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Grobman WA, Gilbert SA, Iams JD, Spong CY, Saade G, Mercer BM, Tita ATN, Rouse DJ, Sorokin Y, Leveno KJ, Tolosa JE, Thorp JM, Caritis SN, Peter Van Dorsten J. Activity restriction among women with a short cervix. Obstet Gynecol 2013; 121:1181-1186. [PMID: 23812450 PMCID: PMC4019312 DOI: 10.1097/aog.0b013e3182917529] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate determinants of and outcomes associated with activity restriction among women with a short cervix. METHODS This was a secondary analysis of a randomized trial of 17-α hydroxyprogesterone caproate for prevention of preterm birth among nulliparous women with singleton gestations and cervices less than 30 mm by midtrimester ultrasonography. Women were asked weekly whether they had been placed on pelvic, work, or nonwork rest. "Any activity restriction" was defined as being placed on any type of rest. Factors associated with any activity restriction were determined and the association between preterm birth and activity restriction was estimated with multivariable logistic regression. RESULTS Of the 657 women in the trial, 646 (98%) responded to questions regarding activity restriction. Two hundred fifty-two (39.0%) were placed on any activity restriction at a median of 23.9 weeks (interquartile range 22.6-27.9 weeks). Women on activity restriction were older, more likely to have private insurance, less likely to be Hispanic, had a shorter cervical length, and were more likely to have funneling and intra-amniotic debris. Preterm birth at less than 37 weeks of gestation was more common among women placed on activity restriction (37% compared with 17%, P<.001). After controlling for potential confounding factors, preterm birth remained more common among those placed on activity restriction (adjusted odds ratio 2.37, 95% confidence interval 1.60-3.53). Results were similar for preterm birth at less than 34 weeks of gestation. CONCLUSION Activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix.
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Weissgerber TL, Gandley RE, McGee PL, Spong CY, Myatt L, Leveno KJ, Thorp JM, Mercer BM, Peaceman AM, Ramin SM, Carpenter MW, Samuels P, Sciscione A, Harper M, Tolosa JE, Saade G, Sorokin Y. Haptoglobin phenotype, preeclampsia risk and the efficacy of vitamin C and E supplementation to prevent preeclampsia in a racially diverse population. PLoS One 2013; 8:e60479. [PMID: 23573260 PMCID: PMC3616124 DOI: 10.1371/journal.pone.0060479] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/27/2013] [Indexed: 12/19/2022] Open
Abstract
Haptoglobin's (Hp) antioxidant and pro-angiogenic properties differ between the 1-1, 2-1, and 2-2 phenotypes. Hp phenotype affects cardiovascular disease risk and treatment response to antioxidant vitamins in some non-pregnant populations. We previously demonstrated that preeclampsia risk was doubled in white Hp 2-1 women, compared to Hp 1-1 women. Our objectives were to determine whether we could reproduce this finding in a larger cohort, and to determine whether Hp phenotype influences lack of efficacy of antioxidant vitamins in preventing preeclampsia and serious complications of pregnancy-associated hypertension (PAH). This is a secondary analysis of a randomized controlled trial in which 10,154 low-risk women received daily vitamin C and E, or placebo, from 9-16 weeks gestation until delivery. Hp phenotype was determined in the study prediction cohort (n = 2,393) and a case-control cohort (703 cases, 1,406 controls). The primary outcome was severe PAH, or mild or severe PAH with elevated liver enzymes, elevated serum creatinine, thrombocytopenia, eclampsia, fetal growth restriction, medically indicated preterm birth or perinatal death. Preeclampsia was a secondary outcome. Odds ratios were estimated by logistic regression. Sampling weights were used to reduce bias from an overrepresentation of women with preeclampsia or the primary outcome. There was no relationship between Hp phenotype and the primary outcome or preeclampsia in Hispanic, white/other or black women. Vitamin supplementation did not reduce the risk of the primary outcome or preeclampsia in women of any phenotype. Supplementation increased preeclampsia risk (odds ratio 3.30; 95% confidence interval 1.61-6.82, p<0.01) in Hispanic Hp 2-2 women. Hp phenotype does not influence preeclampsia risk, or identify a subset of women who may benefit from vitamin C and E supplementation to prevent preeclampsia.
