Allostatic load in women with a history of low birth weight infants: the national health and nutrition examination survey

BACKGROUND

The purpose of our study was to determine whether women of reproductive age with history of low birth weight (LBW) deliveries have higher allostatic load (AL), a measure of the cumulative toll of chronic stress, than those with normal-weight deliveries.

METHODS

We used data from women ages 17-35 who responded to the National Health and Nutrition Examination Survey (NHANES) reproductive-health questionnaire, 1999-2006. Women reported history of LBW infants and those who were preterm. We classified preterm-LBW and term-LBW as surrogates for preterm birth (PTB) and small for gestational age (SGA), respectively. Normal weight included those without LBW infant history. We utilized nine biomarkers measured in NHANES to determine AL and used linear regression to compare unadjusted and adjusted means.

RESULTS

We identified 877 women divided among SGA (2%), PTB (10%), and normal groups (88%). The SGA group had higher unadjusted and adjusted AL scores than did the normal group (2.82 ± 0.35 vs. 1.92 ± 0.07, p=0.011); women in the PTB group had higher AL scores than did the referent in adjusted analyses (2.58 ± 0.21 vs. 1.92 ± 0.07, p=0.001).

CONCLUSIONS

Women with history of SGA or PTB had higher AL than did those with normal birth weight outcomes. This suggests a link between adverse pregnancy outcomes, chronic stress, and subclinical disease.

Preconceptional and prenatal supplementary folic acid and multivitamin intake and autism spectrum disorders

OBJECTIVE

To evaluate whether early folic acid supplementation during pregnancy prevents diagnosis of autism spectrum disorders in offspring.

METHODS

Information on autism spectrum disorder diagnosis was obtained from the National Hospital Register and the Central Psychiatric Register. We estimated risk ratios for autism spectrum disorders for children whose mothers took folate or multivitamin supplements from 4 weeks prior from the last menstrual period through to 8 weeks after the last menstrual period (-4 to 8 weeks) by three 4-week periods.

RESULTS

We did not find an association between early folate or multivitamin intake for autism spectrum disorder (folic acid-adjusted risk ratio: 1.06, 95% confidence interval: 0.82-1.36; multivitamin-adjusted risk ratio: 1.00, 95% confidence interval: 0.82-1.22), autistic disorder (folic acid-adjusted risk ratio: 1.18, 95% confidence interval: 0.76-1.84; multivitamin-adjusted risk ratio: 1.22, 95% confidence interval: 0.87-1.69), Asperger's syndrome (folic acid-adjusted risk ratio: 0.85, 95% confidence interval: 0.46-1.53; multivitamin-adjusted risk ratio: 0.95, 95% confidence interval: 0.62-1.46), or pervasive developmental disorder-not otherwise specified (folic acid-adjusted risk ratio: 1.07, 95% confidence interval: 0.75-1.54; multivitamin: adjusted risk ratio: 0.87, 95% confidence interval: 0.65-1.17) compared with women reporting no supplement use in the same period.

CONCLUSION

We did not find any evidence to corroborate previous reports of a reduced risk for autism spectrum disorders in offspring of women using folic acid supplements in early pregnancy.

Abstract P611: Vascular-mediated Preterm Birth is Associated with Cardiovascular Risk after Pregnancy

Objective: To investigate whether preterm birth and placental evidence of malperfusion is associated with subclinical atherosclerosis and a higher cardiovascular risk factor burden 4 to 12 years after pregnancy.

Methods: A cohort of women with preterm (n=119) and term births (n=242), mean age 38 years, was examined on average eight years after pregnancy for carotid artery intima-media thickness (IMT), fasting lipids, blood pressure and inflammatory markers (C-reactive protein [hsCRP] and Interleukin-6 [IL-6]). Pregnancy characteristics included placental pathology evidence of malperfusion (vasculopathy, infarct, advanced villous maturation, perivillous fibrin, fibrin deposition), infection (chorioamnionitis, funisitis, deciduitus), villitis (chronic inflammation), fetal thrombosis or chorangiosis. Vascular-mediated preterm births were those with malperfusion lesions, and by design, those with preeclampsia were excluded.

Results: Women with malperfusion lesions had a higher mean carotid IMT (+0.055 cm), total cholesterol (+17.49 mg/dl), LDL-C (+11.44), triglycerides (+17%), apolipoprotein-B (+8.95) and systolic and diastolic blood pressure (+4.58/+2.62 mmHg) compared to women with term births, independent of age, race, smoking and adiposity assessed before and after pregnancy (all p<0.05). Women with preterm birth and evidence of malperfusion accompanied by other lesions related to infection or chronic inflammation had the most atherogenic profile after pregnancy, and carotid IMT differences were independent of traditional risk factors (+0.04 cm; p=0.027).

Conclusions: Vascular-mediated preterm birth is associated with maternal subclinical atherosclerosis and a higher cardiovascular risk factor burden in the decade after pregnancy compared to term birth. The placenta may offer unique insight into how pregnancy complications can portend the emergence of maternal cardiovascular disease.

Patterns of gestational weight gain related to fetal growth among women with overweight and obesity

OBJECTIVE

Maternal obesity is associated with increased risk of large-for-gestational-age (LGA) and small-for-gestational-age (SGA) births. Both are related to childhood obesity. This study considers that the patterns of gestational weight gain (GWG) may help to disentangle these competing risks.

METHODS

Patterns of GWG were characterized among a cohort of women with overweight or obesity (n = 651). Polytomous logistic regression models were tested for associations between GWG patterns and birth weight outcomes: SGA (<10th) and LGA (>90th percentile).

RESULTS

Rates of SGA were higher than those for LGA (14.9% vs. 7.8%). Four GWG patterns were identified: consistently high (29%), early adequate/late high (33%), consistently adequate (18%), and consistently low (20%). Risk of LGA was highest in women with consistently high GWG (adjusted odds ratio [OR] 4.62 [1.53, 13.96]), and risk was elevated, but with lower magnitude, among women with early adequate/late high gains (OR 3.07 [1.01, 9.37]). High GWG before 20 weeks, regardless of later gain, was related to LGA. Low gain before 20 weeks accompanied by high gain later may be associated with reduced SGA risk (0.55 [0.29, 1.07]).

CONCLUSIONS

The pattern of weight gain during pregnancy may be an important contributor to or marker of abnormal fetal growth among women with overweight or obesity.

Nulliparity is associated with less healthy markers of subclinical cardiovascular disease in young women with overweight and obesity

OBJECTIVE

Higher parity is associated with increased subclinical cardiovascular disease (CVD) in mid-life and older women and with increased CVD risk overall. The relationship between parity, subclinical CVD, and infertility in young women with overweight and obesity has been infrequently evaluated.

METHODS

Reproductive histories were obtained in 191 (66%) young women with overweight and obesity (BMI 25-39.9 kg/m(2) ) participating in a weight loss trial. Baseline carotid intima-media thickness (IMT) and inter-adventitial diameter (IAD) were assessed via B-mode ultrasound. Linear regression was used to estimate the relationship between parity and carotid measures, adjusted for demographic, cardiovascular, and reproductive risk factors.

RESULTS

Nulliparous women (n = 70, age 34.9 ± 7.1) had increased common carotid IAD (0.230 mm, SE 0.08, P = 0.003) and mean common carotid artery (CCA) IMT (0.031 mm, SE 0.01, P = 0.007) compared with parous women (n = 102, age 39.5 ± 4.9), persisting after adjustment for age, race, and CVD risk factors. No other reproductive factors were statistically significantly associated.

CONCLUSIONS

Nulliparity is associated with markers of less healthy carotid arteries in a sample of disease-free 25- to 45-year-old women with overweight or obesity. This may represent a beneficial effect of pregnancy or indicate overall better health in women with overweight/obesity who are capable of childbearing.

