Tobacco and pregnancy

Prenatal tobacco use and the risk of mood disorders in offspring: a systematic review and meta-analysis

PURPOSE

It is plausible that offspring born to mothers using tobacco during pregnancy may have increased risk of mood disorders (depression and bipolar disorders); however, mixed results have been reported. We conducted a systematic review and meta-analysis to investigate the magnitude and consistency of associations reported between prenatal tobacco use and mood disorders in offspring.

METHODS

We systematically searched EMBASE, SCOPUS, PubMed and Psych-INFO for studies on mood disorders and prenatal tobacco use. Methodological quality of studies was assessed with the revised Newcastle-Ottawa Scale. We estimated pooled relative risk (RR) with inverse variance weighted random-effects meta-analysis. We performed leave-one-out analyses, and stratified analyses by a subgroup (depression and bipolar disorder). Potential publication bias was assessed by inspection of the funnel plot and Egger's test for regression asymmetry. This study protocol was prospectively registered in PROSPERO (CRD42017060037).

RESULTS

Eight cohort and two case-control studies were included in the final meta-analysis. We found an increased pooled relative risk of mood disorders in offspring exposed to maternal prenatal tobacco use RRs 1.43 (95% CI 1.27-1.60) compared to no prenatal tobacco use. Similarly, the pooled relative risks of bipolar and depressive disorders in offspring were 1.44, (95% CI 1.15-1.80) and 1.44, (95% CI 1.21-1.71), respectively. Moreover, the pooled estimated risk of mood disorders was not significantly attenuated in the studies that reported sibling comparison results [RR = 1.21 (95% CI 1.04-1.41)].

CONCLUSION

Taken together, there was strong evidence for a small (RR < 2) association between prenatal tobacco use and mood disorders in offspring.

The association between maternal exposure to secondhand smoke during pregnancy and their children's cerebral palsy, Shandong, China

INTRODUCTION

Tobacco use poses a threat to the health of pregnant women and their children. Our study assessed the association between maternal exposure to secondhand smoke (SHS) during pregnancy and children's cerebral palsy (CP) in Shandong, China.

METHODS

In our observational study, 5067 mother-child pairs were included from Shandong Province, China. Mothers filled in questionnaires about exposure to SHS during pregnancy. Statistical analysis and logistic regression models were built in R program to estimate the association in adjusted odds ratio (AOR) between SHS exposure during pregnancy and risk of children's CP, after adjustment for potential confounders including delivery mode and baby's birthweight.

RESULTS

Exposure to SHS was noted among 3663 (72.3%) of the 5067 non-smoking mothers during their pregnancy. Of the 239 CP children within the study, 192 (80.3%) were exposed to SHS during pregnancy. Children born to mothers exposed to SHS during pregnancy had a higher risk of CP (AOR=1.44; 95% CI: 1.02-2.04) than those born to non-exposed mothers, the risk increased by exposure time in the logistic regression model. The association between SHS exposure during pregnancy and CP children remained significant when adjusting for delivery mode and infant's birthweight due to their significant association with CP, with an AOR of 1.46 (95% CI: 1.13-1.91) for 1-4 days/week and 1.63 (95% CI: 1.22-2.01) for 5-7 days/week exposure to SHS.

CONCLUSIONS

Our study suggests that maternal exposure to secondhand smoke during pregnancy is associated with children's CP. Future preventive interventions of CP should include strategies that target the antenatal women who are exposed to SHS.

Smartphone-based financial incentives to promote smoking cessation during pregnancy: A pilot study

Cigarette smoking during pregnancy increases risk for pregnancy complications, growth restriction, and other adverse health outcomes. The most effective intervention for reducing smoking during pregnancy is financial incentives contingent on biochemically-verified smoking abstinence. The present study examined the efficacy of a smartphone-based intervention whereby smoking monitoring and incentive delivery occurred remotely using a mobile app. If efficacious, this remote intervention would allow pregnant women residing in geographically remote areas to benefit from incentives-based cessation interventions. Sixty U.S. pregnant smokers were recruited between May 2018 to May 2019 via obstetrical clinics, Women, Infants, and Children (WIC) offices, and Facebook. Participants were assigned sequentially to one of two treatments: best practices alone (N = 30) or best practices plus financial incentives (N = 30). Outcomes were analyzed using repeated measures analysis based on generalized estimating equations (GEE). Seven-day point prevalence abstinence rates were greater in the incentives versus best practices arms early- (46.7% vs 20.0%, OR = 3.50, 95%CI = 1.11,11.02) and late-antepartum (36.7% vs 13.3%, OR = 3.76, 95%CI = 1.04,13.65), and four- (36.7% vs 10.0%, OR = 5.21, 95%CI = 1.28,21.24) and eight-weeks postpartum (40.0% vs 6.7%, OR = 9.33, 95%CI = 1.87,46.68), although not at the 12- (23.3% vs 10.0%, OR = 2.74, 95%CI = 0.63,11.82) or 24-week (20.0% vs 6.7%, OR = 3.50, 95%CI = 0.65,18.98) postpartum assessments likely due to this pilot study being underpowered for discerning differences at the later assessments, especially 24-weeks postpartum which was three months after treatment completion. These results support the efficacy of this remote, incentives-based intervention for pregnant smokers. Further research evaluating its efficacy and cost-effectiveness in a well-powered, randomized controlled trial appears warranted.

Abuse liability of cigarettes with very low nicotine content in pregnant cigarette smokers

The U.S. Food and Drug Administration has proposed reducing the nicotine content of cigarettes to a minimally-addictive level. To our knowledge, this study is the first to examine how pregnant smokers respond to very low nicotine content (VLNC) cigarettes. In Phase 1, participants blindly sampled two VLNC cigarettes (0.4 and 2.4 mg/g of tobacco) and their usual brand (UB) cigarette in separate sessions, then completed a behavioral economic simulation task and measures of subjective effects, craving/withdrawal, and smoking topography. Phase 2 directly compared the relative reinforcing effects of the cigarettes using concurrent choice testing. All possible dose-pair combinations were tested in separate sessions where puffs were earned ad libitum by clicking the code associated with their preferred cigarette 10 times. Phase 3 tested the 0.4 mg/g-UB dose-pair where UB puffs could be earned with a progressively incremented number of clicks (maximum 8400). Ten pregnant smokers in Burlington, VT and Baltimore, MD participated in 2017-2018. Regarding abuse liability, participants chose the 0.4-mg/g dose less than UB (22% vs. 78%) during concurrent choice testing and the 0.4-mg/g dose sustained less demand than the 2.4-mg/g and UB doses on the simulation task. Positive subjective effects were also lower for both VLNC cigarettes vs. UB. Each cigarette reduced nicotine craving/withdrawal and no significant changes indicative of compensatory smoking were noted. Reducing the nicotine content of cigarettes may decrease their abuse liability in pregnant smokers without causing untoward craving/withdrawal or compensatory smoking. Studies of extended exposure to VLNCs in pregnant women are warranted.

Randomized controlled trial of the COPE-P intervention to improve mental health, healthy lifestyle behaviors, birth and post-natal outcomes of minority pregnant women: Study protocol with implications

BACKGROUND

Emotionally distressed pregnant minority women experience multiple adverse outcomes, including pre-eclampsia, preterm birth, operative deliveries and low birth weight. Although the United States Preventive Services Task Force recommends screening in pregnant women, many practices do not screen because efficacious interventions and systems are not in place to treat them.

AIM

Purpose of this randomized controlled trial (RCT) is to test a group delivered manualized cognitive-behavioral skills building intervention entitled COPE-P versus an attention control program on the mental health, birth and postpartum outcomes of minority pregnant women experiencing depressive, anxiety and stress symptoms.

METHODS

Design is a longitudinal randomized block RCT with repeated measures (beginning with screening prior to 18 weeks, group prenatal care in both groups from 16 + 1 to 31 + 1 weeks and ending at 6 months postpartum) at two study sites (New York city and Columbus, Ohio). Race/ethnicity is being blocked to ensure equal numbers of Hispanic and Black women. 384 women are being recruited from antenatal clinics if they are: between 18 and 40 years; in an uncomplicated singleton pregnancy <18 weeks; and self-identify as Black or Hispanic. Valid and reliable measures are being used to assess healthy lifestyle behaviors and mental health outcomes immediately following the interventions, six - eight weeks postpartum and at the children's six-month well baby visit. Birth and delivery outcomes also are being assessed.

CONCLUSION

If found to be efficacious, the COPE-P intervention could be a key solution to managing those with emotional distress and improving their outcomes.

