HMOX1 Genetic Polymorphisms Display Ancestral Diversity and May Be Linked to Hypertensive Disorders in Pregnancy

Racial disparity exists for hypertensive disorders in pregnancy (HDP), which leads to disparate morbidity and mortality worldwide. The enzyme heme oxygenase-1 (HO-1) is encoded by HMOX1, which has genetic polymorphisms in its regulatory region that impact its expression and activity and have been associated with various diseases. However, studies of these genetic variants in HDP have been limited. The objective of this study was to examine HMOX1 as a potential genetic contributor of ancestral disparity seen in HDP. First, the 1000 Genomes Project (1 KG) phase 3 was utilized to compare the frequencies of alleles, genotypes, and estimated haplotypes of guanidine thymidine repeats (GTn; containing rs3074372) and A/T SNP (rs2071746) among females from five ancestral populations (Africa, the Americas, Europe, East Asia, and South Asia, N = 1271). Then, using genomic DNA from women with a history of HDP, we explored the possibility of HMOX1 variants predisposing women to HDP (N = 178) compared with an equivalent ancestral group from 1 KG (N = 263). Both HMOX1 variants were distributed differently across ancestries, with African women having a distinct distribution and an overall higher prevalence of the variants previously associated with lower HO-1 expression. The two HMOX1 variants display linkage disequilibrium in all but the African group, and within EUR cohort, LL and AA individuals have a higher prevalence in HDP. HMOX1 variants demonstrate ancestral differences that may contribute to racial disparity in HDP. Understanding maternal genetic contribution to HDP will help improve prediction and facilitate personalized approaches to care for HDP.

Manufacturing processes of peanut (Arachis hypogaea) allergen powder-dnfp

Background

Important components of drug safety, efficacy, and acceptability involve manufacturing and testing of the drug substance and drug product. Peanut flour sourcing/processing and manufacturing processes may affect final drug product allergen potency and contamination level, possibly impacting drug safety, quality, and efficacy. We describe key steps in the manufacturing processes of peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; Palforzia®), a drug used in oral immunotherapy (OIT) for the treatment of peanut allergy.

Methods

Established criteria for source material must be met for manufacturing PTAH drug product. Degree of roasting was determined with a Hunter colorimeter. Protein/allergen content, identity, potency, safety, and quality of each batch of PTAH drug substance were assessed with a combustion analyzer, allergen-specific Western blot (immunoblotting), ELISA, and HPLC. Contaminants (ie, aflatoxin) were measured by UPLC.

Results

Roasting degree beyond "light roast" was associated with variable degrees of protein allergen degradation, or potentially aggregation. Relative potency and amounts of protein allergens showed variability due in part to seasonal/manufacturing variability. Proportion of lots not meeting aflatoxin limits has increased in recent years. Up to 60% of peanut flour source material failed to meet screening selection acceptance criteria for proceeding to drug substance testing, mostly because of failure to meet potency acceptance criteria. Other lots were rejected due to safety (ie, aflatoxin) and quality. Influence of potency variation, within specification parameters, on safety/tolerability observed in trials was considered low, in part due to stringent controls placed at each step of manufacturing.

Conclusions

Extensive variability in allergen potency is a critical issue during immunotherapy, particularly during OIT initial dose escalation and up-dosing, as it may result in lack of efficacy or avoidable adverse allergic reactions. Based on EU and US regulatory requirements, the production of PTAH includes manufacturing controls to ensure drug product safety, potency, and quality. For example, although PTAH contains all peanut allergens, each lot has met strict criteria ensuring consistent allergenic potency of Ara h 1, Ara h 2, and Ara h 6. The rigor of PTAH's manufacturing process ensures reliable dose consistency and stability throughout its shelf life.

Effect of gestational age at first delivery and interpregnancy interval on the recurrence of clinical chorioamnionitis

BACKGROUND

There is an increased odds of having a recurrence of clinical chorioamnionitis in patients with a diagnosis of clinical chorioamnionitis compared with those without clinical chorioamnionitis in a previous pregnancy. However, it is unclear how gestational age at delivery of the first pregnancy or interpregnancy interval may contribute to this increased risk.

OBJECTIVE

This study aimed to evaluate how gestational age of delivery in a first pregnancy and interpregnancy interval affect the odds of recurrent clinical chorioamnionitis.