The relationship between race, inflammation and psychosocial factors among pregnant women

African American women have higher rates of preterm birth (PTB) than women from other racial or ethnic backgrounds. We explored the possibility that African American women experience higher anxiety/lower optimism levels, leading to excess inflammation, a possible pathway leading to PTB. In a cohort of 434 nulliparous women (African American, n = 119; Caucasian, n = 315), standardized measures of anxiety and optimism were completed at 20 weeks' gestation. C-reactive protein (CRP) was measured in serum collected at the same time, and interleukin-6 (IL-6) was additionally measured in African American women. African American women tended to have higher rates of anxiety (>75th percentile) compared to Caucasian women (27.3 vs. 19.2%, p = 0.08), but rates of low optimism (<25th percentile) did not vary by race. Contrary to our hypothesis, higher concentrations of CRP among African American women were associated with lower risk of anxiety in the highest quartile, adjusted for covariates (OR 0.65, 95% CI 0.44, 0.98). Low optimism in African American women was also associated with lower IL-6, but results were only marginally significant (OR 0.43, 95% CI 0.17, 1.10). CRP, anxiety, and optimism were not correlated among Caucasian women. African American women with high anxiety or low optimism had lower concentrations of pro-inflammatory markers at mid-gestation compared to those without these characteristics. Our results suggest that chronic anxiety among African American women may contribute to intractable race disparities in pregnancy outcomes via an impaired inflammatory response.

Prognosis and conditional disease-free survival among patients with ovarian cancer

PURPOSE

Traditional disease-free survival (DFS) does not reflect changes in prognosis over time. Conditional DFS accounts for elapsed time since achieving remission and may provide more relevant prognostic information for patients and clinicians. This study aimed to estimate conditional DFS among patients with ovarian cancer and to evaluate the impact of patient characteristics.

PATIENTS AND METHODS

Patients were recruited as part of the Hormones and Ovarian Cancer Prediction case-control study and were included in the current study if they had achieved remission after a diagnosis of cancer of the ovary, fallopian tube, or peritoneum (N = 404). Demographic and lifestyle information was collected at enrollment; disease, treatment, and outcome information was abstracted from medical records. DFS was calculated using the Kaplan-Meier method. Conditional DFS estimates were computed using cumulative DFS estimates.

RESULTS

Median DFS was 2.54 years (range, 0.03-9.96 years) and 3-year DFS was 48.2%. The probability of surviving an additional 3 years without recurrence, conditioned on having already survived 1, 2, 3, 4, and 5 years after remission, was 63.8%, 80.5%, 90.4%, 97.0%, and 97.7%, respectively. Initial differences in 3-year DFS at time of remission between age, stage, histology, and grade groups decreased over time.

CONCLUSION

DFS estimates for patients with ovarian cancer improved dramatically over time, in particular among those with poorer initial prognoses. Conditional DFS is a more relevant measure of prognosis for patients with ovarian cancer who have already achieved a period of remission, and time elapsed since remission should be taken into account when making follow-up care decisions.

Maternal hypertension after a low-birth-weight delivery differs by race/ethnicity: evidence from the National Health and Nutrition Examination Survey (NHANES) 1999-2006

Studies have suggested an increase in maternal morbidity and mortality due to cardiovascular diseases in women with a prior low-birth-weight (LBW, <2,500 grams) delivery. This study evaluated blood pressure and hypertension in women who reported a prior preterm or small-for-gestational-age (SGA) LBW delivery in the National Health and Nutrition Examination Survey 1999-2006 (n = 6,307). This study also aimed to explore if race/ethnicity, menopause status, and years since last pregnancy modified the above associations. A total of 3,239 white, 1,350 black, and 1,718 Hispanics were assessed. Linear regression models were used to evaluate blood pressure by birth characteristics (preterm-LBW, SGA-LBW, and birthweight ≥2,500). Logistic regression models estimated the odds ratios (OR) of hypertension among women who reported a preterm-LBW or SGA-LBW delivery compared with women who reported an infant with birthweight ≥2,500 at delivery. Overall, there was a positive association between a preterm-LBW delivery and hypertension (adjusted OR = 1.39, 95% confidence interval (CI) 1.02-1.90). Prior SGA-LBW also increased the odds of hypertension, but the estimate did not reach statistical significance (adjusted OR = 1.21, 95% CI 0.76-1.92). Race/ethnicity modified the above associations. Only black women had increased risk of hypertension following SGA-LBW delivery (adjusted OR = 2.09, 95% CI 1.12-3.90). Black women were at marginally increased risk of hypertension after delivery of a preterm-LBW (adjusted OR = 1.49, 95% CI 0.93-2.38). Whites and Hispanics had increased, but not statistically significant, risk of hypertension after a preterm-LBW (whites: adjusted OR = 1.39, 95% CI 0.92-2.10; Hispanics: adjusted OR = 1.22, 95% CI 0.62-2.38). Stratified analysis indicated that the associations were stronger among women who were premenopausal and whose last pregnancy were more recent. The current study suggests that in a representative United States population, women with a history of preterm- or SGA-LBW deliveries have increased odds of hypertension and this risk appears to be higher for black women and younger women.

Fetal sex and race modify the predictors of fetal growth

The objective of this study is unknown if fetal sex and race modify the impact of maternal pre-pregnancy body mass index (BMI), and smoking on fetal growth. The authors studied markers of fetal growth in singleton offspring of 8,801 primiparous, normotensive women, enrolled in the Collaborative Perinatal Project. The authors tested for departures from additivity between sex/race and each predictor. The head-to-chest circumference ratio (HCC) decreased more, while birthweight and ponderal index (PI) increased more for each 1 kg/m(2) increase in pre-pregnancy BMI among term females versus males (P = 0.07, P < 0.01 and P = 0.08, interaction respectively). For term offspring of White compared with Black women, smoking independent of "dose" was associated with larger reductions in growth (165 g vs. 68 g reduction in birthweight, P < 0.01, interaction), greater reduction in fetal placental ratio (P < 0.01, interaction), PI (P < 0.01, interaction), and greater increase in HCC (P = 0.02), respectively. The association of BMI and smoking with fetal size appeared to be reversed in term versus preterm infants. Our study provides evidence that the associations of pre-pregnancy BMI and smoking are not constant across sex and race. This finding may be relevant to sex and race differences in neonatal and long term health outcomes.

First trimester coffee and tea intake and risk of gestational diabetes mellitus: a study within a national birth cohort

OBJECTIVE

Coffee and tea consumption is associated with a decreased type 2 diabetes risk in non-pregnant adults. We examined the relation between first trimester coffee and tea consumption and gestational diabetes mellitus (GDM) risk.

DESIGN

Population-based cohort study.

SETTING

Denmark 1996-2002.

POPULATION

Non-diabetic women with singleton pregnancies in the Danish National Birth Cohort (n = 71,239).

METHODS

Estimated adjusted relative risks (RR) and 95% confidence intervals (95%CI) for the association between first trimester coffee and tea or estimated total caffeine and GDM.

MAIN OUTCOME MEASURES

GDM ascertained from the National Hospital Discharge Register or maternal interview.

RESULTS

Coffee or tea intake was reported in 81.2% (n = 57,882) and 1.3% (n = 912) of pregnancies were complicated by GDM. Among non-consumers, 1.5% of pregnancies were complicated by GDM. Among coffee drinkers, GDM was highest among women who drank ≥8 cups/day (1.8%) with no significant difference across intake levels (P = 0.10). Among tea drinkers, there was no difference in GDM across intake levels (1.2%; P = 0.98). After adjustment for age, socio-occupational status, parity, pre-pregnancy body mass index, smoking, and cola, there was suggestion of a protective, but non-significant association with increasing coffee (RR ≥8 versus 0 cups/day = 0.89 [95%CI 0.64-1.25]) and tea (RR ≥8 versus 0 cups/day = 0.77 [95%CI 0.55-1.08]). Results were similar by smoking status, except a non-significant 1.45-fold increased risk with ≥8 coffee cups/day for non-smokers. There was a non-significant reduced GDM risk with increasing total caffeine.

CONCLUSIONS

Our results suggest that moderate first trimester coffee and tea intake were not associated with GDM increased risk and possibly may have a protective effect.

Nonesterified fatty acids and spontaneous preterm birth: a factor analysis for identification of risk patterns

We considered that accumulation of nonesterified (free) fatty acids (NEFAs) in the first trimester of pregnancy would mark women at excess risk of spontaneous preterm birth (sPTB) and examined the interplay between NEFAs, lipids, and other markers to explore pathways to sPTB. In a case-control study nested in the Pregnancy Exposures and Preeclampsia Prevention Study (Pittsburgh, Pennsylvania, 1997-2001), we assayed NEFA levels in nonfasting serum collected at a mean gestational week of 9.4 (range, 4-20 weeks) in 115 women with sPTB (<37 weeks) and 222 women with births occurring at ≥37 weeks. C-reactive protein, total cholesterol, low-density lipoprotein and high-density lipoprotein (HDL) cholesterol, triglycerides, and uric acid were also measured. Polytomous logistic regression models were used to evaluate tertiles of NEFA levels and sPTB at <34 weeks and 34-36 weeks; factor analysis was used to characterize patterns of biomarkers. Women with NEFA levels in the highest tertile versus the lowest were 2.02 (95% confidence interval: 1.13, 3.48) times more likely to have sPTB, after adjustment for covariates. Risk of sPTB before 34 weeks was particularly high among women with high NEFA levels (odds ratio = 3.73, 95% confidence interval: 1.33, 10.44). Six biomarker patterns were identified, and 2 were associated with sPTB: 1) increasing NEFA and HDL cholesterol levels and 2) family history of gestational hypertension. NEFA levels early in pregnancy were independently associated with sPTB, particularly before 34 weeks. We also detected a novel risk pattern suggesting that NEFAs together with HDL cholesterol may be related to sPTB.

