Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial

Importance

Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival.

Objective

To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia.

Design, Setting, and Participants

Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies.

Exposure

Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age.

Main Outcomes and Measures

The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement.

Results

The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks).

Conclusions and Relevance

Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden.

Trial Registration

ClinicalTrials.gov Identifier: NCT03101891.

Prenatal Intravenous Magnesium at 30-34 Weeks' Gestation and Neurodevelopmental Outcomes in Offspring: The MAGENTA Randomized Clinical Trial

Importance

Intravenous magnesium sulfate administered to pregnant individuals before birth at less than 30 weeks' gestation reduces the risk of death and cerebral palsy in their children. The effects at later gestational ages are unclear.

Objective

To determine whether administration of magnesium sulfate at 30 to 34 weeks' gestation reduces death or cerebral palsy at 2 years.

Design, Setting, and Participants

This randomized clinical trial enrolled pregnant individuals expected to deliver at 30 to 34 weeks' gestation and was conducted at 24 Australian and New Zealand hospitals between January 2012 and April 2018.

Intervention

Intravenous magnesium sulfate (4 g) was compared with placebo.

Main Outcomes and Measures

The primary outcome was death (stillbirth, death of a live-born infant before hospital discharge, or death after hospital discharge before 2 years' corrected age) or cerebral palsy (loss of motor function and abnormalities of muscle tone and power assessed by a pediatrician) at 2 years' corrected age. There were 36 secondary outcomes that assessed the health of the pregnant individual, infant, and child.

Results

Of the 1433 pregnant individuals enrolled (mean age, 30.6 [SD, 6.6] years; 46 [3.2%] self-identified as Aboriginal or Torres Strait Islander, 237 [16.5%] as Asian, 82 [5.7%] as Māori, 61 [4.3%] as Pacific, and 966 [67.4%] as White) and their 1679 infants, 1365 (81%) offspring (691 in the magnesium group and 674 in the placebo group) were included in the primary outcome analysis. Death or cerebral palsy at 2 years' corrected age was not significantly different between the magnesium and placebo groups (3.3% [23 of 691 children] vs 2.7% [18 of 674 children], respectively; risk difference, 0.61% [95% CI, -1.27% to 2.50%]; adjusted relative risk [RR], 1.19 [95% CI, 0.65 to 2.18]). Components of the primary outcome did not differ between groups. Neonates in the magnesium group were less likely to have respiratory distress syndrome vs the placebo group (34% [294 of 858] vs 41% [334 of 821], respectively; adjusted RR, 0.85 [95% CI, 0.76 to 0.95]) and chronic lung disease (5.6% [48 of 858] vs 8.2% [67 of 821]; adjusted RR, 0.69 [95% CI, 0.48 to 0.99]) during the birth hospitalization. No serious adverse events occurred; however, adverse events were more likely in pregnant individuals who received magnesium vs placebo (77% [531 of 690] vs 20% [136 of 667], respectively; adjusted RR, 3.76 [95% CI, 3.22 to 4.39]). Fewer pregnant individuals in the magnesium group had a cesarean delivery vs the placebo group (56% [406 of 729] vs 61% [427 of 704], respectively; adjusted RR, 0.91 [95% CI, 0.84 to 0.99]), although more in the magnesium group had a major postpartum hemorrhage (3.4% [25 of 729] vs 1.7% [12 of 704] in the placebo group; adjusted RR, 1.98 [95% CI, 1.01 to 3.91]).

Conclusions and Relevance

Administration of intravenous magnesium sulfate prior to preterm birth at 30 to 34 weeks' gestation did not improve child survival free of cerebral palsy at 2 years, although the study had limited power to detect small between-group differences.

Trial Registration

anzctr.org.au Identifier: ACTRN12611000491965.

Intraventricular Hemorrhage in Very Preterm Children: Mortality and Neurodevelopment at Age 5

OBJECTIVES

The objectives were to describe mortality and causes of death in children with intraventricular hemorrhage (IVH) and to study neurodevelopmental outcomes.

METHODS

The study was a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. Children were recruited in 2011. A standardized assessment was conducted at age 5. Children born before 32 weeks' gestation and admitted to a NICU were eligible. Exposure was IVH defined by the Papile classification. Main outcomes were mortality, causes of death, and neurodevelopmental outcomes at age 5.

RESULTS

Among the 3468 children included, 578 (16.7%) had grade 1 IVH, 424 (12.2%) grade 2 IVH, and 114 (3.3%) grade 3 IVH; 144 (4.1%) had intraparenchymal hemorrhage (IPH). Mortality was 29.7% (36 of 114) for children with grade 3 IVH and 74.4% (109 of 144) for those with IPH; 67.6% (21 of 31) and 88.7% (86 of 97) of deaths, respectively, were because of withholding and withdrawing of life-sustaining treatment. As compared with no IVH, low-grade IVH was not associated with measured neurodevelopmental disabilities at age 5. High-grade IVH was associated with moderate and severe neurodevelopmental disabilities, reduced full-scale IQ, and cerebral palsy.

CONCLUSIONS

Rates of neurodevelopmental disabilities at age 5 did not differ between children without IVH and those with low-grade IVH. For high-grade IVH, mortality rate was high, mostly because of withholding and withdrawal of life-sustaining treatment, and we found a strong association with overall neurodevelopmental disabilities in survivors.

Preterm neonatal mortality in China during 2009-2018: A retrospective study

In this retrospective analysis, we aimed to analyze the epidemic characteristics of neonatal mortality due to preterm birth at 28-36 weeks gestation in different regions from 2009 to 2018. Data were obtained from China's Under-5 Child Mortality Surveillance System (U5CMSS). The χ2 trend test, Poisson regression and the Cochran-Mantel-Haenszel method were used in this study. We found that 51.3%, 42.0% and 44.5% of neonate deaths were preterm infants, and immaturity was mainly attributed to 60.1%, 64.1% and 69.5% of these deaths, in the eastern, central and western regions, respectively. The preterm neonatal mortality rate due to immaturity dropped from 149.2, 216.5 and 339.5 in 2009 to 47.4, 83.8 and 170.1 per 100 000 live births in 2018, giving an average annual decline rate of 12.1%, 11.6% and 6.3% in the eastern, central and western regions, respectively, during the studying period. The relative risk of preterm neonatal mortality due to immaturity were 1.3 and 2.3 for the central regions and western regions in 2009-2010, ascending to 2.2 and 3.9 in 2017-2018. The proportion of preterm neonatal deaths with a gestational age <32 weeks was highest among the eastern region. There were significantly more preterm neonatal infants who were not delivered at medical institutions in the western region than in the eastern and central regions. The preterm infant, especially with gestational age <32 weeks, should receive the most attention through enhanced policies and programs to improve child survival. Priority interventions should be region-specific, depending on the availability of economic and healthcare resources.

Incidence, associated risk factors, and the ideal mode of delivery following preterm labour between 24 to 28 weeks of gestation in a low resource setting

BACKGROUND

Preterm labour, between 24 to 28 weeks of gestation, remains prevalent in low resource settings. There is evidence of improved survival after 24 weeks though the ideal mode of delivery remains unclear. There are no clear management protocols to guide patient management. We sought to determine the incidence of preterm labour occurring between 24 to 28 weeks, its associated risk factors and the preferred mode of delivery in a low resource setting with the aim of streamlining patient care.

METHODS

Between February 2020 and September 2020, we prospectively followed 392 women with preterm labour between 24 to 28 weeks of gestation and their newborns from admission to discharge at Kawempe National Referral hospital in Kampala, Uganda. The primary outcome was perinatal mortality associated with the different modes of delivery. Secondary outcomes included neonatal and maternal infections, admission to the Neonatal Special Care Unit (SCU), need for neonatal resuscitation, preterm birth and maternal death. Chi-square test was used to assess the association between perinatal mortality and categorical variables such as parity, mode of delivery, employment status, age, antepartum hemorrhage, digital vaginal examination, and admission to Special Care unit. Multivariate logistic regression was used to assess the association between comparative outcomes of the different modes of delivery and maternal and neonatal risk factors.

RESULTS

The incidence of preterm labour among women who delivered preterm babies between 24 to 28 weeks was 68.9% 95% CI 64.2-73.4). Preterm deliveries between 24 to 28 weeks contributed 20% of the all preterm deliveries and 2.5% of the total hospital deliveries. Preterm labour was independently associated with gravidity (p-value = 0.038), whether labour was medically induced (p-value <0.001), number of digital examinations (p-value <0.001), history of vaginal bleeding prior to onset of labour (p-value < 0.001), whether tocolytics were given (p-value < 0.001), whether an obstetric ultrasound scan was done (p-value <0.001 and number of babies carried (p-value < 0.001). At multivariate analysis; multiple pregnancy OR 15.45 (2.00-119.53), p-value < 0.001, presence of fever prior to admission OR 4.03 (95% CI .23-13.23), p-value = 0.002 and duration of drainage of liquor OR 0.16 (0.03-0.87), p-value = 0.034 were independently associated with preterm labour. The perinatal mortality rate in our study was 778 per 1000 live births. Of the 392 participants, 359 (91.5%), had vaginal delivery, 29 (7.3%) underwent Caesarean delivery and 4 (1%) had assisted vaginal delivery. Caesarean delivery was protective against perinatal mortality compared to vaginal delivery OR = 0.36, 95% CI 0.14-0.82, p-value = 0.017). The other protective factors included receiving antenatal corticosteroids OR = 0.57, 95% CI 0.33-0.98, p-value = 0.040, Doing 3-4 digital exams per day, OR = 0.41, 95% 0.18-0.91, p-value = 0.028) and hospital stay of > 7 days, p value = 0.001. Vaginal delivery was associated with maternal infections, postpartum hemorrhage, and admission to the Special Care Unit.

