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Wesselink AK, Kirwa K, Hystad P, Kaufman JD, Szpiro AA, Willis MD, Savitz DA, Levy JI, Rothman KJ, Mikkelsen EM, Laursen ASD, Hatch EE, Wise LA. Ambient air pollution and rate of spontaneous abortion. ENVIRONMENTAL RESEARCH 2024; 246:118067. [PMID: 38157969 PMCID: PMC10947860 DOI: 10.1016/j.envres.2023.118067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/14/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
Spontaneous abortion (SAB), defined as a pregnancy loss before 20 weeks of gestation, affects up to 30% of conceptions, yet few modifiable risk factors have been identified. We estimated the effect of ambient air pollution exposure on SAB incidence in Pregnancy Study Online (PRESTO), a preconception cohort study of North American couples who were trying to conceive. Participants completed questionnaires at baseline, every 8 weeks during preconception follow-up, and in early and late pregnancy. We analyzed data on 4643 United States (U.S.) participants and 851 Canadian participants who enrolled during 2013-2019 and conceived during 12 months of follow-up. We used country-specific national spatiotemporal models to estimate concentrations of particulate matter <2.5 μm (PM2.5), nitrogen dioxide (NO2), and ozone (O3) during the preconception and prenatal periods at each participant's residential address. On follow-up and pregnancy questionnaires, participants reported information on pregnancy status, including SAB incidence and timing. We fit Cox proportional hazards regression models with gestational weeks as the time scale to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of time-varying prenatal concentrations of PM2.5, NO2, and O3 with rate of SAB, adjusting for individual- and neighborhood-level factors. Nineteen percent of pregnancies ended in SAB. Greater PM2.5 concentrations were associated with a higher incidence of SAB in Canada, but not in the U.S. (HRs for a 5 μg/m3 increase = 1.29, 95% CI: 0.99, 1.68 and 0.94, 95% CI: 0.83, 1.08, respectively). NO2 and O3 concentrations were not appreciably associated with SAB incidence. Results did not vary substantially by gestational weeks or season at risk. In summary, we found little evidence for an effect of residential ambient PM2.5, NO2, and O3 concentrations on SAB incidence in the U.S., but a moderate positive association of PM2.5 with SAB incidence in Canada.
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Affiliation(s)
- Amelia K Wesselink
- Department of Epidemiology, Boston University School of Public Health, USA.
| | - Kipruto Kirwa
- Department of Environmental Health, Boston University School of Public Health, USA
| | - Perry Hystad
- College of Public Health and Human Sciences, Oregon State University, USA
| | - Joel D Kaufman
- Departments of Environmental and Occupational Health Sciences, Epidemiology, and Medicine, University of Washington School of Public Health, USA
| | - Adam A Szpiro
- Department of Biostatistics, University of Washington School of Public Health, USA
| | - Mary D Willis
- Department of Epidemiology, Boston University School of Public Health, USA
| | - David A Savitz
- Department of Epidemiology, Brown University School of Public Health, USA
| | - Jonathan I Levy
- Department of Environmental Health, Boston University School of Public Health, USA
| | - Kenneth J Rothman
- Department of Epidemiology, Boston University School of Public Health, USA
| | - Ellen M Mikkelsen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Denmark
| | - Anne Sofie Dam Laursen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Denmark
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, USA
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, USA
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de Feijter M, van Gelder MMHJ, Vissers LCM, Kant AC, Woestenberg PJ. The risk of miscarriage after COVID-19 vaccination before and during pregnancy. Pharmacoepidemiol Drug Saf 2024; 33:e5724. [PMID: 37946587 DOI: 10.1002/pds.5724] [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: 06/08/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Pregnant women are at higher risk of severe illness and adverse pregnancy outcomes due to a SARS-CoV-2 infection, which can be prevented by vaccination. Observational studies are needed to ascertain the safety of COVID-19 vaccination during pregnancy. We aimed to determine whether COVID-19 vaccination before and during pregnancy is associated with the risk of miscarriage. METHODS In this cohort study, we included 4640 pregnant women (mean age: 32.8 ± 3.7 years) from the Dutch Pregnancy Drug Register between February 2021 and August 2022. Information on COVID-19 vaccinations, miscarriage, and confounders was self-reported, using web-based questionnaires. The hazard ratio (HR) of miscarriage (in gestational weeks 6-20) after a COVID-19 vaccination, was estimated using the survival analyses. A COVID-19 vaccination during pregnancy (≥1 COVID-19 vaccination between week 2 and 20 of pregnancy) was included as a time-dependent exposure and vaccination prior to pregnancy was included as a binary exposure. RESULTS A total of 3202 pregnant women (69%) received ≥1 COVID-19 vaccine in gestational week 2-20. We observed no association of vaccination during pregnancy with the risk of miscarriage (adjusted HR = 1.29, 95% CI = 0.93-1.74). Vaccination prior to pregnancy, however, was associated with a decreased risk of miscarriage (adjusted HR = 0.69, 95% CI = 0.48-0.99). CONCLUSIONS We demonstrated that COVID-19 vaccination during pregnancy is not associated with an increased risk of miscarriage in gestational weeks 6-20. This study adds to the growing body of evidence demonstrating the safety of COVID-19 vaccination during pregnancy.
