Perinatal outcomes of pregnancies complicated by maternal depression with or without selective serotonin reuptake inhibitor therapy

Drug-Induced Hypoglycemia in Neonates Born to Nondiabetic Women Treated with Medications during the Pregnancy or the Labor: A Systematic Review of the Literature

The prompt identification of at-risk newborns for drug-induced hypoglycemia can minimize the risk for adverse side effects, inappropriate investigations, and considerable unnecessary costs. Existing literature discusses drug-induced hypoglycemia, but a systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing. We reviewed the association between neonatal hypoglycemia and maternal medications. We systematically searched the literature according to the PICOS model on drug-induced hypoglycemia in neonates born to nondiabetic women treated with medications during the pregnancy or the labor. The main outcomes of the review were: (1) prevalence of hypoglycemia, (2) risk factors and potential confounders, (3) time at onset and severity of hypoglycemia, (4) dose-response gradient, (5) metabolic features of hypoglycemia, (6) modalities to treat hypoglycemia, and (7) quality of the studies. We included 69 studies in this review and we identified 11 groups of maternal drugs related to neonatal hypoglycemia. Results were classified for each outcome. Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia and in the differential diagnosis of neonatal hypoglycemia. Further studies are necessary to assess the risk of neonatal hypoglycemia associated with common maternal medications. KEY POINTS: · A systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing.. · In our review we identified 11 groups of maternal drugs related to neonatal hypoglycemia.. · Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia..

Antenatal Depression as a Stunting Risk Factor: A Systematic Review

BACKGROUND: Depression during pregnancy is often found and ignored even though depression has a negative impact not only on the mother but also on the fetus to adulthood. Stunting is a problem of lack of nutritional status that begins during pregnancy. AIM: The purpose of this article is to systematically identify the description and relationship between depression during pregnancy and stunting in children. METHOD: The approach used is the systematic review method to search articles. Articles were identified from 2010-2020 by conducting a literature search with the keywords "antenatal depression" OR "prenatal depression" OR "depression during pregnancy" and "stunting" in the electronic databases dataset by Sciencedirect, Pubmed Research Gate, and Google Scholar. RESULTS: The search results found 1875 articles selected into 20 journal articles that match the inclusion criteria. CONCLUSION: The results found that depression during pregnancy correlated with risk factors for stunting. As a preventive measure, health workers, especially midwives, can provide psychological care in antenatal care by considering these factors.

Sleep heterogeneity in the third trimester of pregnancy: Correlations with depression, memory impairment, and fatigue

This study aimed to identify sleep subtypes during pregnancy using a person-centered method, explore the underlying factors of these subtypes, and investigate the associations of these subtypes with depression, memory impairment, and fatigue. Accordingly, self-report measures were administered to 1,825 pregnant women to assess demographics, prenatal factors, childhood trauma, personality traits, sleep problems, depression, memory impairment, and fatigue. Data were analyzed using latent class analysis, chi-squared tests, analysis of variance, multinomial logistical regression, and multivariate linear regression analyses. The profiles of "good sleep quality," "poor sleep efficiency," "daily disturbances," and "poor sleep quality" were identified. The results also revealed several factors underlying these subtypes that affect sleep quality: rumination, perinatal complications, high neuroticism, low resilience, history of abortion, and postgraduate education. Further, the "daily disturbances" and the "poor sleep quality" groups reported higher depression, memory impairment, and fatigue than the "good sleep quality" group. Thus, this study elucidated the heterogeneity of sleep subtypes during pregnancy in the Chinese population. Such findings may promote the development of tailored interventions for specific sleep subtypes in pregnant women.