CONCLUSION

Caesarean delivery is the preferred mode of delivery for preterm deliveries between 24 to 28 weeks of gestation especially when labour is not established in low resource settings. It is associated with lesser adverse pregnancy outcomes when compared to vaginal delivery for remote gestation ages.

Bias in comparisons of mortality among very preterm births: A cohort study

BACKGROUND

Several studies of prenatal determinants and neonatal morbidity and mortality among very preterm births have resulted in unexpected and paradoxical findings. We aimed to compare perinatal death rates among cohorts of very preterm births (24-31 weeks) with rates among all births in these groups (≥24 weeks), using births-based and fetuses-at-risk formulations.

METHODS

We conducted a cohort study of singleton live births and stillbirths ≥24 weeks' gestation using population-based data from the United States and Canada (2006-2015). We contrasted rates of perinatal death between women with or without hypertensive disorders, between maternal races, and between births in Canada vs the United States.

RESULTS

Births-based perinatal death rates at 24-31 weeks were lower among hypertensive than among non-hypertensive women (rate ratio [RR] 0.67, 95% CI 0.65-0.68), among Black mothers compared with White mothers (RR 0.94, 95%CI 0.92-0.95) and among births in the United States compared with Canada (RR 0.74, 95%CI 0.71-0.75). However, overall (≥24 weeks) perinatal death rates were higher among births to hypertensive vs non-hypertensive women (RR 2.14, 95%CI 2.10-2.17), Black vs White mothers (RR 1.86, 95%CI 184-1.88;) and births in the United States vs Canada (RR 1.08, 95%CI 1.05-1.10), as were perinatal death rates based on fetuses-at-risk at 24-31 weeks (RR for hypertensive disorders: 2.58, 95%CI 2.53-2.63; RR for Black vs White ethnicity: 2.29, 95%CI 2.25-2.32; RR for United States vs Canada: 1.27, 95%CI 1.22-1.30).

CONCLUSION

Studies of prenatal risk factors and between-centre or between-country comparisons of perinatal mortality bias causal inferences when restricted to truncated cohorts of very preterm births.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Purpose

Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods

Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I² statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings

The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).

Interpretation

RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

Prevalence of common symptoms of neonatal illness in Northwest Ethiopia: A repeated measure cross-sectional study

BACKGROUND

The neonatal period is the most vulnerable stage of life. In Ethiopia, neonatal illness is common and the reduction in neonatal mortality is not as significant as for under-five mortality.

OBJECTIVES

To determine the prevalence and factors associated with neonatal illness symptoms reported by mothers delivering in health facilities in Northwest Ethiopia.

METHODS

A repeated measure cross-sectional study design was employed to collect data from 358 randomly selected deliveries in 11 health facilities from November 2018 to March 2019. A pretested and interviewer-administered structured questionnaire adapted from the literature was employed to record neonatal outcomes (illnesses and/or deaths) at birth, 24 hours, 7th, 14th and 28th day from birth. Cleaned data was exported to STATA version 14 software for analysis. Multilevel analysis was used to identify individual and facility-level characteristics associated with neonatal illness symptoms.

RESULTS

The prevalence of neonatal illness symptoms was 27.8% (95% CI; 23.2, 32.8) of the 338 babies born alive and the neonatal mortality rate was 41/1000 live births (14/338). The most common symptoms or conditions of neonatal illness reported by mothers' in the study area were possible serious bacterial infections (95.8%, 90/94), localized bacterial infections (43.6%, 41/94), low birth weight (23.4%, 22/94), diarrhea (18.1%, 17/94), prematurity (14.9%, 14/94), and jaundice (7.5%, 7/94). Among the babies who died, neonates who had possible serious bacterial infections, low birth weight, localized bacterial infections, and prematurity took the highest proportions with 100% (14/14), 64.3% (9/14), 50% (7/14), and 42.9% (6/14), respectively. Having a maximum of 3 children (AOR = 1.96; 95% CI = 1.1-3.6), having twins or triplets during pregnancy (AOR = 2.43; 95% CI = 1.1-6.1), and lack of antenatal counseling (AOR = 1.83; 95% CI = 1.1-3.3) were among the maternal factors associated with neonatal illness. Having low birth length (AOR = 7.93; 95% CI = 3.6-17.3), and having a poor breastfeeding quality (AOR = 2.37; 95% CI = 1.4-4.0) were found to be the neonatal factors associated with neonatal illness.

CONCLUSIONS

This study indicated a high prevalence of neonatal illness symptoms in Northwest Ethiopia. Therefore, early detection, referral and better management of symptoms or conditions with a high mortality, like sepsis and low birth weight are compulsory to save the lives of many neonates. Strengthening the health extension programme to improve antenatal care service utilization and breastfeeding quality of neonates among postpartum women is crucial.

Factors associated with neonatal mortality in a tertiary hospital in Phnom Penh, Cambodia

This study aimed to identify hospital neonatal mortality rate (NMR) and the causes of neonatal deaths, and to understand risk factors associated with neonatal mortality in a national tertiary hospital in Cambodia. The study included all newborn infants, aged 0-28 days old, hospitalized in the Pediatrics department of Khmer-Soviet Friendship Hospital between January 2016 and December 2017. In total, 925 infants were included in the study. The mean gestational age was 35.9 weeks (range, 24-42 weeks). Preterm infants and low birth weight accounted for 47.5% and 56.7%, respectively. With respect to payment methods, the government (53.5%) and non-governmental organizations (NGO) (13.7%) paid the fees as the families were not in a financial position to do so. The hospital NMR at the Pediatrics department was 9.3%. Respiratory distress syndrome (37.2%) was the main cause of deaths followed by hypoxic-ischemic encephalopathy (31.4%) and neonatal infection (21.0%). Factors associated with neonatal mortality were Apgar score at 5th minute <7 (adjusted odds ratio (AOR) = 3.57), payment by the government or NGO (AOR = 11.32), admission due to respiratory distress (AOR = 11.94), and hypothermia on admission (AOR = 9.41). The hospital NMR in the Pediatrics department was 9.3% (95% confidence interval 7.50-11.35) at Khmer-Soviet Friendship Hospital; prematurity and respiratory distress syndrome were the major causes of neonatal mortality. Introducing continuous positive airway pressure machine for respiratory distress syndrome and creating neonatal resuscitation guidelines and preventing hypothermia in delivery rooms are required to reduce the high NMR.

Mortality Among Young Adults Born Preterm and Early Term in 4 Nordic Nations

IMPORTANCE

Adverse long-term outcomes in individuals born before full gestation are not confined to individuals born at extreme gestational ages. Little is known regarding mortality patterns among individuals born in the weeks close to ideal gestation, and the exact causes are not well understood; both of these are crucial for public health, with the potential for modification of risk.

OBJECTIVE

To examine the risk of all-cause and noncommunicable diseases (NCD) deaths among young adults born preterm and early term.

DESIGN, SETTING, AND PARTICIPANTS

This multinational population-based cohort study used nationwide birth cohorts from Norway, Sweden, Denmark, and Finland for individuals born between 1967 and 2002. Individuals identified at birth who had not died or emigrated were followed up for mortality from age 15 years to 2017. Analyses were performed from June 2019 to May 2020.

EXPOSURES

Categories of gestational age (ie, moderate preterm birth and earlier [23-33 weeks], late preterm [34-36 weeks], early term [37-38 weeks], full term [39-41 weeks] and post term [42-44 weeks]).

MAIN OUTCOMES AND MEASURES

All-cause mortality and cause-specific mortality from NCD, defined as cancer, diabetes, chronic lung disease, and cardiovascular disease (CVD).

RESULTS

A total of 6 263 286 individuals were followed up for mortality from age 15 years. Overall, 339 403 (5.4%) were born preterm, and 3 049 100 (48.7%) were women. Compared with full-term birth, the adjusted hazard ratios (aHRs) for all-cause mortality were 1.44 (95% CI, 1.34-1.55) for moderate preterm birth and earlier; 1.23 (95% CI, 1.18-1.29) for late preterm birth; and 1.12 (95% CI, 1.09-1.15) for early-term birth. The association between gestational age and all-cause mortality were stronger in women than in men (P for interaction = .03). Preterm birth was associated with 2-fold increased risks of death from CVD (aHR, 1.89; 95% CI, 1.45-2.47), diabetes (aHR, 1.98; 95% CI, 1.44-2.73), and chronic lung disease (aHR, 2.28; 95% CI, 1.36-3.82). The main associations were replicated across countries and could not be explained by familial or individual confounding factors.

