A case-control study on the effects of incomplete, one, and more than one dexamethasone course on acute respiratory problems in preterm neonates born between 280 and 366 weeks of gestation.

OBJECTIVE: To compare the effects of an incomplete course and more than 1 course of dexamethasone, relative to a control of a single complete course, on foetal respiratory problems and other adverse outcomes of preterm birth. METHODS: This was a retrospective chart review of 1800 women with preterm delivery. Data were collected on newborns whose mothers administered 1 full course of dexamethasone (916/1800; 50.9%), a partial course (716/1800; 39.8%) and more than 1 course (168/1800; 9.3%). Demographic data and adverse maternal and neonatal outcomes were recorded. RESULTS: Preterm singleton newborns whose mothers received several steroid hormone courses were significantly more likely to have adverse outcomes than newborns of mothers given 1 course. The negative outcomes were the need for positive pressure ventilation ([aOR] 1.831; 95% CI, (1.185,2.829); P = 0.019), ventilator support ([aOR] 1.843; 95% CI, (1.187,2.861); P = 0.011), and phototherapy ([aOR] 1.997; 95% CI, (1.378,2.895); P <  0.001), transient tachypnoea of the newborn ([aOR] 1.801; 95% CI, (1.261,2.571); P = 0.002), intraventricular haemorrhage ([aOR] 2.215; 95% CI, (1.159, 4.233); P = 0.027), sepsis ([aOR] 1.737; 95% CI, (1.086, 2.777); P = 0.007), and admission to neonatal intensive care ([aOR] 1.822; 95% CI, (1.275,2.604); P = 0.001). In the group of very preterm infants, newborns of mothers administered an incomplete course had developed respiratory distress syndrome (RDS) ([aOR] 3.177; 95% CI, (1.485, 6.795); P = 0.006) and used ventilatory support ([aOR] 3.565; 95% CI, (1.912, 6.650); P <  0.001) more than those of mothers receiving a single course. CONCLUSIONS: Preterm singleton newborns whose mothers were given multiple courses of dexamethasone had an increased incidence of RDS and other adverse outcomes than those of mothers receiving a full course. However, very preterm newborns whose mothers were administered 1 full dexamethasone course had a significantly lower incidence of RDS than those whose mothers were given partial courses.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND: Infants who are born at 340/7 to 366/7 weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of administration of antenatal corticosteroids (ACSs) to women at risk for late preterm delivery on the incidence of neonatal outcomes. METHODS: This was a prospective cohort study of singleton gestations at risk of imminent delivery between 340/7 and 366/7 weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. Primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation). RESULTS: During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57, 95% CI 0.35-0.94) and transient tachypnea of newborn (aOR 0.48, 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64, 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery and duration of hospitalization. CONCLUSION: Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND: Infants who are born at 34°/7 to 366/7 weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of the administration of antenatal corticosteroids (ACS) to women at risk for late preterm delivery on the incidence of neonatal outcomes. METHOD: This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34°/7 and 366/7 weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. The primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation). RESULTS: During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (aOR 0.63 95% CI 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57 95% CI 0.35-0.94), and transient tachypnea of the newborn (aOR 0.48 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery, and duration of hospitalization. CONCLUSION: Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review.

BACKGROUND: Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation. OBJECTIVE: To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings. METHODS: A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted. FINDINGS: 1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP. CONCLUSION: Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.

Detemir vs neutral protamine Hagedorn insulin for diabetes mellitus in pregnancy: a comparative effectiveness, randomized controlled trial.

