Association of Continuous Glucose Monitoring Metrics With Pregnancy Outcomes in Patients With Preexisting Diabetes.

OBJECTIVE: Continuous glucose monitoring (CGM) improves maternal glycemic control and neonatal outcomes in type 1 diabetes pregnancies compared with self-monitoring of blood glucose. However, CGM targets for pregnancy are based on expert opinion. We aimed to evaluate the association between CGM metrics and perinatal outcomes and identify evidence-based targets to reduce morbidity. RESEARCH DESIGN AND METHODS: This was a retrospective cohort study of pregnant patients with type 1 or 2 diabetes who used real-time CGM and delivered at a U.S. tertiary center (2018-2021). Multiple gestations, fetal anomalies, and early pregnancy loss were excluded. Exposures included time in range (TIR; 65-140 mg/dL), time above range (TAR), time below range (TBR), glucose variability, average glucose, and glucose management indicator. The primary outcome was a composite of fetal or neonatal mortality, large or small for gestational age at birth, neonatal intensive care unit admission, hypoglycemia, shoulder dystocia or birth trauma, and hyperbilirubinemia. Logistic regression estimated the association between CGM metrics and outcomes, and optimal TIR was calculated. RESULTS: Of 117 patients, 16 (13.7%) used CGM before pregnancy and 68 (58.1%) had type 1 diabetes. Overall, 98 patients (83.8%) developed the composite neonatal outcome. All CGM metrics, except TBR, were associated with neonatal morbidity. For each 5 percentage-point increase in TIR, there was 28% reduced odds of neonatal morbidity (odds ratio 0.72, 95% CI 0.58-0.89). The statistically optimal TIR was 66-71%. CONCLUSIONS: Nearly all CGM metrics were associated with adverse neonatal morbidity and mortality and may aid management of preexisting diabetes in pregnancy. Our findings support the American Diabetes Association recommendation of 70% TIR.

Delivery timing for the opioid-exposed infant.

BACKGROUND: The prevalence of opioid use disorder and medication-assisted treatment in pregnancy is increasing. Compared with term infants, preterm infants have a lower incidence of neonatal opioid withdrawal syndrome. It is unknown whether early term delivery compared with full or late-term delivery decreases the risk of neonatal opioid withdrawal syndrome. OBJECTIVE: This study aimed to compare the neonatal outcomes among opioid-exposed infants born in the early, full, and late-term periods. STUDY DESIGN: This was a retrospective cohort study of opioid-exposed pregnancies delivering at a single center from 2010 to 2017 at ≥37 weeks gestation. Participants with multiple gestations or fetal anomalies were excluded. Maternal opioid exposure was defined as prescription (including medication-assisted treatment) or nonprescription opioid use or a positive urine drug screen in pregnancy for opiates. The primary outcome was a neonatal composite of respiratory distress syndrome, neonatal sepsis, neonatal seizures, hypoxic ischemic encephalopathy, jaundice requiring treatment, 5-minute Apgar <5, neonatal intensive care unit admission, neonatal opioid withdrawal syndrome, or neonatal death. The secondary outcomes included individual components of the primary outcome, birthweight, need for and length of neonatal opioid withdrawal syndrome treatment, length of hospital admission, and maximum Finnegan scores. Early (37-<39), full (39-<41), and late (41-<42 weeks) term groups were defined by the American College of Obstetricians and Gynecologists. RESULTS: Of 399 infants, 136 (34.1%), 229 (57.4%), and 34 (8.5%) were born in the early, full, and late-term periods, respectively. Two hundred and seventy patients (67.7%) received medication-assisted treatment for opioid use disorder, and the baseline characteristics were similar in all the groups except for history of intranasal heroin use, positive urine toxicology screen for heroin or any opiates, and delivery indication (P<.05). The primary composite outcome occurred in 313 (78.4%) neonates, and 296 (74.2%) neonates had neonatal opioid withdrawal syndrome. More than half (219 [54.9%]) of opioid-exposed neonates were admitted to the neonatal intensive care unit, and 160 (40.1%) required pharmacologic neonatal opioid withdrawal syndrome treatment for a mean duration of almost 3 weeks (19.0±16.1 days). There were no significant differences in the primary composite outcome, incidence of neonatal opioid withdrawal syndrome, or other secondary outcomes (except birthweight) between neonates born in the early, full, or late-term periods. CONCLUSION: Although neonatal morbidity was frequent among opioid-exposed neonates, the incidence and severity of neonatal opioid withdrawal syndrome or other neonatal outcomes were not different between neonates delivered in the early, full, and late-term periods, suggesting that opioid-exposed infants may not benefit from early term delivery.

