OBJECTIVE:To describe a maternal-fetal medicine (MFM)-led, protocolized, integrated care model in which subspecialists serve as system-level clinical governors, and to present associated outcomes relative to regional, national, and published benchmarks and existing maternity care models. STUDY DESIGN:We conducted a single-system descriptive analysis of a moderately sized, integrated, MFM-led women's health organization with more than 3,500 annual deliveries during 2024-2025. Outcomes were evaluated across five domains: preterm birth (PTB) prevention, low-risk cesarean reduction, diabetes management, maternal opioid use disorder (OUD), and low-dose aspirin (LDASA) use for preeclampsia prevention. Performance was compared with Clark County, Nevada, national, and literature-based benchmarks, and the organizational structure with existing maternity care models. RESULTS:The PTB rate was 10.0%, compared with 11.4% in Clark County. The nulliparous, term, singleton, vertex cesarean rate was 24.6%, compared with 28.5% in Clark County; the SMFM cesarean rate was 12.0%, compared with 16.7% in Nevada. Self-monitored blood glucose adherence was 96%, versus 68% nationally. Pharmacologic treatment for neonatal opioid withdrawal syndrome was 11.1%, versus published rates of 50%-85%. LDASA self-reported use reached 95% among eligible patients. Applying published per-case costs, estimated annual savings from PTB prevention and low-risk cesarean reduction were $4.03 million. Unlike other models, this architecture places MFMs in system-level governance roles, designing and disseminating protocols across all obstetric provider types while integrating high- and low-risk care. CONCLUSION:This community-based model operationalizes the SMFM call for a transformed maternity care team by combining subspecialist governance with multi-domain protocol implementation. It is designed to identify and treat at-risk patients before progression to high-risk status and adverse outcomes.
Objective: This study aimed to assess the experiences of NPM fellows and early career neonatologists with biostatistics education during fellowship training and to evaluate their confidence in using common biostatistical methods. Study Design: This was an observational cross-sectional survey study of U.S.-based NPM fellows and early career faculty. The survey instrument was designed to assess confidence in various biostatistical techniques and training experience. The anonymous survey was distributed to members of the ONTPD and TECAN listservs in September 2022 and responses were recorded in REDCap. Results: There were 148 responses to the survey, with 87 (59%) of those being current fellows and 61 (41%) early career faculty. Only 16 (11%) respondents felt their biostatistical training was adequate for their scholarly work and future career, while 57 (38%) felt it was inadequate to meet their needs, and 50 (34%) felt it met just their basic needs. Most respondents reported being at a novice or beginner level for most biostatistical techniques. Despite many reported challenges to incorporating a dedicated curriculum into the didactic schedule, 85 (57%) felt it should be required for all NPM fellows. When comparing groups, early career faculty rated their confidence with various biostatistical techniques as higher than current fellows. There were no differences between respondents from smaller or larger programs in their evaluation of the quality of their training, access to statistical programs, or availability of mentorship. Conclusion: There are significant gaps in current biostatistical training for NPM fellows. This gap could lead to significant downstream effects in the field of Neonatology, including poor ability to assess research findings, inability to engage in meaningful quality improvement, and a lack of available mentors in the future. These gaps may be addressed by a targeted curriculum that is readily available for all NPM training programs.
Objective:The purpose of this study was to identify postnatal factors that may confer an increased risk for having a delayed thyroid-stimulating hormone (TSH) rise on the newborn screen (NBS) in infants admitted to the neonatal intensive care unit (NICU). Study Design:NBS results were collected from the Indiana State Department of Health (ISDH) for all cases of congenital hypothyroidism (CH) from 2012 to 2022 and used to identify infants who had a delayed TSH rise (N = 73). Thirty-six infants with a delayed diagnosis were matched by gestational age and birth weight Z-scores to infants with CH who were diagnosed in a timely manner per their initial NBS. A retrospective chart review was performed to compare postnatal factors between these two groups and to determine the treatment outcome in infants with a delayed versus timely diagnosis of CH. Results:Infants with a delayed TSH rise had significantly higher odds of medication exposures, invasive surgical procedures, and complications related to the renal, gastrointestinal, and hematologic systems. Delayed infants had 3.02 times the number of bedside procedures that involved iodine-containing sterile preparation (95% confidence interval [CI]: 1.31-6.93, p = 0.009) compared with the timely cohort. Within the delayed cohort, 38% of infants were found to have transient CH as compared with 27% of infants in the timely cohort. Conclusion:Several postnatal factors appear to play a role in conferring a risk for a delayed TSH rise, implying that the etiology of this phenomenon is multifactorial. Our findings suggest the need for more targeted screening for CH within the NICU. Key Points:· The delayed cohort had a higher likelihood of medication exposure and multiorgan system complications.. · The delayed cohort had a greater degree of iodine exposure than the timely cohort.. · More than a third of infants in the delayed cohort were found to have transient CH..
