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Objective We analyzed the role of environmental risk factors, sociodemographic characteristics, clinical characteristics, and reproductive history in preterm births and their associated perinatal outcomes in families classified according to their histories of preterm recurrence among siblings. Study Design A retrospective study was conducted at Nuestra Señora de la Merced Maternity Hospital in the city of Tucumán, Argentina. A total of 348 preterm, non-malformed, singleton children born to multipara women were reviewed. The family history score described by Khoury was applied, and families were classified as having no, medium, or high genetic aggregation. Results Families with no familial aggregation showed a higher rate of short length of cohabitation, maternal urinary tract infections during the current pregnancy, and maternal history of miscarriage during the previous pregnancy. Families with a high level of aggregation had a significantly higher incidence of pregnancy complications, such as diabetes, hypertension, and immunologic disorders. Conclusion Reproductive histories clearly differed between the groups, suggesting both a different response to environmental challenges based on genetic susceptibility and the activation of different pathophysiological pathways to determine the duration of pregnancy in each woman. [ABSTRACT FROM AUTHOR]

Objective Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC. Study Design We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m2), normal weight (18.5 to 24.9 kg/m2), overweight (25.0 to 29.9 kg/m2), and obese (≥30 kg/m2). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using X2 and nonparametric analyses. Results Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p =0.41). Conclusion In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care. [ABSTRACT FROM AUTHOR]

Objective Shoulder dystocia (SD) and brachial plexus palsy (BPP) are complications of childbirth that can result in significant long-term sequelae. The purpose of the present study was to analyze risk factors in cases of SD and BPP. Methods We performed a retrospective study of laboring women who delivered a singleton, term, live-born infant at the Los Angeles County + University of Southern California Medical Center from 1995 to 2004. Multivariable logistic regression models were used to analyze risk factors among SD cases with and without BPP. Results Of the 13,998 deliveries that met inclusion criteria, 221 (1.6%) had SD. Of these, 42 (19.0%) had BPP. After testing for association with multiple potential risk factors, including maternal demographic variables, diabetes, hypertension, prior cesarean delivery, uterine abnormalities, induction of labor, prolonged second stage (adjusted by parity and epidural use), assisted vaginal delivery, and neonatal birth weight, no statistical association of BPP with any specific risk factor was identified. Conclusion In the present study, we were unable to identify any reliable risk factors for BPP among deliveries with or without SD. SD and BPP remain unpredictable complications of childbirth. [ABSTRACT FROM AUTHOR]

Early onset neonatal group B streptococcal (GBS) sepsis is a serious neonatal illness with high morbidity and mortality. The disease can present in two forms: early clinical manifestation with respiratory distress soon after birth or late presentation with gradual onset of signs of sepsis. The former carries a high risk for serious cardiovascular complication with persistent pulmonary hypertension; the latter is often complicated with meningitis that may lead to serious neurodevelopmental impairment. An important advance in the past three decades is the development and implementation of preventive strategy for this disease by universal screening and identification of maternal GBS carriers and/or risk factors with subsequent use of intrapartum antibiotic prophylaxis. The strategy has resulted in a significant reduction of the disease from 1.5 to 0.3/ 1,000 live births over the past three decades. Some women may have unknown GBS status. The American Academy of Pediatrics has developed an algorithm as guidance for the management of the newborns. [ABSTRACT FROM AUTHOR]

Objective Determine the Bishop score most predictive of induction of labor (IOL) success for different maternal weight groups. Study Design Retrospective cohort study. Prospectively collected database utilized to determine the optimum Bishop score within each prepregnancy body mass index (BMI) category of term, nulliparous patients undergoing IOL. Results For the total group (n = 696), Bishop score ≥5 was most predictive of success (75% versus 56%, p < 0.0001). Within each BMI category, Bishop score ≥5 remained most predictive: normal weight (79% versus 64%, p < 0.01); overweight (72% versus 58%, p = 0.03); and obese (73% versus 45%, p < 0.0001). Overall, nonobese patients hadmore success than obese patients (70% versus 59%, p < 0.01). The nonobese group hadmore success than the obese group when the Bishop score was <3 (57% versus 39%, p < 0.05) but not when it was ≥3 (72% versus 65%, p = 0.1). Also, there was a higher fraction of patients with Bishop score <3 in the obese group compared with the nonobese group (25% versus 14%, p < 0.001). Conclusion The optimum Bishop score for predicting successful IOL in nulliparous patients was 5 regardless of BMI class. The higher IOL failure rate observed in obese women was associated with lower starting Bishop scores and was compounded by higher failure rates in obese women with Bishop scores <3. [ABSTRACT FROM AUTHOR]