CONCLUSIONS AND RELEVANCE

The findings of this study strengthen the evidence of increased risk of death from NCDs in young adults born preterm. Importantly, the increased death risk was found across gestational ages up to the ideal term date and includes the much larger group with early-term birth. Excess mortality associated with shorter gestational age was most pronounced for CVDs, chronic lung disease, and diabetes.

Postpartum hemorrhage in Suriname: A national descriptive study of hospital births and an audit of case management

Background

Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction.

Methods

A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline.

Results

In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3–3.3], Creole aOR 1.8[95%CI 1.1–3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7–7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7–3.4]), cesarean section (aOR 3.9[95%CI 2.9–5.3]), stillbirth (aOR 6.4 [95%CI 3.4–12.2]), preterm birth (aOR 2.1[95%CI 1.3–3.2]), and macrosomia (aOR 2.8 [95%CI 1.5–5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]).

Conclusions

PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.

Mortality Rate and Major Causes of Death by Gestational Age in Korean Children under 5 Years of Age

BACKGROUND

Preterm birth is associated with increased infant mortality. However, it is not clear whether prematurity is associated with mortality after 1 year of age. There is a lack of research on mortality rate and causes of death after infancy in preterm babies in Korea. We aimed to analyze the mortality rates and causes of deaths up to 5 years of age in Korea.

METHODS

Using the Microdata Integrated Service of Statistics Korea database, this retrospective cohort study screened infants born between 2010 and 2012. After applying the exclusion criteria, 1,422,913 live births were classified into the following groups by gestational age: those born at < 32 weeks' gestation (n = 10,411), those born between 32 and 36 weeks' gestation (n = 75,657), and those born at ≥ 37 weeks' gestation (n = 1,336,845). The association of gestational age with mortality in infancy (< 1 year of age) and childhood (1-5 years of age) was analyzed, with and without covariates. The major causes of death in infancy and childhood were analyzed by gestational age.

RESULTS

Overall, 4,930 (0.3%) children died between birth and 5 years of age, with 19.1% of these deaths occurring after infancy. Adjusted hazard ratios (HRs) for infant death were 78.79 (95% confidence interval [CI], 71.33-87.04) and 4.62 (95% CI, 4.07-5.24) for the < 32 and 32-36 weeks groups, respectively, compared to the full-term group; the adjusted HRs for deaths occurring at ages 1-5 years were 9.25 (95% CI, 6.85-12.50) and 2.42 (95% CI, 1.95-3.01), respectively. In infancy, conditions originating in the perinatal period were the most common cause of deaths in the < 32 and 32-36 weeks groups (88.7% and 41.9%, respectively). Contrarily, in the ≥ 37 weeks group, conditions originating in the perinatal period explained 22.7% of infant deaths, with congenital malformations primarily accounting for 29.6% of these deaths. The most common cause of death in children (after infancy) in the < 32 weeks group was perinatal causes (25.0%); in the 32-36 weeks group, congenital malformation and nervous system disease were the common causes (21.7% and 19.1%, respectively). In the ≥ 37 weeks group, injury, poisoning, and other consequences of external causes explained 26.6% of childhood deaths, followed by neoplasms and nervous system disease (15.7% and 14.7%, respectively).

CONCLUSION

Low gestational age is associated with not only infant mortality but also child mortality. The major causes of death differed by gestational age in infancy and childhood. For the care of preterm infants, especially those born at < 32 weeks' gestation, particular attention and continuous monitoring are needed in consideration of the major causes of deaths until 5 years of age.

Mortality, morbidity and clinical care in a referral neonatal intensive care unit in Haiti

Background

Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU.

Methods

A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017.

Results

220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia.

Conclusions

This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti.

Importance Of Clinical Risk Index For Babies Score For Predicting Mortality Among Neonates

BACKGROUND

High mortality among premature and very low birth weight (VLBW) babies necessitates the need to formulate and use scoring systems like CRIB score to predict the mortality in this vulnerable group. Objective of the study was to determine the strength of Clinical Risk Index For Babies (CRIB) score in detecting neonatal mortality in babies presenting with very low birth weight so that timely intervention can be done. It was a cross-sectional study, conducted at NICU, Children Hospital, Pakistan Institute of Medical Sciences Islamabad (PIMS) in nine months starting from First July 2017.

METHODS

A total of two hundred and fifty-four (n=254) new-borns with birth weight of between 500-1500 grams and gestational age lesser than 35 weeks were included in the study. CRIB score was calculated in all neonates and its association was assessed with mortality during NICU stay. Recorded data was analysed for demographic variables. Means and standard deviation was calculated for numeric variables. Chi-square test was applied to find p-value for the correlation between the main variables.

RESULTS

54.3% (n=138) patients were males and 45.7% (n=116) were females. Mean gestational age was 33.3 weeks±1.04 SD and mean birth weight of study population was 1129.9 grams±210.6 SD. Mean CRIB score among the study population was 6.3±3.1SD and overall mortality was found to be 54.7% (n=139). Mean CRIB score was found to be 8.27±2.1 SD among mortality group and it was 3.87±3.4 SD among newborns who were discharged (p<0.05). Mortality was present in 4.3% (n=4) of neonates with CRIB score between 1 to 5, 87.1% (n=121) who had CRIB score between 6 to 10 and 100% (n=14) of neonates who had CRIB score level 11-15 (p<0.05), so a significantly higher percentage mortality was noted among neonates with higher CRIB scores.

CONCLUSIONS

According to our study mean CRIB score is a significant predictor of neonatal mortality.

Prevalence and associated factors of preterm birth in Ethiopia: systematic review and meta-analysis protocol

INTRODUCTION

Preterm birth (PTB) complications are the leading cause of death among neonates globally. The reduction in neonatal mortality is not remarkable in Ethiopia. Therefore, this review will assess the magnitude and associated factors of PTB in Ethiopia.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline will be followed during the systematic review. We will include all observational studies published from 1 January 2009 to 31 December 2019 that examined the level and/or associated factors of any type of PTB among live births in Ethiopia. Inclusion criteria will be all live births, PTB defined as delivery before 37 weeks gestation. The primary outcome will be PTB <37 weeks, and secondary outcomes including PTB <34, <32 and <28 weeks will be analysed. PubMed and Science Direct databases as well as Google search engine and Google Scholar will be searched. The pooled prevalence of preterm and effect size of association for associated factors will be analysed using the Stata software V.14. The heterogeneity between studies will be measured by I2 statistics. A random-effects model will be used to estimate if heterogeneity detected. Publication bias will be assessed using a funnel plot. Subgroup analysis will be sought based on possible characteristics of the studies, specific morbidity (like pre-eclampsia, hypertension), type of PTB (spontaneous or iotrogenic) and quality of study (high-quality or low-risk). Meta-regression will be considered for major covariates (maternal age and maternal body mass index) related to PTB. Forest plots will be used to present the combined estimate with 95% CIs. The quality of evidence of the outcomes will be assessed with the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach.

ETHICS AND DISSEMINATION

No ethical approval is necessary for this systematic review. The findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017077356.

Outcomes after transabdominal cerclage in twin pregnancy with previous unsuccessful transvaginal cerclage

Transabdominal cerclage (TAC) is reported to be effective for preventing preterm birth in women with unsuccessful transvaginal cerclage (TVC) history. However, TAC has rarely been performed in twin pregnancy given the lack of sufficient evidence and the technical difficulty of the operation. Thus, it is unclear whether TAC is an effective procedure for twin pregnancy in women with a history of unsuccessful TVC. The aim of this study is to compare the characteristics and pregnancy outcomes after TAC in twin pregnancy versus singleton pregnancy, to examine whether twin pregnancy is a risk factor for very preterm birth (before 32 weeks) after TAC, and to determine whether TAC is effective in preventing preterm birth in twin pregnancy. This single-center retrospective cohort study included women who underwent TAC because of unsuccessful TVC history between January 2007 and June 2018. Of 165 women who underwent TAC, 19 had twins and 146 had singletons. Our results showed that the neonatal survival rate improved dramatically when TAC was performed (15.4% (prior pregnancy) vs 94.0% (after TAC) in twins, p<0.01; 22.8% (prior pregnancy) vs 91.1% (after TAC) in singletons, p<0.01). Moreover, the risk of very preterm birth was significantly decreased after TAC in both groups (36/39 (92.3%) (prior pregnancy) vs 2/19 (10.5%) (after TAC) in twins, p<0.01; 290/337 (86.1%) (prior pregnancy) vs 17/146 (11.6%) (after TAC) in singletons, p<0.01). More advanced maternal age and history of prior preterm delivery between 26+0 and 36+6 weeks were independently associated with very preterm birth, whereas the presence of a twin pregnancy was not associated with very preterm birth on multivariate logistic regression analysis. These results suggest that TAC is associated with successful prevention of very preterm birth and improved neonatal survival rates in the absence of procedure-related major complications in women with twin pregnancy and previous unsuccessful TVC history.