Background:Periviable rupture of membranes (ROM) occurs in 0.4% of pregnancies and is associated with substantial maternal and neonatal morbidity. Data to inform prognosis and neonatal outcomes are limited. Objective:To assess factors that influence neonatal survival to discharge in expectantly managed pregnancies affected by ROM at less than 25 weeks' gestation. Study Design:Retrospective case control study of nonanomalous, singleton pregnancies complicated by ROM at less than 25 weeks' gestation and delivered at a tertiary center from 2005 to 2024. The cohort included patients who opted for expectant management at the time of ROM diagnosis and subsequently delivered a liveborn neonate eligible for neonatal resuscitation. Resuscitation was offered at ≥23 weeks' gestation from 2004 to 2019 and ≥22 weeks' gestation from 2020 to 2024. Multiple gestations, termination, fetal demise, or planned comfort care were excluded. Patients were stratified by neonatal survival to discharge, and maternal, obstetric, and neonatal variables were compared between groups. The primary outcome of neonatal survival was analyzed using Chi-square test and secondary outcomes analyzed with Chi-square, student's t-test, and Wilcoxon rank sum where appropriate. Results:Of 121 pregnancies meeting inclusion criteria, 82 (67.8%) delivered a neonate that survived to discharge. Gestational age (GA) at delivery was significantly associated with survivorship (25.3 weeks vs. 24.1 weeks, p = 0.01). GA at ROM, latency, and residual amniotic fluid index did not differ between groups. Survivors were more likely to have received antenatal corticosteroids (100% vs. 95%, p = 0.04). Vaginal delivery was more frequent among survivors (p = 0.01), although cesarean delivery was more common overall (59.5%). Maternal morbidity occurred in 45.9% of cases, most commonly due to infection. Conclusion:In our cohort, overall survival of expectantly managed singleton pregnancies affected by ROM at less than 25 weeks' gestation is 67.8%. Gestational age at delivery was significantly associated with survival. Expectant management is associated with significant risk of both neonatal and maternal morbidity. Key Points:· Survival after periviable ROM (less than 25 weeks) was 67.8%.. · Gestational age at delivery is significantly associated with neonatal survival in periviable ROM.. · Neonatal and maternal morbidity remain high in pregnancies affected by periviable ROM..
Objective:NeoNatal Neurobehavioral Scale (NNNS-II) measures behavioral signs of stress according to systems, including the autonomic and central nervous systems. These systems influence heart rate variability (HRV), which is a biomarker for regulatory capacity. The present study aims to investigate whether patterns of autonomic dysregulation are evident in both behavioral and physiological measures. Study Design:HRV metrics-short- and long-term fractal scaling exponents (α1, α2) and root mean square fluctuations (RMS1, RMS2)-were calculated from the heart rates of 51 preterm infants at 33 weeks postmenstrual age. The NNNS-II assessments were conducted at term-equivalent age. Results:Linear regression revealed that higher total stress signs were associated with increased α2 (β = 0.366, p = 0.006), indicating reduced long-scale autonomic complexity. Autonomic and central nervous systems-specific stress signs were significantly associated with elevated α2 (β = 0.349, p = 0.022). Individual items such as high-frequency tremors were also associated with increased α2 (β = 0.303, p = 0.018) whereas startles were not (p = 0.096). Conclusion:Neurobehavioral stress signs, particularly those associated with the central nervous system (CNS), are linked to early diminished autonomic variation in infants. These findings can help researchers and clinicians interpret the significance of neurobehavioral stress signs to autonomic tone in preterm infants. Key Points:· Neurobehavioral stress is linked to HRV.. · CNS stress predicts reduced autonomic complexity.. · Tremors were most strongly related to HRV..