STUDY DESIGN

Using maternally linked birth record files, Nulliparous patients from California with at least 2 consecutive deliveries between the gestational ages of 20 and 44 weeks from 2007 to 2012 were identified. The rates of clinical chorioamnionitis in the second pregnancy for patients with clinical chorioamnionitis vs those without clinical chorioamnionitis in the first pregnancy, stratified by the gestational age at delivery of the first pregnancy were determined. As a secondary analysis, the analysis by interpregnancy interval (<18 months vs ≥18 months) was stratified. Corresponding crude and adjusted odds ratios for each stratum were calculated to assess the association of clinical chorioamnionitis in the first and second pregnancies.

RESULTS

Among 31,571 nulliparous patients with clinical chorioamnionitis in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was 4.0% (1257 cases). This was in comparison with the 1.0% (9177 of 896,154) of nulliparous patients without clinical chorioamnionitis in the first pregnancy who were diagnosed with clinical chorioamnionitis in the next pregnancy (adjusted odds ratio, 2.78; 95% confidence interval, 2.61-2.96). The absolute frequency of recurrence was the highest (54 cases [8.2%]) in those who delivered at 20 to 24 weeks of gestation in the first pregnancy with the diagnosis of clinical chorioamnionitis (adjusted odds ratio, 1.76; 95% confidence interval, 1.25-2.48). For pregnancies delivered at term in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was higher in those diagnosed with clinical chorioamnionitis in the first pregnancy than in those without clinical chorioamnionitis in the first pregnancy (4.0% vs 1.0%; adjusted odds ratio, 2.85; 95% confidence interval, 2.66-3.05). An interpregnancy interval of <18 months was not associated with increased odds of recurrent clinical chorioamnionitis.

CONCLUSION

The odds of recurrence of clinical chorioamnionitis were the strongest when a patient delivered in the term to postterm period in the first pregnancy, with the absolute risk being the highest when the first pregnancy was delivered in the periviable period (20-24 weeks of gestation). The interpregnancy interval did not seem to modify the risk of recurrent clinical chorioamnionitis.

Sexual and/or gender minority parental structures among California births from 2016 to 2020

BACKGROUND

Sexual and/or gender minority people account for roughly 7.1% of the US population, and an estimated one-third are parents. Little is known about sexual and/or gender minority people who become pregnant, despite this population having documented healthcare disparities that may affect pregnancy.

OBJECTIVE

Our objective was to describe parental structures among birth parents and the prepregnancy characteristics of parents giving birth in likely sexual and/or gender minority parental structures from California birth certificates.

STUDY DESIGN

We conducted a population-based study using birth certificate data from all live births in California from 2016 through 2020 (n=2,257,974). The state amended its birth certificate in 2016 to enable the recording of more diverse parental roles. Now, parents on birth certificates are classified as "parent giving birth" and "parent not giving birth" and people in either role can identify as "mother," "father," or "parent." We examined all potential combinations of parenting roles, and grouped parental structures of "mother-mother" and those designating a "father" as the "parent giving birth" into likely sexual and/or gender minority groups. We assessed the distribution of prepregnancy characteristics across parental structure groups ("mother-father," "sexual and/or gender minority," "mother only," "unclassified," and "missing both parental roles").

RESULTS

Sexual and/or gender minority parents accounted for 6802 (0.3%) of live births in California over the 5-year study period. The most common sexual and/or gender minority parental structures were "mother-mother" (n=4310; 63% of the group) and "father-father" (n=1486; 22% of the group). Compared with "parents giving birth" in the "mother-father" structure (n=2,055,038; 91%), a higher proportion of "parents giving birth" in the "sexual and/or gender minority" group were aged ≥35 years, White, college-educated, and had commercial health insurance. In addition, a higher proportion had a high prepregnancy body mass index. Although likely underreported overall, the proportion of those who used assisted reproductive technology was much higher in the "sexual and/or gender minority" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the 3 months before pregnancy was similar in both groups.

CONCLUSION

Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that sexual and/or gender minority parents differ from other parental structures and from the general sexual and/or gender minority population and warrant further research.

Sexual and/or gender minority disparities in obstetrical and birth outcomes

BACKGROUND

Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals.

OBJECTIVE

To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients.

STUDY DESIGN

We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations.

RESULTS

In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations.