Objective To analyze the association between concentration, as measured by the Interactive Metronome, and a prolonged second stage of labor in nulliparous patients. Study Design From September 2008 to November 2009, nulliparous women at ≥34 weeks' gestation who were planning to use an epidural were asked to perform a 1-minute Interactive Metronome clapping test. Scores and demographic information were recorded. Data were then abstracted regarding each patient's labor course. The main outcome measure was the frequency of the second stage of labor exceeding 2 hours. Only patients with epidural anesthesia who completed the second stage of labor and did not require operative delivery performed for fetal indications prior to 2 full hours of pushing were included. Results Of the patients whose Interactive Metronome test scores were in the last quartile, which we associated with poor concentration, 52.9% (18/34) had a second stage of labor exceeding 2 hours compared with only 31.7% (33/104) of patients whose scores placed them in the first three quartiles (p = 0.026). Conclusion Nulliparous patients with poor concentration scores, as measured by the Interactive Metronome, were more likely to push greater than 2 hours in the second stage of labor. [ABSTRACT FROM AUTHOR]

Objective: To examine pregnancy outcomes of women receiving weekly compounded 17 αhydroxyprogesterone caproate (17P) injections through a home nursing program compared with those reported in a multicenter trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Network. Methods: The study sample was comprised of patients receiving compounded 17P through a home nurse administration care management program. Included were women with current singleton gestation and prior spontaneous preterm birth (SPTB) initiating 17P between 16 and 20 weeks. Maternal characteristics and pregnancy outcomes were compared between study group and NICHD Network trial patients. Results: Women (n = 5493) received a mean of 16.9 ± 4.0 injections. Of the 92,700 injections, 98.4% were administered within the recommended 5- to 9-day interval. Recurrent SPTB occurred in 28.3%. The overall rate of SPTB at <37 weeks was similar for black and nonblack women (p = 0.592).Within black or nonblack groups, preterm birth rates at <37 weeks were similar regardless of gestational age at start of 17P (p = 0.894 and p = 0.374, respectively). These results were similar to those reported in the multicenter trial. Fetal and neonatal death occurred in 0.8% (46/5493). No significant difference was observed in rate of fetal or neonatal death by gestational age at initiation of 17P (p = 0.478). Conclusion: Home nurse administration of compounded 17P is safe and effective. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of comorbidities and induction of labor (IOL) on the cesarean delivery (CD) rate in an obese nulliparous cohort. Study Design: This was a retrospective review of medical records of patients who delivered at our institution from January 1, 2010, to January 18, 2011. Nulliparous patients were identified with a bodymass index of ≥30.0 kg/m2. The rates of IOL and CD for patients with a comorbidity were compared with those patients without a comorbidity. Results: Among 1908 patients, 105 met inclusion criteria. The CD rate was significantly higher in the comorbid group (58.5%) than in the control group (34.6%) [odds ratio (OR) 2.66, 95% confidence interval (CI) 1.21 to 5.87, p = 0.019]. The IOL rate was significantly higher in the comorbid group (71.7% versus 15.4%; OR 13.93, 95% CI 5.33 to 36.46, p < 0.0001). Preeclampsia (44.7%) was the most common indication for IOL in the comorbid group, whereas postterm pregnancy (50%) was the most common indication in the control group. Conclusion: The CD rate in obese women with comorbidities is higher than that of obese women without comorbidity. These results suggest that the higher IOL rate and subsequent failed induction in obese women with comorbidities is a significant factor contributing to this association. [ABSTRACT FROM AUTHOR]

