Sex-Specific Differences in Late Preterm Neonatal Outcomes

OBJECTIVE

To estimate sex-specific differences in late preterm outcomes and evaluate whether betamethasone modifies this association.

STUDY DESIGN

We conducted a secondary analysis of a multicenter trial of women at risk for late preterm birth randomized to receive betamethasone or placebo. We included women who delivered at 34 to 37 weeks and excluded major fetal anomalies. The primary outcome was severe neonatal morbidity (mechanical ventilation, respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, necrotizing enterocolitis, and intraventricular hemorrhage). Maternal characteristics were compared using chi-square test, t-test, or Mann-Whitney U-test. Multivariable logistic regression estimated the association between sex and morbidity, and likelihood ratio testing assessed for effect modification by betamethasone.

RESULTS

Of 2,831 women in the primary trial, 2,331 met the inclusion criteria: 1,236 delivered males and 1,095 delivered females. Betamethasone modified the association between sex and severe morbidity (p = 0.047). Among those who received betamethasone, male sex was associated with higher odds of severe morbidity (adjusted odds ratio: 1.95, 95% confidence interval: 1.25-3.05), compared with female sex. Among those who did not receive betamethasone, there was no significant association between sex and morbidity.

CONCLUSION

Male sex is a risk factor for adverse late preterm outcomes, including severe neonatal morbidity after betamethasone receipt.

The association of age at menopause and all-cause and cause-specific mortality by race, postmenopausal hormone use, and smoking status

While a mean age at menopause of 51 years has been reported in the United States (U.S.), some U.S. women experience menopause before age 45, possibly increasing risk of cardiovascular mortality; however, the role in all-cause and cerebrovascular-related mortality is unclear. The purpose of this study was to investigate the association between age at menopause and all-cause and cause-specific mortality by race, hormone replacement therapy (HRT) use, and smoking status. REasons for Geographic and Racial Differences in Stroke (REGARDS) is a population-based study of 30,239 participants aged ≥45 years enrolled between 2003 and 2007 of whom 14,361 were postmenopausal women. Age at menopause was defined as <45 (early) or ≥45. All-cause and cause-specific mortality were ascertained through 2013. Cox proportional hazards models estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association between age at menopause and mortality, adjusting for baseline measures. Of 11,287 eligible women (6403 white; 4884 black), mean menopause age was 45.2 (SD 7.9) with 1524 deaths over 7.1 years. Significant interactions were detected between early age at menopause (39%) and HRT use in association with all-cause mortality (p < 0.01), mortality from coronary heart disease (p = 0.06), and mortality from all other causes (p = 0.04). An association between early age at menopause and all-cause mortality was observed among ever-HRT users (HR = 1.31, 95% CI: 1.10–1.56), but not never-HRT users (HR = 1.01, 95% CI: 0.85–1.20). There were no differences in associations examined by race or smoking status. Increased all-cause mortality risk was observed for ever-HRT users with menopause before age 45.

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Increased all-cause mortality risk in ever-HRT users with menopause before age 45

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HRT use modified the association of menopause before age 45 and CHD mortality.

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There were no differences in associations examined by race or smoking status.

Assessing Child Health and Health Care in the U.S. Virgin Islands Using the National Survey of Children's Health

OBJECTIVES

To characterize the health and health care experiences of children in the U.S. Virgin Islands (USVI), assess differences by household poverty status, and provide comparisons to the general U.S. child population.

METHODS

Data are from the 2011-2012 National Survey of Children's Health, which included 2342 USVI children, aged 0-17 years. Parent-reported measures of health status and health conditions, behavioral characteristics, and health care access and utilization were assessed. Weighted prevalence estimates were calculated and compared by household poverty status using Chi square tests.

