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Fung K, Hernandez-Diaz S, Zash R, Chadwick EG, Van Dyke RB, Broadwell C, Jao J, Powis K, Yee LM, Williams PL. First-trimester exposure to newer antiretroviral agents and congenital anomalies in a US cohort. AIDS 2024; 38:1686-1695. [PMID: 38864586 PMCID: PMC11293967 DOI: 10.1097/qad.0000000000003955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
OBJECTIVE To characterize associations of exposure to newer antiretroviral medications in the first trimester with congenital anomalies among infants born to persons with HIV in the United States. DESIGN Longitudinal cohort of infants born 2012-2022 to pregnant persons with HIV enrolled in the Surveillance Monitoring for ART Toxicities (SMARTT) study. METHODS First-trimester exposures to newer antiretrovirals (ARVs) were abstracted from maternal medical records. Trained site staff conducted physical exams and abstracted congenital anomalies from infant medical records. Investigators classified anomalies using the Metropolitan Atlanta Congenital Defects Program classification system. The prevalence of major congenital anomalies identified by age one year was estimated for infants exposed and unexposed to each ARV. Generalized estimating equation models were used to estimate the odds ratio (OR) of major congenital anomalies for each ARV exposure, adjusting for potential confounders. RESULTS Of 2034 infants, major congenital anomalies were identified in 135 [6.6%; 95% confidence interval (CI): 5.6-7.8%]. Cardiovascular ( n = 43) and musculoskeletal ( n = 37) anomalies were the most common. Adjusted ORs (95% CI) of congenital anomalies were 1.03 (0.62-1.72) for darunavir, 0.91 (0.46-1.81) for raltegravir, 1.04 (0.58-1.85) for rilpivirine, 1.31 (0.71-2.41) for elvitegravir, 0.76 (0.37-1.57) for dolutegravir, and 0.34 (0.05-2.51) for bictegravir, compared to those unexposed to each specific ARV. Findings were similar after adjustment for nucleoside/nucleotide backbones. CONCLUSIONS The odds of congenital anomalies among infants with first-trimester exposure to newer ARVs did not differ substantially from those unexposed to these specific ARVs, which is reassuring. Continued evaluation of these ARVs with larger studies will be needed to confirm these findings.
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Affiliation(s)
- Kelly Fung
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
| | | | - Rebecca Zash
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ellen G Chadwick
- Department of Pediatrics (Infectious Diseases), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Russell B Van Dyke
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA
| | - Carly Broadwell
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health
| | - Jennifer Jao
- Department of Pediatrics (Infectious Diseases), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kathleen Powis
- Division of Internal Medicine and Pediatrics, Massachusetts General Hospital
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lynn M Yee
- Department of Obstetrics and Gynecology (Maternal Fetal Medicine), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paige L Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Fothergill A, Liberman RF, Nestoridi E, Mai CT, Yeung LF, Higgins C, Yazdy MM. Expanding the Massachusetts Birth Defects Monitoring Program to include additional pregnancy outcomes: Programmatic efforts and impacts on case ascertainment, 2012-2020. Birth Defects Res 2024; 116:e2323. [PMID: 38476117 PMCID: PMC11177220 DOI: 10.1002/bdr2.2323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Birth defects affect 1 in 33 infants in the United States and are a leading cause of infant mortality. Birth defects surveillance is crucial for informing public health action. The Massachusetts Birth Defects Monitoring Program (MBDMP) began collecting other pregnancy losses (OPLs) in 2011, including miscarriages (<20 weeks gestation) or elective terminations (any gestational age), in addition to live births and stillbirths (≥20 weeks gestation). We describe programmatic changes for adding OPLs and their impact on prevalence estimates. METHODS Using population-based, statewide, data from the MBDMP (2012-2020), we assessed prevalence per 10,000 live births and 95% confidence intervals (CIs) with and without OPLs overall and for specific birth defects by time period, maternal age, and race/ethnicity. RESULTS Including OPLs required amending a state statute and promulgating regulations, new data sources, and additional data processing, cleaning, and verification. Overall prevalence with OPLs increased from 257.4 (95% CI: 253.5-261.4) to 333.9 (95% CI: 329.4-338.4) per 10,000; increases were observed in all time periods, age, and race/ethnicity groups. After including OPLs, the prevalence increased for neural tube defects [3.2 (2.7-3.6) to 8.3 (7.6-9.0)], and trisomies 13 [0.5 (0.3-0.7) to 4.1 (3.6-4.6)], 18 [1.5 (1.2-1.9) to 8.2 (7.5-8.9)], and 21 [12.3 (11.4-13.2) to 28.9 (27.6-30.2)]. Cardiovascular defects increased slightly, while prevalence of eye/ear, respiratory, and gastrointestinal defects remained similar. CONCLUSIONS Adding OPLs required substantial programmatic efforts and resulted in more complete case ascertainment, particularly for certain birth defects. More complete case ascertainment will allow for improved research, screening, and resource allocation.
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Affiliation(s)
- Amy Fothergill
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rebecca F. Liberman
- Division for Surveillance, Research, and Promotion of Perinatal Health, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Eirini Nestoridi
- Division for Surveillance, Research, and Promotion of Perinatal Health, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Cara T. Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lorraine F. Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cathleen Higgins
- Division for Surveillance, Research, and Promotion of Perinatal Health, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Mahsa M. Yazdy
- Division for Surveillance, Research, and Promotion of Perinatal Health, Massachusetts Department of Public Health, Boston, Massachusetts, USA
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Abdelhafez M, Ahmed K, Ahmed N, Ismail M, Mohd Daud MNB, Ping NPT, Eldiasty A, Amri MFB, Jeffree MS, Kadir F, pg Baharuddin DM, Bolong MFB, Hayati F, BtAzizan N, Sumpat D, Syed Abdul Rahim SS, Abdel Malek EH. Psychiatric illness and pregnancy: A literature review. Heliyon 2023; 9:e20958. [PMID: 37954333 PMCID: PMC10632674 DOI: 10.1016/j.heliyon.2023.e20958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Background Women of reproductive age frequently suffer from psychiatric disorders. The risk of developing anxiety, bipolar, and depressive disorders is especially significant during the perinatal period. Objectives This article aims to identify and discuss the different psychiatric conditions that might affect pregnant women and update the mother's carers about the recent and updated bidirectional relationship between psychiatric disease and adverse pregnancy outcomes, As well as the most updates in diagnostic and management strategies. Methods A thorough analysis of the literature was conducted using database searches in EMBASE, Science Direct, Google Scholar, Scopus, and PubMed to obtain the objectives and aim of the study. Results The presence of maternal mental illness during pregnancy has been linked to preterm delivery, newborn hypoglycemia, poor neurodevelopmental outcomes, and disturbed attachment. Placental anomalies, small-for-gestational-age foetuses, foetal discomfort, and stillbirth are among more undesirable perinatal outcomes. Conclusions Pregnancy-related psychiatric disorders are frequent. The outcomes for pregnant women, infants, and women's health are all improved by proper diagnosis and treatment of psychiatric problems.
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Affiliation(s)
- MohsenM.A. Abdelhafez
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - KarimA.M. Ahmed
- Department of Dermatology, Helios Saint Johannes Klinikum, Duisburg, Germany
| | - NashwaA.M. Ahmed
- Department of Orthodontics, Faculty of Dental and Oral Surgery, Ahram Canadian University, Egypt
| | - MohdHamdy Ismail
- Owner and Leading Clinician, Ulti Care Dental Clinics, Cairo, Egypt
| | - Mohd Nazri Bin Mohd Daud
- Family Medicine Unit, Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Nicholas Pang Tze Ping
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - AyaM. Eldiasty
- Department of Dermatology, Helios Saint Johannes Klinikum, Duisburg, Germany
| | - Mohd Fariz Bin Amri
- Department of Pathology and Microbiology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Mohammad Saffree Jeffree
- Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Fairrul Kadir
- Department of Emergency Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Dg Marshitah pg Baharuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Mohammed Firdaus Bin Bolong
- Department of Emergency Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Nornazirah BtAzizan
- Department of Clinical Pathology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | - Doreen Sumpat
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
| | | | - Ehab Helmy Abdel Malek
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia
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4
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MacArthur C, Hansen M, Baynam G, Bower C, Kelty E. Trends in prenatal diagnosis of congenital anomalies in Western Australia between 1980 and 2020: A population-based study. Paediatr Perinat Epidemiol 2023; 37:596-606. [PMID: 37143205 PMCID: PMC10947594 DOI: 10.1111/ppe.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 04/09/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Advances in screening and diagnostics have changed the way in which we identify and diagnose congenital anomalies. OBJECTIVE To examine changes in rates of prenatal diagnosis of congenital anomalies over time and by demographic characteristics. METHODS We undertook a population-based retrospective cohort study of all children born in Western Australia between 1980 and 2020 and diagnosed with a congenital anomaly. Age at diagnosis (prenatal, neonatal, infancy, early childhood or childhood) prevalence (all-type and type-specific), and prevalence ratios (PR) were calculated. We fit joinpoint regression models to describe the average annual percentage change (APC) in prenatal diagnosis over time, and log-binomial regression models to estimate the association between prenatal diagnosis and demographic characteristics. RESULTS Prenatal diagnosis prevalence between the first (1980-1989: 28.3 per 10,000 births) and last (2005-2014: 156.1 per 10,000 births) decades of the study increased 5.5-fold (95% confidence interval [CI] 5.0, 5.9). Substantial increases were observed for cardiovascular (PR 10.7, 95% CI 8.0, 14.6), urogenital (PR 10.5, 95% CI: 8.7, 12.6) and chromosomal anomalies (PR 7.0, 95% CI 5.9, 8.3). Prenatal diagnosis was positively associated with the birth year (adjusted risk ratio [RR] 1.04, 95% CI 1.03, 1.04), advanced maternal age (RR 1.14, 95% CI 1.11, 1.18), multiple anomalies (RR 2.86, 95% CI 2.77, 2.96) and major anomalies (RR 3.75, 95% CI 3.36, 4.19), and inversely associated with remoteness (RR 0.89, 95% CI: 0.83, 0.95) and Aboriginality (RR 0.90, 95% CI 0.83, 0.97). CONCLUSIONS Increases in prenatal diagnosis of congenital anomalies were observed in Western Australia from 1980 to 2020, reflecting advances in screening. Prenatal diagnosis was less common in remote regions and in Aboriginal children, strengthening calls for increased provision of antenatal care services for these populations.
