Fluid status changes during the transition in infants of diabetic mothers.

In animal and human neonates, expansion of the extracellular fluid volume is associated with "wet" lung and poor respiratory outcomes. To define fluid status changes during the transition from fetal to neonatal life in infants of diabetic mothers (IDM), we conducted a single-centre (Policlinico Abano Terme, Abano Terme, Italy) study of 66 IDM and a 1:2 matched control group from January 1 to September 30, 2020. Fluid status changes were assessed by computing Δ Hct from umbilical cord blood at birth and capillary heel Hct at 48 h, accounting for body weight decrease. IDM presented with significantly lower cord blood Hct levels in comparison to controls (47.33 ± 4.52 vs 50.03 ± 3.51%, p < 0.001), mainly if delivered by elective cesarean Sect. (45.01 ± 3.77 vs 48.43 ± 3.50%, p = 0.001). Hct levels at 48 h were comparable (55.18 ± 5.42 vs 54.62 ± 7.41%, p = 0.703), concurrently with similar body weight decrease (- 217.21 ± 113.34 vs - 217.51 ± 67.28 g, p = 0.614). This supports significantly higher ∆ Hct in IDM (5.13 ± 5.24 vs 7.29 ± 6.48, p < 0.01) and extra circulating fluid loss of 2-3%.Conclusion: Gestational diabetes is associated with an excess of circulating fluids during the transition from fetal to neonatal life, challenging the current assumption that is per se at risk of wet lung. What is Known: • In neonates, evidence suggests that expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor respiratory outcomes. What is New: • Gestational diabetes is associated with an excess of circulating fluids during the transition from fetal to neonatal life, challenging the current assumption that is per se at risk of wet lung.

Pilot study of home phototherapy for neonatal jaundice monitored in maternity ward during the enforced Italy-wide COVID-19 national lockdown.

In Italy, where neonatal jaundice treatment is required, it is largely carried out in hospitals. However, it is possible to safely administer home phototherapy (HPT). We report our pilot center's experience of HPT and its potential benefits during the COVID-19-enforced national lockdown. This is an observational study performed at the Policlinic Abano Terme, a suburban hospital that covers a large catchment area near the Euganean Hills in Northeast Italy with around 1000 deliveries per year. HPT was started after regular nursery discharge, and the mothers brought the neonates back to the hospital maternity ward each day to check infants' bilirubin levels, weight, and general state of health, until it was deemed safe to stop. The efficacy of HPT in bilirubin reduction, hospital readmission rates, and parental satisfaction were evaluated. Thirty infants received HPT. In 4 of these infants, HPT was associated with total serum bilirubin (TSB) between 75 and 95th percentile (high-intermediate-risk zone) and in 26 infants HPT was associated with TSB > 95th percentile (high-risk zone) of the Bhutani nomogram. Among these 30 infants, 27 (90%) completed the HPT with a progressive decrease of TSB levels with 4 neonates requiring a second course and 3 infants requiring a third course of 24-h HPT. Three (10%) neonates failed HPT and were readmitted after one 24-h phototherapy course. No abnormalities of breastfeeding, body weight (defined as > 10% decrease), temperature, nor COVID infections were detected following HPT consultation in the neonatal ward. Home treatment efficacy with varying degrees of parental satisfaction occurred in all but 3 cases that involved difficulties with the equipment and inconsistent lamp manipulation practices. CONCLUSION: Our pilot study suggests that HPT for neonatal jaundice can be carried out effectively and with parental satisfaction as supported by daily back bilirubin monitoring in the maternity ward during the enforced COVID-19 national lockdown in Italy. WHAT IS KNOWN: • No high-quality evidence is currently available to support or refute the practice of phototherapy in patients' own homes. WHAT IS NEW: • Phototherapy can be delivered at home in a select group of infants and could be an ideal option if parents are able to return with their infants to the hospital maternity ward for daily follow-up. • It can be as effective as inpatient phototherapy and potentially helps in delivering family-centered care.

A Randomized Controlled Trial of Intact Cord Milking versus Immediate Cord Clamping in Term Infants Born by Elective Cesarean Section.

