Histologic Funisitis and Likelihood of Intrauterine Inflammation or Infection: A Case-Control Study.

OBJECTIVE: The objective of this study was to ascertain the likelihood of isolated maternal fever and suspected intrauterine inflammation or infection or both (Triple I) among cases of histologic chorioamnionitis with funisitis (HCF) at term. STUDY DESIGN: In this case-control study, placental pathology records were reviewed to identify term singleton laboring patients with HCF. Controls (1:1) were matched for gestational age. RESULTS: During the 6-month period, there were 2,399 term deliveries of laboring women. Of 1,552 (65%) term placentas examined, 4% (n = 60) had HCF.Features of Triple I were significantly more common among cases than controls: (1) isolated maternal fever of ≥100.4°F, twice, at least 30 minutes apart (p = 0.014); (2) fever with fetal tachycardia (p = 0.029); 3) fever with either fetal tachycardia or white blood cell count greater than 15,000 per mm3 (p = 0.034). The feature of Triple I with the highest sensitivity at 10% (95% confidence intervals [CI] 4-21%) was isolated maternal fever using ≥100.4°F on two occasions. The specificity for all features was consistently 100% (95% CI 91-100%). CONCLUSION: To our knowledge, this is the first report on HCF and Triple I features. Though the sensitivity of Triple I to identify HCF is low, specificity is excellent.

Sonographic Examination of The Fetus Vis-à-Vis Shoulder Dystocia: A Vexing Promise.

Since antepartum and intrapartum risk factors are poor at identifying women whose labor is complicated by shoulder dystocia, sonographic examination of the fetus holds promise. Though there are several measurements of biometric parameters to identify the parturient who will have shoulder dystocia, none are currently clinically useful. Three national guidelines confirm that sonographic measurements do not serve as appropriate diagnostic tests to identify women who will have shoulder dystocia with or without concurrent injury. In summary, biometric measurements of the fetus should not be used to alter clinical management with the aim of averting shoulder dystocia.

Stress, anxiety and depression levels in pregnancy: outpatient versus inpatient.

OBJECTIVE: To compare stress, anxiety and depression levels among 3 groups of pregnant women: 1) low-risk outpatient (LRO), 2) high-risk outpatient (HRO), and 3) inpatient (IP). METHODS: This was a cross-sectional study using validated instruments. Inclusion criteria were pregnancies 23-37 weeks and maternal age > 18 years. The primary outcome was mean/median scores of Perceived Stress Scale (PSS), State Trait Anxiety Inventory (STAI), and Edinburgh Depression Scale (EDS). Secondary outcome was rate of abnormal scores. RESULTS: Among 190 women approached, 180 (95%) participated, with 60 (33%) in each group. Mean PSS scores (range 0-40) significantly increased from LRO (12.0, standard deviation [SD] 7.8) to HRO (14.7, SD 7.9) to IP (15.6, SD 8.2); p = .04. Mean STAI scores (range 20-80) also significantly increased from LRO (32.0, SD 11.1) to HRO (35.8, SD 11.9) to IP (40.9, SD 13.1); p < .01. Abnormal anxiety (STAI ≥ 40) was present in 40% of women and significantly higher among IP compared to LRO (56% vs 25%; RR 2.24, 95% CI 1.36-3.67; aRR 2.24, 95% CI 1.34-3.74). CONCLUSION: Stress and anxiety scores significantly differ in LRO, HRO, and IP women. While depression screening is common postpartum, screening for stress, anxiety and depression prenatally may be beneficial.

Daily meditation program for anxiety in individuals admitted to the antepartum unit: a multicenter randomized controlled trial (MEDITATE).

