The unborn smoker: association between smoking during pregnancy and adverse perinatal outcomes

OBJECTIVE

To evaluate a possible dose-response relationship between active maternal smoking during pregnancy and adverse perinatal outcome.

DESIGN

Retrospective cohort study.

SETTING

Population-based in Montreal, Quebec, Canada.

POPULATION

Women who gave birth to a liveborn or stillborn infant during the period of January 2001 to December 2007.

METHODS

Active smokers of different daily cigarette consumption (n=1646) were identified through maternal self-reporting. The reference group comprised 19,292 non-smoking women who delivered during the same period.

MAIN OUTCOME MEASURES

Birth weight, preterm delivery rate, fetal and neonatal mortality and morbidity, and congenital malformations.

RESULTS

Preterm delivery rate was significantly higher in the smoking group compared with controls (22.2% vs. 12.4%, P<0.05), as was intrauterine fetal demise (1.4% vs. 0.3%, P<0.05). Newborns of active smokers were more likely to weigh less (3150±759 g vs. 3377±604 g, P<0.05), suffer from respiratory distress syndrome (2.5% vs. 1.3%, P<0.05), suffer from a cardiac malformation (1.5% vs. 0.8%, P<0.05), and die (neonatal death 1.2% vs. 0.6%, P<0.05). A dose-response relationship was demonstrated between levels of daily cigarette smoking and several adverse outcomes. Using multiple regression models, smoking was found to be an independent predictor of preterm delivery (odds ratios (OR) 1.9, 95% confidence intervals (95%CI) 1.6-2), and intrauterine fetal demise (OR 2.4, 95%CI 1.4-4.2).

CONCLUSION

Any amount of daily smoking appears to harm the fetus and newborn. As pregnancy may be a "window of opportunity" for behavioural changes, efforts to promote smoking cessation should be encouraged.

Mechanical labor induction in the obese population: a secondary analysis of a prospective randomized trial

OBJECTIVE

The objective of this study was to estimate the influence of maternal body mass index (BMI) on progress and outcomes of labor induction using mechanical devices.

METHODS

This study was a secondary analysis of data collected during the Cook Catheter vs. Foley Catheter study, a series of prospective randomized trials of women requiring cervical ripening for labor induction. The duration, characteristics, and outcomes of labor were analyzed after stratification by BMI categories. Outcomes assessed included time from device insertion to delivery, successful ripening, cesarean delivery rates, and any maternal and neonatal adverse events.

RESULTS

One hundred and eighty-one patients were stratified according to BMI categories, with 102 study participants classified as normal weight (BMI ≤30) and 79 as obese (BMI >30). Maternal satisfaction from the induction process was significantly lower in the obese group compared to the normal weight group (5.95 ± 3.14 vs. 7.58 ± 2.7, respectively, in a 1-10 scale, p = 0.009). The cesarean delivery rate was similar in the normal weight and the obese groups (17.6 vs. 25.3 %, respectively, p = 0.27). No statistical differences were found in all other outcomes evaluated, including a sub-analysis of the different mechanical devices.

CONCLUSIONS

During the process of mechanical cervical ripening, maternal satisfaction, but not objective obstetrical parameters, was influenced by increased maternal BMI. The trial is registered at ClinicalTrials.gov, no: NCT00604487. Trial registry name is "Induction of Labor in Patients with Unfavorable Cervical Conditions."