RESULTS

Overall, 31.3% of USVI children lived in households below 100% of the federal poverty level (FPL). Children in these low-income households were more likely to have public insurance (33.0% vs. 8.4%) and unmet health needs (11.6% vs. 6.3%) as compared to those in households with incomes ≥ 100% FPL (all p < 0.01). They were also less likely to have a medical home (22.5% vs. 42.2%), including a usual source of sick care (p < 0.01). Compared with U.S. children in general, USVI children had lower rates of preventive medical visits, preventive dental visits, and care received in a medical home.

CONCLUSIONS

USVI children experience challenges in accessing and utilizing health care services, particularly those in low-income households, and fare worse than U.S. children on many of these measures. These findings will serve as a baseline comparison for an upcoming survey of maternal and child health to be conducted in eight U.S. territories including the USVI.

Risk factors associated with prolonged neonatal intensive care unit stay after threatened late preterm birth

OBJECTIVE

To identify risk factors associated with neonatal intermediate or intensive care unit (NICU) stay ≥3 days among women with threatened late preterm birth (PTB).

STUDY DESIGN

Secondary analysis of women with nonanomalous, singleton gestations enrolled in multicenter trial of betamethasone versus placebo for late PTB. Maternal and obstetric characteristics at time of presentation with threatened PTB were compared between those with and without NICU stay ≥3 days. Multivariable logistic regression identified risk factors for NICU stay ≥3 days.

RESULT

Of 2795 eligible mother-neonate dyads, 962 (34%) had NICU stay ≥3 days. Gestational age and fetal growth restriction as the reason for threatened PTB had the strongest association with NICU stay ≥3 days in the final model (AUC 0.76).

CONCLUSION

Maternal and obstetric characteristics at the time of admission for threatened late PTB should be considered when counseling patients about the probability of NICU stay ≥3 days.

The Association Between Parity and Subsequent Cardiovascular Disease in Women: The Atherosclerosis Risk in Communities Study

Background: Previous studies are inconclusive on the relationship between parity and cardiovascular disease (CVD), with few evaluating multiple cardiovascular outcomes. It is also unclear if any relationship between parity and CVD is independent of breastfeeding. We examined the associations between parity and cardiovascular outcomes, including breastfeeding adjustment. Materials and Methods: Data were from 8,583 White and African American women, 45-64 years of age, in the Atherosclerosis Risk in Communities Study. Coronary heart disease (CHD), myocardial infarction (MI), heart failure, and strokes were ascertained from 1987 to 2016 by annual interviews and hospital surveillance. Parity and breastfeeding were self-reported. Cox proportional hazards regression estimated hazard ratios (HR) for the association between parity and cardiovascular outcomes, adjusting for baseline sociodemographic, clinical and lifestyle factors, and breastfeeding. Results: Women reported no pregnancies (6.0%), or having 0 (1.6%), 1-2 (36.2%), 3-4 (36.4%), or 5+ (19.7%) live births. During 30 years follow-up, there were 1,352 CHDs, 843 MIs, 750 strokes, and 1,618 heart failure events. Compared with women with 1-2 prior births, those with prior pregnancies and no live births had greater incident CHD (HR = 1.64, 95% confidence interval 1.14-2.42) and heart failure risk (1.46, 1.04-2.05), after adjustment for baseline characteristics. Women with 5+ births had greater risk of CHD (1.29, 1.10-1.52) and hospitalized MI (1.38, 1.13-1.69), after adjustment for baseline characteristics and breastfeeding. Conclusions: In a diverse U.S. cohort, a history of 5+ live births is associated with CHD risk, specifically, MI, independent of breastfeeding. Having a prior pregnancy and no live birth is associated with greater CHD and heart failure risk.

