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Importance: Preterm birth (PTB) is a leading cause of neonatal mortality. However, evidence on mortality beyond the neonatal period is limited, especially in North America., Objective: To examine associations of PTB with all-cause and cause-specific mortality from birth through 23 to 36 years of age., Design, Setting, and Participants: This population-based matched cohort study of live births in Canada included individuals born between January 1, 1983, and December 31, 1996, and followed up until December 31, 2019. Data were analyzed from June 1, 2023, to April 30, 2024., Exposure: PTBs, between 24 and 37 weeks' gestation (with gestational age [GA]-specific subcategories of 24 to 27 weeks, 28 to 31 weeks, 32 to 33 weeks, and 34 to 36 weeks) compared with term births (37-41 weeks' gestation)., Main Outcomes and Measures: All-cause mortality and cause-specific mortality were the main outcomes. Risk differences (RDs) and risk ratios (RRs) were estimated for all-cause mortality using log-binomial regressions and hazard ratios were estimated for cause-specific mortality using Cox proportional hazards regression models (censoring individuals who died from other causes) within prespecified age intervals (ages 0-11 months and ages 1-5, 6-12, 13-17, 18-28, and 29-36 years). Observed confounding was accounted for using coarsened exact matching on baseline characteristics., Results: Of 4 998 560 births (54.2% male), 6.9% were born preterm (with GA-specific subcategories of 0.3% born at 24-27 weeks, 0.6% at 28-31 weeks, 0.8% at 32-33 weeks, and 5.1% at 34-36 weeks). During a median of 29 years of follow-up, 72 662 individuals died (14 312 born preterm and 58 350 at term). PTB was associated with an increased risk of death in all age intervals, with the highest RDs and RRs from birth through infancy (ages 0-11 months) (RD, 2.29% [95% CI, 2.23%-2.35%]; RR, 11.61 [95% CI, 11.09-12.15]) and in early childhood (ages 1-5 years) (RD, 0.34% [95% CI, 0.31%-0.36%]; RR, 2.79 [95% CI, 2.61-2.98]) and the lowest RDs and RRs among those between ages 18 and 28 years (RD, 0.07% [95% CI, 0.04%-0.10%]; RR, 1.13 [95% CI, 1.07-1.19]). We identified increased risks of mortality associated with several causes, including respiratory, circulatory, and digestive system disorders; nervous system, endocrine, and infectious diseases; cancers; congenital malformations; and conditions originating in the perinatal period. No associations were found for external causes of deaths. Associations by GA categories suggested lower risks with higher GA., Conclusions and Relevance: The findings of this population-based matched cohort study suggest that individuals born preterm were at an increased risk of death from birth until their third and fourth decades of life, with higher risks as GA decreased. Some of these associations may have been partly due to underlying health determinants that affected PTB and mortality. These findings suggest that PTB should be recognized as a risk factor for mortality and could inform preventive strategies.

Background: External causes of death, such as accidents, substance use, and suicide, contribute substantially to mortality during adolescence and early adulthood and show marked sex differences. Individuals born preterm are at increased risk of mental disorders, and impaired cognitive and executive functions, potentially increasing their vulnerability to death from external causes. We investigated sex-specific associations between gestational age at birth and mortality from external causes during late adolescence and early adulthood., Methods: Individual level data from national health registries in Denmark (1978-2001), Finland (1987-2003), Norway (1967-2002), and Sweden (1974-2001) were linked to form nationwide cohorts. In total, 6,924,697 participants were followed from age 15 years to a maximum of 50 years in 2016-2018. Gestational age was categorized as "very/moderately preterm" (23-33 weeks), "late preterm" (34-36 weeks), "early term" (37-38 weeks), "full term" (39-41 weeks), and "post term" (42-44 weeks). Outcomes were mortality from external causes overall and from the largest subgroups transport accidents, suicide, and drugs or alcohol. We estimated sex-specific hazard ratios (HRs), with full term as the reference, and pooled each country's estimates in meta-analyses., Results: Across gestational ages mortality was higher for males than females. Individuals born very/moderately preterm had higher mortality from external causes, with HRs 1.11 (95% confidence interval [CI] 0.99-1.24) for males and 1.55 (95% CI 1.28-1.88) for females. Corresponding estimates for late preterm born were 1.11 (95% CI 1.04-1.18) and 1.15 (95% CI 1.02-1.29), respectively. Those born very/moderately preterm had higher mortality from transport accidents, but precision was low. For females, suicide mortality was higher following very/moderately preterm birth (HR 1.76, 95% CI 1.34-2.32), but not for males. Mortality from drugs or alcohol was higher in very/moderately and late preterm born males (HRs 1.23 [95% CI 0.99-1.53] and 1.29 [95% CI 1.16-1.45], respectively) and females (HRs 1.53 [95% CI 0.97-2.41] and 1.35 [95% CI 1.07-1.71], respectively, with some heterogeneity across countries)., Conclusions: Mortality from external causes overall was higher in preterm than full term born among both males and females. A clear sex difference was seen for suicide, where preterm birth was a risk factor in females, but not in males., (© 2024. The Author(s).)

Importance: Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival., Objective: To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia., Design, Setting, and Participants: Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies., Exposure: Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age., Main Outcomes and Measures: The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement., Results: The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks)., Conclusions and Relevance: Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden., Trial Registration: ClinicalTrials.gov Identifier: NCT03101891.

Importance: Intravenous magnesium sulfate administered to pregnant individuals before birth at less than 30 weeks' gestation reduces the risk of death and cerebral palsy in their children. The effects at later gestational ages are unclear., Objective: To determine whether administration of magnesium sulfate at 30 to 34 weeks' gestation reduces death or cerebral palsy at 2 years., Design, Setting, and Participants: This randomized clinical trial enrolled pregnant individuals expected to deliver at 30 to 34 weeks' gestation and was conducted at 24 Australian and New Zealand hospitals between January 2012 and April 2018., Intervention: Intravenous magnesium sulfate (4 g) was compared with placebo., Main Outcomes and Measures: The primary outcome was death (stillbirth, death of a live-born infant before hospital discharge, or death after hospital discharge before 2 years' corrected age) or cerebral palsy (loss of motor function and abnormalities of muscle tone and power assessed by a pediatrician) at 2 years' corrected age. There were 36 secondary outcomes that assessed the health of the pregnant individual, infant, and child., Results: Of the 1433 pregnant individuals enrolled (mean age, 30.6 [SD, 6.6] years; 46 [3.2%] self-identified as Aboriginal or Torres Strait Islander, 237 [16.5%] as Asian, 82 [5.7%] as Māori, 61 [4.3%] as Pacific, and 966 [67.4%] as White) and their 1679 infants, 1365 (81%) offspring (691 in the magnesium group and 674 in the placebo group) were included in the primary outcome analysis. Death or cerebral palsy at 2 years' corrected age was not significantly different between the magnesium and placebo groups (3.3% [23 of 691 children] vs 2.7% [18 of 674 children], respectively; risk difference, 0.61% [95% CI, -1.27% to 2.50%]; adjusted relative risk [RR], 1.19 [95% CI, 0.65 to 2.18]). Components of the primary outcome did not differ between groups. Neonates in the magnesium group were less likely to have respiratory distress syndrome vs the placebo group (34% [294 of 858] vs 41% [334 of 821], respectively; adjusted RR, 0.85 [95% CI, 0.76 to 0.95]) and chronic lung disease (5.6% [48 of 858] vs 8.2% [67 of 821]; adjusted RR, 0.69 [95% CI, 0.48 to 0.99]) during the birth hospitalization. No serious adverse events occurred; however, adverse events were more likely in pregnant individuals who received magnesium vs placebo (77% [531 of 690] vs 20% [136 of 667], respectively; adjusted RR, 3.76 [95% CI, 3.22 to 4.39]). Fewer pregnant individuals in the magnesium group had a cesarean delivery vs the placebo group (56% [406 of 729] vs 61% [427 of 704], respectively; adjusted RR, 0.91 [95% CI, 0.84 to 0.99]), although more in the magnesium group had a major postpartum hemorrhage (3.4% [25 of 729] vs 1.7% [12 of 704] in the placebo group; adjusted RR, 1.98 [95% CI, 1.01 to 3.91])., Conclusions and Relevance: Administration of intravenous magnesium sulfate prior to preterm birth at 30 to 34 weeks' gestation did not improve child survival free of cerebral palsy at 2 years, although the study had limited power to detect small between-group differences., Trial Registration: anzctr.org.au Identifier: ACTRN12611000491965.