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Nelson DB, Freeman MP, Johnson NL, McIntire DD, Leveno KJ. A prospective study of postpartum depression in 17 648 parturients. J Matern Fetal Neonatal Med 2013; 26:1155-61. [DOI: 10.3109/14767058.2013.777698] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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79
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Andres RL, Zhao Y, Klebanoff MA, Hauth JC, Caritis SN, Carey JC, Wapner RJ, Iams JD, Leveno KJ, Miodovnik M, Sibai B, Van Dorsten JP, Dombrowski MP, O'Sullivan MJ, Langer O. The impact of tobacco use on preterm premature rupture of the membranes. Am J Perinatol 2013; 30:185-90. [PMID: 22930157 PMCID: PMC3962832 DOI: 10.1055/s-0032-1322517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine if tobacco use increases the incidence of preterm premature rupture of the membranes (pPROM) or alters perinatal outcomes after pPROM. STUDY DESIGN This is a secondary analysis of the databases of three completed Eunice Kennedy Shriver National Institute of Child Health and Human Development-supported Maternal Fetal Medicine Units Network studies. Self-reported tobacco exposure data was obtained. Its relationship with the incidence of pPROM and associated neonatal outcome measures were assessed. RESULTS There was no difference in the incidence of pPROM when comparing nonsmokers to those using tobacco. Although a trend was seen between the incidence of pPROM and the amount smoked, this did not reach statistical significance. Among the patients with pPROM, the use of tobacco was not associated with an increase in perinatal morbidity. CONCLUSION Our data do not support a significant relationship between tobacco use and pPROM.
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Gilbert SA, Grobman WA, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Wapner RJ, Sorokin Y, O'Sullivan MJ, Sibai BM, Thorp JM, Ramin SM, Mercer BM. Cost-effectiveness of trial of labor after previous cesarean in a minimally biased cohort. Am J Perinatol 2013; 30:11-20. [PMID: 23292916 PMCID: PMC4049080 DOI: 10.1055/s-0032-1333206] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC). STUDY DESIGN A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature. RESULTS The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more. CONCLUSION A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.
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Grobman WA, Thom EA, Spong CY, Iams JD, Saade GR, Mercer BM, Tita ATN, Rouse DJ, Sorokin Y, Wapner RJ, Leveno KJ, Blackwell S, Esplin MS, Tolosa JE, Thorp JM, Caritis SN, Van Dorsten JP. 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm. Am J Obstet Gynecol 2012; 207:390.e1-8. [PMID: 23010094 PMCID: PMC3484249 DOI: 10.1016/j.ajog.2012.09.013] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We sought to evaluate whether 17 alpha-hydroxyprogesterone caproate (17-OHP) reduces preterm birth (PTB) in nulliparous women with a midtrimester cervical length (CL) <30 mm. STUDY DESIGN In this multicenter randomized controlled trial, nulliparous women with a singleton gestation between 16 and 22 3/7 weeks with an endovaginal CL <30 mm (<10th percentile in this population) were randomized to weekly intramuscular 17-OHP (250 mg) or placebo through 36 weeks. The primary outcome was PTB <37 weeks. RESULTS The frequency of PTB did not differ between the 17-OHP (n = 327) and placebo (n = 330) groups (25.1% vs 24.2%; relative risk, 1.03; 95% confidence interval, 0.79-1.35). There also was no difference in the composite adverse neonatal outcome (7.0% vs 9.1%; relative risk, 0.77; 95% confidence interval, 0.46-1.30). CONCLUSION Weekly 17-OHP does not reduce the frequency of PTB in nulliparous women with a midtrimester CL <30 mm.
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Bleich AT, Alexander JM, McIntire DD, Leveno KJ. An analysis of second-stage labor beyond 3 hours in nulliparous women. Am J Perinatol 2012; 29:717-22. [PMID: 22644830 DOI: 10.1055/s-0032-1314894] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional. STUDY DESIGN Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database. RESULTS Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours. CONCLUSION Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.
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Stewart RD, Bleich AT, Lo JY, Alexander JM, McIntire DD, Leveno KJ. Defining uterine tachysystole: how much is too much? Am J Obstet Gynecol 2012; 207:290.e1-6. [PMID: 22901710 DOI: 10.1016/j.ajog.2012.07.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/21/2012] [Accepted: 07/25/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to determine if uterine tachysystole, ≥ 6 contractions per 10 minutes, within the first 4 hours of labor induction, is associated with adverse infant outcomes. STUDY DESIGN This was a prospective cohort study of 584 women ≥ 37 weeks' gestation undergoing induction of labor with 100 μg of oral misoprostol. Fetal heart rate tracings were analyzed for contractions per 10 minutes during the initial 4 hours after misoprostol administration. Patients were analyzed based on the maximum number of contractions per 10 minutes. Infant condition at birth was assessed using the fetal vulnerability composite. RESULTS Adverse infant outcomes showed no association with increasing number of contractions per 10 minutes. Six or more contractions in 10 minutes were significantly associated with fetal heart rate decelerations (P ≤ .001). Analysis was performed using the maximum number of contractions per 30 minutes with similar results. CONCLUSION Uterine tachysystole, as currently defined, when occurring remote from delivery is not associated with adverse infant outcomes.
