Neonatal Outcomes among Fetuses with an Abdominal Circumference <3rd %ile and Estimated Fetal Weight 3rd to 9th %ile Compared to Fetuses with an EFW <3rd %ile.

OBJECTIVE: Fetal growth restriction (FGR) is defined as an estimated fetal weight (EFW) or abdominal circumference (AC) <10th percentile (%ile) for gestational age (GA). An EFW <3rd %ile for GA is considered severe FGR (sFGR). It remains unknown if fetuses with isolated AC <3rd %ile should be considered sFGR. Our primary objective was to assess composite neonatal outcomes in fetuses with an AC <3rd %ile and overall EFW 3rd to 9th %ile compared with those with an EFW <3rd %ile. STUDY DESIGN: This retrospective cohort study was undertaken at a tertiary academic center from January 2016 to December 2021. Inclusion criteria were singleton fetuses with an EFW <3rd %ile (Group 1) or AC <3rd %ile with EFW 3rd to 9th %ile (Group 2) at 28 weeks' gestation or greater. Exclusion criteria were multiple gestations, presence of a major fetal anomaly, resolution of FGR, genetic syndrome, or infection. Composite neonatal outcome was defined by any of the following: neonatal intensive care unit admission >48 hours, necrotizing enterocolitis, sepsis, respiratory distress syndrome, mechanical ventilation, retinopathy of prematurity, seizures, intraventricular hemorrhage, stillbirth, or death before discharge. Small for gestational age (SGA) was defined as birth weight <10th %ile for GA. RESULTS: A total of 743 patients fulfilled our study criteria, with 489 in Group 1 and 254 in Group 2. The composite neonatal outcome occurred in 281 (57.5%) neonates in Group 1 and 53 (20.9%) in Group 2 (p < 0.01). The rates of SGA at birth were 94.9 and 75.6% for Group 1 and Group 2, respectively (OR 5.99, 95% confidence interval 3.65-9.82). CONCLUSION: Although AC <3rd %ile with EFW 3rd to 9th %ile is associated with a lower frequency of SGA and neonatal morbidity than EFW <3 %ile, fetuses with AC <3 %ile still exhibited moderate rates of these adverse perinatal outcomes. Consideration should be given to inclusion of an AC <3rd %ile with EFW 3rd to 9th %ile as a criterion for sFGR. However, prospective studies comparing delivery at 37 versus 38 to 39 weeks' gestation are needed to ensure improved outcomes before widespread adaptation in clinical practice. KEY POINTS: · The composite neonatal outcome occurred in 57.5% of fetuses with an overall EFW <3rd %ile and 20.9% of fetuses with an AC <3rd %ile but EFW 3rd to 9th %ile.. · Both groups demonstrated a high positive predictive value for SGA birth weight.. · Consideration should be given to inclusion of an AC <3rd %ile as a criterion for sFGR..

Infant Mortality Categorized by Birth Weight Percentiles for Deliveries Between 22 and 28 Weeks of Gestation.