Maternal diabetes and hypertensive disorders in association with autism spectrum disorder

Previous studies have shown complications of pregnancy, often examined in aggregate, to be associated with autism spectrum disorder (ASD). Results for specific complications, such as maternal diabetes and hypertension, have not been uniformly consistent and should be investigated independently in relation to ASD in a large community-based sample. The Study to Explore Early Development (SEED), a US multisite case-control study, enrolled children born in 2003-2006 at 2-5 years of age. Children were classified into three groups based on confirmation of ASD (n = 698), non-ASD developmental delay (DD; n = 887), or controls drawn from the general population (POP; n = 979). Diagnoses of any diabetes or hypertensive disorder during pregnancy were identified from prenatal medical records and maternal self-report. Logistic regression models estimated adjusted odds ratios (aOR) and confidence intervals (CI) adjusting for maternal age, race/ethnicity, education, smoking during pregnancy, and study site. Models for hypertension were additionally adjusted for parity and plurality. Among 2,564 mothers, we identified 246 (9.6%) with any diabetes and 386 (15.1%) with any hypertension in pregnancy. After adjustment for covariates, any diabetes during pregnancy was not associated with ASD (aOR = 1.10 [95% CI 0.77, 1.56]), but any hypertension was associated with ASD (aOR = 1.69 [95% CI 1.26, 2.26]). Results were similar for DD, and any diabetes (aOR = 1.29 [95% CI 0.94, 1.78]) or any hypertension (aOR = 1.71 [95% CI 1.30, 2.25]). Some pregnancy complications, such as hypertension, may play a role in autism etiology and can possibly serve as a prompt for more vigilant ASD screening efforts. Autism Res 2019, 12: 967-975. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We studied if common complications in pregnancy are associated with autism spectrum disorder (ASD) in a large sample of mothers and children. Our results show an association between conditions marked by high blood pressure and ASD, but no association with conditions marked by high blood sugar and ASD. Associations were similar for children who had a developmental disorder that was not ASD, suggesting that this relationship may not be specific to ASD.

Maternal lipid levels during pregnancy and child weight status at 3 years of age

BACKGROUND

The intrauterine environment is critical in the development of child obesity.

OBJECTIVE

To investigate the association between maternal lipid levels during pregnancy and child weight status.

METHODS

Maternal lipid levels (total cholesterol, high-density and low-density lipoprotein cholesterol, triglycerides) collected from fasting blood samples collected at less than 20 and 24-29 weeks' gestation and child weight status at age 3 were examined prospectively among 183 mother-child dyads enrolled in the Pregnancy, Infection, and Nutrition. Measured height and weight at 3 years were used to calculate age- and sex-specific body mass index z-scores. Child risk of overweight/obesity was defined as body mass index greater than or equal to 85th percentile for age and sex. Regression models estimated the association between maternal lipid levels and child body mass index z-score and risk of being affected by overweight/obesity, respectively.

RESULTS

Higher triglyceride levels at less than 20 and 24-29 weeks of pregnancy were associated with higher body mass index z-scores (β = 0.23; 95% CI: 0.07-0.38 and β = 0.15; 95% CI: 0.01-0.29; respectively) after adjusting for confounders. There was no evidence of an association between total or low-density lipoprotein cholesterol and child weight status at age 3.

CONCLUSIONS

Early childhood body mass index may be influenced by maternal triglyceride levels during pregnancy.

Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children

OBJECTIVES

To use the latest data to estimate the prevalence and correlates of currently diagnosed depression, anxiety problems, and behavioral or conduct problems among children, and the receipt of related mental health treatment.

STUDY DESIGN

We analyzed data from the 2016 National Survey of Children's Health (NSCH) to report nationally representative prevalence estimates of each condition among children aged 3-17 years and receipt of treatment by a mental health professional. Parents/caregivers reported whether their children had ever been diagnosed with each of the 3 conditions and whether they currently have the condition. Bivariate analyses were used to examine the prevalence of conditions and treatment according to sociodemographic and health-related characteristics. The independent associations of these characteristics with both the current disorder and utilization of treatment were assessed using multivariable logistic regression.

RESULTS

Among children aged 3-17 years, 7.1% had current anxiety problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression. The prevalence of each disorder was higher with older age and poorer child health or parent/caregiver mental/emotional health; condition-specific variations were observed in the association between other characteristics and the likelihood of disorder. Nearly 80% of those with depression received treatment in the previous year, compared with 59.3% of those with anxiety problems and 53.5% of those with behavioral/conduct problems. Model-adjusted effects indicated that condition severity and presence of a comorbid mental disorder were associated with treatment receipt.