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Hernandez JS, Alexander JM, Sarode R, McIntire DD, Leveno KJ. Calculated blood loss in severe obstetric hemorrhage and its relation to body mass index. Am J Perinatol 2012; 29:557-60. [PMID: 22495893 DOI: 10.1055/s-0032-1310528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate total calculated blood loss at the time of severe obstetric hemorrhage. STUDY DESIGN This is a prospective observational study of women with obstetric hemorrhage. Women who received a blood transfusion for hypovolemia and those in which a body mass index (BMI) could be calculated were included. Total blood volume lost was calculated. Blood loss was analyzed in relation to maternal size as reflected in the BMI. RESULTS Fourteen hundred forty-three women meeting inclusion criteria delivered at our hospital between March 2002 and June 2006. The median calculated volume of blood lost was 3529 mL, and 93% of women sustained losses ≥3000 mL. The blood loss sufficient to provoke signs and symptoms of hypovolemia was proportional to the woman's BMI. CONCLUSION Women who develop hypovolemia during childbirth have suffered very large losses of blood, and infusion of blood products is required to restore circulation and prevent further morbidity.
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Greer LG, Ziadie MS, Casey BM, Rogers BB, McIntire DD, Leveno KJ. An immunologic basis for placental insufficiency in fetal growth restriction. Am J Perinatol 2012; 29:533-8. [PMID: 22495894 DOI: 10.1055/s-0032-1310525] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to determine whether chronic villitis, an immunologic disease of the placenta, was related to fetal growth restriction. METHODS Beginning in October 1999, a protocol was instituted that required placentas of high-risk births be submitted for standardized histological examination. Chronic villitis was diagnosed when a lymphohistiocytic infiltrate involving placental villi was present and was graded according to the extent and location of the infiltrate. Fetal growth restriction was defined as weight less than 3rd, 5th, and 10th percentiles. Placental hypoplasia was defined as weight less than 10th percentile. RESULTS In the 10,204 placental examinations that were performed, low-grade and high-grade chronic villitis was associated with hypoplastic placentas and fetal growth restriction. Infants with placentas with low-grade and high-grade chronic villitis were more likely to require cesarean delivery for nonreassuring fetal heart rate compared with controls (27% and 25% versus 21%; p < 0.05). Fetal acidemia (umbilical artery pH < 7.0) was associated with high-grade chronic villitis compared with controls (4% versus 2%; p < 0.05). CONCLUSION Chronic villitis was associated with anatomic and functional placental insufficiency manifested as placental hypoplasia, growth restriction, increased risk of cesarean for nonreassuring fetal heart rate, and fetal acidemia. These findings support an immunologic basis for fetal growth restriction.
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Johnson LH, Mapp DC, Rouse DJ, Spong CY, Mercer BM, Leveno KJ, Varner MW, Iams JD, Sorokin Y, Ramin SM, Miodovnik M, O'Sullivan MJ, Peaceman AM, Caritis SN. Association of cord blood magnesium concentration and neonatal resuscitation. J Pediatr 2012; 160:573-577.e1. [PMID: 22056282 PMCID: PMC3998513 DOI: 10.1016/j.jpeds.2011.09.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 08/08/2011] [Accepted: 09/06/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To assess the relationship between umbilical cord blood magnesium concentration and level of delivery room resuscitation received by neonates. STUDY DESIGN This was a secondary analysis of a controlled fetal neuroprotection trial that enrolled women at imminent risk for delivery between 24 and 31 weeks' gestation and randomly allocated them to receive either intravenous magnesium sulfate or placebo. The cohort included 1507 infants with data available on total cord blood Mg concentration and delivery room resuscitation. Multivariate logistic regression was used to estimate the association between cord blood Mg concentration and highest level of delivery room resuscitation, using the following hierarchy: none, oxygen only, bag-mask ventilation with oxygen, intubation, and chest compressions. RESULTS There was no relationship between cord blood Mg and delivery room resuscitation (OR, 0.92 for each 1.0-mEq/L increase in Mg; 95% CI, 0.83-1.03). Maternal general anesthesia was associated with increased neonatal resuscitation (OR, 2.51; 95% CI, 1.72-3.68). Each 1-week increase in gestational age at birth was associated with decreased neonatal resuscitation (OR, 0.63; 95% CI, 0.60-0.66). CONCLUSION Cord blood Mg concentration does not correlate with the level of delivery room resuscitation of infants exposed to magnesium sulfate for fetal neuroprotection.