Objectives: The objectives were to describe mortality and causes of death in children with intraventricular hemorrhage (IVH) and to study neurodevelopmental outcomes., Methods: The study was a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. Children were recruited in 2011. A standardized assessment was conducted at age 5. Children born before 32 weeks' gestation and admitted to a NICU were eligible. Exposure was IVH defined by the Papile classification. Main outcomes were mortality, causes of death, and neurodevelopmental outcomes at age 5., Results: Among the 3468 children included, 578 (16.7%) had grade 1 IVH, 424 (12.2%) grade 2 IVH, and 114 (3.3%) grade 3 IVH; 144 (4.1%) had intraparenchymal hemorrhage (IPH). Mortality was 29.7% (36 of 114) for children with grade 3 IVH and 74.4% (109 of 144) for those with IPH; 67.6% (21 of 31) and 88.7% (86 of 97) of deaths, respectively, were because of withholding and withdrawing of life-sustaining treatment. As compared with no IVH, low-grade IVH was not associated with measured neurodevelopmental disabilities at age 5. High-grade IVH was associated with moderate and severe neurodevelopmental disabilities, reduced full-scale IQ, and cerebral palsy., Conclusions: Rates of neurodevelopmental disabilities at age 5 did not differ between children without IVH and those with low-grade IVH. For high-grade IVH, mortality rate was high, mostly because of withholding and withdrawal of life-sustaining treatment, and we found a strong association with overall neurodevelopmental disabilities in survivors., (Copyright © 2023 by the American Academy of Pediatrics.)

In this retrospective analysis, we aimed to analyze the epidemic characteristics of neonatal mortality due to preterm birth at 28-36 weeks gestation in different regions from 2009 to 2018. Data were obtained from China's Under-5 Child Mortality Surveillance System (U5CMSS). The χ2 trend test, Poisson regression and the Cochran-Mantel-Haenszel method were used in this study. We found that 51.3%, 42.0% and 44.5% of neonate deaths were preterm infants, and immaturity was mainly attributed to 60.1%, 64.1% and 69.5% of these deaths, in the eastern, central and western regions, respectively. The preterm neonatal mortality rate due to immaturity dropped from 149.2, 216.5 and 339.5 in 2009 to 47.4, 83.8 and 170.1 per 100 000 live births in 2018, giving an average annual decline rate of 12.1%, 11.6% and 6.3% in the eastern, central and western regions, respectively, during the studying period. The relative risk of preterm neonatal mortality due to immaturity were 1.3 and 2.3 for the central regions and western regions in 2009-2010, ascending to 2.2 and 3.9 in 2017-2018. The proportion of preterm neonatal deaths with a gestational age <32 weeks was highest among the eastern region. There were significantly more preterm neonatal infants who were not delivered at medical institutions in the western region than in the eastern and central regions. The preterm infant, especially with gestational age <32 weeks, should receive the most attention through enhanced policies and programs to improve child survival. Priority interventions should be region-specific, depending on the availability of economic and healthcare resources., Competing Interests: NO authors have competing interests.

Background: Addressing sustainable development goals to reduce neonatal mortality remains a global challenge, and it is a concern in Ethiopia. As a result, the goal of this study was to assess the incidence and determinants of neonatal mortality in the first 3 days among babies delivered in the referral hospitals of the Amhara National Regional State., Methods: A hospital-based prospective cohort study was conducted among 810 neonates in the first 3 days of delivery between March 1 and August 30, 2018. The neonates were followed up from the time of admission to 72 h. Interviewer-administered questionnaires and medical record reviews were conducted for data collection. Data were entered into Epi-data manager version 4.4 and analysed using STATA™ version 16.0. The neonate's survival time was calculated using the Cox-Proportional hazards model., Results: The overall incidence of neonatal mortality in this study was 151/1000 births. Neonatal mortality was significantly higher among neonates whose mothers came between 17 and 28 weeks of gestation for the first visit; among those whose mothers labour was not monitored with a partograph, mothers experienced postpartum haemorrhage and developed a fistula first 24 h, and experienced obstructed labour. However, 39% were less risky among neonates whose mothers were directly admitted and whose mothers had visited health facilities in less than 1-h, both., Conclusions: This study revealed that approximately 1 in 7 neonates died within the first 3 days of life. The determinants were the timing of the first antenatal visit, quality of labour monitoring, maternal complications, and delay in seeking care. Thus, scaling up evidence-based interventions and harmonising efforts to improve antenatal care quality, promote institutional deliveries, provide optimal essential and emergency obstetric care, and ensure immediate postnatal care may improve neonatal survival., (© 2021. The Author(s).)

Background: Neonatal mortality is a major global public health problem. Ethiopia is among seven countries that comprise 50 % of global neonatal mortality. Evidence on neonatal mortality in referred neonates is essential for intervention however, there is no enough information in the study area. Neonates who required referral frequently became unstable and were at a high risk of death. Therefore, this study aimed to assess the incidence and predictors of mortality among referred neonates., Method: A prospective follow-up study was conducted among 436 referred neonates at comprehensive specialized hospitals in the Amhara regional state, North Ethiopia 2020. All neonates admitted to the selected hospitals that fulfilled the inclusion criteria were included. Face-to-face interviews, observations, and document reviews were used to collect data using a semi-structured questionnaire and checklists. Epi-data™ version 4.2 software for data entry and STATA™ 14 version for data cleaning and analysis were used. Variables with a p-value < 0.25 in the bi-variable logistic regression model were selected for multivariable analysis. Multivariable analyses with a 95% confidence level were performed. Variables with P < 0.05 were considered statistically significant., Result: Over all incidence of death in this study was 30.6% with 95% confidence interval of (26.34-35.16) per 2 months observation. About 23 (17.83%) deaths were due to sepsis, 32 (24.80%) premature, 40 (31%) perinatal asphyxia, 3(2.33%) congenital malformation and 31(24.03%) deaths were due to other causes. Home delivery [AOR = 2.5, 95% CI (1.63-4.1)], admission weight < 1500 g [AOR =3.2, 95% CI (1.68-6.09)], travel distance ≥120 min [AOR = 3.8, 95% CI (1.65-9.14)], hypothermia [AOR = 2.7, 95% CI (1.44-5.13)], hypoglycemia [AOR = 1.8, 95% CI (1.11-3.00)], oxygen saturation < 90% [AOR = 1.9, 95% (1.34-3.53)] at admission time and neonate age ≤ 1 day at admission [AOR = 3.4, 95% CI (1.23-9.84) were predictors of neonatal death., Conclusion: The incidence of death was high in this study. The acute complications arising during the transfer of referral neonates lead to an increased risk of deterioration of the newborn's health and outcome. Preventing and managing complications during the transportation process is recommended to increase the survival of neonates., (© 2021. The Author(s).)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Objectives: The primary aims of this study were to investigate if exposure to antenatal corticosteroids (ACS) was associated with lower rates of perinatal mortality (primary outcome) and other adverse perinatal outcomes (i.e., stillbirth, early neonatal mortality, APGAR score of < 7 at 5 mins, neonatal sepsis and respiratory distress syndrome) in preterm infants in hospitals in Tanzania. We also examine factors associated with administration of ACS among women at risk of preterm delivery., Methods: A hospital-based prospective chart review study was undertaken in four hospitals located in Nyamagana and Sengerema districts, Tanzania. The study population included all stillborn and live born preterm infants delivered between 24 to 34 weeks of gestation between July 2019 to February 2020. A total 1125 preterm infants were delivered by 1008 women (895 singletons, 230 multiple). Sociodemographic and medical data were recorded from participants' medical records., Results: Three hundred and fifty-six (35.3%) women were administered at least one dose of ACS between 24 to 34 weeks' gestation and 385 (34.2%) infants were exposed to ACS. Infants exposed to ACS had a lower rate of perinatal mortality (13.77%) compared to those who were not exposed (28.38%). Multivariate analysis indicated that infants exposed to ACS were less likely to die during perinatal period, aRR 0.34 (95%CI 0.26-0.44). Only one-third of the sample was provided with ACS. Administration of ACS was associated with maternal education, attending antenatal care more than 3 times, method used to assess gestational age, maternal infection, exposure to maternal antibiotics, delivery mode and level of health facility., Conclusion: ACS significantly reduced the risk in perinatal mortality among infants born preterm in a limited resource setting. However, only about one-third of eligible women were provided with ACS, indicating low usage of ACS. Numerous factors were associated with low usage of ACS in this setting., Competing Interests: The authors have declared that no competing interests exist