CONCLUSIONS

The latest nationally representative data from the NSCH show that depression, anxiety, and behavioral/conduct problems are prevalent among US children and adolescents. Treatment gaps remain, particularly for anxiety and behavioral/conduct problems.

Association of chorioamnionitis and its duration with adverse maternal outcomes by mode of delivery: a cohort study

OBJECTIVE

To investigate the association of chorioamnionitis and its duration with adverse maternal outcomes by mode of delivery.

DESIGN

A retrospective cohort study.

SETTING

Data from the Consortium on Safe Labor Study in the USA (2002-2008).

POPULATION

Singleton deliveries at ≥23 weeks of gestation (221 274 assessed deliveries, 62 331 by caesarean section).

METHODS

The association of chorioamnionitis, and secondarily the duration of chorioamnionitis estimated from intrapartum antibiotic use, with adverse maternal outcomes was analysed using logistic regression with generalised estimating equations, adjusting for age, parity, race, pregestational diabetes, chronic hypertension, gestational age at delivery, study site and delivery year. Analyses were stratified by vaginal versus caesarean delivery.

MAIN OUTCOME MEASURES

The composite adverse maternal outcome included: postpartum transfusion, endometritis, wound/perineal infection/separation, venous thromboembolism, hysterectomy, admission to intensive care unit and/or death.

RESULTS

Chorioamnionitis was associated with higher odds of the composite adverse maternal outcome with caesarean delivery (adjusted odds ratio 2.31; 95% CI 1.97-2.71); and the association persisted regardless of whether a woman had a trial of labour, preterm delivery or maternal group B streptococcus colonisation. The most common adverse outcomes after caesarean section were postpartum transfusion (56.0%) and wound/perineal infection or endometritis (38.6%). Chorioamnionitis was not associated with adverse maternal outcomes after vaginal delivery. The duration of chorioamnionitis as the exposure did not alter the association between chorioamnionitis and adverse maternal outcomes.

CONCLUSIONS

Chorioamnionitis, but not the estimated duration, was associated with increased odds of adverse maternal outcomes with caesarean delivery. This finding has implications for care programmes to prevent maternal morbidity after a caesarean section complicated by chorioamnionitis.

TWEETABLE ABSTRACT

Chorioamnionitis, but not its duration, increases the risk of adverse maternal outcomes with caesarean delivery.

Report of the Office of Population Affairs' expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research

BACKGROUND

The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based.

METHODS

To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health.

RESULTS

Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work.

CONCLUSIONS

This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes

BACKGROUND

Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings.

METHODS

In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes.

RESULTS

We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age.

CONCLUSION

This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children

: media-1vid110.1542/5839990273001PEDS-VA_2017-4161Video Abstract OBJECTIVES: To estimate the national prevalence of parent-reported autism spectrum disorder (ASD) diagnosis among US children aged 3 to 17 years as well as their treatment and health care experiences using the 2016 National Survey of Children's Health (NSCH).

METHODS

The 2016 NSCH is a nationally representative survey of 50 212 children focused on the health and well-being of children aged 0 to 17 years. The NSCH collected parent-reported information on whether children ever received an ASD diagnosis by a care provider, current ASD status, health care use, access and challenges, and methods of treatment. We calculated weighted prevalence estimates of ASD, compared health care experiences of children with ASD to other children, and examined factors associated with increased likelihood of medication and behavioral treatment.

RESULTS

Parents of an estimated 1.5 million US children aged 3 to 17 years (2.50%) reported that their child had ever received an ASD diagnosis and currently had the condition. Children with parent-reported ASD diagnosis were more likely to have greater health care needs and difficulties accessing health care than children with other emotional or behavioral disorders (attention-deficit/hyperactivity disorder, anxiety, behavioral or conduct problems, depression, developmental delay, Down syndrome, intellectual disability, learning disability, Tourette syndrome) and children without these conditions. Of children with current ASD, 27% were taking medication for ASD-related symptoms, whereas 64% received behavioral treatments in the last 12 months, with variations by sociodemographic characteristics and co-occurring conditions.

