recruited prior to the pandemic. Demographic and pregnancy characteristics differed between groups: the during-pandemic group was older, had higher levels of education, and were more likely to be married/partnered. There were no significant differences in any of the resilience characteristics before versus during the pandemic in bivariable or multivariable analyses. Conclusion In this cohort, there were no differences in early pregnancy resilience characteristics before versus during the COVID-19 pandemic. This affirms that on a population level, resilience is a stable metric, even in the setting of a global pandemic. Key Points Resilience is associated with mental and somatic health benefits. No difference in early-pregnancy resilience in those recruited before versus during the pandemic. Consistent with conceptualization of resilience as an innate characteristic. [ABSTRACT FROM AUTHOR]

Objective Studies have suggested an association between prenatal care (PNC) and preterm birth (PTB). We evaluated trends in PTB and association of PNC and PTB. Study Design This was a retrospective cohort study of singleton, viable nonanomalous deliveries from 1991 to 2018. PNC utilization was defined by World Health Organization using number of visits: adequate (≥8), suboptimal (5–7), and inadequate (<5). Primary outcome was PTB. Tests of trend were used to assess changes in PTB over time. Baseline characteristics and outcomes were compared. Logistic regression estimated the association of PNC and PTB. We evaluated for effect modification by year of birth. Results Of 92,294 patients, 14,057 (15%) had PTB. Inadequate and suboptimal PNC were associated with higher odds of PTB compared to adequate PNC (adjusted odds ratios = [aOR 6.21], 95% confidence interval [CI]: 5.84–6.60; aOR = 3.57, 95% CI: 3.36–3.79). Inadequate PNC was associated with higher odds of PTB over time (effect modification p < 0.0001). Inadequate PNC was associated with 5.4 times higher odds of PTB in 1998, 7.0 times in 2008, and 9.1 times in 2018. Conclusion Despite an increase in adequate PNC, there was a rise in PTB associated with inadequate and suboptimal PNC. PNC utilization was a stronger risk factor in recent years with higher PTB in patients who attended more than five PNC visits. Key Points PNC utilization is associated with the risk of PTB. Despite an increase in PNC utilization, PTB rates have increased. There is an even stronger association between PNC utilization and PTB over time. [ABSTRACT FROM AUTHOR]

Objective This proof-of-concept study assessed how confidently an artificial intelligence (AI) model can determine the sex of a fetus from an ultrasound image. Study Design Analysis was performed using 19,212 ultrasound image slices from a high-volume fetal sex determination practice. This dataset was split into a training set (11,769) and test set (7,443). A computer vision model was trained using a transfer learning approach with EfficientNetB4 architecture as base. The performance of the computer vision model was evaluated on the hold out test set. Accuracy, Cohen's Kappa and Multiclass Receiver Operating Characteristic area under the curve (AUC) were used to evaluate the performance of the model. Results The AI model achieved an Accuracy of 88.27% on the holdout test set and a Cohen's Kappa score 0.843. The ROC AUC score for Male was calculated to be 0.896, for Female a score of 0.897, for Unable to Assess a score of 0.916, and for Text Added a score of 0.981 was achieved. Conclusion This novel AI model proved to have a high rate of fetal sex capture that could be of significant use in areas where ultrasound expertise is not readily available. Key Points This is the first proof-of-concept AI model to determine fetal sex. This study adds to the growing research in ultrasound AI. Our findings demonstrate AI integration into obstetric care. [ABSTRACT FROM AUTHOR]

Objective Respiratory syncytial virus (RSV) is the most common viral respiratory infection in infants. This study aimed to establish the potential changes in the clinical course of RSV in the neonatal period with the onset of the coronavirus disease 2019(COVID-19) pandemic. Study Design During the observational study period, newborns diagnosed with community-acquired RSV infection and admitted to the neonatal intensive care unit (NICU) were evaluated. RSV-infected neonates before the COVID-19 pandemic were classified as Group 1 , those during the strict isolation period as Group 2 , and RSV-infected newborns after the removal of restrictions were classified as Group 3. Results A total of 208 community-acquired RSV-infected neonates were analyzed. The median age at admission to the NICU was 26 days, and the mean gestational week was 37.2 ± 2.7. The ratio of hospitalized babies with RSV infection to all hospitalized newborns rose after the pandemic significantly (1.9, 1.6, and 5.2%; p < 0.001). Following the pandemic, there was an increase in full-term, early-term, and late-preterm cases. Nevertheless, no change was observed in the number of preterm cases (p > 0.05). There was also a statistically significant increase in the need for intubation, noninvasive ventilation (NIV), supplemental oxygen, inhaled bronchodilator drugs, and length of hospital stay in Group 3 after the pandemic (p < 0.001). All these parameters related to more severe RSV infection when the precautions were removed, while there was a milder disease with restrictions during the pandemic in Group 2 (p < 0.001). However, none died due to RSV infection during the study because of timely supportive care. Conclusion Following the COVID-19 pandemic, the frequency and severity of RSV infection in newborns have increased, and it can result in a serious clinical picture even in full-term babies with no comorbidities. Attention to strict contact precautions, particularly in newborns, who are a more vulnerable population after the pandemic, may play an important role in any future outbreak. Key Points The course of neonatal RSV infection has changed after the pandemic. A statistically significant increase was observed in the need of intubation in newborns with RSV. The strict precautions during the pandemic also helped to prevent the transmission of RSV. [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]

Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. Key Points Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV. In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures. We call for future research on noninvasive support modes to account for mean airway pressures. [ABSTRACT FROM AUTHOR]