The Effects of Different Smoking Patterns in Pregnancy on Perinatal Outcomes in the Southampton Women's Survey

Maternal smoking during pregnancy has established associations with poor perinatal outcomes. Among continuing pregnant smokers, harm-reduction strategies have been suggested, including temporary cessation of smoking during pregnancy, also known as partial quitting. Support for this strategy, however, remains limited. Six hundred and ninety-seven women in the Southampton Women's Survey who smoked at their last menstrual period were categorised into sustained quitters, partial quitters (quit in either the first or third trimester but not both) or sustained smokers (continued to smoke throughout pregnancy). In regression models, compared with infants born to sustained smokers, infants born to sustained quitters and partial quitters were heavier at birth by β = 0.64 standard deviations (SD) (WHO z-score) (95% CI: 0.47-0.80) and 0.48 SD (WHO z-score) (95% CI: 0.24-0.72) respectively, adjusted for confounders, with similar patterns seen for other anthropometric measures (head circumference and crown-heel length). Sustained quitters had longer gestations by β = 3.5 days (95% CI: 1.8-5.2) compared with sustained smokers, but no difference was seen for partial quitters. While sustained quitting remains the most desired outcome for pregnant smokers, partial quitting should be explored as a strategy to reduce some of the harmful effects of smoking on offspring in those who cannot achieve sustained quitting.

Sex-specific alterations in GABA receptor-mediated responses in laterodorsal tegmentum are associated with prenatal exposure to nicotine

Smoking during pregnancy is associated with deleterious physiological and cognitive effects on the offspring, which are likely due to nicotine-induced alteration in the development of neurotransmitter systems. Prenatal nicotine exposure (PNE) in rodents is associated with changes in behaviors controlled in part by the pontine laterodorsal tegmentum (LDT), and LDT excitatory signaling is altered in a sex and age-dependent manner by PNE. As effects on GABAergic LDT signaling are unknown, we used calcium imaging to evaluate GABA_A receptor- (GABA_A R as well as GABA_A -_ρ R) and GABA_B receptor (GABA_B R)-mediated calcium responses in LDT brain slices from female and male PNE mice in two different age groups. Overall, in older PNE females, changes in calcium induced by stimulation of GABA_A R and GABA_B R, including GABA_A -_ρ R were shifted toward calcium rises. In both young and old males, PNE was associated with alterations in calcium mediated by all three receptors; however, the GABA_A R was the most affected. These results show for the first time that PNE is associated with alterations in GABAergic transmission in the LDT in a sex- and age-dependent manner, and these data are the first to show PNE-associated alterations in functionality of GABA receptors in any nucleus. PNE-associated alterations in LDT GABAergic transmission within the LDT would be expected to alter output to target regions and could play a role in LDT-implicated, negative behavioral outcomes following gestational exposure to smoking. Accordingly, our data provide further supportive evidence of the importance of eliminating the consumption of nicotine during pregnancy.

Lifestyle and sociodemographic risk factors for gastroschisis: a systematic review and meta-analysis

BACKGROUND

Gastroschisis is strongly associated with young maternal age. This association suggests the need for further investigations on non-genetic risk factors. Identifying these risk factors is a public health priority in order to develop prevention strategies aimed at reducing the prevalence and health consequences in offspring.

OBJECTIVE

To systematically assess and quantitatively synthesise the available epidemiological studies to evaluate the association between non-genetic risk factors and gastroschisis.

METHODS

Literature from PubMed, EMBASE and Scopus was searched for the period 1990-2018. Epidemiological studies reporting risk estimates between lifestyle and sociodemographic risk factors and gastroschisis were included. Two pairs of reviewers independently extracted information on study characteristics following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and MOOSE (Meta-analysis Of Oservational Studies in Epidemiology) guidelines. Relative risk (RR) estimates were calculated across the studies and meta-analysis was performed using random-effects model.

RESULTS

We identified 58 studies. Meta-analyses were conducted on 29 studies. Maternal smoking (RR 1.56, 95% CI 1.40 to 1.74), illicit drug use (RR 2.14, 95% CI 1.48 to 3.07) and alcohol consumption (RR 1.40, 95% CI 1.13 to 1.70) were associated with an increased risk of gastroschisis. A decreased risk among black mothers compared with non-Hispanic white mothers (RR 0.49, 95% CI 0.38 to 0.63) was found. For Hispanic mothers no association was observed.

CONCLUSIONS

Exposure to smoking, illicit drugs and alcohol during pregnancy is associated with an increased risk of gastroschisis. A significantly decreased risk for black mothers was observed. Further epidemiological studies to assess the potential role of other environmental factors are strongly recommended.

PROSPERO REGISTRATION NUMBER

CRD42018104284.

Maternal arterial blood gas values during delivery: Effect of mode of delivery, maternal characteristics, obstetric interventions and correlation to fetal umbilical cord blood

INTRODUCTION

Obstetricians routinely use biochemical parameters from non-pregnant women to assess the condition of the laboring mother. However, it is well known that pregnancy leads to significant physiological changes in most organ systems. The aim of this study was to determine normal values for maternal arterial blood gases during vaginal deliveries as compared with control values from planned cesarean sections. We also wanted to elucidate the effect of various maternal characteristics, mode of delivery and obstetric interventions on blood gas values.

MATERIAL AND METHODS

We carried out a randomly selected, prospective-observational cohort study of 250 women undergoing vaginal delivery and 58 women undergoing planned cesarean section at the Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden.

RESULTS

We found significant differences for gestational age, parity, umbilical venous blood pH, pCO₂ and lactate values between the two study groups (P < .005). Significantly lower pH, pCO₂ , pO₂ and sO₂ were found in mothers delivering vaginally. Higher base deficit, hemoglobin, bilirubin, potassium, glucose and lactate were found in vaginal deliveries than in planned cesarean sections (P < .02). Maternal body mass index (BMI), smoking and hypertension were not significantly correlated to acid base parameters in women with vaginal deliveries. On the other hand, multiple regression showed significant associations for the use of epidural anesthesia on maternal pH (P < .05) and pO₂ (P < .01); and synthetic oxytocin on pCO₂ (P = .08), glucose (P < .00) and lactate (P < .02) levels in maternal arterial blood. Maternal arterial pH, pCO₂ and lactate values correlated significantly to values in venous umbilical cord blood (P < .000).

CONCLUSIONS

Maternal arterial blood gas parameters varied significantly according to mode of delivery, the use of epidural anesthesia and synthetic oxytocin.

Prenatal nicotine exposure affects cardiovascular function and growth of the developing fetus

AIM

Effects of nicotine on fetal hemodynamics are not well known, especially in the first trimester fetus. We investigated the acute and chronic effects of nicotine on hemodynamics in pregnant mice and their fetuses using ultrasound. Postnatal health status including growth and hemodynamics was also examined.

METHODS

To investigate the acute effects of nicotine on fetal hemodynamics, we injected nicotine 0.2 mg/kg subcutaneously into pregnant mice on gestational days (GD) 9.5, 11.5 and 13.5 and compared with saline-injected group. To determine the chronic effects of nicotine on fetal hemodynamics, we administered nicotine in drinking water (0.1 mg/mL) to pregnant mice from GD 6.5 until they gave birth and compared hemodynamics with water-administered mice.

RESULTS

Regarding the acute effects of nicotine, we found no intergroup difference in maternal hemodynamics; however, fetal blood flow through the dorsal aorta, carotid artery and umbilical artery tended to decrease, particularly on GD 11.5. Regarding the chronic effects of nicotine, we observed no intergroup difference in maternal body weight changes and hemodynamics; however, blood flow to all fetal organs tended to be lower in the nicotine water group than in the water group with significant difference on GD 13.5. The offspring of the nicotine water group had significantly low birth weights and continued to have low body weight until 9 weeks of age. In addition, these offspring developed postnatal cardiac hypertrophy.

CONCLUSION

Nicotine adversely affects fetal hemodynamics acutely and chronically in early pregnancy, potentially leading to fetal tissue hypoxia, intrauterine growth restriction and adverse postnatal health effects.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.

Maternal tobacco use: A third-trimester risk factor for small-for-gestational-age pregnancy outcome

Background

Small for gestational age (SGA) is a well-known consequence of maternal smoking. Here, we newly examine the magnitude of SGA risk by week of gestational age.

Methods

Singleton live births (N = 3,032,928) with recorded birth weight, gestational age (22–44 weeks), and maternal tobacco use (Y/N) were categorized as to SGA (Y/N), based on 10th percentile gender-specific weights-for-age.

