American Journal of Perinatology

Publications in this journal

• Article: Surfactant Inadvertent Loss Using Feeding Catheters or Endotracheal Tubes.

  Daniele De Luca, Angelo Minucci, Leonarda Gentile, Ettore D Capoluongo
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  ABSTRACT: Objective Surfactant has been administered through endotracheal tubes and also under spontaneous breathing using feeding catheters. We asked if different tube diameters and temperature may affect the amount of surfactant effectively delivered to the lungs.Design Bench study using high-accuracy, legal balance and tube/catheters of different diameters. We injected 200 mg of poractant alfa into the tubes followed by air boluses. Experiments were performed in triplicate, both at room temperature and at 37°C. Surfactant and phospholipid remaining in the tube were calculated.Results Surfactant lost into thin catheters (11 ± 0.4%) was more than that in endotracheal tubes (2-mm diameter: 3.6 ± 1.4%; 2.5-mm diameter: 3.7 ± 0.2%; 3-mm diameter: 5.2 ± 0.4%; p < 0.001 at post hoc test in each comparison against the thin catheter). Similar findings were found at 37°C (2-mm tube: 3.4 ± 0.4%; 2.5-mm tube: 3.8 ± 0.2%; 3-mm tube: 3.6 ± 0.4%; feeding tube: 11.5 ± 0.6%; p < 0.001 as above). In terms of lost phospholipids, 23 ± 0.8 mg were lost in the feeding tubes; 7.2 ± 2.9 mg (2-mm diameter), 7.4 ± 0.4 mg (2.5-mm diameter), and 10.3 ± 0.9 mg (3-mm diameter) of phospholipids remained in endotracheal tubes (p < 0.001 in each comparison against the feeding tube).Conclusions Surfactant loss using thin catheters is around two to three times higher than using common endotracheal tubes; on average, 20 mg of phospholipids (11% of the administered dose) are lost. These data may be useful to refine surfactant dosing.
  American Journal of Perinatology 05/2013;
• Article: Influence of Changes in the Evaluation of Neonatal Jaundice.

  Arieh Riskin, Keren Cohen, Amir Kugelman, Marta Abend-Weinger, Miri Hemo, David Bader
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  ABSTRACT: Objective To study the influence of policy changes in the evaluation of neonatal hyperbilirubinemia on discharge process from the nursery. Changes included early assessment of risk factors by universal umbilical blood sampling for blood type, Coombs test, and glucose-6-phosphate dehydrogenase (G6PD) and universal noninvasive transcutaneous bilirubinometry at discharge.Study Design The 1,569 newborns (≥ 36 weeks' gestation) admitted after the implementation of changes were compared with the 1,822 born before.Results Policy changes improved the diagnosis of G6PD deficiency and ABO incompatibility and decreased the number of referrals from the community for jaundice follow-up. The average number of needlesticks per baby as well as the time required for the analysis of serum bilirubin levels on discharge day decreased. Changes did not significantly increase costs.Conclusion Changes seem to have improved the quality of medical care, including early identification of risk factors and better follow-up of neonatal hyperbilirubinemia with reduction of pain and increased efficiency.
  American Journal of Perinatology 04/2013;
• Article: Does Vitamin C and Vitamin E Supplementation Prolong the Latency Period before Delivery following the Preterm Premature Rupture of Membranes? A Randomized Controlled Study.

  Kemal Gungorduk, Osman Asıcıoglu, Ozgu Celıkkol Gungorduk, Gokhan Yıldırım, Berhan Besimoğlu, Cemal Ark
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  ABSTRACT: Objective To determine whether maternal vitamin C and vitamin E supplementation after the premature rupture of membranes is associated with an increase in the latency period before delivery.Methods In the present prospective open randomized trial, 229 pregnant women with preterm premature rupture of membranes (PPROM) at ≥ 24.0 and < 34.0 weeks' gestation were randomly assigned to receive either 1,000 mg of vitamin C and 400 IU of vitamin E (n = 126) or a placebo (n = 123). The primary outcome was the latency period until delivery. Analysis was performed on an intention-to-treat basis.Results No significant differences in demographic or clinical characteristics were observed between the groups. Latency period until delivery was significantly higher in the group that received vitamins compared with the control group (11.2 ± 6.3 days versus 6.2 ± 4.0 days; p < 0.001). Gestational age at delivery was also significantly higher in the vitamin group compared with the control group (31.9 ± 2.6 weeks versus 31.0 ± 2.6 weeks; p = 0.01). No significant differences in adverse maternal outcome (i.e., chorioamnionitis or endometritis) or neonatal outcome (i.e., neonatal sepsis, neonatal death, necrotizing enterocolitis, or grade 3 to 4 intraventricular hemorrhage) were noted between groups.Conclusions The findings of the present study suggest that the use of vitamins C and E in women with PPROM is associated with a longer latency period before delivery. Moreover, adverse neonatal and maternal outcomes, which are often associated with prolonged latency periods, were similar between the groups.
  American Journal of Perinatology 04/2013;
• Article: Prenatal Detection of Fetal Growth Restriction in Newborns Classified as Small for Gestational Age: Correlates and Risk of Neonatal Morbidity.