To estimate the risk of preterm birth in asymptomatic women with twin pregnancies with a normal cervical length (CL) and a positive fetal fibronectin (fFN), we reviewed a retrospective cohort of twin pregnancies delivered in our practice from 2005 to 2010. Patients were screened from 22 to 32 weeks with CL and fFN at 2- to 4-week intervals. We examined 244 patients with twin pregnancies and a normal CL (>25 mm) between 22 and 32 weeks and compared outcomes based on the fFN result. Fourteen (5.7%) patients had a positive fFN and 230 (94.3%) patients had a negative fFN. Positive fFN was associated with an increased the risk of spontaneous preterm birth < 37 weeks (85.7% versus 38.3%, p = 0.001), < 35 weeks (50% versus 11.8%, p <  0.001), < 34 weeks (35.7% versus 6.9%, p <  0.001), and < 32 weeks (21.4% versus 2.2%, p <  0.001). On adjusted analysis, a positive fFN was independently associated with preterm birth < 32 weeks (odds ratio 6.8, 95% confidence interval 1.42, 32.2) and gestational age at delivery (p = 0.001). In the setting of a normal CL, a positive fFN is significantly associated with preterm birth in asymptomatic twin pregnancies. Contingency model screening of fFN in asymptomatic twin pregnancies solely based on CL evaluation may fail to identify a cohort of at-risk patients. [ABSTRACT FROM AUTHOR]

We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets < 33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p = 0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p = 0.04). These trends were significant in mothers ≥ 35 years of age. Neonatal outcomes improved for preterm twins (mortality, p <  0.01; survival without any major morbidity, p <  0.01; severe neurological injury, p = 0.02; and severe retinopathy of prematurity, p = 0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at < 33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period. [ABSTRACT FROM AUTHOR]

We examined the association between midtrimester intra-amniotic sludge and spontaneous preterm birth (PTB) in asymptomatic women undergoing amniocentesis. We performed a prospective cohort study of women having an amniocentesis for fetal karyotyping between 14 and 24 weeks' gestation. Cervical length and the presence of amniotic sludge were assessed by transvaginal ultrasound. Amniotic fluid concentrations of matrix metalloproteinase-8, glucose and lactate were measured. Early (<32 weeks) and late (32 to 36 weeks) preterm premature rupture of membranes (PPROM) and spontaneous PTB constituted primary outcomes. Nonparametric analyses were conducted. Three hundred ten women, including 94 (30%) with free-floating echogenic particles and 16 (5%) with dense amniotic sludge, were recruited. Dense amniotic sludge was linked with early (13%) but not with late (0%) primary outcome (p<0.01). Two women with combined dense amniotic sludge and short cervix delivered 4 and 10 weeks later (at 20 and 25 weeks, respectively) and had a higher median amniotic lactate concentration than controls (p<0.05). A third woman with dense amniotic sludge at 15 weeks was diagnosed with a short cervix and an intra-amniotic infection at 22 weeks that was eradicated with intravenous antibiotics. Midtrimester dense amniotic sludge is associated with early PPROM and spontaneous PTB. [ABSTRACT FROM AUTHOR]

We describe the epidemiological characteristics and identify maternal-fetal outcomes in pregnancies complicated by gastroschisis. We retrospectively reviewed 115 cases of gastroschisis at the University of Mississippi Medical Center. The incidence of gastroschisis trended upward between 2000 and 2008. Significant proportions of mothers were nonobese, nulliparous, teenagers, smokers, and nonconsumers of alcohol. Infants delivered at >36 weeks or without sepsis had shorter hospital stay (HS) and interval to full enteral feeding (FEF). The rates of low birth weight (LBW), fetal growth restriction, and spontaneous preterm birth (PTB) were 63%, 45%, and 24%, respectively. Bowel atresia was noted in 9%. Rates of primary closure (25%), neonatal sepsis (29%), fetal death (2%), and infant mortality (4%) were notable. Median HS and interval to FEF were 40 and 30 days, respectively. The incidence of gastroschisis is increasing in Mississippi. Sepsis, LBW, and PTB are key determinants of poor infant outcomes. [ABSTRACT FROM AUTHOR]

