Exposure of hospitalised pregnant women to plasticizers contained in medical devices

Environmental Exposures and Pediatric Cardiology: A Scientific Statement From the American Heart Association

Environmental toxicants and pollutants are causes of adverse health consequences, including well-established associations between environmental exposures and cardiovascular diseases. Environmental degradation is widely prevalent and has a long latency period between exposure and health outcome, potentially placing a large number of individuals at risk of these health consequences. Emerging evidence suggests that environmental exposures in early life may be key risk factors for cardiovascular conditions across the life span. Children are a particularly sensitive population for the detrimental effects of environmental toxicants and pollutants given the long-term cumulative effects of early-life exposures on health outcomes, including congenital heart disease, acquired cardiac diseases, and accumulation of cardiovascular disease risk factors. This scientific statement highlights representative examples for each of these cardiovascular disease subtypes and their determinants, focusing specifically on the associations between climate change and congenital heart disease, airborne particulate matter and Kawasaki disease, blood lead levels and blood pressure, and endocrine-disrupting chemicals with cardiometabolic risk factors. Because children are particularly dependent on their caregivers to address their health concerns, this scientific statement highlights the need for clinicians, research scientists, and policymakers to focus more on the linkages of environmental exposures with cardiovascular conditions in children and adolescents.

Endocrine-disrupting chemicals: Mainstream recognition of health effects and implications for the practicing internist

Rapidly advancing evidence documents that a broad array of synthetic chemicals found ubiquitously in the environment contribute to disease and disability across the lifespan. Although the early literature focused on early life exposures, endocrine-disrupting chemicals (EDCs) are now understood to contribute substantially to chronic disease in adulthood, especially metabolic, cardiovascular, and reproductive consequences as well as endocrine cancers. The contribution to mortality is substantial, with over 90,000 deaths annually and at least $39 billion/year in lost economic productivity in the United States (US) due to exposure to certain phthalates that are used as plasticizers in food packaging. Importantly, exposures are disproportionately high in low-income and minoritized populations, driving disparities in these conditions. Though non-Hispanic Blacks and Mexican Americans comprise 12.6% and 13.5% of the US population, they bear 16.5% and 14.6% of the disease burden due to EDCs, respectively. Many of these exposures can be modified through safe and simple behavioral changes supported by proactive government action to both limit known hazardous exposures and to proactively screen new industrial chemicals prior to their use. Routine healthcare maintenance should include guidance to reduce EDC exposures, and a recent report by the Institute of Medicine suggests that testing be conducted, particularly in populations heavily exposed to perfluoroalkyl substances-chemicals used in nonstick coatings as well as oil- and water-resistant clothing.

A review on solution- and vapor-responsive sensors for the detection of phthalates

Phthalic acid esters, largely referred to as phthalates, are today acknowledged as important pollutants used in the manufacture of polyvinyl chloride (PVC)-based plastics, whose use extends to almost every aspect of modern life. The risk of exposure to phthalates is particularly relevant as high concentrations are regularly found in drinking water, food-contact materials and medical devices, motivating an immense body of research devoted to methods for their detection in liquid samples. Conversely, phthalate vapors have only recently been acknowledged as potentially important atmospheric pollutants and as early fire indicators; additionally, deposition of these vapors can pose significant problems to the proper functioning of spacecraft and diverse on-board devices, leading to major space agencies recognizing the need of developing vapor-responsive phthalate sensors. In this manuscript we present a literature survey on solution- and vapor-responsive sensors and analytical assays for the detection of phthalates, providing a detailed analysis of a vast array of analytical data to offer a clear idea on the analytical performance (limits of detection and quantification, linear range) and advantages provided by each class of sensor covered in this review (electrochemical, optical and vapor-responsive) in the context of their potential real-life applications; the manuscript also gives detailed fundamental information on the various physicochemical responses exploited by these sensors and assays that could potentially be harnessed by new researchers entering the field.

Assessment of the plasticizer exposure of hospital workers regularly handling medical devices: A pilot study

Plastic medical devices, e.g. infusion sets, blood bags or tubing material, that are used manifold in the medical treatment of hospital patients, usually contain considerable amounts of plasticizers. Whereas several studies showed highly elevated inner plasticizer levels of patients treated with plasticized medical devices, little is known about the exposure situation of hospital staff. The present pilot study aimed to evaluate the urinary plasticizer metabolite levels of selected hospital workers of the blood bank (medical technical assistants, MTA) and of perfusionists that are regularly handling plasticized medical devices in order to estimate the work-related amount of the inner individual plasticizer exposure. The study subjects were asked to collect pre- and post-shift spot urine samples over the course of a working week, that were subsequently analyzed for selected urinary metabolites of the plasticizers DEHP, DINCH, DEHTP and TEHTM. Although the observed differences were rather low, a differentiated approach revealed a perceptible impact of the respective workplace environment on the individual urinary plasticizer metabolite levels. Thus, the group of blood bank MTA showed significantly elevated increment levels of urinary DEHP and DINCH metabolites, while the group of perfusionists, showed a considerable higher detection frequency of the main urinary TEHTM metabolite. All in all, however, it can be cautiously concluded by the results of the presented pilot study that a regular handling of plasticized medical devices by hospital employees (via inhalation or dermal contact) contributes demonstrably but yet only marginally to the individual internal plasticizer exposure.