Results

SGA prevalence among tobacco users (19.5%) and non-users (9.1%) yielded a significant SGA prevalence rate ratio of 2.15 (2.13–2.16) and a significant adjusted odds ratio of 2.36 (2.34–2.38). The tobacco non-users’ rate was steadily near 9% across the week 22–44 gestational age range. The tobacco users’ rate was steady until week 33 when it rose monotonically through week 37 to about 20% at week 38 and remained high. This pattern for SGA by gestational week was similar for prevalence rates and adjusted ORs. Tobacco use only through week 33 was not seen to be an SGA risk factor. The magnitude of tobacco use as an SGA risk factor for late third trimester births increased during the period of preterm birth and became fully evident with a two-fold risk for full term infants.

Conclusion

We newly report the temporal pattern of tobacco-related SGA by week of gestational age. Tobacco-related SGA was only seen for late third trimester births – increasing during weeks 33–37 with a doubling during weeks 38–44. This pattern, informative for issues of mechanism, highlights the potential benefit of extending tobacco cessation programs through the third trimester of pregnancy.

The joint effect of maternal smoking during pregnancy and maternal pre-pregnancy overweight on infants' term birth weight

Background

It is well known that maternal smoking during pregnancy and maternal pre-pregnancy overweight have opposite effects on the infants’ birth weight. We report on the association of the combination between both risk factors and the infants’ birth weight.

Methods

We studied 3241 infants born at term in the PIAMA birth cohort. Maternal smoking during pregnancy and pre-pregnancy height and weight were self-reported. Multivariable regression analysis was performed to assess the associations between infants of mothers who only smoked during pregnancy, who only had pre-pregnancy overweight and who had both risk factors simultaneously, on term birth weight and the risk of being SGA or LGA.

Results

Of 3241 infants, 421 infants (13%) were born to smoking, non-overweight mothers, 514 (15.8%) to non-smoking, overweight mothers, 129 (4%) to smoking and overweight mothers and 2177 (67%) to non-smoking, non-overweight mothers (reference group). Infants of mothers who smoked and also had pre-pregnancy overweight had similar term birth weight (− 26.6 g, 95%CI: − 113.0, 59.8), SGA risk (OR = 1.06, 95%CI: 0.56, 2.04), and LGA risk (OR = 1.09, 95%CI: 0.61, 1.96) as the reference group.

Conclusions

Our findings suggested that the effects of maternal smoking during pregnancy and maternal pre-pregnancy overweight on infants’ birth weight cancel each other out. Therefore, birth weight may not be a good indicator of an infant’s health status in perinatal practice because it may mask potential health risks due to these maternal risk factors when both present together.

Electronic cigarettes and obstetric outcomes: a prospective observational study

OBJECTIVE

To compare the obstetric outcomes and socio-demographic factors in electronic cigarette (EC) users with cigarette smokers and non-smokers in pregnancy.

DESIGN

Prospective observational cohort study.

SETTING

A large urban maternity hospital delivering almost 8500 infants per year.

POPULATION

Pregnant women attending for antenatal care.

METHODS

Electronic cigarette users at time of booking history were prospectively identified. Maternal and neonatal outcomes were compared with those of pregnant smokers and non-smokers. Multiple logistic regression analysis was performed to estimate the association between the explanatory variables and birthweight.

MAIN OUTCOMES MEASURES

Infant birthweight, gestation at delivery, incidence of low birthweight.

RESULTS

A total of 218 women with exclusive EC use and 195 women with dual use of both cigarettes and EC, had a live birth during the study period. EC users were of higher socio-economic status than smokers. Infants born to EC users had a mean birthweight of 3470 g (± 555 g), which was similar to that of non-smokers (3471 ± 504 g, P = 0.97) and significantly greater than that of smokers (3166 ± 502 g, P < 0.001). The mean birth centile of EC users was similar to non-smokers (51st centile versus 47th centile, P = 0.28) and significantly greater than that of smokers (27th centile, P < 0.001). Dual users had a mean birthweight and birth centile similar to that of smokers.

CONCLUSION

The birthweight of infants born to EC users is similar to that of non-smokers, and significantly greater than cigarette smokers. Dual users of both cigarettes and EC have a birthweight similar to that of smokers.

TWEETABLE EXTRACT

Birthweight of infants born to electronic cigarette users appears to be similar to that of non-smokers.

Cellular and Molecular Changes in Hippocampal Glutamate Signaling and Alterations in Learning, Attention, and Impulsivity Following Prenatal Nicotine Exposure

Over 70 million European pregnant women are smokers during their child-bearing years. Consumption of tobacco-containing products during pregnancy is associated with several negative behavioral outcomes for the offspring, including a higher susceptibility for the development of attention-deficit/hyperactive disorder (ADHD). In efforts to minimize fetal exposure to tobacco smoke, many women around the world switch to nicotine replacement therapies (NRTs) during the gestational period; however, prenatal nicotine exposure (PNE) in any form has been associated with alterations in cognitive processes, including learning, memory, and attention. These processes are controlled by glutamatergic signaling of hippocampal pyramidal neurons within the CA1 region, suggesting actions of nicotine on glutamatergic transmission in this region if present prenatally. Accordingly, we aimed to investigate hippocampal glutamatergic function following PNE treatment in NMRI mice employing molecular, cellular electrophysiology, and pharmacological approaches, as well as to evaluate cognition in the rodent continuous performance task (rCPT), a recently developed mouse task allowing assessment of learning, attention, and impulsivity. PNE induced increases in the expression levels of mRNA coding for different glutamate receptors and subunits within the hippocampus. Functional alterations in AMPA and NMDA receptors on CA1 pyramidal neurons of PNE mice were suggestive of higher GluA2-lacking and lower GluN2A-containing receptors, respectively. Finally, PNE was associated with reduced learning, attention, and enhanced impulsivity in the rCPT. Alterations in glutamatergic functioning in CA1 neurons parallel changes seen in the spontaneously hypertensive rat ADHD model and likely contribute to the lower cognitive performance in the rCPT.

Neonatal outcomes and its association among gestational diabetes mellitus with and without depression, anxiety and stress symptoms in Malaysia: A cross-sectional study

OBJECTIVE

Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia.

DESIGN

This was a cross-sectional study.

SETTING

Tertiary hospitals in Malaysia.

PARTICIPANTS

Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia.

MEASUREMENTS

Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined.

FINDINGS

Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21).

KEY CONCLUSIONS

The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus.

IMPLICATIONS FOR PRACTICE

It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions.

Nicotine exposure during pregnancy programs osteopenia in male offspring rats via α4β2-nAChR-p300-ACE pathway

Prenatal nicotine exposure (PNE) induces developmental toxicity in offspring. However, the long-term harmful effects on bone development and the intrauterine programming mechanism attributed to PNE remain unclear. In the present research, pregnant Wistar rats were injected subcutaneously with nicotine (2 mg/kg/d) to obtain and analyze bone samples from the fetal and adult offspring. Bone marrow mesenchymal stem cells (BMSCs) were treated with nicotine during osteogenic differentiation to clarify the related molecular mechanisms. The results indicated that PNE led to bone dysplasia in the fetuses and reduced bone mass in the adult offspring, which was mediated by the sustained activation of the local bone renin angiotensin system (RAS) and suppressed osteogenic differentiation before and after birth. In vitro, nicotine suppressed BMSCs' osteogenic function through promoting angiotensin-converting enzyme (ACE) expression and activating RAS. Furthermore, nicotine induced histone acetylase p300 into the nuclei of the BMSCs by acting on the α4β2-nicotinic acetylcholine receptor (α4β2-nAChR), leading to the increased histone 3 lysine 9 acetylation level of ACE and RAS activation. Taken together, the sustained activation of local bone RAS mediated prenatal nicotine-induced osteopenia in adult offspring via the α4β2-nAChR-p300-ACE pathway.-Xiao, H., Wen, Y., Pan, Z., Shangguan, Y., Magdalou, J., Wang, H., Chen, L. Nicotine exposure during pregnancy programs osteopenia in male offspring rats via α4β2-nAChR-p300-ACE pathway.

Prenatal Secondhand Smoke Exposure: Correlation Between Nicotine in Umbilical Cord Blood and Neonatal Anthropometry

Objectives

Nicotine narrows uterine blood vessels reducing the flow of oxygen and nutrients to the developing fetus. This study examined the effects of fetal exposure to secondhand smoke on neonatal anthropometry.

Methods

This cross sectional study recruited 128 pregnant women in the third trimester of single pregnancies who had no chronic illness, were not active or ex-smokers, and who were willing to participate in the study. Pregnant women who were exposed to secondhand smoke had umbilical cord blood nicotine concentrations of ≥ 1 ng/mL. Neonatal anthropometry was assessed according to the newborn birth weight and length. The independent t-test was used to determine the neonatal difference in mean birth weight and length between the women who were exposed to secondhand smoke, and those who were not exposed. A multiple linear regression analysis was employed to assess the effect of secondhand smoke exposure on birth weight and birth length, controlling for potential confounding variables (weight gain during pregnancy, body mass index, parity, maternal age, and maternal hemoglobin).