CONCLUSIONS

The estimated prevalence of US children with a parent-reported ASD diagnosis is now 1 in 40, with rates of ASD-specific treatment usage varying by children's sociodemographic and co-occurring conditions.

Cardiovascular Health of Mothers in the United States: National Health and Nutrition Examination Survey 2007-2014

Background: Pregnancy and childrearing can impact women's health and alter chronic disease trajectories in later life, including cardiovascular disease. The purpose of this study was to assess measures of women's cardiovascular health by time since last live birth. Materials and Methods: Data were from 4,021 nonpregnant U.S. women, 20-44 years of age, participating in the 2007-2014 National Health and Nutrition Examination Survey (NHANES). Cardiovascular health was assessed using physical measures, laboratory measures, self-reported behaviors, medical conditions, and selected psychosocial factors by time since last live birth. Results: Women reported their last live birth within the past 12 months ("mothers of infants"; 7.4%), >12 months, but <3 years ago ("mothers of toddlers"; 10.0%), or ≥3 years ago ("mothers of older children"; 45.2%); 37.3% were nulliparous. Compared with nulliparous women, mothers of older children had a higher prevalence of selected cardiovascular risk factors, including unhealthy diet (75.6% vs. 68.8%) and smoking (28.1% vs. 21.9%), after adjustment for sociodemographics (including age). Mothers of toddlers had a higher prevalence of unhealthy diet (78.0% vs. 68.8%). Mothers also had poorer metabolic health as indicated by a higher prevalence of low HDL cholesterol among mothers of toddlers and older children (44.2% and 40.4%, respectively, vs. 33.6%), and a higher prevalence of high waist circumference among mothers of infants (65.6% vs. 53.8%). Some mothers also had a higher prevalence of other cardiovascular risk factors, including low physical activity and poor sleep. Conclusion: Prior pregnancy and childrearing may be associated with selected cardiovascular risk factors among nonpregnant reproductive-aged U.S. women.

Implementing Group Prenatal Care in Southwest Georgia Through Public-Private Partnerships

Introduction CenteringPregnancy® is well-regarded as an innovative group model of prenatal care. In 2009, Georgia's Southwest Public Health District partnered with local obstetricians and medical centers to expand prenatal care access and improve perinatal outcomes for low-income women by implementing Georgia's first public health administered CenteringPregnancy program. This paper describes the successful implementation of CenteringPregnancy in a public health setting with no prior prenatal services; assesses the program's first 5-year perinatal outcomes; and discusses several key lessons learned. Methods Prenatal and hospital medical records of patients were reviewed for the time period from October 2009 through October 2014. Descriptive analyses were conducted to examine demographic and clinical characteristics of women initiating prenatal care and to assess perinatal outcomes among patients with singleton live births who attended at least three CenteringPregnancy sessions or delivered prior to attending the third session. Results Six hundred and six low-income women initiated prenatal care; 55.4 and 36.4% self-identified as non-Hispanic black and Hispanic, respectively. The median age was 23 years (IQR 20, 28). Nearly 69% initiated prenatal care in the first trimester. Perinatal outcomes were examined among 338 singleton live births. The 2010-2014 preterm birth rate (% of births < 37 weeks gestation at delivery) and low birth weight rate (% of births < 2500 g) were 9.1 and 8.9%, respectively. Nearly 77% of women initiated breastfeeding. Discussion CenteringPregnancy administered via public-private partnership may improve access to prenatal care and perinatal outcomes for medically underserved women in low-resource settings.