Background: Preterm labour, between 24 to 28 weeks of gestation, remains prevalent in low resource settings. There is evidence of improved survival after 24 weeks though the ideal mode of delivery remains unclear. There are no clear management protocols to guide patient management. We sought to determine the incidence of preterm labour occurring between 24 to 28 weeks, its associated risk factors and the preferred mode of delivery in a low resource setting with the aim of streamlining patient care., Methods: Between February 2020 and September 2020, we prospectively followed 392 women with preterm labour between 24 to 28 weeks of gestation and their newborns from admission to discharge at Kawempe National Referral hospital in Kampala, Uganda. The primary outcome was perinatal mortality associated with the different modes of delivery. Secondary outcomes included neonatal and maternal infections, admission to the Neonatal Special Care Unit (SCU), need for neonatal resuscitation, preterm birth and maternal death. Chi-square test was used to assess the association between perinatal mortality and categorical variables such as parity, mode of delivery, employment status, age, antepartum hemorrhage, digital vaginal examination, and admission to Special Care unit. Multivariate logistic regression was used to assess the association between comparative outcomes of the different modes of delivery and maternal and neonatal risk factors., Results: The incidence of preterm labour among women who delivered preterm babies between 24 to 28 weeks was 68.9% 95% CI 64.2-73.4). Preterm deliveries between 24 to 28 weeks contributed 20% of the all preterm deliveries and 2.5% of the total hospital deliveries. Preterm labour was independently associated with gravidity (p-value = 0.038), whether labour was medically induced (p-value <0.001), number of digital examinations (p-value <0.001), history of vaginal bleeding prior to onset of labour (p-value < 0.001), whether tocolytics were given (p-value < 0.001), whether an obstetric ultrasound scan was done (p-value <0.001 and number of babies carried (p-value < 0.001). At multivariate analysis; multiple pregnancy OR 15.45 (2.00-119.53), p-value < 0.001, presence of fever prior to admission OR 4.03 (95% CI .23-13.23), p-value = 0.002 and duration of drainage of liquor OR 0.16 (0.03-0.87), p-value = 0.034 were independently associated with preterm labour. The perinatal mortality rate in our study was 778 per 1000 live births. Of the 392 participants, 359 (91.5%), had vaginal delivery, 29 (7.3%) underwent Caesarean delivery and 4 (1%) had assisted vaginal delivery. Caesarean delivery was protective against perinatal mortality compared to vaginal delivery OR = 0.36, 95% CI 0.14-0.82, p-value = 0.017). The other protective factors included receiving antenatal corticosteroids OR = 0.57, 95% CI 0.33-0.98, p-value = 0.040, Doing 3-4 digital exams per day, OR = 0.41, 95% 0.18-0.91, p-value = 0.028) and hospital stay of > 7 days, p value = 0.001. Vaginal delivery was associated with maternal infections, postpartum hemorrhage, and admission to the Special Care Unit., Conclusion: Caesarean delivery is the preferred mode of delivery for preterm deliveries between 24 to 28 weeks of gestation especially when labour is not established in low resource settings. It is associated with lesser adverse pregnancy outcomes when compared to vaginal delivery for remote gestation ages., Competing Interests: The authors have declared that no competing interests exist. The address of Ubunifu Afrika Limited was just used by one of the authors as a contact address but we have no dealings in any regard with this company in our study. We therefore declare that Ubunifu Afrika Limited does not in any way alter our adherence to any of the PLOS ONE policies on sharing data and materials. Diane Achanda Genevieve had used the address of her husband as she was changing employment during the study period. She has never worked otherwise under Ubunifu Afrika Limited. She’s currently a Nutritionist at Kawempe National Referral Hospital. Her address has been changed accordingly.

Background: Several studies of prenatal determinants and neonatal morbidity and mortality among very preterm births have resulted in unexpected and paradoxical findings. We aimed to compare perinatal death rates among cohorts of very preterm births (24-31 weeks) with rates among all births in these groups (≥24 weeks), using births-based and fetuses-at-risk formulations., Methods: We conducted a cohort study of singleton live births and stillbirths ≥24 weeks' gestation using population-based data from the United States and Canada (2006-2015). We contrasted rates of perinatal death between women with or without hypertensive disorders, between maternal races, and between births in Canada vs the United States., Results: Births-based perinatal death rates at 24-31 weeks were lower among hypertensive than among non-hypertensive women (rate ratio [RR] 0.67, 95% CI 0.65-0.68), among Black mothers compared with White mothers (RR 0.94, 95%CI 0.92-0.95) and among births in the United States compared with Canada (RR 0.74, 95%CI 0.71-0.75). However, overall (≥24 weeks) perinatal death rates were higher among births to hypertensive vs non-hypertensive women (RR 2.14, 95%CI 2.10-2.17), Black vs White mothers (RR 1.86, 95%CI 184-1.88;) and births in the United States vs Canada (RR 1.08, 95%CI 1.05-1.10), as were perinatal death rates based on fetuses-at-risk at 24-31 weeks (RR for hypertensive disorders: 2.58, 95%CI 2.53-2.63; RR for Black vs White ethnicity: 2.29, 95%CI 2.25-2.32; RR for United States vs Canada: 1.27, 95%CI 1.22-1.30)., Conclusion: Studies of prenatal risk factors and between-centre or between-country comparisons of perinatal mortality bias causal inferences when restricted to truncated cohorts of very preterm births., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy., Methods: Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529)., Findings: The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54-5.33), and perinatal death (6 studies, RR 3.23, 1.92-5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02-4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02-5.95)., Interpretation: RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis., Competing Interests: The authors have declared that no competing interests exist.

In sub-Saharan Africa (SSA), every 1 in 12 children under five dies every year compared with 1 in 147 children in the high-income regions. Studies have shown an association between birth intervals and pregnancy outcomes such as low birth weight, preterm birth, and intrauterine growth restriction. In this study, we examined the association between birth interval and under-five mortality in eight countries in West Africa. A secondary analysis of the Demographic and Health Survey (DHS) data from eight West African countries was carried out. The sample size for this study comprised 52,877 childbearing women (15-49 years). A bivariate logistic regression analysis was carried out and the results were presented as crude odds ratio (cOR) and adjusted odds ratios (aOR) at 95% confidence interval (CI). Birth interval had a statistically significant independent association with under-five mortality, with children born to mothers who had >2 years birth interval less likely to die before their fifth birthday compared to mothers with ≤2 years birth interval [cOR = 0.56; CI = 0.51 - 0.62], and this persisted after controlling for the covariates [aOR = 0.55; CI = 0.50 - 0.61]. The country-specific results showed that children born to mothers who had >2 years birth interval were less likely to die before the age of five compared to mothers with ≤2 years birth interval in all the eight countries. In terms of the covariates, wealth quintile, mother's age, mother's age at first birth, partner's age, employment status, current pregnancy intention, sex of child, size of child at birth, birth order, type of birth, and contraceptive use also had associations with under-five mortality. We conclude that shorter birth intervals are associated with higher under-five mortality. Other maternal and child characteristics also have associations with under-five mortality. Reproductive health interventions aimed at reducing under-five mortality should focus on lengthening birth intervals. Such interventions should be implemented, taking into consideration the characteristics of women and their children., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Eugene Budu et al.)

Clinicopathologic correlations of segmental villous avascularity and other histological lesions of segmental fetal vascular malperfusion (SFVM) were analyzed retrospectively to determine whether lesions of various durations reflect different etiopathogeneses. The frequencies of 25 independent clinical and 43 placental phenotypes were statistically compared by ANOVA or Chi-square among 3 groups containing a total of 378 placentas with SFVM: group 1 contained 44 cases of recent SFVM (endothelial fragmentation, villous hypovascularity by CD34 immunostain, and/or stromal vascular karyorrhexis); group 2 contained 264 cases of established SFVM (clusters of avascular villi); and group 3 contained 70 cases of remote SFVM (villous mineralization). Statistically significant differences among the three study groups (p Bonferroni < 0.002) were found in four clinical variables (gestational age, frequencies of macerated stillbirth, induction of labor, and cesarean section) and in five placental variables (frequencies of fetal vascular ectasia, stem vessel luminal vascular abnormalities, diffusely increased extracellular matrix in chorionic villi, chorionic disk extravillous trophoblast microcysts, and excessive extravillous trophoblasts in the chorionic disc). In summary, the absence of statistically significant differences between the study groups regarding the most common causes of SFVM (hypertensive conditions of pregnancy, diabetes mellitus, fetal anomalies, and clinical and pathological features of umbilical cord compromise) is evidence that the three types of SFVM reflect temporal heterogeneity rather than etiopathogenesis. This evidence can be used to date the onset of fetal vascular malperfusion before delivery or stillbirth. The coexistence of different SVFM lesions of various durations indicates ongoing or repeat occurrences of FVM rather than single episodes.