Results

There were 35 women exposed to secondhand smoke (nicotine ≥ 1 ng/mL). Neonate birth weight and birth length were lower among mothers who were exposed to secondhand smoke. However, only neonate birth weight was significantly reduced by exposure to secondhand smoke (p = 0.005). The mean birth weight of these neonates was 2,916.5 g ± 327.3 g which was 205.6 g less than in unexposed fetuses.

Conclusion

Exposure of mothers to secondhand smoke during pregnancy reduces fetal development and neonatal weight.

Developmental toxicity of e-cigarette aerosols

Maternal smoking during pregnancy represents a major public health concern increasing the risk for low birth weight, congenital anomalies, preterm birth, fetal mortality, and morbidity. In an effort to diminish adverse developmental effects of exposure to cigarette smoking, pregnant women, and women of reproductive age, are increasingly turning to electronic nicotine delivery systems (ENDS), such as e-cigarettes, as an alternative. Given that health risks associated with ENDS use during pregnancy are largely unknown, there is an acute need to determine risks vs. benefits of e-cigarette use by pregnant women. While the most recent Surgeon General's Report on the "Health Consequences of Smoking" states that "the evidence is sufficient to infer that nicotine adversely affects maternal and fetal health during pregnancy, contributing to multiple adverse outcomes," it remains unclear whether use of ENDS represents a "safer alternative" to tobacco smoking during pregnancy. This is due, in part, to the lack of sufficient and conclusive evidence concerning whether or not maternal e-cigarette use adversely affects embryonic/fetal development. While several recent developmental studies have challenged the safety of nicotine inhalation via ENDS, the true risks of smoking e-cigarettes during the first trimester of pregnancy-the period of organogenesis-are largely unknown. Moreover, evidence is emerging that even nicotine-free e-cigarette aerosols may harm the developing conceptus, suggesting that components of e-cigarette liquid, including flavorings, may be developmentally toxicity. Focused human epidemiological analyses, and carefully designed animal studies are critically needed to address the question of the safety of ENDS use during pregnancy.

The 'Dangerous Cocktail': an epidemiological survey on the attitude of a population of pregnant women towards some pregnancy risk factors

Many investigations have shown the important role played by risk factors such as tobacco and alcohol and infectious agents (especially Rubella) in the development of congenital anomalies (CAs). Through the administration of a questionnaire, we evaluated the attitude of a population of pregnant women towards some risk factors in pregnancy (smoking and alcohol habit and risk of contracting one of TORCH agents). 14% of the women continued to smoke despite pregnancy; the majority of these were 34-35 years old, divorced, workers and with a high educational level. The 4.3% who identified as moderate drinkers; were mainly younger and married. Concerning the TORCH agents, it a high percentage were negative to the Rubella antibodies (62.8%). In order to improve the awareness of pregnant women on these risk factors, health education campaigns represent a public health cornerstone. Impact statementWhat is already known on this subject? Several investigations have shown an association between congenital anomalies (CAs) and various exogenous factors such as air pollutants, pesticides, metals, radiations and others present in the environmental matrices. Moreover, an important role is played by some risk factors linked to the lifestyles (i.e. tobacco and alcohol).What do the results of this study add? Our study shows that the awareness of the women about the importance of these risk factors is still rather poor, especially concerning the avoidable risks associated with smoke and alcohol and the preventable risk associated with rubella infection.What are the implications of these findings for clinical practice and/or further research? Our results highlight the importance of continuous health education both about the risk to smoke and drink during pregnancy and about the risk not to have had contract the rubella infection before the pregnancy. Particularly, about the latter issue, it appears necessary to increase the pre-conceptional diagnosis and, eventually, to vaccinate the women resulted negative in order to eliminate congenital rubella.

Smoking-related symptomatology in pregnant smokers during ad libitum smoking and following overnight smoking abstinence

Objective

Current literature suggests there may be a relationship between sex hormones, which dramatically increase during pregnancy, and nicotine use behaviors. We hypothesized that higher progesterone and progesterone:estradiol ratio (P/E₂) would be associated with less smoking-related symptomatology (SRS), better mood and fewer cigarettes smoked per day (CPD) during ad libitum smoking and following overnight abstinence in pregnant women. Associations between SRS, mood, smoking behavior and sex hormones were estimated using multiple linear regression with adjustment for CPD and pregnancy trimester.

Results

There were 35 second trimester and 42 third trimester participants. Participants mean age was 26.2 (SD: 4.1), they smoked 11.3 CPD (SD: 4.4) and the mean nicotine dependence score was 4.94 (SD: 1.98). There were no statistically significant associations between progesterone levels, estradiol levels, or the P/E₂ ratio and SRS or mood measures during ad libitum smoking or following overnight abstinence in this sample of pregnant women. Similarly, there were no associations between sex hormone levels and number of CPD smoked during the ad libitum period. Contrary to our hypothesis, we found no significant associations between sex hormones and SRS, mood or smoking behavior in this sample of pregnant women.

Trial registration ClinicalTrials.gov (NCT01811225), December 6, 2012

Maternal Body Mass Index and Risk of Congenital Heart Defects in Infants: A Dose-Response Meta-Analysis

Objective

The exact shape of the dose-response relationship between maternal body mass index (BMI) and the risk of congenital heart defects (CHDs) in infants has not been clearly defined yet. This study aims to further clarify the relationship between maternal obesity and the risk of CHDs in infants by an overall and dose-response meta-analysis.

Methods

PubMed, Embase, and Web of Science databases were searched to identify all related studies. The studies were limited to human cohort or case-control studies in English language. Random-effect models and dose-response meta-analysis were used to synthesize the results. Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were also assessed.

Results

Nineteen studies with 2,416,546 participants were included in our meta-analysis. Compared with the mothers with normal weight, the pooled relative risks (RRs) of infants with CHDs were 1.08 (95% CI=1.03-1.13) in overweight and 1.23 (95% CI=1.17-1.29) in obese mothers. According to the findings from the linear meta-analysis, we observed an increased risk of infants with CHDs (RR=1.07, 95% CI=1.06-1.08) for each 5 kg/m² increase in maternal BMI. A nonlinear relationship between maternal BMI and risk of infants with CHDs was also found (p=0.012).

Conclusion

The results from our meta-analysis indicate that increased maternal BMI is related to increased risk of CHDs in infants.

Tobacco and Pituri Use in Pregnancy: A Protocol for Measuring Maternal and Perinatal Exposure and Outcomes in Central Australian Aboriginal Women

Maternal tobacco smoking is a recognized risk behavior that has adverse impacts onmaternal and fetal health. However, in some populations, the use of smokeless tobacco exceeds theuse of smoked tobacco. In central Australia, Aboriginal populations utilize wild tobacco plants(Nicotiana spp.) as a smokeless product. These plants are known by a variety of names, one of whichis pituri. The plants are masticated and retained in the oral cavity for extended periods of time andtheir use continues throughout pregnancy, birth, and lactation. In contrast to the evidence related tocombusted tobacco use, there is no evidence as to the effects of pituri use in pregnancy. CentralAustralian Aboriginal women who were at least 28 weeks pregnant were stratified into three tobaccoexposure groups: (a) Pituri chewers, (b) smokers, and (c) non-tobacco users. Routine antenatal andbirth information, pre-existing and pregnancy-related maternal characteristics, fetal characteristics,and biological samples were collected and compared. The biological samples were analysed fortobacco and nicotine metabolite concentrations. Samples from the mother included venous blood,urine, hair and colostrum and/or breast milk. From the neonate, this included Day 1 and Day 3 urineand meconium, and from the placenta, arterial and venous cord blood following delivery. This is thefirst study to correlate the pregnancy outcomes of central Australian Aboriginal women with differenttobacco exposures. The findings will provide the foundation for epidemiological data collection inrelated studies. Note to readers: In this article, the term "Aboriginal" was chosen by central Australianwomen to refer to both themselves and the Aboriginal people in their communities. "Indigenous" waschosen to refer to the wider Australian Aboriginal and Torres Strait Islander people.

Influence of periconception smoking behavior on birth defect risk

BACKGROUND

Smoking is one of the most important modifiable risk factors for adverse maternal and neonatal outcomes. Smoking during pregnancy has been associated with fetal growth restriction, adverse pregnancy outcomes, and chronic adult diseases. Existing research has evaluated the risk of smoking on congenital defects. However, no studies have evaluated how periconception smoking affects birth defects.