Objective In studies of concomitant arterial–venous umbilical cord blood gases (CAV-UBGs), approximately 10% of technically valid samples have very similar pH and/or pCO 2 values and were probably drawn from the same type of blood vessel. Without a way to objectively determine the source in these cases, it has been argued that most of these same-source CAV-UBGs are venous because the vein is larger and more easily sampled than the artery. This study aimed to calculate the probability of an arterial (ProbAS) or venous source (ProbVS) of same-source CAV-UBGs in the clinically and medicolegally important pH range of 6.70 to 7.25 using a statistical predictive model based on the cord blood gas values. Study Design Starting with a dataset of 56,703 CAV-UBGs, the ProbAS, ProbVS, and respective 95% confidence intervals (CIs) were calculated for the 241 sample pairs with near-identical pH, pCO 2 , and pO 2 values and a pH of 6.70 to 7.25. Using a previously validated generalized additive model, the source was categorized as: Probable Arterial or Highly Probable Arterial if the ProbAS and CIs were >0.5 or >0.8, respectively; Probable Venous or Highly Probable Venous if the ProbVS and CIs were >0.5 or >0.8, respectively; or Indeterminant if the CIs encompassed ProbAS/VS = 0.5. Results A total of 39% of the same-source CAV-UBGs were Probable Arterial, 56% were Probable Venous, and 5% were Indeterminant. However, considering samples with a pH ≤7.19, 80% were Probable Arterial and 16% were Probable Venous. Considering the Highly Probable categories, the more acidemic specimens were 9 times more likely to be arterial than venous. Similarly, CAV-UBGs with pCO 2 > 8.2 kPa (62 mm Hg) or pO 2 ≤ 1.9 kPa (14 mm Hg) were more likely to be in the arterial rather than the venous categories. Conclusion Same-source CAV-UBGs in the more acidemic, hypercarbic, or hypoxemic ranges are more likely to be arterial than venous. Key Points Umbilical cord arterial/venous gases (CAV-UBGs) with similar values are thought to be mainly venous. A validated statistical model was used to predict the probability an arterial or venous source. CAV-UBGs with very similar values and pH > 7.19 are likely venous; however, those with pH ≤ 7.19 and/or pCO 2 > 8.2 kPa and/or pO 2 ≤1.9 kPa are more likely arterial. [ABSTRACT FROM AUTHOR]

Objective The influence of thrombocytopenia on blood loss and postpartum hemorrhage (PPH) has been conflicting. Our aim was to determine if there is an association between predelivery platelet count and quantitative blood loss (QBL) and PPH in both vaginal (VD) and cesarean deliveries (CD). Study Design We conducted a retrospective database study at a single institution from April 1, 2017 to September 9, 2020. The platelet count closest to time of delivery and the QBL was assessed separately for VD and CD. Results A total of 22,479 records were reviewed, of which 16,822 (75%) were VD and 5,657 (25%) were CD. A total of 2,600 (12%) patients had thrombocytopenia, defined as a platelet count <150,000/mm 3. Of these, 1,980 (76%) had a VD and 620 (24%) had CD. We found a statistically significant difference in QBL between parturients with thrombocytopenia compared with those without, with a median estimated difference in QBL of 25 (95% confidence interval [CI]: 16–32) and 57 mL (95% CI: 31–87) in VD and CD patients, respectively. We also found a statistically significant difference in QBL when comparing patients among all the platelet count ranges except in the lowest platelet count range of 50,000 to 69,999/mm 3 with a mean difference of 52 (95% CI: 25–81) and 107 mL (95% CI: 39–180) in the VD and CD patients, respectively in the platelet count range of 70,000 to 99,999/mm 3. We also found the incidence of PPH was greater in those with thrombocytopenia, p < 0.001, but the median difference in QBL in all platelet groups was small. Conclusion We found a statistically significant association between lower predelivery platelet counts and QBL and PPH. The clinical significance of these results is debatable, because at all platelet count ranges, differences in blood loss were small. Key Points Hemorrhage is etiology of morbidity and mortality in obstetric parturients. We found a small increase in blood loss in those with thrombocytopenia. The clinical relevance of these findings is debatable since the increased blood loss was small. [ABSTRACT FROM AUTHOR]

