Maternal antenatal profile and immediate neonatal outcome in VLBW and ELBW babies

Outcome of extremely low birth weight (ELBW) infants from a birth cohort (2013-2018) in a tertiary care unit in North India

OBJECTIVE

To evaluate mortality and short-term morbidities in extremely low birth weight (ELBW) infants (<1000 g) in a birth cohort in North India.

METHODS

In-hospital data of 231 ELBW infants (Jan 2013 to Sept 2018) were collected from a prospectively maintained electronic database by using standard definitions.

RESULTS

The mean (SD) gestation and birth weight were 27.9 (2.2) weeks and 783 (133) g, respectively. Major morbidities included respiratory distress syndrome (n = 132, 57%), moderate-to-severe bronchopulmonary dysplasia (n = 62, 26.8%), hemodynamically significant patent ductus arteriosus (n = 65, 28%), intracranial hemorrhage ≥ grade II (n = 38, 16%), and culture-positive sepsis (n = 44, 19%). Median (IQR) duration of hospital stay (survivors) was 50 (17-79) days. The overall survival was 62%. On logistic regression, severe birth asphyxia, gestation ≤26 weeks, and respiratory distress syndrome were major predictors of mortality.

CONCLUSION

In the current ELBW cohort, nearly two-thirds survived until discharge, who had considerable morbidities needing prolonged hospital stay. This study can be utilized for counseling and planning of care of ELBW infants in similar settings.

Anemia in Pregnancy is Still a Public Health Problem: A Single Center Study with Review of Literature

Anemia is a significant public health problem during pregnancy and its prevalence varies in different cohorts. Correct identification of this problem in a given population is important for implementation of various health schemes. This study was carried out at a tertiary care hospital in Haryana. The prevalence of anemia in females at the time pregnancy diagnosis during first trimester was studied. The study period was January 2018 to June 2019. Severity of anemia was categorized as mild (hemoglobin 10-10.9 gm/dl), moderate (hemoglobin 7-9.9 gm/dl) and severe (hemoglobin < 7 gm/dl) as per the WHO definition. Relevant review of literature on prevalence of anemia in pregnancy in different Indian states was done. The median age of 388 females with diagnosis of pregnancy during first trimester was 27 years. Mean hemoglobin concentration was 10.47 gm/dl. 264 (68%) females had anemia. Out of these 191 (72.3%) had mild anemia, 65 (24.6%) had moderate anemia and eight had severe anemia. Out of the total study population, 270 (69.58%) were from rural and 118 (30.41%) were from urban background. Among the anemic pregnant females, 179 (67.8%) belonged to rural areas and 85 (32.20%) belonged to urban areas. Out of 264 patients with anemia, 87 (32.95%) patients were primigravida and 177 (67.04%) were multiparous females. The results of literature review showed a high prevalence of anemia in the other Indian states also. There is high prevalence of anemia in females at the time of diagnosis of pregnancy. Rates of anemia are higher in females with higher parity.

Determinants of Persistent Anemia in Poor, Urban Pregnant Women of Chandigarh City, North India: A Mixed Method Approach

BACKGROUND

Maternal anemia continues to be a public health problem in India, despite existence of multipronged governmental programs to combat it.

OBJECTIVE

This study explores the determinants of persistent anemia in poor pregnant women in an urban population in Chandigarh, India.

METHODS

A mixed method approach was used to examine the causes of maternal anemia. Three focus group discussions with pregnant women from different socioeconomic groups and 2 with female health workers were conducted to explore their perceptions and beliefs about maternal anemia and iron folic acid (IFA) tablets in urban settings in 2009. This was followed by interviews of 120 pregnant women about their nutrition knowledge and practices. Food frequency questionnaires were used to estimate daily consumption of nutrients. Finally, a follow-up survey in health clinics explored issues of stock-outs of IFA.

RESULTS

Sixty-five percent of respondents had hemoglobin less than 11g/dL and were anemic. Only 35% respondents obtained free IFA through public health programs. While 53% of respondents knew that they should eat green leafy vegetables, only 8% reported daily consumption of these vegetables. Focus group discussions highlighted issues around lack of food, especially for slum women, and low decision-making power in the household. Stock-outs of IFA in facilities often pushed women to purchase IFA from chemist shops.

CONCLUSIONS

Clear gaps emerged in pregnant women's knowledge and practice regarding diet and IFA tablet use. Lack of control over decision-making due to their low status of women was also hindering IFA use and healthy eating.

