Associations between provider-assigned Apgar score and neonatal race.

BACKGROUND: For decades, the Apgar scoring system has been used to evaluate neonatal status and determine need for resuscitation or escalation in care, such as admission to a neonatal intensive care unit. However, the variation and accuracy of provider-assigned Apgar scores across neonatal racial groups have yet to be evaluated. OBJECTIVE: This study aimed to investigate how provider-assigned Apgar scores vary by neonatal race independently of clinical factors and umbilical cord gas values. STUDY DESIGN: We conducted a retrospective cohort study at an urban academic medical center. All live births at ≥23 weeks and 0 days of gestation from January 1, 2019 through December 31, 2019 with complete data available were included. Data were queried from the electronic medical record and included race, ethnicity, gestational age of neonate, umbilical cord gas values (umbilical artery pH and base deficit), admission to the neonatal intensive care unit, and presence of maternal-fetal complications. Primary outcome measures were neonates' Apgar scores at 1 and 5 minutes. Color Apgar score and admission to the neonatal intensive care unit served as secondary outcome measures. We performed 3 partially proportional ordinal regression models controlling for an increasing number of covariates, with Model 1, the baseline model, adjusted for gestational age, Model 2 additionally adjusted for umbilical cord gases, and Model 3 additionally adjusted for maternal medical conditions and pregnancy complications. RESULTS: A total of 977 neonates met selection criteria; 553 (56.6%) were Black. Providers assigned Black neonates significantly lower Apgar scores at 1 minute (odds ratio, 0.63; 95% confidence interval, 0.49-0.80) and 5 minutes (odds ratio, 0.64; 95% confidence interval, 0.47-0.87), when controlling for umbilical artery gases, gestational age, and maternal-fetal complications. This difference seemed related to significantly lower assigned color Apgar scores at 1 minute when controlling for all the above factors (odds ratio, 0.52; 95% confidence interval, 0.39-0.68). Providers admitted full-term Black neonates to the neonatal intensive care unit at higher rates than non-Black neonates when controlling for all factors (odds ratio, 1.29; 95% confidence interval, 0.94-1.77). Black neonates did not have more abnormal cord gas values (mean umbilical artery pH of 7.259 for Black vs 7.256 for non-Black neonates), which would have supported their admission to the neonatal intensive care unit. CONCLUSION: Providers applied inaccurate Apgar scores to Black neonates given that the umbilical cord gases were not in agreement with lower Apgar scores. These inaccuracies may be a factor in unnecessary admissions to neonatal intensive care units, and suggest that colorism and racial biases exist among healthcare providers.

Pharmacokinetics of 17 alpha hydroxyprogesterone caproate in singleton pregnancy and its influence of maternal body size measures.