Effect of delayed interval delivery of remaining fetus(es) in multiple pregnancies on survival: a systematic review and meta-analysis

BACKGROUND

The management of the pregnancy after delivery of the first fetus during a second-trimester miscarriage or very early preterm birth has not been well defined.

OBJECTIVE

The objective of the study was to evaluate whether delayed interval delivery of the remaining fetus(es) in twins/triplets is associated with improved survival, when compared with immediate delivery, after miscarriage or very preterm birth of the first fetus in multiple pregnancy.

DATA SOURCES

PubMed, MEDLINE, and Cochrane Library were systematically searched through January 2019. STUDY ELIGIBILITY CRITERIA (STUDY DESIGN, POPULATIONS, AND INTERVENTIONS): The following eligibility criteria applied: full-text original article; included at least 5 cases of delayed interval delivery for remaining fetus(es); and reported the survival rate of the first-born and the remaining fetus(es).

STUDY APPRAISAL AND SYNTHESIS METHODS

K.W.C. and W.W. searched, screened, and reviewed the articles. The quality of the studies was assessed according to the Strengthening the Reporting of Observational studies in Epidemiology checklist. If possible, data were stratified for assigned chorionicity. Effect sizes were pooled through a meta-analysis.

RESULTS

A total of 2295 published article and abstracts were identified. Only 16 studies met inclusion criteria. Meta-analysis of 492 pregnancies (432 twins [88%], 56 triplets [11%], 3 quadruplets and 1 quintuplets) showed that delayed interval delivery significantly improved the perinatal survival of remaining fetus(es) compared with the first born (odds ratio, 5.22, 95% confidence interval, 2.95-9.25, I² = 53%), before 20+0 weeks (odds ratio, 6.32, 95% confidence interval, 1.99-20.13, I² = 0%), between 20+0 and 23+6 weeks (odds ratio, 3.31, 95% confidence interval, 1.95-5.63, I² = 0%), and after 24+0 weeks (odds ratio, 1.92, 95% confidence interval, 1.21-3.05, I² = 0%), in dichorionic twin pregnancy (odds ratio, 14.89, 95% confidence interval, 6.19-35.84, I² = 0%), and unselected triplet pregnancy (odds ratio, 2.33, 95% confidence interval, 1.02-5.32, I² = 0%. ). Among the survivors, there were no significant differences in the short-term and long-term neonatal morbidities between the first-born and the remaining fetus(es). Serious maternal morbidity was reported in 39% of pregnancy after delayed interval delivery (71 of 183). In addition, 2 cases were managed by postpartum hysterectomy and 1 reported postoperative uterovaginal fistula. There were no recorded cases of maternal mortality.

CONCLUSION

Delayed interval delivery when a fetus has delivered in a multiple pregnancy is an effective management option to increase the survival rate of the remaining fetus(es). About 39% of women may experience morbidity following this management option.

Patterns of antenatal corticosteroid administration in a cohort of women with diabetes in pregnancy

Antenatal corticosteroids administered to the mother prior to birth decrease the risk of mortality and major morbidity in infants born at less than 35 weeks’ gestation. However, the evidence relating to women with diabetes in pregnancy is limited. Clinical guidelines for antenatal corticosteroid administration recommend that women with diabetes in pregnancy are treated in the same way as women without diabetes, but there are no recent descriptions of whether contemporary practice complies with this guidance. This study is a retrospective review of antenatal corticosteroid administration at a New Zealand tertiary hospital in women with diabetes in pregnancy. We found that in this cohort, for both an initial course at less than 35 weeks’ gestation and repeat courses at less than 33 weeks’, the administration of antenatal corticosteroid to women with diabetes in pregnancy is largely consistent with current Australian and New Zealand recommendations. However, almost 25% of women received their last dose of antenatal corticosteroid at or beyond the latest recommended gestation of 35 weeks’ gestation. Pre-existing diabetes and planned caesarean section were independently associated with an increased rate of antenatal corticosteroid administration. We conclude that diabetes in pregnancy does not appear to be a deterrent to antenatal corticosteroid administration. The high rates of administration at gestations beyond recommendations, despite the lack of evidence of benefit in this group of women, highlights the need for further research into the risks and benefits of antenatal corticosteroid administration to women with diabetes in pregnancy, particularly in the late preterm and early term periods.

Underlying Causes and Distribution of Infant Mortality in a Statewide Assessment from 2005 to 2016 by Infant, Maternal, and Neighborhood Characteristics

BACKGROUND

We aimed to explore the leading causes and risk factors for infant mortality in a statewide study of infant deaths from 2005 to 2016.

METHODS

Rhode Island Vital Statistics was linked with KIDSNET, a statewide-integrated child health information system. Descriptive analyses examined infant mortality rates as well as risk factors of infant, neonatal, and postneonatal death. A multivariable logistic regression model of the risk of infant mortality adjusting for risk factors was computed.

RESULTS

The majority (74%) of infant deaths occurred during the neonatal period. The top cause of infant mortality was prematurity (20.4%). After adjustment, infants born <28 weeks had 38.1 higher odds of mortality compared to term infants (p<0.01). Low 5-minute Apgar score, birth defects, less than 10 prenatal visits, and low maternal weight gain were associated with higher odds of infant mortality (p<0.01).

DISCUSSION

Substantial reductions in the infant mortality rate will require improving strategies to prevent preterm births as well as using factors identifiable at birth to focus prevention efforts on those at higher risk.

[Extremely preterm birth in Sweden - clear progress but remaining challenges]

The recently documented high survival of extremely preterm infants in Sweden is related to a high degree of centralization of pre- and postnatal care and to recently issued national consensus guidelines providing recommendations for perinatal care at 22-24 gestational weeks. The prevalence of major neonatal morbidity remains high and exceeded 60 % in a recent study of extremely preterm infants born at < 27 gestational weeks delivered in Sweden in 2014-2016 and surviving to 1 year of age. Damage to immature organ systems inflicted during the neonatal period causes varying degrees of functional impairment with lasting effects in the growing child. There is an urgent need for evidence-based novel interventions aiming to prevent neonatal morbidity with a subsequent improvement of long-term outcome.

[Born a few weeks too early; does it matter?]

Late and moderately preterm infants, born between 32+0/7 and 36+6/7 gestational weeks, comprise more than 80 % of all preterm infants and account for almost 40 % of all days of neonatal care. While their total number of days of care has not changed, an increasing part of their neonatal stay (from 29 % in 2011 to 41 % in 2017) is now within home care programmes. Late and moderate preterm birth is often complicated by respiratory disorders, hyperbilirubinemia, hypothermia and feeding difficulties. These infants also have an increased risk of perinatal death and neurologic complications. In the long run, they have higher risks of cognitive impairment, neuropsychiatric diagnoses and need for asthma medication. As young adults, they have a lower educational level and a lower average salary than their full-term counterparts. They also have an increased risk of long-term sick leave, disability pension and need for economic assistance from society.

Oxidative stress - Related spontaneous preterm delivery challenges in causality determination, prevention and novel strategies in reduction of the sequelae

Spontaneous preterm birth (PTB) is one of the major complications of pregnancy and the main cause of neonatal mortality and morbidity. Despite the efforts devoted to the understanding of this obstetrical syndrome and improved medical care, there has been a tendency for the PTB rate to increase in the last decades globally. The costs of the screening for spontaneous PTB, its management, and treatment of the sequelae represent a major burden to the health service economy of high-income countries. In this scenario, it has been widely acknowledged that oxidative stress (OS) plays an important role in the pathogenicity of human disease in wide range of areas of medicine. There is an emerging evidence that an imbalance between pro-and-antioxidants may be associated with spontaneous PTB. However, there are still many controversies on the mechanisms by which OS are involved in the pathogenesis of prematurity. Moreover, the crucial question whether the OS is the cause or consequence of the disease is yet to be answered. The purpose of this article is to briefly summarize the current knowledge and controversies on oxidative stress-related spontaneous PTB and to give a critical approach on future perspectives on this topic as a classical example of translational medicine. Placenta-mediated pregnancy adverse outcome associated with OS leading to iatrogenic PTB (e.g. pre-eclampsia, intrauterine growth restriction, gestational diabetes) will not be discussed.

Neonatal Intensive Care Variation in Medicaid-Insured Newborns: A Population-Based Study

OBJECTIVE

To assess the contribution of maternal and newborn characteristics to variation in neonatal intensive care use across regions and hospitals.

STUDY DESIGN

This was a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 2 subcohorts: very low birth weight (VLBW) singletons and late preterm singletons. Crude and risk-adjusted neonatal intensive care unit (NICU) admission rates, intensive and intermediate special care days, and imaging procedures were calculated across Neonatal Intensive Care Regions (n = 21) and hospitals (n = 100). Total Medicaid payments were calculated.