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Affiliation(s)
- Maud de Feijter
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | | | - Lieke C M Vissers
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Agnes C Kant
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Petra J Woestenberg
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
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Sundermann AC, Slaughter JC, Velez Edwards DR, Hartmann KE. Time-Varying Exposures and Miscarriage: A Comparison of Statistical Models Through Simulation. Am J Epidemiol 2023; 192:790-799. [PMID: 36721373 PMCID: PMC10423631 DOI: 10.1093/aje/kwad021] [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: 02/16/2022] [Revised: 11/13/2022] [Accepted: 01/30/2023] [Indexed: 02/02/2023] Open
Abstract
Epidemiologists face a unique challenge in measuring risk relationships involving time-varying exposures in early pregnancy. Each week in early pregnancy is distinct in its contribution to fetal development, and this period is commonly characterized by shifts in maternal behavior and, consequently, exposures. In this simulation study, we used alcohol as an example of an exposure that often changes during early pregnancy and miscarriage as an outcome affected by early exposures. Data on alcohol consumption patterns from more than 5,000 women in the Right From the Start cohort study (United States, 2000-2012) informed measures of the prevalence of alcohol exposure, the distribution of gestational age at cessation of alcohol use, and the likelihood of miscarriage by week of gestation. We then compared the bias and precision of effect estimates and statistical power from 5 different modeling approaches in distinct simulated relationships. We demonstrate how the accuracy and precision of effect estimates depended on alignment between model assumptions and the underlying simulated relationship. Approaches that incorporated data about patterns of exposure were more powerful and less biased than simpler models when risk depended on timing or duration of exposure. To uncover risk relationships in early pregnancy, it is critical to carefully define the role of exposure timing in the underlying causal hypothesis.
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Affiliation(s)
| | | | | | - Katherine E Hartmann
- Correspondence to Katherine E. Hartmann, Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 600, Nashville, TN 37203 (e-mail: )
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van Gelder MMHJ, Lupattelli A, Nordeng HME. Risk of spontaneous abortion after periconceptional medication use: Time to tackle the methodological challenges. Paediatr Perinat Epidemiol 2023; 37:188-190. [PMID: 36869817 DOI: 10.1111/ppe.12967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023]
Affiliation(s)
| | - Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Hedvig M E Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Bohn JA. Miscarriage Can Kill … But it Usually Does Not: Evaluating Inconsistency Arguments. New Bioeth 2021; 27:245-265. [PMID: 34455942 DOI: 10.1080/20502877.2021.1970374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Recent publications debate the value of inconsistency arguments. Here, I argue that 'Cause of Death Arguments' - inconsistency arguments that claim miscarriage causes death far more often than induced abortion - are unsound or invalid. 'Miscarriage' ambiguously refers both to intrauterine death, an outcome that does not itself cause death, and preterm delivery, which only sometimes causes death. The referential ambiguity also obscures actions people do take to prevent 'miscarriage.' When using the most plausible versions of each premise, these arguments equivocate. Thus, they cannot prove anything. However, missing the equivocation also causes those responding to Cause of Death Arguments to make unconvincing arguments; they inadvertently make or grant false claims themselves. To avoid such mistakes and expose the merely rhetorical power of Cause of Death Arguments, philosophers should replace 'miscarriage' with disambiguated terms. Doing so should lead people across the abortion debate to finally abandon the Cause of Death Argument.
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Affiliation(s)
- Jessalyn A Bohn
- Department of Philosophy, St. Edward's University, Austin, TX, USA
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Dunne J, Tessema GA, Ognjenovic M, Pereira G. Quantifying the influence of bias in reproductive and perinatal epidemiology through simulation. Ann Epidemiol 2021; 63:86-101. [PMID: 34384883 DOI: 10.1016/j.annepidem.2021.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/20/2021] [Accepted: 07/31/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The application of simulated data in epidemiological studies enables the illustration and quantification of the magnitude of various types of bias commonly found in observational studies. This was a review of the application of simulation methods to the quantification of bias in reproductive and perinatal epidemiology and an assessment of value gained. METHODS A search of published studies available in English was conducted in August 2020 using PubMed, Medline, Embase, CINAHL, and Scopus. A gray literature search of Google and Google Scholar, and a hand search using the reference lists of included studies was undertaken. RESULTS Thirty-nine papers were included in this study, covering information (n = 14), selection (n = 14), confounding (n = 9), protection (n = 1), and attenuation bias (n = 1). The methods of simulating data and reporting of results varied, with more recent studies including causal diagrams. Few studies included code for replication. CONCLUSIONS Although there has been an increasing application of simulation in reproductive and perinatal epidemiology since 2015, overall this remains an underexplored area. Further efforts are required to increase knowledge of how the application of simulation can quantify the influence of bias, including improved design, analysis and reporting. This will improve causal interpretation in reproductive and perinatal studies.