Background: The neonatal period is the most vulnerable stage of life. In Ethiopia, neonatal illness is common and the reduction in neonatal mortality is not as significant as for under-five mortality., Objectives: To determine the prevalence and factors associated with neonatal illness symptoms reported by mothers delivering in health facilities in Northwest Ethiopia., Methods: A repeated measure cross-sectional study design was employed to collect data from 358 randomly selected deliveries in 11 health facilities from November 2018 to March 2019. A pretested and interviewer-administered structured questionnaire adapted from the literature was employed to record neonatal outcomes (illnesses and/or deaths) at birth, 24 hours, 7th, 14th and 28th day from birth. Cleaned data was exported to STATA version 14 software for analysis. Multilevel analysis was used to identify individual and facility-level characteristics associated with neonatal illness symptoms., Results: The prevalence of neonatal illness symptoms was 27.8% (95% CI; 23.2, 32.8) of the 338 babies born alive and the neonatal mortality rate was 41/1000 live births (14/338). The most common symptoms or conditions of neonatal illness reported by mothers' in the study area were possible serious bacterial infections (95.8%, 90/94), localized bacterial infections (43.6%, 41/94), low birth weight (23.4%, 22/94), diarrhea (18.1%, 17/94), prematurity (14.9%, 14/94), and jaundice (7.5%, 7/94). Among the babies who died, neonates who had possible serious bacterial infections, low birth weight, localized bacterial infections, and prematurity took the highest proportions with 100% (14/14), 64.3% (9/14), 50% (7/14), and 42.9% (6/14), respectively. Having a maximum of 3 children (AOR = 1.96; 95% CI = 1.1-3.6), having twins or triplets during pregnancy (AOR = 2.43; 95% CI = 1.1-6.1), and lack of antenatal counseling (AOR = 1.83; 95% CI = 1.1-3.3) were among the maternal factors associated with neonatal illness. Having low birth length (AOR = 7.93; 95% CI = 3.6-17.3), and having a poor breastfeeding quality (AOR = 2.37; 95% CI = 1.4-4.0) were found to be the neonatal factors associated with neonatal illness., Conclusions: This study indicated a high prevalence of neonatal illness symptoms in Northwest Ethiopia. Therefore, early detection, referral and better management of symptoms or conditions with a high mortality, like sepsis and low birth weight are compulsory to save the lives of many neonates. Strengthening the health extension programme to improve antenatal care service utilization and breastfeeding quality of neonates among postpartum women is crucial., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article.

This study aimed to identify hospital neonatal mortality rate (NMR) and the causes of neonatal deaths, and to understand risk factors associated with neonatal mortality in a national tertiary hospital in Cambodia. The study included all newborn infants, aged 0-28 days old, hospitalized in the Pediatrics department of Khmer-Soviet Friendship Hospital between January 2016 and December 2017. In total, 925 infants were included in the study. The mean gestational age was 35.9 weeks (range, 24-42 weeks). Preterm infants and low birth weight accounted for 47.5% and 56.7%, respectively. With respect to payment methods, the government (53.5%) and non-governmental organizations (NGO) (13.7%) paid the fees as the families were not in a financial position to do so. The hospital NMR at the Pediatrics department was 9.3%. Respiratory distress syndrome (37.2%) was the main cause of deaths followed by hypoxic-ischemic encephalopathy (31.4%) and neonatal infection (21.0%). Factors associated with neonatal mortality were Apgar score at 5th minute <7 (adjusted odds ratio (AOR) = 3.57), payment by the government or NGO (AOR = 11.32), admission due to respiratory distress (AOR = 11.94), and hypothermia on admission (AOR = 9.41). The hospital NMR in the Pediatrics department was 9.3% (95% confidence interval 7.50-11.35) at Khmer-Soviet Friendship Hospital; prematurity and respiratory distress syndrome were the major causes of neonatal mortality. Introducing continuous positive airway pressure machine for respiratory distress syndrome and creating neonatal resuscitation guidelines and preventing hypothermia in delivery rooms are required to reduce the high NMR., Competing Interests: The authors have nothing to disclose.

Importance: Adverse long-term outcomes in individuals born before full gestation are not confined to individuals born at extreme gestational ages. Little is known regarding mortality patterns among individuals born in the weeks close to ideal gestation, and the exact causes are not well understood; both of these are crucial for public health, with the potential for modification of risk., Objective: To examine the risk of all-cause and noncommunicable diseases (NCD) deaths among young adults born preterm and early term., Design, Setting, and Participants: This multinational population-based cohort study used nationwide birth cohorts from Norway, Sweden, Denmark, and Finland for individuals born between 1967 and 2002. Individuals identified at birth who had not died or emigrated were followed up for mortality from age 15 years to 2017. Analyses were performed from June 2019 to May 2020., Exposures: Categories of gestational age (ie, moderate preterm birth and earlier [23-33 weeks], late preterm [34-36 weeks], early term [37-38 weeks], full term [39-41 weeks] and post term [42-44 weeks])., Main Outcomes and Measures: All-cause mortality and cause-specific mortality from NCD, defined as cancer, diabetes, chronic lung disease, and cardiovascular disease (CVD)., Results: A total of 6 263 286 individuals were followed up for mortality from age 15 years. Overall, 339 403 (5.4%) were born preterm, and 3 049 100 (48.7%) were women. Compared with full-term birth, the adjusted hazard ratios (aHRs) for all-cause mortality were 1.44 (95% CI, 1.34-1.55) for moderate preterm birth and earlier; 1.23 (95% CI, 1.18-1.29) for late preterm birth; and 1.12 (95% CI, 1.09-1.15) for early-term birth. The association between gestational age and all-cause mortality were stronger in women than in men (P for interaction = .03). Preterm birth was associated with 2-fold increased risks of death from CVD (aHR, 1.89; 95% CI, 1.45-2.47), diabetes (aHR, 1.98; 95% CI, 1.44-2.73), and chronic lung disease (aHR, 2.28; 95% CI, 1.36-3.82). The main associations were replicated across countries and could not be explained by familial or individual confounding factors., Conclusions and Relevance: The findings of this study strengthen the evidence of increased risk of death from NCDs in young adults born preterm. Importantly, the increased death risk was found across gestational ages up to the ideal term date and includes the much larger group with early-term birth. Excess mortality associated with shorter gestational age was most pronounced for CVDs, chronic lung disease, and diabetes.

Background: Intrauterine infection and/or inflammation (Triple I) is an important cause of preterm birth (PTB) and adverse newborn outcomes. N-acetylcysteine (NAC) is a Food and Drug Administration (FDA)-approved drug safely administered to pregnant women with acetaminophen toxicity., Methods: We conducted a single-center, quadruple-blind, placebo-controlled trial of pregnant women with impending PTB due to confirmed Triple I. Participants (n = 67) were randomized to an intravenous infusion of NAC or placebo mimicking the FDA-approved regimen. Outcomes included clinical measures and mechanistic biomarkers., Results: Newborns exposed to NAC (n = 33) had significantly improved status at birth and required less intensive resuscitation compared to placebo (n = 34). Fewer NAC-exposed newborns developed two or more prematurity-related severe morbidities [NAC: 21% vs. placebo: 47%, relative risk, 0.45; 95% confidence interval (CI) 0.21-0.95] with the strongest protection afforded against bronchopulmonary dysplasia (BPD, NAC: 3% vs. placebo: 32%, relative risk, 0.10; 95% CI: 0.01-0.73). These effects were independent of gestational age, birth weight, sex, or race. Umbilical cord plasma NAC concentration correlated directly with cysteine, but not with plasma or whole blood glutathione. NAC reduced the placental expression of histone deacetylase-2, suggesting that epigenetic mechanisms may be involved., Conclusions: These data provide support for larger studies of intrapartum NAC to reduce prematurity-related morbidity., Impact: In this randomized clinical trial of 65 women and their infants, maternal intravenous NAC employing the FDA-approved dosing protocol resulted in lower composite neonatal morbidity independent of gestational age, race, sex, and birthweight. Administration of NAC in amniocentesis-confirmed Triple I resulted in a remarkably lower incidence of BPD. As prior studies have not shown a benefit of postnatal NAC in ventilated infants, our trial highlights the critical antenatal timing of NAC administration. Repurposing of NAC for intrapartum administration should be explored in larger clinical trials as a strategy to improve prematurity-related outcomes and decrease the incidence of BPD.

Background: To systematically evaluate short-term efficacy of UCM versus other interventions in preterm infants., Methods: Six engines were searched until February 2020 for randomized controlled trials (RCTs) assessing UCM versus immediate cord clamping (ICC), delayed cord clamping (DCC), or no intervention. Primary outcomes were overall mortality, intraventricular hemorrhage (IVH), and patent ductus arteriosus (PDA); secondary outcomes were need for blood transfusion, mean blood pressure (MBP), serum hemoglobin (Hb), and ferritin levels. Random-effects meta-analyses were used., Results: Fourteen RCTs (n = 1708) were included. In comparison to ICC, UCM did not decrease mortality (RR 0.5, 95% CI 0.2-1.1), IVH (RR 0.7, 95% CI 0.5-1.0), or PDA (RR 1.0, 95% CI 0.7-1.5). However, UCM reduced need of blood transfusion (RR 0.5, 95% CI 0.3-0.9) and increased MBP (MD 2.5 mm Hg, 95% CI 0.5-4.5), Hb (MD 1.2 g/dL, 95% CI 0.8-1.6), and ferritin (MD 151.4 ng/dL, 95% CI 59.5-243.3). In comparison to DCC, UCM did not reduce mortality, IVH, PDA, or need of blood transfusion but increased MBP (MD 3.7, 95% CI 0.6-6.9) and Hb (MD 0.3, 95% CI -0.2-0.8). Only two RCTs had high risk of bias., Conclusions: UCM did not decrease short-term clinical outcomes in comparison to ICC or DCC in preterm infants. Intermediate outcomes improved significantly with UCM., Impact: In 14 randomized controlled trials (RCTs), umbilical cord milking (UCM) did not reduce mortality, intraventricular hemorrhage, or patent ductus arteriosus compared to immediate (ICC) or delayed cord clamping (DCC). UCM improved mean blood pressure and hemoglobin levels compared to ICC or DCC. In comparison to ICC, UCM reduced the need for blood transfusion. We updated searches until February 2020, stratified by type of control, and performed subgroup analyses. There was low quality of evidence about clinical efficacy of UCM. Most of RCTs had low risk of bias. UCM cannot be recommended as standard of care for preterm infants.