OBJECTIVES:Late-onset neonatal sepsis (LOS) remains a major challenge in modern neonatal intensive care units (NICUs), disproportionately affecting very low birth weight (VLBW) and extremely preterm infants. Despite advances in perinatal care, LOS continues to contribute to high mortality, prolonged hospitalization, and long-term neurodevelopmental impairment. Emerging trends-including evolving pathogen profiles, increased antimicrobial resistance (AMR), and widespread microbiome disruption-highlight persistent clinical and public health concerns. This review synthesizes current evidence on the epidemiology, pathophysiology, diagnosis, and management of LOS, with emphasis on evolving diagnostics, antimicrobial stewardship, prevention strategies, and emerging precision approaches. Key gaps and research priorities are highlighted to inform future clinical practice and neonatal health policy. STUDY DESIGN:This narrative review synthesizes contemporary literature, including multicenter cohort studies, national registries, and emerging diagnostic and predictive technologies. RESULTS:LOS arises from the complex interplay between neonatal immune immaturity, invasive NICU interventions, and microbial exposure. Gram-positive organisms predominate in high-income settings, while multidrug-resistant Gram-negative pathogens are increasingly reported in low- and middle-income countries, contributing to higher morbidity and mortality. Early-life antibiotic exposure and dysbiosis compromise the gut microbiome, further increasing susceptibility. Clinical recognition remains challenging due to nonspecific signs, often leading to delayed or excessive empiric antibiotic therapy. Rapid molecular diagnostics, emerging predictive tools, including early-warning models, and serial biomarker monitoring offer opportunities for pathogen-directed therapy, individualized pharmacokinetic optimization, and safe antimicrobial stewardship. Prevention through central-line bundles, human milk feeding, probiotics, strict hand hygiene, and context-specific infection-control strategies remains central to reducing LOS incidence. CONCLUSIONS:LOS represents a multifactorial syndrome with profound implications for survival and neurodevelopment in preterm and VLBW infants. Effective management requires integration of precision diagnostics, individualized therapy, microbiome-preserving strategies, neuroprotective interventions, and equitable implementation of prevention and stewardship programs. Bridging mechanistic understanding with scalable, context-sensitive approaches is critical to improving survival, reducing morbidity, and optimizing long-term outcomes.
Objective:Cervical cancer is preventable with the human papillomavirus (HPV) vaccine; however, vaccination rates remain low. Pregnancy presents an opportunity to complete vaccination. Preliminary safety data are reassuring, but vaccination is currently contraindicated in pregnancy. We aimed to examine patient and provider knowledge and attitudes regarding 9-valent HPV vaccination in pregnancy. Study Design:We performed a mixed-methods study utilizing patient focus group discussions (FGDs) and a national provider survey. FGDs with pregnant patients were conducted until thematic saturation was achieved. Surveys were sent to providers from the American College of Obstetricians and Gynecologists (ACOG) mailing list until the sample size (300) was achieved. Thematic analysis and descriptive statistics were performed on FGD transcripts and survey results. Findings were integrated and interpreted together. Results:We recruited 18 FGD patient participants and analyzed 321 provider surveys. Five key themes emerged from the integrated data: (1) knowledge of the HPV vaccine in pregnancy, (2) perceptions of HPV vaccine safety, (3) perceptions of HPV vaccine efficacy, (4) vaccine decision-making process, and (5) barriers and facilitators of HPV vaccination in pregnancy. Patient participant knowledge of the vaccine was variable. Physician recommendation and personal autonomy were key factors in their patient participants' vaccine decision-making. Patient and provider participants expressed uncertainty about the safety and efficacy of the vaccine in pregnancy. A primary concern was fetal well-being. Both desired more research on vaccine safety and efficacy. Main provider-identified barriers to vaccination during pregnancy were professional organization recommendations against vaccination, safety concerns during pregnancy, and patient vaccine hesitancy. Most provider participants would offer vaccination during pregnancy if not contraindicated. Conclusion:Patients and providers report significant uncertainty about the safety and efficacy of the HPV vaccine in pregnancy. More research and permissive language from professional organizations are needed before patients and providers would feel comfortable with antepartum vaccination. Key Points:· Provider recommendation is the key in vaccine decisions.. · There is uncertainty about the safety of the HPV vaccine in pregnancy.. · There is uncertainty about the efficacy of the HPV vaccine in pregnancy.. · More research is desired on HPV vaccine in pregnancy.. · Providers adhere to professional vaccine guidelines..