Preparation of SERS substrate with 2D silver plate and nano silver sol for plasticizer detection in edible oil

As a widely used industrial additive of plastic products, phthalate ester (PAE) plasticizers can easily migrate into food, threatening human health. In this work, we proposed a rapid, precise, and reliable method to detect PAE plasticizers in edible oils by using surface-enhanced Raman spectroscopy (SERS) technology. A two-dimensional (2D) silver plate synergizing with a nanosilver sol was prepared as a substrate for SERS to detect potassium hydrogen phthalate (PHP), a hydrolysate of a PAE plasticizer. Detection conditions, such as pH values, drying times, and hydrolysate interference, were optimized. The working curve was well fitted with a linear parameter R² of 0.9994, and the minimum detection limit was evaluated as 10^-9 mol/L. Furthermore, the detection accuracy was supported by five edible oil samples. Therefore, using SERS technology to detect PHP is expected to provide an avenue for PAE plasticizer detection in oils and fats, and it features promising potential applications in food safety.

The Pediatrician's Role in Protecting Children from Environmental Hazards

Children suffer disproportionately from disease and disability due to environmental hazards, for reasons rooted in their biology. The contribution is substantial and increasingly recognized, particularly due to ever-increasing awareness of endocrine disruption. Regulatory actions can be traced directly to reductions in toxic exposures, with tangible benefits to society. Deep flaws remain in the policy framework in industrialized countries, failing to offer sufficient protection, but are even more limited in industrializing nations where the majority of chemical production and use will occur by 2030. Evidence-based steps for reducing chemical exposures associated with adverse health outcomes exist and should be incorporated into anticipatory guidance.

Simultaneous and sensitive determination of the main metabolites of the plasticizer DEHP and its substitutes DEHTP, DINCH and TEHTM in human urine by coupling of on-line SPE, UHPLC and tandem mass spectrometry

With the prominent but toxicologically critical plasticizer di-(2-ethylhexyl) phthalate (DEHP) declining, alternative plasticizers are increasingly used leading to a continuously more diverse exposure situation of humans with multiple plasticizers. Therefore, an on-line SPE-LC-MS/MS method for the simultaneous determination of the most relevant urinary biomarkers of exposure to DEHP and the alternative plasticizers 1,2-cyclohexane dicarboxylic acid diisononyl ester (DINCH), di-(2-ethylhexyl) terephthalate (DEHTP) and tri-(2-ethylhexyl) trimellitate (TEHTM) was developed. The method is characterized by a high sensitivity with limits of detection ranging from 0.006 to 0.047 μg L^-1 combined with an easy and straightforward sample preparation procedure. The wide linear working range of the method enables a reliable determination of analyte background levels in the general population as well as its potential use for monitoring studies investigating elevated plasticizer exposure settings. The method was successfully applied to urine samples from ten volunteers without occupational exposure to plasticizers revealing ubiquitous background exposure levels of the common plasticizers DEHP, DEHTP and DINCH.

Medical devices as a source of phthalate exposure: a review of current knowledge and alternative solutions

Phthalates are a group of phthalic acid esters used as plasticisers in a large number of products to improve their flexibility, softness, and extensibility. Their wide use in medical devices, however, raises a lot of concern, as they can enter the organism and have toxic effects on human liver, thyroid, kidneys, lungs, reproductive, endocrine, nervous, and respiratory system and are associated with asthma, obesity, autism, and diabetes. The aim of this review is to summarise current knowledge about phthalate migration from medical devices during different medical procedures and possible impact on patient health. It also looks at alternative plasticisers with supposedly lower migration rates and safer profile. Not enough is known about which and how many phthalates make part of medical devices or about the health impacts of alternative plasticisers or their migration rates.