Current Issues within the Perinatal Mental Health Care System in Aichi Prefecture, Japan: A Cross-Sectional Questionnaire Survey

Mental illnesses commonly occur in the reproductive age. This study aimed to identify the issues that exist within the perinatal mental health care system. A cross-sectional survey was conducted in Aichi Prefecture in central Japan. Questionnaires on the situation between 2016 and 2018 were mailed to the head physicians of 128 maternity care units, 21 neonatal intensive care units (NICUs), and 40 assisted reproductive technology (ART) units. A total of 82 (52.6 per 100,000 births) women were admitted to mental health care units during the perinatal period, and 158 (1.0 per 1000 births) neonates born to mothers with mental illness were admitted to NICUs. Approximately 40% of patients were hospitalized in psychiatric hospitals without maternity care units. Eighty-four (71.1%) and 76 (64.4%) maternity care units did not have psychiatrists or social workers, respectively. Moreover, 20–35% of the head physicians in private clinics, general hospitals, and ART units endorsed the discontinuation of psychotropic drug use during pregnancy. However, the corresponding figures were only 5% among those in maternal-fetal centers. Resources for perinatal mental illness might be limited. Perspectives on psychotropic drug use differed based on the type of facilities where the doctors were working.

The impact of major depressive disorder and antidepressant medication before and during pregnancy on obstetric and neonatal outcomes: A nationwide population-based study

OBJECTIVE

To investigate the impact of major depressive disorder (MDD) and antidepressant medication before and during pregnancy on obstetric and neonatal outcomes.

STUDY DESIGN

A national register-based cohort study of pregnant women born in Sweden, and their first child born in 2012-2015 (n = 262 329). Women diagnosed with MDD and who had redeemed an antidepressant one year before becoming pregnant ("before pregnancy") and women who were diagnosed with MDD and who had redeemed an antidepressant both before and during pregnancy ("before and during pregnancy") were compared with each other and with women who had neither been diagnosed with MDD nor been prescribed antidepressants (population controls).

RESULTS

In comparison to population controls, the "before pregnancy" and the "before and during pregnancy" groups had increased likelihoods of operative childbirth (aOR = 1.19, 95 % CI 1.12-1.27, aOR = 1.38, 95 % CI 1.28-1.48 respectively), and with an increased likelihood for the child being admitted to a neonatal intensive care unit (NICU) (aOR = 1.51, 95 % CI 1.17-1.95, aOR = 1.55, 95 % CI 1.14-2.11). Children born to mothers in the "before and during pregnancy" group had an increased likelihood of preterm birth (aOR = 1.72, 95 % CI 1.52-1.95,), while children to mothers in the "before pregnancy" group had an increased likelihood of low birthweight (aOR = 1.15, 95 % CI 1.00-1.33) compared to population controls. Women in the "before and during pregnancy" group had an increased likelihood for hyperemesis during pregnancy (aOR = 1.93, 95 % CI = 1.60-2.32), having an operative childbirth (aOR = 1.17, 95 % CI = 1.06-1.29) or a preterm birth (aOR = 1.53, 95 % CI = 1.28-1.81) compared to the "before pregnancy" group.

CONCLUSIONS

Women with MDD and antidepressant medication prior to becoming pregnant are at increased risk for adverse obstetric and neonatal outcomes compared to women without an MDD. Continuation of antidepressant medication during pregnancy somewhat increased the risk for adverse obstetric and neonatal outcomes.

Genetic variations of MTHFR gene and their association with preterm birth in Korean women

BACKGROUND AND OBJECTIVE

The MTHFR gene encodes the methylenetetrahydrofolate reductase known to be involved in the homocysteine-methionine pathway. It has been reported that the deficiency of MTHFR activity may cause hyperhomocysteinemia which results in adverse pregnancy outcomes. Previous studies reported a correlation between the MTHFR gene polymorphisms (677 T/C and 1298 A/C) and lower MTHFR activity and its association with preterm birth in various populations. Since these results were conflicting, we analyzed the genetic association of MTHFR gene 677 T/C and 1298 A/C polymorphisms with preterm birth in Korean women.

MATERIALS AND METHODS

The subjects for case-control study were collected a total of 226 Korean women (98 preterm-birth patients and 128 controls). Genotype frequency differences between the case and the control were assessed using chi-square tests. Mann-Whitney t-test was used to estimate the effects of 1298 A/C genotype on clinicopathological characteristics (systolic blood pressure, diastolic blood pressure, birth weight, and gestational age at delivery) in preterm-birth patients.

