Neonatal outcome of second-stage cesarean delivery versus vacuum extraction among neonates <34 weeks.

OBJECTIVE: Among deliveries <34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations <34 weeks. METHODS: A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°/7 and 336/7 weeks, during 2011-2019. The primary outcome was the rate of adverse neonatal outcomes, defined as intrapartum death, mechanical ventilation, asphyxia, respiratory distress syndrome, subgaleal hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and phototherapy. RESULTS: Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°/7. Of those 1674 (58.3%) delivered vaginally unassisted and 1137 (39.6%) delivered by a CD during the first stage of labor. A total of 60 deliveries were analyzed, with a median gestational age of 32 weeks, interquartile range (IQR) 31-33. Median birth weight at delivery was 1845 g, IQR 1574-2095. Overall 25 (42%) of women were delivered by VAD and 35 by CD (58%). Indications for expeditious delivery did not differ between the study groups. Neonates delivered by VAD had a higher median birth weight (1940 vs. 1620 g, p = .02). Second stage of labor was longer in the ECD group as compared to the VAD group (median 200 vs. 52 min, p = .01). The rate of Apgar score at 1 min <7 was higher among the CD group (10 (40%) vs. 5 (14%), OR [95% CI]: 4.0 (1.1-13.8), p = .03). Longer length of stay was evident in the CD group as compared to the VAD group (median 30 vs. 21 days, p = .001). The rate of composite neonatal adverse outcome was comparable between the study groups. Adverse outcomes were associated with lower body mass index (median 27.7 vs. 34.9, p = .04), higher rate of premature preterm rupture of membranes (40 (91%) vs. 5 (31%), OR [95% CI]: 22.0 (5.0-91.1), p < .001) and labor dystocia as the indication for expedited delivery (38 (86%) vs. 7 (44%), OR [95% CI]: 8.1 (2.1-30.1), p = .001). CONCLUSIONS: Cesarean delivery during the second stage of labor of gestations <34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay. SYNOPSIS: Delivery by second stage CD of premature neonates <34 weeks is associated with a higher rate of lower Apgar score.

Length of the Second Stage of Labor in Women Delivering Twins.

OBJECTIVE: To evaluate the length of the second stage of labor in twin deliveries and to compare the length of the second stage in twin and singleton gestations. METHODS: This is a retrospective cohort study from three large hospitals in Israel. Clinical data were collected from the electronic medical record. The primary outcome was the length of the second stage (the time from documented 10-cm dilation until spontaneous vaginal delivery of the first twin). Multivariable linear regression was used to examine the association of clinical factors with the length of the second stage. The length of the second stage in twin and singleton pregnancies was compared. RESULTS: From 2011 to June, 2020, there were 2,009 twin deliveries and 135,217 singleton deliveries. Of the twin deliveries, 655 (32.6%) of the patients were nulliparous (95th percentile length of the second stage 3 hours and 51 minutes), 1,235 (61.5%) were parous (95th percentile 1 hour 56 minutes), and 119 (5.9%) were grand multiparous (five or more prior deliveries) (95th percentile 1 hour 24 minutes). In women delivering twins, epidural use was associated with a statistically significant increase in the length of the second stage of 40 minutes in nulliparous patients and 15 minutes in parous patients. In all groups, the length of the second stage was longer in patients delivering twins compared with singletons. Second-stage length longer than the 95th percentile in twins was associated with admission to the neonatal intensive care unit and need for phototherapy. CONCLUSION: Second-stage labor is longer in twins than singletons and is associated with obstetric history. Normal ranges for the second stage may be useful in guiding clinical practice.

Determinants of adverse neonatal outcome in vaginal deliveries complicated by suspected intraamniotic infection.

