Associations of lifetime active and passive smoking with spontaneous abortion, stillbirth and tubal ectopic pregnancy: a cross-sectional analysis of historical data from the Women's Health Initiative

Impact of pregnancy on women's health-related lifestyle habits: Diet, physical activity, alcohol consumption, and smoking

OBJECTIVES

To explore health-related lifestyles in women before and during pregnancy, and to determine the potential differences between both and the relevant factors.

MATERIALS AND METHODS

A cross-sectional observational study including 348 women with a child <5 years of age was conducted in six health areas. The following variables were recorded: sociodemographic (age, educational level, marital status, social class, type of cohabitation, nationality), health-related habits (physical activity, diet, tobacco use, alcohol consumption), health conditions, and medication intake.

RESULTS

Four lifestyle habits were compared between the pre-conception and pregnancy periods: diet, physical activity, and alcohol and tobacco use. The proportion of women who consumed alcohol (42.8 % vs 3.4 %) or smoked (19.3 % vs 12.4 %) was significantly higher before conception (p < 0.01). Conversely, the proportion of inactive women was lower before pregnancy, with 23.3 % (CI95%: 18.7-27.9) formerly classified as active versus 35.3 % (CI95%: 30.2-40.5) (p < 0.01). Similarly, adherence to the Mediterranean diet increased during pregnancy (62.9 % vs 75.0 %; p < 0.01). Furthermore, 53.2 % (CI95%: 47.8-58.5) of women reported a change from non-healthy to healthy in at least one of the evaluated habits. Logistic regression analyses revealed the variables associated with a positive change, which were being national Spanish (OR: 6.9) and experiencing the first pregnancy (OR: 1.8).

CONCLUSIONS

The lifestyles of women undergo changes between the pre-gestation and pregnancy periods. However, such variations do not affect all health-related habits similarly. A positive change was observed in diet, alcohol consumption, and smoking habit, whereas pregnancy negatively impacted on physical activity and sedentary behaviours.

Cardiovascular disease risk factors and infertility: multivariable analyses and one-sample Mendelian randomization analyses in the Trøndelag Health Study

STUDY QUESTION

Are cardiovascular disease (CVD) risk factors causally associated with higher risk of infertility among women and men?

SUMMARY ANSWER

We found evidence to support a causal relationship between smoking initiation and history of infertility in women.

WHAT IS KNOWN ALREADY

Several CVD risk factors are associated with history of infertility. Previous studies using Mendelian randomization (MR) further support a causal relationship between BMI and infertility in women.

STUDY DESIGN SIZE DURATION

We used data from the Trøndelag Health Study (HUNT) in Norway, a prospective population-based cohort study, including 26 811 women and 15 598 men participating in three survey collections in 1995-1997 (HUNT2), 2006-2008 (HUNT3), and 2017-2019 (HUNT4).

PARTICIPANTS/MATERIALS SETTING METHODS

Our outcome was women's self-reported history of infertility, defined as ever having tried to conceive for 12 months or more or having used ART. We assigned the history of infertility reported by women to their male partners; therefore, the measure of infertility was on the couple level. We used both conventional multivariable analyses and one-sample MR analyses to evaluate the association between female and male CVD risk factors (including BMI, blood pressure, lipid profile measurements, and smoking behaviours) and history of infertility in women and men, separately.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 4702 women (18%) and 2508 men (16%) were classified with a history of infertility. We found a higher risk of infertility among female smokers compared to non-smokers in both multivariable and MR analyses (odds ratio (OR) in multivariable analysis, 1.20; 95% CI, 1.12-1.28; OR in MR analysis, 1.13; CI, 1.02-1.26), and potentially for higher BMI (OR in multivariable analysis, 1.13; CI, 1.09-1.18; OR in MR analysis, 1.11, CI, 0.92-1.34). In multivariable analysis in women, we also found evidence of associations between triglyceride levels, high-density lipoprotein cholesterol, lifetime smoking index, and smoking intensity with higher risk of infertility. However, these results were not consistent in MR analyses. We found no robust or consistent associations between male CVD risk factors and infertility.

LIMITATIONS REASONS FOR CAUTION

Our main limitation was that the CVD risk factors measured might not adequately capture the relevant time periods for when couples were trying to conceive. Additionally, we did not have information on causes of infertility in either women or men.

WIDER IMPLICATIONS OF THE FINDINGS

Women with infertility could have a worse CVD risk factor profile and thus public health interventions aimed at reducing the impact of some CVD risk factors, such as smoking and BMI, could reduce the burden of infertility. However, additional MR studies of the relationship between CVD risk factors and infertility with a larger sample size would be of value.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by a grant from the European Research Council under the European Union's Horizon 2020 research and innovation program (grant agreements no. 947684). This research was also supported by the Research Council of Norway through its Centres of Excellence funding scheme (project no. 262700) and partly funded by the Research Council of Norway, project: Women's fertility-an essential component of health and well-being (project no. 320656). D.A.L. and A.F. work in a unit that is supported by the University of Bristol and the UK Medical Research Council (MC_UU_00011/6). D.A.L.'s contribution to the article is supported by the European Research Council (101021566), the British Heart Foundation (CH/F/20/90003 and AA/18/7/34219). S.B.'s contribution to the article is supported by the Wellcome Trust (225790/Z/22/Z). B.M.B. is funded by The Liaison Committee for education, research and innovation in Central Norway; and the Joint Research Committee between St. Olavs Hospital and the Faculty of Medicine and Health Sciences, NTNU. The genotyping in HUNT was financed by the National Institute of Health (NIH); University of Michigan; The Research Council of Norway; The Liaison Committee for education, research and innovation in Central Norway; and the Joint Research Committee between St. Olavs Hospital and the Faculty of Medicine and Health Sciences, NTNU. None of the funding organizations influenced the study design, reporting, or interpretation of results. The views expressed in the present article are those of the authors and not necessarily any acknowledged funding organization. D.A.L. reports grants from Medtronic Ltd and Roche Diagnostics outside the submitted work. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Arterial hypertension and smoking in pregnant women in the Valencian Community: maternal and neonatal outcomes

OBJECTIVE

Hypertension and smoking during pregnancy have been linked to various adverse maternal and fetal outcomes. The objective of this work is to study how the smoking influences the development of hypertension, its effects on the pregnant woman, and on the newborn.

MATERIALS AND METHODS

An observational study in two phases was carried out: the descriptive first phase allows characterization of the sample and the analytical second phase is a case-control nested in a retrospective cohort corresponding to pregnancy.

RESULTS

A total of 712 women were included in the study. Of the 672 (94.4%) non-hypertensive women, 533 (79.3%) were non-smoking and 139 (20.7%) smoking. For the 40 (5.6%) hypertensive women, 30 (75.0%) were non-smoking and 10 (25.0%) smoking. The prevalence of hypertension was of 5.6%. Women who quit smoking before pregnancy saw a reduced risk of hypertension. For women who smoke during pregnancy, those of younger ages, with a normal body mass index, who are primiparous, employed and with a low-medium level of education have higher risk of hypertension. The risk of hypertension according to the level of physical activity during leisure time follows a "U" shape, with those who perform light physical activity at the lowest risk of hypertension. Hypertensive women have a higher risk of small for gestational age newborns. Smoking does not pose an additional risk for adverse outcomes once hypertension is diagnosed.

CONCLUSIONS

Future studies should aim to determine the role of smoking habit in the appearance of hypertension in pregnancy in order to establish adequate intervention guidelines that may aid in reducing the prevalence of hypertension.

Factors associated with terminated pregnancies in Sri Lanka: A case study of the Sri Lankan Demographic and health survey (DHS) 2016

Pregnancy termination is considered to have adverse effects on women's health and to have created financial, economic, and social problems in their lives. This study aimed to identify factors associated with pregnancy termination in Sri Lanka. The study used 2016 Sri Lanka Demographic and Health Survey (DHS) data of 16,323 ever-married women aged 15-49, who were clustered in selected enumerated areas. A binary logistic random intercept multilevel model was fitted to find the association between pregnancy termination and the predictor variables in this study. The overall pregnancy termination rate among Sri Lankan women was 16.14%. Increasing age of women was found to be associated with increasing odds of pregnancy termination. Women who were overweight or obese had higher odds of pregnancy termination, with 14% and 36%, respectively, compared to women with a normal weight. With increasing parity, the likelihood of pregnancy termination decreased. Women who used contraceptives had a 24% higher likelihood of pregnancy termination than those who refrained from using them. Cohabiting women had a 57% higher chance of pregnancy termination. Working women had 15% higher odds than unemployed women. Women who experienced domestic violence had a 14% higher odds of pregnancy termination than those who did not. Women from the Northern, Eastern, and North Central provinces had a lower likelihood of pregnancy termination compared to those from the Western province. Women in the urban sector were more likely to terminate their pregnancy than those in the estate sector. Further, women residing in households where indoor smoking was permitted had a 13% greater chance of ending their pregnancy compared to non-smoking households. The study highlights the importance of restructuring education related to health and well-being, family planning, and work-life balancing for both women and their partners, and developing and implementing or strengthening policies and laws related to mitigating pregnancy termination including domestic violence for women.