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Affiliation(s)
- Cassandra MacArthur
- School of Population and Global HealthThe University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Michele Hansen
- Telethon Kids InstituteThe University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Gareth Baynam
- Western Australian Register of Developmental AnomaliesKing Edward Memorial HospitalPerthWestern AustraliaAustralia
- Faculty of Health and Medicine, Institute and Division of PaediatricsUniversity of Western AustraliaCrawleyWestern AustraliaAustralia
- Rare Care, Clinical Centre of Expertise for Rare and Undiagnosed DiseasesPerth Children's HospitalPerthWestern AustraliaAustralia
| | - Carol Bower
- Telethon Kids InstituteThe University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Erin Kelty
- School of Population and Global HealthThe University of Western AustraliaCrawleyWestern AustraliaAustralia
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Kyozuka H, Ohhira T, Murata T, Yasuda S, Ishii K, Yasumura S, Fujimori K, Ohto H, Kamiya K. Eight-Year Trends in the Effect of the Great East Japan Earthquake on Obstetrics Outcomes: A Study from the Fukushima Health Management Survey. Life (Basel) 2023; 13:1702. [PMID: 37629559 PMCID: PMC10455406 DOI: 10.3390/life13081702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Information regarding the longitudinal effects of natural/environmental disasters on obstetrics outcomes is limited. This study aimed to analyze the longitudinal changes in obstetrics outcomes over 8 years after the Great East Japan Earthquake and the Fukushima power plant accident. We used data from the first 8 years of the Pregnancy and Birth Survey by the Fukushima prefectural government, launched in 2011. We compared data on obstetrics outcomes by year and divided Fukushima Prefecture into six districts based on administrative districts. Longitudinal changes in the occurrence of preterm birth before 37 gestational weeks, low birth weight, and anomalies in newborns were accessed using the Mantel-Haenszel test for trends in all six districts. Overall, 57,537 participants were included. In 8 years, maternal age, conception rate after sterility treatment, and cesarean section delivery incidence increased. Although significant differences were observed in preterm birth and low birth weight occurrence among districts, there was no significant trend in the occurrence of preterm birth, low birth weight, and anomalies in newborns in all six districts of Fukushima Prefecture. The Great East Japan Earthquake and Fukushima power plant accident were associated with increased cesarean section delivery incidence but had no significant adverse effects on obstetrics outcomes.
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Affiliation(s)
- Hyo Kyozuka
- Department of Obstetrics and Gynecology, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Tetsuya Ohhira
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
- Department of Epidemiology, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Tsuyoshi Murata
- Department of Obstetrics and Gynecology, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Shun Yasuda
- Department of Obstetrics and Gynecology, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
| | - Kayoko Ishii
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
| | - Seiji Yasumura
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
- Department of Public Health, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
| | - Hitoshi Ohto
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
| | - Kenji Kamiya
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima 960-1295, Japan
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6
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Kyozuka H, Murata T, Yasuda S, Ishii K, Fujimori K, Goto A, Yasumura S, Ota M, Hata K, Suzuki K, Nakai A, Ohira T, Ohto H, Kamiya K. The Effects of the Great East Japan Earthquake on Perinatal Outcomes: Results of the Pregnancy and Birth Survey in the Fukushima Health Management Survey. J Epidemiol 2022; 32:S57-S63. [PMID: 36464301 PMCID: PMC9703925 DOI: 10.2188/jea.je20210444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
There are limited studies on the long-term effects of natural/environmental disasters, especially nuclear disasters, on obstetric outcomes. This study aimed to review the results of perinatal outcomes immediately after the Great East Japan Earthquake (GEJE) and the Fukushima Daiichi Nuclear Power Plant accident, as well as their long-term trends over 8 years, in the Fukushima Health Management Survey. The annual population-based Pregnancy and Birth Survey is conducted as part of the Fukushima Health Management Survey. The Fukushima Prefecture government launched it to assess the health conditions of pregnant women and their neonates after the GEJE. The self-reported questionnaire was sent to 115,976 pregnant women by mail from January 2012, with 58,344 women responding to the questionnaire (50.3% response rate). Pregnancy complications, such as gestational hypertension, respiratory diseases, and mental disorders, increased in some women who were pregnant at the time of the earthquake and immediately after the earthquake. However, the direct effects on newborns, such as preterm birth, low birth weight, and congenital anomalies, were not immediately clear after the earthquake. Although there were significant differences in the occurrence of preterm birth and low birth weight among the districts, there was no change in the occurrences of preterm birth, low birth weight, or anomalies in newborns in Fukushima Prefecture from the fiscal year 2011 to the fiscal year 2018. Therefore, the long-term effects of the post-disaster radiation accident on perinatal outcomes are considered to be very small.
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Affiliation(s)
- Hyo Kyozuka
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tsuyoshi Murata
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shun Yasuda
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, Fukushima, Japan,Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
| | - Kayoko Ishii
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine, Fukushima, Japan,Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
| | - Aya Goto
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Center for Integrated Science and Humanities, Fukushima Medical University, Fukushima, Japan
| | - Seiji Yasumura
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Department of Public Health, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Misao Ota
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Department of Midwifery and Maternal Nursing, Fukushima Medical University School of Nursing, Fukushima, Japan
| | - Kenichi Hata
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Fukushima Society of Obstetrics and Gynecology, Fukushima, Japan
| | - Kohta Suzuki
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Department of Health and Psychosocial Medicine, Aichi Medical University School of Medicine, Aichi, Japan
| | - Akihito Nakai
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Tetsuya Ohira
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan,Department of Epidemiology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Ohto
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
| | - Kenji Kamiya
- Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
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7
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Willis ED, Marko AM, Rasmussen SA, McGee M, Broder KR, Marin M. Merck/Centers for Disease Control and Prevention Varicella Vaccine Pregnancy Registry: 19-Year Summary of Data From Inception Through Closure, 1995-2013. J Infect Dis 2022; 226:S441-S449. [PMID: 36265854 DOI: 10.1093/infdis/jiac277] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The VARIVAX® Pregnancy Registry was established in 1995 to monitor pregnancy outcomes of women who received varicella vaccine (ie, VARIVAX) inadvertently while pregnant. METHODS Health care providers and consumers sent voluntary reports about women who received VARIVAX 3 months before or during pregnancy. Follow-up occurred to evaluate pregnancy outcomes for birth defects. Outcomes from prospectively reported pregnancy exposures (ie, reports received before the outcome of the pregnancy was known) among varicella-zoster virus (VZV)-seronegative women were used to calculate rates and 95% confidence intervals (CIs). RESULTS From 17 March 1995 through 16 October 2013, 1601 women were enrolled-966 prospectively-among whom there were 819 live births. Among 164 infants born to women who were VZV seronegative at the time of vaccination, no cases of congenital varicella syndrome (CVS) were identified (rate, 0 per 100, 95% CI, 0.0-2.2) and the birth prevalence of major birth defects was 4.3 per 100 liveborn infants (95% CI 1.7-8.6) with no pattern suggestive of CVS. No defects consistent with CVS were identified in any registry reports. CONCLUSIONS Data collected through the VARIVAX pregnancy registry do not support a relationship between the occurrence of CVS or major birth defects and varicella vaccine exposure during pregnancy, although the small numbers of exposures cannot rule out a low risk. VARIVAX remains contraindicated during pregnancy.
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Affiliation(s)
| | | | - Sonja A Rasmussen
- Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Karen R Broder
- Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mona Marin
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Salari N, Fatahi B, Fatahian R, Mohammadi P, Rahmani A, Darvishi N, Keivan M, Shohaimi S, Mohammadi M. Global prevalence of congenital anencephaly: a comprehensive systematic review and meta-analysis. Reprod Health 2022; 19:201. [PMID: 36253858 PMCID: PMC9575217 DOI: 10.1186/s12978-022-01509-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 09/29/2022] [Indexed: 11/22/2022] Open
Abstract
Background Anencephaly is a fatal congenital anomaly characterized by the absence of brain hemispheres and cranial arch. Timely preventive measures can be taken by knowing the exact prevalence of this common neural tube defect; thus, carried out through systematic review and meta-analysis, the present study was conducted to determine the worldwide prevalence, incidence and mortality of anencephaly. Methods Cochran’s seven-step instructions were used as the guideline. Having determined the research question and inclusion and exclusion criteria, we studied MagIran, SID, Science Direct, WoS, Web of Science, Medline (PubMed), Scopus, and Google Scholar databases. Moreover, the search strategy in each database included using all possible keyword combinations with the help of “AND” and “OR” operators with no time limit to 2021. The I2 test was used to calculate study heterogeneity, and Begg and Mazumdar rank correlation tests were employed to assess the publication bias. Data were analyzed by Comprehensive Meta-Analysis software (Version 2). Results In this study, the statements of Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) were used. In the first stage, 1141 articles were found, of which 330 duplicate studies were omitted. 371 articles were deleted based on the inclusion and exclusion criteria by reviewing the title and abstract of the study. 58 articles were removed by reviewing the full text of the article because it was not relevant to the research. 360 studies with a sample size of 207,639,132 people were considered for the meta-analysis. Overall estimate of the prevalence, incidence and attenuation of anencephaly worldwide were 5.1 per ten thousand births (95% confidence interval 4.7–5.5 per ten thousand births), 8.3 per ten thousand births (95% confidence interval 5.5–9.9 per ten thousand births), 5.5 per ten thousand births (95% confidence interval 1.8–15 per ten thousand births) respectively the highest of which according to the subgroup analysis, belonged to the Australian continent with 8.6 per ten thousand births (95% confidence interval 7.7–9.5 per ten thousand births). Conclusion The overall prevalence of anencephaly in the world is significant, indicating the urgent need for preventive and treating measures. Anencephaly is a fatal congenital anomaly characterized by the absence of brain hemispheres and cranial arch. Cochran’s seven-step instructions were used as the guideline. Having determined the research question and inclusion and exclusion criteria, we studied MagIran, SID, Science Direct, WoS, Web of Science, Medline (PubMed), Scopus, and Google Scholar databases. Moreover, the search strategy in each database included using all possible keyword combinations with the help of “AND” and “OR” operators with no time limit to 2021. Out of 1141 initial articles found, and after excluding repetitive ones in various databases and those irrelevant to inclusion criteria, 360 studies with a sample size of 207,639,132 people were considered for the meta-analysis. Overall estimate of the prevalence, incidence and attenuation of anencephaly worldwide were 5.1 per ten thousand births (95% confidence interval 4.7–5.5 per ten thousand births), 8.3 per ten thousand births (95% confidence interval 5.5–9.9 per ten thousand births), 5.5 per ten thousand births (95% confidence interval 1.8–15 per ten thousand births) respectively the highest of which according to the subgroup analysis, belonged to the Australian continent with 8.6 per ten thousand births (95% confidence interval 7.7–9.5 per ten thousand births). The overall prevalence of anencephaly in the world is significant, indicating the urgent need for preventive and treating measures.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnaz Fatahi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fatahian
- Department of Neurosurgery, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Mohammadi
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Niloofar Darvishi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mona Keivan
- Student Research Committee, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran.