Lipoprotein particle concentration measured by nuclear magnetic resonance spectroscopy is associated with gestational age at delivery: a prospective cohort study

OBJECTIVE

To estimate the association between lipoprotein particle concentrations in pregnancy and gestational age at delivery.

DESIGN

Prospective cohort study.

SETTING

The study was conducted in the USA at the University of North Carolina.

POPULATION

We assessed 715 women enrolled in the Pregnancy, Infection, and Nutrition study from 2001 to 2005.

METHODS

Fasting blood was collected at two time points (<20 and 24-29 weeks of gestation). Nuclear magnetic resonance (NMR) quantified lipoprotein particle concentrations [low-density lipoprotein (LDL), high-density lipoprotein (HDL), very-low density lipoprotein (VLDL)] and 10 subclasses of lipoproteins. Concentrations were assessed as continuous measures, with the exception of medium HDL which was classified as any or no detectable level, given its distribution. Cox proportional hazards models estimated hazard ratios (HR) for gestational age at delivery adjusting for covariates.

MAIN OUTCOME MEASURES

Gestational age at delivery, preterm birth (<37 weeks of gestation), and spontaneous preterm birth.

RESULTS

At <20 weeks of gestation, three lipoproteins were associated with later gestational ages at delivery [large LDL_NMR (HR 0.78, 95% CI 0.64-0.96), total VLDL_NMR (HR 0.77, 95% CI 0.61-0.98), and small VLDL_NMR (HR 0.78, 95% CI 0.62-0.98], whereas large VLDL_NMR (HR 1.19, 95% CI 1.01-1.41) was associated with a greater hazard of earlier delivery. At 24-28 weeks of gestation, average VLDL_NMR (HR 1.25, 95% CI 1.03-1.51) and a detectable level of medium HDL_NMR (HR 1.90, 95% CI 1.19-3.02) were associated with earlier gestational ages at delivery.

CONCLUSION

In this sample of pregnant women, particle concentrations of VLDL_NMR , LDL_NMR , IDL_NMR , and HDL_NMR were each independently associated with gestational age at delivery for all deliveries or spontaneous deliveries <37 weeks of gestation. These findings may help formulate hypotheses for future studies of the complex relationship between maternal lipoproteins and preterm birth.

TWEETABLE ABSTRACT

Nuclear magnetic resonance spectroscopy may identify lipoprotein particles associated with preterm delivery.

Racial Disparities in Delivery Gestational Age among Twin Pregnancies

Objective This study aims to estimate the association between maternal race and delivery gestational age among women with twin gestations.

Study Design Secondary analysis of a prospective, randomized control trial of 17-α hydroxyprogesterone caproate versus placebo for preterm birth (PTB) prevention in twin gestations. Non-Hispanic (NH) black and whites were included. Demographic and antenatal characteristics were compared. The primary outcome was delivery gestational age. Secondary outcomes included a composite of major neonatal morbidity. Kaplan–Meier curves estimated survival probabilities for delivery gestational age by race. Cox proportional hazards models estimated hazard ratios (HR) and 95% confidence intervals (CI).

Results A total of 535 women with twin gestations were included; 150 were NH black. NH blacks delivered earlier than NH whites (33.6 ± 4.8 weeks vs. 35.1 ± 3.5 weeks, p < 0.001). Differences in delivery gestational age between NH blacks and whites were consistent across gestation. In adjusted analyses, NH black race (HR: 1.24, 95% CI: 1.02–1.51), prior PTB (HR: 1.59, 95% CI: 1.15–2.19), and cerclage (HR: 3.90, 95% CI: 2.00–7.60) were associated with an increased risk of earlier delivery. Major neonatal morbidity was higher for NH blacks compared with NH whites (12.7 vs. 7.0%, p = 0.036).

Conclusion NH blacks with twin gestations have an increased risk of early delivery and neonatal morbidity compared with NH whites.

Maternal obesity and major intraoperative complications during cesarean delivery

BACKGROUND

Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications.

OBJECTIVE

To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD).