RESULTS

Our results showed that the MTHFR 677 C/T polymorphism was significantly associated with preterm-birth patients in the analysis of genotype frequency (P=0.044) and the over-dominant model (OR=0.54; 95% CI, 0.320-0.920; P=0.023). The recessive model showed a marginal trend toward significance (OR=0.47; 95% CI, 0.220-1.010; P=0.046). The 1298 A/C polymorphism was also associated with reduced preterm-birth risk in the recessive model (P=0.032). In the correlation analysis, the 1298 C allele was significantly associated with increasing of gestational age at delivery in preterm-birth patients (P=0.034).

CONCLUSIONS

Our findings suggested that the MTHFR gene 677 C/T and 1298 A/C polymorphisms might have protective effects for preterm birth in the Korean women.

Genetic Association of Angiotensin-Converting Enzyme (ACE) Gene I/D Polymorphism with Preterm Birth in Korean Women: Case-Control Study and Meta-Analysis

Background and Objectives: The ACE gene encodes the angiotensin-converting enzyme (ACE), a component of the renin-angiotensin system. Increased ACE activity may cause abnormal regulation of placental circulation and angiogenesis, resulting in adverse pregnancy outcomes. Previous studies have reported that the insertion/deletion (I/D) polymorphism of the ACE gene is associated with the development of preterm birth (PTB). However, results of the association between ACE gene I/D and PTB are inconsistent in various populations. Therefore, we performed a case-control study and a meta-analysis to evaluate the association between ACE I/D polymorphism and PTB. Materials and Methods: We analyzed a total of 254 subjects (111 patients with PTB and 143 women at ≥38 weeks gestation) for the case-control study. For the meta-analysis, we searched Google Scholar, PubMed, and NCBI databases with the terms “ACE,” “angiotensin-converting enzyme,” “preterm birth,” “preterm delivery,” and their combinations. Results: Our results of the case-control study indicated that ACE I/D polymorphism is significantly associated with PTBs in the overdominant genetic model (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.347–0.949, p = 0.029) and that the ID genotype of ACE I/D polymorphism has a protective effect for PTB (OR 0.57, 95% CI 0.333–0.986, p = 0.043). Similarly, the meta-analysis showed that the OR for the ACE gene ID genotype was 0.66 (95% CI 0.490–0.900, p < 0.01). Conclusion: The ACE gene ID genotype has a significant association with PTB and is a protective factor for PTB. A larger sample set and functional studies are required to further elucidate of our findings.

A Prospective Study Evaluating the Effects of SSRI Exposure on Cardiac Size and Function in Newborns

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants prescribed in 10% of pregnancies in the USA. We have previously shown in preclinical studies that sertraline exposure impacts cardiomyocyte development, leading to reductions in left ventricular size and cardiac function.

OBJECTIVES

We hypothesized that in utero SSRI exposure will lead to reduced left ventricular dimensions and cardiac function on echocardiography immediately after birth.

METHODS

Twenty term infants with and 21 term infants without in utero exposure to SSRIs underwent echocardiograms to assess cardiac size and function. The exclusion criteria for infants were prematurity, small or large for gestational age, any respiratory or cardiovascular support needed after birth, and any major congenital malformation.

RESULTS

Infants exposed to in utero SSRIs had significantly reduced right ventricular dimensions in the diastole (controls 1.0 cm [0.86, 1.20], SSRI 0.89 cm [0.730, 1.05], p = 0.03), and left ventricular lengths in the diastole and systole (diastole: controls 3.4 cm [3.25, 3.65], SSRI 3.25 cm [3.10, 3.45], p = 0.03; systole: controls 2.9 cm [2.65, 3.05], SSRI 2.6 cm [2.50, 2.85], p = 0.01). No differences were observed in cardiac function. Importantly, there were no differences in maternal conditions or infant birth weight, body surface area, or gestational age.

CONCLUSIONS

Our findings suggest an association between in utero exposure to SSRIs and ventricular size in infants. Given the increasing use of SSRIs during pregnancy and the importance of early life programming on future cardiovascular health, larger studies need to be completed to determine if in utero SSRI exposure impacts ventricular size.

Parental psychopathology and offspring attention-deficit/hyperactivity disorder in a nationwide sample

OBJECTIVE

To study the associations between a wide range of parental psychiatric disorders and offspring attention-deficit/hyperactivity disorder (ADHD).