Objective The safety of weight loss and low weight gain during pregnancy remains unclear. To determine how different patterns of gestational weight gain (GWG), including weight loss, stability, and low GWG relate to perinatal outcomes by prepregnancy obesity class. Study Design The study population included 29,408 singleton livebirths among pregnant people with obesity from Kaiser Permanente Northern California (2008–2013). Clinically measured GWG was grouped into meaningful categories (Adequate: reference, met 2009 National Academy of Medicine [NAM] Guidelines [5–9.1 kg], Excessive [>9.1 kg], Low [1–4.9 kg], Stable [±1 kg], Weight Loss [>1 kg]) or GWG Z-score quintiles. Modified Poisson regression was used to estimate risk of adverse outcomes, stratified by obesity class. Electronic health record data were used to define outcomes, including cesarean delivery, preterm birth, admission to the neonatal intensive care unit, small- and large-for-gestational age infants. Results Prevalence of weight stability and weight loss was 3.8 and 3.4%, respectively. Compared with those who gained within NAM, increased risk of small-for-gestational age was observed among those with weight loss among obesity class I (Risk Ratio (RR): 1.57, 95% confidence interval [CI]: 1.12, 2.19), obesity class II (RR: 2.18, 95% CI: 1.52, 3.13), and obesity class III (RR: 1.72, 95% CI: 1.21, 2.45). Weight loss was associated with a decreased risk of cesarean delivery among obesity class III, compared with NAM. Conclusion Weight loss during pregnancy is associated with increased risk of small-for-gestational age among all obesity classes, but not other adverse perinatal outcomes and may reduce risk of cesarean delivery. Low weight gain and weight stability are not associated with risk of adverse outcomes among those with class III obesity. GWG guidelines may need to vary by obesity class. Key Points Weight loss during pregnancy is associated with increased risk of small-for-gestational age among all obesity classes; but weight loss was not associated with other adverse perinatal outcomes. Among class III, low weight gain and weight stability are not associated with adverse perinatal outcomes. GWG guidelines may need to vary by obesity class. [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 This study aimed to assess beliefs and attitudes of Argentinean neonatologists and neonatal nurses regarding end-of-life care of newborn infants, including withdrawal of clinically assisted nutrition and hydration (CANH). Study Design A five-domain survey was sent to 465 neonatal health care workers, which included demographic data, general ethical concepts, participation in end-of-life decisions, beliefs about end-of-life care practices, and presentation of four clinical scenarios. Standard statistical tests were used, and a multivariable analysis was done to evaluate variables independently associated with rejecting the withdrawal of CANH. Results A total of 227 questionnaires were anonymously completed, 60% by physicians and 40% by nurses. More respondents agreed to withdraw mechanical ventilation in comparison to CANH in patients under certain circumstances (88 vs. 62%, p < 0.01). The most accepted variables when deciding to withdraw care were the quality of life perceived by parents (86%) and their religious beliefs (73%). A total of 93% agreed that parents should be included in the decision, but only 74% acknowledged they are included in real practice. Considering the scenario of a newborn with severe and irreversible neurological compromise, 46% of respondents were opposed to suspending enteral nutrition. No independent variables were found to be associated with opposing the withdrawal of CANH. Of those agreeing to withdraw enteral feeds under certain circumstances, for the severely neurologically affected neonate 58% would either refuse to limit enteral feeds or consult with an ethics committee before doing so. When given the scenario of their own severe and irreversible neurological compromise, 68% agreed to have enteral feeds withdrawn to themselves, and they were more likely to agree with withdrawing feeds for the severely compromised neonate (odds ratio: 7.2; 95% confidence interval: 2.7–24.1). Conclusion While most health care providers agreed to withdraw life-sustaining support under certain conditions, many were reluctant to suspend CANH. Many responses differed when being asked as general statements versus actual clinical scenarios. Key Points Withdrawal of assisted nutrition is supported by the American Academy of Pediatrics in certain scenarios. Many neonatal intensive care units health care providers from Argentina are reluctant to suspend assisted nutrition. There is a need to learn how to deal with complex bioethical issues. [ABSTRACT FROM AUTHOR]

Objective This study investigated the clinical outcome of monochorionic diamniotic (MCDA) twins with selective intrauterine growth restriction (sIUGR). Study Design International Peace Maternal and Child Health Hospital of Shanghai ultrasound database was investigated to identify all MCDA delivered from January 2013 to December 2017. After identifying 43 pairs of MCDA twins with sIUGR and 282 pairs of normal MCDA twins, we compared clinical outcomes between the two groups. Results Compared with normal twins, sIUGR fetuses had significantly shorter gestational age at delivery, smaller average birth weight of both twins, more significant intertwin difference in birth weight, lower Apgar scores, and higher intrauterine fetal demise (IUFD) rate, and smaller placental weight. The rate of abnormal umbilical cord insertions and abnormal blood flow in the ductus venosus (DV) and middle cerebral artery (MCA) is significantly higher in the sIUGR group. In addition, the subtype analysis of sIUGR groups indicated the poorest outcomes in type II with no significant difference between type I and III. Conclusion MCDA twins with sIUGR generally exhibited limited clinical outcomes than normal MCDA twins. These limitations are mainly associated with abnormal umbilical cord insertions and blood flow in the DV and MCA. Clinical outcomes differed among the three types of sIUGR, with type II having the worst prognosis and the highest IUFD rate. Key points sIUGR generally exhibited limited clinical outcomes than normal MCDA twins. These limitations are mainly associated with blood flow of the DV and MCA. sIUGR with type II has the worst prognosis and the highest IUFD rate. [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]

