Gestational age and the long-term impact on children's infectious urinary morbidity

Uncharted territory: a narrative review of parental involvement in decision-making about late preterm and early term delivery

Almost 30% of live births in England and Wales occur late preterm or early term (LPET) and are associated with increased risks of adverse health outcomes throughout the lifespan. However, very little is known about the decision-making processes concerning planned LPET births or the involvement of parents in these. This aim of this paper is to review the evidence on parental involvement in obstetric decision-making in general, to consider what can be extrapolated to decisions about LPET delivery, and to suggest directions for further research.A comprehensive, narrative review of relevant literature was conducted using Medline, MIDIRS, PsycInfo and CINAHL databases. Appropriate search terms were combined with Boolean operators to ensure the following broad areas were included: obstetric decision-making, parental involvement, late preterm and early term birth, and mode of delivery.This review suggests that parents' preferences with respect to their inclusion in decision-making vary. Most mothers prefer sharing decision-making with their clinicians and up to half are dissatisfied with the extent of their involvement. Clinicians' opinions on the limits of parental involvement, especially where the safety of mother or baby is potentially compromised, are highly influential in the obstetric decision-making process. Other important factors include contextual factors (such as the nature of the issue under discussion and the presence or absence of relevant medical indications for a requested intervention), demographic and other individual characteristics (such as ethnicity and parity), the quality of communication; and the information provided to parents.This review highlights the overarching need to explore how decisions about potential LPET delivery may be reached in order to maximise the satisfaction of mothers and fathers with their involvement in the decision-making process whilst simultaneously enabling clinicians both to minimise the number of LPET births and to optimise the wellbeing of women and babies.

The association between fetal gender in twin pregnancies and the risk of pediatric infectious diseases of the offspring: A population-based cohort study with long-term follow up

OBJECTIVE

We aimed to study the association between fetal gender in twin pregnancies and the risk for childhood infectious morbidity of the offspring.

STUDY DESIGN

A population-based cohort analysis was performed comparing total and subtypes of infectious related pediatric hospitalizations among males versus females offspring of twin pregnancies. The analysis included all dichorionic twins born between the years 1991-2021. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence, and a Cox proportional hazards model was constructed to adjust for confounders.

RESULTS

The study population included 4222 newborns (2111 males and 2111 females). Males had higher rates of infectious-related hospitalizations using a Cox proportional hazards model, an independent association was shown between male gender and infectious related hospitalizations of the offspring (Adjusted HR = 1.2, 95% CI: 1.1-1.4; p < 0.001).

CONCLUSION

Male gender in twin pregnancies is associated with an increased risk for long-term pediatric infectious morbidity.

The significance of maternal asymptomatic bacteriuria during pregnancy on long-term offspring infectious hospitalizations

Asymptomatic bacteriuria (ASB) is a well-acknowledged infectious entity during pregnancy; yet its long-term implications are not well investigated. The present study aimed to test the association between maternal ASB during pregnancy and long-term offspring infectious hospitalizations. A population-based cohort analysis was conducted, comparing the incidence of long-term infectious-related hospitalizations of offspring born to mothers who were diagnosed with ASB during pregnancy, and those who did not have ASB. The study was conducted at a tertiary medical center and included all singleton deliveries between the years 1991 and 2014. Infectious morbidities were based on a predefined set of International Classification of Disease-9 codes. A Kaplan-Meier survival curve compared cumulative infectious hospitalization incidence between the groups, and a Cox regression model was used to adjust for confounding variables. During the study period, 212,984 deliveries met inclusion criteria. Of them, 5378 (2.5%) were diagnosed with ASB. As compared to offspring of non-ASB mothers, total long-term infectious hospitalizations were significantly higher among children to mothers who were diagnosed with ASB (13.1% vs. 11.1%, OR = 1.2, 95% CI 1.11-1.30, P ≤ 0.001). Likewise, a Kaplan-Meier curve demonstrated higher cumulative incidence of infectious hospitalizations among children born to mothers with ASB (log rank, P = 0.006). In the Cox regression model, while controlling for maternal age, diabetes mellitus, ethnicity, hypertensive disorders, and gestational age, maternal ASB was noted as an independent risk factor for long-term infectious morbidity in the offspring (adjusted HR = 1.1, 95% CI 1.01-1.17, P = 0.042). ASB during pregnancy increases offspring susceptibility to long-term infectious hospitalizations.