Spontaneous resolution of an umbilical cord arteriovenous fistula

An umbilical arteriovenous (AV) fistula is an extremely rare anomaly of the umbilical cord, with only one case being documented in the literature. The purpose of this report is to describe the prenatal sonographic characteristics of such a lesion and its potential complications. We report a case of an umbilical cord AV fistula detected at 24 weeks of gestation in one fetus of dichorionic-diamniotic twins. Color flow and spectral Doppler examinations showed a jet originating from one of the umbilical arteries entering the dilated umbilical vein. Serial ultrasounds revealed relative oligohydramnios and deep A waves in the ductus venosus for the affected twin. Upon performing fetal echocardiography assessment, mild cardiomegaly and dilatation of the inferior vena cava were detected. Chromosomal testing revealed a normal karyotype. The patient continued to be followed for close monitoring of fetal well-being and corticosteroids were administered. Cesarean section was planned for 28–30 weeks, but surprisingly, the oligohydramnios resolved, Doppler studies normalized, and no further intra-uterine growth restriction or fetal compromise was observed. Due to the recurrence of abnormal Doppler studies at 36 weeks of gestation, the patient was admitted for an induction of labor followed by a vaginal delivery of two healthy infants. Given the scarcity of reports regarding umbilical cord AV fistula, it is important to perform an extensive investigation of the affected fetus including karyotype and echocardiography. Furthermore, delivery timing should rely on close surveillance of fetal well-being to avoid the risk of fetal demise.

Perinatal outcomes among women with bipolar disorder: a population-based cohort study

OBJECTIVE

To evaluate the risk of adverse perinatal outcomes among pregnant women previously hospitalized for bipolar disorder.

STUDY DESIGN

We completed a population-based cohort study of women with a singleton delivery in Ontario, Canada (2003 to 2011). Women previously hospitalized for bipolar disorder (n = 1859) or major depressive disorder (n = 3724) were each compared to women without a documented mental illness (n = 432,358). Main study outcomes were preterm birth, severe small for gestational age <3rd percentile birthweight, and severe large for gestational age >97th percentile birthweight. Secondary outcomes included stillbirth, congenital malformations, neonatal morbidity and readmission to hospital <28 days. Odds ratios (ORs) were adjusted for maternal age, parity, prepregnancy obesity, substance use, and diabetes mellitus or hypertension before or during pregnancy.

RESULTS

Bipolar disorder (adjusted OR [AOR], 1.95; 95% confidence interval [CI], 1.68-2.26) and major depressive disorder (AOR, 1.91; 95% CI, 1.72-2.13) were each associated with preterm birth. Bipolar disorder was associated with severe large for gestational age (AOR, 1.31; 95% CI, 1.03-1.67). Major depressive disorder was associated with severe small for gestational age (AOR, 1.22; 95% CI, 1.05-1.42). Both mood disorder groups had significantly higher risk of congenital malformations, neonatal morbidity, and neonatal hospital readmission. Although study covariates explained some of the increased risk, we could not address all potential explanatory factors.

CONCLUSION

Women previously hospitalized for bipolar disorder are at increased risk of adverse perinatal outcomes compared with the general population. Their level of risk is comparable to women previously hospitalized for major depressive disorder. These risks must be considered in the management of pregnant women with a history of major mood disorders. Attention to potentially modifiable risk factors such as obesity, diabetes, and hypertension before and during pregnancy could reduce the risk for adverse perinatal outcomes.

Trans-cervical double balloon catheter with and without extra-amniotic saline infusion for cervical ripening: a prospective quasi-randomized trial

OBJECTIVE

To compare the efficacy and safety of the trans-cervical double balloon catheter with and without extra-amniotic saline infusion (EASI) for cervical ripening.

METHODS

This is a secondary analysis of a prospective randomized study conducted between November 2007 and January 2011 evaluating different ripening methods. Women presenting for labor induction were assigned to receive the double balloon catheter with (study group) or without EASI (control group). Outcomes included time from device insertion to delivery, cesarean section rates, and adverse events.

RESULTS

One hundred and sixty women completed the study. Cesarean section rate (8.3% in study group, versus 20% in controls p = 0.07) and ripening success were comparable between the groups. Catheter insertion to delivery interval was significantly shorter and spontaneous catheter expulsion rate was significantly higher in the study group (14:19 hours versus 20:45 hours, p < 0.001, and 68.5% versus 51%, p = 0.04, respectively). Hospitalization length was significantly shorter in the study arm. There were no differences in other outcomes evaluated. A multivariable analysis found the EASI to be an independent predictor of a shorter insertion to delivery interval.