Kangaroo care (KC), skin-to-skin contact between infants and caregivers, is encouraged in neonatal intensive care units (NICUs) to support health through improved weight, growth, and infant–maternal attachment while reducing the incidence of sepsis and infant pain. However, the optimal duration and frequency of KC to maximize health outcomes is unknown. Given parents' time stressors, identifying optimal KC time is critical. A literature review was undertaken on May 28, 2021 via querying the PubMed database from January 1, 1995, to May 28, 2021, regarding KC and NICUs with 442 results. Eleven studies met the eligibility criteria of (1) comparative KC between infants and adult caregivers in NICUs as a randomized controlled trial, (2) peer-reviewed articles in English, (3) study subjects ≥5, (4) health outcomes, and (5) KC sessions >1. Infant physical growth parameters, infant neurodevelopment, infant stress via salivary cortisol levels, and breastfeeding outcomes appear to increase with KC as compared with standard care (SC) without KC. Improvements were observed with longer KC duration, 2 h/d as compared with 1 h/d, for neurodevelopment and breastfeeding outcomes, but no greater improvement with longer KC duration was shown for reducing infant stress through salivary cortisol levels. Regarding maternal stress, the influence of KC duration showed mixed Parental Stressor Score: NICU scores. Further study on the impact of KC duration and frequency on health outcomes and dose–response relationship would help determine how much and how frequent KC is needed to improve specific health outcomes for infants and their mothers. Key Points Data on kangaroo care duration's health impacts is lacking. Establishing dose–response for kangaroo care is needed. Kangaroo care for longer improves some but not all outcomes. [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 This study aimed to explore demographic and health-related factors that may differentiate women who do and do not disclose their marijuana use during pregnancy. Study Design The current study is a secondary analysis of data from a prospective cohort of pregnant women identified as using marijuana during pregnancy via a variety of assessment tools including self-report, urine screen, and obstetrics record abstraction. The cohort included a convenience sample of women recruited from several antenatal clinics at The Ohio State University Wexner Medical Center (OSUWMC). To be eligible, women needed to be within the first or second trimester of their pregnancy, 16 to 50 years of age, able to communicate in English, and intended to deliver at OSUWMC. Chi-square, independent samples t -tests, and logistic regression analyses were used to explore differences between those who did and did not disclose their use in relation to physical and mental health diagnoses, adverse experiences, use of other substances, and demographics. Results Women who used marijuana during their pregnancy and had mental/physical health data available comprised the current sample (n = 109). Women who attended college were more likely to disclose their marijuana use compared with women who did not attend college (p < 0.001). Women who experienced homelessness (p < 0.01) or self-reported alcohol use during pregnancy (p < 0.001) were significantly more likely to disclose their marijuana use. Conclusion Findings, suggesting disclosure of other substance use and adverse experiences, such as homelessness, may increase the likelihood that pregnant women will voluntarily disclose their marijuana use to providers. Findings did not reflect racial differences nor significant differences in mental/physical health status among women based on their disclosure. Future research with larger datasets is needed to build on these findings by confirming results, as well as exploring additional factors, that may more effectively differentiate women who are unlikely to disclose their prenatal marijuana use from those who do disclose their use. Key Points Women with higher education were more likely to self-disclose their prenatal marijuana use. Women who experienced homelessness were more likely to self-disclose their prenatal marijuana use. Self-disclosure of prenatal alcohol use was related to self-disclosure of prenatal marijuana use [ABSTRACT FROM AUTHOR]

Objective Currently, there are no established guidelines for obstetric ultrasound training at the core medical student clerkship level. Our objective was to develop practical, consensus-based learning objectives in second- and third-trimester ultrasound and assess the feasibility of implementing these objectives into a clinical curriculum. Study Design Using the modified Delphi approach, a panel of expert stakeholders (n = 23) was assembled to reach consensus on the proposed learning objectives. A model curriculum was created consisting of a video tutorial, in-person training, and an optional tracker and piloted at two academic medical centers. Participant perception of acquired ultrasound skills and the program were assessed using a modified, previously validated survey. Pre- and postprogram survey responses were compared using the Chi-squared test of association. A p -value of <0.05 was considered statistically significant. Results The expert panel reached consensus on five learning objectives to include determination of fetal number and presentation, assessment of fetal heart rate, determination of placental location, assessment of amniotic fluid volume, and a general understanding of the biophysical profile and its indications. A total of 26 students participated in the piloted curriculum. On completion, a majority of participants reported improved confidence in understanding and performing prenatal ultrasound in the second and third trimesters (p < 0.05). The majority of participants valued a hands-on ultrasound curriculum. Conclusion We propose practical, consensus-based learning objectives for second- and third-trimester sonography during the core clerkship with demonstrated feasibility in a two-center pilot program. Key Points Ultrasound is a valuable skill for medical students. Specific learning objectives in obstetric ultrasound are currently lacking. We propose consensus-based objectives and a model curriculum. A two-center pilot study demonstrated efficacy. [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 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 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 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 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 The cesarean delivery rate in the United States is 31.9%. One of the leading indications for primary cesarean delivery is labor arrest. A modern understanding of the labor curve supports more time prior to the diagnosis of labor arrest. We conducted this study to examine the impact of adherence to the modern criteria for labor arrest and failed induction on rates of primary cesarean delivery and to identify predictors of meeting these criteria. Study Design We analyzed rates of primary cesarean deliveries overall and primary cesarean deliveries occurring due to arrest of dilation, arrest of descent, and failed induction among the 17,877 live births at a large academic center from 2010 through 2013. Multiple logistic regression modeling identified predictors of meeting the new criteria for these indications based on guidelines published by the 2012 National Institute of Child Health and Human Development. Results The primary cesarean delivery rate decreased from 23.5 to 21.1% (p = 0.026) from 2010 to 2013. Primary cesarean delivery rate for labor arrest and failed induction decreased from 8.5 to 6.7% (p = 0.005). The percentage of primary cesarean deliveries meeting the 2012 criteria for labor arrest increased from 18.8 to 34.9% (p = 0.002), and the rate of primary cesarean deliveries due to arrest of dilation decreased from 5.1 to 3.4% (p < 0.0005). The percentage of cases meeting the 2012 criteria for arrest of descent increased from 57.8 to 71.0% (p < 0.007), while primary cesarean delivery rate due to arrest of descent remained relatively unchanged, 3.1 to 2.6% (p = 0.330). Conclusion A decrease in the primary cesarean rate was attributable to a decrease in cesarean for arrest of dilation in the setting of a significant increase in meeting the 2012 criteria for arrest of dilation. At the end of the study period, 65.2% of cesareans still did not meet the criteria for arrest of dilation. Greater rates of adherence to these guidelines may yield further reductions in the cesarean rate. Key Points Primary cesarean delivery for labor arrest was decreased. Meeting criteria for labor arrest increased. A hospitalist provider increased odds of meeting criteria. [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 Therapeutic hypothermia (TH) is the standard treatment for hypoxic–ischemic encephalopathy (HIE). We surveyed parents of infants treated with TH about their experiences of communication and parental involvement in the neonatal intensive care unit (NICU). Study Design A 29-question anonymous survey was posted on a parent support (web site: https://www.hopeforhie.org) and sent to members via e-mail. Responses from open-ended questions were analyzed using thematic analysis. Results A total of 165 respondents completed the survey and 108 (66%) infants were treated with TH. 79 (48%) respondents were dissatisfied/neutral regarding the quality of communication in the NICU, whereas 127 (77%) were satisfied/greatly satisfied with the quality of parental involvement in the NICU. Six themes were identified as follows: (1) setting for communication: parents preferred face to face meetings with clinicians; (2) content and clarity of language: parents valued clear language (use of layman's terms) and being explicitly told the medical diagnosis of HIE; (3) immediate and longitudinal emotional support: parents required support from clinicians to process the trauma of the birth experience and hypothermia treatment; (4) clinician time and scheduling: parents valued the ability to join rounds and other major conversations about infant care; (5) valuing the parent role: parents desired being actively involved in rounds, care times, and decision-making; (6) physical presence and touch: parents valued being physically present and touching their baby; this presence was limited by the novel coronavirus disease 2019 (COVID-19)-related restrictions. Conclusion We highlight stakeholder views on parent involvement and parent–clinician communication in the NICU and note significant overlap with principles of trauma informed care: safety (physical and psychological), trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, and voice and choice. We propose that a greater understanding and implementation of these principles may allow the medical team to more effectively communicate with and involve parents in the care of infants with HIE in the NICU. Key Points Parents of infants with HIE experience trauma both from the birth and the hypothermia treatment. Transparent communication and encouraging parental involvement can ameliorate this trauma. [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]