RESULTS

Overall, 11.5% of live born, 91.7% of VLBW, and 37.6% of infants born late preterm were admitted to a NICU, receiving an average of 2 days, 58 days, and 5 days of special care with payments per newborn inpatient episode of $5231, $128 075, and $10 837, respectively. There was little variation across regions and hospitals in VLBW NICU admissions but marked variation for NICU admissions in late preterm newborn infants and for special care days and imaging rates in all cohorts. The variation decreased slightly after health risk adjustment. There was moderate substitution of intermediate for intensive care days across hospitals (Pearson r VLBW -0.63 P < .001; late preterm newborn -0.53 P < .001).

CONCLUSIONS

Across all risk groups, the variation in NICU use was poorly explained by differences in newborn illness levels and is likely to indicate varying practice styles. Although the "right" rates are uncertain, it is unlikely that all of these use patterns represent effective and efficient care.

Evaluating WHO-Recommended Interventions for Preterm Birth: A Mathematical Model of the Potential Reduction of Preterm Mortality in Sub-Saharan Africa

BACKGROUND

Preterm birth, a leading cause of neonatal mortality, has the highest burden in low-income countries. In 2015, the World Health Organization (WHO) published recommendations for interventions to improve preterm outcomes. Our analysis uses the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model to evaluate the potential effects that WHO-recommended interventions could have had on preterm mortality in sub-Saharan Africa in 2015.

METHODS

We modeled preterm birth subconditions causing mortality (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, birth asphyxia, and low birth weight). For each subcondition, models were populated with estimates of WHO-recommended intervention prevalence, case fatality, coverage, and efficacy. Various scenarios modeled improved coverage of single and combined interventions compared with baseline.

RESULTS

In 2015, approximately 500,000 neonatal deaths due to preterm birth occurred in sub-Saharan Africa. Single interventions with the greatest impact on preterm mortality included oxygen/continuous positive airway pressure (44,000 lives saved), cord care (38,500 lives saved), and breastfeeding (30,200 lives saved). Combined with improved diagnosis/transfer to a hospital, the impact of interventions showed greater reductions in mortality (oxygen/continuous positive airway pressure, 134,100 lives saved; antibiotics, 28,600 lives saved). Combined interventions had the greatest impact. Together, hospital delivery with comprehensive care for respiratory distress syndrome saved 190,600 lives, and comprehensive thermal care, breastfeeding, and prevention/treatment for sepsis saved 94,400 lives.

CONCLUSION

In 2015, WHO-recommended interventions could have saved the lives of nearly 300,000 infants born preterm in sub-Saharan Africa. Combined interventions are necessary to maximize impact. Mathematical models such as MANDATE can estimate effects on health outcomes to allow health officials to prioritize implementation strategies.

Group B streptococcal screening, intrapartum antibiotic prophylaxis, and neonatal early-onset infection rates in an Australian local health district: 2006-2016

Background

Intrapartum antibiotic prophylaxis (IAP) to reduce the likelihood of neonatal early-onset group B streptococcal infection (EOGBS) has coincided with major reductions in incidence. While the decline has been largely ascribed to IAP following either universal screening or a risk-based approach to identify mothers whose babies may most benefit from IAP, there is lack of high quality evidence to support this view.

Aims

To describe management of maternal GBS colonisation in one local health district using universal screening and assess rates of EOGBS over time.

Methods

A retrospective cohort study was undertaken to describe compliance with GBS management, to determine the incidence of EOGBS and association between rates and maternal screening. Linking routinely collected maternity and pathology data, we explored temporal trends using logistic regression and covariates for potential effect modifiers.

Results

Our cohort included 62,281 women who had 92,055 pregnancies resulting in 93,584 live born babies. Screening occurred in 76% of pregnancies; 69% had a result recorded, 21.5% of those were positive for GBS. Prophylaxis was used by 79% of this group. Eighteen babies developed EOGBS, estimated incidence/1000 live births in 2006 and 2016 was 0.35 (95% CI, 0.07 to 0.63) and 0.1 (95% CI, 0 to 0.2) respectively. Seven of 10 term babies with EOGBS were born to mothers who screened negative. Data were unable to provide evidence of difference in rates of EOGBS between screened and unscreened pregnancies. We estimated the difference in EOGBS incidence from crude and weighted models to be 0 (95% CI, -0. 2 to 0.17) and -0.01 (95% CI, -0.13 to 0.10) /1000 live births respectively.

Conclusion

No change was detected in rates of EOGBS over time and no difference in EOGBS in babies of screened and unscreened populations. Screening and prophylaxis rates were modest. Limitations of universal screening suggest alternatives be considered.

Temporal trends in neonatal mortality and morbidity following spontaneous and clinician-initiated preterm birth in Washington State, USA: a population-based study

OBJECTIVE

After a decade of increase, the preterm birth (PTB) rate has declined in the USA since 2006, with the largest decline at late preterm (34-36 weeks). We described concomitant changes in gestational age-specific rates of neonatal mortality and morbidity following spontaneous and clinician-initiated PTB among singleton infants.

DESIGN, SETTING AND PARTICIPANTS

This retrospective population-based study included 754 763 singleton births in Washington State, USA, 2004-2013, using data from birth certificates and hospitalisation records. PTB subtypes included preterm premature rupture of membranes (PPROM), spontaneous onset of labour and clinician-initiated delivery.

OUTCOME MEASURES

The primary outcomes were neonatal mortality and a composite outcome including death or severe neonatal morbidity. Temporal trends in the outcomes and individual morbidities were assessed by PTB subtype. Logistic regression yielded adjusted odds ratios (AOR) per 1 year change in outcome and 95% CI.

RESULTS

The rate of PTB following PPROM and spontaneous labour declined, while clinician-initiated PTB increased (all p<0.01). Overall neonatal mortality remained unchanged (1.3%; AOR 0.99, CI 0.95 to 1.02), though gestational age-specific mortality following clinician-initiated PTB declined at 32-33 weeks (AOR 0.85, CI 0.74 to 0.97) and increased at 34-36 weeks (AOR 1.10, CI 1.01 to 1.20). The overall rate of the composite outcome increased (from 7.9% to 11.9%; AOR 1.06, CI 1.05 to 1.08). Among late preterm infants, combined mortality or severe morbidity increased following PPROM (AOR 1.13, CI 1.08 to 1.18), spontaneous labour (AOR 1.09, CI 1.06 to 1.13) and clinician-initiated delivery (AOR 1.10, CI 1.07 to 1.13). Neonatal sepsis rates increased among all preterm infants (AOR 1.09, CI 1.08 to 1.11).

CONCLUSIONS

Timing of obstetric interventions is associated with infant health outcomes at preterm. The temporal decline in late PTB among singleton infants was associated with increased mortality among late preterm infants born following clinician-initiated delivery and increased combined mortality or severe morbidity among all late preterm infants, mainly due to increased rate of sepsis.

Prevalence, antenatal management and perinatal outcome of monochorionic monoamniotic twin pregnancy: a collaborative multicenter study in England, 2000-2013

OBJECTIVES

To determine the prevalence of monochorionic monoamniotic (MCMA) twin pregnancy and to describe perinatal outcome and clinical management of these pregnancies.

METHODS

In this multicenter cohort study, the prevalence of MCMA twinning was estimated using population-based data on MCMA twin pregnancies, collected between 2000 and 2013 from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units. Pregnancy outcome at < 24 weeks' gestation, antenatal parameters and perinatal outcome (from ≥ 24 weeks to the first 28 days of age) were analyzed using combined data on pregnancies confirmed to be MCMA from NorSTAMP and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort for 2000-2013.

RESULTS

The estimated total prevalence of MCMA twin pregnancies in the North of England region was 8.2 per 1000 twin pregnancies (59/7170), and the birth prevalence was 0.08 per 1000 pregnancies overall (singleton and multiple). Using combined data from NorSTAMP and STORK, the rate of fetal death (at < 24 weeks' gestation), including terminations of pregnancy and selective feticide, was 31.8% (54/170); the overall perinatal mortality rate was 14.7% (17/116), ranging from 69.2% at < 30 weeks to 4.5% at ≥ 33 weeks' gestation. MCMA twins that survived in utero beyond 24 weeks were delivered, usually by Cesarean section, at a median of 33 (interquartile range, 32-34) weeks of gestation.