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Khadka M, Agarwal J, Shrestha R, Das D. Birth Defects among Newborns in a Tertiary Care Centre: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2022; 60:588-591. [PMID: 36705206 PMCID: PMC9297362 DOI: 10.31729/jnma.6610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/25/2022] [Indexed: 01/31/2023] Open
Abstract
Introduction The incidence of birth defects is 2-3% in the general population but it is increasing. An estimated 303,000 newborns die within 4 weeks of birth every year, worldwide, due to congenital anomalies. The objective of this study was to find out the prevalence of birth defects among newborns in a tertiary care centre. Methods A descriptive cross-sectional study was done in the Department of Obstetrics and Gynaecology and the Department of Paediatrics from 15 June 2016 and 14 June 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 142/077/078-IRC). Data of newborns were collected from the hospital records. Convenience sampling method was used. Point estimate and 99% Confidence Interval were calculated. Results Among 32,695 newborns, birth defects were seen in 169 (0.51%) (0.41-0.61, 99% Confidence Interval). The most common birth defect was musculoskeletal defects seen in 60 (35.50%) newborns followed by central nervous system defect seen in 30 (17.75%) newborns. Conclusions The prevalence of birth defects among newborns was lower than in other studies done in a similar setting. Keywords birth defect; congenital malformation; prevalence.
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Affiliation(s)
- Madan Khadka
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal,Correspondence: Dr Madan Khadka, Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal. , Phone: +977-9846044743
| | - Jyoti Agarwal
- Department of Paediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal
| | - Ramesh Shrestha
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal
| | - Dipti Das
- Department of Obstetrics and Gynaecology, B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal
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10
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Byrne JJ, Morgan JL, Twickler DM, McIntire DD, Dashe JS. Utility of follow-up standard sonography for fetal anomaly detection. Am J Obstet Gynecol 2020; 222:615.e1-615.e9. [PMID: 31930994 DOI: 10.1016/j.ajog.2020.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/24/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In 2014, the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Imaging Workshop consensus recommended that sonograms be offered routinely to all pregnant women. In the absence of another indication, this examination is recommended at 18-22 weeks of gestation. Studies of anomaly detection often focus on pregnancies at risk for anomalies and on the yield of detailed sonography, topics less applicable to counseling low-risk pregnancies about the benefits and limitations of standard sonography. The clinical utility of follow-up sonogram in low-risk pregnancies for the purpose of fetal anomaly detection has not been established. OBJECTIVE The objective of the study was to evaluate the utility of follow-up standard sonography for anomaly detection among low-risk pregnancies in a nonreferred population. STUDY DESIGN We performed a retrospective cohort study of singleton pregnancies that underwent standard sonography at 18-21 6/7 weeks of gestation from October 2011 through March 2018 with subsequent delivery of a live-born infant at our hospital. Pregnancies with indications for detailed sonography in our system were excluded to evaluate fetal anomalies first identified with standard sonography. Anomalies were categorized according to the European Registration of Congenital Anomalies and Twins (EUROCAT) system, with confirmation based on neonatal evaluation. Among those with no anomaly detected initially, we evaluated the rate of subsequent detection according to number of follow-up sonograms, gestational age at sonography, organ system(s) affected, and anomaly severity. Statistical analyses were performed using χ2 and a Mantel-Haenszel test. RESULTS Standard sonography was performed in 40,335 pregnancies at 18-21 6/7 weeks, and 11,770 (29%) had at least 1 follow-up sonogram, with a second follow-up sonogram in 3520 (9%). Major abnormalities were confirmed in 387 infants (1%), with 248 (64%) detected initially and 28 (7%) and 5 (1%) detected on the first and second follow-up sonograms. Detection of residual anomalies on follow-up sonograms was significantly lower than detection on the initial standard examination: 64% on initial examination, 45% for first follow-up, and 45% for second follow-up (P < .01). A larger number of follow-up examinations were required per anomalous fetus detected: 163 examinations per anomalous fetus detected initially, 420 per fetus detected at the first follow-up examination, and 705 per fetus detected at the second follow-up sonogram (P < .01). The number of follow-up examinations to detect each additional anomalous fetus was not affected by gestational age (P = .7). Survival to hospital discharge was significantly lower for fetuses with anomalies detected on initial (88%) than for fetuses with anomalies undetected until delivery (90 of 91, 99%; P < .002). CONCLUSION In a low-risk, nonreferred cohort with fetal anomaly prevalence of 1%, follow-up sonography resulted in detection of 45% of fetal anomalies that had not been identified during the initial standard sonogram. Significantly more follow-up sonograms were required to detect each additional anomalous fetus.
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Affiliation(s)
- John J Byrne
- Departments of Obstetrics and Gynecology and Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX.
| | - Jamie L Morgan
- Departments of Obstetrics and Gynecology and Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX
| | - Diane M Twickler
- Departments of Obstetrics and Gynecology and Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX
| | - Donald D McIntire
- Departments of Obstetrics and Gynecology and Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX
| | - Jodi S Dashe
- Departments of Obstetrics and Gynecology and Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX
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11
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Straub L, Huybrechts KF, Bateman BT, Mogun H, Gray KJ, Holmes LB, Hernandez-Diaz S. The Impact of Technology on the Diagnosis of Congenital Malformations. Am J Epidemiol 2019; 188:1892-1901. [PMID: 31241162 PMCID: PMC6825822 DOI: 10.1093/aje/kwz153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/29/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022] Open
Abstract
As technology improves and becomes more widely accessible, more subclinical congenital malformations are being detected. Using a cohort of 1,780,156 pregnant women and their offspring nested in the 2000-2013 US Medicaid Analytic eXtract, we contrasted time trends in malformations which do not necessarily present with overt clinical symptoms early in life and are more likely to be diagnosed via imaging (secundum atrial septal defect, patent ductus arteriosus, ventricular septal defect, pulmonary artery anomalies, pulmonary valve stenosis, hydrocephalus) with trends in malformations that are unlikely to escape clinical diagnosis (tetralogy of Fallot, coarctation of the aorta, transposition of the great vessels, hypoplastic left heart syndrome, oral cleft, abdominal wall defect). Logistic regression was used to account for trends in risk factors while assessing the impact of increased screening intensity. Prevalence of the diagnosis of secundum atrial septal defect rose from 2.3‰ in 2000-2001 to 7.5‰ in 2012-2013, of patent ductus arteriosus from 1.9‰ to 4.1‰, and of ventricular septal defect from 3.6‰ to 4.5‰. Trends were not explained by changes in the prevalence of risk factors but were attenuated when accounting for screening tests. The other malformations showed no temporal trends. Findings suggest that increased screening partially explains the observed increase in diagnosis of milder cases of select common malformations.
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Affiliation(s)
- Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathryn J Gray
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lewis B Holmes
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Medical Genetics Unit, MassGeneral Hospital for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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12
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Woodward M, Marko A, Galea S, Eagel B, Straus W. Varicella Virus Vaccine Live: A 22-Year Review of Postmarketing Safety Data. Open Forum Infect Dis 2019; 6:5544864. [PMID: 31392326 PMCID: PMC6685817 DOI: 10.1093/ofid/ofz295] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/15/2019] [Indexed: 01/13/2023] Open
Abstract
Background Varicella, a contagious infectious disease caused by varicella zoster virus (VZV), can result in hospitalization and, occasionally, death. Varicella virus vaccine live (VVVL [VARIVAX]) was introduced in the United States in 1995. Methods This comprehensive review of the VVVL safety profile is based on 22 years of postmarketing adverse event (AE) data received through spontaneous and noninterventional study reports submitted by health care providers and on a review of the published literature (cumulatively from March 17, 1995, through March 16, 2017, during which period >212 million doses were distributed globally). Results The VVVL safety profile was consistent with previous publications, with common AEs including varicella, rash, and pyrexia. AE reports have decreased over time, from ~500 per million doses in 1995 to ~40 per million doses in 2016; serious AEs comprise 0.8 reports per million doses. Secondary transmission was rare (8 confirmed cases); polymerase chain reaction analysis indicated that 38 of the 66 reported potential secondary transmission cases of varicella were attributable to wild-type VZV. The prevalence of major birth defects in the Pregnancy Registry was similar to that in the general US population. In total, 86 cases of death were reported after vaccination with VVVL; immunocompromised individuals appeared to be most at risk for a fatal varicella- or herpes zoster–related outcome. Conclusions This comprehensive 22-year review confirms the overall safety profile for VVVL, with no new safety concerns identified. Since VVVL’s introduction in 1995, notable declines in varicella cases and in varicella-related deaths have occurred compared with the prevaccination period.
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Affiliation(s)
| | - Ann Marko
- Merck & Co., Inc., Kenilworth, New Jersey
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13
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Huybrechts KF, Bateman BT, Hernández-Díaz S. Use of real-world evidence from healthcare utilization data to evaluate drug safety during pregnancy. Pharmacoepidemiol Drug Saf 2019; 28:906-922. [PMID: 31074570 PMCID: PMC6823105 DOI: 10.1002/pds.4789] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Because preapproval clinical trials typically exclude pregnant women, the evidence on drug safety during pregnancy required to inform drug labeling must come from postapproval controlled observational studies. Common designs have included pregnancy registries and case-control studies. Recently, pregnancy cohorts nested within healthcare utilization databases are increasingly being used. Despite clear advantages, these databases share some important limitations that may threaten the validity of studies emerging from them. METHODS This paper describes the distinctive methodological aspects of conducting drug safety studies in healthcare utilization databases with special emphasis on design and analytic approaches to minimize biases. RESULTS We describe considerations for study design, cohort definition, and follow-up. We then address issues related to exposure ascertainment based on prescription fills, including the importance of the etiologically relevant window and of properly accounting for preterm births. This is followed by a discussion of advantages and challenges when ascertaining maternal and infant outcomes based on secondary data. We then explore useful approaches to address confounding within the context of pregnancy research and of the potential for selection bias when restricting the cohort to live births. Finally, we consider issues related to external validity and statistical significance. The examples are mainly drawn from a pregnancy cohort nested in the Medicaid Analytic Extract. CONCLUSIONS The approaches presented provide guidance regarding the important methodological considerations that need to be attended to in order to generate valid, minimally biased risk when using large healthcare utilization databases for drug safety surveillance in pregnancy.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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14
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Abstract
Transamniotic stem cell therapy (TRASCET) is a novel prenatal therapeutic alternative for the treatment of congenital anomalies. It is based upon the principle of augmenting the pre-existing biological role of select populations of fetal stem cells for targeted therapeutic benefit. For example, amniotic fluid-derived mesenchymal stem cells (afMSCs) play an integral role in fetal tissue repair, validating the use of afMSCs in regenerative strategies. The simple intra-amniotic delivery of these cells in expanded numbers via TRASCET has been shown to promote the repair of and/or significantly ameliorate the effects associated with major congenital anomalies such as neural tube and abdominal wall defects. For example, TRASCET can induce partial or complete coverage of experimental spina bifida through the formation of a host-derived rudimentary neoskin, thus protecting the spinal cord from further damage secondary to amniotic fluid exposure. Furthermore, TRASCET can significantly reduce the bowel inflammation associated with gastroschisis, a common major abdominal wall defect. After intra-amniotic injection, donor stem cells home to the placenta and the fetal bone marrow in the spina bifida model, suggesting a role for hematogenous cell routing rather than direct defect seeding. Therefore, the expansion of TRASCET to congenital diseases without amniotic fluid exposure, such as congenital diaphragmatic hernia, as well as to maternal diseases, is currently under investigation in this emerging and evolving field of fetal stem cell therapy.