Management of ectopic pregnancy after in vitro fertilization/intracytoplasmic sperm injection and embryo transfer: a case series and mini-review

Background

Ectopic pregnancy (EP), reflecting a fertilized ovum implanted outside the normal uterine cavity, represents a frequent cause of morbidity and possibly mortality in women of reproductive age.

Objective

To summarize the diagnosis and treatment of EP after in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET).

Methods

The medical records of patients who were diagnosed with EP after embryo transfer from 2017 to 2019, in a tertiary hospital were reviewed.

Results

Of the 24 cases analyzed, 21 (87.5%) had fallopian tube involvement, while 2 (8.3%) and 1 (4.2%) had cornual and cervical pregnancies, respectively. Clinical manifestations included vaginal bleeding (58.3%) and lower abdominal pain (16.7%); 9 (42.9%) cases had no symptoms. One cornual pregnancy was misdiagnosed as acute appendicitis and later correctly diagnosed by laparoscopic exploration. There were 2 cases of multiple-site EP and 2 of heterotopic pregnancy, including one with an intrauterine pregnancy with double chorionic and four amniotic sacs and right tubal ampullary pregnancy. Five of the 21 cases with fallopian tube involvement received conservative treatment, while the remaining 16 underwent surgeries, including laparoscopic ipsilateral salpingostomy and ipsilateral salpingectomy.

Discussion

Ectopic pregnancy after embryo transfer, mainly involving the fallopian tube, is very complex and is with diverse manifestations. Even with the pregnancy sac observed in the uterus, the pelvic cavity should be scanned thoroughly after embryo transfer.

Associations between obesity, smoking behaviors, reproductive traits and spontaneous abortion: a univariable and multivariable Mendelian randomization study

Background

The correlation between potential risk factors such as obesity (leg fat percentage (left), arm fat percentage (left), waist circumference, body fat percentage, trunk fat percentage), smoking behaviors (past tobacco smoking, smoking initiation, smoking/smokers in household, current tobacco smoking) and reproductive traits (age first had sexual intercourse (AFS), age at menarche (AAM), and age at first birth (AFB)) have been linked to the occurrence of spontaneous abortion (SA). However, the causal associations between these factors and SA remain unclear.

Methods

We conducted univariable and multivariable Mendelian randomization (MR) analyses to evaluate the associations of obesity, smoking behavior and reproductive traits with SA. To select appropriate genetic instruments, we considered those that had reached the genome-wide significance level (P < 5 × 10-8) in their corresponding genome-wide association studies (GWAS) involving a large number of individuals (ranging from 29,346 to 1,232,091). SA was obtained from the FinnGen consortium, which provided summary-level data for 15,073 SA cases and 135,962 non-cases.

Results

Assessed individually using MR, the odds ratios (ORs) of SA were 0.728 (P = 4.3608×10-8), 1.063 (P = 0.0321), 0.926 (P = 9.4205×10-4), 1.141 (P = 7.9882×10-3), 5.154 (P = 0.0420), 1.220 (P = 0.0350), 1.228 (P = 0.0117), 0.795 (P = 0.0056), 1.126 (P = 0.0318), for one standard deviation (SD) increase in AFS, AAM, AFB, smoking initiation, smoking/smokers in household, arm fat percentage (left), leg fat percentage (left), waist circumference and body fat percentage, 0.925 (P = 0.4158) and 1.075 (P = 0.1479) for one SD increase in past tobacco smoking, trunk fat percentage for one SD increase in SA. In multivariable MR (MVMR), only AFS (OR = 0.802; P = 0.0250), smoking initiation (OR = 1.472, P = 0.0258), waist circumference (OR = 0.813, P = 0.0220) and leg fat percentage (left) (OR = 4.446, P = 0.043) retained a robust effect.

Conclusion

Smoking behaviors, reproductive traits and obesity-related anthropometric indicators are potential causal factors for SA. Higher leg fat percentage; smoking initiation; and lower waist circumference and AFS may increase the risk of SA. Understanding the causal relationship for SA may provide more information for SA intervention and prevention strategies.

Prevalence of Secondhand Smoke and Its Associated Factors Among Pregnant Women Attending Antenatal Care at a Hospital in Yangon Region, Myanmar

Smokers are not the only ones who suffer the effects of tobacco; those around them are also harmed, particularly vulnerable groups such as pregnant women. This study aimed to describe the prevalence of secondhand smoke (SHS) among pregnant women and the factors associated with SHS exposure. This study was a cross-sectional descriptive study conducted at Central Women's Hospital in the Yangon Region in 2022. The prevalence of SHS exposure was described, and multivariate analyses were conducted to determine the associated factors. Out of 407 participants, the prevalence of SHS exposure was 65.4%. Education level, religion, smoking rules at home, visiting public places, and avoidance of SHS during pregnancy were significantly associated with SHS exposure. The findings highlighted the need for community guidance programs, policies, and interventions to establish smoke-free environments. It is also important to conduct behavioral interventions for smokers, especially to avoid SHS for pregnant women.

Adverse Maternal and Infant Outcomes of Women Who Differ in Smoking Status: E-Cigarette and Tobacco Cigarette Users

The electronic cigarette (e-cigarette) became commercially available around 2004, yet the characteristics of pregnant women who use these devices and their effects on maternal and infant health remain largely unknown. This study aimed to investigate maternal characteristics and pregnancy outcomes according to maternal smoking status. We conducted a cross-sectional study of Dutch women with reported pregnancies between February 2019 and May 2022, using an online questionnaire to collect data on smoking status and demographic, lifestyle, pregnancy, and infant characteristics. Smoking status is compared among non-smokers, tobacco cigarette users, e-cigarette users, and dual users (tobacco and e-cigarette). We report descriptive statistics and calculate differences in smoking status between women with the chi-square or Fisher (Freeman-Halton) test. Of the 1937 included women, 88.1% were non-smokers, 10.8% were tobacco cigarette users, 0.5% were e-cigarette users, and 0.6% were dual users. Compared with tobacco users, e-cigarette users more often reported higher education, having a partner, primiparity, and miscarriages. Notably, women who used e-cigarettes more often had small infants for gestational age. Despite including few women in the e-cigarette subgroup, these exploratory results indicate the need for more research to examine the impact of e-cigarettes on pregnancy outcomes.

Piloting a complex intervention to promote a tobacco and alcohol-free pregnancy: the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study

BACKGROUND

Tobacco smoking and alcohol consumption before and during pregnancy increase the risk of adverse health outcomes for mother and child. Interventions to address smoking and drinking before and during pregnancy have the potential to reduce early-life health inequalities. In the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pilot study we aimed to evaluate the acceptability, feasibility and effectiveness of a complex intervention supporting women in smoking and alcohol cessation before and during pregnancy.

METHODS

From February 2019 till March 2021, we piloted the SAFER pregnancy intervention among pregnant women and women planning pregnancy in South-West Netherlands in an uncontrolled before-after study. Participants were supported in smoking and alcohol cessation via up to six group sessions and an online platform. In addition, biochemically validated cessation was rewarded with incentives (i.e. shopping vouchers) amounting up to 185 euros. We aimed to include 66 women. The primary outcome was smoking and/or alcohol cessation at 34-38 weeks of gestation (if pregnant) or after six group sessions (if not pregnant). Quantitative data were analysed using descriptive statistics. Focus group interviews among those involved in the study were conducted at the end of the study to explore their experiences. Qualitative data was analysed using thematic analysis.

RESULTS

Thirty-nine women who smoked were included; no women who consumed alcohol were referred to the study. Unemployment (51%), financial problems (36%) and a smoking partner (72%) were common. Thirteen women (33%) dropped out, often due to other problems impeding smoking cessation or 'being too busy' to participate in the group sessions. Eleven women (28%) had quit smoking at the study's endpoint. The personal and positive approach was highly valued and biochemical validation was felt to be helpful.

CONCLUSION

The SAFER pregnancy intervention seems appropriate for women in need of extra support for smoking cessation before and during pregnancy. Its impact on alcohol cessation could not be studied due to recruitment issues. Recruitment and prevention of early dropout need attention in further development of this intervention.