Multiple courses versus a single course of antenatal corticosteroids (ACS) have been associated with mild respiratory benefits but also adverse outcomes like smaller head circumference and birth weight. Long-term effects warrant study. We systematically reviewed long-term outcomes (≥1 year) in both preterm and term birth after exposure to preterm multiple courses (including a rescue dose or course) versus a single course. We searched seven databases from January 2000 to October 2021. We included follow-up studies of randomized controlled trials (RCTs) and cohort studies with births occurring in/after the year 2000, given advances in perinatal care. Two reviewers assessed titles/abstracts, articles, quality, and outcomes including psychological disorders, neurodevelopment, and anthropometry. Six follow-up studies of three RCTs and two cohort studies (over 2,860 children total) met inclusion criteria. Among children born preterm, randomization to multiple courses versus a single course of ACS was not associated with adjusted beneficial or adverse neurodevelopmental/psychological or other outcomes, but data are scant after a rescue dose (120 and 139 children, respectively, low certainty) and nonexistent after a rescue course. For children born at term (i.e., 27% of the multiple courses of ACS 5-year follow-up study of 1,728 preterm/term born children), preterm randomization to multiple courses (at least one additional course) versus a single course was significantly associated with elevated odds of neurosensory impairment (adjusted odds ratio = 3.70, 95% confidence interval: 1.57–8.75; 212 and 247 children, respectively, moderate certainty). In this systematic review of long-term outcomes after multiple courses versus a single course of ACS, there were no significant benefits or risks regarding neurodevelopment in children born preterm but little data after one rescue dose and none after a rescue course. However, multiple courses (i.e., at least one additional course) should be considered cautiously: after term birth, there are no long-term benefits but neurosensory harms. Key Points We systematically reviewed the long-term impact of multiple versus a single course of ACS. Long-term follow-up data were scant after a rescue dose and absent after one rescue course of ACS. In children born preterm, multiple courses of ACS were not associated with long-term benefits/harms. In children born at term, multiple courses of ACS were associated with neurosensory impairment. Preterm administration of multiple courses of ACS should be considered cautiously. [ABSTRACT FROM AUTHOR]

Objective Preeclampsia (PE) is a pregnancy-specific condition featured by high blood pressure, edema, and proteinuria. Research about the role of microRNA (miR)-203 in PE remains insufficient. This experiment is designed to investigate the specific role of miR-203 in trophoblasts in PE. Study Design miR-203 expression in placenta tissues of normal pregnant women and PE patients was examined to analyze the relevance between miR-203 and PE diagnostic efficiency and between miR-203 and blood pressure (systolic pressure and diastolic pressure) and proteinuria of PE patients. miR-203 expression was downregulated in hypoxia-cultured trophoblasts using miR-203 inhibitor to assess matrix metalloproteinase-9 (MMP-9) level. Then, the angiogenesis of trophoblasts with different treatments was determined. Subsequently, the target relation between miR-203 and insulin-like growth factor receptor 1 (IGF-1R) was predicted and verified. Additionally, the effect of IGF-1R in the mechanism of miR-203 modulating trophoblast vascular remodeling was detected. Results miR-203 was overexpressed in the placenta of PE patients and it acted as a promising diagnostic indicator for PE. Moreover, miR-203 was positively associated with blood pressure (systolic pressure and diastolic pressure) and proteinuria of PE patients. miR-203 silencing in hypoxia-cultured trophoblasts enhanced trophoblast vascular remodeling. Mechanically, miR-203 bound to IGF-1R to suppress its transcription. IGF-1R downregulation counteracted the promotive effect of miR-203 silencing on trophoblast vascular remodeling. Conclusion miR-203 was overexpressed in PE, and it targeted IGF-1R to limit trophoblast vascular remodeling. Key Points miR-203 is overexpressed in the placenta of PE patients. miR-203 acts as a potential diagnostic marker for PE. miR-203 targets IGF-1R to reduce trophoblast vascular remodeling in PE. [ABSTRACT FROM AUTHOR]