OBJECTIVE: We evaluated whether intact umbilical cord milking (UCM) is more effective than immediate cord clamping (ICC) in enhancing placental transfusion after elective cesarean delivery. STUDY DESIGN: In a randomized trial, volume of placental transfusion was assessed by Δ hematocrit (Hct) between neonatal cord blood and capillary heel blood at 48 hours of age, corrected for the change in body weight. RESULTS: There were no significant differences in cord blood mean Hct values at birth (UCM, 44.5 ± 4.8 vs. ICC, 44.9 ± 4.2%, p = 0.74). Conversely, at 48 hours of age, the UCM group had significantly higher capillary heel Hct values (UCM, 53.7 ± 5.9 vs. ICC, 49.8 ± 4.6%, p < 0.001), supporting a higher placental transfusion volume (Δ Hct, UCM 9.2 ± 5.2 vs. ICC 4.8 ± 4.7, p < 0.001), despite comparable neonatal body weight decrease (UCM, -7.3 vs. ICC, -6.8%, p = 0.77). CONCLUSION: Higher Δ Hct between cord blood at birth and capillary heel blood at 48 hours of age, corrected for the change in body weight, suggests that intact UCM is an efficacious and safe procedure to enhance placental transfusion among neonates born via elective cesarean delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT03668782.

Gestational weight gain and eating-related disorders.

This prospective cohort study took place at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy, from January to November 2018. In the second day postpartum, 463 healthy at term puerperae, 122 (26.35%) with inadequate gestational weight gain (GWG), 210 (45.46%) with adequate GWG, and 131 (28.29%) with excessive GWG, were studied by EAT-26, through distinguishing three factors: 'Dieting', 'Bulimia and food preoccupation', and 'Oral control'. EAT-26 Global score increased from inadequate, to adequate, and excessive GWG puerperae, resulting significantly higher in excessive GWG group (p = .0029, Anova's). In addition, among EAT-26 subscales 'Dieting' scores significantly increased from inadequate, to adequate, and to excessive GWG category women, resulting significantly higher in excessive GWG group (p = .006, Anova's). It was found that excessive GWG is a warning indicator of unhealthy eating and 'Dieting' disorders. This relationship highlights the potential for interventions directed towards psychosocial support to have salutary effects upon GWG.Excessive gestational weight gain across an uncomplicated pregnancy is a warning indicator of unhealthy eating and dieting disorders.IMPACT STATEMENTWhat is already known on this subject? Pregnancy represents a time of rapid trimester-specific changes in body weight and size.What do the results of this study add? Excessive gestational weight gain is a warning indicator of unhealthy eating and dieting disorders.What are the implications of these findings for clinical practice and/or further research? This relationship highlights the potential for interventions directed towards psychosocial support to have salutary effects upon gestational weight gain.

Determinants and effects of fluid status changes in caesarean delivered neonates.

AIM: Evidence suggests that caesarean section is associated with a reduced placental transfusion and poor iron-related haematological indices, both in cord and peripheral blood, compared with vaginal delivery. We assessed determinants and effects of fluid status changes on placental transfusion in neonates delivered by elective (ElCD) and emergency (EmCD) caesarean section. METHODS: Placental transfusion was estimated by ∆ haematocrit (Hct) increase from birth to 48 hours of life, accounting for contemporaneous ∆ body weight decrease, in 143 women/infant pairs, 62 who underwent ElCD and 81 EmCD, respectively. RESULTS: Cord blood Hct levels at birth of ElCS neonates were significantly lower than those of EmCD neonates (44.58 + 4.87vs 49.93 + 4.29, P = .01). At 48 hours of life, capillary heel Hct levels of ElCD and of EmCD neonates were comparable. ElCD had a higher ∆ body weight decrease (ElCD -7.25 ± 1.74% vs EmCD -6.31 ± 2.34% [P: .011]) and ∆ Hct increase ([ElCD + 5.93 ± 4.92 vs EmCD + 3.59 ± 5.29, [P: .011]). In a linear regression model analysis, gestational age in ElCD neonates had a significant effect on the differences in arterial cord blood Hct, body weight at birth and body weight decrease at 48 hours after birth. CONCLUSION: Early-term surgical delivery is a determinant of transient dilutional anaemia in ElCD neonates, lacking neuroendocrine response of labour and delivery.

Pain and stress after vaginal delivery: characteristics at hospital discharge and associations with parity.