CONCLUSIONS

In MCMA twins surviving beyond 24 weeks of gestation, there was a higher survival rate compared with in previous decades, presumably due to early diagnosis, close surveillance and elective birth around 32-34 weeks of gestation. High perinatal mortality at early gestations was attributed mainly to extreme prematurity due to preterm spontaneous labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Components of the antepartum, intrapartum, and postpartum exposome impact on distinct short-term adverse neonatal outcomes of premature infants: A prospective cohort study

We aimed to test the hypothesis that determinants of the perinatal clinical exposome related to the underlying etiology of premature birth (PTB) impact differently on select neonatal outcomes. We conducted a prospective longitudinal study of 377 singleton preterm neonates [gestational age (GA) at birth: 23-34 weeks] separated into three distinct contemporaneous newborn cohorts: i) spontaneous PTB in the setting of intra-amniotic infection/inflammation (yes-IAI, n = 116); ii) spontaneous PTB in the absence of IAI (no-IAI, n = 130), and iii) iatrogenic PTB for preeclampsia (iPTB-PE, n = 131). Newborns (n = 372) were followed until death or discharge. Amniotic fluid defensins 1&2 and calgranulins A&C were used as biomarkers of IAI. An algorithm considering cord blood interleukin-6 (IL-6) and haptoglobin (Hp switch-on) was used to assess fetal exposure to IAI. Intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), early-onset neonatal (EONS) and late-onset (LOS) sepsis, death. Independent risk factors for adverse outcomes were: i) IVH (n = 53): histologic chorioamnionitis, GA, fetal growth restriction, male sex, Hp switch-on; ii) PVL (n = 11): cord blood IL-6; iii) NEC (n = 25), GA; iv) BPD (n = 53): ventilator support, need for surfactant, GA; v) ROP (n = 79): ventilator support, Hp switch-on, GA; vi) fetal and neonatal death (n = 31): GA, amniotic fluid IL-6; vii) suspect EONS (n = 92): GA, Hp switch-on; viii) LOS (n = 81): GA. Our findings are applicable to pregnancies delivered between 23 and 34 weeks' gestation in the setting of IAI and PE, and suggest that GA and inflammatory intrauterine environment play key roles in occurrence of IVH, PVL, ROP, death, EONS and LOS. Postnatal determinants seem to play major role in NEC and BPD.

Artificial womb technology and the frontiers of human reproduction: conceptual differences and potential implications

In 2017, a Philadelphia research team revealed the closest thing to an artificial womb (AW) the world had ever seen. The 'biobag', if as successful as early animal testing suggests, will change the face of neonatal intensive care. At present, premature neonates born earlier than 22 weeks have no hope of survival. For some time, there have been no significant improvements in mortality rates or incidences of long-term complications for preterms at the viability threshold. Artificial womb technology (AWT), that might change these odds, is eagerly anticipated for clinical application. We need to understand whether AWT is an extension of current intensive care or something entirely new. This question is central to determining when and how the biobag should be used on human subjects. This paper examines the science behind AWT and advances two principal claims. First, AWT is conceptually different from conventional intensive care. Identifying why AWT should be understood as distinct demonstrates how it raises different ethico-legal questions. Second, these questions should be formulated without the 'human being growing in the AW' being described with inherently value laden terminology. The 'human being in an AW' is neither a fetus nor a baby, and the ethical tethers associated with these terms could perpetuate misunderstanding and confusion. Thus, the term 'gestateling' should be adopted to refer to this new product of human reproduction: a developing human being gestating ex utero. While this paper does not attempt to solve all the ethical problems associated with AWT, it makes important clarifications that will enable better formulation of relevant ethical questions for future exploration.

Association of Antenatal Steroid Exposure With Survival Among Infants Receiving Postnatal Life Support at 22 to 25 Weeks' Gestation

IMPORTANCE

Although evidence of antenatal steroids (ANS) efficacy at 22 to 25 weeks' gestation is limited, increasingly these infants are treated with postnatal life support.

OBJECTIVES

To estimate the proportion of infants receiving postnatal life support at 22 to 25 weeks' gestation who had exposure to ANS, and to examine if the provision of ANS was associated with a higher rate of survival to hospital discharge and survival without major morbidities.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter observational cohort study consisted of 33 472 eligible infants liveborn at 431 US Vermont Oxford Network member hospitals between January 1, 2012, and December 31, 2016. We excluded infants with recognized syndromes or major congenital anomalies. Of the eligible infants, 29 932 received postnatal life support and were included in the analyses. Data analysis was conducted from July 2017 to July 2018.

EXPOSURE

Antenatal steroids administered to the mother at any time prior to delivery.

MAIN OUTCOMES AND MEASURES

Survival to hospital discharge, major morbidities among survivors, and the composite of survival to discharge without major morbidities.

RESULTS

Among 29 932 infants who received postnatal life support, 51.9% were male, with a mean (SD) gestational age of 24.12 (0.86) weeks and mean (SD) birth weight of 668 (140) g; 26 090 (87.2%) had ANS exposure and 3842 (12.8%) had no ANS exposure. Survival to hospital discharge was higher for infants with ANS exposure (18 717 of 25 892 [72.3%]) compared with infants without ANS exposure (1981 of 3820 [51.9%]); the adjusted risk ratio for 22 weeks was 2.11 (95% CI, 1.68-2.65), for 23 weeks was 1.54 (95% CI, 1.40-1.70), for 24 weeks was 1.18 (95% CI, 1.12-1.25), and for 25 weeks was 1.11 (95% CI, 1.07-1.14). Survival to hospital discharge without major morbidities was higher for infants with ANS exposure (3777 of 25 833 [14.6%]) compared with infants without ANS exposure (347 of 3806 [9.1%]); the adjusted risk ratio for 22 through 25 weeks was 1.67 (95% CI, 1.49-1.87).

CONCLUSIONS AND RELEVANCE

Concordant receipt of ANS and postnatal life support was associated with significantly higher survival and survival without major morbidities at 22 through 25 weeks' gestation compared with life support alone. Although statistically higher with ANS, survival without major morbidities remains low at 22 and 23 weeks. There is an opportunity to reevaluate national obstetric guidelines, allowing for shared decision making at the edge of viability with concordant obstetrical and neonatal treatment plans.

Contribution of hypertension to severe maternal morbidity

BACKGROUND

Maternal mortality and severe maternal morbidity are growing public health concerns in the United States. The Centers for Disease Control and Prevention Severe Maternal Morbidity measure provides insight into processes underlying maternal mortality and may highlight modifiable risk factors for adverse maternal health outcomes.

OBJECTIVE

The primary objective of this study was to evaluate the association between hypertensive disorders and severe maternal morbidity at a regional perinatal referral center. We hypothesized that women with preeclampsia with severe features would have a higher rate of severe maternal morbidity compared to normotensive women. We also assessed the proportion of severe maternal morbidity diagnoses that were present on admission, in contrast to those arising during the delivery hospitalization.

STUDY DESIGN

In this retrospective cross-sectional analysis, we assessed rates of severe maternal morbidity diagnoses (eg, renal insufficiency, shock, and sepsis) and procedures (eg, transfusion and hysterectomy) for all 7025 women who delivered at the University of Washington Medical Center from Oct. 1, 2013, through May 31, 2017. Severe maternal morbidity was determined from prespecified International Classification of Diseases diagnosis and procedure codes; all diagnoses were confirmed by chart review. Present-on-admission rates were calculated for each diagnosis through hospital administrative data provided by the Vizient University Health System Consortium. Maternal demographic and clinical characteristics were compared for women with and without severe maternal morbidity. The χ² and Fisher exact tests were used to determine statistical significance. Odds ratios and 95% confidence intervals were calculated for the associations between maternal demographic and clinical characteristics and severe maternal morbidity.

RESULTS

Of 7025 deliveries, 284 (4%) had severe maternal morbidity; 154 had transfusion only, 27 had other procedures, and 103 women had 149 severe maternal morbidity diagnoses (26 women had multiple diagnoses). Severe preeclampsia occurred in 438 deliveries (6.2%). Notably, hypertension was associated with severe maternal morbidity in a dose-dependent fashion, with the strongest association observed for preeclampsia with severe features (odds ratio, 5.4; 95% confidence interval, 3.9-7.3). Severe maternal morbidity was also significantly associated with preeclampsia without severe features, chronic hypertension, preterm delivery, pregestational diabetes, and multiple gestation. Among women with severe maternal morbidity, over one third of preterm births were associated with maternal hypertension. American Indian/Alaskan Native women had significantly higher severe maternal morbidity rates compared to other racial/ethnic groups (11.7% vs 3.9% for Whites, P < .01). Overall, 39.6% of severe maternal morbidity diagnoses were present on admission.

CONCLUSION

Hypertensive disorders in pregnancy are strongly associated with severe maternal morbidity in a dose-dependent relationship, suggesting that strategies to address rising maternal morbidity rates should include early recognition and management of hypertension. Prevention strategies focused on hypertension might also impact medically indicated preterm deliveries. The finding of increased severe maternal morbidity among American Indian/Alaskan Native women, a disadvantaged population in Washington State, underscores the role that socioeconomic factors may play in adverse maternal health outcomes. As 39% of severe maternal morbidity diagnoses were present on admission, this measure should be risk-adjusted if used as a quality metric for comparison between hospitals.