The impact of maternal obesity and gestational weight gain on early and mid-pregnancy lipid profiles

OBJECTIVE

The impact of maternal overweight/obesity and excessive weight gain on maternal serum lipids in the first and second trimester of pregnancy was evaluated.

METHODS

Prospective data were collected for 225 women. Maternal serum lipids and fatty acids were measured at <13 weeks and between 24 and 28 weeks. Analyses were stratified by normal weight versus overweight/obese status and excessive versus nonexcessive weight gain.

RESULTS

Overweight/obese women had higher baseline cholesterol (161.3 ± 29.6 vs. 149.4 ± 26.8 mg/dl, P < 0.01), low-density lipoprotein LDL (80.0 ± 19.9 vs. 72.9 ± 18.8 mg/dl, P < 0.01), and triglycerides (81.7 ± 47.2 vs. 69.7 ± 40.3 mg/dl, P = 0.05) when compared to normal weight women, whereas high-density lipoprotein (43.6 ± 10.4 vs. 47.6 ± 11.5 mg/dl, P < 0.01) was lower. However, cholesterol and LDL increased at a higher weekly rate in normal weight women, resulting in higher total cholesterol in normal weight women (184.1 ± 28.1 vs. 176.0 ± 32.1 mg/dl, P = 0.05) at 24-28 weeks. The rate of change in lipid profiles in either group was not affected by excessive weight gain. Overweight/obese women had higher levels of arachidonic acid at both time points.

CONCLUSIONS

Overweight/obese women have significantly more atherogenic lipid profiles than normal weight women during the period of early pregnancy, delineating one physiologic pathway between that could explain differences in pregnancy outcomes normal weight and overweight/obese women.

Periconceptional intake of vitamins and fetal death: a cohort study on multivitamins and folate

BACKGROUND

Women planning to conceive are often advised to take multivitamins. Whether this affects the survival of the fetus is not known.

METHODS

We used data from 35 914 women in the Danish National Birth Cohort who at recruitment had reported the number of weeks of supplement use during a 12-week periconceptional period. A telephone interview provided information about maternal characteristics and data on fetal death came from registers. The associations between periconceptional multivitamin or folate-only use and early (<20 weeks) and late (≥20 weeks) fetal death were estimated by hazard ratios (HR) with 95% confidence intervals (CI). Follow-up started at 8 completed weeks of gestation, and comparisons were made with no supplement use at any time during the periconceptional period.

RESULTS

Any multivitamin use was associated with a small increased crude risk of fetal death [HR 1.12 (1.01-1.25)], which was restricted to early losses [HR 1.18 (1.05-1.33)] compared with late losses [HR 0.82 (0.62-1.10)]. Adjustment for maternal factors increased this excess risk further. Whereas regular users of multivitamins (4-6 weeks of 6) before conception had more early losses [HR 1.29 (1.12-1.48)], a decreased risk of late losses was indicated when use started after conception [HR 0.65 (0.39-1.09)]. Folate-only use was not associated with fetal death.

CONCLUSIONS

Multivitamin use was associated with a modest increased risk of early fetal death. For late fetal death, regular supplement use after conception may decrease risk, but numbers were small. Further studies on preconceptional multivitamin use are needed to guide public health recommendations.

Maternal vitamin D status and spontaneous preterm birth by placental histology in the US Collaborative Perinatal Project

The objective of this study was to determine the association between maternal 25-hydroxyvitamin D (25(OH)D) and the risk of spontaneous preterm birth (sPTB) before 35 weeks' gestation. A random subcohort from the US Collaborative Perinatal Project (1959-1965) was sampled (n = 2,629) and augmented with all remaining cases of sPTB before 35 weeks' gestation for a total of 767 cases. Banked serum samples collected at 26 weeks' gestation or earlier were assayed for 25(OH)D. Constructs for vascular histology and inflammatory histology were developed from placental pathology examinations. There was no relationship between 25(OH)D and sPTB among white women. Among nonwhite mothers, serum 25(OH)D levels of 30-<50, 50-<75, and ≥75 nmol/L were associated with reductions of 1.0-1.6 cases of sPTB per 100 live births and 20%-30% reductions in risk of sPTB compared with 25(OH)D levels less than 30 nmol/L after adjustment for prepregnancy body mass index (weight (kg)/height (m)(2)), season, and other confounders. This association was driven by inflammation-mediated cases of sPTB and sPTB cases without placental lesions. A sensitivity analysis for unmeasured confounding by exercise, fish intake, and skin color suggested some bias away from the null in the conventional results, but conclusions were generally supported. The vitamin D-sPTB relationship should be examined in modern cohorts with detailed data on skin pigmentation and other covariates.

Maternal lipid change in relation to length of gestation: a prospective cohort study with preconception enrollment of women

BACKGROUND/AIMS

We sought to investigate the association between preconception serum lipids and their daily rate of change in relation to length of gestation.

METHODS

In a cohort of 70 women, 61 (87%) became pregnant, resulting in 48 (69%) live births. Serum lipid measurements (in milligrams per deciliter) included total cholesterol, free cholesterol, triglycerides and phospholipids at preconception, upon human chorionic gonadotropin-confirmed pregnancy and following pregnancy loss (<14 weeks) or post partum. Pregnancy outcome (loss, preterm and term delivery) and gestational length were modeled relative to daily rate of change in lipids using multinomial regression and Cox proportional hazards models, respectively, adjusting for body mass index and smoking.

RESULTS

A rate of triglyceride change below the median was associated with an increased risk for pregnancy loss compared with term birth (adjusted odds ratio: 9.02; 95% CI: 1.62-50.30). A rate of triglyceride change of ≤0.01 mg/dl per day versus above the median was associated with a trend for increased risk of pregnancy loss or preterm (<37 weeks) birth (adjusted hazard ratio: 1.77; 95% CI: 0.94-3.33).

CONCLUSION

A low rate of triglyceride change during early pregnancy may be a signal of risk of pregnancy loss or preterm birth. Lipids offer promise for identifying pregnancies at risk for adverse outcomes.

Associations between gestational weight gain and BMI, abdominal adiposity, and traditional measures of cardiometabolic risk in mothers 8 y postpartum

BACKGROUND

Researchers have proposed biologically plausible mechanisms linking excessive gestational weight gain (GWG) to maternal metabolic and cardiovascular diseases later in life.

OBJECTIVE

The objective was to determine the extent to which GWG was associated with abdominal adiposity and other cardiometabolic risk factors in a sample of women 4-12 y after delivery.

DESIGN

We used data from The Women's and Infants' Study of Healthy Hearts, a cohort of women who gave birth between 1997 and 2002 at Magee-Womens Hospital in Pittsburgh, PA. By design, women with small-for-gestational-age and preterm births were oversampled. Women with preeclampsia, prepregnancy hypertension, or diabetes were excluded. GWG was ascertained from prenatal records, and GWG adequacy was assessed according to 2009 Institute of Medicine/National Research Council guidelines. Abdominal obesity was defined as waist circumference (WC) >88 cm and weight change as current weight - prepregnancy weight.

RESULTS

The prevalence of inadequate, adequate, and excessive GWG was 22% (107/478), 30% (145/478), and 47% (226/478), respectively. The analyses were adjusted for age at outcome assessment, prepregnancy BMI, marital status and insurance at delivery, race, smoking during target pregnancy, and current education, parity, and smoking. Associations between excessive GWG and blood pressure, lipids, glucose, insulin, and metabolic syndrome were null. However, women with excessive GWG had a 3.6-kg (1.5, 5.6) greater weight change, a 3.2-cm (1.2, 5.2) greater WC, and 3-fold greater odds of abdominal obesity (2.9; 1.6, 5.1) compared with women who gained weight as recommended.