Early-term deliveries and long-term pediatric ophthalmic morbidity of the offspring. Int J Gynaecol Obstet 2021;157:640-646. [PMID: 34383310 DOI: 10.1002/ijgo.13875]

OBJECTIVE

To examine whether early-term delivery impacts on the long-term ophthalmic health of offspring.

METHODS

A retrospective population-based cohort study was conducted, including all singleton deliveries (1991-2014) occurring at a tertiary medical center. Gestational age was divided into: early prematurity, late prematurity, and early, full, late, and post term. Hospitalizations of offspring up to 18 years of age involving ophthalmic morbidity were evaluated. Survival curves compared cumulative hospitalizations and regression models controlled for confounders.

RESULTS

During the study period, 243 363 deliveries met the inclusion criteria. Ophthalmic-related hospitalization rates were lower among early-term born children (1.0%) as compared with early- (2.2%) and late-preterm (1.3%) born children, but higher than those in full- (0.9%), late- (0.8%), and post-term (0.8%) born offspring (P < 0.001). The survival curve demonstrated significantly different hospitalization rates in the different gestational ages (P < 0.001). The regression demonstrated an independent risk for ophthalmic morbidity among early-term born offspring (adjusted hazard ratio 1.14, confidence interval 1.03-1.27, P = 0.009), whereas late- and post-term deliveries were associated with a lower risk (adjusted hazard ratio 0.83 and 0.74, respectively) as compared with full-term deliveries.

CONCLUSION

The risk for long-term ophthalmic-related hospitalizations of offspring gradually declines as gestational age advances.

Preterm Delivery; Who Is at Risk?

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Adverse effects of preterm birth have a direct correlation with the degree of prematurity, in which infants who are born extremely preterm (24–28 weeks gestation) have the worst outcomes. We sought to determine prominent risk factors for extreme PTB and whether these factors varied between various sub-populations with known risk factors such as previous PTB and multiple gestations. A population-based retrospective cohort study was conducted. Risk factors were examined in cases of extreme PTB in the general population, as well as various sub-groups: singleton and multiple gestations, women with a previous PTB, and women with indicated or induced PTB. A total of 334,415 deliveries were included, of which 1155 (0.35%) were in the extreme PTB group. Placenta previa (OR = 5.8, 95%CI 4.14–8.34, p < 0.001), multiple gestations (OR = 7.7, 95% CI 6.58–9.04, p < 0.001), and placental abruption (OR = 20.6, 95%CI 17.00–24.96, p < 0.001) were the strongest risk factors for extreme PTB. In sub-populations (multiple gestations, women with previous PTB and indicated PTBs), risk factors included placental abruption and previa, lack of prenatal care, and recurrent pregnancy loss. Singleton extreme PTB risk factors included nulliparity, lack of prenatal care, and placental abruption. Placental abruption was the strongest risk factor for extreme preterm birth in all groups, and risk factors did not differ significantly between sub-populations.

Maternal celiac disease and the risk for long-term infectious morbidity of the offspring

PROBLEM

Celiac disease is an autoimmune disease, patients with celiac have increased risk for infections, and offspring of celiac mothers have increased morbidity. The aim of the study was to assess long-term infectious morbidity among offspring of pregnant women with celiac disease.

METHOD OF STUDY

A population-based cohort study was conducted, including all singleton deliveries between the years 1991-2014 at a tertiary medical center. The offsprings were subdivided into two groups: offsprings of mothers with and without celiac disease. Data on demographics, maternal, perinatal, and long-term hospitalizations for infectious morbidity were compared between the two groups.

RESULTS

During the study period there were 210 (0.09%) deliveries of mothers with celiac, and they were compared to 242170 (99.91%) deliveries of non-celiac mothers. Cumulative infectious morbidity was significantly higher in offspring of mothers with celiac compared to offspring of mothers without celiac (Kaplan-Meier, log-rank p = .004). Specifically, among the offspring of mothers with celiac significantly higher rates of bacteremia was noted (1.0% vs. 0.1%; p = .001), and infections of the central nervous system (1% vs. 0.2%; p = .028). In the Cox multivariable model which accounted for confounding variables, being born to mothers with celiac disease was associated with significantly increased risk for long-term infectious morbidity of the offspring (adjusted HR = 1.6, 95% CI 1.165-2.357, p = .005).

CONCLUSIONS

Maternal celiac disease is an independent risk factor for long-term infectious morbidity for the offspring.

