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Birth outcomes across the spectrum of maternal age: dissecting aging effect versus confounding by social and medical determinants.
Olapeju, B, Hong, X, Wang, G, Summers, A, Burd, I, Cheng, TL, Wang, X
BMC pregnancy and childbirth. 2021;(1):594
Abstract
BACKGROUND Given the trend of increasing maternal age and associated adverse reproductive outcomes in the US, this study aimed to assess whether this association is due to an independent aging or confounded by sociodemographic, biomedical, or behavioral determinants in a predominantly Black US population. METHODS Data was from 8509 women enrolled in the Boston Birth Cohort. Adverse reproductive outcomes included spontaneous preterm delivery, cesarean delivery, and low birth weight. Covariates included sociodemographic (parity, race/ethnicity, education, marital status, income, receipt of public assistance, nativity); biomedical (obesity, hypertensive disorders, diabetes mellitus); and behavioral (consistent intake of multivitamin supplements, support from father of baby, support from family, major stress in pregnancy, cigarette smoking, alcohol intake). Analysis included Lowess and marginal probability plots, crude and adjusted sequential logistic regression models to examine age-outcome associations and to what degree the association can be explained by the above covariables. RESULT Overall, the study sample had high levels of spontaneous preterm birth (18%), cesarean delivery (33%) and low birth weight (26%). Unadjusted models showed no significant difference odds of spontaneous preterm birth by maternal age but higher odds of cesarean section (aOR: 1.77, 95% CI: 1.60, 1.95) and low birth weight (aOR: 1.15, 95% CI: 1.04, 1.28) among women 30 years or older. Adjustment for sociodemographic factors, biomedical conditions and behavioral factors revealed higher odds of spontaneous preterm birth: (aOR: 1.30, 95% CI: 1.14, 1.49), cesarean section deliveries (aOR: 1.68, 95% CI: 1.51, 1.87) and low birth weight (aOR: 1.36, 95% CI: 1.21, 1.53). Across all ages, optimal BMI status and consistent multivitamin supplement intake were protective of spontaneous preterm birth and low birth weight. CONCLUSION In this high-risk minority population, we demonstrated that the association between increasing maternal age and adverse pregnancy outcomes was due to an independent aging effect and the presence of confounding by sociodemographic, biomedical, and behavioral factors. Some modifiable risk factors to counteract aging effect, include optimizing BMI and consistent intake of multivitamin supplement. A fundamental change in how care is provided to women, particularly low income Black women, is needed with emphasis on the protective role of optimal nutritional status. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03228875.
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Nausea, vomiting and poor appetite during pregnancy and adverse birth outcomes in rural Nepal: an observational cohort study.
Regodón Wallin, A, Tielsch, JM, Khatry, SK, Mullany, LC, Englund, JA, Chu, H, LeClerq, SC, Katz, J
BMC pregnancy and childbirth. 2020;(1):545
Abstract
BACKGROUND Nausea and vomiting are experienced by a majority of pregnant women worldwide. Previous studies have yielded conflicting results regarding their impact on birth outcomes and few studies have examined this relationship in settings with limited resources. We aimed to determine the effect of nausea, vomiting and poor appetite during pregnancy on birth outcomes in rural Nepal. METHODS Observational cohort study using data collected in two randomized, community-based trials to assess the effect of influenza immunization during pregnancy on reproductive and respiratory outcomes among pregnant women and their offspring. Pregnant women in Sarlahi District, Nepal were recruited from 2011 to 2013. Exposure was defined as nausea, vomiting or poor appetite at any point during pregnancy and by trimester; symptoms were recorded monthly throughout pregnancy. Adverse outcomes were low birth weight (LBW), preterm birth and small for gestational age (SGA). Adjusted relative risks (aRR) with 95% CIs are reported from Poisson regressions with robust variance. RESULTS Among 3,623 pregnant women, the cumulative incidence of nausea, vomiting or poor appetite was 49.5% (n = 1793) throughout pregnancy and 60.6% (n = 731) in the first trimester. Significantly higher aRRs of LBW and SGA were observed among women experiencing symptoms during pregnancy as compared to symptom free women (LBW: aRR 1.20; 95% CI 1.05 1.28; SGA: aRR 1.16; 95% CI 1.05 1.28). Symptoms in the first trimester were not significantly associated with any of the outcomes. In the second trimester, we observed significantly higher aRRs for LBW and SGA (LBW: aRR 1.17; 95% CI 1.01 1.36; SGA: aRR 1.16; 95% CI 1.05 1.29) and a significantly lower aRR for preterm birth (aRR 0.75; 95% CI 0.59 0.96). In the third trimester, we observed significantly higher aRRs for LBW and SGA (LBW: aRR 1.20; 95% CI 1.01 1.43; SGA: aRR 1.14; 95% CI 1.01 1.29). CONCLUSIONS Symptoms of nausea, vomiting or poor appetite during pregnancy are associated with LBW, SGA and preterm birth in a setting with limited resources, especially beyond the first trimester. TRIAL REGISTRATION Prospectively registered at ClinicalTrials.gov on Dec 17, 2009 ( NCT01034254 ).