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15
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Marengo LK, Flood TJ, Ethen MK, Kirby RS, Fisher S, Copeland G, Meyer RE, Dunn J, Canfield MA, Anderson T, Yazzie D, Mai CT. Study of selected birth defects among American Indian/Alaska Native population: A multi-state population-based retrospective study, 1999-2007. Birth Defects Res 2018; 110:1412-1418. [PMID: 30403007 PMCID: PMC6425493 DOI: 10.1002/bdr2.1397] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/30/2018] [Accepted: 08/22/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Higher prevalence of selected birth defects has been reported among American Indian/Alaska Native (AI/AN) newborns. We examine whether known risk factors for birth defects explain the higher prevalence observed for selected birth defects among this population. METHODS Data from 12 population-based birth defects surveillance systems, covering a birth population of 11 million from 1999 to 2007, were used to examine prevalence of birth defects that have previously been reported to have elevated prevalence among AI/ANs. Prevalence ratios (PRs) were calculated for non-Hispanic AI/ANs and any AI/ANs (regardless of Hispanic ethnicity), adjusting for maternal age, education, diabetes, and smoking, as well as type of case-finding ascertainment surveillance system. RESULTS After adjustment, the birth prevalence of two of seven birth defects remained significantly elevated among AI/ANs compared to non-Hispanic whites (NHWs): anotia/microtia was almost threefold higher, and cleft lip +/- cleft palate was almost 70% higher compared to NHWs. Excluding AI/AN subjects who were also Hispanic had only a negligible impact on adjusted PRs. CONCLUSIONS Additional covariates accounted for some of the elevated birth defect prevalences among AI/ANs compared to NHWs. Exclusion of Hispanic ethnicity from the AI/AN category had little impact on birth defects prevalences in AI/ANs. NHWs serve as a viable comparison group for analysis. Birth defects among AI/ANs require additional scrutiny to identify modifiable risk and protective factors.
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Affiliation(s)
| | | | - Mary K. Ethen
- Texas Department of State Health Services, Austin, Texas
| | - Russell S. Kirby
- Department of Community and Family Health, University of South Florida, Tampa, Florida
| | - Sarah Fisher
- New York State Department of Health, Albany, New York
| | - Glenn Copeland
- Michigan Birth Defects Registry, Michigan Department of Community Health, Lansing, Michigan
| | - Robert E. Meyer
- North Carolina Birth Defects Monitoring Program, Raleigh, North Carolina
| | - Julie Dunn
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Tom Anderson
- Association of American Indian Physicians, Formerly Oklahoma Area Tribal Epidemiology Center and Southern Plains Tribal Health Board, Oklahoma City, Oklahoma
| | - Del Yazzie
- Navajo Epidemiology Center, Navajo Nation Department of Health, Window Rock, Arizona
| | - Cara T. Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Transamniotic stem cell therapy: a novel strategy for the prenatal management of congenital anomalies. Pediatr Res 2018; 83:241-248. [PMID: 28915235 DOI: 10.1038/pr.2017.228] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/28/2017] [Indexed: 12/24/2022]
Abstract
Transamniotic stem cell therapy, or TRASCET, is an emerging therapeutic concept for the management of congenital anomalies based on the augmentation of the biological role of select populations of stem cells that already occur in the amniotic fluid, for targeted therapeutic benefit. Amniotic fluid-derived mesenchymal stem cells (afMSCs) have a central role in the enhanced ability of the fetus to repair tissue damage. This germane recent finding constitutes the biological foundation for the use of afMSCs in TRASCET. It has been shown experimentally that simple intra-amniotic delivery of afMSCs in large numbers can either elicit the repair, or significantly mitigate the effects associated with major congenital anomalies by boosting the activity that these cells normally have. For example, TRASCET can induce partial or complete coverage of experimental spina bifida by promoting the local formation of host-derived skin, thus protecting the spinal cord from further damage. In another example, it can significantly alleviate the bowel damage associated with gastroschisis, one of the most common major abdominal wall defects. Other applications involving different congenital anomalies and/or other stem cells present in the amniotic fluid in diseased pregnancies are currently under investigation in this freshly evolving facet of fetal stem cell therapy.
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17
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Hinton CF, Siffel C, Correa A, Shapira SK. Survival Disparities Associated with Congenital Diaphragmatic Hernia. Birth Defects Res 2017; 109:816-823. [PMID: 28398654 DOI: 10.1002/bdr2.1015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/24/2017] [Accepted: 01/26/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND We assessed sociodemographic and clinical factors that are associated with survival among infants with congenital diaphragmatic hernia (CDH). METHODS Using data from the Metropolitan Atlanta Congenital Defects Program, we ascertained 150 infants born with CDH between 1979 and 2003 and followed via linkage with state vital records and the National Death Index. Kaplan-Meier survival probabilities and adjusted hazard ratios (HRs) were calculated for socioeconomic and clinical characteristics. RESULTS Survival increased from 40 to 62% over the study period. White infants born before 1988 were 2.9 times less likely to survive than those born after 1988. Black infants' survival did not show significant improvement after 1988. White infants' survival was not significantly affected by poverty, whereas black infants born in higher levels of poverty were 2.7 times less likely to survive than black infants born in lower levels of neighborhood poverty. White infants with multiple major birth defects were 2.6 times less likely to survive than those with CDH alone. The presence of multiple defects was not significantly associated with survival among black infants. CONCLUSIONS Survival among infants and children with CDH has improved over time among whites, but not among blacks. Poverty is associated with lower survival among blacks, but not among whites. The presence of multiple defects is associated with lower survival among whites, but not among blacks. The differential effects of poverty and race should be taken into account when studying disparities in health outcomes. Birth Defects Research 109:816-823, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Cynthia F Hinton
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Csaba Siffel
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,College of Allied Health Sciences, Augusta University, Augusta, Georgia
| | - Adolfo Correa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,University of Mississippi Medical Center, Jackson, Mississippi
| | - Stuart K Shapira
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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18
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Li R, Simmons KB, Bertolli J, Rivera-Garcia B, Cox S, Romero L, Koonin LM, Valencia-Prado M, Bracero N, Jamieson DJ, Barfield W, Moore CA, Mai CT, Korhonen LC, Frey MT, Perez-Padilla J, Torres-Muñoz R, Grosse SD. Cost-effectiveness of Increasing Access to Contraception during the Zika Virus Outbreak, Puerto Rico, 2016. Emerg Infect Dis 2017; 23:74-82. [PMID: 27805547 PMCID: PMC5176229 DOI: 10.3201/eid2301.161322] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We modeled the potential cost-effectiveness of increasing access to contraception in Puerto Rico during a Zika virus outbreak. The intervention is projected to cost an additional $33.5 million in family planning services and is likely to be cost-saving for the healthcare system overall. It could reduce Zika virus–related costs by $65.2 million ($2.8 million from less Zika virus testing and monitoring and $62.3 million from avoided costs of Zika virus–associated microcephaly [ZAM]). The estimates are influenced by the contraception methods used, the frequency of ZAM, and the lifetime incremental cost of ZAM. Accounting for unwanted pregnancies that are prevented, irrespective of Zika virus infection, an additional $40.4 million in medical costs would be avoided through the intervention. Increasing contraceptive access for women who want to delay or avoid pregnancy in Puerto Rico during a Zika virus outbreak can substantially reduce the number of cases of ZAM and healthcare costs.
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Mai CT, Isenburg J, Langlois PH, Alverson CJ, Gilboa SM, Rickard R, Canfield MA, Anjohrin SB, Lupo PJ, Jackson DR, Stallings EB, Scheuerle AE, Kirby RS. Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence. ACTA ACUST UNITED AC 2016; 103:972-93. [PMID: 26611917 DOI: 10.1002/bdra.23461] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Cara T Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer Isenburg
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,Carter Consulting, Inc., Atlanta, Georgia
| | - Peter H Langlois
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - C J Alverson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Russel Rickard
- National Birth Defects Prevention Network, Houston, Texas
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Suzanne B Anjohrin
- Florida Birth Defects Registry, Florida Department of Health, Tallahassee, Florida
| | - Philip J Lupo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Deanna R Jackson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin B Stallings
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,Carter Consulting, Inc., Atlanta, Georgia
| | - Angela E Scheuerle
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Russell S Kirby
- Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, Florida
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Atta CAM, Fiest KM, Frolkis AD, Jette N, Pringsheim T, St Germaine-Smith C, Rajapakse T, Kaplan GG, Metcalfe A. Global Birth Prevalence of Spina Bifida by Folic Acid Fortification Status: A Systematic Review and Meta-Analysis. Am J Public Health 2016; 106:e24-34. [PMID: 26562127 PMCID: PMC4695937 DOI: 10.2105/ajph.2015.302902] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Birth defects remain a significant source of worldwide morbidity and mortality. Strong scientific evidence shows that folic acid fortification of a region's food supply leads to a decrease in spina bifida (a birth defect of the spine). Still, many countries around the world have yet to approve mandatory fortification through government legislation. OBJECTIVES We sought to perform a systematic review and meta-analysis of period prevalence of spina bifida by folic acid fortification status, geographic region, and study population. SEARCH METHODS An expert research librarian used terms related to neural tube defects and epidemiology from primary research from 1985 to 2010 to search in EMBASE and MEDLINE. We searched the reference lists of included articles and key review articles identified by experts. SELECTION CRITERIA Inclusion criteria included studies in English or French reporting on prevalence published between January 1985 and December 2010 that (1) were primary research, (2) were population-based, and (3) reported a point or period prevalence estimate of spina bifida (i.e., prevalence estimate with confidence intervals or case numerator and population denominator). Two independent reviewers screened titles and abstracts for eligible articles, then 2 authors screened full texts in duplicate for final inclusion. Disagreements were resolved through consensus or a third party. DATA COLLECTION AND ANALYSIS We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, abstracting data related to case ascertainment, study population, folic acid fortification status, geographic region, and prevalence estimate independently and in duplicate. We extracted overall data and any subgroups reported by age, gender, time period, or type of spina bifida. We classified each period prevalence estimate as "mandatory" or "voluntary" folic acid fortification according to each country's folic acid fortification status at the time data were collected (as determined by a well-recognized fortification monitoring body, Food Fortification Initiative). We determined study quality on the basis of sample representativeness, standardization of data collection and birth defect assessment, and statistical analyses. We analyzed study-level period prevalence estimates by using a random effects model (α level of < 0.05) for all meta-analyses. We stratified pooled period prevalence estimates by birth population, fortification status, and continent. RESULTS Of 4078 studies identified, we included 179 studies in the systematic review and 123 in a meta-analysis. In studies of live births (LBs) alone, period prevalences of spina bifida were (1) lower in geographical regions with mandatory (33.86 per 100,000 LBs) versus voluntary (48.35 per 100,000 LBs) folic acid fortification, and (2) lower in studies of LBs, stillbirths, and terminations of pregnancy in regions with mandatory (35.22 per 100,000 LBs) versus voluntary (52.29 per 100,000 LBs) fortification. In LBs, stillbirths, and terminations of pregnancy studies, the lowest pooled prevalence estimate was in North America (38.70 per 100,000). Case ascertainment, surveillance methods, and reporting varied across these population-based studies. CONCLUSIONS Mandatory legislation enforcing folic acid fortification of the food supply lags behind the evidence, particularly in Asian and European countries. This extensive literature review shows that spina bifida is significantly more common in world regions without government legislation regulating full-coverage folic acid fortification of the food supply (i.e., Asia, Europe) and that mandatory folic acid fortification resulted in a lower prevalence of spina bifida regardless of the type of birth cohort. African data were scarce, but needed, as many African nations are beginning to adopt folic acid legislation.