The objective of this study was to characterise pre-discharge maternal pain and stress severity after vaginal delivery and associations with parity. This is a descriptive analysis with 148 women in the early post-partum period (84 primiparae and 64 secondiparae) after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Psychological Stress Measure (PSM). Vaginal delivery in primiparae women was associated with MGPQ, significantly higher pain scores. Sensorial, affective and mixed pain descriptive categories were also significantly higher. Pain location involved lower abdomen, vagina and perianal area. In addition, their PSM showed a significantly higher 'Sense of effort and confusion' subscale scores. In conclusion, this study provides important information on the quality of care implications of hospital-to-home discharge practices in puerperae after vaginal delivery, a critical time characterised by qualitatively and quantitatively high pain and stress in primiparae.Impact statementWhat is already known on this subject? Pain and fatigue are the most common problems reported by women in the early postpartum period.What the results of this study add? Primiparae who delivered vaginally presented at the time of hospital-to-home discharge significantly higher pain and stress, as compared to secondiparae. Pain involved lower abdomen, vagina and perianal area, whereas the stress was quantitatively higher in the 'sense of effort and confusion'.What the implications are of these findings for clinical practice and/or further research? Awareness of problematic pain and stress associations with parity may offer the opportunity to better support puerperae to develop maternal orientation and adjust to motherhood.

Trajectory of serum bilirubin in offspring of women with gestational diabetes mellitus.

AIMS: To investigate the trajectory of bilirubin from birth to the first 48 h of life in neonates of women with gestational diabetes. METHODS: In a cohort of 69 neonates of women with gestational diabetes, delivered at Policlinic Abano, Abano Terme, Italy, from October 2021 to May 2022, we conducted a case-control study (1:2 ratio) on total serum bilirubin (TSB) trajectory over the first 48 h after birth. An ancillary analysis was conducted on arterial cord blood gas analysis at birth and on concurrent hemoglobin, hematocrit, lactate, glycemia, and bilirubin levels. RESULTS: The neonates of women with gestational diabetes showed a significantly higher mean percent variation of TSB from birth to the first 48 h of life (p = 0.01), a finding supported by a higher, although not significant, TSB levels at 48 h of life in comparison to controls (8.05 ± 4.8 vs 8.05 ± 4 mg%, p = 0.082), and by a significantly lower cord TSB levels (2.3 ± 0.9 vs 2.6 ± 0.9 mg%, p = 0.010). CONCLUSIONS: The findings suggest that future primary studies on hyperbilirubinemia risk in neonates of women with gestational diabetes should consider the trajectory of TSB beyond the first 48 h, adjusting for a more complete set of pre-pregnancy and gestational prognostic risk factors.

Calcium and lactate in the fetal-to-neonatal transition.

OBJECTIVE: To explore the relationship between calcium and lactate in arterial cord blood of healthy term neonates in response to the stress of labor. METHODS: This was a prospective cohort study of consecutive, vaginal, term births in a community medical center (April 2029 to February 2020). Calcium and lactate were measured in cord blood gas analysis immediately after delivery. RESULTS: In the arterial cord blood of 480 neonates, calcium levels were 1.5 (1.4; 1.5) mmol/L and lactate levels were 3.8 (2.9; 4.9) mmol/L. Calcium and lactate showed a statistically significant positive correlation (Pearson's correlation, r = 0.15, p = .001). Calcium levels had a significant positive correlation with PaCO2 and a significant negative correlation with pH, PaO2, HCO3-, and ABE levels. Multivariable analysis models confirmed that calcium levels were associated with HCO3-, gestational age, and birth weight, all accounting for 7% of the variability. CONCLUSION: In healthy term vaginally delivered neonates, it was found that calcium and lactate were strongly correlated, together pointing to a neonatal response to the stress of labor and delivery. Cord blood calcium regulation may have an ancillary role in defining neonatal adaptation to extrauterine life.

COVID-19 pandemic: Impact on gestational diabetes mellitus prevalence.

AIM: Although an increased risk of gestational diabetes mellitus (GDM) has been noted in women exposed to stressful conditions and traumatic events, limited information is available about such risk in the context of the COVID-19 pandemic. METHODS: The study was designed as a non-concurrent case-control study on the prevalence of GDM, defined according to IADPSG 2010, in women giving birth during the COVID-19 pandemic in the hot spot of Northeast Italy from March 9th to May 18th, 2020, with an antecedent puerperae-matched group whose women had given birth in 2019. RESULTS: Analysis revealed that during the COVID-19 pandemic in 2020, GDM prevalence was significantly higher than in 2019 (GDM, 48/533, 9 vs 86/637, 13.5%, p = 0.01), as illustrated by a higher GDM prevalence in 5/6 months of the final semester of 2020. In addition, logistic regression analysisconfirmed a statistically significant temporal relationship between experiencing the lockdown during the first trimester of gestation and later GDM incidence (t = 2.765, P = 0.012), with an 34% increase in mean number of GDM diagnoses per month (antilog of the parameter = 1.34). CONCLUSION: The COVID-19 pandemic negatively impacted GDM prevalence in 2020 compared to 2019, especially for pregnant women in the 1st trimester of gestation.