TRIAL REGISTRATION

Netherlands Trial Register: NL7493. Date registered: 04/02/2019.

The psychological status mediates the effect of indoor air pollution on recurrent spontaneous abortion

BACKGROUND

Indoor air pollution (IAP) exposure and psychological status have been recognized as important risk factors for adverse pregnancy outcomes, but their mediating effects on recurrent spontaneous abortion (RSA) have not been analyzed. Therefore, the purpose of this study is to explore the association between IAP and RSA and to examine the mediating effect of psychological status on their association.

METHODS

This study included 830 RSA cases and 2156 controls in Gansu province, China. The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) questionnaires were used to collect information on participants' psychological status. The IAP exposure was collected by the survey on cooking fuel use, kitchen ventilation characteristics, cooking styles, and indoor smoking, etc. Multivariable logistic regression was used to examine the associations between IAP exposure and RSA. The mediation analysis was used to evaluate the mediation effects of IAP and psychological status on RSA while controlling for confounding.

RESULTS

Among these cases, 16.87% cooked with unclean cooking fuel (UCF) and 37.00% lacked cooking ventilation, which was much higher than the controls. Active smoking and the use of UCF were associated with RSA, with an odds ratio (OR) of 3.374 [95% confidence interval (CI): 1.510-7.541] and 1.822 (95% CI: 1.328-2.500), respectively. We found that the use of a range hood was a protective factor for RSA, with an OR of 0.590 (95% CI: 0.463-0.752). There was a significant mediation effect of depression on the association between IAP and RSA, which accounted for 5.61%-9.22% of the total effect of IAP on RSA.

CONCLUSION

The IAP may be an important risk factor for RSA, which may be intensified by the poor psychological status, and the use of ventilation equipment when cooking is a protective factor for RSA.

Pregnant Women's Perception of Secondhand Smoke Exposure

BACKGROUND

Birth outcomes including low birth weight, preterm birth, and delayed infant neurodevelopment are associated with secondhand smoke exposure while pregnant. The purpose of the study was to explore pregnant women's perspectives on secondhand smoke exposure to understand their experience and inform recommendations.

STUDY DESIGN AND METHODS

Qualitative semistructured interviews were conducted with 15 secondhand smoke-exposed pregnant women in the United States.

RESULTS

Four primary themes were identified: feeling powerless, trapped, and discomfort; enhancing women's self-advocacy and initiative; having conflicting feelings about secondhand smoke exposure; and desiring professional advice and education. Women expressed concern about prenatal secondhand smoke exposure, although they felt unable to request that people refrain from smoking in their presence or personal space. Women's strategies to minimize secondhand smoke exposure often involved their own social isolation. Women described sources of support, educational needs, and desire for practical advice in secondhand smoke avoidance.

CLINICAL IMPLICATIONS

Findings underscore the role of nurses working with pregnant women living with household members who smoke to educate women about secondhand smoke risks and strategies for avoidance and to enhance women's self-confidence in advocating for themselves to reduce their exposure.

Non-Motherhood between Obligation and Choice: Statistical Analysis Based on Permutation Tests of Spontaneous and Induced Abortion Rates in the Italian Context

(1) Background: This paper aims to examine two relevant phenomena in the context of public health: spontaneous abortion (SA) and induced abortion (IA). SA is one of the most common complications of pregnancies; IA is a conscious choice that is made by the mother/couple. (2) Methods: Permutation tests were applied to SA and IA standardized rates detected by ISTAT (2016–2020). The NPC test, chosen for its optimal properties, was applied to compare different Italian territorial divisions (stratifying for year and age classes of women) and analyze the trend of years by stochastic ordering. (3) Results: Only for SA, there are significant differences among the three territorial divisions: the South records higher SA standardized rates than the North and the Center; the rates of IA are similar. Relating to distinct women age classes, the SA standardized rates do not show significant differences among the three analyzed geographical areas; different results are highlighted for IA. Stochastic ordering shows that only the IA standardized rates are characterized by a significant monotonous decreasing trend over the years. (4) Conclusion: The SA phenomenon has shown a decreasing trend that could be justified by the progress of science. For IA, we can certainly say that the general decrease in the phenomenon is due to the greater use of contraceptive methods that help to prevent unwanted pregnancies.

Trauma Chronicity and the Long-Term Needs of Childhood Sexual Trauma Survivors

Research has linked childhood sexual trauma (CST) with adverse adult outcomes (AAOs) that span physical, psychological, and social domains of functioning. Differences in conceptualizing and measuring CST, however, have inhibited the examination of trauma-related variables hypothesized to impact adult outcomes. We used National Sexual Health Survey (NSHS; 1995–1996) data to examine trauma chronicity (i.e., duration) and AAOs (domains: physical and mental health, close relationships, and achievement). The NSHS (N = 6537, 18–70 years) assessed duration using perpetrator-specific CST reports. Adjusting for background characteristics, we examined CST duration in relation to AAOs and CST-related help-seeking. Approximately 8% of participants reported CST. Chronic (vs. single-exposure) CST survivors were at substantially higher risk of experiencing AAOs [i.e., mean AAOs and specific AAOs (e.g., physical and emotional health problems, divorce/separation, and poverty)]. CST had direct effects on sexual dysfunction and satisfaction, and on relationship stressors which may impact sexual relationship quality. Although 62% of CST survivors did not seek help, those with more chronic CST histories reported a higher prevalence of trauma-related help-seeking. Our work underscores the importance of examining CST chronicity in relation to long-term developmental outcomes. Chronicity assessment may be an important screening tool in the therapeutic context and in broader community screening efforts.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana

Background

Approximately 1–2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities.

Methods

We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant.

Results

Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33–9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07–0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56–4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy.

Conclusion

Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

Urinary cotinine assessment of maternal smoking and environmental tobacco smoke exposure status and its associations with perinatal outcomes: a cross-sectional birth study

Tobacco consumption and environmental tobacco smoke (ETS) exposure remains an important public health concern. Pregnant women require particular attention as active and passive smoking during pregnancy are associated with multiple adverse perinatal outcomes. This study aimed to biochemically validate self-reported smoking and ETS exposure status among pregnant women, to more precisely ascertain its association with adverse perinatal outcomes. Data refers to 595 pregnant women who sought prenatal care in a public hospital in Porto, Portugal. A standard questionnaire on smoking and ETS-related variables was completed. Urinary cotinine (UC) concentrations were assessed by solid-phase competitive ELISA, in maternal urine samples collected on the day of delivery. The results showed that the optimal UC cut-off value to distinguish smokers from non-smokers and within non-smokers those who were exposed to ETS from those non-exposed in the third trimester of pregnancy was 74.1 ng/mL (sensitivity and specificity of 96.7% and 98.0%, respectively) and 1.6 ng/mL (sensitivity of 66.2% and specificity of 75.7%, respectively). The agreement between maternal self-reported and UC-based smoking status was very good (κ=0.919, p<0.001), but much lower for ETS exposure (κ=0.386, p<0.001). Maternal active smoking in the third trimester of pregnancy was associated with a significant decrease in birth weight, length and head circumference of 157.66 g (95% CI: -245.81, -69.52; p<0.001), 0.78 cm (95% CI: -1.22, -0.34; p=0.001) and 0.39 cm (95% CI: -0.70, -0.07; p=0.016), respectively. Maternal ETS exposure in the third trimester of pregnancy was associated with a non-significant increase in birth weight of 38.37 g (95% CI: -28.91, 105.64; p=0.263). Furthermore, maternal smoking cessation was associated with the increase of approximately 172 g in birth weight (95% CI: 50.00, 293.19). As such, there is an urgent need for increased public health awareness campaigns to encourage smoking cessation during pregnancy, in order to improve perinatal outcomes.

The Impact of Early-Life Exposures on Women's Reproductive Health in Adulthood

Purpose of Review

To review the effects of early-life, preconception, and prior-generation exposures on reproductive health in women.

Recent Findings

Women’s early-life factors can affect reproductive health by contributing to health status or exposure level on entering pregnancy. Alternately, they can have permanent effects, regardless of later-life experience. Nutrition, social class, parental smoking, other adverse childhood experiences, environmental pollutants, infectious agents, and racism and discrimination all affect reproductive health, even if experienced in childhood or in utero. Possible transgenerational effects are now being investigated through three- or more-generation studies. These effects occur with mechanisms that may include direct exposure, behavioral, endocrine, inflammatory, and epigenetic pathways.