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Affiliation(s)
- Jennifer Dunne
- Curtin School of Population Health, Curtin University, Bentley, WA, Australia.
| | - Gizachew A Tessema
- Curtin School of Population Health, Curtin University, Bentley, WA, Australia; School of Public Health, University of Adelaide, Adelaide, SA, Australia
| | - Milica Ognjenovic
- Curtin School of Population Health, Curtin University, Bentley, WA, Australia
| | - Gavin Pereira
- Curtin School of Population Health, Curtin University, Bentley, WA, Australia; Center for Fertility and Health (CeFH), Norwegian Institute of Public Health, Oslo, Norway
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Week-by-week alcohol consumption in early pregnancy and spontaneous abortion risk: a prospective cohort study. Am J Obstet Gynecol 2021; 224:97.e1-97.e16. [PMID: 32673615 DOI: 10.1016/j.ajog.2020.07.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 05/28/2020] [Accepted: 07/07/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Half of women use alcohol in the first weeks of gestation, but most stop once pregnancy is detected. The relationship between timing of alcohol use cessation in early pregnancy and spontaneous abortion risk has not been determined. OBJECTIVE This study aimed to evaluate the association between week-by-week alcohol consumption in early pregnancy and spontaneous abortion. STUDY DESIGN Participants in Right from the Start, a community-based prospective pregnancy cohort, were recruited from 8 metropolitan areas in the United States (2000-2012). In the first trimester, participants provided information about alcohol consumed in the prior 4 months, including whether they altered alcohol use; date of change in use; and frequency, amount, and type of alcohol consumed before and after change. We assessed the association between spontaneous abortion and week of alcohol use, cumulative weeks exposed, number of drinks per week, beverage type, and binge drinking. RESULTS Among 5353 participants, 49.7% reported using alcohol during early pregnancy and 12.0% miscarried. Median gestational age at change in alcohol use was 29 days (interquartile range, 15-35 days). Alcohol use during weeks 5 through 10 from last menstrual period was associated with increased spontaneous abortion risk, with risk peaking for use in week 9. Each successive week of alcohol use was associated with an 8% increase in spontaneous abortion relative to those who did not drink (adjusted hazard ratio, 1.08; 95% confidence interval, 1.04-1.12). This risk is cumulative. In addition, risk was not related to number of drinks per week, beverage type, or binge drinking. CONCLUSION Each additional week of alcohol exposure during the first trimester increases risk of spontaneous abortion, even at low levels of consumption and when excluding binge drinking.
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Suarez EA, Boggess K, Engel SM, Stürmer T, Lund JL, Jonsson Funk M. Ondansetron use in early pregnancy and the risk of miscarriage. Pharmacoepidemiol Drug Saf 2020; 30:103-113. [PMID: 33000871 DOI: 10.1002/pds.5143] [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: 04/24/2020] [Revised: 09/02/2020] [Accepted: 09/21/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ondansetron is commonly used to treat nausea and vomiting in pregnancy despite inconclusive evidence of its safety. Previous studies have reported no increase in risk of miscarriage but relied on methods that failed to account for gestational weeks at risk and non-user comparators, which may increase the potential for unmeasured confounding. Our objective was to estimate the risk of miscarriage among women prescribed ondansetron vs alternative antiemetics during the first 20 weeks of pregnancy. METHODS A pregnancy cohort was created using electronic health record data from a health care system in North Carolina. Women were classified as exposed to either ondansetron or comparator antiemetics (metoclopramide or promethazine) based on the first antiemetic prescription received in the first 20 weeks of gestation. Cumulative incidence of miscarriage at 20 weeks was estimated in each antiemetic group. Hazard ratios (HR) were estimated with 95% confidence intervals and measured confounding was controlled using inverse probability of treatment weights. Sensitivity analyses assessed the potential impact of exposure misclassification, latency period, and selection bias. RESULTS We identified 2620 eligible pregnancies with antiemetic orders; 65% had a first ondansetron order and 35% had a first comparator antiemetic order. In total, 95 women had a miscarriage. After adjustment, there was no difference in risk of miscarriage (HR 1.21, 95% CI 0.77, 1.90). Results from the per-protocol and other sensitivity analyses were similar to the main analysis. CONCLUSIONS We did not observe an increase in the risk of miscarriage for pregnancies exposed to ondansetron vs comparator antiemetics.
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Affiliation(s)
- Elizabeth A Suarez
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kim Boggess
- Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Stephanie M Engel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michele Jonsson Funk
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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