We assessed if first-trimester vitamin D deficiency is more prevalent in women who experienced a spontaneous preterm birth compared with women who delivered at term. We conducted a nested case-control study of pregnant women who had previously given blood for first-trimester combined screening for trisomy 21 and subsequently delivered at a tertiary hospital between November 2004 and July 2009. From an overall cohort of 4225 women, 40 cases of spontaneous preterm birth (230/7 and 346/7 weeks) were matched by race/ethnicity with 120 women delivering at term (370/7 weeks) with uncomplicated pregnancies. Banked maternal serum was used to measure maternal 25- hydroxyvitamin D [25(OH)D]. The prevalence of first-trimester maternal vitamin D deficiency [25(OH)D <50 nmol/L] was comparable among women who subsequently delivered preterm compared with controls (7.5% versus 6.7%, p¼0.90). The median 25(OH)D level for all subjects was 89 nmol/L (interquartile range, 73 to 106 nmol/L). Seventy-three percent (117/160) of the cohort had sufficient vitamin D levels [25(OH)D ≥75 nmol/L]. In a cohort of pregnant women with mostly sufficient levels of firsttrimester serum 25(OH)D, vitamin D deficiency was not associated with spontaneous preterm birth. [ABSTRACT FROM AUTHOR]

To estimate the risk of preterm birth in asymptomatic women with twin pregnancies with a normal cervical length (CL) and a positive fetal fibronectin (fFN), we reviewed a retrospective cohort of twin pregnancies delivered in our practice from 2005 to 2010. Patients were screened from 22 to 32 weeks with CL and fFN at 2- to 4-week intervals. We examined 244 patients with twin pregnancies and a normal CL (>25 mm) between 22 and 32 weeks and compared outcomes based on the fFN result. Fourteen (5.7%) patients had a positive fFN and 230 (94.3%) patients had a negative fFN. Positive fFN was associated with an increased the risk of spontaneous preterm birth <37 weeks (85.7% versus 38.3%, p=0.001), <35 weeks (50% versus 11.8%, p <0.001), <34 weeks (35.7% versus 6.9%, p <0.001), and <32 weeks (21.4% versus 2.2%, p <0.001). On adjusted analysis, a positive fFN was independently associated with preterm birth <32 weeks (odds ratio 6.8, 95% confidence interval 1.42, 32.2) and gestational age at delivery (p=0.001). In the setting of a normal CL, a positive fFN is significantly associated with preterm birth in asymptomatic twin pregnancies. Contingency model screening of fFN in asymptomatic twin pregnancies solely based on CL evaluation may fail to identify a cohort of at-risk patients. [ABSTRACT FROM AUTHOR]

We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets <33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p=0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p=0.04). These trends were significant in mothers ≥35 years of age. Neonatal outcomes improved for preterm twins (mortality, p<0.01; survival without any major morbidity, p<0.01; severe neurological injury, p=0.02; and severe retinopathy of prematurity, p=0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at <33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period. [ABSTRACT FROM AUTHOR]

We sought to examine neonatal morbidity in four groups of offspring (asymmetric large for gestational age [LGA], symmetric LGA, asymmetric non-LGA, symmetric non-LGA) exposed in utero to maternal type 1 diabetes, and the association between rate of fetal abdominal circumference growth and asymmetric LGA. We performed a secondary analysis of 302 singleton pregnancies. Neonatal morbidity (respiratory distress syndrome, polycythemia, hypoglycemia, hyperbilirubinemia, acidosis, and composite morbidity [any of the five]) was assessed. Serial ultrasound examinations after 20 weeks' gestation were available for 35 fetuses. Logistic regression and general linear mixed modeling were used for analysis. Asymmetric LGA infants had 3.5-, 2.2-, and 3.2-fold greater odds of hypoglycemia, hyperbilirubinemia, and composite morbidity, respectively, compared with symmetric non-LGA infants. The rate of growth of the abdominal circumference in asymmetric LGA infants (1.11 cm/wk) was greater than for both the symmetric LGA infants (0.87 cm/wk, p = 0.09) and the symmetric non-LGA infants (0.87 cm/wk, p = 0.03). Asymmetric LGA infants are at higher risk for morbidity than symmetric LGA and non-LGA infants. Intrauterine growth rate of the abdominal circumference may potentially be used as a marker to identify the asymmetric LGA and thereby aid in the identification of newborns at greatest risk for perinatal complications. [ABSTRACT FROM AUTHOR]