METHOD

This study is based on a nested case-control design. The association between parental registered psychiatric diagnoses and offspring ADHD was examined adjusting for socioeconomic and prenatal factors. Data was linked from Finnish nationwide registers. The cases (n = 10,409) were all the children born between years 1991 and 2005 in Finland and diagnosed with ADHD by the end of 2011. Four controls without ADHD (n = 39,124) were matched for every case by sex, age and place of birth. Main outcomes were adjusted odds ratio (aOR) for parental diagnosis of cases vs controls. Analyses were further stratified by sex. Disorders diagnosed before and after birth were analyzed separately.

RESULTS

The odds ratio for ADHD increased when only mother (aOR 2.2, 95% CI 2.0-2.3), only father (aOR 1.7, 95% CI 1.6-1.8) and both parents (aOR 3.6, 95% CI 3.3-4.0) were diagnosed. Maternal diagnosis showed stronger association than paternal. The weight of association between several parental disorders and offspring ADHD were similar. Maternal psychopathology overall showed stronger associations with girls than boys with ADHD. The diagnoses registered after birth did not show stronger association than the diagnoses registered before.

CONCLUSIONS

Maternal psychopathology showing stronger association than paternal implies that environmental factors or their interaction with genetic factors partly mediates the risk of parental psychopathology. Similar associations between several maternal psychiatric disorders and offspring ADHD points towards the need for investigating some common mother-related risk factors.

Prenatal care: associations with prenatal depressive symptoms and social support in low-income urban women

We examined associations of depressive symptoms and social support with late and inadequate prenatal care in a low-income urban population. The sample was prenatal care patients at five community health centers. Measures of depressive symptoms, social support, and covariates were collected at prenatal care entry. Prenatal care entry and adequacy came from birth certificates. We examined outcomes of late prenatal care and less than adequate care in multivariable models. Among 2341 study participants, 16% had elevated depressive symptoms, 70% had moderate/poor social support, 21% had no/low partner support, 37% had late prenatal care, and 29% had less than adequate prenatal care. Women with both no/low partner support and elevated depressive symptoms were at highest risk of late care (AOR 1.85, CI 1.31, 2.60, p < 0.001) compared to women with both good partner support and low depressive symptoms. Those with good partner support and elevated depressive symptoms were less likely to have late care (AOR 0.74, CI 0.54, 1.10, p = 0.051). Women with moderate/high depressive symptoms were less likely to experience less than adequate care compared to women with low symptoms (AOR 0.73, CI 0.56, 0.96, p = 0.022). Social support and partner support were negatively associated with indices of prenatal care use. Partner support was identified as protective for women with depressive symptoms with regard to late care. Study findings support public health initiatives focused on promoting models of care that address preconception and reproductive life planning. Practice-based implications include possible screening for social support and depression in preconception contexts.

Maternal history of child maltreatment and maternal depression risk in the perinatal period: A longitudinal study

Existing research is limited, with only a few studies considering each single type and multiple types of child maltreatment (CM) as well as multiple assessments of maternal depression throughout the perinatal period. The purpose of the study was to assess each type and accumulative types of CM in relation to the risk of maternal depression throughout the perinatal period. In total, 276 pregnant women were recruited from the prenatal clinic at a general hospital in China. Maternal CM history and depression risk were assessed at late pregnancy, postpartum week 1, and postpartum week 4 using the Childhood Trauma Questionnaire (CTQ) and Edinburgh Postnatal Depression Scale (EPDS). The GEE showed that physical and emotional neglect and multiple types of CM were associated with higher overall depression risk across the perinatal period. The multinomial regression models showed physical neglect and multiple types of CM predicted higher risk of both antepartum and postpartum depression. Emotional and sexual abuse and emotional neglect predicted antepartum depression risk, while none of the three types of CM predicted postpartum depression risk. Physical abuse did not predict antepartum and postpartum depression risk. The findings suggest that maternal history of child physical and emotional neglect play significant roles in perinatal depression risk with physical neglect as the most important predictor. Routine screening for maternal CM history and depression risk in prenatal clinics is needed to aid in the early detection and treatment of depression.