Risk Factors and Clinical Profile of Preterm Deliveries at Dhulikhel Hospital, Kathmandu University Hospital

Background Preterm delivery is one of the major determinants of neonatal morbidity and mortality and has long term adverse health outcomes. Objective To study the risk factors of preterm deliveries and the clinical profile of preterm births presenting to a tertiary center in Kavre district. Method A hospital based prospective study was carried out in the Department of Pediatrics and Department of Obstetrics and Gynaecology, Dhulikhel Hospital, Kavre from 1st April 2016 to 31st October 2017. Result Study included 152 babies born premature and attending Dhulikhel Hospital. There were 5.26% babies less than 1000 grams and the least weight being 700 grams. Majority of the premature babies were male (57.24%). Most of the babies were in the gestational age of 28 to 32 weeks (60%). Steroids were given to 42.10% of the cases. Mode of delivery was vaginal route (60.53%) followed by cesearean section in 37.50%. Hyperbilirubinemia (53.29%), neonatal sepsis (46.05%) and respiratory distress syndrome (43.42%) were the commonest morbid conditions. Among the 152 cases, mortality was seen in 13.82%. The minimum weight to have survived was 900 grams. The most common modifiable risk factors responsible for preterm birth in mother were inadequate antenatal visits (29.60%), history of premature rupture of membranes (28.29%), history of urinary tract infection (21.05%) and weight less than 45 kg (14.47%). The non modifiable risk factors were mothers with blood group A (33.55%) and height of less than 145 cm (20.40%). Conclusion The modifiable risk factors such as inadequate antenatal visits, history of premature rupture of the membranes and urinary tract infection and under weighing mothers can be corrected by early interventions and preventive measures which will help in reducing perinatal morbidity and mortality.

Quality Improvement in Perinatal Medicine and Translation of Preterm Birth Research Findings into Clinical Care

Billions of dollars are spent yearly in perinatal medicine on studies designed to improve outcomes for mothers and their neonates. However, implementing research findings is challenging and imperfect. Strategies for implementation must be multifaceted and comprehensive. These implementation challenges extend to, and are often greater in, translational and basic science research. The purpose of this review is to discuss current challenges in the provision of quality perinatal and neonatal medical care, particularly those related to preterm birth, and provide examples of prematurity-related perinatal quality collaborative initiatives. Finally, the authors review considerations in implementing both clinical and translational/basic science prematurity research.

Causal inference in studies of preterm babies: a simulation study

OBJECTIVE

Using a simple simulation, we illustrate why associations estimated from studies restricted to preterm births cannot be interpreted causally.

DESIGN, SETTING AND POPULATION

Data simulation involving a hypothetical cohort of fetuses who may be healthy or have one or more of four pathological factors (termed A through D, increasing in severity) with known effects on gestational length and risk of mortality. We focus on babies born at ≤32 weeks of gestation.

METHODS

We visually represent the simulated population and compare the association between A (which may represent pre-eclampsia) and neonatal death. We then repeat the exercise with D (standing in for chorioamnionitis) as the exposure of interest.

MAIN OUTCOME MEASURES

Odds ratios of neonatal death in the simulated data.

RESULTS

In most weeks, and for both A and D, the calculated odds ratios are substantially biased and underestimate the true risk of neonatal death associated with each pathology. For example, factor A has a true causal odds ratio of 1.50, yet it appears protective among births ≤32 weeks (estimated crude odds ratio 0.39; gestational age-adjusted odds ratio 0.71).

CONCLUSIONS

Among very preterm births, virtually all babies are born with pathologies that increase the risk of adverse outcomes. Hence, babies exposed to one factor (e.g. pre-eclampsia) are compared with babies who have a mix of other pathologies. Such selection bias affects studies carried out among very preterm births (e.g. where pre-eclampsia appears to reduce risk of adverse neonatal outcomes).

TWEETABLE ABSTRACT

Selection bias affects studies of preterm births, complicating interpretation.

[In the case of premature live birth, is very early rupture of the membranes an additional risk factor for morbidity and mortality?]

OBJECTIVE

To describe survival rate after preterm premature rupture of membranes (PPROM) before 25 weeks of gestation and compare neonatal morbidity and mortality among those born alive with a control group of infants born at a similar gestational age without premature rupture of membranes.

METHODS

We conducted a retrospective single-centre study at Port-Royal maternity, from 2007 to 2015, comparing neonatal outcomes between liveborninfants exposed to PPROM prior to 25 weeks of gestation (WG) and a control group not exposed to premature rupture of the membranes. For each live-born child, the next child born after spontaneous labor without PPROM was matched for gestational age at birth, sex, and whether or not they received antenatal corticosteroid therapy. The primary endpoint was severe neonatal complications assessed by a composite endpoint including neonatal deaths, grade 3-4 HIV, bronchopulmonary dysplasia, leukomalacia and stade 3-4 retinopathies.

RESULTS

Among 77 cases of very premature rupture of the membranes, 55 children were born alive. Among these, the average gestational age at birth was 28 WG and 1 day. The rate of severe neonatal complications did not differ between the two groups (43.6% in the PPROM group vs. 36.4%, P=0.44) and the survival rate at discharge was also similar in the two groups (85.5% vs. 83.6%, P=0.98).

CONCLUSIONS

In our cohort and among livebirths after 24 WG, PPROM before 25 WG was not associated with an increased risk of morbidity and mortality compared to children born at the same gestational age after a spontaneous labor with intact membranes.

Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant data meta-analysis

BACKGROUND

Babies born preterm are at an increased risk of dying in the first weeks of life, and those who survive have a higher rate of cerebral palsy (CP) compared with babies born at term. The aim of this individual participant data (IPD) meta-analysis (MA) was to assess the effects of antenatal magnesium sulphate, compared with no magnesium treatment, given to women at risk of preterm birth on important maternal and fetal outcomes, including survival free of CP, and whether effects differed by participant or treatment characteristics such as the reason the woman was at risk of preterm birth, why treatment was given, the gestational age at which magnesium sulphate treatment was received, or the dose and timing of the administration of magnesium sulphate.

METHODS AND FINDINGS

Trials in which women considered at risk of preterm birth (<37 weeks' gestation) were randomised to magnesium sulphate or control treatment and where neurologic outcomes for the baby were reported were eligible for inclusion. The primary outcomes were infant death or CP and severe maternal outcome potentially related to treatment. Studies were identified based on the Cochrane Pregnancy and Childbirth search strategy using the terms [antenatal or prenatal] and [magnesium] and [preterm or premature or neuroprotection or 'cerebral palsy']. The date of the last search was 28 February 2017. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. For each prespecified outcome, IPD were analysed using a 1-stage approach. All 5 trials identified were included, with 5,493 women and 6,131 babies. Overall, there was no clear effect of magnesium sulphate treatment compared with no treatment on the primary infant composite outcome of death or CP (relative risk [RR] 0.94, 95% confidence interval (CI) 0.85 to 1.05, 6,131 babies, 5 trials, p = 0.07 for heterogeneity of treatment effect across trials). In the prespecified sensitivity analysis restricted to data from the 4 trials in which the intent of treatment was fetal neuroprotection, there was a significant reduction in the risk of death or CP with magnesium sulphate treatment compared with no treatment (RR 0.86, 95% CI 0.75 to 0.99, 4,448 babies, 4 trials), with no significant heterogeneity (p = 0.28). The number needed to treat (NNT) to benefit was 41 women/babies to prevent 1 baby from either dying or having CP. For the primary outcome of severe maternal outcome potentially related to magnesium sulphate treatment, no events were recorded from the 2 trials providing data. When the individual components of the composite infant outcome were assessed, no effect was seen for death overall (RR 1.03, 95% CI 0.91 to 1.17, 6,131 babies, 5 trials) or in the analysis of death using only data from trials with the intent of fetal neuroprotection (RR 0.95, 95% CI 0.80 to 1.13, 4,448 babies, 4 trials). For cerebral palsy in survivors, magnesium sulphate treatment had a strong protective effect in both the overall analysis (RR 0.68, 95% CI 0.54 to 0.87, 4,601 babies, 5 trials, NNT to benefit 46) and the neuroprotective intent analysis (RR 0.68, 95% CI 0.53 to 0.87, 3,988 babies, 4 trials, NNT to benefit 42). No statistically significant differences were seen for any of the other secondary outcomes. The treatment effect varied little by the reason the woman was at risk of preterm birth, the gestational age at which magnesium sulphate treatment was given, the total dose received, or whether maintenance therapy was used. A limitation of the study was that not all trials could provide the data required for the planned analyses so that combined with low event rates for some important clinical events, the power to find a difference was limited.

CONCLUSIONS

Antenatal magnesium sulphate given prior to preterm birth for fetal neuroprotection prevents CP and reduces the combined risk of fetal/infant death or CP. Benefit is seen regardless of the reason for preterm birth, with similar effects across a range of preterm gestational ages and different treatment regimens. Widespread adoption worldwide of this relatively inexpensive, easy-to-administer treatment would lead to important global health benefits for infants born preterm.

Trend analysis of mortality rates and causes of death in children under 5 years old in Beijing, China from 1992 to 2015 and forecast of mortality into the future: an entire population-based epidemiological study

OBJECTIVES

To analyse trends in mortality and causes of death among children aged under 5 years in Beijing, China between 1992 and 2015 and to forecast under-5 mortality rates (U5MRs) for the period 2016-2020.

METHODS

An entire population-based epidemiological study was conducted. Data collection was based on the Child Death Reporting Card of the Beijing Under-5 Mortality Rate Surveillance Network. Trends in mortality and leading causes of death were analysed using the χ² test and SPSS 19.0 software. An autoregressive integrated moving average (ARIMA) model was fitted to forecast U5MRs between 2016 and 2020 using the EViews 8.0 software.