Summary

Pregnancy is increasingly understood in a life course perspective, but rigorously testing hypotheses on early-life effects is still difficult. In order to improve the health outcomes of all women, we need to expand our toolkit of methods and theory.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40471-021-00279-0.

Smoking, alcohol and coffee consumption and pregnancy loss: a Mendelian randomization investigation

OBJECTIVE

To determine the associations of smoking and alcohol and coffee consumption with pregnancy loss.

DESIGN

Mendelian randomization study.

SETTING

The UK Biobank study and FinnGen consortium.

PATIENTS

A total of 60,565 cases with pregnancy loss and 130,687 noncases from UK Biobank and 3,312 cases with pregnancy loss and 64,578 noncases from FinnGen.

INTERVENTION(S)

None.

MAINS OUTCOME MEASURE

Pregnancy loss.

RESULT(S)

Genetic predisposition to smoking initiation was associated with an increased risk of pregnancy loss in both UK Biobank and FinnGen. The combined odds ratio (OR) was 1.31 (95% confidence interval [CI], 1.25-1.37) for one standard deviation increase in the prevalence of smoking initiation. There were no significant associations of genetically predicted consumption of alcohol (OR, 1.09; 95% CI, 0.93-1.27) or coffee (OR, 0.96; 95% CI, 0.87-1.06) with pregnancy loss.

CONCLUSION(S)

This study on the basis of genetic data suggests the causal potential of the association of smoking but not moderate alcohol and coffee consumption with pregnancy loss.

Effects of active and/or passive smoking during pregnancy and the postpartum period

INTRODUCTION

Tobacco smoking may cause adverse effects during pregnancy and postpartum. The aim of this study was to evaluate several repercussions of active and/or passive smoking by the mother at home, during pregnancy, at delivery, as well as for the newborn baby and breastfeeding, including the effect of quitting smoking in the first trimester of pregnancy.

METHODS

A prospective longitudinal study was carried out with a sample of 800 pregnant women. Four evaluations were made: first and third trimester of pregnancy, and 2 and 6/8 months postpartum. Sociodemographic, obstetric, health and tobacco consumption details were collected, with biochemical tests being performed to confirm the self-reported abstinence.

RESULTS

Being an active and passive smoker predicted suffering complications in pregnancy (OR 2.50; 95% CI; 1.42-4.35) and delivery (OR 3.10; 95% CI; 1.75-5.51), and also tended not to breastfeed (OR 2.44; 95% CI; 1.35-4.42). Being an active smoker predicted complications at childbirth (OR 5.58; 95% CI; 2.64-7.77), for the baby (OR 3.77; 95% CI; 1.53-9.36) and not breastfeeding at 2 (OR 25.73; 95% CI; 11.95-55.40), and 6/8 months postpartum (OR 6.61; 95% CI; 3.21-13.58). Being a passive smoker reduces the intend to breastfeed (OR 1.81; 95% CI; 1.11-2.95), and the practice of breastfeeding at 2 months postpartum (OR 1.94; 95% CI; 1.11-3.37). Women who quit smoking are less likely to suffer complications in pregnancy and childbirth, and are more likely to attend antenatal and breastfeeding classes, and to have babies with higher birth weight.

CONCLUSIONS

Active and passive tobacco consumption has significant implications during pregnancy and postpartum period. Smoking cessation at the beginning of pregnancy reverses much of these effects.

Association between exposure to ambient air pollutants and the outcomes of in vitro fertilization treatment: A multicenter retrospective study

BACKGROUND

Exposure to ambient air pollution has been reported to be inversely correlated with human reproductive health. However, the results of previous studies exploring the association between air pollution and in vitro fertilization (IVF) outcomes are conflicting, and further research is needed to clarify this association.

OBJECTIVES

This study aimed to investigate the associations between exposure to air pollutants and IVF outcomes.

METHODS

We conducted a multicenter retrospective cohort study involving 20,835 patients from four cities in Northern China, contributing to 11,787 fresh embryo transfer cycles, 9050 freeze-all cycles, and 17,676 frozen-thawed embryo transfer (FET) cycles during 2014-2018. We calculated the daily average concentrations of six criteria air pollutants (PM_2.5, PM₁₀, O₃, NO₂, CO, and SO₂) during different exposure windows in IVF treatment timeline using data from the air monitoring station nearest to the residential site as approximate individual exposure. Generalized estimation equation models were used to assess the association between air pollution exposure and IVF outcomes.

RESULTS

Exposure to O₃, NO₂, and CO during most exposure windows in fresh embryo transfer cycles were correlated with lower possibilities of biochemical pregnancy, clinical pregnancy, and live birth. An inverse association of exposure to O₃ and SO₂ with pregnancy outcomes was observed in FET cycles. In addition, we found a significant association of exposure to air pollutants with a higher risk of ectopic pregnancy and lower oocyte yield.

CONCLUSIONS

Our study provided large-scale human evidence of the association between air pollution and adverse human reproductive outcomes in the population opting for IVF. Thus, exposure to air pollutants in the population opting for IVF should be limited to improve treatment outcomes.

Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828

ABSTRACT

The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study: a before-after study protocol

Despite existing interventions, tobacco smoking and alcohol consumption during pregnancy are common. The Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy intervention combines monthly group sessions, access to a web-based platform and incentives upon biochemically validated cessation for a maximum duration of 6 months to promote cessation of smoking and alcohol use before and during pregnancy. To inform development of the SAFER pregnancy intervention, two focus groups with the target population were held beforehand, with results reported here alongside the final SAFER pregnancy study protocol. In a before−after study we aim to include 66 women who are pregnant or have a wish to become pregnant and who smoke and/or consume alcohol (i.e. target population of the SAFER pregnancy intervention). The primary outcome measure is cessation of smoking and/or alcohol use at 34−38 weeks of gestation, or after six group sessions if women did not become pregnant during the study period. Secondary outcomes focus on the barriers and facilitators for implementation of the SAFER pregnancy intervention.

Effects of Tobacco Consumption and Anxiety or Depression during Pregnancy on Maternal and Neonatal Health

This study analyzed the possible interaction effects between tobacco consumption and anxiety or depression during pregnancy on maternal and neonatal health. We recruited a sample of 807 pregnant Spanish women from public healthcare services. Women completed a questionnaire on sociodemographic variables, health status and tobacco consumption (continuous, quitting or no consumption) in the first and third trimester of pregnancy and at 2 months postpartum, and self-reported measures of anxiety and depression in the first trimester. Abstinence of tobacco consumption was verified through biochemical measurements. Interaction effects between tobacco consumption and anxiety were found for delivery (p < 0.001), neonatal health complications (p = 0.026) and gestational age at birth (p = 0.029). Interaction effects between tobacco consumption and depression were found for pregnancy (p = 0.032), delivery complications (p < 0.001) and weeks of gestation at birth (p = 0.031). This study suggests that there are different kinds of interaction effects between tobacco consumption and anxiety or depression. Smokers with high anxiety presented more delivery complications compared to quitters and non-smokers with high anxiety. There is a cumulative effect of anxiety on the effects of tobacco consumption on maternal health. The results highlighted the beneficial impact of quitting smoking during pregnancy to reduce the risk of suffering anxiety, depression and health complications.

[Effects of active and/or passive smoking during pregnancy and the postpartum period]

INTRODUCTION

Tobacco smoking may cause adverse effects during pregnancy and postpartum. The aim of this study was to evaluate several repercussions of active and/or passive smoking by the mother at home, during pregnancy, at delivery, as well as for the new born baby and breastfeeding, including the effect of quitting smoking in the first trimester of pregnancy.

METHODS

A prospective longitudinal study was carried out with a sample of 800 pregnant women. Four evaluations were made: first and third trimester of pregnancy, and 2 and 6/8 months postpartum. Sociodemographic, obstetric, health and tobacco consumption information was collected, with biochemical tests being performed to confirm the self-reported abstinence.

RESULTS

Being an active and passive smoker predicted suffering complications in pregnancy (OR 2.50; 95% CI; 1.42-4.35) and delivery (OR 3.10; 95% CI; 1.75-5.51), and also intend not to breastfeed (OR 2.44; 95% CI; 1.35-4.42). Being an active smoker predicted complications at childbirth (OR 5.58; 95% CI; 2.64-7.77), for the baby (OR 3.77; 95% CI; 1.53-9.36) and not breastfeeding at 2 (OR 25.73; 95% CI; 11.95-55.40), and 6/8 months postpartum (OR 6.61; 95% CI; 3.21-13.58). Being a passive smoker reduces the intention to breastfeed (OR 1.81; 95% CI; 1.11-2.95), and the practice of breastfeeding at 2 months postpartum (OR 1.94; 95% CI; 1.11-3.37). Women who quit smoking are less likely to suffer complications in pregnancy and childbirth, and are more likely to attend antenatal and breastfeeding classes, and to have babies with higher birth weight.

