Does acute funisitis predict worse neonatal outcomes among term newborns?

BACKGROUND: Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response to infection. Although acute funisitis has been associated with an increased risk of adverse outcomes among preterm neonates, there are limited and conflicting data with term deliveries. OBJECTIVE: This study aimed to evaluate the association between acute funisitis and neonatal morbidity in neonates born at term to pregnant patients with a clinical diagnosis of intraamniotic infection. STUDY DESIGN: This was a retrospective cohort study of pregnant patients who had clinically diagnosed intraamniotic infection at term, delivered vaginally at a single tertiary institution from 2013 to 2019, and had histologic chorioamnionitis on placental pathology. Patients with intrauterine fetal demise or missing neonatal/placental pathology data were excluded. The primary outcome was a neonatal sepsis composite, defined as culture-positive bacteremia, neutropenia (absolute neutrophil count<3500/µL), or immature-to-total neutrophil ratio>0.2. The secondary outcomes included composite neonatal morbidity, defined as neonatal intensive care unit admission, 5-minute Apgar score <7, bacteremia, endotracheal intubation or need for continuous positive airway pressure, intraventricular hemorrhage (grade 3 or 4), necrotizing enterocolitis (stage 3 or 4), umbilical artery pH<7.1, umbilical artery base excess>12, and neonatal mortality. The components of these composites, neonatal intensive care unit length of stay, and Kaiser early-onset sepsis score were also measured. Neonates with acute funisitis on pathology were compared with those without acute funisitis using bivariate statistics. Regression was used to estimate the relative risk of outcomes. RESULTS: Of 184 neonates with deliveries complicated by intraamniotic infection, acute funisitis was present in 109 (59%) placental specimens. Composite neonatal sepsis was significantly higher among neonates with acute funisitis (relative risk, 1.85; 95% confidence interval, 1.13-3.03) than in those without acute funisitis. As a marker for sepsis, acute funisitis has a sensitivity of 39.4%, negative predictive value of 47.2%, specificity of 78.7%, and positive predictive value of 72.9%. An immature-to-total neutrophil ratio>0.2 (relative risk, 1.83; 95% confidence interval, 1.09-3.08) was also significantly associated with acute funisitis. Neonatal morbidity composite, intraventricular hemorrhage, necrotizing enterocolitis, neonatal intensive care unit admission, higher Kaiser early-onset sepsis scores, and other examined outcomes were not statistically associated with acute funisitis. CONCLUSION: In term deliveries complicated by intraamniotic infection, acute funisitis was associated with increased neonatal sepsis. Current approaches for estimating neonatal sepsis risk are limited by their reliance on indirect maternal factors such as maximum maternal temperature and intrapartum antibiotic use. This study suggests that acute funisitis may serve as a marker that could be utilized to augment risk stratification at birth if a protocol for evaluating the umbilical cord in real-time were widely adopted.

Incidence and Risk Factors for Postpartum Depression among Women with Preterm Prelabor Rupture of Membranes.

OBJECTIVE: Patients admitted for preterm prelabor rupture of membranes are more likely to have risk factors for postpartum depression, including preterm delivery, low-birthweight infants, and a stressful life event. However, there is a paucity of data characterizing the development of postpartum depression in this population. We aim to evaluate the incidence of and describe risk factors for postpartum depression among patients admitted with preterm prelabor rupture of membranes. STUDY DESIGN: This is a retrospective cohort study of patients admitted for preterm prelabor rupture of membranes in a single health system between 2013 and 2019. Patients who developed depression were compared with patients who did not develop depression. Demographic, antepartum/intrapartum/postpartum, and neonatal characteristics were compared. Bivariate statistics were used to compare outcomes and logistic regression was used to estimate adjusted odds ratios. RESULTS: Of 132 included patients with preterm prelabor rupture of membranes, 25 (18.9%) had postpartum depression. Factors significantly (p < 0.05) associated with postpartum depression included history of depression, anxiety, or any prior mental health condition. Earlier admission gestational age, rupture of membranes < 28 weeks, earlier delivery gestational age, neonatal morbidity, and neonatal necrotizing enterocolitis also were significantly associated with postpartum depression. Latency, maternal postpartum length of stay, and neonatal intensive care unit length of stay were not significantly associated. In regression models, only a history of depression (odds ratio [OR], 11.89; 95% confidence interval [CI], 2.78-50.95) and neonatal morbidity (OR, 5.01; 95% CI, 1.15-21.89) remained associated with postpartum depression. CONCLUSION: Postpartum depression occurred in nearly one in five patients with preterm prelabor rupture of membranes. Pre-existing depression and adverse neonatal outcomes strongly predicted postpartum depression. There is an urgent need to prioritize maternal mental health among patients with preterm prelabor rupture of membranes in the peripartum period. Further research is needed to identify optimal resources for mitigating the risk of postpartum depression in this cohort. KEY POINTS: · After PPROM, postpartum depression is common.. · Maternal depression and neonatal morbidity are risk factors for PPD.. · Hospital admission permits intervention for PPD..