RESULTS

Mortality in neonates, infants and children aged under 5 years decreased by 84.06%, 80.04% and 80.17% from 1992 to 2015, respectively. However, the U5MR increased by 7.20% from 2013 to 2015. Birth asphyxia, congenital heart disease, preterm/low birth weight and other congenital abnormalities comprised the top five causes of death. The greatest, most rapid reduction was that of pneumonia by 92.26%, with an annual average rate of reduction of 10.53%. The distribution of causes of death differed among children of different ages. Accidental asphyxia and sepsis were among the top five causes of death in children aged 28 days to 1 year and accident was among the top five causes in children aged 1-4 years. The U5MRs in Beijing are projected to be 2.88‰, 2.87‰, 2.90‰, 2.97‰ and 3.09‰ for the period 2016-2020, based on the predictive model.

CONCLUSION

Beijing has made considerable progress in reducing U5MRs from 1992 to 2015. However, U5MRs could show a slight upward trend from 2016 to 2020. Future considerations for child healthcare include the management of birth asphyxia, congenital heart disease, preterm/low birth weight and other congenital abnormalities. Specific preventative measures should be implemented for children of various age groups.

Maternal Smoking during Pregnancy and Necrotizing Enterocolitis-associated Infant Mortality in Preterm Babies

Few studies have examined the possible pregnancy-related risk factors for necrotizing enterocolitis (NEC)-associated deaths during infancy. Infant death due to NEC in preterm babies was identified from the US Linked Livebirth and Infant Death records between 2000 and 2004. The average number of cigarettes per day reported by the mothers who were smoking during pregnancy was classified in three categories: non-smoking, light smoking (<10 cigarettes/day) and heavy smoking (≥10 cigarettes/day). Logistic regression analyses examined the association between prenatal smoking and NEC-associated infant mortality rates with adjustment for potential confounders. Compared with non-smoking mothers, light and heavy smoking mothers have a higher risk of NEC-associated infant mortality [light smoking: adjusted odds ratio (aOR) = 1.21, 95% confidence interval (CI), 1.03-1.43; heavy smoking: aOR = 1.30, 95% CI, 1.12-1.52], respectively. Moreover, the association was stronger among white race (light smoking: aOR = 1.69, 95% CI, 1.34-2.13; heavy smoking: aOR = 1.44, 95% CI, 1.18-1.75) and female babies (light smoking: aOR = 1.31, 95% CI, 1.02-1.69; heavy smoking: aOR = 1.62, 95% CI, 1.29-2.02). Maternal smoking during pregnancy is associated with increased risks of infant mortality due to NEC in preterm babies, especially in white race and female babies.

Epidemiological aspects of prematurity in the Eastern region of Saudi Arabia

OBJECTIVES

To assess the epidemiological characteristics of prematurity and survival rate in preterm infants diagnosed at a university hospital in the Eastern province of Saudi Arabia.

METHODS

A retrospective study was carried out of 476 preterm infants who were admitted with the diagnosis of prematurity to King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, between June 2008 and 2013. Demographics, birth weight, and neonatal survival rate were analyzed.

RESULTS

Four hundred and seventy-six preterm infants were admitted with a total prevalence of 7.5%. Descriptive analysis revealed 55% were males. Extremely preterm infants (less than 28 weeks' gestation) comprised 9% and very preterm infants (28 to less than 32 weeks' gestation) comprised 20%. Extremely low-birth-weight (ELBW) infants (less than 1000 g) comprised 11%. One hundred and fifty-seven (32%) infants were small for gestational age. Out of the total number of ELBW infants, 58% of them were discharged. The overall mortality was 7.6%. The mortality rate of male infants was 53%. The survival to discharge according to gestational age ranged from 30-97.6%.

CONCLUSION

The estimated prevalence of preterm births in a university hospital in eastern province of Saudi Arabia, is consistent with various studies from different parts of the world.

mTOR inhibitors rescue premature lethality and attenuate dysregulation of GABAergic/glutamatergic transcription in murine succinate semialdehyde dehydrogenase deficiency (SSADHD), a disorder of GABA metabolism

Recent studies have identified a role for supraphysiological gamma-aminobutyric acid (GABA) in the regulation of mechanistic target of rapamycin (mTOR), a protein kinase with pleiotropic roles in cellular development and homeostasis, including integration of growth factors and nutrient sensing and synaptic input in neurons (Lakhani et al. 2014; Vogel et al. 2015). Aldehyde dehydrogenase 5a1-deficient (aldh5a1 ^-/- ) mice, the murine orthologue of human succinic semialdehyde dehydrogenase deficiency (SSADHD), manifest increased GABA that disrupts mitophagy and increases mitochondria number with enhanced oxidant stress. Treatment with the mTOR inhibitor, rapamycin, significantly attenuates these GABA-related anomalies. We extend those studies through characterization of additional rapamycin analog (rapalog) agents including temsirolimus, dual mTOR inhibitors [Torin 1 and 2 (Tor 1/ Tor 2), Ku-0063794, and XL-765], as well as mTOR-independent autophagy inducers [trehalose, tat-Beclin 1, tacrolimus (FK-506), and NF-449) in aldh5a1 ^-/- mice. Rapamycin, Tor 1, and Tor 2 rescued these mice from premature lethality associated with status epilepticus. XL-765 extended lifespan significantly and induced weight gain in aldh5a1 ^-/- mice; untreated aldh5a1 ^-/- mice failed to increase body mass. Expression profiling of animals rescued with Tor 1/Tor 2 and XL-765 revealed multiple instances of pharmacological compensation and/or correction of GABAergic and glutamatergic receptors, GABA/glutamate transporters, and GABA/glutamate-associated proteins, with Tor 2 and XL-765 showing optimal outcomes. Our studies lay the groundwork for further evaluation of mTOR inhibitors in aldh5a1 ^-/- mice, with therapeutic ramifications for heritable disorders of GABA and glutamate neurotransmission.

Universal cervical length screening in singleton gestations without a previous preterm birth: ten reasons why it should be implemented

A short cervix is associated strongly with preterm birth. Pharmacologic intervention with vaginal progesterone in women with a singleton pregnancy and a short cervix in the second trimester decreases the incidence of preterm birth. We explore the evidence that universal cervical length screening in women with a singleton pregnancy meets the criteria for an effective screening test for preterm birth prevention, driving it towards becoming routinely offered in prenatal care.

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe

OBJECTIVE

Infants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level.

METHODS

We used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups.

RESULTS

In 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1-9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0-12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5-3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1-8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8-20.2) versus 9.8% (95% Cl 9.6-11.0) for neonatal death and 29.6% (96% CI 28.5-30.6) versus 17.5% (95% CI 15.7-18.3) for very preterm births, respectively).

CONCLUSIONS

Wide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health.

[FREQUENCY AND MEDICAL SOCIAL ASPECTS PREMATURE BIRTH]

Premature birth (PB) remains an unresolved problem, despite progress in prenatal medicine and the introduction of new methods and techniques of prolonged respiratory resuscitation in recent decades. Premature birth is the cause of 70% of neonatal mortality and 50% of long-term neurological complications in newborns, many of whom debilitating. Notwithstanding the significant progress prenatal care in the last twenty years in developed countries is a trend towards a gradual and continuous increase in premature births. PB is not only medical but also social problem. Despite the efforts of the scientific and practical obstetrics and modern tocolytic therapy, the rate of premature births in the last decade reduced. The causes of preterm birth are multifactorial and vary depending on gestational age, genetic factors and environmental factors. The long-term consequences of premature birth bear behind not only economic but also social problems. In many developing countries, premature birth is a major cause of disability. Clinical studies in recent years have been aimed at creating a comprehensive therapeutic algorithm behavior in premature births in order to reduce their frequency, especially for those born weighing less than 1000g.

Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set

OBJECTIVES

This report presents 2013 period infant mortality statistics from the linked birth/infant death data set (linked file) by maternal and infant characteristics. The linked file differs from the mortality file, which is based entirely on death certificate data.

METHODS

Descriptive tabulations of data are presented and interpreted.

RESULTS

The U.S. infant mortality rate was 5.96 infant deaths per 1,000 live births in 2013, similar to the rate of 5.98 in 2012. The number of infant deaths was 23,446 in 2013, a decline of 208 infant deaths from 2012. From 2012 to 2013, infant mortality rates were stable for most race and Hispanic origin groups; declines were reported for two Hispanic subgroups: Cuban and Puerto Rican. Since 2005, the most recent high, the U.S. infant mortality rate has declined 13% (from 6.86), with declines in both neonatal and postneonatal mortality overall and for most groups. In 2013, infants born at 37–38 weeks of gestation (early term) had mortality rates that were 63% higher than for full-term (39–40 week) infants. For multiple births, the infant mortality rate was 25.84, 5 times the rate of 5.25 for singleton births. In 2013, 36% of infant deaths were due to preterm-related causes of death, and an additional 15% were due to causes grouped into the sudden unexpected infant death category.