  Suneet P Chauhan, Hind Beydoun, Eugene Chang, Adam T Sandlin, Josh D Dahlke, Elena Igwe, Everett F Magann, Kristi R Anderson, Alfred Z Abuhamad, Cande V Ananth
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  ABSTRACT: We examined the rate of detecting small for gestational age (SGA; birth weight < 10%) as intrauterine growth restriction (IUGR) prenatally at four centers and determined risks of composite neonatal morbidity (CNM) and mortality among detected versus undetected (no antenatal diagnosis of IUGR). A multicenter cohort study of 11,487 nonanomalous, singleton live births with sonographic exam before 22 weeks was performed. Of 11,487 births, 8% (n = 929) were SGA that met the inclusion criteria, with 25% of them being prenatally detected. The CNM among SGA births that were prenatally detected as IUGR was higher (23.3%) than undetected SGA (9.7%), but this difference was no longer significant following adjustments for confounding factors. Among preterm births (< 37 weeks), undetected SGA had significantly higher CNM (risk ratio [RR] 10.0, 95% confidence interval [CI] 6.3, 16.1) for deliveries at 24 to 33 weeks and RR 3.0, 95% CI 1.7, 5.4 for 34 to 36 weeks). In summary, only a quarter of SGA births were detected prenatally as IUGR and among preterm SGA, the CNM is significantly higher when SGA births are undetected as IUGR.
  American Journal of Perinatology 04/2013;
• Article: Risk Factors for Preeclampsia in Twin Pregnancies.

  Nathan S Fox, Ashley S Roman, Daniel H Saltzman, Tanya Hourizadeh, Jeffrey Hastings, Andrei Rebarber
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  ABSTRACT: Objective Twin pregnancy is associated with an increased incidence of preeclampsia. However, it is unknown if the risk factors for preeclampsia in twin pregnancies are the same as those in singleton pregnancies.Methods Case-control analysis of all twin pregnancies managed by one maternal-fetal medicine practice from 2005 to 2012. Patients with chronic hypertension were excluded, as were monochorionic-monoamniotic twins. We compared patient and pregnancy characteristics between patients who did and did not develop preeclampsia, according to standard American College of Obstetricians and Gynecologists definitions. Odds ratios, adjusted odds ratios (aORs), and 95% confidence intervals (CIs) were obtained using chi-square analysis and logistic regression.Results Of the patients with twin pregnancies, 513 were included, and 76 (14.8%) patients developed preeclampsia. On univariable analysis, the risk factors associated with preeclampsia in twin pregnancies were egg donation, nonwhite race, nulliparity, prepregnancy obesity, and gestational diabetes. On adjusted analysis, the risk factors independently associated with preeclampsia were egg donation (aOR 2.409, 95% CI 1.051, 5.524) and prepregnancy obesity (aOR 2.367, 95% CI 1.079, 5.192).Conclusions In twin pregnancy, the risk factors independently associated with preeclampsia are egg donation and prepregnancy obesity.
  American Journal of Perinatology 04/2013;
• Article: Urinary Neutrophil Gelatinase-Associated Lipocalin as an Early Biomarker for Prediction of Acute Kidney Injury in Preterm Infants.