CONCLUSION

Excessive GWG is associated with long-term maternal abdominal adiposity, which may increase a woman's risk of cardiovascular and metabolic disease.

Prior preterm birth and maternal subclinical cardiovascular disease 4 to 12 years after pregnancy

BACKGROUND

We considered that women with prior preterm birth (PTB) would have evidence of subclinical atherosclerosis, endothelial dysfunction, and arterial stiffness.

METHODS

Four to 12 years after pregnancy, blood pressure and fasting lipids were analyzed, and women underwent evaluation, following standardized protocols, of carotid intima-media thickness (IMT), brachial flow-mediated dilation (FMD), and pulse wave velocity (PWV). Women with prior preterm (<37 weeks, n=181) or term births (>= 37 weeks, n=306) were compared. Those with preeclampsia or term small-for-gestational-age (SGA) births were excluded.

RESULTS

Women with a prior preterm vs. term birth had higher blood pressure, on average, and a more atherogenic lipid profile. They also had marginally higher IMT (0.579 standard error [SE] 0.005-vs. 0.567 [0.004] mm, p=0.06), adjusted for body size, demographics, and smoking. IMT differences were greater among those with non-preeclamptic-indicated PTB (0.034 mm, p=0.05) and PTB<34 weeks (0.024 mm, p=0.04) compared to those with term births. These differences appeared to be explained in part by the atherogenic lipid elevations in women with preterm birth. Women with prior PTB<34 weeks tended to have lower FMD, but results were not statistically significant. PWV did not differ according to PTB.

CONCLUSIONS

In the decade following pregnancy, women with non-preeclamptic-indicated PTB or PTB delivered before 34 weeks had higher blood pressure, atherogenic lipids, and IMT compared to women with term births. There may be subgroups of women with a prior PTB with excess cardiovascular risk that is detectable before overt clinical disease.

Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health?

Growing evidence indicates that women with a history of common pregnancy complications, including fetal growth restriction and preterm delivery (often combined as low birth weight), hypertensive disorders of pregnancy, and gestational diabetes, are at increased risk for cardiovascular disease later in life. The purpose of this paper was to review the associations of parity and these 4 pregnancy complications with cardiovascular morbidity and mortality; to review the role of cardiovascular risk factors before, during, and after pregnancy complications in explaining these associations; and to explore the implications of this emerging science for new research and policy. We systematically searched for relevant cohort and case-control studies in Medline through December 2012 and used citation searches for already published reviews to identify new studies. The findings of this review suggest consistent and often strong associations of pregnancy complications with latent and future cardiovascular disease. Many pregnancy complications appear to be preceded by subclinical vascular and metabolic dysfunction, suggesting that the complications may be useful markers of latent high-risk cardiovascular trajectories. With further replication research, these findings would support the utility of these prevalent pregnancy complications in identifying high-risk women for screening, prevention, and treatment of cardiovascular disease, the leading cause of morbidity and mortality among women.

First trimester exposure to ambient air pollution, pregnancy complications and adverse birth outcomes in Allegheny County, PA

Despite numerous studies of air pollution and adverse birth outcomes, few studies have investigated preeclampsia and gestational hypertension, two pregnancy disorders with serious consequences for both mother and infant. Relying on hospital birth records, we conducted a cohort study identifying 34,705 singleton births delivered at Magee-Women's Hospital in Pittsburgh, PA between 1997 and 2002. Particle (<10 μm-PM10; <2.5 μm-PM2.5) and ozone (O3) exposure concentrations in the first trimester of pregnancy were estimated using the space-time ordinary Kriging interpolation method. We employed multiple logistic regression estimate associations between first trimester exposures and preeclampsia, gestational hypertension, preterm delivery, and small for gestational age (SGA) infants. PM2.5 and O3 exposures were associated with preeclampsia (adjusted OR = 1.15, 95% CI = 0.96-1.39 per 4.0 μg/m(3) increase in PM2.5; adjusted OR = 1.12, 95% CI = 0.89-1.42 per 16.8 ppb increase in O3), gestational hypertension (for PM2.5 OR = 1.11, 95 % CI = 1.00-1.23; for O3 OR = 1.12, 95 % CI = 0.97-1.29), and preterm delivery (for PM2.5 ORs = 1.10, 95% CI = 1.01-1.20; for O3 ORs = 1.23, 95% CI = 1.01-1.50). Smaller 5-8 % increases in risk were also observed for PM10 with gestational hypertension and SGA, but not preeclampsia. Our data suggest that first trimester exposure to particles, mostly PM2.5, and ozone, may increase the risk of developing preeclampsia and gestational hypertension, as well as preterm delivery and SGA.

Preterm birth and future maternal blood pressure, inflammation, and intimal-medial thickness: the CARDIA study

Preterm birth (PTB, <37 weeks) may be a marker of endothelial dysfunction and a proinflammatory phenotype; both are risk factors for cardiovascular disease. We studied 916 women (46% black) with 1181 live births between enrollment in the Coronary Artery Risk Development in Young Adults study (age 18-30 years) and 20 years later. C-reactive protein was measured at years 7, 15, and 20. Interleukin-6 and carotid intima-media thickness, which incorporated the common carotid arteries, bifurcations, and internal carotid arteries, were measured at year 20. Blood pressure, lipids, anthropometrics, and pregnancy events were assessed at all visits. Change in risk factors and differences in inflammatory markers and intima-media thickness according to PTB were evaluated. Women with PTBs (n=226) had higher mean systolic blood pressures before pregnancy (106 versus 105 mm Hg, respectively; P=0.03). Systolic and diastolic blood pressure increased more rapidly over 20 years compared with women with term births (P<0.01 time interaction), even after removing women with self-reported hypertension in pregnancy. Women with PTB versus term births had similar mean intima-media thickness adjusted for age, body mass index, race, lifestyle, and cardiovascular risk factors. C-reactive protein and interleukin-6 did not differ according to PTB. Women with PTB, regardless of hypertension during pregnancy, had higher blood pressure after pregnancy compared with women with term births. In the United States, where rates of PTB are high and race disparities persist, PTB may identify women with higher blood pressure in the years after pregnancy.

Ambient air pollution exposure and blood pressure changes during pregnancy

BACKGROUND

Maternal exposure to ambient air pollution has been associated with adverse birth outcomes such as preterm delivery. However, only one study to date has linked air pollution to blood pressure changes during pregnancy, a period of dramatic cardiovascular function changes.

OBJECTIVES

We examined whether maternal exposures to criteria air pollutants, including particles of less than 10 μm (PM(10)) or 2.5 μm diameter (PM(2.5)), carbon monoxide (CO), nitrogen dioxide (NO(2)), sulfur dioxide (SO(2)), and ozone (O(3)), in each trimester of pregnancy are associated with magnitude of rise of blood pressure between the first 20 weeks of gestation and late pregnancy in a prospectively followed cohort of 1684 pregnant women in Allegheny County, PA.

METHODS

Air pollution measures for maternal ZIP code areas were derived using Kriging interpolation. Using logistic regression analysis, we evaluated the associations between air pollution exposures and blood pressure changes between the first 20 weeks of gestation and late pregnancy.

RESULTS

First trimester PM(10) and ozone exposures were associated with blood pressure changes between the first 20 weeks of gestation and late pregnancy, most strongly in non-smokers. Per interquartile increases in first trimester PM(10) and O(3) concentrations were associated with mean increases in systolic blood pressure of 1.88 mm Hg (95% CI=0.84 to 2.93) and 1.84 (95% CI=1.05 to 4.63), respectively, and in diastolic blood pressure of 0.63 mm Hg (95% CI=-0.50 to 1.76) and 1.13 (95% CI=-0.46 to 2.71) in non-smokers.

CONCLUSIONS

Our novel finding suggests that first trimester PM(10) and O(3) air pollution exposures increase blood pressure in the later stages of pregnancy. These changes may play a role in mediating the relationships between air pollution and adverse birth outcomes.

Maternal lipids at mid-pregnancy and the risk of preterm delivery

OBJECTIVE

This study examined associations between maternal lipid levels at mid-pregnancy and preterm delivery, medically indicated or spontaneous.

DESIGN

Prospective cohort study.

SETTING

Women were recruited from 52 clinics in five Michigan, USA communities (1998-2004).

POPULATION

Pregnant women were enrolled at 15-27 weeks' gestation and followed to delivery (n=3019).