OBJECTIVE: Our objective was to describe infant mortality within 1 year of life according to gestational age and birth weight percentile in infants delivered between 22 and 28 weeks of gestation. STUDY DESIGN: This study was a retrospective cohort study based on publicly available U.S. birth certificate data linked to infant death data between 2014 and 2020. Maternal-neonate pairs of singleton live births between 220/7 and 286/7 weeks' gestation (vaginal or cesarean) were evaluated. We excluded infants with major fetal anomalies, chromosomal disorders, and birth weight outliers. Our primary outcome was infant mortality within 1 year of life. Individuals were categorized into eight sex-specific birth weight percentiles categories: less than the 3rd, 3rd-less than the 10th, 10th-less than the 25th, 25th-to less than the 50th, 50th-less than the 75th, 75th-to less than the 90th, 90th-less than the 97th, and 97th or higher. RESULTS: Of 27,014,444 individuals with live births from January 2014 to December 2020, 151,677 individuals who gave birth at 22 to 28 weeks of gestation were included in the study population. The mortality rate ranged from 4.2% for the 50th-less than the 75th percentiles at 28 weeks to 80.3% for the 3rd-less than the 10th percentile at 22 weeks. Using the 50th-less than the 75th birth weight percentile at each gestational age as a reference group, birth weight less than the 50th percentile was associated with increased mortality at all gestational ages in a dose-dependent manner. From 22 to 25 weeks of gestation, higher birth weight percentiles were associated with lower mortality, while the 97th or higher birth weight percentile was associated with increased mortality compared with the 50th-less than the 75th birth weight percentile at 26 to 28 weeks of gestation. CONCLUSION: The lower birth weight percentiles were associated with higher mortality across all gestational ages, but the association between higher birth weight percentiles and infant mortality exhibited an opposite pattern at 22 to 25 weeks as compared to later gestational age. KEY POINTS: · Birth weight ≥97th percentile was associated with increased infant mortality at 26 to 28 weeks.. · Higher birth weight percentiles were associated with a lower risk of mortality at 22 to 25 weeks.. · Lower birth weight percentiles were associated with a higher risk of mortality at 22 to 28 weeks..

Neonatal and Maternal Outcomes at 22-28 Weeks of Gestation by Mode of Delivery.

OBJECTIVE: To compare neonatal and maternal outcomes after 22- to 28-week delivery between cesarean and vaginal delivery after stratification by gestational age and fetal presentation. METHODS: This study was a repeated cross-sectional analysis using U.S. birth certificate data linked to infant death data from 2017 to 2020. We limited analyses to women with singleton pregnancies who gave birth at 22-28 weeks of gestation and whose neonates were admitted to the intensive care unit. Our primary outcome was neonatal death within 28 days. We also examined infant mortality within 1 year and severe maternal morbidity (SMM; any transfusion, unplanned hysterectomy, and intensive care unit admission). Outcomes were compared between cesarean and vaginal delivery after stratification by gestational age and fetal presentation. Multivariable logistic regression was performed to calculate adjusted odds ratios (vaginal delivery as a referent), controlling for potential confounders. RESULTS: Of 69,672 individuals with eligible deliveries, 1,740 (2.5%) delivered at 22 weeks of gestation, 6,155 (8.8%) delivered at 23 weeks, 9,341 (13.4%) delivered at 24 weeks, 10,516 (15.1%) delivered at 25 weeks, 11,994 (17.2%) delivered at 26 weeks, 13,662 (19.6%) delivered at 27 weeks, and 16,264 (23.3%) delivered at 28 weeks. In cephalic fetuses, cesarean delivery compared with vaginal delivery was associated with neonatal death and infant mortality at 24 weeks of gestation and greater (not significant at 22-23 weeks) and SMM in all gestational age groups. In contrast, in noncephalic fetuses, cesarean delivery compared with vaginal delivery was associated with decreased odds of neonatal death and infant mortality in all gestational age groups. Sample size for SMM in noncephalic fetuses precluded multivariable modeling. CONCLUSION: Cesarean delivery in cephalic fetuses was associated with increased odds of adverse neonatal outcomes (24 weeks of gestation or greater) and SMM (all gestational age groups). Cesarean delivery was associated with decreased odds of neonatal death compared with vaginal delivery for noncephalic fetuses in all gestational age groups.

Infant Outcomes Categorized by Birth Weight Percentile for Deliveries Between 28 and 41 Weeks of Gestation.