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Affiliation(s)
- Callie A M Atta
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Kirsten M Fiest
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Alexandra D Frolkis
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Nathalie Jette
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Tamara Pringsheim
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Christine St Germaine-Smith
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Thilinie Rajapakse
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Gilaad G Kaplan
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Amy Metcalfe
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
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McNeese ML, Selwyn BJ, Duong H, Canfield M, Waller DK. The association between maternal parity and birth defects. ACTA ACUST UNITED AC 2015; 103:144-56. [PMID: 25721953 DOI: 10.1002/bdra.23360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 12/15/2014] [Accepted: 01/20/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Previous studies observed that first birth is associated with an increased risk of some categories of birth defects. However, multiple statistical tests were conducted and it was unclear which of these associations would be replicated in a larger study. We used a large database to assess the association between maternal parity and 65 birth defects including birth defects that have not been previously studied. METHODS Using data from the Texas Birth Defects Registry for years 1999-2009, the risk of a birth defect occurring in a first, third, or fourth or higher birth was compared to the risk of a birth defect occurring in a second birth. RESULTS Women having their first birth had significantly increased odds of having an infant with 24 of 65 categories of birth defects when compared to women having their second birth. We also observed associations between first birth and an increased risk of five birth defects not previously reported (small penis, preaxial polydactyly, anomalies of the thoracic vertebrae, anomalies of the lumbar vertebrae, and sacroccygeal anomalies). Women having their third or fourth or higher birth had significantly increased odds of giving birth to infants with five of 65 birth defects when compared to second births. CONCLUSIONS Our observations regarding the categories of birth defects that were associated with first births were highly consistent with observations from two previous studies. Research into biological, behavioral, and environmental factors that may increase the risk of specific birth defects among first births is needed to further explore these associations.
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Affiliation(s)
- Melanie L McNeese
- Department of Epidemiology, The University of Texas School of Public Health, Houston, Texas
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22
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Westerfield LE, Stover SR, Mathur VS, Nassef SA, Carter TG, Yang Y, Eng CM, Van den Veyver IB. Reproductive genetic counseling challenges associated with diagnostic exome sequencing in a large academic private reproductive genetic counseling practice. Prenat Diagn 2015; 35:1022-9. [PMID: 26275793 DOI: 10.1002/pd.4674] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/09/2015] [Accepted: 08/10/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Diagnostic whole exome sequencing (WES) is rapidly entering clinical genetics, but experience with reproductive genetic counseling aspects is limited. The purpose of this study was to retrospectively review and report on our experience with preconception and prenatal genetic counseling for diagnostic WES. METHOD We performed a retrospective chart review over 34 months in a large private prenatal genetic counseling practice and analyzed data for referral indications, findings, and results of genetic counseling related to diagnostic WES. RESULTS Ten of 14 patients counseled about diagnostic WES for ongoing pregnancies pursued the test, resulting in identification of three pathogenic variants (30%). Five of 15 patients seeking counseling about familial WES results in an affected proband pursued prenatal diagnosis, resulting in identification of one affected fetus and five unaffected fetuses. We experienced challenges related to complexity and uncertainty of results, turnaround time, cost and insurance overage, and multidisciplinary fetal care coordination. CONCLUSION Despite having experienced complexity and identified challenges of the reproductive genetic counseling, availability of diagnostic WES contributed important information that aided in prenatal care planning and decision-making. Future enhanced provider education and larger studies to systematically study the integration of WES in reproductive genetic counseling and prenatal care will be important.
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Affiliation(s)
- Lauren E Westerfield
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Samantha R Stover
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Veena S Mathur
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Salma A Nassef
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Tiffiney G Carter
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Yaping Yang
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.,Baylor Miraca Genetics Laboratories, Houston, TX, USA
| | - Christine M Eng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.,Baylor Miraca Genetics Laboratories, Houston, TX, USA
| | - Ignatia B Van den Veyver
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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23
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Tinker SC, Carmichael SL, Anderka M, Browne ML, Caspers Conway KM, Meyer RE, Nembhard WN, Olney RS, Reefhuis J. Next steps for birth defects research and prevention: The birth defects study to evaluate pregnancy exposures (BD-STEPS). ACTA ACUST UNITED AC 2015; 103:733-40. [PMID: 25846741 DOI: 10.1002/bdra.23373] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/22/2015] [Accepted: 03/02/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS) is a population-based, multi-Center case-control study of modifiable risk factors for selected birth defects in the United States. BD-STEPS is the second major research effort of the Centers for Birth Defects Research and Prevention, which extends and expands the initial research effort, the National Birth Defects Prevention Study (NBDPS). METHODS BD-STEPS focuses on 17 categories of structural birth defects selected based on severity, prevalence, consistent ascertainment, and previous findings that warrant additional research. Cases are identified through existing birth defects surveillance programs; controls are from vital records or birth hospital logs from the same catchment area. BD-STEPS uses a standardized computer-assisted telephone interview to collect information from case and control mothers on topics including demographics, health conditions, and medication use. Following the maternal interview, selected Centers request permission to sample residual newborn screening blood spots from state repositories for genetic analyses. New components planned for BD-STEPS include linkages with external datasets and use of online questionnaires to collect in-depth information on selected exposures. RESULTS BD-STEPS extends NBDPS by continuing to collect data on many exposures that were assessed in NBDPS, allowing data from both studies to be combined and providing an unprecedented sample size to analyze rare exposures. BD-STEPS expands upon NBDPS by collecting more detailed information on existing exposures as well as new exposures. CONCLUSION The goal of BD-STEPS is to provide women and healthcare providers with information they need to make decisions to promote the healthiest pregnancy possible.
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Affiliation(s)
- Sarah C Tinker
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Marlene Anderka
- Center for Birth Defects Research and Prevention at the Massachusetts Department of Public Health, Boston, Massachusetts
| | - Marilyn L Browne
- Congenital Malformations Registry, New York State Department of Health, Albany, New York
| | | | - Robert E Meyer
- Birth Defects Monitoring Program, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh, North Carolina
| | - Wendy N Nembhard
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Richard S Olney
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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24
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Tennis P, Chan KA, Curkendall SM, Li DK, Mines D, Peterson C, Andrews EB, Calingaert B, Chen HY, Deshpande G, Everage N, Holick CN, Meyer NM, Nkhoma ET, Quinn S, Rothman KJ, Esposito DB. Topiramate use during pregnancy and major congenital malformations in multiple populations. ACTA ACUST UNITED AC 2015; 103:269-75. [PMID: 25776342 DOI: 10.1002/bdra.23357] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/06/2015] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND We measured birth prevalence of major congenital malformations (MCMs) after topiramate use during pregnancy to screen for a possible signal of increased risk. METHODS Using four healthcare databases, we identified three cohorts of pregnant women: cohort 1, used topiramate during the first trimester; cohort 2, used topiramate or another antiepileptic drug previously but not during pregnancy; and cohort 3, were pregnant and did not use topiramate but had indications for use individually matched to those of users. Cohort 1 was compared with cohorts 2 and 3. MCMs were a code for any major congenital malformation dated within 30 days of the delivery date on the mother's claims or within 365 days after infant birth date, excluding a genetic or syndromic basis, and with procedure or healthcare usage consistent with the MCM diagnosis code in the 365 days after infant birth. RESULTS Of the 10 specific common MCMs evaluated, 1 (conotruncal heart defects) had a prevalence ratio greater than 1.5 for both primary comparisons, and 4 (ventricular septal defect, atrial septal defect, hypospadias, coarctation of the aorta) had a prevalence ratio greater than 1.5 for one of the two comparisons. Following screening of organ systems with elevated MCMs, the prevalence ratio was greater than 1.5 for patent ductus arteriosus in both comparisons and for obstructive genitourinary defects in one comparison. CONCLUSION To evaluate a large number of MCMs across many pregnancies, we used crude methods for detecting potential signals. Therefore, these results should be seen as potential signals, not causal.