CONCLUSIONS

The addition of EASI to the double balloon catheter for cervical ripening results in a shorter labor induction process without compromising its safety.

Making cervical ripening EASI: a prospective controlled comparison of single versus double balloon catheters

OBJECTIVE

To compare the efficacy of two mechanical devices for cervical ripening: double versus single balloon catheters, both with extra-amniotic saline infusion (EASI).

METHODS

Women at term with a singleton pregnancy presenting for labor induction were assigned to receive the double balloon catheter (with EASI) or the single balloon catheter (with EASI). Outcomes included time from device insertion to delivery, rates of successful vaginal delivery and occurrence of adverse events.

RESULTS

One hundred and eighty-six women completed the study. Ripening success was comparable between the double and single balloon arms (96.4% versus 92.7%, p = 0.55, respectively). Balloon insertion to delivery interval was significantly shorter, and cesarean section rate was significantly lower in the double balloon arm compared with the single balloon arm (14.3 versus 15.8 h, p = 0.04 and 8.3% versus 20%, p = 0.05, respectively). There were no significant differences in maternal characteristics, satisfaction or adverse outcomes.

CONCLUSIONS

This study is the first documented assessment of the double balloon catheter combined with EASI. Our findings suggest that the double balloon catheter results in reduced time to delivery and higher vaginal delivery rates, compared with the single balloon catheter with EASI, without compromising maternal or fetal safety.

Prediction of preeclampsia: liver function tests during the first 20 gestational weeks

OBJECTIVE

To examine whether plasma levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) during the first 20 weeks of pregnancy can predict preeclampsia in the second half of pregnancy.

METHODS

The study population included 150,10 registered births. Receiver operating characteristic (ROC) curve analysis was used to describe the relationship between different values of AST and ALT during the first 20 weeks of pregnancy in the prediction of preeclampsia.

RESULTS

Using ROC curve analyses, elevated ALT levels were significantly associated with both mild preeclampsia (p < 0.001) and severe preeclampsia (p = 0.032). However, an ALT level of 50 IU/L had a sensitivity of only 3.3% (despite a specificity of 97%) in the prediction of severe preeclampsia. While no significant association was noted between AST levels and mild preeclampsia (p = 0.669), elevated levels of AST during this period were significantly associated with severe preeclampsia (p = 0.027). However, AST of 50I U/L had a sensitivity of only 2.0% (despite a specificity of 98%) in the prediction of severe preeclampsia.

CONCLUSIONS

Higher levels of the liver enzymes AST and ALT during the first 20 weeks of pregnancy are associated with higher risk for the development of severe preeclampsia in the second half of the pregnancy. Nevertheless, there is no clinical cutoff value that can be practically used for the prediction of preeclampsia.

Proangiogenic immature myeloid cells populate the human placenta and their presence correlates with placental and birthweight

OBJECTIVE

To determine whether proangiogenic immature myeloid cells are present in human placentas.

STUDY DESIGN

Biopsies were obtained from 61 placentas of term pregnancies. Percentage of CD45(+)CD33(+)LIN2(-)HLADR(-) immature myeloid cells of total CD45(+) hematopoietic cells was determined by flow cytometry. Location of immature myeloid cells in the placenta was identified using confocal microscopy. The proangiogenic potential of immature myeloid cells was analyzed by endothelial tube formation.

RESULTS

Immature myeloid cells comprise ∼25% of human placental CD45(+) hematopoietic cells and infiltrate placentas in proximity of blood vessels. The percentage of immature myeloid cells correlated positively with placental weight (r(2) = 0.108, P = .01) and birthweight (r(2) = 0.087, P = .02). Endothelial tube formation was increased in the presence of immature myeloid cells as compared with the presence of CD45(+)LIN2(+) control cells.

CONCLUSION

Human placentas are populated by immature myeloid cells in the proximity of blood vessels. Consistent with their involvement in angiogenesis, immature myeloid cells accelerated endothelial tube formation. The presence of immature myeloid cells in pathologic pregnancies warrants further studies.