BACKGROUND: Inpatient antepartum women have higher levels of anxiety than outpatient. Former randomized trials using mindful meditation programs to decrease maternal anxiety have conflicting results; some studies showed a considerable decrease in anxiety levels, whereas others showed no difference. A paucity of trials exist using mindful meditation for maternal anxiety in the inpatient antepartum population; most studies focus on the outpatient clinic population. Because of inpatient acuity and anxiety factors, we conducted a randomized trial to target this population. OBJECTIVE: This study aimed to compare anxiety levels on day 4 of either routine care or routine care plus a twice-daily application-based mindful meditation program in women admitted to the antepartum unit. STUDY DESIGN: In a multisite randomized trial (ClinicalTrials.gov Identifier: NCT03737279), women admitted to the antepartum units were randomized to either routine care plus educational pamphlets (control arm) or routine care plus a twice-daily application-based mindful meditation program (intervention arm). The inclusion criteria were age of at least 18 years, gestational age of at least 23 weeks, planned inpatient care for >3 days from randomization, and care by our university physician team. The primary outcome was maternal state anxiety level (measured using the validated State-Trait Anxiety Inventory) on day 4 (randomization being day 1). The secondary outcomes included stress (measured using the Perceived Stress Scale) and depression (measured using the Edinburgh Depression Scale) on day 4, latency period from randomization to delivery, patient experience, number of meditation sessions, and total meditation time. A total of 56 women were needed for 90% power to detect a decrease in the primary outcome by 30% in the intervention group, compared with the control group. All women were observed using an intention-to-treat analysis. We compared the continuous variables using the Wilcoxon rank-sum test or t test and the categorical variables using the chi-squared test or the Fisher exact test. RESULTS: From March 4, 2019, to December 20, 2019, 412 women were screened for eligibility, 77 women (18.7%) were found eligible, and 56 women (72.7%) were randomized with 28 women in each group. Of note, 96.4% of women completed at least 1 meditation session, and 39.3% of women completed all meditation sessions. The mean score of the anxiety level using the State-Trait Anxiety Inventory on day 4 was not significantly different (P=.24) between the control group (42.0±10.8) and meditation group (37.5±13.1). A decreased anxiety score from day 1 to day 4 was seen in both the control group and meditation group (-4.7 vs -9.4, respectively; P=.12). The rate of abnormal State-Trait Anxiety Inventory scores on day 4 was not significantly different between the control group and meditation group (62% vs 45%, respectively; P=.28). When asked about the experience with the research trial, 88.8% of women in the control group and 89.5% of women in the meditation group reported a positive experience. CONCLUSION: Compared with the control group, a twice-daily application-based mindful meditation program for women admitted to the antepartum unit did not considerably decrease the anxiety score on day 4. However, >88% of women in both groups had a positive experience with the nonpharmacologic intervention.

The association of adverse outcomes with pregnancy conception methods among low-risk term pregnancies.

OBJECTIVE: To compare composite neonatal and maternal adverse outcomes among low-risk singleton pregnancies at 37-41 weeks among conception methods: spontaneously-conceived (SC) pregnancy; infertility medications and/or intrauterine insemination (IFM/IUI); and assisted reproductive technology (ART). DESIGN: Population-based retrospective cohort study. SETTING: US Vital Statistics datasets 2013-2017. PATIENT(S): Low-risk pregnancies (without hypertensive disorders, pregestational or gestational diabetes, or history of preterm birth) of women ≥20 years with nonanomalous singletons, who labored, delivered at 37-41 weeks, and had data on pregnancy conception method. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome was the composite neonatal adverse outcome (CNAO). The secondary outcome was the composite maternal adverse outcome (CMAO). RESULT(S): Of the 19.7 million deliveries during the study period, 54.0% (N = 10,676,184) met the inclusion criteria, with 99.0% (N = 10,573,741) being conceived spontaneously, 0.4% (N = 47,227) by IFM/IUI, and 0.5% (N = 55,216) by ART. The overall rate of CNAO was 6.68 per 1,000 live births. Compared with SC, the risk of CNAO was significantly higher among IFM/IUI (adjusted relative risk [aRR], 1.29; 95% CI, 1.18-1.41) and ART (aRR, 1.29; 95% CI, 1.18-1.39). The overall rate of CMAO was 2.50 per 1,000 live births. Compared with SC, the risk of CMAO was significantly increased among IFM/IUI (aRR, 1.72; 95% CI, 1.50-1.97) and ART (aRR, 2.40; 95% CI, 2.17-2.65). CONCLUSION(S): Among low-risk term singleton pregnancies, IFM/IUI and ART have modestly higher rates of adverse outcomes to maternal-neonatal dyad than SC.

Neonatal Seizures Among Low-Risk Pregnancies at Term: Risk Factors and Adverse Outcomes.