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Association of preterm birth with lipid disorders in early adulthood: A Swedish cohort study.
Crump, C, Sundquist, J, Sundquist, K
PLoS medicine. 2019;(10):e1002947
Abstract
BACKGROUND Preterm birth has previously been linked with cardiovascular disease (CVD) in adulthood. However, associations with lipid disorders (e.g., high cholesterol or triglycerides), which are major risk factors for CVD, have seldom been examined and are conflicting. Clinicians will increasingly encounter adult survivors of preterm birth and will need to understand the long-term health sequelae. We conducted the first large population-based study to determine whether preterm birth is associated with an increased risk of lipid disorders. METHODS AND FINDINGS A retrospective national cohort study was conducted of all 2,235,012 persons born as singletons in Sweden during 1973 to 1995 (48.6% women), who were followed up for lipid disorders identified from nationwide inpatient, outpatient, and pharmacy data through 2016 (maximum age 44 years). Cox regression was used to adjust for other perinatal and maternal factors, and co-sibling analyses assessed the potential influence of unmeasured shared familial (genetic and/or environmental) factors. A total of 25,050 (1.1%) persons were identified with lipid disorders in 30.3 million person-years of follow-up. Each additional 5 weeks of gestation were associated with a 14% reduction in risk of lipid disorders (adjusted hazard ratio [HR], 0.86; 95% CI, 0.83-0.89; P < 0.001). Relative to full-term birth (gestational age 39-41 weeks), the adjusted HR associated with preterm birth (<37 weeks) was 1.23 (95% CI, 1.16-1.29; P < 0.001), and further stratified was 2.00 (1.41-2.85; P < 0.001) for extremely preterm (22-27 weeks), 1.33 (1.19-1.49; P < 0.001) for very preterm (28-33 weeks), and 1.19 (1.12-1.26; P < 0.001) for late preterm (34-36 weeks). These findings were similar in men and women (e.g., preterm versus full-term, men: HR, 1.22; 95% CI, 1.14-1.31; P < 0.001; women: HR, 1.23; 1.12-1.32; P < 0.001). Co-sibling analyses suggested that they were substantially though not completely explained by shared genetic or environmental factors in families. The main study limitation was the unavailability of laboratory data to assess specific types or severity of lipid disorders. CONCLUSIONS In this large national cohort, preterm birth was associated with an increased risk of lipid disorders in early- to midadulthood. Persons born prematurely may need early preventive evaluation and long-term monitoring for lipid disorders to reduce their future cardiovascular risks.
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Timing and Amount of Gestational Weight Gain in Association with Adverse Birth Outcomes.