OBJECTIVE: To examine the association between birth weight percentile and severe infant outcomes according to gestational age category. METHODS: We conducted a population-based retrospective cohort study using publicly available U.S. birth certificate data linked to infant death data from 2017 to 2019. Maternal-neonate pairs of singleton live births between 28 0/7 and 41 6/7 weeks of gestation (vaginal or cesarean delivery) were evaluated. We excluded infants with major fetal anomalies, chromosomal disorders, missing data, and birth weight outliers. The primary outcome was infant mortality within 1 year of life. Neonates were divided into eight sex-specific birth weight percentile categories: less than the 3rd, 3rd-less than the 10th, 10th-less than the 25th, 25th-to less than the 49th, 50th-less than the 75th, 75th-to less than the 90th, 90th-less than the 97th, and 97th or higher. RESULTS: There were 10,459,388 births between 28 and 41 weeks of gestation: 69,793 (0.7%) at 28-31 weeks, 88,673 (0.8%) at 32-33 weeks, 635,904 (6.1%) at 34-36 weeks, 2,763,110 (26.4%) at 37-38 weeks, 6,269,894 (59.9%) at 39-40 weeks, and 632,014 (6.0%) at 41 weeks. Infant mortality during the first year of life significantly increased at higher and lower birth weight percentiles at 28-36 weeks of gestation, with the lowest risk observed at the 50th-less than the 75th percentile. The highest mortality rates were 13.6% at less than the 3rd percentile and 8.4% at the 97th percentile or higher at 28-31 weeks of gestation; the second-highest mortality rates were 7.7% at less than the 3rd percentile and 3.1% at the 97th percentile or higher at 32-33 weeks of gestation. At 34-36 weeks of gestation, the highest and second-highest mortality rates were 3.4% at less than the 3rd percentile and 1.4% at the 3rd-10th percentile. At 37-41 weeks of gestation, infant mortality was associated with lower birth weight percentile, but higher birth weight percentiles were not significantly associated with increased mortality. CONCLUSION: We found different patterns in the association between birth weight percentile and infant mortality depending on gestational age category.

Comparison of Labor Curves Between Spontaneous and Induced Labor.

OBJECTIVE: To compare the labor curve between individuals with induced labor and those undergoing spontaneous labor. METHODS: This was a secondary analysis of the Consortium on Safe Labor database, including nulliparous and multiparous individuals with singleton vertex pregnancy who delivered vaginally after spontaneous labor or induction of labor at term. Labor that resulted in uterine rupture and neonates with a 5-minute Apgar scores less than 7, birth injury, or neonatal intensive care unit admission was excluded. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function. We compared traverse time , defined as the elapsed time between two given dilation measures, between induced and spontaneous labor using interval-censored regression. RESULTS: Of 46,835 nulliparous individuals, 18,576 and 28,259 underwent induced and spontaneous labor, respectively. Of 77,503 multiparous individuals, 29,684 and 47,819 underwent induced and spontaneous labor, respectively. The start of the active phase on the labor curve was 6 cm in induced labor, regardless of parity. In nulliparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 1.8 hours [5th-95th percentile 0.4-8.6 hours] vs 2.3 hours [5th-95th percentile 0.6-9.4 hours]; P <.01). In multiparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 0.9 hours [5th-95th percentile 0.1-6.0 hours] vs 1.4 hours [5th-95th percentile 0.3-7.9 hours]; P <.01). CONCLUSION: Similar to spontaneous labor, the start of the active phase of induced labor was at 6 cm of dilation. Comparatively, induced labor had a shorter active phase than spontaneous labor. These findings suggest that the current criteria for active phase arrest provided by the American College of Obstetricians and Gynecologists do not need to be lengthened for individuals in induced labor.

Post Antenatal Late Preterm Steroids trial: interrupted time series analysis of respiratory outcomes in twin and pregestational diabetes.