Long-Term Infectious Morbidity of Premature Infants: Is There a Critical Threshold?

In this study, we sought to ascertain a relationship between gestational age at birth and infectious morbidity of the offspring via population-based cohort analysis comparing the long-term incidence of infectious morbidity in infants born preterm and stratified by extremity of prematurity (extreme preterm birth: 24 + 0–27 + 6, very preterm birth: 28 + 0–31 + 6, moderate to late preterm birth: 32 + 0−36 + 6 weeks of gestation, and term deliveries). Infectious morbidity included hospitalizations involving a predefined set of International Classification of Diseases 9 (ICD9) codes, as recorded in hospital records. A Kaplan–Meier survival curve compared cumulative incidence of infectious-related morbidity. A Cox proportional hazards model controlled for confounders and time to event. The study included 220,594 patients: 125 (0.1%) extreme preterm births, 784 (0.4%) very preterm births, 13,323 (6.0%) moderate to late preterm births, and 206,362 term deliveries. Offspring born preterm had significantly more infection-related hospitalizations (18.4%, 19.8%, 14.9%, and 11.0% for the aforementioned stratification, respectively, p < 0.001). Multivariate analysis found being born very or late to moderate preterm was independently associated with long-term infectious morbidity (adjusted hazard ratio (aHR) 1.5, 95% confidence interval (CI) 1.27–1.77 and aHR 1.23, 95% CI 1.17–1.3, respectively, p < 0.001). A comparable risk of long-term infectious morbidity was found in the two groups of premature births prior to 32 weeks gestation. In our population, a cutoff from 32 weeks and below demarks a significant increase in the risk of long-term infectious morbidity of the offspring.

Perinatal Outcome and Long-Term Infectious Morbidity of Offspring Born to Women with Known Tuberculosis

Objective: To evaluate the perinatal outcome of women with tuberculosis and to assess a possible association between maternal tuberculosis and long-term infectious morbidity of the offspring. Study design: Perinatal outcome and long-term infectious morbidity of offspring of mothers with and without tuberculosis were assessed. The study groups were followed until 18 years of age tracking infectious-related morbidity and infectious-related hospitalizations and then compared. For perinatal outcome, generalized estimation equation models were used. A Kaplan-Meier survival curve was used to compare cumulative incidence of long-term infectious morbidity. A Cox proportional hazards model was conducted to control for confounders. Results: During the study period, 243,682 deliveries were included, of which 46 (0.018%) occurred in women with tuberculosis. Maternal tuberculosis was found to be independently associated with placental abruption, cesarean deliveries, and very low birth weight. However, offspring born to mothers with tuberculosis did not demonstrate higher rates of infectious-related morbidity. Maternal tuberculosis was not noted as an independent risk factor for long-term infectious morbidity of the offspring. Conclusion: In our study, maternal tuberculosis was found to be independently associated with adverse perinatal outcomes. However, higher risk for long-term infectious morbidity of the offspring was not demonstrated. Careful surveillance of these women is required.

Maternal hepatitis B or hepatitis C virus carrier status and long-term infectious morbidity of the offspring: A population-based cohort study

The objective of the study was to investigate the long-term effects of maternal hepatitis B virus (HBV) or hepatitis C virus (HCV) carrier status on the long-term infectious morbidity of their offspring. A population-based cohort study was conducted, including all singleton deliveries between the years 1991 and 2014 at a tertiary medical centre. The mothers were subdivided into three groups: HBV carriers, HCV carriers and non-carriers. Data on demographics, maternal, perinatal and long-term hospitalization for infectious morbidity were compared between the groups. During the study period, 242 905 (99.7%) non-carrier mothers, 591 (0.2%) HBV carriers and 186 (0.1%) HCV carriers were observed. Hospitalizations related to infectious morbidity was significantly higher in the offspring of HBV carriers compared with HCV and non-carriers (15.6% vs 11.3% vs 11.0%; P = .002, respectively; Kaplan-Meier, log-rank P < .001). Specifically, a significantly higher rate of hospitalizations gastrointestinal infectious morbidity was noted among the offspring of HBV carrier mothers (3.6% in the HBV carrier group, 1.6% in the HCV carrier group and 1.6% in the non-carrier group [P = .001]). There was a respiratory infectious morbidity of 8.1% among the offspring of HBV carriers, 8.6% among HCV carriers and 5.5% in non-carriers (P = .005). Using a Cox multivariable model, controlling for confounding variables, maternal HBV carrier status was associated with a significantly increased long-term infectious morbidity of the offspring, with an adjusted HR of 1.7 (95% CI, 1.388-2.077, P < .001). Maternal HBV carrier status is an independent risk factor for long-term infectious morbidity of the offspring, particularly for gastrointestinal and respiratory infections.