Umbilical cord bilirubin level and pre-discharge hyperbilirubinemia risk.

OBJECTIVES: To assess whether arterial umbilical cord bilirubin (aUCB) level at delivery predicts predischarge neonatal hyperbilirubinemia, facilitating a safe discharge from the hospital. METHODS: Prospective analysis of hospital biochemistry records identified near term and term infants with recorded aUCB and predischarge, at 36 h of life, capillary heal bilirubin (cHB), to identify those with a cutoff of bilirubin levels >9 mg/ml, >75th percentile on the nomogram of Bhutani et al. RESULTS: Of 616 study neonates, median (IQR) aUCB and cHB levels were 1.5 mg % (IQR 0.7-2.2) and 7.7 mg % (IQR 6.6-8.9), respectively. The values resulted statistically correlated (Pearson correlation coefficient 0.26, p < .0001) and an increment of 1 mg/dl in aUCB was associated with an increment (Regression coefficient, 95% confidence interval) of mean cHB 0.49 (0.33-0.65, p < .0001). Among these, 143 (23.2%) neonates developed bilirubin levels >9 mg/ml at 36 h of life and multivariable analysis confirmed that cHB levels (OR 1.49, 95% CI 1.22-1.82; p < .0001) and vaginal delivery (OR 2.34, 95% CI 1.33-4.36; p = .005) were significantly associated with bilirubin levels >9 mg/ml. CONCLUSIONS: These data suggest that aUCB should be added to the list of major risk factors for neonatal hyperbilirubinemia.

Infant feeding initiation practices in the context of COVID-19 lockdown.

OBJECTIVE: Limited information is available regarding barriers to breastfeeding during the COVID-19 lockdown. STUDY DESIGN: This study was designed as a non-concurrent case-control study on breastfeeding initiation practices, defined according to WHO, in women giving birth during lockdown, between March 8 and May 18, 2020, in the COVID-19 'hotspot' in Northeastern Italy (study group), with an antecedent puerperae-matched group (control group). Exclusive, complementary, and formula feeding practices were collected from maternal charts at hospital discharge, on the second day post-partum, when puerperae filled out the Edinburg Postnatal Depression Scale (EPDS). RESULTS: The COVID-19 study group presented significantly lower exclusive breastfeeding rates than the control group who members gave birth the previous year (-15%, p = 0.003), as a consequence of the significantly higher prevalence of complementary feeding practices in the former (+20%, p = 0.002). Conversely, the COVID-19 study group showed significantly higher EPDS scores (8.03 ± 4.88 vs. 8.03 ± 4.88, p < 0.005) and higher anhedonia (0.56 ± 0.65 vs. 0.18 ± 0.38, p < 0.001) and depression (0.62 ± 0.60 vs. 0.39 ± 0.44, <0.001) subscale scores. In the general linear model analysis, women practicing exclusive breastfeeding showed significantly lower EPDS scores in comparison with those practicing complementary (p = 0.003) and formula feedings (p = 0.001). Furthermore, the highest EPDS scores were observed in women adopting formula feeding, mainly during the COVID-19 quarantine (p = 0.019). CONCLUSION: This study indicates that hospital containment measures adopted during lockdown in the 'hotspot' COVID-19 epidemic area of Northeastern Italy have a detrimental effect on maternal emotions and on breastfeeding exclusivity practices.

Psychological impact of COVID-19 quarantine measures in northeastern Italy on mothers in the immediate postpartum period.

OBJECTIVE: To explore whether quarantine measures and hospital containment policies among women giving birth in a COVID-19 "hotspot" area in northeastern Italy enhanced psycho-emotional distress in the immediate postpartum period. METHODS: We designed a non-concurrent case-control study of mothers who gave birth during a COVID-19 quarantine period between March 8 and May 3, 2020 (COVID-19 study group), with an antecedent group of matched postpartum women (control group) who delivered in the same period in 2019. Participants completed the Edinburgh Postnatal Depression Scale (EPDS) on the second day postpartum. RESULTS: The COVID-19 study group (n=91) had significantly higher mean EPDS scores compared with the control group (n=101) (8.5 ± 4.6 vs 6.34 ± 4.1; P<0.001). Furthermore, 28.6% of women in the COVID-19 group had a global EPDS score above 12. Analysis of three EPDS subscales revealed significantly higher scores among the COVID-19 group compared with the control group for anhedonia (0.60 ± 0.61 vs 0.19 ± 0.36; P<0.001) and depression (0.58 ± 0.54 vs 0.35 ± 0.45; P=0.001). CONCLUSIONS: Concerns about risk of exposure to COVID-19, combined with quarantine measures adopted during the COVID-19 pandemic, adversely affected the thoughts and emotions of new mothers, worsening depressive symptoms.