METHODS

This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m², BMI 30 to 39.9 kg/m², BMI 40 to 49.9 kg/m², and BMI ≥ 50 kg/m². The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision.

RESULTS

A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m², 47% BMI 30 to 39.9 kg/m², 12% BMI 40 to 49.9 kg/m² and 3% BMI ≥ 50 kg/m². Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m², 3.2% BMI 30 to 39.9 kg/m², 2.6% BMI 40 to 49.9 kg/m² and 4.3% BMI ≥ 50 kg/m² (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m² had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m². Women with BMI 30 to 39.9 kg/m² (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication.

CONCLUSION

In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity.

Maternal super obesity and risk for intensive care unit admission in the MFMU Cesarean Registry

INTRODUCTION

Obesity is a risk factor for intensive care unit (ICU) admission in nonpregnant populations. Less is known about maternal obesity and ICU admission risk. The objective of this study was to estimate the association between maternal obesity and ICU admission among women who delivered via cesarean section or vaginal birth after cesarean section (VBAC).

MATERIAL AND METHODS

This is a retrospective cohort analysis of women who delivered via VBAC or cesarean section in the Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry. We defined exposure as body mass index (BMI) at delivery stratified as non-obese (BMI 18.5-29.9 kg/m² ), class I or II obese (BMI 30-39.9 kg/m² ), morbidly obese (BMI 40-49.9 kg/m² ), and super obese (BMI ≥ 50 kg/m² ). The primary outcome was ICU admission. Modified Poisson regression models estimated relative risk (RR) of ICU admission by obesity strata, after adjusting for confounders. Mediation analysis was used to estimate the proportion of ICU admission risk attributable specifically to obesity.

RESULTS

We included 68 455 women; 40% non-obese, 46% class I or II obese, 12% morbidly obese, and 2% super obese. Super obese women were at higher risk for ICU admission compared with non-obese women (0.7 vs. 1.3%, adjusted RR 1.61; 95% CI 1.01-2.65), after adjusting for confounders. Among super obese women, medical comorbidities mediated 58% of ICU admission risk, suggesting that a significant proportion of ICU admission is driven by maternal obesity.

CONCLUSIONS

Super obese women who deliver by cesarean section or VBAC are at increased risk of peripartum ICU admission. Obstetricians and critical care specialists should consider possible ICU admission during delivery planning.

Higher number of live births is associated with left ventricular diastolic dysfunction and adverse cardiac remodelling among US Hispanic/Latina women: results from the Echocardiographic Study of Latinos

Introduction

Female sex is a risk factor for heart failure with preserved ejection fraction (HFpEF). Previous literature suggests that some diastolic dysfunction (DD) develops during pregnancy and may persist postdelivery. Our objective was to examine the relationship between parity and cardiac structure and function in a population-based cohort.

Methods

Participants included 1172 Hispanic/Latina women, aged ≥45 years, enrolled in the Echocardiographic Study of Latinos from four US communities (Bronx, Miami, San Diego and Chicago). Standard echocardiographic techniques were used to measure cardiac volumes, left ventricular mass, systolic and diastolic function. Using sampling weights and survey statistics, multivariable linear and logistic regression models were constructed adjusting for age, body mass index, diabetes or prediabetes, systolic blood pressure, use of antihypertensive medications, smoking, total cholesterol and high-density lipoprotein cholesterol.

Results

In the target population, 5.0% were nulliparous (no live births) and 10.5% were grand multiparous (≥5 live births). Among the nulliparous women, 46% had DD as compared with 51%–58% of women with 1–4 live births and 81% of women with ≥5 live births (p<0.01). In full multivariate models, higher parity was significantly associated with greater left ventricular end-systolic volumes, end-diastolic volumes, left atrial volume indices and presence of DD (all p<0.01) but was not associated with ejection fraction. The log odds for having any grade of DD in grand-multiparous women was over three times that seen in nulliparous women (OR=3.4, 95% CI 1.5 to 7.9, p<0.01) in models further adjusted for income and education.