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Affiliation(s)
- Patricia Tennis
- Pharmacoepidemiology and Risk Management, RTI Health Solutions, RTI International, Research Triangle Park, North Carolina
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25
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Rasmussen SA, Hernandez-Diaz S, Abdul-Rahman OA, Sahin L, Petrie CR, Keppler-Noreuil KM, Frey SE, Mason RM, Nesin M, Carey JC. Assessment of congenital anomalies in infants born to pregnant women enrolled in clinical trials. Clin Infect Dis 2014; 59 Suppl 7:S428-36. [PMID: 25425721 PMCID: PMC4303054 DOI: 10.1093/cid/ciu738] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In 2011 and 2012, the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases, National Institutes of Health, held a series of meetings to provide guidance to investigators regarding study design of clinical trials of vaccines and antimicrobial medications that enroll pregnant women. Assessment of congenital anomalies among infants born to women enrolled in these trials was recognized as a challenging issue, and a workgroup with expertise in epidemiology, pediatrics, genetics, dysmorphology, clinical trials, and infectious diseases was formed to address this issue. The workgroup considered 3 approaches for congenital anomalies assessment that have been developed for use in other studies: (1) maternal report combined with medical records review, (2) standardized photographic assessment and physical examination by a health professional who has received specific training in congenital anomalies, and (3) standardized physical examination by a trained dysmorphologist (combined with maternal interview and medical records review). The strengths and limitations of these approaches were discussed with regard to their use in clinical trials. None of the approaches was deemed appropriate for use in all clinical trials. Instead, the workgroup acknowledged that decisions regarding the optimal method of assessment of congenital anomalies will likely vary depending on the clinical trial, its setting, and the agent under study; in some cases, a combination of approaches may be appropriate. The workgroup recognized the need for more research on approaches to the assessment of congenital anomalies to better guide investigators in optimal design of clinical trials that enroll pregnant women.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - John C. Carey
- University of Utah School of Medicine, Salt Lake City
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Mburia-Mwalili A, Yang W. Birth Defects Surveillance in the United States: Challenges and Implications of International Classification of Diseases, Tenth Revision, Clinical Modification Implementation. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:212874. [PMID: 27351001 PMCID: PMC4897534 DOI: 10.1155/2014/212874] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/21/2014] [Indexed: 11/29/2022]
Abstract
Major birth defects are an important public health issue because they are the leading cause of infant mortality. The most common birth defects are congenital heart defects, neural tube defects, and Down syndrome. Birth defects surveillance guides policy development and provides data for prevalence estimates, epidemiologic research, planning, and prevention. Several factors influence birth defects surveillance in the United States of America (USA). These include case ascertainment methods, pregnancy outcomes, and nomenclature used for coding birth defects. In 2015, the nomenclature used by most birth defects surveillance programs in USA will change from ICD-9-CM to ICD-10-CM. This change will have implications on birth defects surveillance, prevalence estimates, and tracking birth defects trends.
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Affiliation(s)
- Adel Mburia-Mwalili
- Environmental Sciences and Health Graduate Program, University of Nevada, Reno, NV 89557, USA
| | - Wei Yang
- Environmental Sciences and Health Graduate Program, University of Nevada, Reno, NV 89557, USA
- School of Community Health Sciences, University of Nevada, Reno, NV 89557, USA
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Mai CT, Kucik JE, Isenburg J, Feldkamp ML, Marengo LK, Bugenske EM, Thorpe PG, Jackson JM, Correa A, Rickard R, Alverson CJ, Kirby RS. Selected birth defects data from population-based birth defects surveillance programs in the United States, 2006 to 2010: featuring trisomy conditions. ACTA ACUST UNITED AC 2014; 97:709-25. [PMID: 24265125 DOI: 10.1002/bdra.23198] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 09/21/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Cara T Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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28
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Parker SE, Yazdy MM, Mitchell AA, Demmer LA, Werler MM. A description of spina bifida cases and co-occurring malformations, 1976-2011. Am J Med Genet A 2013; 164A:432-40. [PMID: 24357196 DOI: 10.1002/ajmg.a.36324] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 10/06/2013] [Indexed: 11/06/2022]
Abstract
Mandatory folic acid fortification in the United States corresponded with a decline in the prevalence of spina bifida (SB). The aim of this study was to describe the epidemiologic characteristics of isolated versus non-isolated SB cases in both pre- and post-fortification periods. SB cases in the Slone Epidemiology Center Birth Defects Study from 1976 to 2011 without chromosomal anomalies and syndromes were included. A maternal interview, conducted within 6 months of delivery, collected information on demographics, reproductive history, diet, and supplement use. Daily folic acid intake in the periconceptional period was calculated using both dietary and supplement information and categorized as low intake (<400 µg/day) or high intake (≥400 µg/day). SB cases (n = 1170) were classified as isolated (80.4%) or non-isolated (19.1%). Non-isolated cases were further divided into subgroups based on accompanying major malformations (midline, renal, genital, heart, laterality). Compared to non-isolated cases, isolated cases were more likely to be white, non-Hispanic and have more than 12 years of education. Cases in the renal, genital, and heart subgroups had the lowest proportions of mothers with a high folic acid intake. The change from pre- to post-fortification was associated with a decrease in the proportion of isolated cases from 83% to 72%, though in both periods isolated cases were more likely to be female and their mothers were more likely to have high folic acid intake. These findings highlight the importance of separating isolated and non-isolated cases in etiologic research of SB.
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Affiliation(s)
- Samantha E Parker
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
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29
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Jackson JM, Crider KS, Cragan JD, Rasmussen SA, Olney RS. Frequency of prenatal cytogenetic diagnosis and pregnancy outcomes by maternal race-ethnicity, and the effect on the prevalence of trisomy 21, Metropolitan Atlanta, 1996-2005. Am J Med Genet A 2013; 164A:70-6. [PMID: 24273106 DOI: 10.1002/ajmg.a.36247] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 08/12/2013] [Indexed: 11/11/2022]
Abstract
The prevalence of trisomy 21 has been reported to differ by race-ethnicity, however, the results are inconsistent and the cause of the differences is unknown. Using data from 1996 to 2005 from the Metropolitan Atlanta Congenital Defects Program (MACDP), we analyzed the use of prenatal cytogenetic testing and the subsequent use of elective termination among pregnancies affected with any MACDP-eligible birth defect and trisomy 21, by maternal race-ethnicity. We then examined whether these factors could explain the observed differences in the prevalence of trisomy 21 among race-ethnicity groups. Among all pregnancies with birth defects, prenatal cytogenetic testing as well as elective terminations after an abnormal prenatal cytogenetic test result were observed less frequently among Hispanic women than among non-Hispanic white women (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.56-0.78, respectively). In pregnancies affected by trisomy 21, both the Hispanic and the non-Hispanic black populations had more live births (89.5% and 77.8%, respectively) and fewer elective terminations (5.7% and 15.2%, respectively) compared to the non-Hispanic white population (63.0% live births, 32.3% elective terminations). After adjusting for elective terminations, non-Hispanic white mothers had a higher live birth prevalence of trisomy 21 compared to non-Hispanic black (OR 0.64, 95% CI 0.54-0.76) or Hispanic mothers (OR 0.69, 95% CI 0.55-0.86). Overall, our data suggest that factors associated with decisions made about the use of prenatal testing, and about pregnancy management after testing, might play a large role in the race-ethnicity differences observed in the live birth prevalence of trisomy 21.
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Affiliation(s)
- Jodi M Jackson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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30
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Tinker SC, Devine O, Mai C, Hamner HC, Reefhuis J, Gilboa SM, Dowling NF, Honein MA. Estimate of the potential impact of folic acid fortification of corn masa flour on the prevention of neural tube defects. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2013; 97:649-57. [PMID: 24142499 PMCID: PMC4515957 DOI: 10.1002/bdra.23158] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hispanics in the US have a higher prevalence of neural tube defect (NTD) -affected pregnancies than non-Hispanic whites, and lower median total folic acid (FA) intake. FA fortification of corn masa flour (CMF) is a policy-level intervention for NTD prevention; however, the impact on NTD prevalence has not been estimated. METHODS We developed a model to estimate the percentage reduction in prevalence of spina bifida and anencephaly (NTDs) that could occur with FA fortification of CMF. Model inputs included estimates of the percentage reduction in United States NTD prevalence attributed to FA fortification of enriched cereal grain products (1995-1996 vs. 1998-2002), the increase in median FA intake after enriched cereal grain product fortification, and the estimated increase in median FA intake that could occur with CMF fortification at the same level as enriched cereal grain products (140 μg/100 g). We used Monte Carlo simulation to quantify uncertainty. We stratified analyses by racial/ethnic group and rounded results to the nearest 10. RESULTS We estimated CMF fortification could prevent 30 Hispanic infants from having spina bifida (95% uncertainty interval: 0, 80) and 10 infants from having anencephaly (95% uncertainty interval: 0, 40) annually. The estimated impact among non-Hispanic whites and blacks was smaller. CONCLUSION CMF fortification with FA could prevent from 0 to 120 infants, with the most likely value of approximately 40, from having spina bifida or anencephaly among Hispanics, the population most likely to benefit from the proposed intervention. While this estimated reduction is unlikely to be discernible using current birth defect surveillance methods, it still suggests an important benefit to the target population.
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Affiliation(s)
- Sarah C. Tinker
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Owen Devine
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Cara Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Heather C. Hamner
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Suzanne M. Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Nicole F. Dowling
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Margaret A. Honein
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Sanchis Calvo A, Roselló-Sastre E, Marcos Puig B, Balanzá Chancosa R, Pérez Ebri ML, Alcover Barrachina I, Camarasa Lillo N, Bermejo-Sánchez E, Escandón Alvarez J. [Evolution of the frequency of congenital defects in newborn infants and fetuses from terminations of pregnancy after prenatal diagnosis in the period 1982-2009]. Med Clin (Barc) 2013; 141:152-8. [PMID: 22841468 DOI: 10.1016/j.medcli.2012.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 05/03/2012] [Accepted: 05/10/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The study of congenital defects (CD) must include termination of pregnancy (TOP) for CD and evaluate risk factors that modify their frequency. PATIENTS AND METHODS Consecutive series of 517 newborn and 202 TOP with CD among 38,191 childbirths, between 1982-2009 years. RESULTS The mean frequency for newborns with CD is 13.54‰ and for newborn and TOP with CD is 18.73‰. Single CD are 61.12% in newborns and 52.17% in TOP. The 18.37% of CD in newborn and 40.58% of TOP are syndromic. Mean gestational age for TOP is 17.92 weeks. Overall frequency of anencephaly is 2.62‰ for newborns and 6.77 for 10,000 for newborns and TOP. Spina bifida is 3.14 for 10,000 newborns and 5.99 for 10,000 newborns and TOP. Overall frequency of Down syndrome (DS) is 10.74 for 10,000 newborns and 22.14 for 10,000 newborns and TOP. The percentage of foreign mothers was 35.9% in 2009 and the mean maternal age significantly increased in this period. CONCLUSION We observe a significant decrease of CD in newborns but not in their conception. We have not detected primary prevention for neural tube defects. The decrease in DS in newborns is not statistically relevant but ethnic diversity and maternal aging may be modifying the frequency. The 53% of CD were TOP in the period 2007-2009. It is mandatory a complete study for CD in TOP in order to offer serious reproductive counselling.