Fertility treatments and offspring pediatric infectious morbidities: results of a population-based cohort with a median follow-up of 10 years

OBJECTIVE

To study the association between mode of conception and offspring infectious morbidity risk.

DESIGN

Population-based cohort study.

SETTING

Regional university medical center.

PATIENT(S)

All singleton infants born between the years 1991 and 2014 and discharged alive from the hospital.

INTERVENTION(S)

Follow-up time in the study was calculated from birth to an event, defined as the first offspring hospitalization with any infectious morbidity. All infectious diagnoses were compared between the study groups, and a multivariable survival model was created to study the association between mode of conception and offspring pediatric hospitalization with infectious morbidity, and adjusting for confounding or clinically significant variables.

MAIN OUTCOME MEASURE(S)

First offspring pediatric hospitalization with infectious morbidity.

RESULT(S)

During the study period, 242,187 newborns met the inclusion criteria: 2,603 (1.1%) of which were conceived after undergoing IVF, 1,172 (0.7%) after ovulation induction (OI), and 237,863 (98.3%) were conceived spontaneously. Mothers receiving fertility treatments were older and with higher rates of preterm births and low birthweights. The hospitalizations rates per 1,000 person years of follow-up were 16.34/1,000 person years, 11.61/1,000 person years, and 10.19/1,000 person years, among the IVF, OI, and spontaneously conceived offspring, respectively. The adjusted hazard ratios were 1.26 (95% confidence interval 1.13-1.42) and 1.14 (95% confidence interval 1.00-1.38), for the IVF and OI compared with the spontaneously conceived offspring, respectively. The model adjusted for preterm delivery, birthweight, maternal age, hypertension, diabetes, and cesarean section.

CONCLUSION(S)

Higher risk for infectious morbidity was found among offspring conceived after fertility treatments compared with spontaneously conceived offspring.

Long-Term Incidence of Infectious-Related Hospitalizations of Offspring Born to Mothers With Intrauterine Device: A Retrospective Population-Based Cohort Study

BACKGROUND

Pregnancy with an Intrauterine device (IUD) is a risk factor for adverse pregnancy outcomes. The purpose of this study was to examine a possible association between presence of IUD during pregnancy and long-term incidence of infectious-related hospitalizations of the offspring.

METHODS

A population-based cohort analysis was performed including all singleton deliveries between 1991 and 2014 at a single tertiary hospital. Primary exposure was defined as delivery of an infant to a mother who conceived with an IUD, that was either removed or retained during pregnancy. Offspring of mothers who conceived without an IUD comprised the comparison group. The main outcome evaluated was infectious-related hospitalizations of the offspring up to the age of 18 years.

RESULTS

The number of deliveries that met the inclusion criteria was 227,431, of which 209 were to mothers who conceived with an IUD that was removed and 52 were to mothers who retained their device. Long-term incidence of infections-related hospitalizations was compared between the groups (12.5% in the retained IUD, 12.9% in the removed IUD and 11.2% in the No-IUD group, P = 0.638). A Kaplan-Meier survival curve did not demonstrate a significantly higher cumulative incidence of infectious-related hospitalizations in offspring of women who conceived with an IUD (log-rank P = 0.340). In a Cox regression model, while controlling for confounders such as maternal age and preterm birth, conceiving with an IUD was not found to be independently associated with long-term incidence of infectious-related hospitalizations of the offspring.

CONCLUSION

Offspring of women conceiving with an IUD are not at increased risk for long-term incidence of infectious-related hospitalizations.