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Gilbert SA, Grobman WA, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Sorokin Y, Carpenter M, O'Sullivan MJ, Sibai BM, Thorp JM, Ramin SM, Mercer BM. Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis. Am J Obstet Gynecol 2012; 206:311.e1-9. [PMID: 22464069 PMCID: PMC3337034 DOI: 10.1016/j.ajog.2012.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/04/2012] [Accepted: 02/06/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or trial of labor (TOL). STUDY DESIGN Women who were eligible for a TOL with 1 previous low transverse incision were categorized according to whether they underwent an ERCD or TOL. A propensity score technique was used to develop ERCD and TOL groups with comparable baseline characteristics. Outcomes were assessed with conditional logistic regression. RESULTS The rates of endometritis, operative injury, respiratory distress syndrome, and newborn infant infection were lower and the rates of hysterectomy and wound complication were higher in the ERCD group. CONCLUSION Propensity score techniques can be used to generate comparable ERCD and TOL groups. Some types of maternal morbidity (such as hysterectomy) are higher; other types (such as operative injury) are lower in the ERCD group. Although the absolute risk is low, neonatal morbidity appears to be lower in the ERCD group.
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Stewart RD, Bleich AT, Alexander JM, McIntire DD, Leveno KJ. 313: Defining uterine tachysystole: how much is too much? Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Clark EAS, Mele L, Wapner RJ, Spong CY, Sorokin Y, Peaceman A, Iams JD, Leveno KJ, Harper M, Caritis SN, Mercer BM, Thorp JM, Ramin SM, Carpenter M, Rouse DJ. Repeated course antenatal steroids, inflammation gene polymorphisms, and neurodevelopmental outcomes at age 2. Am J Obstet Gynecol 2011; 205:79.e1-5. [PMID: 21529753 PMCID: PMC3743532 DOI: 10.1016/j.ajog.2011.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/04/2011] [Accepted: 02/17/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We sought to evaluate the interaction between repeated-course antenatal corticosteroids and inflammation gene polymorphisms with neurodevelopmental outcomes at age 2 years. STUDY DESIGN We conducted nested case-control analysis of a randomized controlled trial of single- vs repeated-course antenatal corticosteroids. Cases had mental and/or psychomotor delay at age 2 years. Controls had normal neurodevelopment. Previous analyses of 125 cases and 147 controls identified 4 inflammation gene polymorphisms associated with neurodevelopmental delay at age 2 years. RESULTS The interaction between repeated-course corticosteroids and the interleukin (IL)-6 -174 genotype with neurodevelopmental delay was significant (P = .046). The IL-6 -174 GG genotype was associated with neurodevelopmental delay at age 2 years in the single-course corticosteroid group (odds ratio, 6.47; 95% confidence interval, 1.86-22.50). Exposure to repeated-course antenatal corticosteroids abrogated this genotype effect (odds ratio, 1.30; 95% confidence interval, 0.48-3.54). Results were unchanged after controlling for potential confounders. CONCLUSION Repeated-course antenatal steroids may reduce the increased risk of neurodevelopmental delay at age 2 years associated with IL-6 -174 GG genotype.
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Villano KS, Lo JY, Alexander JM, McIntire DD, Leveno KJ. A dose-finding study of oral misoprostol for labor augmentation. Am J Obstet Gynecol 2011; 204:560.e1-5. [PMID: 21514556 DOI: 10.1016/j.ajog.2011.02.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 02/14/2011] [Accepted: 02/24/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We designed a dose-finding trial of oral misoprostol administered for labor augmentation. STUDY DESIGN Healthy, nulliparous women in active labor and diagnosed with arrest of dilation were enrolled in cohorts of 10 at a time. Five regimens were studied: (1) 25 μg every 4 hours, (2) 50 μg every 4 hours, (3) 100 μg every 4 hours, (4) 50 μg every 2 hours, and (5) 75 μg every 4 hours. RESULTS A total of 46 women were enrolled. Baseline uterine activity approximately doubled with 4 of the regimens and tripled with the highest dosage regimen (100 μg) (P < .001). The 100-μg regimen was truncated due to excessive uterine hyperstimulation (40%). CONCLUSION An oral dose of 75 μg of misoprostol given at a 4-hour interval for a maximum of 2 doses is the highest tolerated dose. Randomized, controlled trials will be required before a regimen is employed routinely.