Darling, AM, Werler, MM, Cantonwine, DE, Fawzi, WW, McElrath, TF
Epidemiology (Cambridge, Mass.). 2019;(5):695-705
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BACKGROUND Most existing research on gestational weight gain and pregnancy outcomes has not accounted for timing of weight gain. The area under the weight gain curve (AUC) provides a single measure that incorporates both timing of weight gain and total amount gained. This study evaluated predictors and outcomes associated with second- and third-trimester weight gain AUC from the second and third trimester using time-to-event analysis to account for the correlation between gestational weight gain and gestational duration. METHODS Our prospective cohort study used data from the LifeCodes study at Brigham and Women's Hospital. Maternal weights were available from all prenatal and study visits. We used log-Poisson models with empirical variance estimation to identify predictors of total AUC from 14 weeks to delivery and Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between AUC quintile and adverse pregnancy outcomes. RESULTS Compared to the middle quintile, the highest quintile of accumulated pound-days was associated with a decreased hazard of spontaneous preterm birth among multigravid women (HR = 0.44; 95% CI = 0.23, 0.84), a decreased hazard of small-for-gestational-age births (HR = 0.65; 95% CI = 0.45, 0.92) overall and an increased hazard of large-for-gestational-age births among normal and underweight women (HR = 3.21; 95% CI = 1.50, 6.89) CONCLUSIONS In our study, a pattern of gestational weight gain characterized by more rapid gains earlier in pregnancy was associated with improved pregnancy outcomes in some subgroups of pregnant women.
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Comparison of Interfaces for the Delivery of Noninvasive Respiratory Support to Low Birthweight Infants.
Drescher, GS, Hughes, CW
Respiratory care. 2018;(10):1197-1206
Abstract
BACKGROUND Bench and clinical data indicate that techniques for applying noninvasive respiratory support may vary in terms of effectiveness, application, and tolerability. We implemented a new nasal interface and flow-generation system for the delivery of noninvasive respiratory support (NRS) to replace previously used systems. Our goal was to determine whether there were significant differences in clinically relevant outcomes between our new method and conventional systems. METHODS We conducted a prospective observational study of preterm infants requiring noninvasive respiratory support during our initial implementation of a new nasal interface (RAM), and compared these data with a historic control group. Demographic, baseline, and clinical outcome data were collected. Clinical outcomes and comorbid conditions were compared by using the chi-square test for categorical information and the Student t test or Wilcoxon rank-sum test for quantitative data, depending on normality testing when using the Shapiro-Wilk test. Uni- and multivariate logistic regression were conducted to determine predictive factors for the development of bronchopulmonary dysplasia. RESULTS There were no significant group differences in important comorbid conditions, invasive mechanical ventilation days (P = .16), or NRS failure within the first 7 d after birth (P = .10). Although there were no significant differences in the use of CPAP or noninvasive ventilation, settings with were significantly higher (P < .001) in the RAM group. There were more incidences of retinopathy of prematurity (P = .02) post RAM implementation, and the time to first reintubation was significantly shorter in the RAM group (P = .044). However, there were significant reductions post RAM in total days on any respiratory support (P = .009), total NRS days (P = .02), and supplemental O2 duration (P = .02). There was a trend toward reductions in bronchopulmonary dysplasia rates (P = .053), and the incidence of device-related tissue breakdown was significantly reduced (P < .001) post RAM. Multivariate logistic regression results showed the type of system (odds ratio [OR] 0.19, 95% CI 0.04-0.87; P = .032) and total invasive ventilation time (OR 0.94, 95% CI 0.89-0.99; P = .02) were predictors for the development of bronchopulmonary dysplasia. CONCLUSIONS The ability to apply continuous distending pressure through consistent application of NRS with the RAM cannula attached to a ventilator may improve clinical outcomes, including the duration of respiratory support and pressure-ulcer rates. The influence of this system on the development of bronchopulmonary dysplasia and the significantly increased retinopathy of prematurity requires further study.
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Outcome of extremely preterm infants after iatrogenic or spontaneous birth.
Fritz, T, Källén, K, Maršál, K, Jacobsson, B
Acta obstetricia et gynecologica Scandinavica. 2018;(11):1388-1395
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INTRODUCTION The risks of preterm birth are known. We investigated the perinatal and infant mortality and morbidity after iatrogenic or spontaneous onset of extremely preterm birth. MATERIAL AND METHODS The present study used data from the population-based EXPRESS study comprising all infants delivered before 27+0 gestational weeks in Sweden between 2004 and 2007. All fetuses alive at admission and with known mode of onset of delivery were included (682 live-born infants; 65 intrapartum deaths). Four multivariate regression models were applied with adjustments for gestational age, fetal gender, multiple pregnancy, and birthweight. RESULTS After adjustment for gestational age, no significant differences were found between iatrogenic and spontaneous onsets of birth regarding intrapartum death, early neonatal death (0-6 d), or death within 364 days. In the group with iatrogenic onset of delivery, there was an increased risk for severe morbidity (odds ratio [OR] 1.86, 95% confidence interval [95% CI] 1.15-3.02), severe bronchopulmonary dysplasia (OR 1.90, 95% CI 1.10-3.26), and retinopathy of prematurity (OR 1.99, 95% CI 1.21-3.27) after adjustment for gestational age, fetal gender, and multiple pregnancy. After additional adjustment for weight z-scores at 36 gestational weeks, the associations were not significant. Within the group with spontaneous onset of delivery, fetuses with preterm prelabor rupture of membranes had increased mortality risk. CONCLUSIONS No evidence was found for mode of onset of delivery (iatrogenic vs spontaneous) having an impact on neonatal or infant mortality or morbidity in extremely preterm infants. Instead, gestational age and growth deviation at birth seem to be associated with the outcome.