CONCLUSIONS

Active and passive tobacco consumption has significant implications during pregnancy and postpartum period. Smoking cessation at the beginning of pregnancy reverses much of these effects.

[Consequences of Active Cigarette Smoking in Pregnancy - CNGOF-SFT Expert Report and Guidelines on the management of smoking during pregnancy]

OBJECTIVE

To synthesize knowledge on the consequences of active smoking in pregnancy.

METHODS

The MedLine database, the Cochrane Library and French and foreign guidelines from 1999 to 2019 have been consulted.

RESULTS

Active maternal smoking is associated with an increased risk of first trimester complications such as early miscarriage and ectopic pregnancy with a dose-effect relationship between smoking and those risks. Active cigarette smoking during pregnancy is associated with an increased risk of certain type of birth defects, placenta abruptio, placenta previa, stillbirth and cesarean delivery. Active maternal smoking is associated with a reduced risk of pre-eclampsia. Children born to mothers who smoke are more at risk of premature birth and low birth weight with a dose-effect relationship for those two risks.

CONCLUSION

Apart from preeclampsia which is reduced in case of active maternal smoking, perinatal morbidity is increased among women who smoke during their pregnancy.

Smoke, alcohol and drug addiction and female fertility

BACKGROUND

Considerable interest has been gathered on the relevant impact of preventable factors, including incorrect lifestyle and unhealthy habits, on female fertility. Smoking, alcohol and addictive drugs consumption represent a major concern, given the broad range of diseases which might be favored or exacerbated by these dependable attitudes. Despite the well-characterized effects of prenatal exposure on pregnancy outcomes and fetus health, a substantial proportion of women of reproductive age is still concerned with these habits. At present, the impact of smoke, alcohol and addictive drugs on women fertility, and, particularly, the specific targets and underlying mechanisms, are still poorly understood or debated, mainly due to the scarcity of well-designed studies, and to numerous biases.

OBJECTIVE

The current review will provide a comprehensive overview of clinical and experimental studies in humans and animals addressing the impact of smoke, alcohol and addictive drugs on female fertility, by also embracing effects on ovary, oviduct, and uterus, with particular reference to primary endpoints such as ovarian reserve, steroidogenesis, ovulation and menstrual cycle, oviduct function and uterus receptivity and implantation. A brief focus on polycystic ovary syndrome and endometriosis will be also included.

METHODS

A Pubmed literature search was performed with selected keywords; articles were individually retrieved by each author. No limitation was set for publication date. Articles in languages other than English were excluded. Additional articles were retrieved from references list of selected manuscripts.

RESULTS AND CONCLUSIONS

Currently, the most consistent evidences of a detrimental effect of smoke, alcohol and addictive drugs on specific domains of the female reproductive function are provided by experimental studies in animals. Overall, clinical studies suggest that smoking is associated to decreased fertility, although causal inference should be further demonstrated. Studies addressing the effect of alcohol consumption on female fertility provide conflicting results, although the majority reported lack of a correlation. Extremely scarce studies investigated the effects of addictive drugs on female fertility, and the specific actions of selected drugs have been difficult to address, due to multidrug consumption.

Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009)

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Management of Stillbirth: Obstetric Care Consensus No, 10

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

Exposure to tobacco smoke and stillbirth: a national prospective cohort study in rural China

INTRODUCTION

Parental exposure to tobacco smoke has been associated with an increased risk of stillbirth, while only a few studies took the overall parental tobacco exposure status into consideration. We aim to explore the relationship of parental smoking and passive smoking before and during pregnancy with stillbirth in a large Chinese rural cohort.

DESIGN

248 501 couples were enrolled in a national prospective cohort study conducted in rural China. Parental exposure to tobacco smoke before and during pregnancy, along with other risk factors, was ascertained by questionnaires. Pregnancy outcomes were recorded by physicians.

RESULTS

The ORs (Odds Ratios) of maternal active smoking, maternal passive smoking, paternal active smoking and paternal passive smoking were 2.07 (95% CI 1.25 to 3.41), 1.22 (95% CI 1.01 to 1.47), 1.36 (95% CI 1.13 to 1.63) and 1.10 (95% CI 0.87 to 1.39), respectively. The rates of stillbirth increased from 0.31% for the maternal non-smoking group to 0.43% for the smoking cessation during pregnancy group, to 0.64% for the decreased smoking group and 1.28% for the continuing smoking group. A similar pattern was found in the change in paternal smoking status and stillbirth. Stratified by maternal passive smoking, the OR of paternal smoking was 1.35 (95% CI 1.13 to 1.61) in the maternal non-smoking group and 1.67 (95% CI 1.09 to 2.56) in the maternal passive smoking group.

CONCLUSIONS

Parental exposure to tobacco smoke increased the risk of stillbirth, especially for those continuing smoking during pregnancy. Paternal smoking is an independent risk factor for stillbirth despite maternal passive smoking status.

Toxic effects of 1-(N-methyl-N-nitrosamino)-1-(3-pyridinyl)-4-butanal on the reproduction of female mice

Cigarette smoke can affect female reproductive health by causing follicle destruction and oocyte dysfunction. Third-hand smoke has received increasing attention as a public health issue. However, the effects of third-hand smoke on the female reproductive system, particularly the ovaries, remain unclear. 1-(N-methyl-N-nitrosamino)-1-(3-pyridinyl)-4-butanal (NNA) can be used as a biomarker of third-hand smoke. We studied the in vivo toxic effects of NNA on mice ovaries and offspring development. Three-week-old premature female mice were exposed to NNA at two different concentrations (0.075 μg/kg and 0.15 μg/kg body weight) and tap water (blank control) and diluted dimethylsulfoxide (solvent control) for 30 days. We found that oral administration of NNA (0.075 μg/kg and 0.15 μg/kg) significantly reduced ovary weight (the 0.15 μg/kg group was reduced to 18.69% ± 0.89%) and ovarian follicle number (reduced by about 30%) (p < 0.05). Consumption of 0.15 μg/kg NNA reduced the survival rate of superovulated oocytes from 91.36% to 60.55% (p < 0.05). In addition, treated female mice in each group were mated with normal male mice to observe the effects of NNA on the F1 offspring, and during mating and lactation, all groups were given tap water. Two different concentrations of NNA exposure also significantly reduced body weight and impaired ear opening, tooth eruption and eye opening in F1 offspring, especially those exposed to 0.15 μg/kg NNA (p < 0.05). Our study suggested that NNA exposure had toxic effects on the reproductive health of female mice and their offspring. The results obtained may help evaluate the risks of third-hand smoke to women's reproductive health and to the health of their offspring.

Toxic effects of 1-(N-methyl-N-nitrosamino)-1-(3-pyridinyl)-4-butanal on the maturation and subsequent development of murine oocyte

Cigarette smoke can cause follicle destruction and oocyte dysfunction and increase the risks of spontaneous abortion, stillbirth, and tubal ectopic pregnancy, affecting female reproductive health. Third-hand smoke (THS) is residual tobacco smoke existing in the environment long after cigarettes are extinguished, which can react with other compounds in the environment to produce secondary pollutants. However, the effects of THS on the female reproductive system, particularly the maturation of the oocyte, remain unclear. 1-(N-methyl-N-nitrosamino)-1-(3-pyridinyl)-4-butanal (NNA), a component of THS, is a logical biomarker of THS exposure. Thus, this study aims to investigate the toxic effects of NNA on the maturation of murine oocytes and subsequent developmental competence. Herein, murine oocytes were exposed to 0 (control group), 0.1, 1.0, 10, and 50 μM NNA for 24 h. Our results showed that NNA exposure reduced the polar body extrusion rate by causing 8-oxo-deoxyguanosine (8-OHdG) to increase and disrupting the meiotic spindle morphology by inhibiting ERK1/2 activation during in vitro maturation. Additionally, NNA exposure resulted in cleavage and blastocyst rate reduction by altering DNA and histone methylations by reducing 5 mC and H3K4me2 levels and by inducing apoptosis caused by mitochondrial dysfunction and reactive oxygen species accumulation, as shown by the increased superoxide dismutase mRNA level and by the decreased Bcl-x mRNA level. Collectively, our results demonstrate that NNA exposure reduces the maturation and developmental capability of murine oocytes by increasing the risk of DNA damage and abnormal spindle morphology, altering epigenetic modifications, and inducing apoptosis, suggesting the toxic effect of NNA on mammalian productive health.