The Impact of a Prenatal Education Program for Opioid-Dependent Mothers on Breastfeeding Rates of Infants at Risk for Neonatal Abstinence Syndrome.

INTRODUCTION: This study aimed to determine the effect of a prenatal education program for opioid-dependent women on breastfeeding frequency, newborn hospital length of stay, and cost of care for neonates at risk of developing neonatal abstinence syndrome. METHODS: From January 1, 2015 to January 1, 2020, opioid-dependent obstetric patients were educated on non-pharmacological preventative measures for neonatal abstinence syndrome (NAS), with focused counseling on breastfeeding. Data were collected and compared to a control group of opioid-dependent pregnant women who received standard care before initiation of the education program. RESULTS: Sample size calculation revealed that to detect doubling of the breastfeeding rate from 25% to 50% with 80% power and α error of 0.05, 66 participants were required in each group. CONCLUSION: There were 75 women with opioid use disorder who had prenatal NAS education (study group) and 108 women with opioid use disorder who underwent standard care before NAS education (control group). Prenatal NAS education participants significantly increased breastfeeding initiation rates compared to the control group. Newborn length of stay significantly decreased after initiation of prenatal NAS education compared to the 36 months before NAS education program.

Obesity's impact on intrapartum electronic fetal monitoring.

OBJECTIVE: The objective of this study is to evaluate the impact maternal obesity has on the percentage of unmonitored electronic fetal monitoring (EFM). STUDY DESIGN: Women undergoing induction of labor at term were categorized into three groups: Group 1 (body mass index (BMI) < 30 kg/m2), Group 2 (30 < BMI < 40 kg/m2), and Group 3 (BMI ≥ 40 kg/m2). External EFM tracings were reviewed from the time of induction of labor until amniotomy; the percentage of time off of EFM was calculated. Statistical analysis was performed using commercially available software. RESULTS: Three hundred and thirty-seven patients were stratified into the following groups: 104 patients in Group 1, 156 patients in Group 2, and 77 in Group 3. No significant differences were found between groups when analyzed for gestational age, bishop score, parity, race, and 5 min APGAR less than 7 or admission to the NICU. The mean percentage unmonitored by EFM was 5% for Group 1, 7% for Group 2 and 11% for Group 3. There was a significant association between percent of time unmonitored by EFM and BMI (r = 0.344 p < .0001). CONCLUSION: At term gestation, the fetuses of obese women spend more time unmonitored by external intrapartum EFM than non-obese women. This represents a disparity among a high-risk group that may result in poor pregnancy outcomes if fetal distress is present.

Delayed Cord Clamping in Preterm Neonates: A Review of Benefits and Risks.

IMPORTANCE: Delayed clamping of the umbilical cord of premature neonates decreases perinatal morbidity. Allowing time for autotransfusion of placental blood before the umbilical cord is clamped represents a simple practice that may have significant impact. In light of many professional societies recommending delayed cord clamping in premature neonates because of its beneficial effects, the topic still holds many unanswered questions. OBJECTIVE: The purpose of this article is to review the most recent evidence available regarding delayed cord clamping in premature neonates. EVIDENCE ACQUISITION: A literature search using PubMed, Cochrane database, and cumulative index of nursing and allied health literature provided the references for this review. RESULTS: Although the evidence comes primarily from small trials, delayed umbilical cord clamping in premature neonates is associated with less need for red blood cell transfusions, increase in hemoglobin and hematocrit levels, and decrease in risk of intraventricular hemorrhage and necrotizing enterocolitis. No maternal or neonatal risks have been demonstrated. Data on long-term outcomes are lacking. CONCLUSIONS AND RELEVANCE: Delayed cord clamping in premature neonates is a simple procedure that the current evidence supports to improve neonatal morbidity. The impact on long-term outcomes remains limited. The optimal time to delay cord clamping and potential risks are poorly studied.