Neonatal Morbidity After Maternal Use of Antidepressant Drugs During Pregnancy

OBJECTIVES

To estimate the rate of admissions to NICUs, as well as infants' morbidity and neonatal interventions, after exposure to antidepressant drugs in utero.

METHODS

Data on pregnancies, deliveries, prescription drug use, and health status of the newborn infants were obtained from the Swedish Medical Birth Register, the Prescribed Drug Register, and the Swedish Neonatal Quality Register. We included 741 040 singletons, born between July 1, 2006, and December 31, 2012. Of the infants, 17 736 (2.4%) had mothers who used selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Infants exposed to an SSRI were compared with nonexposed infants, and infants exposed during late pregnancy were compared with those exposed during early pregnancy only. The results were analyzed with logistic regression analysis.

RESULTS

After maternal use of an SSRI, 13.7% of the infants were admitted to the NICU compared with 8.2% in the population (adjusted odds ratio: 1.5 [95% confidence interval: 1.4-1.5]). The admission rate to the NICU after treatment during late pregnancy was 16.5% compared with 10.8% after treatment during early pregnancy only (adjusted odds ratio: 1.6 [95% confidence interval: 1.5-1.8]). Respiratory and central nervous system disorders and hypoglycemia were more common after maternal use of an SSRI. Infants exposed to SSRIs in late pregnancy compared with early pregnancy had a higher risk of persistent pulmonary hypertension (number needed to harm: 285).

CONCLUSIONS

Maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU. The absolute risk for severe disease was low, however.

Selective serotonin reuptake inhibitor exposure constricts the mouse ductus arteriosus in utero

Use of selective serotonin reuptake inhibitors (SSRIs) is common during pregnancy. Fetal exposure to SSRIs is associated with persistent pulmonary hypertension of the newborn (PPHN); however, a direct link between the two has yet to be established. Conversely, it is well known that PPHN can be caused by premature constriction of the ductus arteriosus (DA), a fetal vessel connecting the pulmonary and systemic circulations. We hypothesized that SSRIs could induce in utero DA constriction. Using isolated vessels and whole-animal models, we sought to determine the effects of two commonly prescribed SSRIs, fluoxetine and sertraline, on the fetal mouse DA. Cannulated vessel myography studies demonstrated that SSRIs caused concentration-dependent DA constriction and made vessels less sensitive to prostaglandin-induced dilation. Moreover, in vivo studies showed that SSRI-exposed mice had inappropriate DA constriction in utero. Taken together, these findings establish that SSRIs promote fetal DA constriction and provide a potential mechanism by which SSRIs could contribute to PPHN.

Untreated depression during pregnancy: Short- and long-term effects in offspring. A systematic review

Aim of this systematic review is to assess short- and long-lasting effects of antenatal exposure to untreated maternal depressive symptoms. Pertinent articles were identified through combined searches of Science.gov, Cochrane library, and PubMed databases (through August 2015). Forty-three, selected articles revealed that untreated gestational depression and even depressive symptoms during pregnancy may have untoward effects on the developing fetus (hyperactivity, irregular fetal heart rate), newborns (increased cortisol and norepinephrine levels, decreased dopamine levels, altered EEG patterns, reduced vagal tone, stress/depressive-like behaviors, and increased rates of premature deaths and neonatal intensive care unit admission), and children (increased salivary cortisol levels, internalizing and externalizing problems, and central adiposity). During adolescence, an independent association exists between maternal antenatal mood symptoms and a slight increase in criminal behaviors. In contrast, the relationship between gestational depression and increased risks of prematurity and low birth weight remains controversial. Given this background, when making clinical decisions, clinicians should weigh the growing evidences suggesting the detrimental and prolonged effects in offspring of untreated antenatal depression and depressive symptoms during pregnancy against the known and emerging concerns associated with in utero exposure to antidepressants.

MTHFR genetic polymorphism increases the risk of preterm delivery

AIMS

This study aimed to investigate the association between the methylene tetrahydrofolate reductase (MTHFR) gene C677T and A1298C polymorphisms and premature delivery susceptibility.