Background: Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction., Methods: A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline., Results: In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3-3.3], Creole aOR 1.8[95%CI 1.1-3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7-7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7-3.4]), cesarean section (aOR 3.9[95%CI 2.9-5.3]), stillbirth (aOR 6.4 [95%CI 3.4-12.2]), preterm birth (aOR 2.1[95%CI 1.3-3.2]), and macrosomia (aOR 2.8 [95%CI 1.5-5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117])., Conclusions: PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines., Competing Interests: The authors have declared that no competing interests exist.

Objective: We sought to evaluate the association between low birth weight (LBW) and outcomes following neonatal cardiac surgery in a low-income and middle-income country setting where LBW prevalence is high and its impact on surgical outcomes is undefined., Design: Single-centre retrospective cohort study., Setting: Referral paediatric hospital in Southern India PATIENTS: All neonatal cardiac surgical cases between January 2011 and December 2018. LBW was defined as <2.5 kg., Main Outcome Measures: Patient demographics, corrective versus palliative surgery and postoperative outcomes were collected from the institutional database which undergoes regular audit as part of International Quality Improvement Collaborative for Congenital Heart Disease. In-hospital mortality was the primary outcome measure., Results: Of 569 neonatal cardiac operations, 123 (21.6%) had LBW (mean: 2.2±0.3 kg); 18.7% <2 kg and 21.1% were preterm (<37 weeks). Surgery type (corrective vs palliative) or non-cardiac anomalies were not associated with birth weight. Birth weight did not correlate with ICU length of stay (LOS) and mechanical ventilation but was lower in those with postoperative sepsis. Overall in-hospital mortality was 7.0%; LBW neonates had higher mortality (OR 2.16, 95% CI 1.09 to 4.29, p=0.025). Multivariable analyses revealed birth weight (OR per 100 g decrease in weight: 1.12; 95% CI 1.03 to 1.22), age at surgery (OR per day increase in age of 0.93; 95% CI 0.87 to 0.99) and palliative intervention (OR 4.46 (95% CI 1.91 to 10.44) as independent predictors of in-hospital mortality., Conclusion: LBW adversely impacts in-hospital mortality outcomes following neonatal cardiac surgery in a resource-limited setting without increase in ICU or hospital LOS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Context: Women with disabilities are at elevated risk for pregnancy, delivery, and postpartum complications. However, there has not been a synthesis of literature on the neonatal and infant health outcomes of their offspring., Objective: We examined the association between maternal disability and risk for adverse neonatal and infant health outcomes., Data Sources: Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, and PsycINFO were searched from database inception to January 2020., Study Selection: Studies were included if they reported original data on the association between maternal physical, sensory, or intellectual and/or developmental disabilities and neonatal or infant health outcomes; had a referent group of women with no disabilities; were peer-reviewed journal articles or theses; and were written in English., Data Extraction: We used standardized instruments to extract data and assess study quality. DerSimonian and Laird random effects models were used for pooled analyses., Results: Thirty-one studies, representing 20 distinct cohorts, met our inclusion criteria. Meta-analyses revealed that newborns of women with physical, sensory, and intellectual and/or developmental disabilities were at elevated risk for low birth weight and preterm birth, with smaller numbers of studies revealing elevated risk for other adverse neonatal and infant outcomes., Limitations: Most studies had moderate ( n = 9) or weak quality ( n = 17), with lack of control for confounding a common limitation., Conclusions: In future work, researchers should explore the roles of tailored preconception and perinatal care, along with family-centered pediatric care particularly in the newborn period, in mitigating adverse outcomes among offspring of women with disabilities., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

The bilirubin content in the vitreous body of the eye of human fetuses of gestation week 17-31 was measured. During gestation weeks 17-19, the mean bilirubin concentration was 8.67 μmol/liter; then, decreased to 1.37 μmol/liter (gestation weeks 20 to 31). Bilirubin, being an endogenous antioxidant, is probably involved in protection of the retina and lens from LPO processes that intensively develop in retinal neurons and lens fibers.

Background: Preterm birth is associated with increased infant mortality. However, it is not clear whether prematurity is associated with mortality after 1 year of age. There is a lack of research on mortality rate and causes of death after infancy in preterm babies in Korea. We aimed to analyze the mortality rates and causes of deaths up to 5 years of age in Korea., Methods: Using the Microdata Integrated Service of Statistics Korea database, this retrospective cohort study screened infants born between 2010 and 2012. After applying the exclusion criteria, 1,422,913 live births were classified into the following groups by gestational age: those born at < 32 weeks' gestation (n = 10,411), those born between 32 and 36 weeks' gestation (n = 75,657), and those born at ≥ 37 weeks' gestation (n = 1,336,845). The association of gestational age with mortality in infancy (< 1 year of age) and childhood (1-5 years of age) was analyzed, with and without covariates. The major causes of death in infancy and childhood were analyzed by gestational age., Results: Overall, 4,930 (0.3%) children died between birth and 5 years of age, with 19.1% of these deaths occurring after infancy. Adjusted hazard ratios (HRs) for infant death were 78.79 (95% confidence interval [CI], 71.33-87.04) and 4.62 (95% CI, 4.07-5.24) for the < 32 and 32-36 weeks groups, respectively, compared to the full-term group; the adjusted HRs for deaths occurring at ages 1-5 years were 9.25 (95% CI, 6.85-12.50) and 2.42 (95% CI, 1.95-3.01), respectively. In infancy, conditions originating in the perinatal period were the most common cause of deaths in the < 32 and 32-36 weeks groups (88.7% and 41.9%, respectively). Contrarily, in the ≥ 37 weeks group, conditions originating in the perinatal period explained 22.7% of infant deaths, with congenital malformations primarily accounting for 29.6% of these deaths. The most common cause of death in children (after infancy) in the < 32 weeks group was perinatal causes (25.0%); in the 32-36 weeks group, congenital malformation and nervous system disease were the common causes (21.7% and 19.1%, respectively). In the ≥ 37 weeks group, injury, poisoning, and other consequences of external causes explained 26.6% of childhood deaths, followed by neoplasms and nervous system disease (15.7% and 14.7%, respectively)., Conclusion: Low gestational age is associated with not only infant mortality but also child mortality. The major causes of death differed by gestational age in infancy and childhood. For the care of preterm infants, especially those born at < 32 weeks' gestation, particular attention and continuous monitoring are needed in consideration of the major causes of deaths until 5 years of age., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU., Methods: A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017., Results: 220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia., Conclusions: This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti., Competing Interests: The authors have declared that no competing interests exist.

Background: High mortality among premature and very low birth weight (VLBW) babies necessitates the need to formulate and use scoring systems like CRIB score to predict the mortality in this vulnerable group. Objective of the study was to determine the strength of Clinical Risk Index For Babies (CRIB) score in detecting neonatal mortality in babies presenting with very low birth weight so that timely intervention can be done. It was a cross-sectional study, conducted at NICU, Children Hospital, Pakistan Institute of Medical Sciences Islamabad (PIMS) in nine months starting from First July 2017., Methods: A total of two hundred and fifty-four (n=254) new-borns with birth weight of between 500-1500 grams and gestational age lesser than 35 weeks were included in the study. CRIB score was calculated in all neonates and its association was assessed with mortality during NICU stay. Recorded data was analysed for demographic variables. Means and standard deviation was calculated for numeric variables. Chi-square test was applied to find p-value for the correlation between the main variables., Results: 54.3% (n=138) patients were males and 45.7% (n=116) were females. Mean gestational age was 33.3 weeks±1.04 SD and mean birth weight of study population was 1129.9 grams±210.6 SD. Mean CRIB score among the study population was 6.3±3.1SD and overall mortality was found to be 54.7% (n=139). Mean CRIB score was found to be 8.27±2.1 SD among mortality group and it was 3.87±3.4 SD among newborns who were discharged (p<0.05). Mortality was present in 4.3% (n=4) of neonates with CRIB score between 1 to 5, 87.1% (n=121) who had CRIB score between 6 to 10 and 100% (n=14) of neonates who had CRIB score level 11-15 (p<0.05), so a significantly higher percentage mortality was noted among neonates with higher CRIB scores., Conclusions: According to our study mean CRIB score is a significant predictor of neonatal mortality.