BACKGROUND: Insulin detemir, being used increasingly during pregnancy, may have pharmacologic benefits compared with neutral protamine Hagedorn. OBJECTIVE: We evaluated the probability that compared with treatment with neutral protamine Hagedorn, treatment with insulin detemir reduces the risk for adverse neonatal outcome among individuals with type 2 or overt type 2 diabetes mellitus (gestational diabetes mellitus diagnosed at <20 weeks' gestation). STUDY DESIGN: We performed a multiclinic randomized controlled trial (September 2018 to January 2020), which included women with singleton gestation with type 2 or overt type 2 diabetes mellitus who sought obstetrical care at ≤21 weeks' gestation. Participants were randomized to receive either insulin detemir or neutral protamine Hagedorn by a clinic-stratified scheme. The primary outcome was a composite of adverse neonatal outcomes, including shoulder dystocia, large for gestational age, neonatal intensive care unit admission, respiratory distress (defined as the need of at least 4 hours of respiratory support with supplemental oxygen, continuous positive airway pressure or ventilation at the first 24 hours of life), or hypoglycemia. The secondary neonatal outcomes included gestational age at delivery, small for gestational age, 5-minute Apgar score of <7, lowest glucose level, need for intravenous glucose, respiratory distress syndrome, need for mechanical ventilation or continuous positive airway pressure, neonatal jaundice requiring therapy, brachial plexus injury, and hospital length of stay. The secondary maternal outcomes included hypoglycemic events, hospital admission for glucose control, hypertensive disorder of pregnancy, maternal weight gain, cesarean delivery, and postpartum complications. We used the Bayesian statistics to estimate a sample size of 108 to have >75% probability of any reduction in the primary outcome, assuming 80% power and a hypothesized effect of 33% reduction with insulin detemir. All analyses were intent to treat under a Bayesian framework with neutral priors (a priori assumed a 50:50 likelihood of either intervention being better; National Clinical Trial identifier 03620890). RESULTS: There were 108 women randomized in this trial (57 in insulin detemir and 51 in neutral protamine Hagedorn), and 103 women were available for analysis of the primary outcome (n=5 for pregnancy loss before 24 weeks' gestation). Bayesian analysis indicated an 87% posterior probability of reduced primary outcome with insulin detemir compared with neutral protamine Hagedorn (posterior adjusted relative risk, 0.88; 95% credible interval, 0.61-1.12). Bayesian analyses for secondary outcomes showed consistent findings of lower adverse maternal outcomes with the use of insulin detemir vs neutral protamine Hagedorn: for example, maternal hypoglycemic events (97% probability of benefit; posterior adjusted relative risk, 0.59; 95% credible interval, 0.29-1.08) and hypertensive disorders (88% probability of benefit; posterior adjusted relative risk, 0.81; 95% credible interval, 0.54-1.16). CONCLUSION: In our comparative effectiveness trial involving individuals with type 2 or overt type 2 diabetes mellitus, use of insulin detemir resulted in lower rates of adverse neonatal and maternal outcomes compared with neutral protamine Hagedorn.

Reduced fetal movements is twin pregnancies and the association with adverse neonatal outcomes.

OBJECTIVE: Reduced fetal movements (RFM) is an obstetric complaint known to be associated with adverse neonatal outcomes and should serve as an alarming sign in obstetric triage. Whether this assumption holds for twin pregnancies, is still an obstetric enigma, and this complaint is sometimes overlooked in twins. We, therefore, aimed to study neonatal outcomes in twin pregnancies complicated by RFM. We hypothesised that in twin pregnancy, maternal ability to perceive RFM will be limited, and therefore, will not be associated with adverse neonatal outcome. STUDY DESIGN: Included were all dichorionic twin pregnancies between 2009-2019 who presented to our obstetric triage at a gestational age >34 weeks with an isolated complaint of RFM and delivered during the subsequent two weeks (RFM group). The control group included patients with twin pregnancies (matched for gestational age and maternal age) who presented for routine assessment and reported regular fetal movements throughout pregnancy (no RFM group). Data regarding pregnancy, delivery, and neonatal outcomes were compared between the groups. The primary outcome was a composite of adverse neonatal outcomes, which included one or more of the following: neonatal hypoglycemia, respiratory morbidity, cerebral morbidity, phototherapy, neonatal sepsis, blood transfusions, necrotizing enterocolitis, or neonatal death. Multivariable regression analysis was used to identify independent associations with adverse neonatal outcomes. RESULTS: Maternal demographics and gestational age at delivery did not differ between the RFM group (n = 83 pregnancies and 166 neonates) and the no RFM group (n = 83 pregnancies and 166 neonates). Neonatal birthweights, as well as the rate of birthweights <10th centile, did not differ between the groups. There were 2 cases of fetal demise diagnosed at triage in the RFM group. The rate of the primary outcome, as well as NICU admissions, were significantly higher in the RFM group compared to the no RFM group (29.5 % vs. 19.2 %, p = 0.01 and 32.5 % vs. 19.2 %, p = 0.001). In multivariable analysis RFM (aOR = 1.18, 95 % CI = 1.06-2.73), and GA at delivery (aOR = 0.88, 95 % CI = 0.67-0.97) were associated with adverse neonatal outcome-independent from background confounders. CONCLUSION: Patients presented to obstetric triage with twin pregnancies and isolated RFM had higher rates of adverse neonatal outcomes and NICU admissions compared to twin pregnancies without RFM.