Objective:Nutritional education in twin gestations improves perinatal outcomes. Our objective was to determine if a prenatal nutrition consultation led to more patients with diamniotic twin pregnancies achieving adequate weight gain according to Institute of Medicine (IOM) guidelines. Study Design:We collected data of a retrospective cohort of diamniotic twin pregnancies cared for by maternal-fetal medicine specialists at one academic institution from January 2021 to December 2022. Patients were grouped based on whether they received at least one outpatient nutrition consult, and these groups were compared based on whether they met weight gain guidelines or not and other perinatal outcomes. Analyses were performed with Chi-square, t-tests, and multivariable logistic regression adjusted for characteristics that were significantly associated with each outcome. Results:Nutrition consultation was associated with a significantly higher rate of meeting IOM goals (59 vs. 29%, p = 0.003) and a significantly higher mean total weight gain (17.9 vs. 13.4 kg, p < 0.001). Mean gestational age at delivery was 5.6 days later in the nutrition group (p = 0.04). When adjusted for age, race, parity, marital status, pre-gravid BMI, and chorionicity, those who did not receive a nutrition consult had over doubled odds of delivery before 34 weeks (aOR 2.65, 95% CI: 1.12-6.23). Conclusion:One prenatal nutrition consult in diamniotic twin pregnancies resulted in a significantly higher proportion of patients meeting IOM weight gain goals and significantly fewer births before 34 weeks. Key Points:· A single prenatal nutrition consult helps appropriate weight gain in diamniotic twin pregnancies.. · Nutrition consult is associated with fewer preterm births.. · Nutrition consult should be routine for twin pregnancies and is paid for by most U.S. payors..
Objective:Among those with a prior cesarean, Black individuals are more likely to have labor after cesarean compared with White individuals but have lower rates of vaginal birth after cesarean following labor. However, little is known about indications for cesarean among these patients. We examined whether indication for unplanned cesarean delivery varied by race and ethnicity among individuals with one prior cesarean. Study Design:Using linked Massachusetts birth certificate and hospital discharge data (2012-2022), we identified individuals with one prior cesarean who labored and subsequently had an unplanned cesarean. Indications were categorized as nonreassuring fetal status, labor dystocia/arrest, or other. A multilevel multinomial logit model assessed associations between race and ethnicity and cesarean indication, adjusting for covariates. Results:Overall, 41% had cesarean for nonreassuring fetal status, 16% for labor dystocia/arrest, and 43% for other indications. Nonreassuring fetal status was the indication for 59% of Black patients versus 36% of White patients. In adjusted analyses, Black individuals had a 42% higher relative risk of having a cesarean for an indication of nonreassuring fetal status, compared with White individuals and compared with having a cesarean for an indication of labor arrest/dystocia (relative risk ratio: 1.42, 95% confidence interval: 1.14-1.76). Black and Latinx individuals had a lower relative risk of having a cesarean for other indication, compared with White individuals and compared with cesarean for an indication of labor arrest/dystocia. Conclusion:Racial and ethnic differences exist in indications for unplanned cesarean after labor among those with one prior cesarean, mirroring disparities reported for primary cesarean indications. Key Points:· Indications for unplanned repeat cesarean delivery varied by race and ethnicity.. · Nonreassuring fetal status was a more common indication among Black versus White individuals.. · Other indications were less common among Black and Latinx versus White patients..
Objective:Placental pathology is a leading contributor to stillbirth; however, whether placental histopathological lesions differ according to parity in stillbirth remains poorly defined. The aim of the present study is to evaluate the association between parity and placental histopathological lesions in singleton pregnancies ending in antepartum stillbirth. Study Design:Retrospective review of placentas from singleton antepartum stillbirths, in nonmacerated and morphologically normal fetuses, was performed blinded to clinical data. Placental lesions were classified per international consensus criteria and compared between nulliparous and parous women. Results:Placental histopathological abnormalities were identified in the vast majority of cases in both nulliparous and parous women (>94%). The prevalence of maternal vascular malperfusion, fetal vascular malperfusion, delayed villous maturation, and ascending intrauterine infection did not differ between groups. In contrast, villitis of unknown etiology (VUE) was significantly more frequent in parous than in nulliparous women (13.2 vs. 1.6%). All VUE cases represented high-grade lesions and were frequently associated with low birth weight. Conclusion:Among placental lesions in stillbirth, high-grade VUE shows an association with parity. Systematic placental histopathology evaluation may enhance the etiological classification of stillbirth, providing potential mechanistic insights. This knowledge can support more accurate recurrence risk stratification and individualized counseling. Key Points:· Placental pathology is a major contributor to stillbirth.. · High-grade VUE is strongly associated with stillbirth.. · High-grade VUE is more prevalent in parous women.. · Detailed placental evaluation informs risk stratification and individualized care..