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Bjornard K, Riehle-Colarusso T, Gilboa SM, Correa A. Patterns in the prevalence of congenital heart defects, metropolitan Atlanta, 1978 to 2005. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2013; 97:87-94. [PMID: 23404870 DOI: 10.1002/bdra.23111] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 11/30/2012] [Accepted: 12/04/2012] [Indexed: 07/13/2024]
Abstract
BACKGROUND Knowledge of patterns in prevalence of congenital heart defects (CHDs) is important for clinical care, etiologic research, and prevention. We evaluated temporal and racial/ethnic trends in the birth prevalence of CHDs in metropolitan Atlanta from 1978 to 2005. METHODS Cases of CHDs were obtained from the Metropolitan Atlanta Congenital Defects Program among live born infants, stillborn infants, and pregnancy terminations of at least 20 weeks gestation. We calculated birth prevalence per 10,000 live births and used joinpoint regression analysis to calculate the average annual percent change for total CHDs and for 23 specific subtypes in the total population and among whites and blacks. To evaluate racial/ethnic variations, we calculated prevalence ratios among blacks and Hispanics compared with whites. RESULTS Between 1978 and 2005, 7301 infants and fetuses with major structural CHDs were ascertained among 1,079,062 live births (67.7 per 10,000). The prevalence of all CHDs in aggregate increased from 50.3 per 10,000 in 1978-1983 to 86.4 per 10,000 in 2000-2005. The prevalence of septal defects and vascular rings increased and the prevalence of tricuspid atresia decreased, while other CHD prevalences were stable. Racial/ethnic prevalence differences were found for all CHDs combined and muscular ventricular septal defects, aortic stenosis, and atrioventricular septal defects. CONCLUSIONS The prevalence of total CHDs, primarily common, less severe types, are increasing, with some racial/ethnic differences. Further studies could clarify the possible reasons for such variations including differences in ascertainment, risk factors, or susceptibility.
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Affiliation(s)
- Kari Bjornard
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Kucik JE, Shin M, Siffel C, Marengo L, Correa A. Trends in survival among children with Down syndrome in 10 regions of the United States. Pediatrics 2013; 131:e27-36. [PMID: 23248222 PMCID: PMC4547551 DOI: 10.1542/peds.2012-1616] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study examined changes in survival among children with Down syndrome (DS) by race/ethnicity in 10 regions of the United States. A retrospective cohort study was conducted on 16,506 infants with DS delivered during 1983-2003 and identified by 10 US birth defects monitoring programs. Kaplan-Meier survival probabilities were estimated by select demographic and clinical characteristics. Adjusted hazard ratios (aHR) were estimated for maternal and infant characteristics by using Cox proportional hazard models. RESULTS The overall 1-month and 1-, 5-, and 20-year survival probabilities were 98%, 93%, 91%, and 88%, respectively. Over the study period, neonatal survival did not improve appreciably, but survival at all other ages improved modestly. Infants of very low birth weight had 24 times the risk of dying in the neonatal period compared with infants of normal birth weight (aHR 23.8; 95% confidence interval [CI] 18.4-30.7). Presence of a heart defect increased the risk of death in the postneonatal period nearly fivefold (aHR 4.6; 95% CI 3.9-5.4) and continued to be one of the most significant predictors of mortality through to age 20. The postneonatal aHR among non-Hispanic blacks was 1.4 (95% CI 1.2-1.8) compared with non-Hispanic whites and remained elevated by age 10 (2.0; 95% CI 1.0-4.0). CONCLUSIONS The survival of children born with DS has improved and racial disparities in infant survival have narrowed. However, compared with non-Hispanic white children, non-Hispanic black children have lower survival beyond infancy. Congenital heart defects are a significant risk factor for mortality through age twenty.
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Affiliation(s)
- James E. Kucik
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mikyong Shin
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Division of Environmental Hazards & Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia,Research Triangle Institute International, Atlanta, Georgia
| | - Csaba Siffel
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Marengo
- Texas Department of State Health Services, Austin, Texas
| | - Adolfo Correa
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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Johnson CY, Honein MA, Dana Flanders W, Howards PP, Oakley GP, Rasmussen SA. Pregnancy termination following prenatal diagnosis of anencephaly or spina bifida: a systematic review of the literature. ACTA ACUST UNITED AC 2012; 94:857-63. [PMID: 23097374 DOI: 10.1002/bdra.23086] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/28/2012] [Accepted: 09/04/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND In regions where prenatal screening for anencephaly and spina bifida is widespread, many cases of these defects are diagnosed prenatally. The purpose of this study was to estimate the frequency of termination of pregnancy (TOP) following prenatal diagnosis of anencephaly or spina bifida and to investigate factors associated with TOP that might lead to selection bias in epidemiologic studies. METHODS We included articles indexed in Medline or Embase between 1990 and May 2012 reporting the frequency of TOP following prenatal diagnosis of anencephaly or spina bifida with English-language abstracts, 20 or more prenatally diagnosed cases, and at least half of the study years in 1990 or later. We summarized the frequency of TOP across studies using random-effects metaanalysis and stratified results by fetal and study characteristics. RESULTS Among the 17 studies identified, 9 included anencephaly and 15 included spina bifida. Nine were from Europe, six were from North America, and one each was from South America and Asia. The overall frequency of TOP following prenatal diagnosis was 83% for anencephaly (range, 59-100%) and 63% for spina bifida (range, 31-97%). There were insufficient data to stratify the results for anencephaly; TOP for spina bifida was more common when the prenatal diagnosis occurred at less than 24 weeks' gestation, with defects of greater severity, and in Europe versus North America. CONCLUSIONS Because underascertainment of birth defects might be more likely when the pregnancy ends in TOP and TOP is associated with fetal characteristics, selection bias is possible in epidemiologic studies of anencephaly or spina bifida.
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Affiliation(s)
- Candice Y Johnson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Broussard CS, Gilboa SM, Lee KA, Oster M, Petrini JR, Honein MA. Racial/ethnic differences in infant mortality attributable to birth defects by gestational age. Pediatrics 2012; 130:e518-27. [PMID: 22908111 PMCID: PMC4605418 DOI: 10.1542/peds.2011-3475] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Birth defects are a leading cause of infant mortality in the United States. Previous reports have highlighted black-white differences in overall infant mortality and infant mortality attributable to birth defects (IMBD). We evaluated the impact of gestational age on US racial/ethnic differences in IMBD. METHODS We estimated the rate of IMBD as the underlying cause of death using the period-linked birth/infant death data for US residents for January 2003 to December 2006. We excluded infants with missing gestational age, implausible values based on Alexander's index of birth weight for gestational age norms, or gestational ages <20 weeks or >44 weeks; we categorized gestational age into 3 groups: 20 to 33, 34 to 36, and 37 to 44 weeks. Using Poisson regression, we compared neonatal and postneonatal IMBD for infants of non-Hispanic black and Hispanic mothers with that for infants of non-Hispanic white mothers stratified by gestational age. RESULTS IMBD occurred in 12.2 per 10 000 live births. Among infants delivered at 37 to 44 weeks, blacks (and Hispanics, to a lesser degree) had significantly higher neonatal and postneonatal IMBD than whites; however, among infants delivered at 20 to 33 or 34 to 36 weeks, neonatal (but not postneonatal) IMBD was significantly lower among blacks compared with whites. CONCLUSIONS Racial/ethnic differences in IMBD were not explained in these data by differences in gestational age. Further investigation should include an assessment of possible racial/ethnic differences in severity and/or access to timely diagnosis and management of birth defects.
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Affiliation(s)
- Cheryl S. Broussard
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M. Gilboa
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kyung A. Lee
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Northrop Grumman Information Systems, Atlanta, Georgia
| | - Matthew Oster
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University
| | | | - Margaret A. Honein
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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Kucik JE, Alverson CJ, Gilboa SM, Correa A. Racial/ethnic variations in the prevalence of selected major birth defects, metropolitan Atlanta, 1994-2005. Public Health Rep 2012; 127:52-61. [PMID: 22298922 DOI: 10.1177/003335491212700106] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Birth defects are the leading cause of infant mortality and are responsible for substantial child and adult morbidity. Documenting the variation in prevalence of birth defects among racial/ethnic subpopulations is critical for assessing possible variations in diagnosis, case ascertainment, or risk factors among such groups. METHODS We used data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects registry with active case ascertainment. We estimated the racial/ethnic variation in prevalence of 46 selected major birth defects among live births, stillbirths, and pregnancy terminations at >20 weeks gestation among mothers residing in the five central counties of metropolitan Atlanta between 1994 and 2005, adjusting for infant sex, maternal age, gravidity, and socioeconomic status (SES). We also explored SES as a potential effect measure modifier. RESULTS Compared with births to non-Hispanic white women, births to non-Hispanic black women had a significantly higher prevalence of five birth defects and a significantly lower prevalence of 10 birth defects, while births to Hispanic women had a significantly higher prevalence of four birth defects and a significantly lower prevalence of six birth defects. The racial/ethnic disparities in the prevalence of some defects varied by SES, but no clear pattern emerged. CONCLUSIONS Racial/ethnic disparities were suggested in 57% of included birth defects. Disparities in the prevalence of birth defects may result from different underlying genetic susceptibilities; exposure to risk factors; or variability in case diagnosis, ascertainment, or reporting among the subpopulations examined. Policies that improve early diagnosis of birth defects could reduce associated morbidity and mortality.
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Affiliation(s)
- James E Kucik
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30333, USA.
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Duong HT, Hoyt AT, Carmichael SL, Gilboa SM, Canfield MA, Case A, McNeese ML, Waller DK. Is maternal parity an independent risk factor for birth defects? ACTA ACUST UNITED AC 2012; 94:230-6. [PMID: 22371332 DOI: 10.1002/bdra.22889] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 12/10/2011] [Accepted: 12/13/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although associations between maternal parity and birth defects have been observed previously, few studies have focused on the possibility that parity is an independent risk factor for birth defects. We investigated the relation between levels of parity and a range of birth defects, adjusting each defect group for the same covariates. METHODS We included infants who had an estimated delivery date between 1997 and 2007 and participated in the National Birth Defects Prevention Study, a multisite case-control study. Cases included infants or fetuses belonging to 38 phenotypes of birth defects (n = 17,908), and controls included infants who were unaffected by a major birth defect (n = 7173). Odds ratios (ORs) were adjusted for 12 covariates using logistic regression. RESULTS Compared with primiparous mothers, nulliparous mothers were more likely to have infants with amniotic band sequence, hydrocephaly, esophageal atresia, hypospadias, limb reduction deficiencies, diaphragmatic hernia, omphalocele, gastroschisis, tetralogy of Fallot, and septal cardiac defects, with significant ORs (1.2 to 2.3). Compared with primiparous mothers, multiparous mothers had a significantly increased risk of omphalocele, with an OR of 1.5, but had significantly decreased risk of hypospadias and limb reduction deficiencies, with ORs of 0.77 and 0.77. CONCLUSIONS Nulliparity was associated with an increased risk of specific phenotypes of birth defects. Most of the phenotypes associated with nulliparity in this study were consistent with those identified by previous studies. Research into biologic or environmental factors that are associated with nulliparity may be helpful in explaining some or all of these associations.