OBJECTIVE

The purpose of this study was to assess the association of maternal smoking and the timing of periconception exposure with congenital birth defects.

STUDY DESIGN

This study was a population-based retrospective cohort of live births in Ohio from 2006-2015 with the use of data from birth certificates. Rates of cardiovascular, musculoskeletal, gastrointestinal, and neural tube birth defects were compared between a referent group of women who did not smoke and a group of women who smoked (1) during the preconception period of 3 months before conception only and not in the first trimester and (2) in the preconception period plus throughout the first trimester of pregnancy. Multivariate logistic regression was used to quantify the relationship between periconception smoking and the rate of birth defects after adjustment for maternal race, age, pregestational diabetes mellitus, and socioeconomic factors.

RESULTS

Of the 1,436,036 live births in the study period, 75% of mothers did not smoke during the preconception period or during pregnancy. There were 334,156 women (23.3%) who smoked during pregnancy; 6.0% of the population smoked preconception only, and 17.3% of the population smoked both during the preconception period and through the first trimester. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis. Smoking that was limited to preconception only was not associated with any other individual birth defects. However, smoking through the first trimester was associated with a statistically significant increased risk of several defects that included gastroschisis and limb reduction and a composite outcome of any defect, even after adjustment for coexisting factors.

CONCLUSION

Smoking during the period of fetal organogenesis (during the first trimester of pregnancy) is associated with increased risk of some birth defects. In this study, we provide novel data that smoking during the few months before conception, even with cessation in the first trimester, may also pose a risk for fetal malformation such as gastroschisis. These findings highlight the importance of preconception women's public health education efforts and warrant further investigation.

Postnatal growth in children born small for gestational age with and without smoking mother

BACKGROUND

Maternal smoking impairs fetal growth; however, if postnatal growth differs between children born small for gestational age (SGA) with smoking and non-smoking mother is unknown.

METHODS

Cohort-study of term born children born appropriate for gestational age with non-smoking mother (AGA-NS, n = 30,561), SGA (birthweight <10^th percentile) with smoking mother (SGA-S, n = 171) or SGA with non-smoking mother (SGA-NS, n = 1761). Means of height and weight measurements, collected at birth, 1.5, 3, 4, and 5 years, were compared using a generalized linear mixed effect model. Relative risks of short stature (<10^th percentile) were expressed as adjusted risk ratios (aRR).

RESULTS

At birth, children born SGA-S were shorter than SGA-NS, but they did not differ in weight. At 1.5 years, SGA-S had reached the same height as SGA-NS. At 5 years, SGA-S were 1.1 cm taller and 1.2 kg heavier than SGA-NS. Compared with AGA-NS, SGA-S did not have increased risk of short stature at 1.5 or 5 years, while SGA-NS had increased risk of short stature at both ages; aRRs 3.0 (95% CI 2.6;3.4) and 2.3 (95% CI 2.0;2.7), respectively.

CONCLUSIONS

Children born SGA-S have a more rapid catch-up growth than SGA-NS. This may have consequences for metabolic and cardiovascular health in children with smoking mothers.

A three-generation study on the association of tobacco smoking with asthma

Background

Mothers’ smoking during pregnancy increases asthma risk in their offspring. There is some evidence that grandmothers’ smoking may have a similar effect, and biological plausibility that fathers’ smoking during adolescence may influence offspring’s health through transmittable epigenetic changes in sperm precursor cells. We evaluated the three-generation associations of tobacco smoking with asthma.

Methods

Between 2010 and 2013, at the European Community Respiratory Health Survey III clinical interview, 2233 mothers and 1964 fathers from 26 centres reported whether their offspring (aged ≤51 years) had ever had asthma and whether it had coexisted with nasal allergies or not. Mothers and fathers also provided information on their parents’ (grandparents) and their own asthma, education and smoking history. Multilevel mediation models within a multicentre three-generation framework were fitted separately within the maternal (4666 offspring) and paternal (4192 offspring) lines.

Results

Fathers’ smoking before they were 15 [relative risk ratio (RRR) = 1.43, 95% confidence interval (CI): 1.01–2.01] and mothers’ smoking during pregnancy (RRR = 1.27, 95% CI: 1.01–1.59) were associated with asthma without nasal allergies in their offspring. Grandmothers’ smoking during pregnancy was associated with asthma in their daughters [odds ratio (OR) = 1.55, 95% CI: 1.17–2.06] and with asthma with nasal allergies in their grandchildren within the maternal line (RRR = 1.25, 95% CI: 1.02–1.55).

Conclusions

Fathers’ smoking during early adolescence and grandmothers’ and mothers’ smoking during pregnancy may independently increase asthma risk in offspring. Thus, risk factors for asthma should be sought in both parents and before conception.

Funding

European Union (Horizon 2020, GA-633212).

Maternal, prenatal and traditional practice factors associated with perinatal mortality in Yemen

BACKGROUND

Perinatal mortality remains a major international problem responsible for nearly six million stillbirths and neonatal deaths.

OBJECTIVES

To estimate the perinatal mortality rate in Sana'a, Yemen and to identify risk factors for perinatal deaths.

METHODS

A community-based prospective cohort study was carried out between 2015 and 2016. Nine-hundred and eighty pregnant women were identified and followed up to 7 days following birth. A multi-stage cluster sampling was used to select participants from community households', residing in the five districts of the Sana'a City, Yemen.

RESULTS

Total of 952 pregnant women were tracked up to 7 days after giving birth. The perinatal mortality rate, the stillbirth rate and the early neonatal mortality rate, were 89.3 per 1000, 46.2 per 1000 and 45.2 per 1000, respectively. In multivariable analysis older age (35+ years) of mothers at birth (Relative Risk=2.83), teenage mothers' age at first pregnancy (<18 years) (Relative Risk=1.57), primipara mothers (Relative Risk=1.90), multi-nuclear family (Relative Risk=1.74), mud house (Relative Risk=2.02), mothers who underwent female genital mutilation (Relative Risk=2.92) and mothers who chewed khat (Relative Risk=1.60) were factors associated with increased risk of perinatal death, whereas a positive mother's tetanus vaccination status (Relative Risk=0.49) were significant protective factors against perinatal deaths.

CONCLUSION

Rates of perinatal mortality were higher in Sana'a City compared to perinatal mortality at the national level estimated by World Health Organization. It is imperative there be sustainable interventions in order to improve the country's maternal and newborn health.

Smoking during pregnancy reduces vitamin D levels in a Finnish birth register cohort

OBJECTIVE

Maternal vitamin D level in pregnancy may have implications for both the mother and fetus. Deficiency of vitamin D has been linked to several pregnancy complications and fetal skeletal health. Smoking has been associated with reduced serum level of the vitamin D metabolite, 25-hydroxyvitamin D (25(OH)D).

DESIGN

A nested case-control study within the Finnish Maternity Cohort, a population-based cohort which includes first-trimester sera from 98 % of pregnancies in Finland since 1987. The selection consisted of women with uncomplicated pregnancies. We studied serum concentration of 25(OH)D in 313 non-smoking and forty-six self-reported smoking pregnant women.

SETTING

We hypothesize that pregnant smokers may have an increased risk of low 25(OH)D levels especially during winter months.

PARTICIPANTS

A control group from an unpublished pregnancy complication study consisting of 359 uncomplicated pregnancies. Individuals who reported that they do not smoke were considered 'non-smokers' (n 313) and those who reported continued smoking after the first trimester of pregnancy were considered 'smokers' (n 46).

RESULTS

Smokers had significantly lower levels of 25(OH)D irrespective of sampling time (P<0·0001). Furthermore, during the low sun-exposure season, only 14 % of smokers met the guideline level of 40 nmol/l for serum 25(OH)D in comparison with 31 % of non-smokers.

CONCLUSIONS

Expectant mothers who smoke have an increased risk of vitamin D deficiency during low sun-exposure months in northern regions. Further studies are needed to assess the associated risks for maternal and fetal health as well as possible long-term implications for the infant.

Neighborhood affluence protects against antenatal smoking: evidence from a spatial multiple membership model

A spatial multiple membership model formalizes the effect of neighborhood affluence on antenatal smoking. The data are geocoded New Jersey birth certificate records linked to United States census tract-level data from 1999 to 2007. Neighborhood affluence shows significant spatial autocorrelation and local clustering. Better model fit is observed when incorporating the spatial clustering of neighborhood affluence into multivariate analyses. Relative to the spatial multiple membership model, the multilevel model that ignores spatial clustering produced downwardly biased standard errors; the effective sample size of the key parameter of interest (neighborhood affluence) is also lower. Residents of communities located in high-high affluence clusters likely have better access to health-promoting institutions that regulate antenatal smoking behaviors.