Conclusions

Higher parity is associated with increased cardiac mass, volumes and the presence of DD. Further studies are needed to elucidate this apparent deleterious relation and whether parity can help explain the increased risk of HFpEF in women.

Parity and Components of the Metabolic Syndrome Among US Hispanic/Latina Women: Results From the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Physiological adaptations occurring across successive pregnancies may increase the risk of adverse cardiovascular health outcomes in later life.

METHODS AND RESULTS

The association between parity and metabolic syndrome was examined among 7467 Hispanic/Latina women of diverse backgrounds, aged 18 to 74 years, who participated in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) from 2008 to 2011. Metabolic syndrome components were defined according to American Heart Association/National Heart, Lung, and Blood Institute criteria and included abdominal obesity, elevated triglycerides, low high-density lipoprotein cholesterol, high blood pressure, and elevated fasting glucose. Logistic regression models estimated odds ratios (ORs) adjusting for sociodemographic, behavioral, and reproductive characteristics. At HCHS/SOL baseline, women reported none (21.1%), 1 (19.9%), 2 (25.7%), 3 (18.6%), 4 (8.8%), and ≥ 5 (5.9%) live births. When compared with women with 1 birth, those with 4 births had the highest odds of abdominal obesity (OR, 2.0; 95% confidence interval, 1.5-2.8) and overall metabolic syndrome (OR, 1.4; 95% confidence interval, 1.0-2.0) and those with ≥ 5 births had the highest odds of low high-density lipoprotein cholesterol (OR, 1.5; 95% confidence interval, 1.2-2.0) and elevated fasting glucose (OR, 1.6; 95% confidence interval, 1.1-2.4), after adjusting for age, background, education, marital status, income, nativity, smoking, physical activity, menopause, oral contraceptive use, hormone therapy, and field center. Further adjustment for percent body fat attenuated these associations. No associations were observed between parity and elevated triglycerides or high blood pressure.

CONCLUSIONS

Higher parity is associated with an increased prevalence of selected components of the metabolic syndrome among Hispanic/Latina women in the US. High parity among Hispanics/Latinas with a high prevalence of abdominal obesity suggests high risk for metabolic dysregulation.

Racial Differences in the Association between Parity and Incident Stroke: Results from the REasons for Geographic and Racial Differences in Stroke Study

BACKGROUND

Circulatory and vascular changes across consecutive pregnancies may increase the risk of later-life cerebrovascular health outcomes.

METHODS

The association between parity and incident stroke was assessed among 7674 white and 6280 black women, aged 45 years and older, and enrolled in the REasons for Geographic and Racial Differences in Stroke Study from 2003 to 2007. Parity was assessed at baseline, and incident stroke was ascertained from physician-adjudicated medical records through September 2014. Cox proportional hazards models were used to estimate hazard ratios (HR) for the association between parity and stroke, adjusting for baseline measures.

RESULTS

At baseline, 12.7% of white women and 16.2% of black women reported 1 live birth, while 8.2% and 19.0%, respectively, reported 5 or more live births. Mean follow-up time was 7.5 years (standard deviation = 2.8); there were 447 incident strokes. A significant interaction between race and parity was detected (P = .05). Among white women, those with 5 or more live births had a higher stroke risk than those with 1 live birth (HR = 1.57; 95% confidence interval [CI] .93-2.65). However, the association was eliminated after adjustment for baseline characteristics (HR = 1.00, 95% CI .59-1.71). For black women, those with 5 or more live births had the highest stroke risk compared with those with 1 live birth (HR = 1.91, 95% CI 1.25-2.93), but the association was attenuated and no longer statistically significant after adjustment for confounders (HR = 1.40, 95% CI .89-2.18).

CONCLUSIONS

In adjusted models, no statistically significantassociations were observed between parity and stroke risk in a diverse cohort of U.S. women. Further studies are needed to elucidate the role of lifestyle and psychosocial factors in the race-specific associations that were observed.