Objective This article aims to assess statewide uptake of HIV repeat testing in the first 2 years after the implementation of an amendment to the Illinois Perinatal HIV Prevention Act (IPHPA) mandating universal repeat HIV testing in the third trimester. Study Design This is a retrospective, population-based study of all birthing individuals in Illinois (2018–2019). Data were collected using the state-mandated closed system of perinatal HIV test reporting. We evaluated the incidence of mother–infant pairs with negative early tests and repeat third-trimester tests (RTTTs) performed in adherence with the law, as well as the timing of the performance of the RTTTs (outpatient vs. inpatient). Chi-square tests of trend by quarter were performed to ascertain sustainability. Results Of 138,805 individuals delivered in 2018, 80.6% presented with early test and RTTTs. In 2018, outpatient RTTTs improved from 71.8% (quarter 1) to 85.1% (quarter 4; p < 0.001). In 2018, the proportion of mother–infant dyads who received testing that was adherent to the IPHPA Amendment was 92.1, 95.5, 96.7, and 96.4% in quarters 1 through 4, respectively (p < 0.001). In 2019, outpatient RTTTs performance remained high (87.4%) and stable (p = 0.06). In 2019, 99.9% of mother–infant dyads had testing adherent to the mandate in quarters 1 through 4 (p = 0.39). Of individuals who presented without RTTTs, 93.5% (2018) and 98.8% (2019) underwent inpatient testing before delivery. Conclusion Implementation of RTTTs in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing RTTT programs. Key Points In 2018, Illinois enacted statewide RTTT for HIV among all parturients. In 2019, over 99% of mother–infant dyads had documentation of both early and repeat HIV testing before hospital discharge. Implementation of repeat third-trimester HIV testing in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing similar programs. [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 As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above 40 kg/m 2 together, making risk assessment for women in higher BMI categories challenging. The objective of this study was to evaluate the impact of extreme obesity on postpartum infectious morbidity and wound complications during the postpartum period. Study Design The present study is a secondary analysis of women who underwent cesarean delivery and had BMI ≥ 40 kg/m 2 in the Maternal-Fetal Medicine Units Cesarean Registry. The primary outcome was a composite of postpartum infectious morbidity including endometritis, wound infection, inpatient wound complication prior to discharge, and readmission due to wound complications. Appropriate statistics used to compare baseline demographics, pregnancy complications, and primary outcomes among women by increasing BMI groups (40–49.9, 50–59.9, 60–69.9, and >70 kg/m 2). Results Rates of postpartum infectious morbidity increased with BMI category (11.7% BMI: 50–59.9 kg/m 2 ; 13.7% BMI: 60–69.9 kg/m 2 ; and 21.9% BMI >70+ kg/m 2 ; p = 0.001). Readmission for wound complications also increased with BMI (3.1% for BMI: 50–59.9 kg/m 2 ; 6.2% for BMI: 60–69.9 kg/m 2 ; and 9.4% for BMI >70+ kg/m 2 ; p = 0.001). After adjusting for confounders, increased BMI of 70+ kg/m 2 category remained the most significant predictor of postpartum infectious complications compared with women with BMI of 40 to 49.9 kg/m 2 (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI]: 1.37–29.7). The adjusted odds of readmission also increased with BMI (aOR = 2.33, 95% CI: 1.35–4.02 for BMI 50–59.9 kg/m 2 ; aOR = 4.91, 95% CI: 2.07–11.7 for BMI of 60–69.9 kg/m 2 ; and aOR = 36.2, 95% CI: 7.45–176 for BMI >70 kg/m 2). Conclusion Women with BMI 50 to 70+ kg/m 2 are at an increased risk of postpartum wound infections and complications compared with women with BMI 40 to 49.9 kg/m 2. These data provide increased guidance for counseling women with an extremely elevated BMI and highlight the importance of postpartum wound prevention bundles. Key Points Women with super obesity have higher rates of wound complications. Women at extremes of obesity experience worse postpartum infectious morbidity. More research is needed on effective strategies to minimize morbidity in this population. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to evaluate the effect of pravastatin to prevent preeclampsia (PE) in pregnant women at a high risk of developing PE and the maternal and perinatal outcomes and the soluble fms-like tyrosine kinase 1/placental growth factor (sFlt1/PlGF) ratio. Study Design This is an open-labeled randomized controlled trial (RCT), a part of INOVASIA (Indonesia Pravastatin to Prevent Preeclampsia study) trial. Pregnant women at a high risk of developing PE were recruited and randomized into an intervention group (40) and a control group (40). The inclusion criteria consisted of pregnant women with positive clinical risk factor and abnormal uterine artery Doppler examination at 10 to 20 weeks' gestational age. The control group received low dose aspirin (80 mg/day) and calcium (1 g/day), while the intervention group received additional pravastatin (20-mg twice daily) starting from 14 to 20 weeks' gestation until delivery. Research blood samples were collected before the first dose of pravastatin and before delivery. The main outcome was the rate of maternal PE, maternal–perinatal outcomes, and sFlt-1, PlGF, sFlt-1/PlGF ratio, and soluble endoglin (sEng) levels. Results The rate of PE was (nonsignificantly) lower in the pravastatin group compared with the control group (17.5 vs. 35%). The pravastatin group also had a (nonsignificant) lower rate of severe PE, HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome, acute kidney injury, and severe hypertension. The rate of (iatrogenic) preterm delivery was significantly (p = 0.048) lower in the pravastatin group (n = 4) compared with the controls (n = 12). Neonates in the pravastatin group had significantly higher birth weights (2,931 ± 537 vs. 2,625 ± 872 g; p = 0.006), lower Apgar's scores < 7 (2.5 vs. 27.5%, p = 0.002), composite neonatal morbidity (0 vs. 20%, p = 0.005), and NICU admission rates (0 vs. 15%, p = 0.026). All biomarkers show a significant deterioration in the control group compared with nonsignificant changes in the pravastatin group. Conclusion Pravastatin holds promise in the secondary prevention of PE and placenta-mediated adverse perinatal outcomes by improving the angiogenic imbalance. Key Points Prophylactic pravastatin was associated with a significantly lower rate of adverse perinatal outcome. The sFlt1/PlGF ratio stabilized in the pravastatin group compared with a deterioration in the control group. Pravastatin holds promise in the secondary prevention of PE and placenta-mediated adverse perinatal outcomes. [ABSTRACT FROM AUTHOR]