The effect of meconium thickness level on neonatal outcome.

BACKGROUND: Despite its prevalence and potential maternal and neonatal implications, the literature on the thickness levels of meconium stained amniotic fluid (MSAF) and its impact on neonatal outcomes is relatively outdated and relies on relatively small sample sizes. AIMS: To study if different thickness levels of MSAF correlate with adverse neonatal outcome. STUDY DESIGN: A retrospective cohort study. SUBJECTS: The medical records and neonatal charts of all women with a singleton pregnancy, who underwent a trial of labor, at 37 + 0/7 weeks or beyond, between 10/2008 and 7/2018 were reviewed. OUTCOME MEASURES: The cohort was divided according to the level of meconium reported during labor into four groups: Clear (C group), Light meconium (LM group), Intermediate meconium (IM group), and Heavy meconium (HM group). Composite neonatal outcome included at least one of the following: umbilical artery pH ≤ 7.1, sepsis, need for blood transfusion, need for phototherapy, respiratory distress syndrome, meconium aspiration syndrome, need for mechanical ventilation support, necrotizing enterocolitis, intraventricular hemorrhage, hypoxic ischemic encephalopathy, periventricular leukomalacia, seizures, hypoglycemia, hypothermia, and death. Continuous parameters were compared with Anova's test or Kruskal Wallis, and categorical variables by chi-square test or Fisher exact test, as appropriate. Multivariant logistic regression was performed in order to eliminate possible cofounders. RESULTS: Overall, 24,445 deliveries were reviewed (C-20,185, LM-1074, IM-2736, HM-450). Composite adverse neonatal outcome was more common with increasing thickness of MSAF. On multivariable analysis, IM and HM were independently associated with composite adverse neonatal outcome. CONCLUSION: The degree of meconium thickness independently correlates with composite adverse neonatal outcome.

The effect of different forms of dysglycemia during pregnancy on maternal and fetal outcomes in treated women and comparison with large cohort studies.

AIMS OF THE STUDY: We describe the impact of different forms of dysglycemia on maternal and neonatal health. This research is a part of the PEARL-Peristat Maternal and newborn registry, funded by Qatar National Research Fund (QNRF) Doha, Qatar. METHODS: A population-based retrospective data analysis of 12,255 women with singleton pregnancies screened during the year 2016-2017, of which 3,027 women were identified with gestation diabetes mellitus (GDM) during pregnancy and 233 were diabetic before pregnancy. Data on maternal outcome was collected from the PEARL-Peristat Maternal and newborn registry. RESULTS: The prevalence of GDM and diabetes mellitus (DM) was 24.7 % and 1.9%, respectively. 55% of DM, 38% of GDM and 25.6% of controls were obese (p<0.001). 71% of pregnant women with DM and 57.8% of those with GDM were older than 30 years versus 44.2% of controls. Pregnant women with DM or GDM had higher prevalence of hypertension versus normal controls (9.9%, 5.5% and 3.5%, respectively; p<0.001). Among women with vaginal deliveries, the proportion of women with induction of labor was significantly higher in the DM and GDM compared to control subjects (33.9%, 26.5% and 12.4%, respectively; p<0.001). The number of women who underwent Cesarean section was significantly higher in the DM and GDM groups versus normal controls (51.9%, 36.8%, and 28.5%, respectively; p<0.001).  Preterm delivery was significantly higher in women with DM and GDM (13.7% and 9%, respectively versus normal women (6.4%); p<0.001). Babies of DM and GDM had significantly higher occurrence of respiratory distress (RDS) or transient tachypnea (TTS): 9% and 5.8 % versus normal controls (4.8%). Macrosomia was more prevalent in babies of DM (6.4%) and GDM (6.8%) compared to controls (5%) (p: <0.001). Significant hypoglycemic episodes occurred more frequently in babies of DM and GDM women (11.2% and 3%, respectively) versus controls (0.6%) (p: <0.001. Infants of DM and GDM mothers required more treatments of phototherapy (9.4% and 8.9%, respectively) versus those born to normal women (7.2%) (p: 0.006). The prevalence of congenital anomalies and neonatal death did not differ between the groups. CONCLUSIONS: Despite the improvement in the prenatal diagnosis and management of dysglycemia, there is still a higher prevalence of prematurity, macrosomia, and hypoglycemia in infants of mothers with DM and GDM. Measurements to reduce obesity and control dysglycemia in women during the childbearing period are highly required to prevent the still higher morbidity during pregnancy.