Children who are born small for gestational age (SGA) are at increased risk of adverse neurological outcomes, and there is limited evidence that maternal genitourinary (GU) infections may be associated with SGA. Our objective was to explore the possible relationship between maternal GU infection during pregnancy and SGA. We modeled the association between maternal GU infections and SGA using linked South Carolina Medicaid billing data and birth certificate records for 141,035 women and infants born from 1996 through 2002. Controlling for demographic covariates and maternal medical conditions, GU infection was not significantly associated with SGA (odds ratio?=?1.03, P?=?0.143). When categorizing GU infections by trimester, second-trimester infection had a statistically significant but weak association with SGA (odds ratio?=?1.08, P?=?0.005). Young and old maternal age, female sex, maternal alcohol and tobacco use, preeclampsia/eclampsia, and hypertension were significantly associated with increased risk of SGA. White race, maternal education, diabetes mellitus, and more recent year of birth were associated with lower risk. Maternal GU infection generally was not associated with SGA, though there may be an association for second-trimester infections only. Even this association was modest and may not be clinically significant. [ABSTRACT FROM AUTHOR]

We investigated whether abnormal concentrations of first-trimester free-? subunit human chorionic gonadotropin (f?hCG) and pregnancy-associated plasma protein A (PAPP-A) are associated with preterm delivery in twin gestations. This was a hospital-based, retrospective study of 70 twin gestations between 11 1/ 7and 13 6/ 7weeks' gestation undergoing first-trimester screening. Free ?hCG and PAPP-A multiples of the median were determined by our laboratory standards. Odds ratios (ORs) were estimated that compared the prevalence of very preterm (

We sought to determine if there has been any change in the proportion of mothers with preeclampsia in a sample of very low-birth-weight (VLBW) infants over time. We performed a retrospective cohort study. Study sample included infants with birth weights 1500 g or less cared for from July 1994 to July 2006 ( N?=?2045) from a single level 3 neonatal intensive care unit in Delaware. The main outcome examined was the occurrence of maternal preeclampsia over the study time. The proportion of mothers with preeclampsia delivering VLBW infants increased over time. After controlling for potential confounding variables, the odds of maternal preeclampsia were increased (1.3, 95% confidence interval 1.2 to 1.5) in infants born between 2003 and 2006 compared with those born between 1994 and 1997. In our population of VLBW infants, the proportion of mothers with the diagnosis of preeclampsia increased over time. From our investigation, we cannot determine if the increase in the proportion of mothers with preeclampsia is related to a true increase in the disease, changes in diagnostic surveillance, or other factors. [ABSTRACT FROM AUTHOR]

Gestational hypertension (GHTN) and gestational diabetes mellitus (GDM) are both insulin resistance states. Perinatal outcome of GHTN or GDM alone are well established, but their combined effect on pregnancy outcome is underinvestigated. Our objective was to determine if pregnancies complicated by GHTN/GDM have higher rates of morbidity. We identified nulliparous women with singleton pregnancies delivering at 37 to 40 weeks of gestation from 1995 to 2004 from a database. Outcomes of pregnancies complicated by GHTN only, GDM only, or combined GHTN/GDM were compared with controls. Data analysis included the Mann-Whitney U test, the Kruskal-Wallis H test, and analysis of variance. Multivariate analysis was used to adjust for confounders. Of 14,880 patients, there were 11,349 controls, 2604 GHTN, 728 GDM, and 199 GHTN/GDM. After controlling for covariates, GHTN significantly increased cesarean section (C/S) rate (odd ratio [OR], 1.62; confidence interval [CI], 1.47 to 1.78), rates of admittance to the neonatal intensive care unit (NICU), and birth of large for gestational age (LGA) infants. GDM significantly increased C/S (OR, 1.42; CI 1.21 to 1.66), rates of NICU admission (OR, 1.32; CI, 1 to 1.75), birth of LGA (OR, 1.51; CI 1.14 to 1.98), and macrosomic infants (OR, 1.53; CI, 1.12 to 2.08). Rates of LGA infants (OR, 1.85; CI, 1.19 to 2.86) and C/S (OR, 2.03; CI, 1.52 to 2.71) were significantly increased with GHTN/GDM. We concluded that GHTN or GDM is associated with increased rates of adverse outcomes. Their coexistence further increases adverse perinatal outcomes. [ABSTRACT FROM AUTHOR]