Perinatal Outcomes and Long-term Health in Offspring of Teenage Mothers

STUDY OBJECTIVE

To evaluate whether extremely young maternal age (≤17 years) is associated with an increased risk of adverse perinatal outcome and an increased risk for long-term pediatric morbidity in offspring. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective population-based cohort study, in which all singleton deliveries of women, between the years 1991 and 2014 were compared. Parturients were classified into 3 groups according to age at delivery: 17 years or younger, 18-20 years, and 21-35 years (the comparison group). The incidence of long-term hospitalizations of offspring because of cardiovascular, endocrine, hematological, and respiratory morbidity were evaluated in the 3 maternal age groups. Kaplan-Meier survival curves were used to compare the cumulative morbidity incidence. Multiple regression models were used to estimate the association between young maternal age and adverse pregnancy outcomes, and long-term offspring morbidities (using survival analysis) while controlling for multiple potential confounders.

RESULTS

Of 213,177 deliveries that met the inclusion criteria, 90.1% (n = 192,185) occurred in mothers aged 21-35 years, 8.7% (n = 18,645) in mothers 18-20 years old, and 2347 were in mothers aged 17 years or younger (1.1%). Using multivariable logistic regression models, low birth weight and preterm delivery were significantly associated with young maternal age. The incidence of long-term morbidities of the offspring did not differ between the groups, in either the Kaplan-Meier analysis or the multivariable survival analysis.

Maternal urinary tract infection during pregnancy and long-term infectious morbidity of the offspring

BACKGROUND

Urinary tract infection (UTI) is a common bacterial infection in pregnant women and is associated with adverse perinatal outcomes. We sought to investigate the long-term infectious outcomes of children to mothers who were diagnosed with UTI during their pregnancy.

METHODS

A population-based cohort analysis was conducted at a single tertiary medical center. The study included all singleton deliveries between the years 1991-2014, comparing offspring born to mothers diagnosed with UTI during their pregnancy with those born to non-exposed mothers. Infectious-related hospitalizations of the offspring up to the age of 18 years were assessed according to a predefined set of ICD-9 codes. A Kaplan-Meier survival curve was conducted to compare cumulative hospitalization incidence between the groups. A Cox regression model was used to adjust for confounders.

RESULTS

During the study period, 243,725 deliveries met the inclusion criteria. Of them, 8034 (3.3%) were exposed to maternal UTI during pregnancy. Infectious-related hospitalizations were significantly prevalent in offspring to exposed mothers (12.3% vs. 11.0%, OR = 1.125, 95% CI 1.051-1.204, Kaplan-Meier log rank p < 0.001). In the Cox regression model, while controlling for clinically relevant confounders, maternal UTI (adjuster HR = 1.240), as well as preterm delivery (adjusted HR = 1.385) and cesarean delivery (adjusted HR = 1.198) were noted as independent risk factors for long-term infectious morbidity of the offspring.

CONCLUSIONS

Maternal UTI in pregnancy may influence offspring susceptibility to pediatric infections, as it was found to be an independent risk factor for long-term infectious morbidity of the offspring.

Meconium-stained amniotic fluid exposure is associated with a lower incidence of offspring long-term infectious morbidity

OBJECTIVE

Meconium-stained amniotic fluid (MSAF) is a well-established risk factor for immediate adverse neonatal outcomes and was recently suggested to be associated with microbial invasion of the amniotic cavity. We aimed to determine whether MSAF exposure during labor carries a longer lasting impact on pediatric infectious morbidity.

STUDY DESIGN

A population-based cohort analysis was performed including all singleton deliveries occurring between 1991 and 2014 at a single tertiary medical center. Exposure was defined as the presence of MSAF during labor. Hospitalizations of the offspring up to the age of 18 years involving infectious diseases were evaluated. A Kaplan-Meier survival curve was used to compare cumulative morbidity and a Cox regression model to control for confounders.

RESULTS

During the study period, 243 725 deliveries met the inclusion criteria. Of them, 35 897 (14.7%) involved MSAF. Rate of infectious-related hospitalizations of the offspring was significantly lower in children exposed to MSAF as compared with the unexposed group (10.8% vs 11.1%, P < 0.05). Specifically, hospitalizations involving respiratory infections were significantly less common among the MSAF group (5.1% vs 5.6%, P < 0.001). The survival curve demonstrated significantly lower cumulative total infectious morbidity rates in the MSAF-exposed group (log rank P < 0.001). In the Cox model, controlled for maternal age, diabetes, hypertension, mode of delivery, and gestational age, exposed children exhibited lower rates of long-term childhood infectious morbidity (adjusted HR 0.96, 95% CI 0.92-0.99, P < 0.001).

CONCLUSION

Fetal exposure to MSAF during labor and delivery appears to be associated with lower rates of long-term infectious-related hospitalizations in the offspring.