PURPOSE: Intraamniotic infection, categorized into isolated maternal fever, suspected intraamniotic infection (SII), and confirmed intraamniotic infection, is associated with neonatal morbidity. However, there is paucity of data regarding the association between intraamniotic infection duration and neonatal outcomes among term singleton vaginal deliveries. We aimed to study the risk factors for adverse neonatal outcome among vaginal deliveries complicated by SII. METHODS: A retrospective observational study conducted at a tertiary medical center. All consecutive singleton term deliveries with SII were included between 2011 and 2019. Maternal and obstetrical characteristics were evaluated to identify risk factors for adverse neonatal outcome. Correlation between SII duration and neonatal adverse outcome was analyzed. RESULTS: Overall, 882 were analyzed. Most women (85.4%) were primiparous. Median gestation age at delivery was 40 2/7 weeks. Median time from SII to delivery was 170 min. Adverse neonatal outcomes occurred in 113 (12.8%) of deliveries. Duration of SII was not associated with adverse neonatal outcome. Analysis for determinants of adverse neonatal outcome revealed that oligohydramnios was more common in pregnancies with adverse neonatal outcome (7/113 (6.2%) vs. 41 (5.4%) OR [95% CI] 2.47 (1.02-5.98), p = 0.03). Duration of second stage of labor was longer in the adverse outcome group (median 179 min vs. 126 min, p = 0.008). Prolonged second stage was more common in the adverse outcome group (60 (53.1%) vs. 273 (35.5%) OR [95% CI] 2.05 (1.38-3.06), p < 0.001). On logistic regression analysis, prolonged second stage was the only modifiable factor independently associated with adverse neonatal outcome [adjusted OR 2.09 (1.37-3.2), p = 0.001]. Other variables tested did not differ between groups. Only phototherapy and base excess ≥ 12 mmol/L were significantly associated with the duration of second stage of labor; for each additional hour of the second stage, the OR for the former increased by 0.34 (p = 0.008), and for the latter by 0.69 (p = 0.007). CONCLUSION: Duration of suspected intraamniotic infection was not associated with increased neonatal morbidity among women delivering vaginally at term. Prolonged second stage was a strong independent predictor of an adverse neonatal outcome among fetuses exposed to intraamniotic infection.

Factors associated with early phosphate levels in preterm infants.

To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32 weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72 h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.

Pravastatin improves fetal survival in mice with a partial deficiency of heme oxygenase-1.

INTRODUCTION: Statins induce heme oxygenase-1 (HO-1) expression in vitro and in vivo. Low HO-1 expression is associated with pregnancy complications, e.g. preeclampsia and recurrent miscarriages. Here, we investigated the effects of pravastatin on HO-1 expression, placental development, and fetal survival in mice with a partial HO-1 deficiency. METHODS: At E14.5, untreated pregnant wild-type (WT, n=13-18), untreated HO-1+/- (Het, n=6-9), and Het mice treated with pravastatin (Het+Pravastatin, n=12-14) were sacrificed. Numbers of viable fetuses/resorbed concepti were recorded. Maternal livers and placentas were harvested for HO activity. Hematoxylin and eosin (H&E) and CD31 immunohistochemical staining were performed on whole placentas. RESULTS: Compared with WT, HO activity in Het livers (65±18%, P<0.001) and placentas (74±7%, P<0.001) were significantly decreased. Number of viable fetuses per dam was significantly lower in Untreated Het dams (6.0±2.2) compared with WT (9.1±1.4, P<0.01), accompanied by a higher relative risk (RR) for concepti resorption (17.1, 95% CI 4.0-73.2). In Hets treated with pravastatin, maternal liver and placental HO activity increased, approaching levels of WT controls (to 83±7% and 87±14%, respectively). The number of viable fetuses per dam increased to 7.7±2.5 with a decreased RR for concepti resorption (2.7, 95% CI 1.2-5.9). In some surviving Untreated Het placentas, there were focal losses of cellular architecture and changes suggestive of reduced blood flow in the labyrinth. These findings were absent in Het+Pravastatin placentas. DISCUSSION: Pravastatin induces maternal liver and placental HO activity, may affect placental function and improve fetal survival in the context of a partial deficiency of HO-1.