Objective Ampicillin is used for multiple peripartum indications including prevention of neonatal group B streptococcus (GBS) and treatment of chorioamnionitis. Despite its widespread use in obstetrics, existing pharmacokinetic data for ampicillin do not address contemporary indications or dosing paradigms for this population. We sought to characterize the pharmacokinetic profile of ampicillin administered to laboring women. Study Design Using whole blood dried blood spot sampling technique, maternal blood samples were collected at specified times from 31 women receiving intravenous (IV) ampicillin for peripartum indications. Women received either a 2-g loading dose with 1-g administered every 4 hours (GBS) or 2-g every 6 hours (chorioamnionitis). Pharmacokinetics were analyzed via a population approach with nonlinear mixed-effect modeling. Results The data were best described by a two-compartment model with first-order elimination, with the following whole blood parameters: central volume of distribution (V 1), 75.2 L (95% confidence interval [CI]: 56.3–93.6); clearance (CL), 82.4 L/h (95% CI: 59.7–95.7); intercompartmental clearance (Q), 20.9 L/h (95% CI: 16.2–38.2); and peripheral volume of distribution (V 2), 61.1 L (95% CI: 26.1–310.5). Interpatient variation in CL and V 1 was large (42.0 and 56.7%, respectively). Simulations of standard dosing strategies demonstrated over 98% of women are predicted to achieve an estimated free plasma concentration above mean inhibitory concentration (MIC) of 0.5 μg/mL for more than 50% of the dosing interval. Conclusion Although large variation in the pharmacokinetics of ampicillin in pregnant women exists, as predicted by our model, current standard dosing strategies achieve adequate exposure for GBS in nearly all patients. Key Points IV ampicillin is widely used in obstetrics. Pharmacokinetic studies are lacking. Ampicillin pharmacokinetics were established. Ampicillin clearance and volume of distribution are high. Current ampicillin dosing strategies are sufficient. [ABSTRACT FROM AUTHOR]

Objective Our objective was to summarize the literature regarding the effects of cannabis use during pregnancy on low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). Study Design This is a systematic review and meta-analysis. A literature search was conducted in PubMed, Scopus, EBSCO, and Web of Science in May 2021 and updated in November 2021. Only studies that assessed the isolated use of cannabis during pregnancy, controlling for cigarette smoking, and other illicit drug use were included. Data were synthesized using a narrative summary and pooled adjusted estimates, and 95% confidence intervals (CIs) were calculated for each outcome. Data were analyzed using Stata 13.0 with METAN software package, using random effects. Statistical heterogeneity was assessed using Cochran's Q and Higgins I2 tests. Results In total, 32 studies were included with data from approximately 5.5 million women with the LBW outcome and 23 million with the PTB and SGA outcomes. Pregnant women using cannabis are at increased risk for LBW (adjusted odds ratio [aOR] = 1.52; 95% CI = [1.18; 1.96]), PTB (aOR = 1.39; 95% CI = [1.28; 1.51]), and SGA (aOR = 1.47; 95% CI = [1.38; 1.58]). Studies that assessed the type of PTB and gestational age at birth indicate higher risks of spontaneous PTB and of early or very-early PTBs associated with cannabis use during pregnancy. The few studies that assessed the timing and frequency of consumption suggest a dose–response effect, with higher odds of negative outcomes among women who reported heavy use and with continued use during the second and third trimesters of gestation. Conclusion There is an effect of cannabis irrespective of other illicit drugs and tobacco despite high heterogeneity and low quality of evidence. There is a need to discuss public policies regarding cannabis' regulation and how it influences its consumption. Future studies should focus on the effects of cannabis's type (medicinal or recreational), timing, and dosage during pregnancy on perinatal outcomes. Key Points Cannabis use during pregnancy is increasing. Cannabis has an independent effect on PTB, LBW, and SGA. Future studies should focus on the timing of exposure during pregnancy, mode of use, and dosage. [ABSTRACT FROM AUTHOR]

Objective:  This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES., Study Design:  In this cohort study, parents ( n  = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t -test, and logistic regression., Results:  In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping ( p  > 0.05)., Conclusion:  Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES., Key Points: · Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation.., Competing Interests: O.O. is currently employed as a Physician-Scientist by Merck & Co (September 2023–present).The other authors of this study declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Thieme. All rights reserved.)