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Trends and Outcomes of Patent Ductus Arteriosus Treatment in Very Preterm Infants in Canada.
Lokku, A, Mirea, L, Lee, SK, Shah, PS, ,
American journal of perinatology. 2017;(5):441-450
Abstract
Objective To assess trends in patent ductus arteriosus (PDA) management and examine concurrent changes in neonatal mortality and morbidities. Methods This retrospective observational study examined infants born at 23 to 32 weeks' gestational age with PDA and admitted to a neonatal unit during 2006 to 2012. Multivariable logistic regression assessed trends in yearly PDA treatment rates and compared a composite outcome of mortality or any severe morbidity (bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, or necrotizing enterocolitis) between and within time periods and PDA treatments. Results Study subjects included 5,824 preterm neonates with clinical/echocardiographic PDA diagnosis. During 2006 to 2012, conservative management increased (14-38%), whereas pharmacotherapy-only (58-49%), surgical ligation-only (7.1-2.5%), and both pharmacotherapy and surgical ligation (21-10%) decreased (p-values <0.01). From 2006 to 2008 and 2009 to 2012, the composite outcome decreased for infants managed conservatively (AOR = 0.70, 95% CI 0.52-0.92), with no changes detected for pharmacotherapy and/or ligation. Lower composite outcome after conservative management versus pharmacotherapy-only during 2009 to 2012 (AOR = 0.61, 95% CI 0.51-0.74), but not during 2006 to 2008 reflect significant effect modification by time period. Conclusion In Canada, during 2006 to 2012, conservative PDA management increased while pharmacotherapy and/or surgical ligation decreased. Lower composite outcome was detected during later years after increases in conservative management; however, bias due to unmeasured confounders remains possible.
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Childhood stress and birth timing among African American women: Cortisol as biological mediator.
Gillespie, SL, Christian, LM, Alston, AD, Salsberry, PJ
Psychoneuroendocrinology. 2017;:32-41
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Preterm birth (PTB) occurs among 1:11U.S. white women and 1:7.5 African American women and is a significant driver of racial disparities in infant mortality. Maternal stress is the most common clinical phenotype underlying spontaneous PTB. Specific patterns of stress and biological mediators driving PTB remain unclear. We examined the effect of childhood stress on birth timing among African American women and evaluated maternal cortisol elevation as a biological mediator. A prospective observational design was employed, with a single study visit at 28-32 weeks gestation and medical record review. The Stress and Adversity Inventory was administered, which provides a comprehensive estimate of childhood stress, stress in adulthood, and five core characteristic subscales (interpersonal loss, physical danger, humiliation, entrapment, role disruption). Venipuncture was performed between 11:00am and 4:00pm and plasma cortisol quantified by ELISA. Analyses controlled for stress in adulthood. Among a final sample of 89, cumulative childhood stress predicted birth timing (p=0.01). The association was driven by stress related to interpersonal loss and physical danger, with support for maternal cortisol as a biological mediator (ab=0.02, 95% CI [0.001, 0.045]; ab=0.02, 95% CI [0.001, 0.043], respectively). Results were similar, overall, in sub-group analyses among spontaneously laboring women (n=53); however, role disruption arose as an additional predictor, as mediated by cortisol elevations (ab=0.03, 95% CI [0.005, 0.074]). Of note, cortisol was no longer supported as a mediator linking physical danger to birth timing after adjusting for sleep quality and hours awake prior to venipuncture (ab=0.02, 95% CI [-0.0001, 0.046]). We provide preliminary evidence that, independent of stress in adulthood, childhood stress of specific core characteristics may shape birth timing, with cortisol elevation as a biological mediator. Further investigation is warranted and may bolster the development of biologically-informed screening tools for the prediction and targeted prevention of stress-related PTB.