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Affiliation(s)
- Hao T Duong
- The University of Texas, Houston Health Science Center, School of Public Health, USA
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Hartman RJ, Rasmussen SA, Botto LD, Riehle-Colarusso T, Martin CL, Cragan JD, Shin M, Correa A. The contribution of chromosomal abnormalities to congenital heart defects: a population-based study. Pediatr Cardiol 2011; 32:1147-57. [PMID: 21728077 DOI: 10.1007/s00246-011-0034-5] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 06/15/2011] [Indexed: 11/28/2022]
Abstract
We aimed to assess the frequency of chromosomal abnormalities among infants with congenital heart defects (CHDs) in an analysis of population-based surveillance data. We reviewed data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth-defects surveillance system, to assess the frequency of chromosomal abnormalities among live-born infants and fetal deaths with CHDs delivered from January 1, 1994, to December 31, 2005. Among 4430 infants with CHDs, 547 (12.3%) had a chromosomal abnormality. CHDs most likely to be associated with a chromosomal abnormality were interrupted aortic arch (type B and not otherwise specified; 69.2%), atrioventricular septal defect (67.2%), and double-outlet right ventricle (33.3%). The most common chromosomal abnormalities observed were trisomy 21 (52.8%), trisomy 18 (12.8%), 22q11.2 deletion (12.2%), and trisomy 13 (5.7%). In conclusion, in our study, approximately 1 in 8 infants with a CHD had a chromosomal abnormality. Clinicians should have a low threshold at which to obtain testing for chromosomal abnormalities in infants with CHDs, especially those with certain types of CHDs. Use of new technologies that have become recently available (e.g., chromosomal microarray) may increase the identified contribution of chromosomal abnormalities even further.
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Affiliation(s)
- Robert J Hartman
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-86, Atlanta, GA, USA
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The association between mountaintop mining and birth defects among live births in central Appalachia, 1996–2003. ENVIRONMENTAL RESEARCH 2011; 111:838-46. [PMID: 21689813 DOI: 10.1016/j.envres.2011.05.019] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 05/09/2011] [Accepted: 05/26/2011] [Indexed: 01/09/2023]
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Parks SE, Canfield MA, Ramadhani TA. Importance of including all pregnancy outcomes to reduce bias in epidemiologic studies of neural tube defects--Texas, 1999 to 2005. ACTA ACUST UNITED AC 2011; 91:185-91. [PMID: 21290567 DOI: 10.1002/bdra.20772] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 11/01/2010] [Accepted: 11/15/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Neural tube defects (NTDs) often result in fetal death or elective termination; therefore, not all cases are captured in typical hospital-based surveillance. We examined sociodemographic differences among pregnancy outcomes to assess sources of bias in NTD surveillance and research. METHODS We used 1999 to 2005 Texas Birth Defects Registry data, a population-based active surveillance system, and calculated crude and adjusted prevalence ratios (aPRs). We then assessed the association of anencephaly and spina bifida with the selected characteristics, stratified by pregnancy outcomes (fetal death, elective termination, or live birth). RESULTS Data were available for 1852 NTD cases (anencephaly, 677; spina bifida, 954; and encephalocele, 221), resulting in 1211 live births, 236 fetal deaths, and 405 elective terminations. For both anencephaly and spina bifida, a significant excess of Hispanic mothers was observed among live-birth cases (aPRs=1.2-2.4), but not among mothers experiencing other pregnancy outcomes. Mothers of anencephaly cases resulting in a non-live birth were more likely to be adolescents (aPRs=2.4-2.7 for ages<20 years old vs. ages 25-29 years old), but this pattern was not observed for live-birth cases. A trend of increasing anencephaly risk with increasing parity was demonstrated only among fetal-death cases. For spina bifida, mothers of fetal-death (but not live-birth) cases were less likely to live along the Texas-Mexico border (aPR=0.30). CONCLUSIONS Demographic differences across NTD pregnancy outcomes exist and are a potential source of bias. Inclusion of all pregnancy outcomes in NTD surveillance is vital in NTD monitoring and research.
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Affiliation(s)
- Sharyn E Parks
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
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Ryan MAK, Jacobson IG, Sevick CJ, Smith TC, Gumbs GR, Conlin AMS. Health outcomes among infants born to women deployed to United States military operations during pregnancy. ACTA ACUST UNITED AC 2010; 91:117-24. [PMID: 21319279 DOI: 10.1002/bdra.20746] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 09/02/2010] [Accepted: 09/03/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND Military professionals who deploy to combat operations may encounter hazards that could adversely affect reproductive health. Pregnant women are generally exempt from deployment to military operations; however, exposures to such environments may inadvertently occur. We investigated whether maternal deployment during pregnancy was associated with adverse health outcomes in infants. METHODS The United States Department of Defense Birth and Infant Health Registry identified infants born to military service women between 2002 and 2005, and defined their health outcomes at birth and in the first year of life. Multivariable modeling was applied to investigate preterm birth and birth defects among infants, based on maternal deployment experience during pregnancy. RESULTS Among 63,056 infants born to military women from 2002 to 2005, 22,596 were born to women with deployment experience in support of the current military operations before, during, or after their pregnancy. These included 2941 infants born to women who appeared to have been deployed some time during their first trimester of pregnancy. Compared to infants born to women who deployed at other times, or never deployed, exposed infants were not more likely to be born preterm, diagnosed with a major birth defect, or diagnosed with a malignancy. CONCLUSIONS In this exploratory analysis, infants born to women who inadvertently deployed to military operations during their pregnancy were not at increased risk of adverse birth or infant health outcomes. Future analyses should examine outcomes related to specific maternal exposures during deployment, and outcomes among the growing number of infants conceived after deployment.
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Affiliation(s)
- Margaret A K Ryan
- United States Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055, USA.
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Gilboa SM, Salemi JL, Nembhard WN, Fixler DE, Correa A. Mortality resulting from congenital heart disease among children and adults in the United States, 1999 to 2006. Circulation 2010; 122:2254-63. [PMID: 21098447 PMCID: PMC4911018 DOI: 10.1161/circulationaha.110.947002] [Citation(s) in RCA: 400] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 08/17/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous reports suggest that mortality resulting from congenital heart disease (CHD) among infants and young children has been decreasing. There is little population-based information on CHD mortality trends and patterns among older children and adults. METHODS AND RESULTS We used data from death certificates filed in the United States from 1999 to 2006 to calculate annual CHD mortality by age at death, race-ethnicity, and sex. To calculate mortality rates for individuals ≥1 year of age, population counts from the US Census were used in the denominator; for infant mortality, live birth counts were used. From 1999 to 2006, there were 41,494 CHD-related deaths and 27,960 deaths resulting from CHD (age-standardized mortality rates, 1.78 and 1.20 per 100,000, respectively). During this period, mortality resulting from CHD declined 24.1% overall. Mortality resulting from CHD significantly declined among all race-ethnicities studied. However, disparities persisted; overall and among infants, mortality resulting from CHD was consistently higher among non-Hispanic blacks compared with non-Hispanic whites. Infant mortality accounted for 48.1% of all mortality resulting from CHD; among those who survived the first year of life, 76.1% of deaths occurred during adulthood (≥18 years of age). CONCLUSIONS CHD mortality continued to decline among both children and adults; however, differences between race-ethnicities persisted. A large proportion of CHD-related mortality occurred during infancy, although significant CHD mortality occurred during adulthood, indicating the need for adult CHD specialty management.
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Affiliation(s)
- Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Mail Stop E-86, 1600 Clifton Rd, Atlanta, GA 30333, USA.
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Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, Anderson P, Mason CA, Collins JS, Kirby RS, Correa A. Updated national birth prevalence estimates for selected birth defects in the United States, 2004-2006. ACTA ACUST UNITED AC 2010; 88:1008-16. [DOI: 10.1002/bdra.20735] [Citation(s) in RCA: 1320] [Impact Index Per Article: 94.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Fletcher JM, Brei TJ. Introduction: Spina bifida--a multidisciplinary perspective. ACTA ACUST UNITED AC 2010; 16:1-5. [PMID: 20419765 DOI: 10.1002/ddrr.101] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jack M Fletcher
- Department of Psychology, University of Houston, Houston, Texas 77204-5053, USA.
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45
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Current world literature. Curr Opin Obstet Gynecol 2010; 22:166-75. [PMID: 20216348 DOI: 10.1097/gco.0b013e328338c956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Solomon BD, Rosenbaum KN, Meck JM, Muenke M. Holoprosencephaly due to numeric chromosome abnormalities. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2010; 154C:146-8. [PMID: 20104610 DOI: 10.1002/ajmg.c.30232] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Holoprosencephaly (HPE) is the most common malformation of the human forebrain. When a clinician identifies a patient with HPE, a routine chromosome analysis is often the first genetic test sent for laboratory analysis in order to assess for a structural or numerical chromosome anomaly. An abnormality of chromosome number is overall the most frequently identified etiology in a patient with HPE. These abnormalities include trisomy 13, trisomy 18, and triploidy, though several others have been reported. Such chromosome number abnormalities are almost universally fatal early in gestation or in infancy. Clinical features of specific chromosome number abnormalities may be recognized by phenotypic manifestations in addition to the HPE.
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Affiliation(s)
- Benjamin D Solomon
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Gilboa SM, Correa A, Botto LD, Rasmussen SA, Waller DK, Hobbs CA, Cleves MA, Riehle-Colarusso TJ. Association between prepregnancy body mass index and congenital heart defects. Am J Obstet Gynecol 2010; 202:51.e1-51.e10. [PMID: 19796755 DOI: 10.1016/j.ajog.2009.08.005] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 07/09/2009] [Accepted: 08/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study was to examine associations between prepregnancy body mass index (BMI) and congenital heart defects (CHDs). STUDY DESIGN These analyses included case infants with CHDs (n = 6440) and liveborn control infants without birth defects (n = 5673) enrolled in the National Birth Defects Prevention Study (1997-2004). RESULTS Adjusted odds ratios for all CHDs combined were 1.16 (95% confidence interval [CI], 1.05-1.29), 1.15 (95% CI, 1.00-1.32), and 1.31 (95% CI, 1.11-1.56) for overweight status, moderate obesity, and severe obesity, respectively. Phenotypes associated with elevated BMI (> or =25.0 kg/m(2)) were conotruncal defects (tetralogy of Fallot), total anomalous pulmonary venous return, hypoplastic left heart syndrome, right ventricular outflow tract (RVOT) defects (pulmonary valve stenosis), and septal defects (secundum atrial septal defect). CONCLUSION These results corroborated those of previous studies and suggested new associations between obesity and conotruncal defects and RVOT defects.
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