Preterm birth is a live birth that occurs before 37 completed weeks of pregnancy. Approximately 15 million babies are born preterm annually worldwide, indicating a global preterm birth rate of about 11%. With 1 million children dying due to preterm birth before the age of 5 years, preterm birth is the leading cause of death among children, accounting for 18% of all deaths among children aged under 5 years and as much as 35% of all deaths among newborns (aged <28 days). There are significant variations in preterm birth rates and mortality between countries and within countries. However, the burden of preterm birth is particularly high in low- and middle-income countries, especially those in Southeast Asia and sub-Saharan Africa. Preterm birth rates are rising in many countries. The issue of preterm birth is of paramount significance for achieving United Nations Sustainable Development Goal 3 target #3.2, which aims to end all preventable deaths of newborns and children aged under 5 years by 2030., (© 2020 International Federation of Gynecology and Obstetrics.)

Objective: To estimate whether improvement in outcomes from antenatal corticosteroid treatment in extremely and very preterm twins is similar to that observed in singletons, and to investigate whether antenatal corticosteroid treatment has different effects according to chorionicity or birth order., Methods: This population-based study was based on an analysis of data collected by the Neonatal Research Network of Japan from 2003 to 2015 of neonates weighing 1,500 g or less at birth, from gestational ages of 24 0/7 to 31 6/7 weeks of gestation. After propensity score matching, univariate logistic and interaction analyses were performed to compare short-term (neonatal period) and medium-term (3 years of age) outcomes of the children of mothers who received antenatal corticosteroids with those of children of mothers who did not receive antenatal corticosteroids. We focused on differences between singletons and twins, between monochorionic and dichorionic twins and between the first and second twin., Results: The study comprised 23,502 singletons and 6,546 twins. Antenatal corticosteroid treatment was associated with significant decreased short-term neurologic outcomes in both singletons and twins. However, antenatal corticosteroid treatment was associated with significantly decreased mortality (odds ratio [OR] 0.61; 95% CI 0.53-0.70), respiratory distress syndrome (OR 0.71, 95% CI 0.67-0.76), and cerebral palsy (OR 0.85, 95% CI 0.72-0.99) in singletons but not in twins (OR 0.89, 95% CI 0.68-1.17; OR 0.99, 95% CI 0.87-1.12; and OR 0.82, 95% CI 0.61-1.11, respectively). No association was found between chorionicity and the efficacy of antenatal corticosteroid treatment on outcomes. Further, no association was found between birth order and the efficacy of antenatal corticosteroid treatment on outcomes, except for periventricular leukomalacia and necrotizing enterocolitis (interaction: P=.02 and P=.04, respectively)., Conclusion: Antenatal corticosteroid treatment in twins was associated with a beneficial effect on short-term neurologic outcomes only, without improvement in other short-term and medium-term outcomes. There was no difference related to chorionicity.

Objectives: The purpose of this article is to provide thoracic and cardiovascular surgeons with a practical step-by-step strategy to use in collaboration with a biostatistician for implementation of competing risks analysis when analyzing time-to-event data. Patients may have an outside event that precludes the event of interest. Traditional time-to-event analysis incorrectly assumes noninformative censoring in this scenario, which will lead to invalid results and conclusions., Methods: The steps are (1) to determine whether competing risks analysis is needed, (2) to perform a nonparametric analysis, (3) to perform a model-based analysis, (4) to interpret the results, and (5) to compare to traditional survival analysis methods. We apply our approach to a hypothetical cardiovascular surgery example in determining the hazard of mortality after the stage 3 Fontan operation associated with prematurity among patients with hypoplastic left heart syndrome who had successful completion of Norwood stage 1 while incorporating mortality during the stage 2 bidirectional Glenn procedure as a competing risk. We apply nonparametric, semiparametric, and parametric methods., Results: Although Cox regression establishes prematurity as a significant risk factor of mortality after stage 3 (hazard ratio, 1.26; 95% confidence interval, 1.06-1.50; P = .009), the competing risks analysis with the Fine-Gray model accounting for mortality after stage 2 determines that prematurity is not a significant predictor (hazard ratio, 1.07; 95% confidence interval, 0.90-1.27; P = .467)., Conclusions: This article provides a practical step-by-step approach for making competing risks more accessible for cardiac surgeons collaborating with a biostatistician in analyzing and interpreting time-to-event data., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Studies on the optimal mode of delivery in women with a twin pregnancy <32 weeks are scarce. We studied the effects of the mode of delivery on perinatal and maternal outcomes in very preterm twin pregnancy. Study Design: Population-based cohort study including all women with twin pregnancy who delivered very preterm (26-32 weeks of gestation) in the Netherlands between January 2000 and December 2010. We compared perinatal mortality and neonatal and maternal morbidity according to the intended mode of delivery as well as to the actual mode of delivery. Perinatal outcomes were paired taking into account the dependency between the children of the same twin pregnancy and were also analysed for each child separately. We used logistic regression to correct for possible confounding factors. Results: We studied 1,655 women with a very preterm delivery of a twin pregnancy. A planned caesarean section ( n  = 212) was associated with a significantly higher perinatal mortality compared to a planned vaginal delivery ( n  = 1.443) (10% compared to 6.5%; adjusted odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2). The same applied for perinatal morbidity (66% compared to 63%; adjusted OR 1.5, 95% CI 1.1-2.0), maternal morbidity (17% compared to 4.9%; adjusted OR 4.0, 95% CI 2.6-6.3) and for perinatal mortality for the second twin (7.1% compared to 3.5% adjusted OR 2.9, 95% CI 1.7-5.2). Conclusion: In very preterm delivery of twins a vaginal delivery is the preferred mode of delivery.

Introduction: Preterm birth (PTB) complications are the leading cause of death among neonates globally. The reduction in neonatal mortality is not remarkable in Ethiopia. Therefore, this review will assess the magnitude and associated factors of PTB in Ethiopia., Methods and Analysis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline will be followed during the systematic review. We will include all observational studies published from 1 January 2009 to 31 December 2019 that examined the level and/or associated factors of any type of PTB among live births in Ethiopia. Inclusion criteria will be all live births, PTB defined as delivery before 37 weeks gestation. The primary outcome will be PTB <37 weeks, and secondary outcomes including PTB <34, <32 and <28 weeks will be analysed. PubMed and Science Direct databases as well as Google search engine and Google Scholar will be searched. The pooled prevalence of preterm and effect size of association for associated factors will be analysed using the Stata software V.14. The heterogeneity between studies will be measured by I 2 statistics. A random-effects model will be used to estimate if heterogeneity detected. Publication bias will be assessed using a funnel plot. Subgroup analysis will be sought based on possible characteristics of the studies, specific morbidity (like pre-eclampsia, hypertension), type of PTB (spontaneous or iotrogenic) and quality of study (high-quality or low-risk). Meta-regression will be considered for major covariates (maternal age and maternal body mass index) related to PTB. Forest plots will be used to present the combined estimate with 95% CIs. The quality of evidence of the outcomes will be assessed with the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach., Ethics and Dissemination: No ethical approval is necessary for this systematic review. The findings will be published in a peer-reviewed journal., Prospero Registration Number: CRD42017077356., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America., Methods: A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group., Results: 18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3-2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2-1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8-2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5-0.6)). Cesarean section rates varied between the hospitals from 17 to 36%., Conclusion: This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

Purpose: To characterize the population of women who underwent mid-trimester preterm premature rupture of membrane (PPROM) in a country where mid-trimester abortions are legal and available., Methods: A retrospective cross-sectional cohort study was conducted at a tertiary referral hospital, during 2013-2016. Mid-trimester defined as gestational age 13 + 0 to 23 + 6 weeks. Rupture of membrane was defined by documentation of fluid passing through the cervix on sterile speculum examination, and a positive Nitrazine (Bristol-Myers Squibb, Princeton, NJ) or erning test. All records were evaluated for medical history, laboratory data, postnatal examination, and autopsy findings, and a database was constructed., Results: A total of 61 women were hospitalized for mid-trimester PPROM during the study period. Mean maternal age was 32 ± 5.98, range 20-45 years old. The majority (50, 82%) of patients decided to terminate their pregnancy before reaching the limit of viability at 24 weeks gestation. The overall prognosis of pregnancies reaching term was better than expected, with six (9.8%) patients delivering live babies and four of them born at term (36 ± 5 to 40 ± 6 weeks gestation), all after PPROM following amniocentesis or selective fetal reduction. A total of 60% of women with hypothyroidism had unbalanced TSH levels above 4.0 mIU/L prior to their pregnancy. A notable number of women (15, 24.6%) had PPROM following a pregnancy achieved by assisted reproductive technology (ART)., Conclusions: Most women with diagnosed mid-trimester PPROM opted for pregnancy termination before the limit of viability when granted the choice. Possible risk factors for early PPROM are unbalanced hypothyroidism and ART. PPROM following amniocentesis can in some cases reseal and reach term, suggesting conservative treatment is a reasonable management for those cases.