Prepregnancy Body Mass Index shift across gestation: primary evidence of an association with eating disorders.

Objective: Previous studies indicated that gestational weight gain-related disorders share many similarities with feeding and eating disorders (EDs).Design: To examine the association of prepregnancy Body Mass Index (BMI), defined according to 2009 Institute of Medicine (IOM), and its shift across gestation with symptoms of feeding and EDs, defined by EDE-Q.Setting: This prospective cohort study took place at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy, from Jannuary 2015 to October 2015.Population and sample: The sample included 655 healthy at term puerperae.Main outcomes measures: We correlated gestational BMI in different women categories to EDE-Q Global score and Restrain, Eating concern, Shape concern, and Weight concern subscales, by Spearman's correlation test.Results: Among 655 women, 59 (9.0%) were categorized as underweight, 463 (70.7%) normal weight, 98 (15.0%) overweight, and 35 (5.3%) as obese in prepregnancy period. At the end of gestation, underweight women category disappeared, normal weight women lightened to one third, overweight women tripled, and obese women doubled. At the same time, EDE-Q global scores increased from normal weight (0.25 ± 0.41), to overweight (0.47 ± 0.58), and to obese (0.72 ± 0.70) puerperae. In addition, EDE-Q global scores were significantly correlated with gestational BMI increase in Global score (rho = 0.326; p < .001) and in the four subscales: Restrain (rho = 0.161; p < .001), Eating concern (rho = 0.193; p < .001), Shape concern (rho = 0.335; p < .001), and Weight concern (rho = 0.365; p < .001), respectively.Conclusions: It was found that the shift of woman BMI across an uncomplicated pregnancy is a warning indicator of unhealthy eating and feeding symptoms.

Correction to: Morphine-induced supraventricular tachycardia in near-term fetus.

The original article [1] contained an error whereby all authors' names were mistakenly inverted.

Morphine-induced supraventricular tachycardia in near-term fetus.

BACKGROUND: Fetal supraventricular tachycardia (SVT), characterized by fetal heart rate between 220 and 260 bpm, is a rare but most commonly encountered fetal cardiac arrhythmia in pregnancy that may be associated with adverse perinatal outcome. CASE PRESENTATION: We describe a 36/6 week near term fetus who presented morphine-induced SVT after maternal treatment of a renal colic. Following emergency cesarean section, the neonate had resolution of symptoms. CONCLUSIONS: The pathophysiology of morphine-related SVT, previously documented in experimental animal models, and for the first time reported in the human fetus, is presented.

Maternal areola pH: A chemical basis for mother-infant recognition.

BACKGROUND: The human female's areolar region is the point of arrival of a natural progression from birth to breastfeeding continuum, supported by numerous functional features. AIMS: The aim of this study was to look more closely into the areola' skin chemical signals that are uniquely important for mother-infant chemoemission, chemoreception, and breastfeeding continuum. STUDY DESIGN: A dermatological study of the areolae and corresponding breast quadrants was undertaken on 71 healthy, at-term women. Areolar and corresponding breast quadrant pH were assessed pre-partum and 1 and 2 days post-partum using a corneometer (Soft Plus 5.5; Callegari S.P.A., Parma, Italy). RESULTS: Pre-partum, the pH of the areola was significantly higher than the pH of the breast quadrant (4.25 ±â€¯0.26 vs. 4.06 ±â€¯0.44, p < 0.015). Post-partum, the pH of the areola was significantly higher that the pH of the breast quadrant both on day one (4.28 ±â€¯0.31 vs 4.01 ±â€¯0.25, p < 0.001) and on day two (4.39 ±â€¯0.19 vs 4.01 ±â€¯0.16, p < 0.001), respectively. In addition, pre-labor pH of the areola increased on day one post-partum and significantly on day two postpartum (4.25 ±â€¯0.26 vs 4.39 ±â€¯0.19, p 0.004). Moreover, the pH of the areola increased significantly from day one to day two post-partum (4.28 ±â€¯0.31 v s 4.39 ±â€¯0.19, p < 0.041). CONCLUSIONS: Our findings show, for the first time, that the areola has a higher pH than the surrounding breast skin, and this increases from day one to day two postpartum. We believe that the pH changes of the areolar region may act as a unique chemical signal to guide the infant directly to the nipple.