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Mertz HL, Mele L, Spong CY, Dudley DJ, Wapner RJ, Iams JD, Sorokin Y, Peaceman A, Leveno KJ, Caritis SN, Miodovnik M, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter M, Rouse DJ, Sibai B. Placental endothelial nitric oxide synthase in multiple and single dose betamethasone exposed pregnancies. Am J Obstet Gynecol 2011; 204:545.e11-6. [PMID: 21529755 DOI: 10.1016/j.ajog.2011.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 01/13/2011] [Accepted: 02/04/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare endothelial nitric oxide synthase expression and capillary density (CDS) in placentas exposed to single or multiple courses of betamethasone. STUDY DESIGN Placental specimens exposed to single vs repeat courses of betamethasone were analyzed through immunohistochemistry and digital image quantification for endothelial nitric oxide synthase and CD34. Quantified endothelial nitric oxide synthase staining, calculated capillary density, ratio of endothelial nitric oxide synthase to capillary density, and clinical characteristics were compared. Linear regression was performed with these as dependent variables. RESULTS Mean and maximum capillary density were increased (P = .013 and .005) and the ratio of endothelial nitric oxide synthase to capillary density decreased (P = .016) in specimens exposed to 4 courses of betamethasone compared with 1 to 3 courses. Exposure to 4 courses of betamethasone was associated with increased capillary density, but not with endothelial nitric oxide synthase expression. CONCLUSION Exposure to 4 courses of betamethasone is associated with increased placental capillary density. The placental effects of multiple courses of betamethasone are unrelated to endothelial nitric oxide synthase expression.
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Hauth JC, Clifton RG, Roberts JM, Myatt L, Spong CY, Leveno KJ, Varner MW, Wapner RJ, Thorp JM, Mercer BM, Peaceman AM, Ramin SM, Carpenter MW, Samuels P, Sciscione A, Tolosa JE, Saade G, Sorokin Y, Anderson GD. Maternal insulin resistance and preeclampsia. Am J Obstet Gynecol 2011; 204:327.e1-6. [PMID: 21458622 PMCID: PMC3127262 DOI: 10.1016/j.ajog.2011.02.024] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/14/2011] [Accepted: 02/03/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether mid-trimester insulin resistance is associated with subsequent preeclampsia. STUDY DESIGN This was a secondary analysis of 10,154 nulliparous women who received vitamin C and E or placebo daily from 9-16 weeks gestation until delivery. Of these, 1187 women had fasting plasma glucose and insulin tested between 22 and 26 weeks gestation. Insulin resistance was calculated by the homeostasis model assessment of insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index. RESULTS Obese women were twice as likely to have a HOMA-IR result of ≥75th percentile. Hispanic and African American women had a higher percentage at ≥75th percentile for HOMA-IR than white women (42.2%, 27.2%, and 16.9%, respectively; P < .001). A HOMA-IR result of ≥75th percentile was higher among the 85 nulliparous women who subsequently had preeclampsia, compared with women who remained normotensive (40.5% vs 24.8%; adjusted odds ratio, 1.9; 95% confidence interval, 1.1-3.2). Quantitative insulin sensitivity check index results were similar to the HOMA-IR results. CONCLUSION Midtrimester maternal insulin resistance is associated with subsequent preeclampsia.