Importance: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals., Objective: To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States., Design, Setting, and Participants: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019., Exposures: Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids., Main Outcomes and Measures: The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use)., Results: Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%)., Conclusions and Relevance: An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.

Transabdominal cerclage (TAC) is reported to be effective for preventing preterm birth in women with unsuccessful transvaginal cerclage (TVC) history. However, TAC has rarely been performed in twin pregnancy given the lack of sufficient evidence and the technical difficulty of the operation. Thus, it is unclear whether TAC is an effective procedure for twin pregnancy in women with a history of unsuccessful TVC. The aim of this study is to compare the characteristics and pregnancy outcomes after TAC in twin pregnancy versus singleton pregnancy, to examine whether twin pregnancy is a risk factor for very preterm birth (before 32 weeks) after TAC, and to determine whether TAC is effective in preventing preterm birth in twin pregnancy. This single-center retrospective cohort study included women who underwent TAC because of unsuccessful TVC history between January 2007 and June 2018. Of 165 women who underwent TAC, 19 had twins and 146 had singletons. Our results showed that the neonatal survival rate improved dramatically when TAC was performed (15.4% (prior pregnancy) vs 94.0% (after TAC) in twins, p<0.01; 22.8% (prior pregnancy) vs 91.1% (after TAC) in singletons, p<0.01). Moreover, the risk of very preterm birth was significantly decreased after TAC in both groups (36/39 (92.3%) (prior pregnancy) vs 2/19 (10.5%) (after TAC) in twins, p<0.01; 290/337 (86.1%) (prior pregnancy) vs 17/146 (11.6%) (after TAC) in singletons, p<0.01). More advanced maternal age and history of prior preterm delivery between 26+0 and 36+6 weeks were independently associated with very preterm birth, whereas the presence of a twin pregnancy was not associated with very preterm birth on multivariate logistic regression analysis. These results suggest that TAC is associated with successful prevention of very preterm birth and improved neonatal survival rates in the absence of procedure-related major complications in women with twin pregnancy and previous unsuccessful TVC history., Competing Interests: The authors have declared that no competing interests exist.

Background: The first month is the most crucial period for child survival. Neonatal mortality continues to remain high with little improvement over the years in Sub-Saharan Africa, including Ethiopia. This region shows the least progress in reducing neonatal mortality and continues to be a significant public health issue. In this study setting, the causes and predictors of neonatal death in the neonatal intensive care units are not well documented. Hence, this study aimed to determine the causes and predictors of neonatal mortality among infants admitted to neonatal intensive care units in eastern Ethiopia., Methods: A facility-based in prospective follow-up study was conducted among neonates admitted to neonatal intensive care units of public hospitals of eastern Ethiopia from November 1 to December 30, 2018. Data were collected using a pre-tested structured questionnaire and a follow-up checklist. The main outcomes and causes of death were set by pediatricians and medical residents. EpiData 3.1 and Statistical Package for Social Sciences Version 25 software were used for data entry and analysis, respectively. Multivariable logistic regression was used to identify the predictors of facility-based neonatal mortality., Results: The proportion of facility-based neonatal mortality was 20% (95% CI:16.7-23.8%). The causes of death were complications of preterm birth (28.58%), birth asphyxia (22.45%), neonatal infection (18.36%), meconium aspiration syndrome (9.18%), respiratory distress syndrome (7.14%), and congenital malformation (4.08%). Low birth weight, preterm births, length of stay of the neonatal intensive care unit, low 5 min APGAR score, hyperthermia, and initiation of feeding were predictors of neonatal death among infants admitted to the neonatal intensive care units of public hospitals in eastern Ethiopia., Conclusions: The proportion of facility-based neonatal deaths was unacceptably high. The main causes of death were preventable and treatable. Hence, improving the timing and quality of antenatal care is essential for early detection, anticipating high-risk newborns, and timely interventions. Furthermore, early initiation of feeding and better referral linkage to tertiary health facilities could lead to a reduction in neonatal death in this setting.

Introduction: Preterm birth-related complications are the leading cause of under-5 mortality globally. Bhutan does not have a reliable preterm birth rate or data regarding outcome of preterm babies., Aim: To determine the preterm birth rate at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu, Bhutan, and assess their outcomes., Methods: All live preterm births at JDWNRH from 1 January 2017 to 31 December 2017 were followed from birth till hospital discharge. Maternal demographic data, pregnancy details and delivery details were collected. Morbidity and mortality information as well as discharge outcome were collected on babies admitted to neonatal intensive care unit (NICU)., Results: Preterm birth rate among live births was 6.4%. Most mothers were younger than 30 years, housewives and had secondary education. Pregnancy registration rate and adequacy of antenatal visits were high. Most preterm births were singleton and the predominant mode of delivery was cesarean section. More than half of the births were initiated spontaneously, and the male:female ratio was 1.2:1. Most babies were late preterm and low birth weight. Half of them required NICU admission. Overall mortality rate was 11% and 21.6% for admitted preterm neonates. Preterm small-for-gestational-age neonates, and those born after provider-initiated preterm birth had significantly increased risk of mortality. Most preterm neonates were discharged without complications. The rate of extrauterine growth restriction was high., Conclusion: This is the first study on the prevalence of preterm births and their outcomes in the largest tertiary-care hospital in Bhutan., (© The Author(s) [2019]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The management of the pregnancy after delivery of the first fetus during a second-trimester miscarriage or very early preterm birth has not been well defined., Objective: The objective of the study was to evaluate whether delayed interval delivery of the remaining fetus(es) in twins/triplets is associated with improved survival, when compared with immediate delivery, after miscarriage or very preterm birth of the first fetus in multiple pregnancy., Data Sources: PubMed, MEDLINE, and Cochrane Library were systematically searched through January 2019. STUDY ELIGIBILITY CRITERIA (STUDY DESIGN, POPULATIONS, AND INTERVENTIONS): The following eligibility criteria applied: full-text original article; included at least 5 cases of delayed interval delivery for remaining fetus(es); and reported the survival rate of the first-born and the remaining fetus(es)., Study Appraisal and Synthesis Methods: K.W.C. and W.W. searched, screened, and reviewed the articles. The quality of the studies was assessed according to the Strengthening the Reporting of Observational studies in Epidemiology checklist. If possible, data were stratified for assigned chorionicity. Effect sizes were pooled through a meta-analysis., Results: A total of 2295 published article and abstracts were identified. Only 16 studies met inclusion criteria. Meta-analysis of 492 pregnancies (432 twins [88%], 56 triplets [11%], 3 quadruplets and 1 quintuplets) showed that delayed interval delivery significantly improved the perinatal survival of remaining fetus(es) compared with the first born (odds ratio, 5.22, 95% confidence interval, 2.95-9.25, I 2  = 53%), before 20+0 weeks (odds ratio, 6.32, 95% confidence interval, 1.99-20.13, I 2  = 0%), between 20+0 and 23+6 weeks (odds ratio, 3.31, 95% confidence interval, 1.95-5.63, I 2  = 0%), and after 24+0 weeks (odds ratio, 1.92, 95% confidence interval, 1.21-3.05, I 2  = 0%), in dichorionic twin pregnancy (odds ratio, 14.89, 95% confidence interval, 6.19-35.84, I 2  = 0%), and unselected triplet pregnancy (odds ratio, 2.33, 95% confidence interval, 1.02-5.32, I 2  = 0%. ). Among the survivors, there were no significant differences in the short-term and long-term neonatal morbidities between the first-born and the remaining fetus(es). Serious maternal morbidity was reported in 39% of pregnancy after delayed interval delivery (71 of 183). In addition, 2 cases were managed by postpartum hysterectomy and 1 reported postoperative uterovaginal fistula. There were no recorded cases of maternal mortality., Conclusion: Delayed interval delivery when a fetus has delivered in a multiple pregnancy is an effective management option to increase the survival rate of the remaining fetus(es). About 39% of women may experience morbidity following this management option., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Antenatal corticosteroids administered to the mother prior to birth decrease the risk of mortality and major morbidity in infants born at less than 35 weeks' gestation. However, the evidence relating to women with diabetes in pregnancy is limited. Clinical guidelines for antenatal corticosteroid administration recommend that women with diabetes in pregnancy are treated in the same way as women without diabetes, but there are no recent descriptions of whether contemporary practice complies with this guidance. This study is a retrospective review of antenatal corticosteroid administration at a New Zealand tertiary hospital in women with diabetes in pregnancy. We found that in this cohort, for both an initial course at less than 35 weeks' gestation and repeat courses at less than 33 weeks', the administration of antenatal corticosteroid to women with diabetes in pregnancy is largely consistent with current Australian and New Zealand recommendations. However, almost 25% of women received their last dose of antenatal corticosteroid at or beyond the latest recommended gestation of 35 weeks' gestation. Pre-existing diabetes and planned caesarean section were independently associated with an increased rate of antenatal corticosteroid administration. We conclude that diabetes in pregnancy does not appear to be a deterrent to antenatal corticosteroid administration. The high rates of administration at gestations beyond recommendations, despite the lack of evidence of benefit in this group of women, highlights the need for further research into the risks and benefits of antenatal corticosteroid administration to women with diabetes in pregnancy, particularly in the late preterm and early term periods., Competing Interests: The authors have declared that no competing interests exist.