Objective:The objective of this study is to evaluate whether a nursing-led postdelivery inpatient workflow increased universal perinatal depression screening and improved referrals to behavioral health services. A secondary objective was to evaluate implementation process using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Study Design:This retrospective cohort study included all postpartum patients delivering at an urban academic hospital from February through June 2024. We developed a standardized workflow with nursing leadership and reproductive psychiatry, training nurses to administer the Edinburgh Postnatal Depression Scale (EPDS), to all postpartum patients on postpartum day 0. Scores ≥ 10 prompted nurses to place a social work consult and request the obstetric provider to place a reproductive psychiatry consult. Reach and effectiveness were evaluated using a pre-post study with social work referrals as the primary outcome. Secondary outcomes included EPDS completion rate, screen-positive rate, and psychiatry referrals. Logistic regression was used for adjusted analyses. Adoption was assessed through provider workflow adherence, and implementation was assessed through semistructured patient interviews and nursing surveys. Results:Among 522 postpartum patients (260 preintervention and 262 postintervention), screening completion increased from 25.7 to 95.0% (67/260 vs. 249/262, p < 0.001). Positive screens rose from 1.5 to 6.8% (1/67 vs. 17/249, p < 0.001). Social work referrals rose from 34.6 to 47.7% (90/260 vs. 125/262, p = 0.002). In an adjusted analysis, the intervention remained associated with higher odds of social work referral (adjusted odds ratio: 1.56; 95% confidence interval: 1.02-2.41, p = 0.04). Reproductive psychiatry referrals increased but were not statistically significant. Most nurses reported comfort with the workflow, and patients indicated screening was acceptable and helpful. Conclusion:A simple and scalable nursing-led workflow achieved near-universal inpatient perinatal depression screening, improved identification of depressive symptoms, and increased behavioral health referrals. This workflow is feasible, acceptable to nurses and patients, and offers a replicable framework for hospitals seeking to integrate inpatient perinatal depression screening into standard practice. Key Points:· A simple nursing-led workflow integrates perinatal depression screening into routine inpatient care.. · Universal inpatient postpartum screening increased symptom detection and social work referrals.. · Patients and nurses found the workflow acceptable and easy to integrate into standard care..
Objective:The objective of this study is to investigate whether tortuous ductus arteriosus (DA) is associated with changes in ductal Doppler flow or right ventricular (RV) functional findings in late gestation, structurally normal heart fetuses. Study Design:Fetuses ≥ 32 weeks' gestation with tortuous DA from January 2016 to November 2023 were evaluated. Using the narrowest ductal angle and number of ductal bends, DA tortuosity grade was assigned as mild (one bend, ≥ 90 degrees), moderate (one bend, < 90 degrees), and severe (≥2 bends). DA flow included peak systolic flow velocity (PSV) and pulsatility index (PI). RV functional markers included tricuspid regurgitation, RV to left ventricle (LV) (RV/LV) size ratio, RV function, and venous Dopplers. Results:Eighty fetal echocardiograms were evaluated. The mean gestational age (GA) was 34.9 weeks. The majority of our cohort had either moderate tortuosity (47.5%) or mild tortuosity (40%) grade. The mean PSV was 1.6 m/s and 45% of subjects had elevated PSV for GA. The mean PI was 2.4, with 95% of our cohort having a normal or high PI for GA. DA tortuosity was not associated with DA PSV or PI for GA. Compared with the group with mild tortuosity grade, the moderate group had significantly higher mean RV/LV size ratio and lower mean narrowest ductal tortuosity angle. Conclusion:Variable ductal tortuosity is seen in late gestation fetuses with normal cardiac anatomy. The majority of our cohort had elevated PSV for GA but with a normal or high PI for GA. The degree of ductal tortuosity was not associated with PSV or significant RV functional changes. Key Points:· Variable ductal tortuosity is seen in late gestation fetuses with normal hearts.. · The majority of our fetuses had elevated PSV but with a normal or high PI.. · Ductal tortuosity does not correlate with PSV, PI, or significant changes in right ventricular functional findings..
