Predicting long-term neurodevelopmental outcomes in very preterm neonates by umbilical cord gas parameters.

BACKGROUND: The predictive value of acidemia at birth on long-term neurodevelopmental outcomes remains poorly understood, especially in preterm neonates. OBJECTIVE: This study aimed to assess the relationship between the umbilical artery acid-base status and major neurodevelopmental disability at an age of between 5 and 8 years among children born very prematurely. STUDY DESIGN: We performed a secondary analysis of the data from a follow-up study of a prospective cohort of 457 children aged between 23 weeks and 31 weeks and 6 days from 1996 to 2001. Arterial cord gas parameters that were <10th percentile in the original cohort of 457 neonates (ie, pH of <7.1, base deficit of <-8.6 mEq/L, and a partial pressure of CO2 of >77 mm Hg) were considered abnormal. Sensitivity analyses considered alternative definitions for abnormal cord gases including a pH of <7.0 or base deficit of <-12 mEq/L. The primary outcome was a composite of major neurodevelopmental disability, including an intelligence quotient score of <70, cerebral palsy, blindness, deafness, abnormal balance, impaired cognition, dystonia, and seizure disorder. A logistic regression analysis was used to adjust for race and caregiver intelligence quotient score and, in an additional analysis, for gestational age. RESULTS: A total of 259 of 261 maternal-infant dyads were evaluated at a mean child age of 6.8 years, with complete umbilical cord gas data for 228 of those. Infants with an abnormal pH and a base deficit (defined above) were over 4-fold more likely to have the composite disability and an intelligence quotient score of <70. These increased odds persisted after adjusting for age and caregiver intelligence quotient score, but when considering gestational age as well, none of the umbilical cord gas parameters significantly predicted the presence of the composite disability or an intelligence quotient score of <70. However, when using the stricter umbilical cord gas criteria (ie, pH of <7.0 and a base deficit of <-12 mEq/L), a base deficit of <-12 mEq/L was independently associated with both neurodevelopmental disability and an intelligence quotient score of <70. CONCLUSION: When defined more strictly, abnormal umbilical cord gases, specifically a base deficit of <-12 mEq/L, are associated with an increased risk for major long-term neurodevelopmental disability and an intelligence quotient score of <70 in children born very prematurely.

Association between antenatal corticosteroids and neonatal hypoglycemia in indicated early preterm births.

PURPOSE: We sought to determine if administration of antenatal corticosteroids in early preterm births (<34 weeks) is associated with an increased risk of developing neonatal hypoglycemia (<40 mg/dL) within the first 48 h of neonatal life. MATERIALS AND METHODS: Retrospective cohort of all indicated singleton preterm births (23-34 weeks) in a single tertiary center from 2011 to 2014. The primary outcome was neonatal hypoglycemia (<40 mg/dL) within the first 48 h of life. The outcome was compared by antenatal corticosteroids received at any point during the gestation, within 2-7 d of delivery, and whether the patient received a partial, full, or repeat course of antenatal corticosteroids. Logistic regression was used to adjust for confounders. RESULTS: Six hundred thirty-five patients underwent an indicated preterm birth during the study period. Six hundred and four (95%) received antenatal corticosteroids prior to delivery and 31 (5%) did not. The incidence of neonatal hypoglycemia within 48 h of life was not significantly different between those who received any antenatal corticosteroids and those who did not (23.0 versus 16.1%, adjusted odds ratio [OR] 1.3, 95%CI 0.5-3.6). Infants who received a full antenatal corticosteroid course within 2-7 d of delivery had similar incidences of hypoglycemia compared with those who received antenatal corticosteroids more than 7 d before delivery (20.4 versus 25.4%, adjusted OR 1.5, 95% confidence interval(CI) 0.8-2.9). Neonatal hypoglycemia was not increased by the number of antenatal corticosteroid doses (partial, full, or repeat course) administered. There was not a correlation between timing of antenatal corticosteroid administration before delivery, up to 250 h, and the lowest neonatal blood sugar in the first 48 h of life. CONCLUSION: Our findings suggest antenatal corticosteroid administration in indicated early preterm infants (<34 weeks) may not increase the risk of developing neonatal hypoglycemia within the first 48 h of life. Further studies should validate our findings.

Impact of Intended Mode of Delivery on Outcomes in Preterm Growth-Restricted Fetuses.

BACKGROUND: Scheduled cesarean is frequently performed for fetal growth restriction due to concerns for fetal intolerance of labor. OBJECTIVE: We compared neonatal outcomes in preterm growth-restricted fetuses by intended mode of delivery. STUDY DESIGN: We performed a retrospective cohort study of indicated preterm births with prenatally diagnosed growth restriction from 2011 to 2014 at a single institution. Patients were classified by intended mode of delivery. The primary outcome was a composite of adverse neonatal outcomes, including perinatal death, cord blood acidemia, chest compressions during neonatal resuscitation, seizures, culture-proven sepsis, necrotizing enterocolitis, and grade III-IV intraventricular hemorrhage. Secondary analysis was performed examining the impact of umbilical artery Dopplers. RESULTS: Of 101 fetuses with growth restriction, 75 underwent planned cesarean deliveries. Of those induced, 46.2% delivered vaginally. Delivery by scheduled cesarean was not associated with a decreased risk of the composite outcome (adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 0.45-5.78), even when only those with abnormal umbilical artery Dopplers were considered (aOR, 2.8; 95% CI, 0.40-20.2). CONCLUSION: In this cohort, planned cesarean was not associated with a reduction in neonatal morbidity, even when considering only those with abnormal umbilical artery Dopplers. In otherwise appropriate candidates for vaginal delivery, fetal growth restriction should not be considered a contraindication to trial of labor.

Does Early Artificial Rupture of Membranes Speed Labor in Preterm Inductions?

OBJECTIVE: In full-term patients, early artificial rupture of membranes (AROMs) decreases time in labor. We assessed the impact of early AROM in preterm patients undergoing indicated induction of labor. STUDY DESIGN: We conducted a retrospective cohort study of all patients undergoing indicated preterm induction (23-34 weeks) at a single tertiary care center from 2011 to 2014. Early AROM was defined as <4 cm and late AROM was defined as ≥4 cm. The primary outcomes evaluated were cesarean delivery and time in labor. Secondary outcomes were chorioamnionitis and a composite of maternal and neonatal adverse outcomes. RESULTS: Of the 149 women included, 65 (43.6%) had early AROM. Early AROM was associated with an increased time from the start of induction to delivery (25.7 ± 13.0 vs. 19.0 ± 10.3 hours, p < 0.01) and with an increase in the risk of cesarean (53.4 vs. 22.6%, adjusted odds ratio: 3.5, 95% confidence interval: 1.60-7.74). Early AROM was not associated with an increased risk of chorioamnionitis or adverse maternal or fetal outcomes. CONCLUSION: In this observational cohort, early AROM was associated with an increased risk of cesarean. A randomized controlled trial is necessary to determine the optimal timing of AROM in preterm patients requiring delivery.