Objective: To identify antenatal predictors of adverse perinatal outcomes in a population of preterm fetuses with early placental insufficiency diagnosed by Doppler abnormalities., Method: In this cross-sectional study of a cohort of singleton pregnant women diagnosed with early placental insufficiency, relationships between perinatal variables (arterial and venous Doppler, gestational age, birth weight, oligohydramnios, estimated fetal weight, and fetal weight z-scores) and major neonatal complications were analyzed by logistic regression., Results: Two hundred sixty-five women were delivered, between 24 and 33 weeks gestation. The overall frequency of intact survival was 57.9% (n = 154). Gestational age thresholds for best prediction of survival was 27 + 6 weeks and for intact survival was 29 + 0 weeks gestation. Fetal weight and absent/reversed ductus venosus a-wave were the main predictors of survival in the regression model. When fetal weight was substituted for fetal weight z-score, ductus venosus abnormal Doppler predicted mortality and absent or reversed umbilical artery diastolic velocities predicted intact survival., Conclusions: This study illustrates the impact of gestational age and fetal weight on perinatal outcomes in early placental insufficiency, with well-defined thresholds. Gestational age and fetal weight, or a combination of fetal weight z-scores and fetal Doppler parameters, were the best predictors of intact survival in our sample., (© 2019 John Wiley & Sons, Ltd.)

In recent years, significant improvements in survival and survival-free of major morbidity in babies born at 23 +0 to 24 +6  weeks of gestation have led to a more pro-active approach to resuscitation at these peri-viable gestations. Antenatal counselling and interventions, intrapartum care and postnatal advice should be part of the package of care provided to optimise outcomes for these babies and their families. This observational study assesses the perinatal care provided to mothers and their babies who were born at 23 and 24 weeks of gestations over a two-year period at a tertiary maternity hospital in New Zealand., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Congenital limb malformations are rare, and their perinatal outcomes are not well described. This study analyzed the perinatal outcomes of infants with congenital limb malformations., Methods: All infants with congenital limb malformations who underwent prenatal assessment and delivery at our tertiary referral center from 2004 through 2017 were retrospectively identified. Neonatal outcome parameters were assessed, and the predictors of worse perinatal outcomes were determined., Results: One hundred twenty-four cases of congenital limb malformations were identified, of which 104 (83.9%) were analyzed. The upper limb was affected in 15 patients (14.4%), the lower limb in 49 (47.1%), and both limbs in 40 (38.5%) patients. A fetal syndrome was identified in 66 patients (63.5%); clubfoot and longitudinal reduction defects were the most frequent malformations. In total, 38 patients (36.5%) underwent termination, seven (6.7%) had stillbirth, and 59 (56.7%) had live-born delivery. Rates of preterm delivery and transfer to the Neonatal Intensive Care Unit were 42.4 and 25.4%, respectively. Localization of the malformation was a determinant of perinatal outcome (P = .006) and preterm delivery (P = .046)., Conclusions: Congenital limb malformations frequently occur bilaterally and are associated with poor perinatal outcomes, including high rates of stillbirth and preterm delivery. Multidisciplinary care and referral to a perinatal center are warranted.

Background: A large recent study analyzed the relationship between multiple factors and neonatal outcome and in preterm births. Study variables included the reason for admission, indication for delivery, optimal steroid use, gestational age, and other potential prognostic factors. Using stepwise multivariable analysis, the only two variables independently associated with serious neonatal morbidity were gestational age and the presence of suspected intrauterine growth restriction as a reason for admission. This finding was surprising given the beneficial effects of antenatal steroids and hazards associated with some causes of preterm birth. Multivariable logistic regression techniques have limitations. Without testing for multiple interactions, linear regression will identify only individual factors with the strongest independent relationship to the outcome for the entire study group. There may not be a single "best set" of risk factors or one set that applies equally well to all subgroups. In contrast, machine learning techniques find the most predictive groupings of factors based on their frequency and strength of association, with no attempt to identify independence and no assumptions about linear relationships. Objective: To determine if machine learning techniques would identify specific clusters of conditions with different probability estimates for severe neonatal morbidity and to compare these findings to those based on the original multivariable analysis. Materials and methods: This was a secondary analysis of data collected in a multicenter, prospective study on all admissions to the neonatal intensive care unit between 2013 and 2015 in 10 hospitals. We included all patients with a singleton, stillborn, or live newborns, with a gestational age between 23 0/7 and 31 6/7 week. The composite endpoint, severe neonatal morbidity, defined by the presence of any of five outcomes: death, grade 3 or 4 intraventricular hemorrhage (IVH), and ≥28 days on ventilator, periventricular leukomalacia (PVL), or stage III necrotizing enterocolitis (NEC), was present in 238 of the 1039 study patients. We studied five explanatory variables: maternal age, parity, gestational age, admission reason, and status with respect to antenatal steroid administration. We concentrated on Classification and Regression Trees because the resulting structure defines clusters of risk factors that often bear resemblance to clinical reasoning. Model performance was measured using area under the receiver-operator characteristic curves (AUC) based on 10 repetitions of 10-fold cross-validation. Results: A hybrid technique using a combination of logistic regression and Classification and Regression Trees had a mean cross-validated AUC of 0.853. A selected point on its receiver-operator characteristic (ROC) curve corresponding to a sensitivity of 81% was associated with a specificity of 76%. Rather than a single curve representing the general relationship between gestational age and severe morbidity, this technique found seven clusters with distinct curves. Abnormal fetal testing as a reason for admission with or without growth restriction and incomplete steroid administration would place a 20-year-old patient on the highest risk curve. Conclusions: Using a relatively small database and a few simple factors known before birth it is possible to produce a more tailored estimate of the risk for severe neonatal morbidity on which clinicians can superimpose their medical judgment, experience, and intuition.

Background: Low birth weight and prematurity are associated with increased morbidity, mortality and multiple short and long-term complications, exerting impacts on the individual, the families, the community and the health care system. Fetal, maternal and environmental factors have been associated with low birth weight and prematurity, based primarily on researches from high-income countries. It is unknown whether these risk factors are the same in low and middle income countries. The aims of this study are to determine the prevalence of low birth weight and prematurity and associated factors in Jimma University Specialized Hospital, Ethiopia., Methods: This observational study was conducted at Jimma University Specialized Hospital, Ethiopia, from December 2014 to September 2016. Multivariable logistic regression was used to determine the associated factors, with results reported as odds ratios (OR) and 95% confidence intervals (CI)., Results: The prevalence of low birth weight and prematurity were 14.6% and 10.2%, respectively. The mean birth weight was 2,975g (standard deviation 494). Prematurity (OR 23.54, 95%CI 15.35-36.08, p<0.001) and unmarried marital status (OR 5.73, 95%CI 1.61-20.40, p=0.007) were positively associated with low birth weight. Female sex (OR 1.69, 95%CI 1.18-2.42, p=0.004) and unmarried marital status (OR 4.07, 95%CI 1.17-14.14, p=0.027) were positively associated with prematurity., Conclusion: The prevalence of lower birth weight and prematurity in this study is lower than other studies reported from similar facilities. Prematurity and unmarried marital status are associated with LBW whereas female sex and unmarried marital status are associated with prematurity in this population., (©2019 Melkamu Bi, et al.)

Background: We aimed to explore the leading causes and risk factors for infant mortality in a statewide study of infant deaths from 2005 to 2016., Methods: Rhode Island Vital Statistics was linked with KIDSNET, a statewide-integrated child health information system. Descriptive analyses examined infant mortality rates as well as risk factors of infant, neonatal, and postneonatal death. A multivariable logistic regression model of the risk of infant mortality adjusting for risk factors was computed., Results: The majority (74%) of infant deaths occurred during the neonatal period. The top cause of infant mortality was prematurity (20.4%). After adjustment, infants born <28 weeks had 38.1 higher odds of mortality compared to term infants (p<0.01). Low 5-minute Apgar score, birth defects, less than 10 prenatal visits, and low maternal weight gain were associated with higher odds of infant mortality (p<0.01)., Discussion: Substantial reductions in the infant mortality rate will require improving strategies to prevent preterm births as well as using factors identifiable at birth to focus prevention efforts on those at higher risk.