Objective:We sought to evaluate outcomes of pregnant patients with Chiari malformation (CM). We evaluated the relationships between mode of anesthesia and delivery with neurologic outcome in these patients. Study Design:We conducted a single-center, retrospective review of pregnant patients with CM between 2008 and 2024. Clinical and radiographic data were collected. Additionally, three neurosurgeons retrospectively determined eligibility for vaginal delivery with the Valsalva maneuver and neuraxial anesthesia with the available information. Results:We identified 56 deliveries in 40 patients with Type I CM. Median tonsillar descent was 8 mm (interquartile range [IQR] 4.5-11.5). Seven deliveries (16.7%; six patients) featured patients with syrinxes (median diameter 4.5 mm, IQR 4.0-4.5 mm). During pregnancy, 11 patients (19.6%) had symptoms attributable to CM, most commonly headache (5 patients, 8.9%). Two (40%) patients with Chiari-related headaches experienced worsening symptoms during pregnancy. Twenty-two pregnancies resulted in vaginal deliveries (39.3%), and 34 in cesarean deliveries (60.7%). Eleven cesarean deliveries (32.3%; 19.6% of whole cohort) had primary indication of CM for operative delivery. Neuraxial anesthesia was used in 29 patients (52%), 17 of whom were for cesarean deliveries (50% of cesareans). During labor, there were no maternal mortalities or worsening CM-related symptoms. On blinded retrospective assessment, one neurosurgeon found 51/56 deliveries (91.1%) safe for vaginal delivery and all safe for neuraxial anesthesia; one neurosurgeon found all deliveries safe for vaginal delivery and neuraxial anesthesia; the last one found 54/56 deliveries (96.4%) safe for vaginal delivery and 55/56 (98.2%) safe for neuraxial anesthesia. Concerns arose from brainstem compression and foramen magnum crowding with symptomatic worsening during pregnancy. Conclusion:A diagnosis of Type I CM imparts higher rates of cesarean delivery (61%) and lower rates of neuraxial anesthesia to pregnant persons. Yet, our outcomes suggest that vaginal delivery with the Valsalva maneuver and neuraxial anesthesia appear to be safe in almost all pregnant patients with CM. Key Points:· Type I CM does not appear to significantly increase neurologic risk during pregnancy.. · Most persons with CM can safely undergo vaginal delivery with neuraxial anesthesia.. · Cesarean section and general anesthesia are likely over-recommended for those with Type I CM..
Objective:Cesarean delivery (CD) remains a key obstetric quality metric among nulliparous, term, singleton, vertex (NTSV) pregnancies. In 2024, the NTSV CD rate at New York University (NYU) Langone Hospital-Long Island was 32.9%, exceeding The Joint Commission (TJC) benchmark of ≤30% and demonstrating racial and ethnic disparities. This study aimed to reduce the institutional NTSV CD rate to ≤30% through a multidisciplinary quality improvement (QI) initiative while prospectively monitoring safety outcomes and racial disparities. Study Design:A single-site QI initiative was implemented from 2024 to 2025, incorporating provider education, patient-centered interventions (TeamBirth and structured labor huddles), standardized labor management, and performance monitoring through monthly case review, clinician feedback, and quarterly equity-focused data review. Outcome measures included monthly overall and quarterly race- and ethnicity-stratified NTSV CD rates. Process measures assessed adherence to evidence-based labor dystocia criteria. Balancing measures included postpartum hemorrhage (PPH) and TJC PC-06 rates. TEMPORAL TRENDS WERE EVALUATED USING MULTIVARIABLE POISSON REGRESSION WITH ADJUSTMENT FOR MATERNAL AGE, GESTATIONAL AGE AT DELIVERY, AND BODY MASS INDEX. Results:The overall NTSV CD rate decreased from 32.9% in 2024 to 27.8% in 2025, remaining below TJC benchmark in 10 out of 12 months. ACROSS THE EIGHT-QUARTER STUDY PERIOD, THERE WAS A SIGNIFICANT DECLINE IN THE OUTCOME OVER TIME (ADJUSTED RELATIVE RISK PER QUARTER 0.97, 95% CONFIDENCE INTERVAL 0.95-0.99,: p = 0.003).: Reductions were observed across racial and ethnic groups, including among Black non-Hispanic patients (44.0% to 40.0%) and Asian non-Hispanic patients (37.0% to 29.6%). Adherence to evidence-based labor dystocia criteria remained high, while PPH and PC-06 rates remained stable. Conclusion:A standardized, multidisciplinary QI initiative was associated with the NTSV CD rate below TJC benchmark without increases in maternal or neonatal adverse outcomes. The initiative was also associated with partial reduction in racial disparities in CD rates, although persistent inequities remained. Future Plan-Do-Study-Act (PDSA) cycles will focus on sustaining standardized care and advancing equitable obstetric outcomes.
Abstract:OBJECTIVE: Inequalities contribute substantially to adverse perinatal outcomes; however, data on stillbirth risk and its etiologic diversity across maternal migrant status remain limited in Italy. Understanding these patterns is essential for developing targeted prevention strategies. The aim of the present study was to assess stillbirth risk and evaluate differences in underlying causes between Italian and migrant women in a large population-based cohort. Abstract:STUDY DESIGN: We conducted a retrospective cohort study including 323,635 births in Emilia-Romagna, Italy (2014-2023). Stillbirth (SB) was defined as fetal death at ≥28 weeks. Maternal origin was categorized as Italian versus migrant according to the citizenship. Risk factors were assessed using multivariable logistic and Cox regression models, and causes of fetal death were classified by Re.Co.De. Abstract:RESULTS: SB incidence was significantly higher in migrants (0.32%) than Italians (0.21%; OR 1.52; HR 1.55, p < 0.001). Low birthweight, advanced maternal age, obesity, and low number of antenatal visits emerged as significant risk factors for SB irrespective of maternal citizenship. Importantly, fetal deaths related to placental pathologies were significantly more frequent in migrants (n = 150/328, 45.7% in migrants vs. n = 159/464, 34.3% in Italians, p = 0.001), as well as infection/inflammation (n = 33/328, 10.1% in migrants vs. 25/464, 5.4% in Italians, p = 0.019). Abstract:CONCLUSION: Substantial diversity in SB etiology exists across mothers of different origin, underscoring the need for tailored prevention strategies. Accordingly, ultrasounds and infection screening (i.e., antenatal care) should be implemented, especially in migrants. Such measures, combined with culturally sensitive counseling could reduce preventable stillbirths in the multicultural Italian population.