Vitamin D deficiency and respiratory morbidity among African American very low birth weight infants.

BACKGROUND: Very low birth weight infants (VLBWI) have unexplained variation in respiratory morbidity, including respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). We examined a potential association to serum 25-hydroxyvitamin D (s-25OHD) on day one. STUDY DESIGN: Prospective, observational study on 89 VLBWI (≤1250 g). S-25OHD (day one and 21) and respiratory severity score (RSS) (day one) were examined. Other respiratory morbidities including BPD were compared between infants with s-25OHD ≤ 10 ng/ml (deficient) versus >10 ng/ml (adequate). RESULTS: Eighty one neonates (91%) were African Americans. The mean (SD) birthweight was 868 (229) g, gestational age 27 (2) weeks. On day one, mean (SD) s-25OHD was 15.48 (8.31) ng/ml, with 32 (37%) being vitamin D deficient. The deficiency and adequate VLBWI groups had similar birthweight; 860 (262) vs 873 (210) g, and gestational age; 27 (2) vs 27 (2) weeks. In 78 survivors, s-25OHD rose from 15.48 (8.31) ng/ml day one to 52.36 (22.49) ng/ml day 21 after supplementation, p < 0.001. On day one, increasing RSS was inversely related to s-25OHD, trend p = 0.054. Compared to the adequate group, the deficiency group had higher RSS (5.0 ±â€¯2.7 vs 3.6 ±â€¯1.9), required surfactant therapy more frequently (91% vs 72%), and needed home oxygen therapy more often (48% vs 26%), p ≤ 0.05 for all. Among infants with BPD, the severity of disease was inversely related to s-25OHD, trend p < 0.09. CONCLUSION: Lower levels of s-25OHD were associated with increased severity of RDS and BPD among a cohort of mostly African American VLBWI.

Adverse Maternal and Neonatal Outcomes in Indicated Compared with Spontaneous Preterm Birth in Healthy Nulliparas: A Secondary Analysis of a Randomized Trial.

OBJECTIVE: To compare the risks of adverse maternal and neonatal outcomes associated with spontaneous (SPTB) versus indicated preterm births (IPTB). METHODS: A secondary analysis of a multicenter trial of vitamin C and E supplementation in healthy low-risk nulliparous women. Outcomes were compared between women with SPTB (due to spontaneous membrane rupture or labor) and those with IPTB (due to medical or obstetric complications). A primary maternal composite outcome included: death, pulmonary edema, blood transfusion, adult respiratory distress syndrome (RDS), cerebrovascular accident, acute tubular necrosis, disseminated intravascular coagulopathy, or liver rupture. A neonatal composite outcome included: neonatal death, RDS, grades III or IV intraventricular hemorrhage (IVH), sepsis, necrotizing enterocolitis (NEC), or retinopathy of prematurity. RESULTS: Of 9,867 women, 10.4% (N = 1,038) were PTBs; 32.7% (n = 340) IPTBs and 67.3% (n = 698) SPTBs. Compared with SPTB, the composite maternal outcome was more frequent in IPTB-4.4% versus 0.9% (adjusted odds ratio [aOR], 4.0; 95% confidence interval [CI], 1.4-11.8), as were blood transfusion and prolonged hospital stay (3.2 and 3.7 times, respectively). The frequency of composite neonatal outcome was higher in IPTBs (aOR, 1.8; 95% CI, 1.1-3.0), as were RDS (1.7 times), small for gestational age (SGA) < 5th percentile (7.9 times), and neonatal intensive care unit (NICU) admission (1.8 times). CONCLUSION: Adverse maternal and neonatal outcomes were significantly more likely with IPTB than with SPTB.