METHODS

A single blood sample was obtained at study enrollment. Blood lipids, i.e. total cholesterol (TC), high-density lipoprotein (HDLc), low-density lipoprotein (LDLc) cholesterol, and triglycerides (TG), were measured on a sub-cohort (n=1309).

MAIN OUTCOME MEASURES

There were 221 spontaneous, 100 medically indicated preterm deliveries and 988 term deliveries. Polytomous logistic regression models examined relationships among cholesterol levels (Low: <10(th) percentile, Referent: 10(th) -<70(th) percentile, High: ≥70(th) percentile), quartiles of TG (Referent: first quartile) and delivery outcome (Referent: term).

RESULTS

Odds of medically indicated preterm delivery were increased among women with low TC (adjusted odds ratio (aOR)=2.04, 95% confidence interval (CI): 1.12, 3.72), low HDLc (aOR=1.89, 95%CI: 1.04, 3.42) or low LDLc (aOR=1.96, 95%CI: 1.09, 3.54). Odds of spontaneous preterm delivery were increased among women with high TC (aOR=1.51, 95%CI: 1.06, 2.15), high LDLc (aOR=1.42, 95%CI: 0.99, 2.04) or high TG (aOR=1.90, 95%CI: 1.21, 2.97 and aOR=1.72, 95%CI: 1.06, 2.78 for third and fourth quartiles, respectively).

CONCLUSIONS

Extremely low TC, HDLc, and LDLc were associated with a modest increase in risk of medically indicated preterm delivery, whereas high TC, LDLc and TG modestly increased the risk of spontaneous preterm delivery. Further research is needed to uncover explanations for these associations and to identify optimal ranges for maternal lipids.

Maternal serum fatty acid binding protein 4 (FABP4) and the development of preeclampsia

CONTEXT

Serum fatty acid binding protein 4 (FABP4) is associated with components of the metabolic syndrome in nonpregnant individuals, including dyslipidemia and insulin resistance. Preeclampsia shares many features with the metabolic syndrome, but the relationship between early pregnancy serum FABP4 levels and the development of preeclampsia is unknown.

OBJECTIVE

The aim of the study was to test the hypothesis that FABP4 is elevated in women who develop preeclampsia before the onset of disease.

STUDY DESIGN

This was a nested case-control study within a larger prospective cohort of healthy women with singleton gestations. Cases included 22 women who developed preeclampsia, and a random sample of 72 unmatched controls delivered without preeclampsia was identified. Maternal serum FABP4 was measured at less than 13 wk gestation and 24-28 wk gestation, which was before the onset of preeclampsia in all patients.

MAIN OUTCOME MEASURES

The main outcome measure was preeclampsia (new-onset gestational hypertension and proteinuria for the first time after 20 wk gestation).

RESULTS

Maternal serum FABP4 concentrations were higher in women who ultimately developed preeclampsia both at 8-13 wk (20.4±12.3 vs. 10.1±4.7 ng/ml; P<0.01) and at 24-28 wk (20.7±11.7 vs. 9.9±4.5 ng/ml; P<0.01). After controlling for first trimester body mass index, systolic blood pressure, and nulliparity, FABP4 was associated with the development of preeclampsia (adjusted odds ratio, 1.2; 95% confidence interval, 1.1-1.3; P<0.01).

CONCLUSION

Maternal serum FABP4 levels are elevated before the clinical onset of preeclampsia, and this increase occurs independently of maternal body mass index.

Periconceptional multivitamin use and risk of preterm or small-for-gestational-age births in the Danish National Birth Cohort

BACKGROUND

The intake of periconceptional multivitamins may decrease the risk of preterm births (PTBs) or small-for-gestational-age (SGA) births.

OBJECTIVE

We related the timing and frequency of periconceptional multivitamin use to SGA births and PTBs and its clinical presentations (ie, preterm labor, premature rupture of membranes, and medical induction).

DESIGN

Women in the Danish National Birth Cohort (n = 35,897) reported the number of weeks of multivitamin use during a 12-wk periconceptional period. Cox regression was used to estimate the relation between any multivitamin use and PTBs (<37 wk) or SGA births (birth weight adjusted for gestational age >2 SDs below the mean on the basis of fetal growth curves). The timing (preconception and postconception) and frequency of use were also analyzed. Regular users (4-6 wk) and partial users (1-3 wk) in each period were compared with nonusers.

RESULTS

The association between periconceptional multivitamin use and PTBs varied according to prepregnancy overweight status (P-interaction = 0.07). Regular preconception and postconception multivitamin use in women with a prepregnancy BMI (in kg/m(2)) <25 was associated with reduced risks of a PTB (HR: 0.84; 95% CI: 0.73, 0.95) and preterm labor (HR: 0.80; 95% CI: 0.69, 0.94). No similar associations were shown for overweight women. The adjusted risk of an SGA birth was reduced in multivitamin users regardless of their prepregnancy BMI (HR: 0.83; 95% CI: 0.73, 0.95), with the strongest association in regular users in the postconception period.

CONCLUSION

Regular periconceptional multivitamin use was associated with reduced risk of SGA births and PTBs in nonoverweight women.

Accuracy of maternal recall of gestational weight gain 4 to 12 years after delivery

There is growing interest in the relationship between gestational weight gain (GWG) and long-term maternal and child outcomes, yet little is known about the accuracy of long-term maternal recall of GWG. Our objective was to assess the accuracy of maternal recall of GWG at 4-12 years postpartum (mean, 8 years) compared with medical-record documented GWG, and compare recalled GWG to documented GWG with respect to their associations with adverse pregnancy outcomes including small for gestational age (SGA) birth, preterm birth, cesarean delivery, and postpartum weight retention (PPWR) (n = 503). Adequacy of recalled and documented GWG was assessed according to the 2009 Institute of Medicine (IOM) guidelines. We observed moderate agreement between documented and maternal self-reported GWG as continuous variables (r = 0.63, P < 0.01). When recalled GWG was used to categorize women, 45, 53, and 20% of women with inadequate, adequate, and excessive documented GWG were misclassified, respectively. When comparing models fitted with documented or recalled GWG, there were no meaningful differences in associations between inadequate GWG and SGA birth (odds ratio 2.2 (95% confidence interval: 1.3, 3.7) vs. 2.1 (1.2, 3.8), respectively) or excessive GWG and PPWR (2.5 (1.6, 3.9) vs. 2.5 (1.5, 4.0), respectively). However, the use of recalled GWG attenuated associations between inadequate GWG and PPWR (documented: 0.5 (0.3, 0.9) vs. recalled GWG: 1.3 (0.7, 2.3)) and excessive GWG and preterm birth (documented: 2.5 (1.4, 4.5) vs. recalled GWG: 1.5 (0.9, 2.7)). Our data suggest a varying degree of bias when using recalled GWG to study selected adverse outcomes.

Diseases in children born to mothers with preeclampsia: a population-based sibling cohort study

OBJECTIVE

We previously reported associations between preeclampsia and the occurrence of metabolic and respiratory diseases in the offspring. In this article we examine whether the associations were due to preeclampsia or factors leading to preeclampsia.

STUDY DESIGN

From 1978 through 2004, we identified 22,264 discordant sib-pairs in Denmark according to prenatal exposure to preeclampsia. Exposed children were compared to their unexposed siblings by using stratified Cox regression to estimate hazard ratios and 95% confidence intervals for metabolic and respiratory diseases.

RESULTS

Exposed children had rather similar risks for metabolic disorders compared to their unexposed siblings. However, when the second child within each sib-pair was exposed, this child had an increased risk for respiratory diseases (hazard ratio, 1.55; 95% confidence interval, 1.20-2.01).

CONCLUSION

Factors leading to preeclampsia may shape susceptibility to metabolic or respiratory diseases in the offspring but a programming effect on respiratory diseases induced by preeclampsia cannot be ruled out.