BACKGROUND: The Antenatal Late Preterm Steroids trial found that corticosteroid administration decreased respiratory complications by 20% among late preterm singleton deliveries. After the Antenatal Late Preterm Steroids trial, corticosteroid administration increased by 76% among twin pregnancies and 113% among singleton pregnancies complicated by pregestational diabetes mellitus compared with expected rates based on the pre-Antenatal Late Preterm Steroids trial trend. However, the effect of corticosteroids on twin pregnancies and pregnancies complicated by pregestational diabetes mellitus is not well studied, as the Antenatal Late Preterm Steroids trial excluded twin pregnancies and pregnancies complicated by pregestational diabetes mellitus. OBJECTIVE: This study aimed to examine the change in the incidence rate of immediate assisted ventilation use and ventilation use for more than 6 hours among 2 populations after the dissemination of the Antenatal Late Preterm Steroids trial at the population level. STUDY DESIGN: This study was a retrospective analysis of publicly available US birth certificate data. The study period was from August 1, 2014, to April 30, 2018. The dissemination period of the Antenatal Late Preterm Steroids trial was from February 2016 to October 2016. Population-based interrupted time series analyses were performed for 2 target populations: (1) twin pregnancies not complicated by pregestational diabetes mellitus and (2) singleton pregnancies complicated by pregestational diabetes mellitus. For both target populations, analyses were limited to individuals who delivered nonanomalous live neonates between 34 0/7 and 36 6/7 weeks of gestation (vaginal or cesarean delivery). As a sensitivity analysis, a total of 23 placebo tests were conducted before (5 tests) and after (18 tests) the dissemination period. RESULTS: For the analysis of late preterm twin deliveries, 191,374 individuals without pregestational diabetes mellitus were identified. For the analysis of late preterm singleton pregnancy with pregestational diabetes mellitus, 21,395 individuals were identified. After the dissemination period, the incidence rate of immediate assisted ventilation use for late preterm twin deliveries was significantly lower than the expected value based on the pre-Antenatal Late Preterm Steroids trial trend (11.6% observed vs 13.0% expected; adjusted incidence rate ratio, 0.87; 95% confidence interval, 0.78-0.97). The incidence rate of ventilation use for more than 6 hours among late preterm twin deliveries did not change significantly after the dissemination of the Antenatal Late Preterm Steroids trial. A significant increase in the incidence rate of immediate assisted ventilation use and ventilation use for more than 6 hours was found among singleton pregnancies with pregestational diabetes mellitus. However, the results of placebo tests suggested that the increase in incidence was not necessarily due to the dissemination period of the Antenatal Late Preterm Steroids trial. CONCLUSION: The dissemination of the Antenatal Late Preterm Steroids trial was associated with decreased incidence of immediate assisted ventilation use, but no change in ventilation use for more than 6 hours, among late preterm twin deliveries in the United States. In contrast, the incidence of neonatal respiratory outcomes among singleton deliveries with pregestational diabetes mellitus did not decrease after the dissemination of the Antenatal Late Preterm Steroids trial.

Comparison of Adverse Maternal Outcomes between Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Superimposed preeclampsia (SIPE), defined as preeclampsia in individuals with chronic hypertension, is one of the most common complications, accounting for 13 to 40% of pregnancies with chronic hypertension. However, there are limited data regarding maternal outcomes of early- and late-onset SIPE in individuals with chronic hypertension. We hypothesized that early-onset SIPE was associated with increased odds of adverse maternal outcomes compared with late-onset SIPE. Therefore, we aimed to compare adverse maternal outcomes between individuals with early-onset SIPE and those with late-onset SIPE. STUDY DESIGN: This was a retrospective cohort study of pregnant individuals with SIPE who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as the onset of SIPE before 34 weeks' gestation. Late-onset SIPE was defined as the onset of SIPE at or after 34 weeks' gestation. Our primary outcome was a composite of eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, maternal death, placental abruption, pulmonary edema, SIPE with severe features, and thromboembolic disease. Maternal outcomes were compared between early- and late-onset SIPE. We used simple and multivariate logistic regression models to calculate crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of 311 individuals, 157 (50.5%) had early-onset SIPE, 154 (49.5%) had late-onset SIPE. There were significant differences in the proportions of obstetric complications, including the primary outcome, HELLP syndrome, SIPE with severe features, fetal growth restriction (FGR), and cesarean delivery between early- and late-onset SIPE. Compared with individuals with late-onset SIPE, those with early-onset SIPE had increased odds of the primary outcome (aOR: 3.28; 95% CI: 1.42-7.59), SIPE with severe features (aOR: 2.72; 95% CI: 1.25-5.90), FGR (aOR: 6.07; 95% CI: 3.25-11.36), and cesarean delivery (aOR 3.42; 95% CI: 2.03-5.75). CONCLUSION: Individuals with early-onset SIPE had higher odds of adverse maternal outcomes compared with those with late-onset SIPE. KEY POINTS: · We revealed the incidence of maternal outcomes in early- and late-onset SIPE.. · Severe features were common in individuals with SIPE.. · Early-onset SIPE was associated with increased adverse maternal outcomes compared with late-onset SIPE..