Cigarette consumption and biomarkers of nicotine exposure during pregnancy and postpartum

BACKGROUND AND AIMS

Smokers can regulate their nicotine intake by altering the number of cigarettes smoked per day (CPD) and their smoking intensity. The current study aimed to compare the utility of self-reported CPD, total nicotine equivalents (TNE) and urinary cotinine to estimate nicotine intake during pregnancy.

DESIGN

Longitudinal smoking behavior and biomarker data were collected at early pregnancy, late pregnancy and at postpartum as part of a smoking cessation trial to examine voucher-based incentives for decreasing smoking.

SETTING

Obstetric practices in Burlington, Vermont, United States.

PARTICIPANTS

A subset of participants (n = 47) from the parent trial, recruited between December 2006 and June 2012, who provided a urine sample at each assessment during early pregnancy, late pregnancy and postpartum.

MEASUREMENTS

Smoking was assessed using self-reported CPD, TNE, TNE/CPD and urinary cotinine.

FINDINGS

Pregnant smokers reported smoking 10.4 CPD at early pregnancy, 7.2 CPD at late pregnancy (a 31% reduction at late pregnancy, P = 0.001) and 8.6 CPD at postpartum (a 19% increase from late pregnancy, P = 0.08). TNE exposure was 41% (P = 0.07) and 48% (P = 0.03) lower at early and late pregnancy, respectively, compared to postpartum. TNE/CPD was on average 167% higher at late pregnancy compared to early pregnancy (P = 0.01) and remained high at postpartum, where it was 111% higher compared to early pregnancy (P = 0.007). Uriniary cotinine underestimated nicotine intake by 55% during early pregnancy and by 65% during late pregnancy compared to postpartum (P_interaction  < 0.001); the underestimation was greater in slower (P_interaction  < 0.001) versus faster (P_interaction  = 0.04) nicotine metabolizers.

CONCLUSIONS

Neither cigarettes smoked per day (CPD) nor cotinine provides an accurate estimate of nicotine exposure during pregnancy. CPD underestimates nicotine intake substantially due to under-reporting and/or higher intensity of smoking, while cotinine underestimates nicotine intake markedly due to accelerated nicotine (and cotinine) metabolism during pregnancy.

Maternal smoking during pregnancy and academic achievement of offspring over time: A registry data-based cohort study

Few studies have assessed the cumulative impact of maternal smoking during pregnancy (MSDP) on scholastic outcomes over time. We examined the relations between MSDP and academic achievement in the 4th, 7th and 10th grades using registry data collected at birth, during the neonatal period, and at each grade level from the 2000, LIFECOURSE study birth cohort in Reykjavik, Iceland (N = 1151, girls = 49.3%). Latent growth modeling showed that MSDP influenced Icelandic achievement scores, standardized to a range from 0 to 60, at baseline (β = -0.04), and over time (β = -0.05). Likewise, MSDP was negatively associated with standardized mathematics scores at baseline (ß = -0.09) and continued to exert a negative impact on mathematics scores over time (ß = -0.08) after controlling for gender, income, cohabitation, and baseline mathematics and Icelandic achievement scores. Results provide evidence of the persistent negative impact of MSDP on academic achievement in offspring. Findings support the proposition that children whose mothers smoke during the first trimester of pregnancy are, on average, at greater risk for poor scholastic outcomes over time than children whose mothers do not smoke during their first trimester. To our knowledge, this is the first study using a longitudinal cohort design to assess whether the impacts of maternal smoking during pregnancy may persist over time. This study contributes to the current state of knowledge by providing an assessment that focuses on the impact of smoking during pregnancy on academic achievement from childhood into early adolescence.

Maternal smoking during pregnancy and scholastic achievement in childhood: evidence from the LIFECOURSE cohort study

Background

Research on the impact of maternal smoking during pregnancy (MSDP) on scholastic achievement in the offspring has shown conflicting findings. The objective of this study was to assess the impact of MSDP on scholastic achievement in a birth cohort of children in 4th, 7th and 10th grades.

Methods

We analysed data from the LIFECOURSE study, a cohort study of risk and protective factors in all children born in Reykjavik, Iceland, in the year 2000 (N = 1151, girls = 49.3%). Retrospective registry data for 2014–2015 were merged with prospective survey data that were collected in April 2016. Data on MSDP were assessed during regular antenatal visits at the end of the first trimester. Standardized academic achievement scores were obtained from official school transcripts. Data were analysed using OLS regressions that were entered in three hierarchical blocks.

Results

Children of mothers who smoked tobacco during the first trimester consistently revealed between 5% and 7% lower scores on standardized academic achievement in 4th, 7th and 10th grade (∼6–8 points on a normally distributed 120 point scale) than those of mothers who had not smoked tobacco during this period (P < 0.05). These findings held after controlling for several factors associated with the time of birth (e.g. birth weight, maternal age at birth, birth order, parental cohabitation and household income), as well as the year of scholastic assessment (parental cohabitation, household income and parental education).

Conclusions

Maternal smoking during pregnancy was negatively related to scholastic achievement in the offspring during 4th, 7th and 10th grade.

The investigation of effect of alpha lipoic acid against damage on neonatal rat lung to maternal tobacco smoke exposure

This study was carried out to determine the changes in the lungs of the rat pups exposed to tobacco smoke during pregnancy period and to investigate the protective effects of alpha lipoic acid, which is administered during pregnancy, on these changes. Spraque-Dawley female rats were divided into four groups: control, tobacco smoke (TS), tobacco smoke + alpha lipoic acid (TS + ALA) and alpha lipoic acid (ALA). The rats in control group were untreated. Rats were exposed to TS twice a day for one hour starting from eight weeks before mating and during pregnancy. 20 mg / kg of ALA was administered to rats. On 7th and 21st days 7 of the pups from each group were decapitated. Histological, morphometric, biochemical and quantitative real-time RT-PCR analyzes were performed. Histopathological and biochemical changes were observed in TS group. While a significant decrease was observed both in SP-A and VEGF immunoreactivities and mRNA levels, caspase-3 immunoreactivity and TUNEL positive cells were increased in TS group. It is suggested that prenatal TS exposure leads to morphological and histopathological changes on lung development by causing oxidative damage in lungs of neonatal rats and the maternal use of ALA can provide a limited protective effect on the neonatal lung development against this oxidative stress originating from TS. Although pregnant women are increasingly aware on health risks of smoking, environmental tobacco smoke exposure is still a widespread problem. For this reason, it is thought that this damage can be partially reduced by some antioxidant supplements in pregnancy.

Childhood asthma and smoking exposures before conception-A three-generational cohort study

BACKGROUND

Some human and animal studies have recently shown that maternal grandmother's smoking during pregnancy increases the risk of asthma in the grandchildren. We have investigated whether sex of the exposed parent and/or grandchild modifies the association between grandmaternal smoking and grandchild asthma.

METHODS

We formed a cohort study based on linkage of national registries with prospectively collected data over three generations. Smoking habits in early pregnancy were registered since 1982 and purchases of prescribed medication since 2005. In all, 10 329 children born since 2005 had information on maternal and grandmaternal smoking on both sides and were followed from birth up to 6 years of age. Ages when medication was purchased were used to classify the cohort into never, early transient (0-3 years), early persistent (0-3 and 4-6 years), and late-onset (4-6 years) phenotypes of childhood asthma.

RESULTS

Maternal grandmother's smoking was associated with an increased odds of early persistent asthma after adjustment for maternal smoking and other confounders (odds ratio 1.29, 95% confidence interval 1.10-1.51). Grandchild sex did not modify the association. Paternal grandmother's smoking was not associated with any of the asthma phenotypes.

CONCLUSION

Maternal but not paternal exposure to nicotine before conception was related to an increased risk of early persistent childhood asthma, but not other asthma phenotypes. Our findings are possibly consistent with a sex-specific mode of epigenetic transfer.

Education is the strongest socio-economic predictor of smoking in pregnancy

AIMS

To investigate socio-economic disparities in smoking in pregnancy (SIP) by the mother's education, occupational class and current economic conditions.

DESIGN

Cross-sectional analysis with linked survey and register data.

SETTING

South-western Finland.

PARTICIPANTS

A total of 2667 pregnant women [70% of the original sample (n = 3808)] from FinnBrain, a prospective pregnancy cohort study.