Variability in survival of very low birth weight neonates in hospitals of India

This prospective cohort study was conducted to evaluate variability in mortality of very low birth weight (VLBW) neonates during their birth hospitalization in different hospitals of India. A liveborn neonate was eligible for inclusion in the study if it was born or admitted in a participating hospital between 1st January and 31st December 2012 and weighed 1500g or less at birth. Neonates were given clinical care as per standard protocols. Standardized neonatal mortality ratio (SNMR) was calculated as the ratio of the observed mortality to the expected mortality. Expected mortality rate for each unit was calculated by adjusting for various prognostic factors at the time of birth or admission in the participating unit. Among 1345 neonates [mean birth weight: 1168 ± 240g, median gestation: 30wk (IQR: 28-32)] enrolled in the study 199 (14.8%) died before hospital discharge. Although variation in inter-hospital SNMR was statistically insignificant (P 0.49), 95% CI of SNMR of most hospitals was broad reaching level of clinical significance on both sides of line of equivalence. This indicates the need to establish an ongoing quality-improvement collaborative network to identify and adopt clinical practices associated with decreased mortality.

Risk Assessment of Adverse Birth Outcomes in Relation to Maternal Age

BACKGROUND

Although a number of studies have investigated correlations of maternal age with birth outcomes, an extensive assessment using age as a continuous variable is lacking. In the current study, we estimated age-specific risks of adverse birth outcomes in childbearing women.

METHOD

National population-based data containing maternal and neonatal information were derived from the Health Promotion Administration, Taiwan. A composite adverse birth outcome was defined as at least anyone of stillbirth, preterm birth, low birth weight, macrosomia, neonatal death, congenital anomaly, and small for gestational age (SGA). Singletons were further analyzed for outcomes of live birth in relation to each year of maternal age. A log-binomial model was used to adjust for possible confounders of maternal and neonatal factors.

RESULTS

In total, 2,123,751 births between 2001 and 2010 were utilized in the analysis. The risk of a composite adverse birth outcome was significantly higher at extreme maternal ages. In specific, risks of stillbirth, neonatal death, preterm birth, congenital anomaly, and low birth weight were higher at the extremes of maternal age. Furthermore, risk of macrosomia rose proportionally with an increasing maternal age. In contrast, risk of SGA declined proportionally with an increasing maternal age. The log-binomial model showed greater risks at the maternal ages of <26 and > 30 years for a composite adverse birth outcome.

CONCLUSIONS

Infants born to teenagers and women at advanced age possess greater risks for stillbirth, preterm birth, neonatal death, congenital anomaly, and low birth weight. Pregnancies at advanced age carry an additional risk for macrosomia, while teenage pregnancies carry an additional risk for SGA. The data suggest that the optimal maternal ages to minimize adverse birth outcomes are 26∼30 years.

Clinical outcome and cost of treatment and care for neonates less than 1000 grams admitted to Vali-e ASR Hospital

BACKGROUND

The aim of this study is to estimate the cost of care and treatment for extremely low birth weight (ELBW) neonates admitted to a teaching and referral hospital. This cost estimation project can help health policy makers and planners make decisions and develop plans for perinatal service staging programs and better management of NICUs (Neonatal Intensive Care Units).

METHODS

This cohort study performed on 50 extremely low birth weight neonates (w ≤ 1000gr) born in Vali-e Asr Hospital, Tehran-Iran in the period of March 2012 to September 2013. This teaching and referral hospital had 15 NICU beds as well as an active neonatal growth and development follow-up clinic with a pediatric neurodevelopment specialist during the period of the study. Cases would undergo initial developmental visits and preventative measures immediately after being admitted to the ward. Also after discharge, they were followed up monthly for six months and then every two months, during first year of life.

RESULTS

Overalls, 23 newborns -46% of ELBW and 40% of total neonatal mortality rate (that amounted 55) died during hospital stay. Beside hospitalization, the major part of expenses was related to medication and medical supplies. All neonates needing rehabilitation underwent this type of intervention for one year. The mean cost of rehabilitation in neonates with no insurance coverage was 6700 US Dollars per year, which is reduced by half (3350 US Dollars) when covered by insurance.

CONCLUSION

Medication, medical supplies and equipment cost was significantly high. This is especially due to the fact that the present types of insurances do not cover such expenses very well, forcing parents to pay themselves. Insurance systems are expected to take this issue into immediate account.

Mortality and morbidity in extremely low birth weight (ELBW) infants in a neonatal intensive care unit

OBJECTIVE

To determine the morbidity and mortality in ELBW babies till discharge from a Neonatal Intensive Care Unit (NICU).

METHODS

This study was a prospective observational study conducted in a 40 bed well equipped level III care NICU between 01.12.2006 and 30.04.2008. All ELBW babies admitted during this period were assessed for morbidities and interventions required during NICU stay and for their outcome like survival or death.

RESULTS

The survival rate of 87 ELBW babies admitted during this period was 56.1 %. Pulmonary hemorrhage was the commonest cause of death (25 %) followed by respiratory distress syndrome (22.5 %), intraventricular hemorrhage (22.5 %) and sepsis (20 %). Significantly higher number of non-survivors were <750 g at birth (p = 0.0001) and <28 wk gestation (p = 0.0001). Small for gestational babies had better chances of survival compared to those appropriate for gestational age (p = 0.005). RDS (67.8 %), probable sepsis (62.1 %) and hyperbilirubinemia (59.8 %) were the most frequent morbidities. Conventional ventilation (72.4 %) and nasal CPAP(48.3 %) were the commonest respiratory interventions. Surfactant replacement therapy was required in 47.1 % babies.