Risk factors for spontaneous abortion from a prevention perspective in rural China: a population-based follow-up study

OBJECTIVES

We conducted this study to investigate the risk factors for spontaneous abortion among rural Chinese women.

METHODS

Risk factors prior to pregnancy associated with spontaneous abortion were identified among 17,248 rural women enrolled in a prospective population-based follow-up study. The risk of spontaneous abortion was estimated with odds ratio (OR) and 95% confidence interval (CI) for several factors. A nonconditional logistic regression analysis was then performed to identify the independently associated factors.

RESULTS

The total sample of this study population consisted of 17,248 pregnant women including 921 of them whose pregnancies resulted in spontaneous abortion and the incidence of spontaneous abortion was 5.04%. After the adjustment of confounding factors, menarche age, serum creatinine, family genetic diseases or maternal congenital defects was associated with an increased risk of spontaneous abortion while folic acid supplementation reduced the risk among rural Chinese women.

CONCLUSIONS

The findings of our study suggest that multiple modifiable factors may increase the risk of spontaneous abortion which may help relevant departments better to guide detailed effectively prevention strategies toward spontaneous abortion to improve the reproductive quality of rural population. Further studies are required to elaborate these risk factors for spontaneous abortion.

Tobacco Cost of Illness Studies: A Systematic Review

Introduction

To identify studies reporting costs arising from tobacco use and detail their (1) economic approaches, (2) health outcomes, and (3) other cost areas included.

Methods

We searched PubMed, Scopus, Cochrane Library, EconLit, and Google Scholar for studies published between 2008 and April 2018 in English. Eligible articles reported tobacco-related costs and included all tobacco-using populations (multinational, national, subpopulations, and involuntary smokers). All economic approaches that resulted in monetary outcomes were included. We reported USD or converted local currencies to USD. Two health economists extracted and two researchers independently reviewed the data.

Results

From 4083 articles, we reviewed 361 abstracts and examined 79 full-texts, with 63 (1.6%) deemed eligible. There were three multinational, thirty-four national, twenty-one subpopulation or condition(s)-specific analyses, and five evaluating involuntary smoking. The diverse approaches and outcomes precluded integrating costs, but these were substantial in all studies. For instance, about USD 1436 billion in global health expenditures and productivity losses in 2012 and USD 9 billion in lost productivity in China, Brazil, and South Africa in 2012. At the national level, costs ranged from USD 4665 in annual per respondent health expenses (Germany 2006–2008) to USD 289–332.5 billion in medical expenses (United States 1964–2014).

Conclusions

Despite wide variations in the methods used, the identified costs of tobacco are substantial. Studies on tobacco cost-of-illness use diverse methods and hence produce data that are not readily comparable across populations, time, and studies, precluding a consistent evidence-base for action and measurement of progress. Recommendations are made to improve comparability.

Implications

In addition to the health and financial costs to individual smokers, smoking imposes costs on the broader community. Production of comparable estimates of the societal cost of tobacco use is impaired by a plethora of economic models and inconsistently included costs and conditions. These inconsistencies also cause difficulties in comparing relative impacts caused by differing factors. The review systematically documents the post-2007 literature on tobacco cost-of-illness estimations and details conditions and costs included. We hope this will encourage replication of models across settings to provide more consistent data, able to be integrated across populations, over time, and across risk factors.

Smoking cessation education and training in obstetrics and gynecology residency programs in the United States

BACKGROUND

OB/GYN physicians should be involved in providing smoking cessation counseling to their patients who smoke, especially pregnant patients. However, the smoking cessation practices of OB/GYN physicians seem to be dependent on their education and training and not much is known about their training during medical school. Therefore, the purpose of this study was to assess the smoking cessation education provided by OB/GYN residency training programs in the United States.

METHODS

The investigators developed and mailed a valid and reliable survey to all allopathic and osteopathic OB/GYN Residency Directors in the US (n = 275). The internal reliability coefficients (Cronbach alpha) for the four major subscales ranged from 0.63 to 0.90. Best practices in survey research were used to achieve a final response rate of 58%.

RESULTS

The majority of residency programs (60%) did not have a formal, structured curriculum in tobacco topics and/or smoking cessation. In contrast, 40% of programs reported having a formal, structured tobacco education curriculum. Sixty-five percent of programs did not formally evaluate residents' competence in providing smoking cessation counseling to patients. A range of 42% to 57% of residency programs reported spending less than one hour/year on teaching various basic science and clinical science topics related to tobacco use. The majority of residency programs spent no time teaching residents about the socio-political aspects of tobacco use cessation. Lack of teaching time was identified by the majority (51%) of the residency directors as a barrier to teaching smoking cessation.

CONCLUSION

Although OB/GYN physicians are expected to provide smoking cessation counseling to their patients, the majority of OB/GYN residency programs in the United States provide minimal education and training in this area. Therefore, continuing medical education on smoking cessation counseling should be broadly implemented for OB/GYN physicians.

University students' awareness of causes and risk factors of miscarriage: a cross-sectional study

Background

Spontaneous miscarriage is the most common complication of pregnancy, occurring in up to 20% of pregnancies. Despite the prevalence of miscarriage, little is known regarding peoples’ awareness and understanding of causes of pregnancy loss. The aim of this study was to explore university students’ understanding of rates, causes and risk factors of miscarriage.

Methods

A cross-sectional study including university students. An online questionnaire was circulated to all students at the University College Cork using their university email accounts in April and May 2016. Main outcomes included identification of prevalence, weeks of gestation at which miscarriage occurs and causative risk factors for miscarriage.

Results

A sample of 746 students were included in the analysis. Only 20% (n = 149) of students correctly identified the prevalence of miscarriage, and almost 30% (n = 207) incorrectly believed that miscarriage occurs in less than 10% of pregnancies. Female were more likely to correctly identify the rate of miscarriage than men (21.8% versus 14.5%). However, men tended to underestimate the rate and females overestimate it. Students who did not know someone who had a miscarriage underestimated the rate of miscarriage, and those who were aware of some celebrities who had a miscarriage overestimated the rate. Almost 43% (n = 316) of students correctly identified fetal chromosomal abnormalities as the main cause of miscarriage. Females, older students, those from Medical and Health disciplines and those who were aware of a celebrity who had a miscarriage were more likely to identify chromosomal abnormalities as a main cause. However, more than 90% of the students believed that having a fall, consuming drugs or the medical condition of the mother was a causative risk factor for miscarriage. Finally, stress was identified as a risk factor more frequently than advanced maternal age or smoking.

Conclusion

Although almost half of the participants identified chromosomal abnormalities as the main cause of miscarriage, there is still a lack of understanding about the prevalence and most important risk factors among university students. University represents an ideal opportunity for health promotion strategies to increase awareness of potential adverse outcomes in pregnancy.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0682-1) contains supplementary material, which is available to authorized users.

Impact of Maternal Air Pollution Exposure on Children's Lung Health: An Indian Perspective

Air pollution has become an emerging invisible killer in recent years and is a major cause of morbidity and mortality globally. More than 90% of the world’s children breathe toxic air every day. India is among the top ten most highly polluted countries with an average PM₁₀ level of 134 μg/m³ per year. It is reported that 99% of India’s population encounters air pollution levels that exceed the World Health Organization Air Quality Guideline, advising a PM_2.5 permissible level of 10 μg/m³. Maternal exposure to air pollution has serious health outcomes in offspring because it can affect embryonic phases of development during the gestation period. A fetus is more prone to effects from air pollution during embryonic developmental phases due to resulting oxidative stress as antioxidant mechanisms are lacking at that stage. Any injury during this vulnerable period (embryonic phase) will have a long-term impact on offspring health, both early and later in life. Epidemiological studies have revealed that maternal exposure to air pollution increases the risk of development of airway disease in the offspring due to impaired lung development in utero. In this review, we discuss cellular mechanisms involved in maternal exposure to air pollution and how it can impact airway disease development in offspring. A better understanding of these mechanisms in the context of maternal exposure to air pollution can offer a new avenue to prevent the development of airway disease in offspring.