MEASUREMENTS

The outcome was smoking during the first pregnancy trimester, measured from the Finnish Medical Birth Register. Education and occupational class were linked from population registers. Income support recipiency and subjective economic wellbeing were questionnaire-based measures of current economic conditions. These were adjusted for age, partnership status, residential area type, parental separation, parity, childhood socio-economic background, childhood adversities (the Trauma and Distressing Events During Childhood scale) and antenatal stress (Edinburgh Postnatal Depression Scale). Logistic regressions and attributable fractions (AF) were estimated.

FINDINGS

Mother's education was the strongest socio-economic predictor of SIP. Compared with university education, adjusted odds ratios (aORs) of SIP were: 2.2 [95% confidence interval (CI) = 1.2-3.9; P = 0.011] for tertiary vocational education, 4.4 (95% CI = 2.1-9.0; P < 0.001) for combined general and vocational secondary education, 2.9 (95% CI = 1.4-6.1; P = 0.006) for general secondary education, 9.5 (95% CI 5.0-18.2; P < 0.001) for vocational secondary education and 14.4 (95% CI = 6.3-33.0; P < 0.001) for compulsory schooling. The total AF of education was 0.5. Adjusted for the other variables, occupational class and subjective economic wellbeing did not predict SIP. Income support recipiency was associated positively with SIP (aOR = 1.8; 95% CI = 1.1-3.1; P = 0.022). Antenatal stress predicted SIP (aOR = 2.0; 95% CI = 1.4-2.8; P < 0.001), but did not attenuate its socio-economic disparities.

CONCLUSIONS

In Finland, socio-economic disparities in smoking in pregnancy are attributable primarily to differences in the mother's educational level (low versus high) and orientation (vocational versus general).

Cigarette smoke extract interferes with placenta macrophage functions: A new mechanism to compromise placenta functions?

The success of pregnancy depends on the maternal immune system's ability to promote tolerance and host defense. This equilibrium is compromised in inflammatory and infectious impairment of placenta. Smoking during pregnancy exposes the fetus to severe complications which might result from an alteration in placenta macrophages (pMφ) functions. In this study, we assessed the effect of cigarette smoke extract (CSE) on the functions of third trimester pMφs.CSE inhibited particles uptake and the formation of multinucleated giant cells, a recently reported property of pMφs based on their ability to fuse in vitro. These alterations were associated with a CSE-induced abnormal activation of pMφs, which was characterized by an increased release of TNF, interleukin (IL)-33, and decreased IL-6 and IL-10 release. Furthermore, CSE enhanced the expression of metalloproteinase genes known to be involved in tissue remodeling. This effect of CSE on pMφs was specific because CSE affected circulating monocytes in a different way. Finally, we showed that nicotine affected in part the functional properties of pMφs. Taken together, these results showed that CSE modulated the functional activity of pMφs, which may compromise pregnancy.

National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis

BACKGROUND

Smoking during pregnancy has been linked to numerous adverse health consequences for both the developing fetus and mother. We estimated the prevalence of smoking during pregnancy by country, WHO region, and globally and the proportion of pregnant women who smoked during pregnancy, by frequency and quantity, on a global level.

METHODS

For this systematic review and meta-analysis, we did a comprehensive systematic literature search for studies reporting the prevalence of smoking during pregnancy in the general population, published between Jan 1, 1985 and Feb 1, 2016, using several electronic bibliographic databases (CINAHL, Embase, ERIC, Medline, Medline in process, PsychINFO, Scopus, and Web of Science), without language or geographical restrictions. We included original research studies published in a peer-reviewed journal and assessed study quality using a tool specifically developed for use in systematic reviews addressing questions of prevalence. Studies were excluded if they did not include lifetime non-smokers in their sample or estimate, used a sample not generalisable to the general population of the respective country, or did not provide primary data. To estimate the prevalence by country, we did country-specific random-effects meta-analyses for countries with two or more available empirical studies, and we predicted the prevalence using a multilevel fractional response regression model with country-specific indicators for countries with one or no study. We estimated the proportion of female daily smokers who do not quit once pregnant by calculating the regional and global averages of the prevalence of daily smoking during pregnancy and of the prevalence of daily smoking in women. To estimate the global prevalence, by frequency and quantity, we did random-effects meta-analyses using available data from all countries and applied the respective proportions to the global prevalence estimate. We did a time-trend analysis using a univariate multilevel fractional response model. The review protocol is available on PROSPERO, registration number CRD42017075837.

FINDINGS

Of 21 329 studies identified, 295 were retained for data extraction. We calculated estimates via meta-analysis for 43 countries and via statistical modelling for 131 countries. The three countries with the highest estimated prevalence of smoking during pregnancy were Ireland (38·4%, 95% CI 25·4-52·4), Uruguay (29·7%, 16·6-44·8), and Bulgaria (29·4%, 26·6-32·2). The global prevalence of smoking during pregnancy was estimated to be 1·7% (95% CI 0·0-4·5). The prevalence of smoking during pregnancy was 8·1% (95% CI 4·0-12·2) in the European Region, 5·9% (3·2-8·6) in the Region of the Americas, 1·2% (0·7-1·7) in the Southeast Asian Region, 1·2% (0·0-3·7) in the Western Pacific Region, 0·9% (0·0-1·9) in the Eastern Mediterranean Region, and 0·8% (0·0-2·2) in the African Region. Globally, 72·5% (95% CI 70·4-75·0) of pregnant women who smoked were daily smokers, and 27·5% (25·4-29·6) of them were occasional smokers; 51·8% (95% CI 50·0-53·5) women who smoked were light smokers, 34·8% (33·1-36·4) were moderate smokers, and 13·5% (12·3-14·7) were heavy smokers. Furthermore, the proportion of women who smoked daily and continued to smoke daily during pregnancy was 52·9% (95% CI 45·6-60·3), ranging from 30·6% (95% CI 25·6-36·4) in the European Region to 79·6% (44·2-100·0) in the Western Pacific Region.

INTERPRETATION

Smoking during pregnancy is still a prevalent behaviour in many countries. These findings should inform smoking prevention programmes and health promotion strategies, as well as draw attention to the need for improved access to smoking cessation programmes for pregnant women.

FUNDING

Centre for Addiction and Mental Health.

Smoking Exposure in Early Pregnancy and Adverse Pregnancy Outcomes: Usefulness of Urinary Tobacco-Specific Nitrosamine Metabolite 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol Levels

OBJECTIVES

The aim was to investigate the effect of -maternal smoking exposure assessed by urinary tobacco-specific nitrosamine metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-a1-butanol (NNAL) with adverse pregnancy outcomes.

METHODS

A total of 251 pregnant women were recruited. Urinary cotinine and NNAL were measured. Participants' sociodemographics were obtained by questionnaire and pregnancy outcomes were collected by charts review after delivery.

RESULTS

The prevalence of smoking was 8.4% (21 of 249), 1.2% (3 of 241), and 3.7% (9 of 241) in pregnant women according to questionnaire, cotinine, and NNAL, respectively. As compared with questionnaire positivity and cotinine levels, women with positive NNAL were independent determinants for spontaneous abortion (adjusted OR 12.357, 95% CI 2.053-74.368), preterm birth (adjusted OR 22.239, 95% CI 3.737-132.357), and small for gestational age (adjusted OR 6.915, 95% CI 1.385-34.524).

CONCLUSIONS

Urinary NNAL might be a useful biomarker in detection of maternal smoking status in association with adverse pregnancy outcomes. Use of this marker in preconception and pregnancy counselling before planning pregnancy may allow prevention of several adverse pregnancy outcomes.

Predictors of smoking cessation during pregnancy: a systematic review and meta-analysis

AIM

To identify factors found in the research literature to be associated with smoking cessation in pregnancy.

METHODS

Electronic searches of the bibliographic databases of PubMed, EMBASE, PsycINFO, Elsevier, Scopus and ISI Web of Science were conducted to April 2017. All studies reporting factors associated with smoking cessation or continuing smoking during pregnancy were included and reviewed systematically, irrespective of study design. The Newcastle-Ottawa Quality Assessment Scale was used to assess the study quality. The DerSimonian & Laird random-effects model was used to conduct meta-analyses, and where effect estimates were reported for factors included in at least three studies.