Anxiety and optimism associated with gestational age at birth and fetal growth

Psychosocial factors such as anxiety or optimism may be related to the risk of adverse pregnancy outcomes, but the evidence is conflicting. We investigated the relation between maternal anxiety, optimism, gestational age and infant birth weight in a cohort of 667 nulliparous women from the Prenatal Exposures and Preeclampsia Prevention study, Pittsburgh PA. Women completed the Spielberger Trait Anxiety Inventory and the Life Orientation Test at 18 weeks gestation. Linear and logistic regression models assessed the relation of anxiety and optimism to gestational age, birth weight centile, preterm delivery (<37 weeks) or small for gestational age (<10th percentile) births. After adjustment for age, race, preeclampsia, and smoking, higher anxiety was associated with decreasing gestational age (-1.6 days per SD increase in anxiety score, P = 0.06). This relationship was modified by maternal race (P < 0.01 for interaction). Among African American women, each SD increase in anxiety was associated with gestations that were, on average, 3.7 days shorter (P = 0.03). African American women with anxiety in the highest quartile had gestations that were 8.2 days shorter, and they had increased risk for preterm birth after excluding cases of preeclampsia (OR 1.69, 95% CI 1.08, 2.64). There was no association between anxiety and gestational age among White women. There was also no relation between anxiety, optimism and birth weight centile. Trait anxiety was associated with a reduction in gestational age and increased risk for preterm birth among African American women. Interventions that reduce anxiety among African American pregnant women may improve pregnancy outcomes.

Early or recurrent preterm birth and maternal cardiovascular disease risk

PURPOSE

Preterm birth (PTB) has been associated with a later increased risk of maternal cardiovascular disease (CVD). We hypothesized a more pronounced relation between early or recurrent PTB and maternal CVD risk.

METHODS

We related PTB severity (earlier gestational age at delivery) and recurrence (>/=2) among women with births from 1973-1983 in Denmark (n = 427,765) to maternal CVD morbidity or mortality (1977-2006). Birth data were linked to CVD hospitalizations and deaths identified in national registers and data were analyzed using Cox proportional hazards models.

RESULTS

Women with a prior PTB had excess CVD after adjustment for age, parity, and education (hazard ratio [HR] = 1.36 [95% confidence interval (CI): 1.31, 1.41]). This was only modestly attenuated when women with preeclampsia or small for gestational age births were excluded, and the relationship was stronger for CVD mortality (HR = 1.98 [1.73, 2.26]). Recurrent PTB was associated with higher CVD morbidity compared to women with one PTB, particularly for ischemic events (HR = 1.78 [1.40, 2.27] vs. 1.22 [1.09, 1.36]). Risk was similarly elevated among women with early, moderate, and late PTB. Sensitivity analysis suggested that confounding by smoking only partly explained these associations.

CONCLUSIONS

Women with PTB, especially recurrent PTB, were at increased risk for CVD, suggesting common causes of these conditions.

Parity and the association with diabetes in older women

OBJECTIVE

To examine the relationship of parity with diabetes and markers of glucose homeostasis in older women.

RESEARCH DESIGN AND METHODS

We used data from the female participants in the Cardiovascular Health Study, a longitudinal cohort of adults aged >or=65 years. These data included an assessment of parity (baseline) and fasting serum levels of glucose, insulin, and medication use (baseline and follow-up). We estimated both the cross-sectional relationship of parity with baseline diabetes and the relationship of parity with incident diabetes.

RESULTS

In unadjusted analyses, women with grand multiparity (>or=5 live births) had a higher prevalence of diabetes at baseline compared with those with fewer births and with nulliparous women (25 vs. 12 vs. 15%; P < 0.001). In regression models controlling for age and race, grand multiparity was associated with increased prevalence of diabetes (prevalence ratio 1.57 [95% CI 1.20-2.06]); with addition of demographic and clinical factors to the model, the association was attenuated (1.33 [1.00-1.77]). In final models that included body anthropometrics, the association was no longer significant (1.21 [0.86-1.49]). In those without diabetes at baseline, parity was not associated with incident diabetes or with fasting glucose; however, there was a modest association of parity with fasting insulin and homeostasis assessment model of insulin resistance.

CONCLUSIONS

Grand multiparity is associated with diabetes in elderly women in cross-sectional analyses. This relationship seems to be confounded and/or mediated by variation in body weight and sociodemographic factors by parity status. In older nondiabetic women, higher parity does not pose an ongoing risk of developing diabetes.

Prepregnancy lipids related to preterm birth risk: the coronary artery risk development in young adults study

CONTEXT

Preterm birth is associated with maternal cardiovascular risk, but mechanisms are unknown.

OBJECTIVE

We considered that dyslipidemia may predispose women to both conditions and that prepregnancy lipids may be related to preterm birth risk. We hypothesized that low or high prepregnancy plasma lipids would be associated with preterm birth.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1010 women (49% black) enrolled in the multicenter, prospective Coronary Artery Risk Development in Young Adults study with at least one singleton birth during 20 yr of follow-up were evaluated.

MAIN OUTCOME MEASURE

Postbaseline preterm births less than 34 wk or 34 to less than 37 wk vs. greater than 37 wk gestation.

RESULTS

We detected a U-shaped relationship between prepregnancy cholesterol concentrations and preterm birth risk. Women with prepregnancy cholesterol in the lowest quartile compared with the second quartile (<156 vs. 156-171 mg/dl) had an increased risk for preterm birth 34 to less than 37 wk (odds ratio 1.86; 95% confidence interval 1.10, 3.15) and less than 34 wk (odds ratio 3.04; 1.35, 6.81) independent of race, age, parity, body mass index, hypertension during pregnancy, physical activity, and years from measurement to birth. Prepregnancy cholesterol in the highest quartile (>195 mg/dl) was also associated with preterm birth less than 34 wk among women with normotensive pregnancies (odds ratio 3.80; 95% confidence interval 1.07, 7.57). There were no associations between prepregnancy triglycerides, low-density lipoprotein cholesterol, or high-density lipoprotein cholesterol and preterm birth.

CONCLUSIONS

Both low and high prepregnancy cholesterol were related to preterm birth risk. These may represent distinct pathways to the heterogeneous outcome of preterm birth. Additional studies are needed to elucidate mechanisms that link low or high cholesterol to preterm birth and later-life sequelae.

Low concentrations of thrombin-inhibitor complexes and the risk of preterm delivery

OBJECTIVE

High maternal concentrations of thrombin-antithrombin (TAT) complexes have been associated with adverse outcomes. The objective of this study was to evaluate the relationship between TAT in asymptomatic subjects at 24 and 28 weeks and spontaneous preterm birth (SPTB).

STUDY DESIGN

A secondary analysis of the National Institute of Child Health and Human Development Preterm Prediction Study was performed. Subjects with SPTB were matched to controls. Maternal TAT concentrations were previously measured at 24 and 28 weeks. Differences between cases and controls were analyzed with Mann-Whitney U and logistic regression.

RESULTS

TAT was lower in cases than controls at 28 weeks (P = .01). The odds ratio for SPTB with TAT less than 25% was 2.55 (95% confidence interval, 1.34-4.89) when adjusted for clinical variables.

CONCLUSION

Early third-trimester TAT was lower in subsequent cases of SPTB. In some patients, low TAT concentrations may represent impaired thrombin activation and be pathologic.

Is there evidence of separate inflammatory or metabolic forms of preeclampsia?

OBJECTIVES

To examine whether high insulin resistance versus high inflammation identifies subtypes of preeclampsia.

METHODS

A cytokine panel, glucose and insulin were measured in 37 preeclampsia plasma samples. Wilcoxon rank sum assessed median concentration of HOMA(IR) by pro-inflammatory:anti-inflammatory ratio. Regression stratifying by BMI and preterm birth was conducted.

RESULTS

There was no difference in median HOMA(IR) by the pro-inflammatory:anti-inflammatory ratio (p = 0.16). No subsets scatterplot clusters emerged. A positive correlation between HOMAlog and the ratio was significant (p = 0.04).

CONCLUSIONS

No dichotomous subsets of preeclampsia by inflammation versus insulin resistance were detected. Contrary to our hypothesis, insulin resistance was higher as inflammation increased in preeclampsia.

Maternal serum 25-hydroxyvitamin D concentrations are associated with small-for-gestational age births in white women

Maternal vitamin D deficiency has been associated with numerous adverse health outcomes, but its association with fetal growth restriction remains uncertain. We sought to elucidate the association between maternal serum 25-hydroxyvitamin D [25(OH)D] concentrations in early pregnancy and the risk of small-for-gestational age birth (SGA) and explore the association between maternal single nucleotide polymorphisms (SNP) in the vitamin D receptor (VDR) gene and the risk of SGA. We conducted a nested case-control study of nulliparous pregnant women with singleton pregnancies who delivered SGA infants (n = 77 white and n = 34 black) or non-SGA infants (n = 196 white and n = 105 black). Women were followed from <16 wk gestation to delivery. Women's banked sera at <22 wk were newly measured for 25(OH)D and DNA extracted for VDR genotyping. SGA was defined as live-born infants that were <10th percentile of birth weight according to nomograms based on gender and gestational age. After confounder adjustment, there was a U-shaped relation between serum 25(OH)D and risk of SGA among white mothers, with the lowest risk from 60 to 80 nmol/L. Compared with serum 25(OH)D 37.5-75 nmol/L, SGA odds ratios (95% CI) for levels <37.5 and >75 nmol/L were 7.5 (1.8, 31.9) and 2.1 (1.2, 3.8), respectively. There was no relation between 25(OH)D and SGA risk among black mothers. One SNP in the VDR gene among white women and 3 SNP in black women were significantly associated with SGA. Our results suggest that vitamin D has a complex relation with fetal growth that may vary by race.