Abstract:Diabetes mellitus (DM) is one of the most common medical complications of pregnancy and is associated with increased maternal and fetal morbidity and mortality. The placenta has a unique role as a transient organ that can profoundly influence the lifelong health of both mother and child. In pregnancies complicated by diabetes, the placenta plays a central role in bridging maternal vascular, hormonal and metabolic effects on fetal neurodevelopment. The objective of this study is to review the current literature on in vivo placental and fetal neurodevelopment in pregnant women with DM. We present a narrative literature review detailing human studies of placental and fetal neurodevelopment in pregnant persons with DM, along with promising new avenues of in vivo placental assessments. Advances in imaging, particularly sonography and magnetic resonance imaging, provide novel insights on placental structure and function, as well as fetal brain development in pregnant women with DM. Improving our understanding of the in vivo consequences of maternal DM may provide new opportunities to intervene and mitigate adverse pregnancy outcomes in future.
Objective:Minimally invasive surfactant therapy (MIST) techniques for instillation of surfactant via a thin intratracheal catheter in a spontaneously breathing neonate with respiratory distress syndrome are being increasingly adopted worldwide. We designed this study to describe the short-term respiratory outcomes in neonates who received high-volume bovine lipid extract surfactant (BLES) at 5 mL/kg via MIST and analyze predictors of MIST failure. Study Design:This was a retrospective, observational cohort study that included all neonates who received BLES via MIST between January 1, 2018 and December 31, 2023. Baseline demographic characteristics, immediate- and short-term respiratory outcomes were compared between patients with MIST success and MIST failure (defined as the need for mechanical ventilation within 7 days of procedure). Predictors of MIST failure were examined using logistic regression models. Results:Of a total of 213 neonates, 41 (19.2%) were deemed MIST failure. Neonates with MIST failure compared with MIST success had lower mean (standard deviation [SD]) gestational age in weeks (29.0 [2.8] vs. 31.3 [3.4], p < 0.001) and lower mean birthweight (SD) (1247.2 [602] vs. 1654.1 [747] g, p <0.001). Neonates with MIST failure had higher preprocedural positive end expiratory pressures and higher oxygen needs than neonates with MIST success. On regression analysis, fraction of inspired oxygen (FiO2) at 1 hour (p = 0.049) and FiO2 at 6 hours (p = 0.03) post-MIST was identified as independent predictors of MIST failure after accounting for differences in baseline characteristics. Conclusion:Successful administration of high-volume surfactant via MIST, without any need of mechanical ventilation within 7 days of procedure was achieved in 80.8% of the cohort with a low MIST failure rate of 19.2%. Oxygen requirements measured at 1- and 6-hour post-MIST serve as independent predictors of MIST failure. Key Points:· High-volume surfactant can be delivered safely via MIST.. · MIST failure rate was 19.2% in our cohort.. · O2 needs at 1- and 6-hour postprocedure can predict MIST failure.. · Early post-MIST response may guide treatment escalation needs..
The coronavirus disease 2019 (COVID-19) pandemic fundamentally disrupted health care systems worldwide, with disproportionate consequences for maternal and newborn health. Pregnant individuals and neonates faced both direct clinical consequences of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection and indirect effects of health system disruption. This narrative review synthesizes global evidence on the pandemic's impact on perinatal outcomes, neonatal care, breastfeeding practices, and financial burden on health care institutions, contrasting high-income countries (HICs) and low- and middle-income countries (LMICs). PubMed, the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the Centers for Disease Control and Prevention (CDC) databases were searched for peer-reviewed publications through early 2026. The pandemic increased maternal mortality, stillbirth, and neonatal morbidity, particularly in LMICs, alongside paradoxical preterm birth reductions in some HICs. Vertical SARS-CoV-2 transmission remained infrequent. Neonatal admissions fell while acuity and length of stay increased. Breastfeeding was profoundly disrupted by inconsistent separation policies and infection control measures. Health care institutions absorbed substantial additional costs from screening programs and care pathway reorganization. COVID-19 exposed and exacerbated existing global health inequities in maternal and neonatal care. Evidence-based, context-sensitive policies from the WHO, AAP, and CDC are essential to preserve perinatal care quality during future health emergencies. · COVID-19 worsened maternal and neonatal outcomes, with LMICs bearing the greatest burden.. · Separation policies disrupted breastfeeding; breast milk was confirmed safe and protective.. · Vaccination in pregnancy reduced hospitalization by 62% and stillbirth risk by up to 45%..