Meconium-Stained Amniotic Fluid and Neonatal Morbidity in Low-Risk Pregnancies at Term: The Effect of Gestational Age.

Objective To assess the association of gestational age at delivery with perinatal outcome in low-risk term deliveries complicated by meconium-stained amniotic fluid (MSAF). Methods We retrospectively analyzed all singleton deliveries that underwent a trial of labor in a single hospital (2007-2013). Exclusion criteria included pregnancy-related complications (e.g., hypertensive disorders, diabetes, oligohydramnios, and fetal anomalies). First, only deliveries with MSAF were analyzed. Perinatal outcome of deliveries at 370/7 to 386/7 weeks (early term) and 410/7 to 416/7 weeks (late term) were compared with those at 390/7 to 406/7 weeks of gestation (full term). Additionally, a gestational age based comparison was made between the risk for neonatal respiratory morbidity in deliveries with clear amniotic fluid and MSAF. Results During the study period, 28,248 deliveries were considered as low risk. Of them, 3,399 (12.0%) were diagnosed with MSAF and were divided to full term (n = 2,413), early term (n = 405), and late term (n = 581). In multivariate analysis, MSAF at early term was associated with neonatal jaundice, need for phototherapy, and neonatal sepsis. In a gestational age based stratification, when comparing between deliveries with clear amniotic fluid and those with MSAF, late term had the highest odds (4.2 vs. 0.5%; p < 0.001) for neonatal respiratory morbidity. Conclusion Gestational age was associated with specific complications in deliveries complicated by MSAF and otherwise low-risk deliveries.

Antenatal corticosteroids in the late preterm period: A prospective cohort study.

OBJECTIVE: The study objective was to examine the effect of antenatal corticosteroids on the incidence of short-term neonatal morbidities in singletons born during the late preterm period. STUDY DESIGN: This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34 0/7 and 36 6/7 weeks. Short-term neonatal morbidities were compared between the corticosteroid exposed and non-exposed groups. The rates of Neonatal Morbidity Composite and Any Adverse Neonatal Morbidity were then compared between the two groups. RESULTS: During the two-year study period, a total of 295 subjects were included. Of those, 74 were exposed to antenatal corticosteroids, while 221 cases constituted the non-exposed group. There was no statistically significant difference in the rate of Any Adverse Neonatal Morbidity (47.3% vs. 40.7% , p = 0.32) or the rate of Neonatal Morbidity Composite (34.4% vs. 37.8% , p = 0.59) between the two groups. Additionally, there was no statistically significant difference in the rates of neonatal intensive care unit admission, respiratory distress syndrome, transient tachypnea of the newborn, hypothermia, and need for phototherapy. CONCLUSION: Administration of antenatal corticosteroids to parturients at risk of imminent delivery during the late preterm period does not appear to reduce short-term neonatal morbidities.

Neonatal outcome of late preterm uncomplicated monochorionic twins: what is the optimal time for delivery?

OBJECTIVE: To determine the neonatal outcome at late prematurity of uncomplicated monochorionic (MC) twin pregnancies. METHODS: A retrospective cohort study of 166 patients with uncomplicated MC diamniotic twins delivered between 34 and 37 weeks of gestation at a single tertiary center. The study population was classified into four groups according to the gestational age at delivery: (1) 34 weeks, (2) 35 weeks, (3) 36 weeks and (4) 37 weeks. Neonatal outcome measures were compared between the groups. RESULTS: Neonatal morbidity was significantly higher at 34 weeks of gestation compared to the other three groups including respiratory distress syndrome, oxygen requirement, hypothermia and hyperbilirubinemia. Moreover, the rate of admission to the special care unit and need for phototherapy were significantly higher in newborns born at 36 weeks compared to 37 weeks of gestation (p = 0.02 and 0.03 respectively). Multiple regression analysis revealed that the risk for adverse neonatal outcome was significantly associated with gestational age at delivery. Of note, there were no fetal or neonatal deaths in our cohort. CONCLUSIONS: The risk of neonatal morbidity of uncomplicated MC twins delivered at 34-37 weeks of gestation significantly decreases with advanced gestation. Therefore, under close fetal surveillance, uncomplicated MC twin pregnancies should be delivered at 37 weeks of gestation.