Phthalates and Alternative Plasticizers Differentially affect Phenotypic Parameters in Gonadal Somatic and Germ Cell Lines

The developmental and reproductive toxicity associated with exposure to phthalates has motivated a search for alternatives. However, there is limited knowledge regarding the adverse effects of some of these chemicals. We used high-content imaging to compare the effects of mono (2-ethylhexyl) phthalate (MEHP) with six alternative plasticizers: di-2-ethylhexyl terephthalate (DEHTP); diisononyl-phthalate (DINP); di-isononylcyclohexane-1,2-dicarboxylate (DINCH); 2-ethylhexyl adipate (DEHA); 2,2,4-trimethyl 1,3-pentanediol diisobutyrate (TXIB) and di-iso-decyl-adipate (DIDA). A male germ spermatogonial cell line (C18-4), a Sertoli cell line (TM4) and two steroidogenic cell lines (MA-10 Leydig and KGN granulosa) were exposed for 48h to each chemical (0.001-100 μM). Cell images were analyzed to assess cytotoxicity and effects on phenotypic endpoints. Only MEHP (100 μM) was cytotoxic and only in C18-4 cells. However, several plasticizers had distinct phenotypic effects in all four cell lines. DINP increased Calcein intensity in C18-4 cells, whereas DIDA induced oxidative stress. In TM4 cells, MEHP, and DINCH affected lipid droplet numbers, while DEHTP and DINCH increased oxidative stress. In MA-10 cells, MEHP increased lipid droplet areas and oxidative stress; DINP decreased the number of lysosomes, while DINP, DEHA and DIDA altered mitochondrial activity. In KGN cells, MEHP, DINP and DINCH increased the number of lipid droplets, whereas DINP decreased the number of lysosomes, increased oxidative stress and affected mitochondria. The Toxicological Priority Index (ToxPi) provided a visual illustration of the cell line specificity of the effects on phenotypic parameters. The lowest administered equivalent doses were observed for MEHP. We propose that this approach may assist in screening alternative plasticizers.

Urinary phthalate metabolite concentrations and serum hormone levels in pre- and perimenopausal women from the Midlife Women's Health Study

BACKGROUND

Phthalate exposure is associated with altered reproductive function, but little is known about associations between phthalate and hormone levels in midlife women.

METHODS

This cross-sectional analysis includes 45-54-year-old pre- and perimenopausal women from Baltimore, MD and its surrounding counties enrolled in the Midlife Women's Health Study (n = 718). Serum and urine samples were collected from participants once a week for four consecutive weeks to span the menstrual cycle. Serum samples were assayed for estradiol, testosterone, progesterone, sex hormone binding globulin (SHBG), follicle-stimulating hormone (FSH), and anti-Müllerian hormone (AMH), and geometric means were calculated for each hormone across all four weeks. Urine samples were analyzed for nine phthalate metabolites from pools of one-to-four urine samples. Phthalate metabolite concentrations were specific gravity-adjusted and assessed as individual metabolites or as molar sums of metabolites from common parents (di(2-ethylhexyl) phthalate metabolites, ∑DEHP), exposure sources (plastic, ∑Plastics; personal care products, ∑PCP), biological activity (anti-androgenic, ∑AA), and sum of all metabolites (∑Phthalates). We used linear regression models to assess overall associations of phthalate metabolites with hormones, controlling for important demographic, lifestyle, and health factors. We also explored whether associations differed by menopause status, body mass index (BMI), and race/ethnicity.

RESULTS

Most participants were non-Hispanic white (67%) or black (29%), college-educated (65%), employed (80%), and had somewhat higher mean urinary phthalate metabolite concentrations than other U.S. women. Overall, the following positive associations were observed between phthalate metabolites and hormones: ∑DEHP (%Δ: 4.9; 95%CI: 0.5, 9.6), ∑Plastics (%Δ: 5.1; 95%CI: 0.3, 10.0), and ∑AA (%Δ: 7.8; 95%CI: 2.3, 13.6) with estradiol; MiBP (%Δ: 6.6; 95%CI: 1.5, 12.1) with testosterone; ∑DEHP (%Δ: 8.3; 95%CI: 1.5, 15.6), ∑Plastics (%Δ: 9.8; 95%CI: 2.4, 17.7), MEP (%Δ: 4.6; 95%CI: 0.1, 9.2), ∑PCP (%Δ: 6.0; 95%CI: 0.2, 12.2), ∑Phthalates (%Δ: 9.0; 95%CI: 2.1, 16.5), and ∑AA (%Δ: 12.9; 95%CI: 4.4, 22.1) with progesterone; and MBP (%Δ: 8.5; 95%CI: 1.2, 16.3) and ∑AA (%Δ: 9.0; 95%CI: 1.3, 17.4) with AMH. Associations of phthalate metabolites with hormones differed by menopause status (strongest in premenopausal women for estradiol, progesterone, and FSH), BMI (strongest in obese women for progesterone), and race/ethnicity (strongest in non-Hispanic white women for estradiol and AMH).

CONCLUSIONS

We found that phthalate metabolites were positively associated with several hormones in midlife women, and that some demographic and lifestyle characteristics modified these associations. Future longitudinal studies are needed to corroborate these findings in more diverse midlife populations.