Risk Factors for Adverse Maternal Outcomes following Expectantly Managed Preterm Prelabor Rupture of Membranes.

OBJECTIVE: We sought to characterize the incidence and risk factors associated with developing maternal morbidity following preterm prelabor rupture of membranes. STUDY DESIGN: Retrospective case-control study of patients with preterm prelabor rupture of membranes at a single institution from 2013 to 2019 admitted at ≥23 weeks gestational age. The primary outcome was a composite of maternal morbidity which included: death, sepsis, intensive care unit (ICU) admission, acute kidney injury, postpartum dilation and curettage, postpartum hysterectomy, venous thromboembolism, postpartum hemorrhage, postpartum wound complication, postpartum endometritis, pelvic abscess, postpartum pneumonia, readmission, and/or need for blood transfusion were compared with patients without above morbidities. Severe morbidity was defined as: death, ICU admission, venous thromboembolism, acute kidney injury, postpartum hysterectomy, sepsis, and/or transfusion >2 units. Demographics, antenatal, and delivery characteristics were compared between patients with and without maternal morbidity. Bivariate statistics and regression models were used to compare outcomes and calculate adjusted odd ratios. RESULTS: Of 361 included patients, 64 patients (17.7%) experienced maternal morbidity and nine (2.5%) had severe morbidity. Patients who experienced maternal morbidity were significantly (p < 0.05) more likely to be older, have private insurance, have BMI ≥40, have chorioamnionitis at delivery, and undergo cesarean or operative vaginal delivery when compared with patients who did not experience morbidity. After controlling for confounders, cesarean delivery (aOR 2.38, 95% CI[1.30,4.39]), body mass index ≥40 at admission (aOR 2.54, 95% CI[1.12,5.79]), private insurance (aOR 3.08, 95% CI[1.54,6.16]), and tobacco use (aOR 3.43, 95% CI[1.58,7.48]) were associated with increased odds of maternal morbidity. CONCLUSION: In this cohort, maternal morbidity occurred in 17.7% of patients with preterm prelabor rupture of membranes. Private insurance, body mass index ≥40, tobacco use, and cesarean delivery were associated with higher odds of morbidity. These data can be used in counseling and to advocate for smoking cessation. KEY POINTS: · 17.7% of patients with PPROM experienced maternal morbidity.. · BMI ≥40 was associated with higher odds of maternal morbidity.. · Tobacco use and cesarean delivery were associated with higher odds of maternal morbidity..

Maternal and peripartum risk factors for acute funisitis among term deliveries complicated by intraamniotic infection.