Neonatal Outcome of the Late Preterm Infant (34 to 36 Weeks): The Singapore Story.

INTRODUCTION: Late preterm (LP) neonates (34 to 36 weeks gestation) are often managed like term neonates though current literature has identified them to have greater complications. The primary objective of our study was to evaluate and compare morbidity and resource utilisation in LPs especially in view of paucity of Asian studies in this regard. MATERIALS AND METHODS: A retrospective audit was carried out on 12,459 neonates born in KK Women's and Children's Hospital (KKWCH). The chief outcome measures were hypoglycaemia, hypothermia, respiratory morbidity, feeding problems and neonatal jaundice. Resource utilisation included neonatal intensive care unit (NICU) admission, mechanical ventilation, parenteral nutrition and length of hospitalisation. RESULTS: Of 12,459 deliveries, 1221 (10%) were LP deliveries with a significantly increasing trend of 8.6% to 10% from 2002 to 2008 (P = 0.001). Neonatal morbidity in the form of hypoglycaemia (34 weeks vs 35 to 36 weeks vs term: 26% vs 16% vs 1%); hypothermia (5% vs 1.7% vs 0.2%); feeding difficulties (30% vs 9% vs 1.4%); respiratory distress syndrome (RDS) (4% vs 1% vs 0.1%); transient tachypnea of the newborn (TTNB) (23% vs 8% vs 3%) and neonatal jaundice (NNJ) needing phototherapy (63% vs 24% vs 8%), were significantly different between the 3 groups, with highest incidence in 34-week-old infants. Resource utilisation including intermittent positive pressure ventilation (IPPV) (15% vs 3.5% vs 1%), total parenteral nutrition/intravenous (TPN/IV) (53% vs 17% vs 3%) and length of stay (14 ± 22 days vs 4 ± 4.7 days vs 2.6 ± 3.9 days) was also significantly higher (P <0.001) in LPs. CONCLUSION: LP neonates had significantly higher morbidity and resource utilisation compared to term infants. Among the LP group, 34-week-old infants had greater complications compared to infants born at 35 to 36 weeks.

Omega-3 fatty acid supplementation during pregnancy and respiratory symptoms in children.

BACKGROUND: Prenatal consumption of omega-3 fatty acids can act as an adjuvant in the development of the immune system and affect the inflammatory response of neonates. METHODS: We conducted a double-blind, randomized, placebo-controlled trial in Cuernavaca, Mexico. We randomly assigned 1,094 pregnant women (18-35 years of age) to receive 400 mg/d of algal docosahexaenoic acid (DHA) or placebo from 18 to 22 weeks of gestation through delivery. Birth outcomes and respiratory symptoms information until 18 months were available for 869 mother-child pairs. Questionnaires were administered, and maternal blood samples were obtained at baseline. Maternal atopy was based on specific IgE levels. During follow-up, information on infants' respiratory symptoms was collected through questionnaires administered at 1, 3, 6, 9, 12, and 18 months of age. Negative binomial regression models were used to evaluate the effect of supplementation on respiratory symptoms in infants. RESULTS: Among infants of atopic mothers, a statistically significant protective effect of DHA treatment was observed on phlegm with nasal discharge or nasal congestion (0.78; 95% CI, 0.60-1.02) and fever with phlegm and nasal discharge or nasal congestion (0.53; 95% CI, 0.29-0.99), adjusting for potential confounders. CONCLUSIONS: Our results support the hypothesis that DHA supplementation during pregnancy may decrease the incidence of respiratory symptoms in children with a history of maternal atopy. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00646360; URL: www.clinicaltrials.gov.

Short-term neonatal outcome in late preterm vs. term infants.