  Yilmaz Tabel, Ahmet Elmas, Sevcan Ipek, Ahmet Karadag, Ozlem Elmas, Fatma Ozyalin
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  ABSTRACT: Background Our aims are to determine whether the urinary neutrophil gelatinase-associated lipocalin (uNGAL) can predict acute kidney injury (AKI) development in nonseptic and nonasphyxiated but critically ill preterm infants.Methods Fifty preterm infants, gestational age (GA) between 28 and 34 weeks, were included in this case control study. Blood and urine samples were taken for blood urea nitrogen, serum creatinine, and uNGAL on postnatal (PN) days 1 and 7. uNGAL levels were measured by enzyme-linked immunoassay. Clinical and laboratory characteristics of the AKI group were compared with the non-AKI group.Results AKI was diagnosed in six infants during the first week. The median uNGAL levels were significantly higher in the preterm infants with AKI than those of the controls on PN days 1 and 7 (p = 0.006 and p = 0.023, respectively). Backward stepwise logistic regression analysis identified that 5-minute Apgar score and uNGAL levels were significantly associated with the development of AKI, even after controlling for GA, birth weight, gender, and 1-minute Apgar score in nonseptic and nonasphyxiated but critically ill preterm infants.Conclusions uNGAL can be useful as a predictive marker of AKI in nonseptic and nonasphyxiated but critically ill preterm infants.
  American Journal of Perinatology 04/2013;
• Article: Labor Induction for Premature Rupture of Membranes Using Vaginal Misoprostol versus Dinoprostone Vaginal Insert.

  Cynthia Abraham, Natalie Meirowitz, Nina Kohn
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  ABSTRACT: Objective To compare labor induction outcomes using vaginal misoprostol versus dinoprostone insert in women with premature rupture of membranes (PROM) and an unfavorable cervix.Study Design Charts of singleton gestations beyond 34 weeks with PROM and an unfavorable cervix from 2008 to 2011 were reviewed. Group assignment was determined by initial induction agent used. Dinoprostone was administered as a 10-mg vaginal insert left for up to 12 hours. Misoprostol was administered vaginally as a 25-μg tablet every 4 hours for up to six doses. Times to active labor, complete dilatation, and delivery and incidence of adverse outcomes (intrapartum fever, tachysystole, fetal heart rate abnormalities) were compared.Results Ninety-eight women were included. Baseline characteristics between groups were not different. Median times to active labor (7 versus 11 hours, p < 0.001) and complete dilatation (13.5 versus 19 hours, p < 0.001) were shorter in the misoprostol group. In the misoprostol group, 41.7 and 88.4% of patients delivered vaginally within 12 and 24 hours, respectively, compared with 20.8 and 58.0% in the dinoprostone group (p < 0.001). There was no difference in incidence of adverse outcomes.Conclusion Vaginal misoprostol is more effective than dinoprostone insert for induction secondary to PROM without increasing the incidence of adverse outcomes.
  American Journal of Perinatology 04/2013;
• Article: Foley Catheter versus Vaginal Misoprostol: Randomized Controlled Trial (PROBAAT-M Study) and Systematic Review and Meta-Analysis of Literature.

  Marta Jozwiak, Mieke Ten Eikelder, Katrien Oude Rengerink, Christianne de Groot, Hanneke Feitsma, Marc Spaanderman, Mariëlle van Pampus, Jan Willem de Leeuw, Ben Willem Mol, Kitty Bloemenkamp
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  ABSTRACT: Objectives To assess effectiveness and safety of Foley catheter versus vaginal misoprostol for term induction of labor.Study Design This trial randomly allocated women with singleton term pregnancy to 30-mL Foley catheter or 25-μg vaginal misoprostol tablets. Primary outcome was cesarean delivery rate. Secondary outcomes were maternal and neonatal morbidity and time to birth. Additionally, a systematic review was conducted.Results Fifty-six women were allocated to Foley catheter, 64 to vaginal misoprostol tablets. Cesarean delivery rates did not differ significantly (25% Foley versus 17% misoprostol; relative risk [RR] 1.46, 95% confidence interval [CI] 0.72 to 2.94), with more cesarean deliveries due to failure to progress in the Foley group (14% versus 3%; RR 4.57, 95% CI 1.01 to 20.64). Maternal and neonatal outcomes were comparable. Time from induction to birth was longer in the Foley catheter group (36 hours versus 25 hours; p < 0.001). Meta-analysis showed no difference in cesarean delivery rate and reduced vaginal instrumental deliveries and hyperstimulation in the Foley catheter group. Other outcomes were not different.Conclusion Our trial and meta-analysis showed no difference in cesarean delivery rates and less hyperstimulation with fetal heart rate changes and vaginal instrumental deliveries when using Foley catheter, thereby supporting potential advantages of the Foley catheter over misoprostol as ripening agent.
  American Journal of Perinatology 04/2013;
• Article: Neonatal Morbidity by Week of Gestational Age for Twins Compared to Singletons: A Population-Based Cohort Study.