BACKGROUND: Reducing spontaneous preterm deliveries is a worldwide public health priority. Although many interventions have been studied, 1 of the most effective treatments to decrease recurrent preterm birth is the use of weekly 17 alpha hydroxy progesterone caproate. Previous studies on the influence of excessive adipose tissue and obesity on the use of 17 alpha hydroxyprogesterone caproate for the prevention of recurrent spontaneous preterm deliveries have shown conflicting findings. OBJECTIVE: To estimate the pharmacokinetics of weekly17 alpha hydroxyprogesterone caproate in singleton and to evaluate the effect of maternal body size on the pharmacokinetics parameters. STUDY DESIGN: A prospective, open-label, longitudinal design was implemented for this population pharmacokinetic study. Plasma samples and clinical variables were collected in pregnant women between 16 and 36 weeks' gestational age, carrying a singleton pregnancy and receiving 17 alpha hydroxyprogesterone caproate, 250 mg intramuscularly weekly for the prevention of recurrent spontaneous preterm birth. Pharmacokinetics parameters and significant clinical covariates were estimated using mixed effect modeling. Four body size indicators were used in the model to predict pharmacokinetics parameters: lean body weight, total body weight, body mass index, and body surface area. RESULTS: A total of 56 pregnant women, aged 18-44 years with body mass index of 14.5-54.6 kg/m2, provided 114 17 alpha hydroxyprogesterone caproate plasma samples concentration for analysis. A 1-compartment model with first-order absorption satisfactorily described 17 alpha hydroxyprogesterone caproate pharmacokinetics. Compared to other body size indicators, lean body weight best explained intersubject variability. Age, race, and gestational age did not influence 17 alpha hydroxyprogesterone caproate pharmacokinetics. Lean body weight was the best descriptor for the influence of body size on 17 alpha hydroxyprogesterone caproate apparent clearance. Simulations showed that administration of a standard fixed dose of 250 mg intramuscularly produced substantially lower 17 alpha hydroxyprogesterone caproate plasma concentrations in pregnant women with body mass index >30 kg/m2 compared to those with body mass index <30 kg/m2. Conversely, adjustment of the standard dose for differences in total body weight among women resulted in markedly higher 17 alpha hydroxyprogesterone caproate concentrations in women with body mass index >30 kg/m2 compared to women with lower body mass index. Administration of doses adjusted for lean body weight produced nearly identical 117 alpha hydroxyprogesterone caproate plasma concentrations in both the low- and high-body mass index groups. CONCLUSION: Population pharmacokinetics analysis indicates the clearance significantly increases with increasing lean body mass. Higher 17 alpha hydroxyprogesterone caproate doses, adjusted by maternal lean body mass, may be required in patients with a body mass index >30 to achieve equivalent plasma concentrations in pregnant women with a body mass index <30. Adjustment of 17 alpha hydroxyprogesterone caproate doses for lean body weight produces equivalent systemic 17 alpha hydroxyprogesterone caproate exposure in pregnant women regardless of body size.

Pearls in clinical obstetrics: challenges in anticoagulation in pregnancy.

Women are at increased risk for venous thromboembolism (VTE) during both pregnancy and in the post-partum period. We have conducted a comprehensive literature review of the use of anticoagulation in pregnancy for pregnant women at increased risk for VTE. Multiple factors, including physiologic and pharmacokinetic changes make the treatment and prevention of VTE complicated in pregnancy. Adequate treatment and prevention of VTE in pregnancy is critically important, yet good quality medical studies continue to be lacking. There is a growing amount of data for the use of low molecular weight heparin (LMWH) in pregnant women and this remains the treatment of choice in most indications. For both prophylactic and therapeutic treatments, when LMWHs are chosen, monitoring of antifactor Xa level, although controversial, is advised. Women with prosthetic valve who become pregnant face challenges in regard of type of anticoagulation, dosing and monitoring during pregnancy. Delivery options and peripartum care should be defined with a multidisciplinary approach and taking patient's preference and autonomy in consideration. More high-quality research on this topic is needed to guide the clinical care of this unique population.

Multifocal Rounded Intraplacental Hematomas, Placental Abruption and Intrauterine Fetal Demise.

BACKGROUND: Rounded intraplacental hematomas (RIH) have a distinct rounded hemorrhagic appearance located within the placental parenchyma. Hemorrhagic villous infarctions (infarcts that when sectioned have hemorrhagic centers) are probably older RIH. RIH have been associated with acute abruptions. CASE REPORT: We describe multiple RIHs and hemorrhagic villous infarctions in various stages of development that arose between 20 and 27 weeks gestation, demonstrated by ultrasound, that developed an acute abruption and fetal death. CONCLUSIONS: The findings of RIHs, hemorrhagic infarcts, and lesions in between support the evolution of hemorrhagic villous infarctions from RIHs. These lesions can arise in the second trimester, and can be detected by ultrasound. These multiple lesions in various stages of evolution suggest an ongoing rather than a discrete insult.

Characteristics of Isolated Ventricular Septal Defects Less Likely to Close In Utero.