OBJECTIVE: To determine the short-term neonatal outcomes in late preterm infants (LPI's) as compared to term infants and their association with maternal risk factors. STUDY DESIGN: A case control, descriptive study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, Pakistan, from January to December 2009. METHODOLOGY: The study included 326 late preterm babies (defined as those born between 340/7 to 376/7 weeks of gestation) and equal number of term control babies at the Aga Khan University Hospital, Karachi, Pakistan. Data, including obstetric history, maternal complications, neonatal morbidities, etc., was retrieved from patients' medical records. The data was compared with the control group for complications, fetal morbidity and maternal morbidity. RESULTS: Late preterm infants constituted 10.6% of all deliveries and 77% of all live preterm births during the study period. Respiratory distress syndrome (RDS) (16.5% vs. 0.3%, p < 0.001), growth retardation (24.8% vs. 4%, p < 0.001), hyperbilirubinemia requiring phototherapy (37.9% vs. 11%, p < 0.001), and sepsis (4.9% vs. 0.3%, p < 0.001) were found to be the major morbidities in the study group. The need for resuscitation was 12.7 times higher in the study group as compared to the term babies (21.4% vs. 1.2%, p < 0.001). NICU admissions in the study group were also higher (18.8% vs. 2.4%, p < 0.001). Hypertension (12.5% vs. 1.5%, p < 0.001), diabetes (12.5% vs. 9.2%, p < 0.001), antenatal history of UTI (1.5% vs. 0.3%, p < 0.001), and prolong rupture of membrane (8.9% vs. 4%, p < 0.001) were significant maternal morbidities in the late preterm group. CONCLUSION: The late preterm group had greater morbidity, compared to term neonates. Prior awareness of the morbidities associated with late preterm babies is helpful for the health care providers to anticipate and manage potential complications in late preterm infants.

Is vitamin d deficiency a risk factor for respiratory distress syndrome?

BACKGROUND: Previous studies have shown the relationship between in utero lung development and vitamin D [25(OH)D], but there have been no studies to investigate whether vitamin D deficiency is a risk factor for respiratory distress syndrome (RDS) in preterm babies. OBJECTIVES: In this study, we investigated if 25(OH)D deficiency is a risk factor for RDS. METHODS: One hundred fifty-two preterm newborns, born at 29 - 35 weeks gestational age, were included in the study following informed consent from the parents. Peripheral blood samples were collected within the first 24 hours of life and 25(OH)D levels were measured by liquid chromatography-tandem mass spectrometry. Demographic characteristics of the babies and the diagnosis of RDS were recorded. RESULTS: In 64 % of preterm infants, 25(OH)D levels were compatible with severe deficiency (≤ 10 ng/mL), 33 % with moderate deficiency (10 - 20 ng/mL), and 3 % with mild deficiency (20 - 30 ng/mL). In none of the babies was a normal 25(OH)D level observed. Serum 25(OH)D levels were not correlated with gestational age. Respiratory distress syndrome was more common in preterm babies with severe (28 %) compared to mild-moderate 25(OH)D deficiency (14 %) (p < 0.05). CONCLUSIONS: None of the preterm infants in this study had normal vitamin D level, which underlined the burden of vitamin D deficiency in pregnant women and their offspring. RDS was more common in severely vitamin D-deficient preterms. Determination of vitamin D status of the mothers and appropriate supplementation might be a valuable strategy to reduce RDS, in addition to antenatal steroids. Besides, since vitamin D is a regulatory factor in many organs during fetal development, long-term effects of in utero vitamin D deficiency warrant further studies.

[Clinical efficacy and perinatal outcome of nifedipine for severe preeclampsia: meta-analysis].