  Katherine Wolfe, Meredith Tabangin, Jareen Meinzen-Derr, Candice Snyder, David Lewis, Emily Defranco
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  ABSTRACT: Objective Quantify neonatal morbidity by week of gestation for twins compared with singletons.Study Design We performed a population-based retrospective cohort study of all Ohio births from 2006 to 2007. Composite neonatal morbidity consisting of Apgar score < 7 at 5 minutes, assisted ventilation > 6 hours, neonatal transport, or seizures was compared between singletons and twins from 34 to 41 weeks.Results Neonatal morbidity was the lowest in twins delivered at 37 completed weeks and 2 weeks later for singletons at 39 weeks. Twin morbidity rapidly increased after 37 weeks and reached 15.8% at 41 weeks versus the singleton morbidity rate of 3.4% at 41 weeks. Twins delivered at 39 weeks and beyond were more than twice as likely to incur neonatal morbidity compared with singletons.Conclusion The lowest rate of neonatal morbidity occurs at 37 weeks for twins versus 39 weeks for singleton births. The increased risk after 37 weeks for twins accelerates at a faster rate compared with that for singletons born past 39 weeks.
  American Journal of Perinatology 04/2013;
• Article: Combined Sonographic Testing Index and Prediction of Adverse Outcome in Preterm Fetal Growth Restriction.

  Anthony O Odibo, Katherine R Goetzinger, Alison G Cahill, Linda Odibo, George A Macones
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  ABSTRACT: Objective We sought to test the hypothesis that a combined sonographic scoring system (CSTI) that incorporates features of the biophysical profile (BPP) and multivessel Doppler evaluation improves prediction of adverse outcomes in preterm intrauterine growth restriction.Methods This was a prospective cohort study of growth-restricted fetuses with abnormal umbilical artery (UA) Doppler studies, defined as pulsatility index (PI) > 95th percentile for gestational age or absent/reversed end diastolic flow. Fetuses were followed with weekly BPP and Doppler evaluation of the UA, middle cerebral artery (MCA), and ductus venosus (DV) until the time of delivery. The cerebroplacental Doppler ratio (CPR) was then calculated (MCA PI/UA PI). MCA PI < 5th percentile, MCA peak systolic velocity (PSV) > 1.5 multiples of the median, DV PI > 95th percentile with or without absent/reversed flow, and CPR < 1.08 were considered abnormal. Using logistic regression modeling, a weighted scoring index for the prediction of a composite fetal vulnerability index (FVI), which included 5-minute Apgar score < 3, cord pH < 7.2, seizures, necrotizing enterocolitis, grade 4 intraventricular hemorrhage, periventricular leukomalacia, and neonatal death, was developed. A receiver operating characteristic (ROC) curve was used to identify the best score associated with the FVI.Results Of 66 patients meeting inclusion criteria over a 5-year period, 17 (25.8%) had a positive FVI. Abnormal BPP (< 8), MCA PI, MCA PSV, DV PI, and CPR were observed in 6, 27.3, 13.6, 56.1, and 33.3% of patients, respectively. From the logistic regression model, a CSTI was developed including a score of 1 for abnormal BPP, 3 for MCA PSV, 1 for DV, 6 for CPR, and 3 for oligohydramnios. The ROC curve identified a score of ≥ 7 to be the best predictor of FVI with sensitivity of 35.1% and specificity of 91.8% and a positive likelihood ratio of 4.3 (area under ROC curve 0.73). These test characteristics were better than those for any of the individual component antenatal tests.Conclusion Although this novel scoring system performs modestly in predicting adverse outcomes in FGR, it appears to perform better than any individual antenatal test currently available.
  American Journal of Perinatology 04/2013;
• Article: Perinatal Outcomes of Multiple-Gestation Pregnancies in Kenya, Zambia, Pakistan, India, Guatemala, and Argentina: A Global Network Study.