Objective: In 2013, the Section of Neonatal and Perinatal Medicine at the University of Oklahoma's Children's Hospital began providing advanced care to a regional level II neonatal intensive care unit (NICU), using a hybrid telemedicine program. This project compares health care providers' and parents' assessments of health care quality using this program., Study Design: This is a prospective, anonymous, nonrandomized survey of health care providers and parents of neonates using our hybrid telemedicine services. Physicians, neonatal nurse practitioners (NNPs), nurses, and parents completed pencil-and-paper surveys based on their participatory roles. Institutional Review Board approval was obtained at OU Medical Center and Comanche County Memorial Hospital. Surveys consisted of 5-point Likert's scale questions. Descriptive statistics compared the level of agreement with each question across participant groups. A service quality (SQ) composite score was created by summing responses from six SQ questions. Between-group analysis was done on the SQ score using the Mann-Whitney U -test., Results: Nine physicians, 10 NNPs, 12 nurses, and 40 parents completed the survey. Providers agreed (90%) that telemedicine can effectively deliver advanced neonatal care; the care patients receive is comparable to direct patient care (87%); telemedicine enhanced overall patient care quality (90%); providers can effectively interact with each other and families using telemedicine (90.3%), and overall telemedicine experience was good (90%). In total, 61% of providers reported telemedicine improves physician-patient interaction. Parents of newborns agreed that they were well informed about telemedicine use for their child's care (88%), were able to communicate routinely with neonatologists (85%), and were comfortable with their child's physical examinations (93%). Provider's versus family's (SQ) score was not significantly different., Conclusion: All survey participants, including neonatologists, NNPs, nurses, and patient families, reported high levels of satisfaction with the hybrid telemedicine model developed and implemented at this institution which may be comparable to in-person direct patient care., Key Points: · Implementation of a hybrid telemedicine system provides an alternative to the transfer of newborns needing advanced care to tertiary care facilities.. · In this study, both health care providers and patient family members were satisfied with the quality of care using hybrid telemedicine.. · In this study, families of newborns could fully participate in their child's care using the hybrid telemedicine system.., Competing Interests: None declared., (Thieme. All rights reserved.)

This paper aims to evaluate whether there is a device-dependent effect on the reduction of surgical site complications in obese patients (body mass index [BMI] ≥ 30 kg/m 2 ) undergoing cesarean section (C-section). PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for the period, January 2011 to September 2021. English language articles describing a randomized controlled trial (RCT) that compared either a -80 or -125 mm Hg single-use negative pressure wound therapy (sNPWT) device to standard dressings in obese (BMI ≥ 30 kg/m 2 ) patients undergoing C-section were included. Conference abstracts and "terminated" RCTs with published results were deemed eligible for inclusion. The primary outcome of interest was surgical site infection (SSI), classified as composite, superficial, or deep. Secondary outcomes assessed included seroma, dehiscence, hematoma, bleeding, reoperation, readmission, blistering, and (composite) wound complications. A total of 223 titles were identified, of which 129 were screened by full-text review. Eleven RCTs encompassing 5,847 patients met the inclusion criteria and were considered eligible for further analysis (-80 mm Hg: six studies; -125 mm Hg: five studies). A statistically significant improvement in the composite SSI (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.54-0.89) and superficial SSI (OR: 0.66; 95% CI: 0.50-0.86) outcomes was observed with the -80 mm Hg device, compared with standard dressings. The same effect on SSI outcomes was not observed with the -125 mm Hg device (composite SSI-OR: 0.91; 95% CI: 0.64-1.28; superficial SSI-OR: 1.12; 95% CI: 0.70-1.78). There were no statistically significant differences in any of the other assessed outcomes. sNPWT devices may differ in their ability to reduce composite or superficial SSI after C-section. KEY POINTS: · Negative pressure benefits obese patients undergoing C-section.. · Negative pressure devices may differ in performance.. · A head-to-head clinical trial is needed.., Competing Interests: T.G. has a consultancy agreement with Smith & Nephew for this work and B.C. is an employee of Smith & Nephew., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: The objective of this paper was to determine inhaled corticosteroid (IC) use in infants with bronchopulmonary dysplasia (BPD), define the interhospital variation of IC administration to infants with BPD, and compare clinical, demographic, and hospital factors associated with IC use., Study Design: Using the Pediatric Health Information System database, a retrospective multicenter cohort of 4,551 infants born at <32 weeks of gestation with developing BPD was studied. The clinical, demographic, and hospital characteristics of infants exposed and not exposed to ICs were compared., Results: IC use varied markedly between hospitals, ranging from 0 to 66% of infants with BPD exposed to ICs. Increased annual BPD census was not associated with IC use. In total, 25% (1,144 out of 4,551) of patients with BPD and 43% (536 out of 1,244) of those with severe BPD received ICs. Increased IC exposure was associated with lower birth weight and gestational age, days on respiratory support, need for positive pressure ventilation at 36-week postmenstrual age, need for tracheostomy, and increased use of systemic steroids, bronchodilators, and diuretics., Conclusion: IC exposure is common in infants with BPD, with substantial interhospital variability. IC use was associated with more severe disease. Hospital experience did not account for the wide variability in IC use by the hospital. Further research into the effects of ICs use is urgently needed to help guide their use in this vulnerable population., Key Points: · The risks and benefits of IC use in infants with BPD are incompletely understood.. · IC use is common in infants with BPD (25%) and severe BPD (43%) varies widely by hospital (0-66% of patients with BPD received an IC).. · Hospital experience did not account for the wide interhospital variation in IC use.., Competing Interests: Dr. McCulloh occasionally provides expert advice on legal matters., (Thieme. All rights reserved.)