BACKGROUND: Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response and has been associated with adverse neonatal outcomes. Little is known regarding the maternal and intrapartum risk factors associated with the development of acute funisitis among term deliveries complicated by intraamniotic infection. OBJECTIVE: This study aimed to identify the maternal and intrapartum risk factors associated with developing acute funisitis among term deliveries complicated by intraamniotic infection. STUDY DESIGN: After institutional review board approval, we conducted a retrospective cohort study of term deliveries affected by clinical intraamniotic infection at a single tertiary center between 2013 and 2017, with placental pathology consistent with histologic chorioamnionitis. The exclusion criteria included intrauterine fetal demise, missing delivery information or placental pathology, and documented congenital fetal abnormalities. Maternal sociodemographic, antepartum, and intrapartum factors were compared among patients with acute funisitis on pathology to those without acute funisitis using bivariate statistics. Regression models were developed to estimate the adjusted odds ratios. RESULTS: Of 123 patients meeting the inclusion criteria, 75 (61%) had acute funisitis on placental pathology. Compared with placental specimens without acute funisitis, acute funisitis was observed more frequently among patients with maternal BMI ≥30 kg/m2 (58.7% vs 39.6%, P=.04) and labor courses with increased rupture of membrane duration (17.3 vs 9.6 hours, P=.001). Use of fetal scalp electrode was observed less frequently in acute funisitis (5.3% vs 16.7%, P=.04) than cases without acute funisitis. In regression models, maternal BMI ≥30 kg/m2 (adjusted odds ratio, 2.67; 95% confidence interval, 1.21-5.90) and rupture of membrane >18 hours (adjusted odds ratio, 2.48; 95% confidence interval, 1.07-5.75) were significantly associated with acute funisitis. Fetal scalp electrode use (adjusted odds ratio, 0.18; 95% confidence interval, 0.04-0.71) was negatively associated with acute funisitis. CONCLUSION: In term deliveries with intraamniotic infection and histologic chorioamnionitis, maternal BMI ≥30 kg/m2, and rupture of membrane>18 hours were associated with acute funisitis on placental pathology. As insight into the clinical impact of acute funisitis grows, the ability to predict which pregnancies are at the greatest risk for its development may allow for a tailored approach to predicting neonatal risk for sepsis and related comorbidity.

Prenatal Diagnosis of Arhinia.

Arhinia is a rare congenital anomaly that is not typically associated with known genetic mutations and is usually discovered after an affected infant is born. Prenatal diagnosis is important because neonates with arhinia often require specialized respiratory support with creation of an artificial airway. We present a case of isolated arhinia diagnosed on second-trimester ultrasound. A patient presented for routine ultrasound at 18 weeks gestation, and nasal tissues were absent in an otherwise morphologically normal appearing fetus. Cell free fetal DNA was unremarkable. The patient elected to undergo termination of pregnancy by dilation and evacuation. Subsequent genetic analysis confirmed a normal fetal karyotype and microarray, and no examination of fetal structural anatomy was possible. Antenatal diagnosis of arhinia is important to guide maternal-fetal care decisions and requires methodical sonographic evaluation to identify this malformation prior to delivery.

Trends in Performance of Anti-Incontinence Treatment at the Time of Pelvic Organ Prolapse Repair From 2011 to 2019.

IMPORTANCE: There are no publications on national trends in performance of concomitant stress urinary incontinence (SUI) treatment with pelvic organ prolapse surgery over the past decade. OBJECTIVES: The objective of this study was to describe trends in the performance and type of concomitant SUI treatment from 2011 to 2019. STUDY DESIGN: Surgical procedures for pelvic organ prolapse and coding for prolapse repair were identified from the American College of Surgeons National Surgical Quality Improvement Program database. An autoregressive interrupted time series model estimated temporal trends in concomitant SUI treatment associated with 3 consequential events: U.S. Food and Drug Administration's (FDA) requirement for postmarketing studies from mesh manufacturers (January 2012), publication of the Outcomes following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial (June 2012), and the FDA's reclassification of vaginal mesh as a high-risk device (January 2016). RESULTS: There were 43,370 cases identified. The rate of concomitant SUI treatment decreased from 46.1% to 35.7% across the analysis period. No significant trend before postmarketing studies (-0.2%; 95% confidence interval [CI], -0.8 to 1.1) was observed. After postmarketing studies, there was a downward deflection of -2.0% per quarter (95% CI, -3.6 to -0.4). After OPUS, we observed a flattening of the trend to -0.2% (95% CI, -0.8 to 0.4) that persisted after FDA reclassification. Sling procedures remained predominant (96.2% of SUI procedures) and performance of urethropexy decreased across the analysis period (-0.1%; 95% CI, -0.08 to -0.2). CONCLUSIONS: After the FDA's order for postmarketing studies, rates of concomitant SUI treatment significantly decreased. Rates stabilized after the OPUS trial at around 35% and did not subsequently change. Rates of nonmesh concomitant SUI treatment decreased during the analysis period.