CONTRIBUTIONWhat are the novel findings of this work? In this study, we developed an integrated and comprehensive prediction model for assessing the risk of Cesarean delivery in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor, based on variables known at the time of admission.
What are the clinical implications of this work?Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for Cesarean delivery, or additional neonatal support at the time of birth, in pregnancies with a SGA fetus undergoing induction of labor.
ABSTRACTObjectives To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery.
INTRODUCTION:
Growth restricted fetuses are at risk for admission to the neonatal intensive care unit (NICU). NICU admission is a proxy for long-term health consequences and societal costs. We aimed to assess risk factors for NICU admission among pregnancies complicated by fetal growth restriction.
METHODS:
This is a retrospective cohort study of non-anomalous, singleton, growth restricted fetuses - defined as estimated fetal weight (EFW) less than the 10th percentile - delivered in a single tertiary referral center from 01/2011 to 12/2016. Institutional Review Board approval was obtained. Factors significantly associated with NICU admission were identified using univariate analyses (P<.1). Multivariable logistic regression analysis was used to determine the final risk factors and to estimate adjusted odds ratios.
RESULTS:
594 pregnancies with fetal growth restriction met inclusion criteria. 204 (34.3%) resulted in NICU admission. Significant risk factors for NICU admission were smoking, EFW < 5th percentile, method of labor induction, non-reassuring fetal heart tracing, and gestational age at delivery. Labor induction with oxytocin or prostaglandins and higher gestational age at delivery appeared to be protective from NICU admission. If these risk factors were used to develop a prediction model, the area under the receiver-operator curve would be 0.83 (95% CI 0.79-0.86). The model would have a sensitivity of 50.0%, specificity of 92.3%.
CONCLUSION:
We identified several significant risk factors for NICU admission among growth restricted fetuses, which could be helpful in anticipating need for additional neonatal support at the time of delivery and for counseling women with growth restricted fetuses about risk of NICU admission.
:
Ramelteon is a melatonin receptor agonist that is approved for the treatment of
insomnia. It is widely used due to its relatively benign side effect profile and lack of dependence
or withdrawal. Due to its tolerability, clinicians have attempted to utilize ramelteon
to normalize the sleep/wake patterns in patients with delirium as a safer alternative
to antipsychotics or other medications. We present the case of a 75-year-old man with
long-standing dementia who was hospitalized due to mental status changes, agitation, and
sleep disturbance. After addressing possible underlying causes with minimal improvement,
the team initiated treatment with ramelteon (8mg nightly) which resulted in rapid
improvement of symptoms. Uses and mechanisms of action of ramelteon will be reviewed,
as well as current pharmacologic treatments of delirium. Prior research studies
and case reports regarding the use of ramelteon in the treatment of delirium will be discussed
and suggestions made regarding possible areas of future study.
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