CONCLUSION

Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.

Leukocyte telomere dynamics across gestation in uncomplicated pregnancies and associations with stress

BACKGROUND

Short leukocyte telomere length is a biomarker associated with stress and morbidity in non-pregnant adults. Little is known, however, about maternal telomere dynamics in pregnancy. To address this, we examined changes in maternal leukocyte telomere length (LTL) during uncomplicated pregnancies and explored correlations with perceived stress.

METHODS

In this pilot study, maternal LTL was measured in blood collected from nulliparas who delivered live, term, singleton infants between 2012 and 2018 at a single institution. Participants were excluded if they had diabetes or hypertensive disease. Samples were collected over the course of pregnancy and divided into three time periods: < 200/7 weeks (Timepoint 1); 201/7 to 366/7 weeks (Timepoint 2); and 370/7 to 9-weeks postpartum (Timepoint 3). All participants also completed a survey assessing a multivariate profile of perceived stress at the time of enrollment in the first trimester. LTL was measured using quantitative polymerase chain reaction (PCR). Wilcoxon signed-rank tests were used to compare LTL differences within participants across all timepoint intervals. To determine whether mode of delivery affected LTL, we compared postpartum Timepoint 3 LTLs between participants who had vaginal versus cesarean birth. Secondarily, we evaluated the association of the assessed multivariate stress profile and LTL using machine learning analysis.

RESULTS

A total of 115 samples from 46 patients were analyzed. LTL (mean ± SD), expressed as telomere to single copy gene (T/S) ratios, were: 1.15 ± 0.26, 1.13 ± 0.23, and 1.07 ± 0.21 for Timepoints 1, 2, and 3, respectively. There were no significant differences in LTL between Timepoints 1 and 2 (LTL T/S change - 0.03 ± 0.26, p = 0.39); 2 and 3 (- 0.07 ± 0.29, p = 0.38) or Timepoints 1 and 3 (- 0.07 ± 0.21, p = 0.06). Participants who underwent cesareans had significantly shorter postpartum LTLs than those who delivered vaginally (T/S ratio: 0.94 ± 0.12 cesarean versus 1.12 ± 0.21 vaginal, p = 0.01). In secondary analysis, poor sleep quality was the main stress construct associated with shorter Timepoint 1 LTLs (p = 0.02) and shorter mean LTLs (p = 0.03).

CONCLUSIONS

In this cohort of healthy pregnancies, maternal LTLs did not significantly change across gestation and postpartum LTLs were shorter after cesarean than after vaginal birth. Significant associations between sleep quality and short LTLs warrant further investigation.

Interpregnancy weight change: associations with severe maternal morbidity and neonatal outcomes

BACKGROUND

Prepregnancy body mass index and gestational weight gain have been linked with severe maternal morbidity, suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes.

OBJECTIVE

This study assessed the association of changes in prepregnancy body mass index between 2 consecutive singleton pregnancies with the outcomes of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants in the subsequent pregnancy.

STUDY DESIGN

This observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy body mass index change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy body mass index at index birth.

RESULTS

Substantial interpregnancy body mass index gain (≥4 kg/m2) was associated with severe maternal morbidity in crude but not adjusted analyses. Substantial interpregnancy body mass index loss (>2 kg/m2) was associated with increased risk of severe maternal morbidity (adjusted relative risk, 1.13; 95% confidence interval (1.07-1.19), and both substantial loss (adjusted relative risk, 1.11 [1.02-1.19]) and gain (≥4 kg/m2; adjusted relative risk, 1.09 [1.02-1.17]) were associated with nontransfusion severe maternal morbidity. Substantial loss (adjusted relative risk, 1.17 [1.05-1.31]) and gain (1.26 [1.14-1.40]) were associated with stillbirth. Body mass index gain was positively associated with large-for-gestational-age infants and inversely associated with small-for-gestational-age infants.

CONCLUSION

Substantial interpregnancy body mass index changes were associated with modestly increased risk of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants.

Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups

BACKGROUND

A recently developed obstetrical comorbidity scoring system enables the comparison of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity.

OBJECTIVE

This study aimed to evaluate the performance of an obstetrical comorbidity scoring system when applied across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity.