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Tita ATN, Lai Y, Landon MB, Spong CY, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Peaceman AM, O'Sullivan MJ, Sibai BM, Thorp JM, Ramin SM, Mercer BM. Timing of elective repeat cesarean delivery at term and maternal perioperative outcomes. Obstet Gynecol 2011; 117:280-286. [PMID: 21252740 PMCID: PMC3127233 DOI: 10.1097/aog.0b013e3182078115] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Elective repeat cesarean delivery at 37 or 38 weeks compared with 39 completed weeks of gestation is associated with adverse neonatal outcomes. We assessed whether delivery before 39 weeks is justifiable on the basis of decreased adverse maternal outcomes. METHODS We conducted a cohort study of women with live singleton pregnancies delivered by prelabor elective repeat cesarean delivery from 1999 through 2002 at 19 U.S. academic centers. Gestational age was examined by completed weeks (eg, 37 completed weeks=37 0/7-37 6/7 weeks). Maternal outcomes included a primary composite of death, hysterectomy, uterine rupture or dehiscence, blood transfusion, uterine atony, thromboembolic complications, anesthetic complications, surgical injury or need for arterial ligation, intensive care unit admission, wound complications, or endometritis. RESULTS Of 13,258 elective repeat cesareans performed at 37 weeks of gestation or later, 11,255 (84.9%) were between 37 0/7 and 39 6/7 weeks (6.3% at 37, 29.5% at 38, and 49.1% at 39 completed weeks), and 15.1% were at 40 0/7 weeks or more. The primary outcome occurred in 7.43% at 37 weeks, 7.47% at 38 weeks and 6.56% at 39 weeks (P for trend test=.09). Delivery before 39 weeks was not associated with a decrease in the primary outcome when compared with delivery at 39 weeks (adjusted odds ratio 1.16; 95% confidence interval 1.00-1.34). Early delivery was associated with increased maternal hospitalization of 5 days or more [1.96 (1.54, 2.49)] but not with a composite of death or hysterectomy or with individual maternal morbidities. CONCLUSION Elective repeat cesarean delivery at 37 or 38 weeks is not associated with decreased maternal morbidity. LEVEL OF EVIDENCE II.
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Bakhshi T, Landon MB, Lai Y, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Mercer BM. Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision. Am J Perinatol 2010; 27:791-6. [PMID: 20458666 PMCID: PMC2955172 DOI: 10.1055/s-0030-1254238] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P < 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.
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96
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Manuck TA, Price TM, Thom E, Meis PJ, Dombrowski MP, Sibai B, Spong CY, Rouse DJ, Iams JD, Simhan HN, O'Sullivan MJ, Miodovnik M, Leveno KJ, Conway D, Wapner RJ, Carpenter M, Mercer B, Ramin SM, Thorp JM, Peaceman AM. Absence of mitochondrial progesterone receptor polymorphisms in women with spontaneous preterm birth. Reprod Sci 2010; 17:913-6. [PMID: 20693499 PMCID: PMC3210024 DOI: 10.1177/1933719110374365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The truncated mitochondrial progesterone receptor (PR-M) is homologous to nuclear PRs with the exception of an amino terminus hydrophobic membrane localization sequence, which localizes PR-M to mitochondria. Given the matrilineal inheritance of both spontaneous preterm birth (SPTB) and the mitochondrial genome, we hypothesized that (a) PR-M is polymorphic and (b) PR-M localization sequence polymorphisms could result in variable progesterone-mitochondrial effects and variable responsiveness to progesterone prophylaxis. METHODS Secondary analysis of DNA from women enrolled in a multicenter, prospective, study of 17 alpha-hydroxyprogesterone caproate (17OHPC) versus placebo for the prevention of recurrent SPTB. DNA was extracted from stored saliva. RESULTS The PR-M localization sequence was sequenced on 344 patients. Sequences were compared with the previously published 48 base-pair sequence, and all were identical. CONCLUSIONS We did not detect genetic variation in the mitochondrial localization sequence of the truncated PR-M in a group of women at high risk for SPTB.
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97
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Hauth JC, Clifton RG, Roberts JM, Spong CY, Myatt L, Leveno KJ, Pearson GD, Varner MW, Thorp JM, Mercer BM, Peaceman AM, Ramin SM, Sciscione A, Harper M, Tolosa JE, Saade G, Sorokin Y, Anderson GB. Vitamin C and E supplementation to prevent spontaneous preterm birth: a randomized controlled trial. Obstet Gynecol 2010; 116:653-658. [PMID: 20733448 PMCID: PMC2987650 DOI: 10.1097/aog.0b013e3181ed721d] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate whether maternally administered vitamins C and E lower the risk of spontaneous preterm birth. METHODS This is a secondary analysis of a randomized, double-masked, placebo-controlled trial in nulliparous women at low-risk administered 1,000 mg vitamin C and 400 international units vitamin E or placebo daily from 9 to 16 weeks of gestation until delivery. Outcomes include preterm birth attributable to premature rupture of membranes (PROM) and total spontaneous preterm births (spontaneous preterm birth attributable to PROM or spontaneous labor). RESULTS Of the 10,154 women randomized, outcome data were available for 9,968 (4,992 vitamin group and 4,976 placebo group). A total of 1,038 women (10.4%) delivered preterm, of whom 698 (7.0%) had spontaneous preterm birth. A spontaneous preterm birth occurred in 356 women (7.1%) assigned to daily vitamin C and E supplementation and in 342 (6.9%) assigned to placebo. There were 253 women (2.5%) who delivered after preterm PROM and 445 (4.5%) after a spontaneous preterm labor. In women supplemented with vitamins C and E, births attributed to preterm PROM were similar at less than 37 and 35 weeks of gestation, but births were less frequent before 32 weeks of gestation (0.3% compared with 0.6%, adjusted odds ratio 0.3-0.9). However, total spontaneous preterm births across gestation in women supplemented with vitamins C and E or a placebo were similar. CONCLUSION Maternal supplementation with vitamins C and E beginning at 9 to 16 weeks of gestation in nulliparous women at low risk did not reduce spontaneous preterm births. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00135707. LEVEL OF EVIDENCE I.