Induction of labor with an unfavorable cervix: how does BMI affect success? (‡).

OBJECTIVE: Obesity places women and their babies at risk for obstetric and perinatal morbidity including induction of labor and cesarean delivery. We sought to evaluate the impact of body mass index (BMI) on successful induction of labor using misoprostol at our institution. The primary outcome was time to delivery. Secondary outcomes were number of doses of misoprostol, duration of oxytocin and cesarean delivery. METHODS: A retrospective cohort over two years found 329 patients who were > 37 weeks of gestational age and had a Bishop score < 5 prior to beginning induction. Patients were divided into three categories based on their BMI: Group 1: BMI ≤ 30 kg/m(2), Group 2: BMI 30 to 39.9 kg/m(2) and Group 3: BMI ≥ 40 kg/m(2). Statistical analysis included the use of multivariate analysis, contingency tables and Chi-square tests for categorical data and Pearson's correlation coefficient for numerical data. RESULTS: There were no significant differences among the groups when analyzed for gestational age, bishop score, median parity or race. Time to delivery increased significantly with increasing BMI (p < 0.01). Furthermore, women with higher BMIs required more doses of misoprostol (p < 0.01), longer duration of oxytocin administration prior to delivery (p < 0.02) and increased risk of cesarean section (p < 0.0006). CONCLUSION: As BMI increases, obese patients undergoing induction with misoprostol have a longer time to delivery, require more doses of misoprostol, require a longer duration of oxytocin and have higher cesarean delivery rate.

A novel translational model of percutaneous fetoscopic endoluminal tracheal occlusion - baboons (Papio spp.).

INTRODUCTION: Percutaneous fetoscopic endoluminal reversible tracheal occlusion (FETO) was developed to prevent the pulmonary complications of fetal congenital diaphragmatic herniation. There is an urgent need to establish the closest to human translational model of FETO in order to improve fetal outcomes and to determine new clinical approaches and applications. MATERIAL AND METHODS: Seven non-human primates underwent two subsequent surgeries: the first, the FETO in the experimental group (n = 3) or sham operation in the control animals (S-FETO, n = 4) at 132-142 days of gestation (dGA); the second, the reversal of occlusion or sham operation at 162 ± 5 dGA. Maternal stress axis, complete blood count, and biochemical parameters were evaluated and newborn tracheal radiography was performed. RESULTS: The average pregnancy duration and neonatal weights in the FETO group did not differ from the animals in the S-FETO group. There was no bleeding or premature fetal membrane rupture during the procedures in any of the baboons. The maximal tracheal width was 7.02 ± 0.6 mm in the FETO versus 5.46 ± 0.6 mm in S-FETO group. DISCUSSION: This is the very first report of a successful FETO model in non-human primates. Similarities to human tracheomegaly were for the first time documented in any model studied.

The effect of cesarean delivery skin incision approach in morbidly obese women on the rate of classical hysterotomy.

OBJECTIVE: To assess the risk of classical hysterotomy and surgical morbidity among women with a body mass index (BMI) greater than 40 kg/m² who underwent a supraumbilical incision at the time of cesarean delivery. METHODS: We conducted a retrospective cohort study in women having a BMI greater than 40 kg/m² who underwent a cesarean delivery of a live, singleton pregnancy from 2007 to 2011 at a single tertiary care institution. Intraoperative and postoperative outcomes were compared between patients undergoing supraumbilical vertical (cohort, n = 45) or Pfannenstiel (controls, n = 90) skin incisions. RESULTS: Women undergoing supraumbilical incisions had a higher risk of classical hysterotomy (OR, 24.6; 95% CI, 9.0-66.8), surgical drain placement (OR, 6.5; 95% CI, 2.6-16.2), estimated blood loss greater than 1 liter (OR, 3.4; 95% CI, 1.4-8.4), and longer operative time (97 ± 38 minutes versus 68 ± 30 minutes; P < .001) when compared to subjects with Pfannenstiel incisions (controls). There was no difference in the risk of wound complication between women undergoing supraumbilical or Pfannenstiel incisions (OR, 2.7; 95% CI, 0.9-8.0). CONCLUSION: In women with a BMI above 40 kg/m², supraumbilical incision at the time of cesarean delivery is associated with a greater risk of classical hysterotomy and operative morbidity.