Association of periconceptional multivitamin use with reduced risk of preeclampsia among normal-weight women in the Danish National Birth Cohort

The timing and frequency of periconceptional multivitamin use may be related to the risk of preeclampsia. Women in the Danish National Birth Cohort (1997-2003) reported multivitamin or folate-only supplement use during a 12-week periconceptional period (from 4 weeks prior to 8 weeks after the last menstrual period). Preeclampsia cases were identified by using International Classification of Diseases, Tenth Revision, codes. Cox regression was used to estimate the association of frequency (weeks of use) and timing (preconception and postconception) of use with preeclampsia risk. Overall, there were 668 cases of preeclampsia (2.3%), and 18,551 women (65%) reported periconceptional multivitamin use. After adjustment, regular use (12 of 12 weeks) was related to a reduced risk of preeclampsia among normal-weight women. Compared with nonusers with a body mass index of 22 kg/m(2), regular multivitamin users with the same body mass index had a 20% reduced risk of preeclampisa (hazard ratio = 0.78, 95% confidence interval: 0.60, 0.99). In addition, regular use in the postconception period only was associated with reduced risk, a relation that also appeared to be limited to women with a body mass index of <25 kg/m(2) (hazard ratio = 0.63, 95% confidence interval: 0.42, 0.93). Folate-only supplement use was unrelated to preeclampsia risk. Regular periconceptional multivitamin use was associated with a reduced risk of preeclampsia among normal-weight women, and the immediate postconception period appeared to be the relevant exposure window.

Parity and cardiovascular disease risk among older women: how do pregnancy complications mediate the association?

PURPOSE

To determine whether parity is associated with increased risk of cardiovascular disease (CVD) after accounting for perinatal complications.

METHODS

CVD prevalence, number of births, and a history of preeclampsia, term low birth weight, preterm or stillbirth were evaluated among 540 women (mean age, 80 years; 47% black) enrolled in the Pittsburgh, PA site of the Health, Aging and Body Composition Study. Biomarkers were measured and CVD status was determined by self-report and hospital records.

RESULTS

Nulliparous women (n = 89) had lower CVD prevalence compared with parous women (18.0% vs. 30.2%). Parous women without perinatal complications of interest (n = 321) had higher statin use compared with nulliparas, a trend accompanied by lower high-density lipoprotein (HDL) and higher triglycerides among women with perinatal complications (n = 130). After adjustment, parous women with no complicated births had a 1.95-fold (95% confidence interval [CI], 1.03-3.7) higher CVD prevalence compared to nulliparas. Among women with one or more pregnancy complications, CVD prevalence was 2.67 times (CI, 1.34-5.33) higher. Women with five or more births had the highest CVD prevalence (odds ratio [OR], 2.60; CI, 1.17-5.76) that was attenuated to 2.27 (1.00-5.15) after adjustment for complications of interest.

CONCLUSIONS

History of pregnancy complications and higher statin use accounted for some but not all of the excess CVD prevalence among older parous women.

Activation of the fibrinolytic cascade early in pregnancy among women with spontaneous preterm birth

OBJECTIVE

To evaluate the association of early pregnancy concentrations of thrombin-antithrombin III complex with subsequent spontaneous preterm birth.

METHODS

In a nested case-control study, thrombin-antithrombin III complex was measured in plasma before 20 weeks of gestation (mean 9.9 weeks) among women without chronic conditions, preeclampsia, or growth restriction. C-reactive protein and non-high-density lipoprotein cholesterol were also measured. Women with spontaneous preterm birth before 34 weeks of gestation (n=29) and 34 weeks to 36 weeks of gestation (n=72) were compared with women with term births occurring at or after 37 weeks (n=219). Polychotomous logistic regression was used to relate elevated thrombin-antithrombin III complex (greater than 5.5 ng/mL), dyslipidemia (non-high-density lipoprotein cholesterol greater than the 90th percentile), and inflammation (C-reactive protein at or above 8 micrograms/mL) to risk of spontaneous preterm birth subtypes.

RESULTS

Women with spontaneous preterm birth compared with term births had elevated thrombin-antithrombin III complex (P=.02), and they were more likely to have a thrombin-antithrombin III complex greater than 5.5 ng/mL (P<.01). Women with thrombin-antithrombin III complex in the highest compared with lowest quartile had a 4.6-fold (95% confidence interval 1.3-15.8) increased risk for spontaneous preterm birth before 34 weeks of gestation, adjusted for body mass index, race, inflammation, dyslipidemia, and gestational age at sampling. There was a dose-response trend between thrombin-antithrombin III complex and spontaneous preterm birth before 34 weeks (P<.01) and 34 to 36 weeks (P=.03).

CONCLUSION

There is evidence of early pregnancy systemic fibrinolysis among women with spontaneous preterm birth before 34 weeks of gestation independent of inflammation and dyslipidemia, perhaps secondary to microvascular injury.

LEVEL OF EVIDENCE

II.

Factors associated with zidovudine receipt and prenatal care among HIV-infected pregnant women in New Jersey

Despite reductions in perinatal HIV transmission, cases continue to occur. To determine factors associated with zidovudine (ZDV) receipt among HIV-infected pregnant women we merged three data sets for women in New Jersey in 1995-1997, identifying 395 HIV-infected pregnant women. Half received two arms of ZDV prophylaxis. Attendance at five or more prenatal visits was the strongest independent factor related to ZDV receipt (OR 6.37, 95% CI 3.84, 10.57). Half (49.0%) had limited prenatal care. AIDS diagnosis, race/ethnicity, and drug use were also independently related to ZDV receipt. Post hoc analysis revealed that being unmarried, Black, multiparous, having no insurance, and illegal drug use were associated with limited prenatal care. Although the U.S. has seen reductions in HIV perinatal transmission, our research showed that HIV-infected women who did not get prenatal care were less likely to receive two arms of ZDV prophylaxis. A wide public health net that brings all women into care is necessary to reduce perinatal transmission further.

Evidence of endothelial dysfunction in preeclampsia and risk of adverse pregnancy outcome

The purpose of this study is to investigate whether endothelial dysfunction, as assessed by elevated cellular fibronectin (cFN), in women with preeclampsia is associated with an increased risk of preterm and/or small-for-gestational-age (SGA) births. Maternal plasma cFN was measured by enzyme-linked immunosorbent assay in samples collected at admission to delivery in 605 normotensive women, 171 women with transient hypertension, and 187 women with preeclampsia. Logistic regression was used to estimate the risk for preterm delivery, SGA, or both. Elevated cFN in women with preeclampsia was associated with an increased risk of both preterm and SGA births (odds ratio, 3.0; confidence interval [CI], 1.0-8.7) compared with women with preeclampsia without elevated cFN. The risk of preterm birth was 14.7-fold higher (CI, 8.1-26.7) and the risk of SGA was 6.8-fold higher (CI, 3.5-13.1) in women with preeclampsia, hyperuricemia, and elevated cFN compared with normotensive women. Elevated cFN is prevalent among women with preeclampsia and identifies women at increased risk of preterm delivery and SGA.

Early pregnancy lipid concentrations and spontaneous preterm birth

OBJECTIVE

Women who deliver preterm infants may be at increased risk for cardiovascular disease, perhaps related to dyslipidemia.

STUDY DESIGN

In a nested case control study of women with spontaneous preterm birth, cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were evaluated. Lipid concentrations and gestational changes, as well as risk for preterm birth, were evaluated in women who delivered <34 (n = 23), >or=34-<37 (n = 67), and >or=37 weeks (n = 199).

RESULTS

High cholesterol or triglycerides <or=15 weeks were associated with a 2.8-fold (1.0-7.9) and 2.0-fold (1.0-3.9) increased risk for preterm birth <34 weeks and >or=34-<37 weeks, respectively. Overweight women who delivered <34 weeks had particularly elevated early pregnancy concentrations of cholesterol and low-density lipoprotein; lean women with moderate preterm birth had elevated triglycerides. There was a reduced triglyceride response in the first half of pregnancy among women who delivered <34 weeks.