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98
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Sorokin Y, Romero R, Mele L, Wapner RJ, Iams JD, Dudley DJ, Spong CY, Peaceman AM, Leveno KJ, Harper M, Caritis SN, Miodovnik M, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter MW, Rouse DJ, Sibai B. Maternal serum interleukin-6, C-reactive protein, and matrix metalloproteinase-9 concentrations as risk factors for preterm birth <32 weeks and adverse neonatal outcomes. Am J Perinatol 2010; 27:631-40. [PMID: 20195952 PMCID: PMC2976602 DOI: 10.1055/s-0030-1249366] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Elevated concentrations of interleukin-6 (IL-6), C-reactive protein (CRP), and matrix metalloproteinase-9 (MMP-9) in fetal and neonatal compartments have been associated with an increased risk for preterm birth (PTB) and/or neonatal morbidity. The purpose of this study was to determine if the maternal serum concentration of IL-6, CRP, and MMP-9 in women at risk for PTB, who are not in labor and have intact membranes, are associated with an increased risk for PTB <32 weeks and/or neonatal morbidity. Maternal serum samples collected from 475 patients enrolled in a multicenter randomized controlled trial of single versus weekly corticosteroids for women at increased risk for preterm delivery were assayed. Serum was collected at randomization (24 to 32 weeks' gestation). Maternal serum concentrations of IL-6, CRP, and MMP-9 were subsequently determined using enzyme-linked immunoassays. Multivariate logistic regression analysis was performed to explore the relationship between maternal serum concentrations of IL-6, CRP, and MMP-9 and PTB <32 weeks, respiratory distress syndrome (RDS), chronic lung disease (CLD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and any sepsis. Maternal serum concentrations of IL-6 and CRP, but not MMP-9, above the 90th percentile at the time of randomization were associated with PTB <32 weeks. In contrast, there was no significant relationship between RDS and NEC and the maternal serum concentration of IL-6, CRP, or MMP-9 (univariate analysis). The development of CLD was associated with a high (above 90th percentile) IL-6 and CRP in maternal serum, even after adjustment for gestational age (GA) at randomization and treatment group. However, when GA at delivery was added to the model, this finding was nonsignificant. Neonatal sepsis was more frequent in neonates born to mothers with a high maternal serum concentration of CRP (>90th percentile). However, there was no significant association after adjustment for GA at randomization and treatment group. Logistic regression analysis for each analyte indicated that high maternal serum concentrations of IL-6 and CRP, but not MMP-9, were associated with an increased risk of IVH (odds ratio [OR] 4.60, 95% confidence interval [CI] 1.86 to 10.68; OR 4.07, 95% CI 1.63 to 9.50) after adjusting for GA at randomization and treatment group. Most babies (25/30) had grade I IVH. When GA at delivery was included, elevated IL-6 remained significantly associated with IVH (OR 2.77, 95% CI 1.02 to 7.09). An elevated maternal serum concentration of IL-6 and CRP are risk factors for PTB <32 weeks and subsequent development of neonatal IVH. An elevated maternal serum IL-6 appears to confer additional risk for IVH even after adjusting for GA at delivery.