Air pollution exposure during pregnancy and spontaneous abortion and stillbirth

The developing fetus is particularly susceptible to environmental pollutants, and evidence has shown adverse effects of air pollutants on pregnancy and birth outcomes. Pregnancy loss, including spontaneous abortion (miscarriage) and stillbirth, is the most severe adverse pregnancy outcome. This review focuses on air pollution exposure during pregnancy in relation to spontaneous abortion and stillbirth. A total of 43 studies are included in this review, including 35 human studies and eight animal studies. Overall, these studies suggest that exposure to air pollutants such as particulate matter (PM), carbon monoxide (CO) and cooking smoke may be associated with higher risk for stillbirth and spontaneous abortion. PM₁₀ exposure during an entire pregnancy was associated with increased risk of spontaneous abortion, and exposure to PM_2.5 and PM₁₀ in the third trimester might increase the risk of stillbirth. CO exposure during the first trimester of pregnancy was associated with an increased risk of spontaneous abortion and exposure during the third trimester was associated with an increased risk of stillbirth. Cooking smoke was found to increase the risk of stillbirths, and the evidence was consistent. Insufficient and conflicting evidence was found for various other pollutants, such as NO₂ and SO₂. Studies did not show clear evidence for associations between pregnancy loss and others pollutants such as heavy metals, organochlorine compounds, PAH and total dust count. Further research is warranted to better understand the relationship between air pollution exposure and pregnancy loss.

Caffeine, alcohol, smoking, and reproductive outcomes among couples undergoing assisted reproductive technology treatments

During the past decade, as the use of assisted reproductive technologies (ART) has continued to increase worldwide, research investigating whether modifiable lifestyle factors, such as alcohol, caffeine, and smoking, may affect ART outcomes has grown. Despite the vast literature, there is still uncertainty regarding the effects of some of these exposures on ART outcomes. The objective of this review is to summarize the epidemiologic literature on intakes of caffeine and alcohol, smoking, and reproductive outcomes among women undergoing ART. Of the five epidemiologic studies on caffeine intake and ART outcomes, only one found a significant negative effect of caffeine intake on live birth following ART. There have been six epidemiologic studies exploring whether alcohol intake is associated with fertility outcomes among women undergoing ART. Three studies assessed current alcohol consumption and observed a negative effect on outcomes such as fertilization, embryo quality, and implantation. When alcohol intake in the year before treatment was assessed, no relationships were observed with clinical outcomes following ART. Finally, numerous epidemiologic studies and a handful of meta-analyses have confirmed that female current smokers have worse ART outcomes compared with nonsmokers. Although former smokers tend to have better ART outcomes than current smokers, very few individual studies have investigated the influence of smoking cessation on ART outcomes. Literature on male smoking, drinking, and caffeine habits in relation to ART outcomes is even sparser and inconsistent, making it difficult to draw strong conclusions on that topic. In summary, there is little evidence supporting a detrimental effect of moderate caffeine intake on ART outcomes. Current consumption of alcohol may have a negative effect on ART outcomes, but at present the evidence is limited. Women who currently smoke cigarettes have been consistently found to have poorer ART outcomes, including reduced live birth rates, but a quantification of the benefits of smoking cessation is lacking.

Paternal smoking and spontaneous abortion: a population-based retrospective cohort study among non-smoking women aged 20-49 years in rural China

BACKGROUND

To comprehensively evaluate the association of paternal smoking and spontaneous abortion.

METHODS

We conducted a population-based retrospective cohort study among 5 770 691 non-smoking rural Chinese women, along with their husbands, participating in the National Free Pre-Pregnancy Checkups Project, regarding outcome events that occurred in 2010-2016. The main outcome was spontaneous abortion (SA). Multivariable logistic regression was used to estimate OR and 95% CI, and restricted cubic spline was used to estimate the non-linear relationship.

RESULTS

The multivariable-adjusted OR of exposure to paternal smoking for SA was 1.17 (95% CI 1.16 to 1.19), compared with women without exposure to paternal smoking; and corresponding OR of exposure to preconception paternal smoking for SA was 1.11 (95% CI 1.08 to 1.14), compared with women without exposure to preconception paternal smoking. The ORs of preconception paternal smoking also increased with increases in paternal smoking (p_nonlinear<0.05, almost linearly shaped) and preconception paternal smoking (p_nonlinear>0.05). In addition, periconception paternal smoking cessation was associated with an 18% (15%-22%) lower risk of SA.

CONCLUSION

Paternal smoking was associated with SA. The importance of tobacco control, specifically pertaining to paternal smoking, should be emphasised during preconception and pregnancy counselling.

Antiepileptic drug exposure in pregnancy and pregnancy outcome from national drug usage data

Background

Antiepileptic drugs (AEDs) are used by pregnant women to manage conditions such as epilepsy and bipolar disorder even though they pose a risk to the developing foetus. This study aimed to determine the overall use of AEDs by women during their childbearing years and women who are pregnant and the association between AED use and rates of pregnancy termination and spontaneous abortion.

Methods

Retrospective population based cohort study using administrative databases in New Zealand between 2008 and 2014. Women who had been pregnant were identified by the National Minimum Dataset and were linked to the Pharmaceutical Collection to obtain information on use of AEDs. Women aged between 15 and 45 years dispensed AEDs were identified in the Pharmaceutical Collection.

Results

There was an increase in the number of women of child-bearing potential prescribed AEDs, from 9 women per 1000 women in 2008 to 11.4 women per 1000 women in 2014. Women who had been dispensed an AED had an increased rate of spontaneous abortion 8.97 spontaneous abortions per 100 pregnancies, compared with, 6.31 per 100 pregnancies (risk ratio 1.42, 95% CI 1.40 to 1.44), and a decreased rate of pregnancy termination, 18.51 terminations per 100 pregnancies compared with 19.58 per 100 pregnancies (risk ratio 1.95, 95% CI 0.94–0.96).

Conclusion

Use of newer AEDs is increasing in women of child-bearing potential in New Zealand leading to an overall increase in AED use in this group despite a fall in the use of older AEDs. AED use is this study was associated with an increased risk of spontaneous abortion and decreased rate of pregnancy termination, however confounding by indication could not be excluded.

Counseling Women on Smoking Relapse Prevention During Postpartum

Many women who quit smoking after learning they are pregnant revert back to smoking after birth of their baby. The high rate of recidivism suggests that women need education about risk of relapse and effective strategies to remain smoke free even before they are discharged from the hospital. Despite evidence that smoking cessation and relapse prevention counseling is effective during early postpartum, many nurses do not provide their patients with this important information, perhaps because they feel inadequately prepared to do so. Helping Women Stop Smoking in Pregnancy and Beyond is an education program designed to help perinatal nurses inform women of negative risks of smoking and offer women strategies to avoid the high probability of resuming smoking after birth. It includes evidence-based interventions that can be used by nurses to provide effective smoking relapse prevention counseling to women during postpartum.

Do Clinicians Ask Pregnant Women about Exposures to Tobacco and Cannabis Smoking, Second-Hand-Smoke and E-Cigarettes? An Australian National Cross-Sectional Survey

Clinicians often ask pregnant women about tobacco smoking, but their practices of asking about other smoking and nicotine exposures are unknown. This study analysed how often clinicians ask pregnant women about their use of e-cigarettes, cannabis, chewing tobacco, and second-hand smoke (SHS) exposure. Two cross-sectional surveys were undertaken. A random sample of 500 General Practitioner (GP) members were invited from the National Faculty of Aboriginal and Torres Strait Islander Health (NFATSIH) to complete an on-line survey, and 5571 GP and Obstetrician (OBS) members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were sent a paper survey by mail. Questions on frequency of asking about the exposures used Likert Scales, later dichotomized to "often-always" and "never-sometimes". Logistic regressions estimated associations between clinician type and asking about cannabis, e-cigarettes, chewing tobacco, and SHS. An adjusted model reduced potential confounders of location, guidelines, gender and population. n = 378 GPs and OBS participated (6.2% response). In total, 13-14% asked "often-always" about e-cigarettes; 58% cannabis; 38% cannabis with tobacco; 27% SHS, and 10% chewing tobacco-compared to 95% of the sample asking about cigarette smoking. After adjustment, the odds of RANZCOG GPs (OR 0.34) and OBS (OR 0.63) asking about cannabis were lower compared to NFATSIH GPs. Clinician type was non-significant for asking about e-cigarettes, chewing tobacco and SHS. Surveyed Australian GPs and obstetricians asked less frequently about e-cigarettes, chewing, SHS exposure, and cannabis, potentially missing important exposures for mother and child.

"When a woman is pregnant, her grave is open": health beliefs concerning dietary practices among pregnant Kalenjin women in rural Uasin Gishu County, Kenya

BACKGROUND

Reducing malnutrition remains a major global challenge especially in low- and middle-income countries. Lack of knowledge on the motive of nutritional behaviour could ultimately cripple nutrition intervention outcomes. The purpose of this study was to investigate how health beliefs influence nutritional behaviour intention of the pregnant Kalenjin women of rural Uasin Gishu County in Kenya. The study findings provide useful information for culturally congruent nutrition counselling and intervention.