Risk Factors for Early- and Late-Onset Superimposed Preeclampsia.

OBJECTIVE: Risk factors of early- and late-onset preeclampsia among pregnant individuals with chronic hypertension are not well described in the literature. We hypothesized that early- and late-onset superimposed preeclampsia (SIPE) have different risk factors. Therefore, we aimed to examine the risk factors of early- and late-onset SIPE among individuals with chronic hypertension. STUDY DESIGN: This was a retrospective case-control study of pregnant individuals with chronic hypertension who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as SIPE diagnosed before 34 weeks' gestation. To identify risk factors, we compared individuals' characteristics between individuals who developed early- and late-onset SIPE and those who did not. We then compared characteristics between individuals who developed early-onset SIPE and late-onset SIPE. Characteristics with p-values of less than 0.05 by bivariable variables were analyzed by simple and multivariable logistic regression models to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Missing values were imputed with multiple imputation. RESULTS: Of 839 individuals, 156 (18.6%) had early-onset, 154 (18.4%) had late-onset SIPE and 529 (63.1%) did not have SIPE. The multivariate logistic regression model showed that serum creatinine ≥ 0.7 mg/dL compared to less than 0.7 mg/dL (aOR: 2.89 [95% CI: 1.63-5.13]), increase of creatinine (1.33 [1.16-1.53]), nulliparity compared to multiparity (1.77 [1.21-2.60]), and pregestational diabetes (1.70 [1.11-2.62]) were risk factors for early-onset SIPE. The multivariate logistic regression model showed that nulliparity compared to multiparity (1.53 [1.05-2.22]) and pregestational diabetes (1.74 [1.14-2.64]) was a risk factor for late-onset SIPE. Serum creatinine ≥ 0.7 mg/dL (2.90 [1.36-6.15]) and increase of creatinine (1.33 [1.10-1.60]) were significantly associated with early-onset SIPE compared to late-onset SIPE. CONCLUSION: Kidney dysfunction seemed to be associated with the pathophysiology of early-onset SIPE. Nulliparity and pregestational diabetes were common risk factors for both early- and late-onset SIPE. KEY POINTS: · Serum creatinine level was positively associated with early-onset superimposed preeclampsia (SIPE).. · Pregestational diabetes and nulliparity were associated with both early- and late-onset SIPE.. · The identification of risk factors may provide an opportunity to decrease the rates of SIPE..

The effect of cervical cerclage on the labor curve.