  Irene Marete, Constance Tenge, Omrana Pasha, Shivaprasad Goudar, Elwyn Chomba, Archana Patel, Fernando Althabe, Ana Garces, Elizabeth M McClure, Sarah Saleem, [......], Patricia L Hibberd, Nancy Krebs, Pierre Buekens, Robert L Goldenberg, Waldemar A Carlo, Dennis Wallace, Janet Moore, Marion Koso-Thomas, Linda L Wright, Edward A Liechty
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  ABSTRACT: Aim To determine the rates of multiple gestation, stillbirth, and perinatal and neonatal mortality and to determine health care system characteristics related to perinatal mortality of these pregnancies in low- and middle-income countries.Methods Pregnant women residing within defined geographic boundaries located in six countries were enrolled and followed to 42 days postpartum.Results Multiple gestations were 0.9% of births. Multiple gestations were more likely to deliver in a health care facility compared with singletons (70 and 66%, respectively, p < 0.001), to be attended by skilled health personnel (71 and 67%, p < 0.001), and to be delivered by cesarean (18 versus 9%, p < 0.001). Multiple-gestation fetuses had a relative risk (RR) for stillbirth of 2.65 (95% confidence interval [CI] 2.06, 3.41) and for perinatal mortality rate (PMR) a RR of 3.98 (95% CI 3.40, 4.65) relative to singletons (both p < 0.0001). Neither delivery in a health facility nor the cesarean delivery rate was associated with decreased PMR. Among multiple-gestation deliveries, physician-attended delivery relative to delivery by other health providers was associated with a decreased risk of perinatal mortality.Conclusions Multiple gestations contribute disproportionately to PMR in low-resource countries. Neither delivery in a health facility nor the cesarean delivery rate is associated with improved PMR.
  American Journal of Perinatology 03/2013;
• Article: Vitamin C Supplementation in Pregnancy-Does It Decrease Rates of Preterm Birth? A Systematic Review.

  Paul Swaney, John Thorp, Ian Allen
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  ABSTRACT: Objective To assess the evidence available on the use of vitamin C supplementation greater than recommended dietary intake to reduce preterm birth rates.Study Design Systematic review of randomized controlled trials using vitamin C alone or with one other supplement other than iron. Trials must report preterm birth rates but can have other primary outcomes. Preterm birth is defined as birth at less than 37 weeks' gestational age for this review. Review focused on studies with populations representative of Organization for Economic Co-operation and Development countries.Results Inadequate level of evidence on the use of vitamin C alone to prevent preterm birth rates in low-risk populations based on one study. Three studies provided convincing evidence of no benefit in low-risk groups of use of vitamins C and E combined. Three studies provided adequate evidence of no benefit in high-risk groups of use of vitamins C and E combined.Conclusion The available evidence supports no benefit gained from using vitamin C to prevent preterm birth. Evidence does not support limiting use of vitamin C supplementation for other indications.
  American Journal of Perinatology 03/2013;
• Article: Predicting the Need for Medical Therapy in Patients with Mild Gestational Diabetes.

  Hector Mendez-Figueroa, Julie Daley, Vrishali V Lopes, Donald R Coustan
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  ABSTRACT: Objective The enforcement of a one-step gestational diabetes mellitus (GDM) diagnosis would capture more patients with milder forms of glucose intolerance thereby increasing the incidence. We propose to identify characteristics predicting the need for medical therapy in such patients.Study Design Retrospective chart review of patients with mild GDM, defined as a fasting plasma glucose (FPG) < 95 mg/dL on the 3-hour 100-g oral glucose tolerance test (OGTT). Patients requiring medical therapy for glucose control were compared with diet-controlled patients. A predictive model was constructed with variables of significance.Results Included were 143 patients requiring medical therapy and 224 diet-treated patients. Mean FPG on 3-hour OGTT, prepregnancy body mass index (BMI), and BMI at 26 to 30 weeks were all significantly higher in patients requiring therapy. Combining several variables produced a predictive model with 76% sensitivity, 52% specificity, 48% positive predictive value, and 78% negative predictive value.Conclusions Antenatal factors (alone or in combination) do not allow for prediction of the possible need for therapy in mild GDM patients.
  American Journal of Perinatology 03/2013;
• Article: The Clinical and Economic Impact of Nurse to Patient Staffing Ratios in Women Receiving Intrapartum Oxytocin.