OBJECTIVE: To examine risk factors and adverse outcomes for neonatal-maternal dyads among low-risk pregnancies at term with subsequent neonatal seizures. METHODS: United States vital statistics data sets were used for this retrospective study. Inclusion criteria were low-risk women (without hypertensive disease or diabetes) with nonanomalous singleton pregnancies, who delivered after labor at 37-41 weeks of gestation. The primary composite neonatal adverse outcome included 5-minute Apgar score less than 5, assisted ventilation longer than 6 hours, and neonatal death. A secondary outcome was composite maternal adverse outcome. Multivariable Poisson regression models with robust error variance were used, with adjusted relative risk (aRR) and 95% CI reported. RESULTS: Of 19.76 million live births during the study interval, 11.7 million (59.4%) met inclusion criteria. The rate of neonatal seizures after low-risk pregnancies delivered at term was 0.2 per 1,000 live births. The maternal risks factors associated with neonatal seizures included no prenatal care, smoking during pregnancy, being overweight or obese, and gestational age of 41 weeks. The strongest risk factors for neonatal seizures were chorioamnionitis (relative risk [RR] 5.04, 95% CI 4.40-5.77; aRR 3.27, 95% CI 2.84-3.76) and route of delivery, with operative vaginal (RR 3.62, 95% CI 3.20-4.09; aRR 3.02, 95% CI 2.66-3.43) and cesarean (RR 4.13, 95% CI 3.81-4.48; aRR 3.14, 95% CI 2.86-3.45) higher than spontaneous vaginal. Compared with neonates without seizures, those with seizures had higher risk of composite neonatal adverse outcome (RR 64.55, 95% CI 61.83-67.39; aRR 37.09, 95% CI 35.20-39.08). Compared with women who delivered neonates without seizures, those who delivered neonates with seizures had higher risk of composite maternal adverse outcome (RR 16.27, 95% CI 13.66-19.37; aRR 9.70, 95% CI 8.15-11.53). CONCLUSION: We identified modifiable maternal risk factors associated with neonatal seizures among low-risk pregnancies at term. Though infrequent, neonatal seizures are associated with higher risk of adverse outcomes in neonatal-maternal dyads.

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia.

Objective The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.

Maternal and Neonatal Morbidity Associated With Early Term Delivery of Large-for-Gestational-Age But Nonmacrosomic Neonates.

OBJECTIVE: To evaluate whether, at 37-39 weeks of gestation, delivery of a neonate with a birth weight that is 90% or greater for gestational age but less than 4,000 g is associated with increased composite maternal and neonatal morbidity. METHODS: This retrospective cohort study used U.S. Vital Statistics datasets for the years 2011-2013. Inclusion criteria were singleton pregnancies delivered at 37-39 weeks of gestation after labor in which the neonates were nonanomalous, and either appropriate for gestational age or large for gestational age (LGA) neonates with birth weights of less than 4,000 g (our threshold for macrosomia). The coprimary outcomes were composite maternal morbidity (any of the following: maternal transfusion, ruptured uterus, unplanned hysterectomy, admission to intensive care unit, or unplanned procedure) and composite neonatal morbidity (any of the following: Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure or serious neurologic dysfunction, significant birth injury or neonatal mortality). Multivariable Poisson regression models were used to calculate adjusted relative risk (aRR) and 95% CI. RESULTS: Among the 3.9 million women who met inclusion criteria, 1.3% delivered neonates who were LGA but nonmacrosomic. The rate of composite maternal morbidity was 53% higher women who delivered nonmacrosomic LGA neonate (6.27 vs 4.09/1,000 live births; aRR 1.40, 95% CI 1.25-1.56). This increased risk of composite maternal morbidity persisted in analyses stratified by diabetes. The rate of composite neonatal morbidity was 83% higher for nonmacrosomic LGA neonates (11.09 vs 6.07/1,000 live births; aRR 1.47, 95% CI 1.35-1.60) and persisted in analyses stratified by diabetes. CONCLUSION: At 37-39 weeks of gestation, delivery of a neonate with a birth weight that is 90% or greater for gestational age but less than 4,000 g is associated with increased composite maternal and neonatal morbidity.