BACKGROUND: Cervical cerclage is an effective intervention to prevent preterm birth among individuals with a history of cervical insufficiency, individuals with a short cervix and history of preterm birth, or individuals with second-trimester painless dilation. Although cerclage reduces the mechanical stress on the cervix by reinforcing it with sutures, cerclage could also cause scarring of the cervix, which may affect the progress of labor. OBJECTIVE: This study aimed to compare the labor curves between individuals who underwent cerclage and those who did not undergo cerclage. STUDY DESIGN: This was a retrospective cohort study of individuals with singleton term pregnancy, vertex presentation, and vaginal delivery, using the data from the Consortium on Safe Labor. We excluded individuals with fetal anomalies, stillbirth, or abnormal perinatal outcomes, including 5-minute Apgar score of <7, birth injury, and neonatal intensive care unit admission. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function and generated smoothed labor curves. An interval-censored regression analysis was performed to estimate traverse times (the elapsed time between 2 cervical dilation measures). The traverse times were compared between individuals who underwent cerclage and those who did not undergo cerclage, controlling for induction of labor and parity. RESULTS: There were 245 individuals who underwent cerclage and 110,080 individuals who did not undergo cerclage. Individuals who underwent cerclage compared with those who did not undergo cerclage had a similar traverse time from 1 to 6 cm (median, 9.1 vs 10.3 hours; adjusted P=.37) and from 6 to 10 cm (median, 1.5 vs 1.5 hours; adjusted P=.23). Individuals who underwent cerclage compared with those who did not undergo cerclage had a longer traverse time from rupture of membranes to delivery (median, 4.0 vs 3.0 hours; adjusted P<.01). CONCLUSION: Cervical cerclage did not affect the overall progress of labor.

Laboratory prognostic score for predicting 14-day mortality in terminally ill patients with gynecologic malignancy.

BACKGROUND: There are few studies developing a scoring system for short-term survival of patients with gynecologic malignancy. METHODS: Seventy-three terminally ill patients with gynecologic malignancy who were admitted to our palliative care unit (PCU) from June 2009 to February 2018 were included. We accumulated routine blood data within 3 months before PCU discharge. Receiver-operating characteristic analysis was performed on each blood factor, and area under the curve (AUC) was calculated to determine the predictive value for 14-day survival after the blood test. Multivariable logistic regression analysis was performed to identify significant independent prognostic factors of 14-day mortality. To develop a scoring system for 14-day mortality, laboratory prognostic score for gynecologic malignancy (G-LPS) was calculated using the sum of indices of the independent prognostic factors. RESULTS: Multivariable analysis showed that 6 of 24 indices, namely, C-reactive protein ≥ 13.3 mg/dL, total bilirubin ≥ 1.1 mg/dL, sodium < 131 mEq/L, blood urea nitrogen ≥ 28 mg/dL, white blood cell count ≥ 17.7 × 103/µL, and eosinophil level < 0.2%, were significant independent factors of 14-day survival. G-LPS was obtained from the sum of the six indices. The AUC was 0.7977 at the optimal cut-off value of G-LPS 3. G-LPS 3 predicted death within 14 days with a sensitivity of 72% and a specificity of 79%. CONCLUSIONS: Six of the 24 laboratory indices were identified as independent prognostic factors of 14-day mortality in terminally ill patients with gynecologic malignancy. G-LPS showed acceptable ability of predicting 14-day survival.

The impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of placental abruption.

Objective: We examined the impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of cases of clinically diagnosed placental abruption (PA).Material and methods: We investigated 84 patients who were diagnosed with PA at our hospital from January 2009 to September 2017. We classified the patients with PA into three groups based on the extent of the abruption: (1) mild abruption, <20%; (2) moderate abruption, 20-49%; (3) severe abruption, ≥50%, which was defined by the attending obstetricians at the time of delivery. The neonatal outcome was measured by the umbilical artery pH and the maternal outcome was measured by the obstetric disseminated intravascular coagulation score (DIC score).Results: The rate of hypertensive disorders of pregnancy in the moderate abruption group was significantly lower than that in other groups (p = .010). The umbilical artery pH was below 7.00 in 29 cases. The umbilical artery pH of the severe abruption group (6.92) was the lowest and was significantly lower in comparison to other groups (mild group [7.24], p < .001; moderate group [7.11], p < .05). There was a significant correlation between the onset-to-delivery time and the umbilical artery pH in the moderate group (R = -0.43). The maternal DIC scores in the three groups did not differ to a statistically significant extent.Conclusions: The severity of placental separation is significantly correlated with poor neonatal outcomes and there was a significant negative correlation between the onset-to-delivery time and the umbilical artery pH in moderate abruption.