STUDY DESIGN

We analyzed a population-based cohort of live births that occurred in California during 2011 through 2017 with linked birth certificates and birth hospitalization discharge data (n=3,308,554). We updated a previously developed comorbidity scoring system to include the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modifications diagnosis codes and applied the scoring system to subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated the risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) for each group and estimated the disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression.

RESULTS

The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68 to 0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities when compared with the White group (1.3% before, 1.3% after) (American Indian-Alaska Native: 2.1% before, 1.8% after; Asian: 1.5% before, 1.7% after; Black: 2.5% before, 2.0% after; Latinx: 1.6% before, 1.7% after; Pacific Islander: 2.2% before, 1.9% after; and multi-race groups: 1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and government insurance groups. Higher educational attainment was associated with decreased severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity.

CONCLUSION

These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for other groups after adjustment for the comorbidity score.

Association of infertility with atherosclerotic cardiovascular disease among postmenopausal participants in the Women’s Health Initiative

OBJECTIVE

To investigate the association of infertility with atherosclerotic cardiovascular disease (ASCVD) among postmenopausal participants in the Women's Health Initiative (WHI). We hypothesized that nulliparity and pregnancy loss may reveal more extreme phenotypes of infertility, enabling further understanding of the association of infertility with ASCVD.

DESIGN

Prospective cohort study.

SETTING

Forty clinical centers in the United States.

PATIENT(S)

A total of 158,787 postmenopausal participants in the Women's Health Initiative cohort.

INTERVENTION(S)

Infertility, parity, and pregnancy loss.

MAIN OUTCOME MEASURE(S)

The primary outcome was risk of ASCVD among women with and without a history of infertility, stratified by history of live birth and pregnancy loss. Cox proportional-hazards models were adjusted for demographics and risk factors for ASCVD.

RESULT(S)

Among 158,787 women, 25,933 (16.3%) reported a history of infertility; 20,427 (80%) had at least 1 live birth; and 9,062 (35%) had at least 1 pregnancy loss. There was a moderate overall association between infertility and ASCVD (adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.99-1.06) over 19 years of follow-up. Among nulliparous women, infertility was associated with a 13% higher risk of ASCVD (95% CI, 1.04-1.23). Among nulliparous women who had a pregnancy loss, infertility was associated with a 36% higher risk of ASCVD (95% CI, 1.09-1.71).

CONCLUSION(S)

Women with a history of infertility overall had a moderately higher risk of ASCVD compared with women without a history of infertility. Atherosclerotic cardiovascular disease risk was much higher among nulliparous infertile women and among nulliparous infertile women who also had a pregnancy loss, suggesting that in these more extreme phenotypes, infertility may be associated with ASCVD risk.

"Ignored and Invisible": Perspectives from Black Women, Clinicians, and Community-Based Organizations for Reducing Preterm Birth

OBJECTIVES

The preterm birth rate for Black women in the U.S. is consistently higher than other racial groups. The crisis of preterm birth and adverse birth outcomes among Black people is a historical, systematic confluence of racism, stressors, and an unsupportive and hostile healthcare system. To inform the development of preterm birth risk reduction interventions, this study aimed to collect and synthesize the experiences of Black women who gave birth preterm along with clinicians and community-based organizations who serve them.

METHODS

A qualitative study design was employed whereby nine focus groups and 17 key informant interviews that included Black women, clinicians, and representatives from community-based organizations were facilitated in Los Angeles County from March 2019 to March 2020. Participants were recruited through the organizations and the focus groups took place virtually and in person. The process of thematic analysis was employed to analyze the focus group and interview transcripts.

RESULTS

Five overarching themes emerged from the data. Black women experience chronic and pregnancy-related stress, and have lasting trauma from adverse maternal health experiences. These issues are exacerbated by racism and cultural incongruence within healthcare and social services systems. Black women have relied on self-education and self-advocacy to endure the barriers related to racism, mistreatment, and their experiences with preterm birth.

CONCLUSIONS FOR PRACTICE

Healthcare and social service providers must offer more holistic care that prioritizes, rather than ignores, the racial components of health, placing increased importance on implementing inclusive and culturally-appropriate patient education, attentiveness to patient needs, respectful care, and support for Black women.

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity

INTRODUCTION

The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.

METHODS

California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.

RESULTS

Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]).

CONCLUSIONS

Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy

Background

While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies.

Methods

This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development.

Results

Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems.

Conclusions

Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.