RESULTS

Fifty-four studies, including 505 584 women globally who smoked before pregnancy, 15 clinical trials and 40 observational studies, were included in the review and 36 (65.5%) were considered to be of high quality. This review identified 11 socio-demographic, seven socially related, 19 smoking behaviour-related, five pregnancy-related, six health-related and six psychological factors that were associated significantly with smoking cessation during pregnancy. The most frequently observed significant factors associated with cessation were: higher level of education, pooled odds ratio (OR), 95% confidence interval (CI) = 2.16 (1.80-2.84), higher socio-economic status: 1.97 (1.20-3.24), overseas maternal birth: 2.00 (1.40-2.84), Medicaid coverage or private insurance: 1.54 (1.29-1.85), living with partner or married: 1.49 (1.38-1.61), partner/other members of the household do not smoke: 0.42 (0.35-0.50), lower heaviness of smoking index score: 0.45 (0.27-0.77, lower baseline cotinine level: 0.78 (0.64-0.94), low exposure to second-hand smoking: 0.45 (0.20-1.02), not consuming alcohol before and/or during pregnancy: 2.03 (1.47-2.80), primiparity: 1.85 (1.68-2.05), planned breastfeeding:1.99 (1.94-2.05), perceived adequate pre-natal care: 1.74 (1.38-2.19), no depression: 2.65 (1.62-4.30) and low stress during pregnancy: 0.58 (0.44-0.77).

CONCLUSION

A wide range of socio-demographics, relationship, social, smoking-related, pregnancy-related, health and psychological factors have been found to predict smoking cessation in pregnancy.

Improving Prenatal Care for Minority Women

Since the inception of prenatal care in the early 1900s, the focus of care has been on risk reduction rather than on health promotion. Prenatal care began as individualized care, but more recently group prenatal care has been shown to be very successful in improving birth outcomes. For all women, an emphasis on improving health behaviors is important at this critical time while women are engaging regularly with the healthcare system. An emphasis on mental health promotion may decrease some of the disparities in birth outcomes that are well documented between minority and majority women, as minority women are known to experience increased levels of stress, anxiety, and depression. Providing support for pregnant women and incorporating knowledge and skills through prenatal care may promote both physical and mental health in minority women.

Influence of exposure to nicotine during pregnancy on the learning and memory for adult offspring

We aimed to investigate the indirect influence of exposure to nicotine during pregnancy on the learning and memory of adult offspring mice. Thirty pregnant C57 mice were randomly divided into either the control group (CON) or the nicotine group (NIC), with 15 mice each. The CON group was given access to drug-free water, and the NIC group was given 60 g/ml nicotine in drinking water. Sixteen adult mice were randomly selected from the 8 litters for Morris water maze test. The level of products of related factors in the hippocampus of mice in the NIC and the CON groups were compared using the ¹H-MRS method. The escape latency time that the adult offspring mice in the NIC group took in the place navigation test was significantly longer than that of the CON group. In addition, the NIC group took longer time to arrive at the plate than the CON group (P<0.05). mRNA and protein levels of NR1 in the hippocampus of the NIC group was significantly higher than that in the CON group (P<0.05).α7nACh mRNA in the hippocampus of the NIC group was not significantly different from that of the CON group (P>0.05), while the expression levels of α7nACh protein in the hippocampus of the NIC group was significantly lower than that in the CON group (P<0.05). Detection of protein level of muscarinic receptors in the hippocampus of adult offspring mice in the NIC group showed that when compared to the CON group, the expression levels of M1, M3, M5 of the NIC group was not significantly different from that of the CON group (P>0.05). Therefore, exposure to nicotine during pregnancy can cause damage to the learning ability of adult offspring mice but do not significantly influence their working memory.

Associations between lifestyle factors and smoking status during pregnancy in a group of Romanian women

BACKGROUND

There is an estimated birth rate of 9.27 births/1,000 population in Romania each year, with approximately 8.4% born with low birth weight (LBW). Our purpose was to evaluate the relationships between maternal smoking and LBW and preterm birth in Mureș County, Romania.

METHODS

We conducted a cross-sectional survey of 1,278 mothers who had given birth in Mureș County obstetrical wards in 2015, based on a lifestyle questionnaire of 109 items and personal and laboratory data from hospitals records.

RESULTS

The variables associated with smoking during pregnancy taken into account were: Rroma ethnicity, education <8 grades, income lower than 140 dollars (minimum wages in our country), and lack of facilities in their households. In a multivariable model, smoking during pregnancy was correlated with a low level of education (p = .02), coffee and alcohol use (p = .0001), and lack of interest in potential environmental and behavioral risks during pregnancy (including smoking and diet). The newborn baby's weight was associated with smoker status of the mother (OR 1.71, 95%CI 1.09-2.66, p = .01), by the lack of ownership of a household (OR 3.52, 95%CI 2.27-5.47, p = .0001), and by the pregnant woman not receiving proper information regarding a healthy behavior and diet during pregnancy (OR 1.91, 95%CI 1.33-2.74, p = .0005).

CONCLUSION

Our study aimed to emphasize the high rates of maternal smoking during pregnancy and its importance in LBW outcomes in Romanian pregnant women. Moreover, the study highlights disparities in smoking status observed in ethnic minorities and those living in poverty.

Modelling foetal exposure to maternal smoking using hepatoblasts from pluripotent stem cells

The liver is a dynamic organ which is both multifunctional and highly regenerative. A major role of the liver is to process both endo and xenobiotics. Cigarettes are an example of a legal and widely used drug which can cause major health problems for adults and constitute a particular risk to the foetus, if the mother smokes during pregnancy. Cigarette smoke contains a complex mixture of thousands of different xenobiotics, including nicotine and polycyclic aromatic hydrocarbons. These affect foetal development in a sex-specific manner, inducing sex-dependant molecular responses in different organs. To date, the effect of maternal smoking on the foetal liver has been studied in vitro using cell lines, primary tissue and animal models. While these models have proven to be useful, poor cell phenotype, tissue scarcity, batch-to-batch variation and species differences have led to difficulties in data extrapolation toward human development. Therefore, in this study we have employed hepatoblasts, derived from pluripotent stem cells, to model the effects of xenobiotics from cigarette smoke on human hepatocyte development. Highly pure hepatocyte populations (>90%) were produced in vitro and exposed to factors present in cigarette smoke. Analysis of ATP levels revealed that, independent of the sex, the majority of smoking derivatives tested individually did not deplete ATP levels below 50%. However, following exposure to a cocktail of smoking derivatives, ATP production fell below 50% in a sex-dependent manner. This was paralleled by a loss metabolic activity and secretory ability in both female and male hepatocytes. Interestingly, cell depletion was less pronounced in female hepatocytes, whereas caspase activation was ~twofold greater, indicating sex differences in cell death upon exposure to the smoking derivatives tested.

Factors Influencing the Initiation of Smokeless Tobacco Consumption Among Low Socioeconomic Community in Bangladesh: A Qualitative Investigation

This study explored factors influencing the initiation of smokeless tobacco (SLT) consumption in a low socioeconomic urban community in Bangladesh. The study conducted four focus group discussions among 33 informants involves school teachers, community leaders, women, and betel-nut shops owners. The results were prepared by thematic analysis of the transcripts where informants mean age was 30 ( SD ± 6.8) years with varying level of education. Tradition of hospitality, curiosity, offer from an elderly person, and avoiding nausea during pregnancy and at time of quitting smoking were key factors for the initiation of SLT consumption. The results also revealed most people were aware about the danger of SLT consumption but, in practice, consumed frequently. The research suggested that doctors might advise people not to use any form of SLT while they seeking health services. Furthermore, community-based awareness program could minimize the wider use of SLT among low-income community in Bangladesh.

Low-level maternal exposure to nicotine associates with significant metabolic perturbations in second-trimester amniotic fluid

Decades of public health research have documented that smoking in pregnancy poses significant health risks to both mother and child. More recent studies have shown that even passive maternal exposure to secondhand smoke associates with negative birth outcomes. However, the mechanisms linking exposure to outcomes have remained obscure. As a first step toward defining the metabolic consequence of low-level nicotine exposure on fetal development, we conducted an untargeted metabolomic analysis of 81 paired samples of maternal serum and amniotic fluid collected from karyotypically normal pregnancies in the second trimester. By comparing the m/z and retention times of our mass spectral features with confirmed standards, we identified cotinine, a nicotine derivative, and used the calculated cotinine concentrations to classify our maternal serum samples into exposure groups using previously defined cut-offs. We found that cotinine levels consistent with low-level maternal exposure to nicotine associated with distinct metabolic perturbations, particularly in amniotic fluid. In fact, the metabolic effects in amniotic fluid of ostensibly low-level exposed mothers showed greater overlap with perturbations previously observed in the sera of adult smokers than did the perturbations observed in the corresponding maternal sera. Dysregulated fetal pathways included aspartate and asparagine metabolism, pyrimidine metabolism, and metabolism of other amino acids. We also observed a strong negative association between level of maternal serum cotinine and acetylated polyamines in the amniotic fluid. Combined, these results confirm that low-level maternal nicotine exposure, indicated by a maternal serum cotinine level of 2-10ng/mL, is associated with striking metabolic consequences in the fetal compartment, and that the affected pathways overlap those perturbed in the sera of adult smokers.