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Association among prematurity (<30 weeks' gestational age), blood pressure, urinary albumin, calcium, and phosphate in early childhood.
Vashishta, N, Surapaneni, V, Chawla, S, Kapur, G, Natarajan, G
Pediatric nephrology (Berlin, Germany). 2017;(7):1243-1250
Abstract
BACKGROUND There is a paucity of data on blood pressures (BP), urinary albumin, and mineral excretion in early childhood in contemporary cohorts of extremely low gestational age (GA) neonates. Our aim was to compare BPs and the urinary excretion of albumin, calcium, and phosphate in preterm and term-born cohorts in early childhood. METHODS This was a prospective observational study conducted at a single center, involving children <5 years age, born preterm (GA <30 weeks) or at term (≥37 weeks' GA). Urinary albumin (mg/L), calcium and phosphate levels indexed to creatinine (mg/dL), and BP were measured. RESULTS The median (IQR) follow-up age of our cohort (n = 106) was 30 (16-48) months. Preterm-born children (n = 55) had a significantly lower mean GA and birth weight and higher mean systolic, diastolic, and mean BPs, compared with term (n = 51) controls. A significantly higher proportion of preterm-born children weighed <10th centile and had systolic BP >95th centile at follow-up. Albumin and calcium excretion did not differ between the groups; median urine-phosphate creatinine ratios were higher in the preterm group. On logistic regression, lower GA and younger age at follow-up were significantly associated with an increased risk of systolic and diastolic BP above the 95th centile; male gender was associated with decreased risk of diastolic hypertension. CONCLUSIONS Even in early childhood, children born preterm had significantly elevated BP, compared with their term-born counterparts. Closer monitoring of BPs in this population may be warranted.
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A vegetable, fruit, and white rice dietary pattern during pregnancy is associated with a lower risk of preterm birth and larger birth size in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort study.
Chia, AR, de Seymour, JV, Colega, M, Chen, LW, Chan, YH, Aris, IM, Tint, MT, Quah, PL, Godfrey, KM, Yap, F, et al
The American journal of clinical nutrition. 2016;(5):1416-1423
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BACKGROUND Maternal dietary patterns during pregnancy have been shown to influence infant birth outcomes. However, to our knowledge, only a few studies have examined the associations in Asian populations. OBJECTIVE We characterized maternal dietary patterns in Asian pregnant women and examined their associations with the risk of preterm birth and offspring birth size. DESIGN At 26-28 wk of gestation, 24-h recalls and 3-d food diaries were collected from the women in the Growing Up in Singapore Towards healthy Outcomes mother-offspring cohort. Dietary patterns were derived from exploratory factor analysis. Gestational age was determined by a dating ultrasound scan in the first trimester, and infant birth anthropometric measurements were obtained from hospital records. Associations were assessed by logistic and linear regressions with adjustment for confounding factors. RESULTS Three maternal dietary patterns were identified: vegetable, fruit, and white rice (VFR); seafood and noodle (SfN); and pasta, cheese, and processed meat (PCP). Of 923 infants, 7.6% were born preterm, 13.4% were born small for gestational age, and 14.7% were born large for gestational age. A greater adherence to the VFR pattern (per SD increase in VFR score) was associated with a lower risk of preterm births (OR: 0.67; 95% CI: 0.50, 0.91), higher ponderal index (β: 0.26 kg/m3; 95% CI: 0.06, 0.45 kg/m3), and increased risk of a large-for-gestational-age birth (RR: 1.31; 95% CI: 1.06, 1.62). No associations were observed for the SfN and PCP patterns in relation to birth outcomes. CONCLUSIONS The VFR pattern is associated with a lower incidence of preterm birth and with larger birth size in an Asian population. The findings related to larger birth size warrant further confirmation in independent studies. This trial was registered at clinicaltrials.gov as NCT01174875.