title: A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery.
abstract: Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling.
  
  
  
  We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity.
  
  
  
  This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra-amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra-amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture-proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively.
  
  
  
  The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5-minute Apgar were associated with an increase in morbidity.
  
  
  
  Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.
authors.affiliation: University of California, Irvine Medical Center, Orange, CA; Obstetrix Medical Group, Center for Research Education & Quality, Mednax, Inc., Sunrise, FL. Electronic address: tjgarite@uci.edu.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Garite
authors.affiliation: Obstetrix Medical Group, Center for Research Education & Quality, Mednax, Inc., Sunrise, FL; Obstetrix Medical Group, California, San Jose, CA.
authors.forename: C Andrew
authors.initials: CA
authors.lastname: Combs
authors.affiliation: Obstetrix Medical Group, Center for Research Education & Quality, Mednax, Inc., Sunrise, FL.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Maurel
authors.affiliation: Das Consulting, San Francisco, CA.
authors.forename: Anita
authors.initials: A
authors.lastname: Das
authors.affiliation: Phoenix Perinatal Associates/Mednax Inc., Phoenix, AZ.
authors.forename: Kevin
authors.initials: K
authors.lastname: Huls
authors.affiliation: Obstetrix Medical Group, Denver, CO.
authors.forename: Richard
authors.initials: R
authors.lastname: Porreco
authors.affiliation: Obstetrix Medical Group, Seattle, WA.
authors.forename: Dale
authors.initials: D
authors.lastname: Reisner
authors.affiliation: Obstetrix Medical Group, Kansas City, MO.
authors.forename: George
authors.initials: G
authors.lastname: Lu
authors.affiliation: Obstetrix Medical Group, Southern California, Laguna Hills, CA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Bush
authors.affiliation: Midwest Maternal-Fetal Medicine, St. Louis, MO.
authors.forename: Bruce
authors.initials: B
authors.lastname: Morris
authors.affiliation: Obstetrix Medical Group of Texas, Fort Worth, TX.
authors.forename: April
authors.initials: A
authors.lastname: Bleich
authors.affiliation: Obstetrix Medical Group, Center for Research Education & Quality, Mednax, Inc., Sunrise, FL.
mesh_terms: D000328:Adult; D001997:Bronchopulmonary Dysplasia / Q000453:epidemiology; D002543:Cerebral Hemorrhage / Q000453:epidemiology; D036861:Delivery, Obstetric / Q000379:methods; D020345:Enterocolitis, Necrotizing / Q000453:epidemiology; D005260:Female; D005317:Fetal Growth Retardation / Q000453:epidemiology; D005322:Premature Rupture of Fetal Membranes; D005865:Gestational Age; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007234:Infant, Premature / Q000502:physiology*; D007235:Infant, Premature, Diseases / Q000453:epidemiology*; D007363:Intensive Care Units, Neonatal; D007969:Leukomalacia, Periventricular / Q000453:epidemiology; D009017:Morbidity; D007752:Obstetric Labor, Premature; D011247:Pregnancy; D011446:Prospective Studies; D012127:Respiratory Distress Syndrome, Newborn / Q000453:epidemiology
keywords: intrauterine growth restriction; maternal admission and delivery; neonatal outcomes; premature labor; premature rupture of membranes