Objective:Cesarean hysterectomy for placenta accreta spectrum (PAS) is associated with significant morbidity. The role of adjunctive procedures, including tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement, in mitigating surgical morbidity during cesarean hysterectomy for PAS is currently under active investigation. This study aimed to assess temporal trends, characteristics, and outcomes associated with adjunctive procedures during cesarean hysterectomy for PAS. Study Design:This retrospective study used the Premier Perspective database in the United States. The study population included pregnant patients who underwent cesarean hysterectomies for PAS between 2016 and 2023. Targeted adjunctive procedures included tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement. A multivariate model was created to assess the association between adjunctive procedures and surgical morbidity. Results:Among 4,337 cesarean hysterectomies for PAS, 39.3%, 24.6%, and 16.1% received tranexamic acid, ureteral stent placement, and endoarterial embolization or balloon placement, respectively. During the 8-year study period, tranexamic acid administration increased 5.7-fold from 11.7% to 66.4%, and ureteral stent placement increased 1.6-fold from 19.2% to 30.3% (both p-trend <0.001). Nearly two-thirds of patients had postpartum hemorrhage (62.6%), and nearly one in five had urinary tract injury (18.7%). These three adjunctive procedures were not associated with decreased postpartum hemorrhage or urinary tract injury. Conclusion:These data suggest that the utilization of tranexamic acid and ureteral stent placement is increasing during cesarean hysterectomy for PAS in the United States. Reflecting the increases in real-world practice, whether these adjunctive procedures improve surgical morbidity of cesarean hysterectomy for PAS warrants further investigation with prospective studies. Key Points:· Tranexamic acid and ureteral stent use increased during PAS cesarean hysterectomy.. · Endoarterial procedures showed no significant temporal increase.. · Surgical morbidity remained substantial despite adjunctive procedure use..
Objective:To evaluate whether the clinician specialty managing gestational diabetes mellitus (GDM) during pregnancy is associated with postpartum 2-hour oral glucose tolerance testing (OGTT) completion and long-term risk of type 2 diabetes mellitus (T2DM). Study Design:We performed a retrospective cohort study of individuals with GDM who delivered at a single academic center from 2016 to 2020. Patients were categorized according to primary GDM managing clinician type: Maternal-Fetal Medicine (MFM), Endocrinology (Endo), or Obstetrics/Family Medicine (OB/FM). The primary outcome was completion of postpartum 2-hour OGTT within 12 weeks of delivery. Secondary outcomes included abnormal postpartum OGTT and diagnosis of T2DM within 5 years postpartum. Multivariable logistic regression models were adjusted for nulliparity, GDM managed with medications, insurance status, and chronic hypertension. Results:Among 715 individuals with GDM, 27% were managed by MFM, 20% by Endo, and 53% by OB/FM. Overall, 13.3% were diagnosed with T2DM within 5 years postpartum. Postpartum OGTT completion rates were similar among Endo (29.8%), MFM (24.2%), and OB/FM (26.1%) groups (p = 0.52). In adjusted analyses, clinician type was not associated with completion of postpartum OGTT or abnormal OGTT results. Compared with endocrinology management, OB/FM care was associated with lower crude odds of T2DM diagnosis at 5 years (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.30-0.99), although this association was no longer significant after adjustment (adjusted OR [aOR], 0.56; 95% CI, 0.30-1.06). Conclusion:Clinician specialty type managing GDM was not associated with postpartum diabetes screening completion or long-term risk of T2DM. These findings suggest that provider specialty alone may not meaningfully influence postpartum diabetes surveillance or long-term metabolic outcomes and underscore the need for system-level interventions to improve care transitions after GDM, such as immediate postpartum testing during hospital stay after birth. Key Points:· Postpartum oral glucose tolerance test completion was low across specialties.. · Clinician type was not linked to oral glucose tolerance test completion.. · T2DM risk did not differ by clinician specialty type at 5 years..