CONCLUSION

Our results indicate the presence of dyslipidemia in women with spontaneous preterm birth.

Inflammation and dyslipidemia related to risk of spontaneous preterm birth

Women who deliver preterm are at increased risk for cardiovascular disease, but mechanisms are not understood. The authors considered that inflammation in women with spontaneous preterm birth (sPTB) might be related to their metabolic profile, such as lipids, and tested this in a nested case-control study from the Pregnancy Exposures and Preeclampsia Prevention Study (1997-2001). Cases were women with sPTB at 34-<37 weeks (n = 76) or < 34 weeks (n = 33). Controls were randomly selected women with term births (n = 228). Early pregnancy inflammation (C-reactive protein: > or = 8 microg/ml) and dyslipidemia (cholesterol: > 230 mg/dl or triglycerides: > 140 mg/dl) were evaluated in serum collected at < 21 weeks. Late pregnancy elevated C-reactive protein (> or = 12 microg/ml) was measured in a subset (n = 295). Polycotomous logistic regression was used to estimate the joint effects of C-reactive protein elevations and dyslipidemia on the risk of sPTB subtypes. After adjustment for race, body mass index, periconceptional vitamin use, and gestational age at sampling, early pregnancy inflammation (odds ratio = 2.9, 95% confidence interval (CI): 1.1, 7.2) and dyslipidemia (odds ratio = 2.0, 95% CI: 1.0, 4.2) were independently associated with sPTB at 34-<37 weeks. The presence of both conditions increased risk of sPTB at < 34 weeks 6.4-fold (95% CI: 1.7, 24.1). Half of the women with early pregnancy inflammation had elevated C-reactive protein late in gestation, and each was independently related to the risk of sPTB at < 34 weeks. The results indicate that some metabolic factors together with inflammation may be related to the risk of sPTB.

Prepregnancy obesity predicts poor vitamin D status in mothers and their neonates

Obesity is a risk factor for vitamin D deficiency, but this relation has not been studied among pregnant women, who must sustain their own vitamin D stores as well as those of their fetuses. Our objective was to assess the effect of prepregnancy BMI on maternal and newborn 25-hydroxyvitamin D [25(OH)D] concentrations. Serum 25(OH)D was measured at 4-21 wk gestation and predelivery in 200 white and 200 black pregnant women and in their neonates' cord blood. We used multivariable logistic regression models to assess the independent association between BMI and the odds of vitamin D deficiency [25(OH)D <50 nmol/L] after adjustment for race/ethnicity, season, gestational age, multivitamin use, physical activity, and maternal age. Compared with lean women (BMI <25), pregravid obese women (BMI >or=30) had lower adjusted mean serum 25(OH)D concentrations at 4-22 wk (56.5 vs. 62.7 nmol/L; P < 0.05) and a higher prevalence vitamin D deficiency (61 vs. 36%; P < 0.01). Vitamin D status of neonates born to obese mothers was poorer than neonates of lean mothers (adjusted mean, 50.1 vs. 56.3 nmol/L; P < 0.05). There was a dose-response trend between prepregnancy BMI and vitamin D deficiency. An increase in BMI from 22 to 34 was associated with 2-fold (95% CI: 1.2, 3.6) and 2.1-fold (1.2, 3.8) increases in the odds of mid-pregnancy and neonatal vitamin D deficiency, respectively. The rise in maternal obesity highlights that maternal and newborn vitamin D deficiency will continue to be a serious public health problem until steps are taken to identify and treat low 25(OH)D.

Maternal vitamin D deficiency increases the risk of preeclampsia

CONTEXT

Vitamin D has direct influence on molecular pathways proposed to be important in the pathogenesis of preeclampsia, yet the vitamin D-preeclampsia relation has not been studied.

OBJECTIVES

We aimed to assess the effect of maternal 25-hydroxyvitamin D [25(OH)D] concentration on the risk of preeclampsia and to assess the vitamin D status of newborns of preeclamptic mothers.

DESIGN AND SETTING

We conducted a nested case-control study of pregnant women followed from less than 16 wk gestation to delivery (1997-2001) at prenatal clinics and private practices.

PATIENTS

Patients included nulliparous pregnant women with singleton pregnancies who developed preeclampsia (n = 55) or did not develop preeclampsia (n = 219). Women's banked sera were newly measured for 25(OH)D.

MAIN OUTCOME MEASURE

The main outcome measure was preeclampsia (new-onset gestational hypertension and proteinuria for the first time after 20 wk gestation). Our hypotheses were formulated before data collection.

RESULTS

Adjusted serum 25(OH)D concentrations in early pregnancy were lower in women who subsequently developed preeclampsia compared with controls [geometric mean, 45.4 nmol/liter, and 95% confidence interval (CI), 38.6-53.4 nmol/liter, vs. 53.1 and 47.1-59.9 nmol/liter; P < 0.01]. There was a monotonic dose-response relation between serum 25(OH)D concentrations at less than 22 wk and risk of preeclampsia. After confounder adjustment, a 50-nmol/liter decline in 25(OH)D concentration doubled the risk of preeclampsia (adjusted odds ratio, 2.4; 95% CI, 1.1-5.4). Newborns of preeclamptic mothers were twice as likely as control newborns to have 25(OH)D less than 37.5 nmol/liter (adjusted odds ratio, 2.2; 95% CI, 1.2-4.1).

CONCLUSIONS

Maternal vitamin D deficiency may be an independent risk factor for preeclampsia. Vitamin D supplementation in early pregnancy should be explored for preventing preeclampsia and promoting neonatal well-being.

Association of periconceptional multivitamin use and risk of preterm or small-for-gestational-age births

The authors' objective was to determine the relation between periconceptional multivitamin use and the risk of small-for-gestational-age (SGA: <5th percentile; 5th-<10th percentiles) or preterm (<34 weeks; 34-<37 weeks) births. Women in the Pregnancy Exposures and Preeclampsia Prevention Study (1997-2001) reported at enrollment their regular multivitamin use in the past 6 months (n=1,823). Women were classified as users or nonusers in multinomial logistic models. After adjustment for race, age, education, enrollment gestational age, and household density, periconceptional multivitamin use was associated with a reduced risk of preterm births (<34 weeks) (odds ratio (OR)=0.29, 95% confidence interval (CI): 0.13, 0.64) and spontaneous preterm births (<34 weeks) (OR=0.40, 95% CI: 0.16, 0.99). Risk of SGA (<5th percentile) was marginally lower (OR=0.64, 95% CI: 0.40, 1.03) after adjustment for smoking, education, parity, enrollment gestational age, and body mass index. Prepregnancy body mass index modified this relation. Nonobese users had a reduction (OR=0.54, 95% CI: 0.32, 0.91) in risk of SGA (<5th percentile); there was no effect among obese women. There was no effect of multivitamin use on risk of preterm births (34-<37 weeks) or SGA (5th-<10th percentiles). Sensitivity analysis for unmeasured confounding by folate intake supported these findings. Study results indicate lower rates of severe preterm births and extreme SGA in women who report periconceptional vitamin use, although these should be considered cautiously until replicated.

Maternal leptin across pregnancy in women with small-for-gestational-age infants

OBJECTIVE

We hypothesized that women with small-for-gestational-age (SGA) neonates would have lower concentrations of leptin compared to women with appropriately grown infants (AGA).

STUDY DESIGN

This is a nested case-control study of normotensive nulliparous women. Cases (n = 28) delivered SGA < 10 percentile and controls (n = 77) delivered AGA. Maternal plasma leptin concentrations were compared at 18, 28, and 40 weeks' gestation via repeated measures.

RESULTS

Maternal leptin concentrations at 18 weeks were correlated with prepregnancy BMI (r = 0.69, P < .0001) and early pregnancy waist circumference (r = 0.59, P < .0001). After adjustment for maternal body composition, leptin was lower across pregnancy in women with SGA compared to AGA neonates (13.6 vs 15.2 ng/mL at 18 weeks; 13.6 vs 17.3 ng/mL at 28 weeks; 16.6 vs 20.7 ng/mL at 40 weeks; P = .04).

CONCLUSION

Maternal leptin was correlated with maternal adiposity; however, after adjustment for body composition, leptin was lower across pregnancy in women with SGA.