METHODS

With matched age and gender, 108 premature delivery pregnant women as cases and 108 healthy pregnant women as controls were recruited in this case-control study. The cases and controls had same gestational weeks. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was adopted to analyze C677T and A1298C polymorphisms of the participants. Linkage disequilibrium (LD) and haplotype analysis were conducted by Haploview software. The differences for frequencies of gene type, allele and haplotypes in cases and controls were tested by chi-square test. The relevant risk of premature delivery was represented by odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

TT gene type frequency of C677T polymorphsim was higher in cases than the controls (P=0.004, OR=3.077, 95% CI=1.469-6.447), so was allele T (P=0.002, OR=1.853, 95% CI=1.265-2.716). Whereas, CC gene type of A1298C polymorphism had a lower distribution in cases than the controls (P=0.008, OR=0.095, 95% CI=0.012-0.775), so was allele C (P=0.047, OR=0.610, 95% CI=0.384-0.970). Haplotype analysis and linkage disequilibrium test conducted on the alleles of two polymorphisms in MTHFR gene, we discovered that haplotype T-A had a higher distribution in cases, which indicated that susceptible haplotype T-A was the candidate factor for premature delivery.

CONCLUSIONS

Gene type TT of MTHFR C677T polymorphism might make premature delivery risk rise while gene type CC of A1298C polymorphism might have protective influence on premature delivery.

Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period

BACKGROUND

Relatively few studies have focused on the validation of psychometric scales measuring depression during pregnancy. The aim of this review was to critically appraise and review antenatal validation studies of the Edinburgh Postnatal Depression Scale (EPDS).

METHODS

A systematic search was performed in MEDLINE, EMBASE, ISI, CINAHL, SCIELO and PsyCINFO for the period 1987-2013.

RESULTS

Eleven validation studies met the inclusion criteria. The study design varied between studies. Sensitivity and specificity estimates also varied between 64-100% and 73-100%, respectively. The confidence interval estimates also showed a high degree of variability. Our estimates suggest lower positive predictive values in the general population than those reported in the validation study samples. The sensitivity values in validation studies of the EPDS show fairly large variability, ranging from good to acceptable.

LIMITATIONS

Future studies should have larger sample sizes and include both representative and clinical samples and look at the psychometric performance of the EPDS in each trimester.

CONCLUSIONS

Due to differences in study design and variation in the cultural/linguistic adaptation, uncertainty remains regarding the comparability of the sensitivity and specificity estimates of different EPDS versions. Future studies should have larger sample sizes, include both representative and clinical samples, and look at the psychometric performance of the EPDS in each trimester. Reporting quality, especially as regards checks to ensure content validity, should be improved.

Maternal Nicotine Exposure Induces Epithelial-Mesenchymal Transition in Rat Offspring Lungs

BACKGROUND

Maternal nicotine exposure induces lung injuries and fibrosis in rat offspring. Epithelial-mesenchymal transition (EMT) following lung injury is a process in which epithelial cells mediate tissue repair.

OBJECTIVE

To determine the effects of maternal nicotine exposure on EMT in neonatal rat lungs.

METHODS

Nicotine was administered to pregnant Sprague-Dawley rats using a subcutaneous osmotic minipump that delivered a dose of 6 mg/kg/day on gestational days 7-21 or from gestational day 7 to postnatal day 14. A control group received an equal volume of saline.

RESULTS

The percentage of 8-hydroxy-2'-deoxyguanosine-positive cells in nuclear staining was significantly higher, the E-cadherin protein expression was significantly lower, and the N-cadherin protein expression was significantly higher in rats born to prenatal and postnatal nicotine-treated dams than in those born to prenatal saline- and nicotine-treated dams on postnatal day 7. These characteristics of EMT were associated with a significant increase in α-smooth muscle actin (SMA) expression on postnatal day 21. Rats born to prenatal and postnatal nicotine-treated dams showed significantly higher α-SMA expression and total collagen than those born to prenatal saline- and nicotine-treated dams on postnatal day 21. The number of cells expressing fibroblast-specific protein 1 and vimentin was higher in rats born to prenatal and postnatal nicotine-treated dams than in those born to prenatal saline- and nicotine-treated dams on postnatal days 7 and 21.

CONCLUSIONS

Maternal nicotine exposure during gestation and lactation induces EMT and contributes to lung fibrosis in rat offspring.