OBJECTIVES: To determine the characteristics of fetal ventricular septal defects (VSDs) that will be less likely to close prenatally. METHODS: In this 4-year retrospective cohort study, 148 fetuses had a diagnosis of a VSD during a comprehensive fetal anatomy survey. The VSD diagnosis was confirmed by color and pulsed wave Doppler studies. These fetuses were followed monthly until their birth. They had postnatal echocardiography performed within 1 month of age to assess the persistence of a VSD. Fisher exact, Wilcoxon rank sum, and log rank tests and bivariate and multivariate logistic regressions were used to examine the association of each individual variable with prenatal VSD closure. RESULTS: One hundred twenty-five of 148 fetuses (84%) had prenatal VSD closure at a mean gestational age ± SD of 26.9 ± 4.5 weeks. Fetuses with a persistent VSD more frequently had other cardiac defects than the closed VSD group (12 of 23 versus 5 of 125; P < .001). Fetuses having a persistent VSD more frequently had an abnormal karyotype (9 of 23 versus 5 of 125; P < .001). The persistent VSDs were larger in their initial size (5.9 ± 8.4 mm versus 2.7 ± 0.8 mm; P = .002) and in their maximal prenatal size (6.0 ± 9.1 mm versus 2.9 ± 0.9 mm; P < .001). The presence of associated cardiac defects (adjusted odds ratio = 0.071; P = .031) and an abnormal karyotype (adjusted odds ratio = 0.058; P = .021) were significantly associated with a lower likelihood of prenatal VSD closure. All VSDs with a maximal size of 2 mm or less closed prenatally. CONCLUSIONS: Fetuses with a complex cardiac defect or an abnormal karyotype were less likely to have prenatal VSD closure.

Adipokinins in pregnancies at risk of preterm delivery.

OBJECTIVE: To compare adipokinins between women experiencing preterm labor (PTL) and prior preterm deliveries (PTD). STUDY DESIGN: In this prospective observational cohort, 110 women with a singleton <35 weeks at increased risk of PTD were studied. Serum leptin, adiponectin, and resistin were obtained at three times (23-34 weeks, 35-36 weeks, at delivery) and analyzed via enzyme-linked immunosorbent assay. The adipokinins were compared across time and between PTL (n = 59) and prior PTD (n = 51) groups using generalized estimated equation models. RESULTS: There were no differences in leptin, adiponectin, or resistin levels over the three times between the PTL and PTD groups. There was a trend toward higher leptin levels (p = 0.06 unadjusted analysis, p = 0.09 adjusted analysis) at 23-34 weeks. When stratified by body mass index (BMI), there were differences in leptin (p < 0.001 for BMI < 30; p = 0.77 for BMI ≥ 30) and adiponectin (p = 0.04 for BMI < 30; p = 0.09 for BMI ≥ 30), but not in resistin over the three times between the PTL and prior PTD groups. CONCLUSION: There were no significant differences in adipokinins in women with PTL and a prior PTD. The trends toward higher leptin levels at 23-34 weeks in women with PTL may represent a compensatory response and require further evaluation in the study of treatments for PTL.

Complex actions of estradiol-3-sulfate in late gestation fetal brain.

The most abundant form of estrogen circulating in fetal plasma is sulfo-conjugated estrogen; for example, estradiol-3-sulfate (E(2)SO(4)) is more highly abundant than estradiol (E(2)). The present study investigated the ontogeny of the deconjugating (steroid sulfatase [STS]) and conjugating (estrogen sulfotransferase [STF]) enzymes in ovine fetal brain and tested the hypothesis that treatment with E(2)SO(4) would alter the expression of one or both enzymes. Steroid sulfatase was more highly expressed than STF, and both changed as a function of gestational age. Estradiol-3-sulfate infused intracerebroventricularly (icv) significantly increased plasma adrenocorticotropic hormone (ACTH) and cortisol concentrations. Plasma E(2) and E(2)SO(4) were increased, and brain expression of estrogen receptor α was decreased. The proteins STS and STF were up- and downregulated, respectively. Pituitary proopiomelanocortin (POMC) and follicle-stimulating hormone (FSH) and hypothalamic corticotrophin-releasing hormone (CRH) messenger RNA (mRNA) was decreased. We conclude that E(2)SO(4) has complex actions on the fetal brain, which might involve deconjugation by STS, but that the net result of direct E(2)SO(4) icv infusion is more complex than can be accounted for by infusion of E(2) alone.