  Steven L Clark, George A Saade, Janet A Meyers, Donna R Frye, Jonathan B Perlin
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  ABSTRACT: Objective To examine the relationship between nurse-to-patient staffing ratios and perinatal outcomes in women receiving oxytocin during labor.Study Design A retrospective analysis of perinatal outcomes in women receiving oxytocin for induction or augmentation of labor during 2010. Outcomes examined were fetal distress, birth asphyxia, primary cesarean delivery, chorioamnionitis, endomyometritis, and a composite of adverse events. Frequency of 1:1 nurse-to-patient staffing was determined for each hospital. Outcomes were compared between hospitals categorized into quartiles of staffing ratios.Results In 208,033 women delivering during 2010, there was no relation between frequency of 1:1 nurse-to-patient staffing ratio and improved perinatal outcomes. Adoption of universal 1:1 staffing in the United States would result in the need for an additional 27,000 labor nurses and a cost of $1.6 billion.Conclusion Available data do not support the imposition of mandatory 1:1 nurse-to-patient staffing ratios for women receiving oxytocin in all U.S. facilities.
  American Journal of Perinatology 03/2013;
• Article: The Use of Digital Peripheral Artery Tonometry to Detect Endothelial Dysfunction in Pregnant Women Who Smoke.

  Christy F Pearce, Kristine Lain, Wendy F Hansen, Thomas Curry, John M O'Brien
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  ABSTRACT: Objective We hypothesized that, as has been shown outside of pregnancy, endothelial dysfunction would be seen in a dose-dependent fashion among women who smoke in the midtrimester of pregnancy.Study Design Endothelial function in women with singleton pregnancies between 16 and 23 weeks was analyzed utilizing the Endo-PAT2000 device (Itamar Medical Ltd., Caesarea, Israel) and expressed as a reactive hyperemia ratio (RHI). Serum was drawn to check cotinine and high-sensitivity C-reactive protein (CRP) levels. SAS 9.2 (SAS Institute, Cary, NC) was used to perform statistical tests including Student t test, analysis of variance, Fisher exact test, and Pearson coefficient.Results Endothelial function was noninvasively examined in 29 smokers and 31 nonsmokers. Demographics including age, race, and parity were similar between groups. Mean RHI was not significantly different between smokers and nonsmokers (1.43 ± 0.32 versus 1.53 ± 0.39, p = 0.27). No correlation was noted when cotinine values were plotted against RHI or CRP values in smokers (rho = 0.24, p = 0.21 and rho = 0.26, p = 0.18, respectively). RHI did correlate with diastolic blood pressure (rho = -0.40, p = 0.002), systolic blood pressure (rho = -0.35, p = 0.006), and heart rate (rho = -0.37, p = 0.004).Conclusion We did not find an association between smoking status and endothelial dysfunction in the midtrimester utilizing a noninvasive methodology.
  American Journal of Perinatology 03/2013;
• Article: Morphine Sleep in Pregnancy.

  A Dhanya Mackeen, Eric Fehnel, Vincenzo Berghella, Thomas Klein
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  ABSTRACT: Objectives To determine the incidence of admission in labor after morphine sleep (therapeutic rest), patient characteristics associated with labor, and adverse outcomes associated with treatment.Methods We reviewed medical records of women treated with morphine sleep from December 2005 to December 2009. Variables evaluated included medications used for treatment, cervical examination, maternal demographic characteristics and obstetric history, fetal heart rate patterns, and maternal/neonatal outcomes. These characteristics were compared between those admitted in labor after morphine sleep versus those discharged.Results Fifty-eight women received morphine sleep: 36 (62%) were admitted in labor, 17 (29%) were discharged, and 5 (9%) were admitted secondary to category II fetal heart rate tracings. All fetuses had category I fetal heart rate tracings prior to treatment. Median dose of morphine sulfate was 20 mg. Those with effacement > 50% (p < 0.01) and carrying term gestations (p < 0.01) were more likely to be admitted in labor after treatment. There were no adverse maternal outcomes. There were no significant differences in neonatal outcomes.Conclusion Sixty-two percent of women were admitted in labor after morphine sleep. Admission effacement > 50% and term gestational age were associated with admission in labor. There were no significant differences in maternal or neonatal morbidity in those admitted versus discharged home after treatment with morphine sleep.
  American Journal of Perinatology 03/2013;