OBJECTIVE: To assess the efficacy, side effects and perinatal outcome of nifedipine compared with other antihypertensives for treating severe preeclampsia in pregnant women. METHODS: Randomized controlled trials (RCTs) that comparing nifedipine with other antihypertensives for severe preeclampsia were searched in PubMed, EMBase, Cochrane library, CNKI and VIP database etc(till January 2012). The quality of the included RCTs was evaluated, and Meta-analysis was performed with Rev Man 5.1 software. RESULTS: Nine trials were included, involving 386 women in the nifedipine group, and 378 women in other antihypertensives group. Compared with other antihypertensives, nifidepine was associated with greater effective control of blood pressure (OR = 2.65, 95%CI: 1.65 - 4.25, P < 0.01). There was no clear difference in the time needed to control blood pressure (WMD = -3.64, 95%CI: -10.90 - 3.61, P = 0.32). Nifedipine could prolong gestation better than other antihypertensives (WMD = 5.14, 95%CI: 3.29 - 6.99, P < 0.01). There were no clear differences in maternal side effects headache (P = 0.28), palpitation (P = 0.06), and nausea vomiting (P = 0.28). No noticeable difference was found between the two groups in the Apgar score at five minutes (WMD = -0.21, 95%CI: -0.32 - 0.91, P = 0.72), neonatal respiratory distress syndrome (OR = 1.24, 95%CI: 0.57 - 2.67, P = 0.59), or perinatal deaths (OR = 0.49, 95%CI: 0.22 - 1.11, P = 0.09). CONCLUSION: Nifedipine is associated with greater effective control of blood pressure and prolongation of gestation, with no additional neonatal respiratory distress syndrome or perinatal deaths, compared with other antihypertensives for women with severe preeclampsia.

Prognostic factors for treatment outcomes in transient tachypnea of the newborn.

BACKGROUND: Transient tachypnea of the newborn (TTN) is a clinical syndrome associated with respiratory distress usually seen shortly after delivery in infants. This study aims to determine the risk factors predicting treatment outcomes in infants with TTN. METHODS: Data from 236 infants diagnosed with TTN during the study period were evaluated retrospectively. Logistic regression analyses were performed to select significant risk factor for prognosis (prolonged oxygen therapy, application of mechanical ventilator, and prolonged hospital stay) of TTN among components of clinical variables. RESULTS: Of the 236 TTN infants, 111 (47.0%) infants were delivered via cesarean section (CS) without labor, 29 (12.3%) infants were delivered via CS with labor, and 96 (40.7%) were delivered via vaginal birth. Lower Apgar score at 1 min (OR: 3.03; 95%CI: 1.25-7.36) and lower umbilical artery pH (OR: 4.00; 95%CI 1.55-10.49) were associated with a significantly increased risk for mechanical ventilator care. Also, late-preterm delivery (OR: 4.70; 95%CI: 2.11-10.49) was independently associated with risk of prolonged duration of hospital stay. CONCLUSIONS: Late-preterm delivery, lower initial umbilical artery pH (<7.25), and lower Apgar score at 1 min were independently associated with poor prognostic treatment outcomes in infants with TTN.

'The influence of gestational age and socioeconomic status on neonatal outcomes in late preterm and early term gestation: a population based study'.

BACKGROUND: Infants born late preterm (34 + 0 to 36 + 6 weeks GA (gestational age)) are known to have higher neonatal morbidity than term (37 + 0 to 41 + 6 weeks GA) infants. There is emerging evidence that these risks may not be homogenous within the term cohort and may be higher in early term (37 + 0 to 38 + 6 weeks GA). These risks may also be affected by socioeconomic status, a risk factor for preterm birth. METHODS: A retrospective population based cohort of infants born at 34 to 41 weeks of GA was assembled; individual and area-level income was used to develop three socioeconomic (SES) groups. Neonatal morbidity was grouped into respiratory distress syndrome (RDS), other respiratory disorders, other complications of prematurity, admission to a Level II/III nursery and receipt of phototherapy. Regression models were constructed to examine the relationship of GA and SES to neonatal morbidity while controlling for other perinatal variables. RESULTS: The cohort contained 25 312 infants of whom 6.1% (n = 1524) were born preterm and 32.4% (n = 8203) were of low SES. Using 39/40 weeks GA as the reference group there was a decrease in neonatal morbidity at each week of gestation. The odds ratios remained significantly higher at 37 weeks for RDS or other respiratory disorders, and at 38 weeks for all other outcomes. SES had an independent effect, increasing morbidity with odds ratios ranging from 1.2-1.5 for all outcomes except for the RDS group, where it was not significant. CONCLUSIONS: The risks of morbidity fell throughout late preterm and early term gestation for both respiratory and non-respiratory morbidity. Low SES was associated with an independent increased risk. Recognition that the morbidities associated with prematurity continue into early term gestation and are further compounded by SES is important to develop strategies for improving care of early term infants, avoiding iatrogenic complications and prioritizing public health interventions.