METHODS

In this qualitative study semi-structured interviews were conducted with 42 pregnant and post-natal (with children less than one year) Kalenjin women in selected rural public health facilities of Uasin Gishu County Kenya. Furthermore, key informant interviews took place with 6 traditional birth attendants who were also pregnancy herbalists, two community health workers and one nursing officer in charge of Maternal and Child Health (MCH) for triangulation and provision of in-depth information. Content analysis of interview transcripts followed a grounded theory (Protection Motivation Theory) approach, using software MAXQDA version 12.1.3.

RESULTS

Abstracted labour (big babies and lack of maternal strength), haemorrhage (low blood), or having other diseases and complications (evil or bad food) were the major perceived health threats that influence nutritional behaviour intention of the pregnant Kalenjin women in rural Uasin Gishu County in Kenya.

CONCLUSION

The pregnancy nutritional behaviour and practices of the Kalenjin women in rural Uasin Gishu County act as an adaptive response to the perceived health threats, which seem to be within the agency of pregnant women. As a result, just giving antenatal nutritional counselling without addressing these key health assumptions that underlie a successful pregnancy outcome is unlikely to lead to changes in nutritional behaviour.

Childhood secondhand smoke exposure and pregnancy loss in never smokers: the Guangzhou Biobank Cohort Study

OBJECTIVE

Studies of secondhand smoke (SHS) exposure especially childhood SHS exposure and pregnancy loss are limited. We used baseline data of the Guangzhou Biobank Cohort Study (GBCS) to examine the association of childhood SHS exposure with a history of pregnancy loss.

METHODS

Never smoking women aged 50 years or above in GBCS from 2003 to 2008 were included. Propensity score matching (PSM) was used to control for confounding. Negative binomial regression and logistic regression were used to examine the association of childhood SHS, assessed by number of smokers in childhood household and frequency of exposure, with past pregnancy loss.

RESULTS

Of 19 562 women, 56.7% (11 096) had SHS exposure during childhood. In negative binomial regression, after adjusting for age, education, past occupational dust exposure, past home fuel exposure, oral contraceptive, adulthood SHS exposure, age at first pregnancy and age at first menarche, compared to non-exposure, the incidence rate ratio of one more pregnancy loss was 1.20 (95% CI1.05 to 1.37) in those who lived with ≥2 smokers in the same household, and 1.14 (95% CI 1.04 to 1.25) in those exposed ≥5 times/week. After similar adjustment, logistic regression showed that the OR of pregnancy loss ≥2 times (versus 0 to 1 time) was 1.25 (95% CI 1.00 to 1.57) and 1.20 (95% CI 1.03 to 1.40) for high density (≥2 smokers in the same household) and frequency (≥5 times/week) of childhood exposure, respectively.

CONCLUSIONS

Childhood SHS exposure was associated with higher risks of pregnancy loss in middle-aged and older Chinese women.

Clinical Aspects of Miscarriage

It is estimated that 750,000 to 1,000,000 miscarriages occur every year in the United States. Women experiencing a miscarriage enter the healthcare system in a variety of ways. A family may be seen for a miscarriage in the prenatal clinic, the emergency department, same-day surgical department, or perhaps the labor and birth unit. Nurses must be prepared to guide and support these families. Understanding the clinical aspects of miscarriage as well as the emotional care of families experiencing early pregnancy loss is important to nurses in all areas of the medical center. Clinical aspects of miscarriage are reviewed along with the needed emotional care for families experiencing the most common cause of early pregnancy loss.

Discrete survival model analysis of a couple's smoking pattern and outcomes of assisted reproduction

Background

Cigarette smoking has been associated with worse infertility treatment outcomes, yet some studies have found null or inconsistent results.

Methods

We followed 225 couples who underwent 354 fresh non-donor assisted reproductive technology (ART) cycles between 2006 and 2014. Smoking history was self-reported at study entry. We evaluated the associations between smoking patterns and ART success using multivariable discrete time Cox proportional hazards models with six time periods: cycle initiation to egg retrieval, retrieval to fertilization, fertilization to embryo transfer (ET), ET to implantation, implantation to clinical pregnancy, and clinical pregnancy to live birth to estimate hazard ratios (HR) and 95% CIs. Time-dependent interactions between smoking intensity and ART time period were used to identify vulnerable periods.

Results

Overall, 26% of women and 32% of men reported ever smoking. The HR of failing in the ART cycle without attaining live birth for male and female ever smokers was elevated, but non-significant, compared to never smokers regardless of intensity (HR = 1.02 and 1.30, respectively). Female ever smokers were more likely to fail prior to oocyte retrieval (HR: 3.37; 95% CI: 1.00, 12.73). Every one cigarette/day increase in smoking intensity for females was associated with a HR of 1.02 of failing ART (95% CI: 0.97, 1.08), regardless of duration or current smoking status. Women with higher smoking intensities were most likely to fail a cycle prior to oocyte retrieval (HR: 1.07; 95% CI: 1.00, 1.16). Among past smokers, every additional year since a man had quit smoking reduced the risk of failing ART by 4% (HR: 0.96; 95% CI: 0.91, 1.00) particularly between clinical pregnancy and live birth (HR: 0.86; 95% CI: 0.76, 0.96).

Conclusions

Female smoking intensity, regardless of current smoking status, is positively associated with the risk of failing ART cycles between initiation and oocyte retrieval. In men who ever smoked, smoking cessation may reduce the probability of failing ART, particularly between clinical pregnancy and live birth.

Trial registration

NCT00011713. Registered: 27 February 2001.

Electronic supplementary material

The online version of this article (doi:10.1186/s40738-017-0032-2) contains supplementary material, which is available to authorized users.

Thyroid Hormone Status in Umbilical Cord Serum Is Positively Associated with Male Anogenital Distance

CONTEXT

In human adults and adolescents, thyroid function affects sex hormones and male reproductive functions. Little is known about the thyroid function effects on the gonadal development in human infants.

OBJECTIVE

The aim was to examine the association between thyroid hormones (THs) and sexually dimorphic genital development or fetal growth.

DESIGN

This is a birth cohort study.

PARTICIPANTS

A total of 616 mothers and newborns were analyzed from two local hospitals.

MAIN OUTCOME MEASURES

TSH, free T3 (FT3), and free T4 (FT4) levels in cord blood serum, anogenital distance (AGD), birth weight, birth length, birth body mass index, and head circumference in neonates.

RESULTS

Longer AGD in male newborns was observed with higher cord serum FT3 (β, 1.36 mm [95% confidence interval (CI), 0.58-2.13] for 1 pmol/L FT3), FT4 (β, 0.12 mm [95% CI, 0.00-0.25] for 1 pmol/L FT4), and TSH (β, 3.14 mm [95% CI, 0.65-5.63] for a 10-fold TSH increase), and with a lower FT4/FT3 ratio (β, -0.11 mm [95% CI, -0.20 to -0.02] for doubling FT4/FT3 ratio). The relationships between TSH, birth weight, and birth length were different by secondhand smoke exposure. Secondhand smoke exposure had an effect modification, with interaction P value .039 and .010, respectively. Secondhand smoke exposure also had an effect modification on the relation between FT4 and head circumference with interaction P value .020.

CONCLUSIONS

In the absence of overt thyroid dysfunction, THs are positively associated with AGD in male newborns. TH effects on body size and head circumference may be modified by maternal secondhand smoke exposure.

Combined effects of AHR, CYP1A1, and XRCC1 genotypes and prenatal maternal smoking on infant birth size: Biomarker assessment in the Hokkaido Study

OBJECTIVES

We investigated the individual and combined effects of maternal polymorphisms encoding the aromatic hydrocarbon receptor (AHR; rs2066853), cytochrome P450 (CYP) 1A1 (rs1048963), and the X-ray-complementing gene 1 (XRCC1; rs1799782) and prenatal smoking in relation to infant birth size.

METHODS

Totally, 3263 participants (1998 non-smokers and 1265 smokers) were included in the study between 2003 and 2007. Two groups of mothers were distinguished by plasma cotinine levels by ELISA measured during the third trimester (cut-off=11.48ng/mL). We conducted data analysis using multiple linear regression models.

RESULTS

Infants whose mothers smoked and had AHR-GG, CYP1A1-AG/GG, and XRCC1-CT/TT genotypes weighed, -145g less than those born of mothers who did not smoke and had the AHR-GA/AA, CYP1A1-AA, and XRCC1-CC genotypes (95% CI: -241, -50).

CONCLUSIONS

We demonstrated that infants whose mothers smoked during pregnancy with the combination of AHR, CYP1A1, and XRCC1 polymorphisms had lower birth size.