CONCLUSIONS

ELBW babies have a major contribution to mortality in a NICU. Babies with birth weight <750 g and gestation <28 wk have poor survival. RDS, pulmonary hemorrhage, IVH and sepsis are the common causes of death while RDS, sepsis and hyperbilirubinemia are the most common morbidities.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.

Stillbirths: why they matter

In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.

Presumed and definite bacteremia in extremely low gestational age newborns

AIM

To explore risk patterns for presumed and definite, early and late neonatal bacteremia.

METHODS

We studied 1106 extremely low gestational age newborns who survived until postnatal day 28. We defined early definite bacteremia as a positive bacterial culture in the first week and definite late bacteremia as a positive bacterial culture in week 2, 3 or 4. Bacteremia was presumed if antibiotics were given for more than 72 h despite negative blood cultures.

RESULTS

Risk patterns did not differ much for presumed and definite bacteremia in the first postnatal month. While maternal and pregnancy characteristics were associated with early bacteremia, neonatal comorbidities, especially NEC, were the main antecedents/correlates of late bacteremia. All four categories of bacteremia were associated with younger gestational age and lower birth weight. Infants with presumed and definite bacteremia had similar distributions of days of ventilation and oxygenation.

CONCLUSION

Definite and presumed late bacteremias have rather similar risk patterns, while those of early and late bacteremia differ appreciably.

Risk factors for low birth weight infants of Hispanic, African American, and White women in Bexar County, Texas

OBJECTIVES

The aim of this study was to compare the risk factors in women who delivered an infant of low birth weight (LBW, <2,500 g) versus women who delivered an infant weighing >2,500 g in a large metropolitan county (Bexar) in South Texas.

DESIGN

An exploratory case comparison design was used to identify factors related to LBW outcomes in women receiving prenatal care.

SAMPLE

The cases were obtained from community hospitals. A stratified random sample was selected from a population of 38,064 infant births, of which 2,910 were identified as LBW. The final sample size was N=321 (<2,500 g, n=151; >or=2,500 g, n=170).

MEASUREMENTS

Dependent variable of infant birth weight; independent variables of maternal age, maternal race/ethnicity, education, smoking, prior pregnancy history, timing of and number of prenatal visits, prepregnancy body mass index and weight gain during pregnancy, and past medical history and medical problems during pregnancy.

RESULTS

Independent variables found to be predictive of LBW in this study included maternal race/ethnicity, timing of first prenatal visit, number of prenatal visits, prior pregnancy history, and maternal weight gain.

CONCLUSIONS

This study confirmed previous findings that African American women are at a higher risk for LBW deliveries and demonstrated that Anglo and Hispanic women have similar rates of LBW deliveries.

Histochemical and immunohistochemical study of the glomerular development in human fetuses

Few studies exist that establish the normal morphological patterns of glomerular development, though this is one of the organs that continues to evolve morphologically during the postnatal period up to 4 weeks after birth. In our study one kidney from each autopsy of a total of 86 autopsies was analyzed [15 weeks to 40 weeks of gestational age (GA)]. We examined the variation in the nephrogenic zone thickness, the area and diameter of the glomerular tuft, the area and diameter of the glomerular capsule, and the immunohistochemical markers, anti-CD31 and anti-CD34 antibodies, which accompany the development of the glomerular microvasculature. Periodic acid-methenamine silver (PAMS) stain was used for the morphological and morphometrical analyses, and it was particularly useful in fetuses in which autolysis had occurred. The length of the nephrogenic zone (NZ) decreased with the increase of the GA (P < 0.001) according to the formula: GA = 36.5 - (0.05 x length of NZ). The areas of the Bowman capsule (P < 0.0001), the capillary tuft (P < 0.0001), and the capillary tuft diameter (P = 0.00393) of the intermediary glomeruli increased with the advance of GA, with a positive significant correlation. The same parameters of the juxtamedullary and superficial glomeruli had no correlation with the advance of GA. The cells of the primary structures in the "S" shape of the primitive nephrons were negative for CD31 and CD34. Staining for both antibodies was found, for all GAs, in the endothelial cells of the mature glomeruli tuft and in the renal interstitial vessels. The data obtained in this work contribute to the evaluation of renal maturity in autopsied fetuses and are particularly important in fetuses when autolysis has occurred, to which the parameters used in this study can also be applied. The establishment of normal morphometric and immunohistochemical parameters for the evaluation of renal maturity increases the diagnostic precision of renal pathological alterations in aborted material and perinatal autopsy.