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MESH Headings
- Biomarkers/blood
- C-Reactive Protein/metabolism
- Enterocolitis, Necrotizing/congenital
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/metabolism
- Enterocolitis, Necrotizing/physiopathology
- Enterocolitis, Necrotizing/therapy
- Female
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/metabolism
- Infant, Newborn, Diseases/therapy
- Interleukin-6/blood
- Intracranial Hemorrhages/congenital
- Intracranial Hemorrhages/diagnosis
- Intracranial Hemorrhages/metabolism
- Intracranial Hemorrhages/physiopathology
- Intracranial Hemorrhages/therapy
- Lung Diseases/congenital
- Lung Diseases/diagnosis
- Lung Diseases/metabolism
- Lung Diseases/physiopathology
- Lung Diseases/therapy
- Maternal-Fetal Exchange
- Matrix Metalloproteinase 9/blood
- Pregnancy
- Pregnancy Outcome/epidemiology
- Pregnancy Trimester, Second/blood
- Pregnancy Trimester, Third/blood
- Premature Birth/blood
- Premature Birth/mortality
- Premature Birth/physiopathology
- Respiratory Distress Syndrome, Newborn/diagnosis
- Respiratory Distress Syndrome, Newborn/etiology
- Respiratory Distress Syndrome, Newborn/metabolism
- Respiratory Distress Syndrome, Newborn/physiopathology
- Respiratory Distress Syndrome, Newborn/therapy
- Risk Factors
- Sepsis/congenital
- Sepsis/diagnosis
- Sepsis/metabolism
- Sepsis/physiopathology
- Sepsis/therapy
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99
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Gyamfi C, Mele L, Wapner RJ, Spong CY, Peaceman A, Sorokin Y, Dudley DJ, Johnson F, Leveno KJ, Caritis SN, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter M, Rouse DJ, Miodovnik M, Sibai B. The effect of plurality and obesity on betamethasone concentrations in women at risk for preterm delivery. Am J Obstet Gynecol 2010; 203:219.e1-5. [PMID: 20579955 PMCID: PMC3214971 DOI: 10.1016/j.ajog.2010.04.047] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 03/08/2010] [Accepted: 04/29/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Antenatal corticosteroids (ACS) decrease respiratory distress syndrome in singleton gestations. Twin data are less clear. Obesity and body mass index (BMI) also affect medication distribution volume. We evaluated whether maternal or neonatal cord betamethasone concentrations differed in twin gestations or obese patients. STUDY DESIGN Participants receiving betamethasone in a randomized controlled trial of weekly ACS were identified. We analyzed maternal delivery and cord serum betamethasone concentrations comparing singletons with twins and obese (BMI > or =30 kg/m(2)) with nonobese women. RESULTS Fifty-five maternal and 45 cord blood samples were available. Unadjusted median maternal serum concentrations appeared paradoxically higher in both twin gestations and the obese. However, after controlling for confounders, there were no differences in betamethasone concentrations in maternal serum or cord blood between singletons and twins (P = .61 vs P = .14) or nonobese and obese women (P = .67 vs .12). CONCLUSION Maternal and umbilical cord blood serum betamethasone concentrations are not different in twin gestations or obese women.
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100
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Clark EAS, Mele L, Wapner RJ, Spong CY, Sorokin Y, Peaceman A, Iams JD, Leveno KJ, Harper M, Caritis SN, Miodovnik M, Mercer BM, Thorp JM, Ramin SM, Carpenter M, Rouse DJ. Association of fetal inflammation and coagulation pathway gene polymorphisms with neurodevelopmental delay at age 2 years. Am J Obstet Gynecol 2010; 203:83.e1-83.e10. [PMID: 20417488 PMCID: PMC2900538 DOI: 10.1016/j.ajog.2010.01.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 10/18/2009] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the association between fetal inflammation and coagulation gene single-nucleotide polymorphisms (SNPs) and neurodevelopmental delay at age 2 years. STUDY DESIGN We conducted a case-controlled secondary analysis of a randomized trial of single- vs multiple-course corticosteroids. Multiplex assay assessed 46 SNPs. Cases had mental developmental and/or psychomotor delay at age 2 years. Control subjects had normal neurodevelopment. RESULTS One hundred twenty-five cases and 147 control subjects were analyzed. Allele frequencies were different between cases and control subjects for interleukin (IL)1beta-511 (P = .009), IL4R-148 (P = .03), IL6-174 (P = .02), and IL6-176 (P = .007). Genotype frequencies were different for IL1beta-511 (P = .03) and IL6-174 (P = .04). Results for IL1beta-511, IL4R-148, and IL6-176 remained significant after logistic regression analysis. IL1beta-511 and IL6-176 minor alleles were associated with increased risk of neurodevelopmental delay (odds ratio, 3.1; 95% confidence interval [CI], 1.2-8.2 and 2.2; 95% CI, 1.2-3.9, respectively). IL4R-148 minor allele was protective (odds ratio, 0.6; 95% CI, 0.4-0.9). CONCLUSION Fetal SNPs in IL1beta, IL-4R, and IL-6 may be associated with neurodevelopmental delay at age 2 years.
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