Parenteral Nutrition and Oxidant Load in Neonates

Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via parenteral nutrition (PN) becomes necessary for short-term survival, as well as long-term health. However, the elemental nutrients in PN can be a major source of oxidants due to interactions between nutrients, imbalances of anti- and pro-oxidants, and environmental conditions. Moreover, neonates fed PN are at greater risk of oxidative stress, not only from dietary sources, but also because of immature antioxidant defences. Various interventions can lower the oxidant load in PN, including the supplementation of PN with antioxidant vitamins, glutathione, additional arginine and additional cysteine; reduced levels of pro-oxidant nutrients such as iron; protection from light and oxygen; and proper storage temperature. This narrative review of published data provides insight to oxidant molecules generated in PN, nutrient sources of oxidants, and measures to minimize oxidant levels.

Endocrine Disruptors and the Induction of Insulin Resistance

INTRODUCTION

The incidence of insulin resistance syndrome and type 2 diabetes mellitus has increased at an alarming rate worldwide and constitutes a serious challenge to public health care in the 21st century. Endocrine disrupting chemicals are defined as "substances or mixtures of substances that alter the endocrine system functions and, hence, adversely affect organisms, their progeny, or sub populations" and may be associated with this increase in prevalence.

OBJECTIVE

This study aimed to assess the role of endocrine disrupting chemicals in insulin resistance and the importance of approaching the subject during anamnesis.

METHODS

A full review of the literature regarding insulin resistance, type-2 diabetes and endocrine disruptors were conducted.

CONCLUSION

Large-scale production and distribution of endocrine disrupting chemicals coincide with the increase in the prevalence of insulin resistance globally. In recent years, studies have shown that endocrine disrupting chemicals are positively associated with insulin resistance syndrome, evidenced by worse prognoses among individuals with higher levels of exposure. Health professionals should recognize the forms of exposure, most susceptible people, and lifestyle habits that can worsen patients' prognoses.

The effects of the phthalate DiNP on reproduction†

Di-isononyl phthalate (DiNP) is a high molecular weight, general purpose, plasticizer used primarily in the manufacture of polymers and consumer products. It can be metabolized rapidly and does not bioaccumulate. The primary metabolite of DiNP is monoisononyl-phthalate (MiNP) and the secondary metabolites include three oxidative derivatives of DiNP, which have been identified mainly in urine: mono-oxoisononyl phthalate (MOINP or oxo-MiNP), mono-carboxyisooctyl phthalate (MCIOP, MCOP or cx-MiNP), and mono-hydroxyisononyl phthalate (MHINP or OH-MiNP). The secondary metabolites are very sensitive biomarkers of DiNP exposure while primary metabolites are not. As the usage of DiNP worldwide increases, studies evaluating its potential reproductive toxicity are becoming more prevalent in the literature. In studies on female animals, the researchers found that the exposure to DiNP appears to induce negative effects on ovarian function and fertility in animal models. Whether or not DiNP has direct effects on the uterus is still controversial, and the effects on human reproduction require much more research. Studies on males indicate that DiNP exposure has disruptive effects on male reproduction and fertility. Occupational studies also indicate that the exposure to DiNP might induce negative effects on male reproduction, but larger cohort studies are needed to confirm this. This review presents an overview of the literature regarding the reproductive effects of exposure to DiNP.

An update on the hazard of and exposure to diethyl hexyl phthalate (DEHP) alternatives used in medical devices

The use of the plasticizer diethyl hexyl phthalate (DEHP) in PVC medical devices is being questioned due to its potential reprotoxic effects in patients exposed as a result from migration from the device. This article reviews new information on migration and toxicity data of eleven alternative plasticizers that have previously been evaluated by the Danish EPA and the EU SCENIHR (Scientific Committee on Emerging and Newly Identified Health Risks). The new toxicity data did not justify the reconsideration of the critical NOAELs as established by SCENIHR and Danish EPA. The dataset on oral toxicity studies is rather complete for most substances; however, in particular for reproductive toxicity and endocrine disruption, data gaps still exist for many alternatives. Toxicity data on intravenous exposure are lacking and these are essential to conclude on hazard characteristics of alternatives that are poorly absorbed via the oral exposure route. Migration data are emerging for a few alternatives but still sparse for the majority of the alternatives. Taking all data on migration and toxicity in consideration, 1,2-cyclohexanedicarboxylic acid, diisononylester (DINCH), and tris(2-ethylhexyl)benzene-1,2,4-tricarboxylate display a more favorable profile compared to DEHP. For these promising alternatives, a risk assessment for use in medical devices should be conducted. As a next step, we recommend the (further) generation of relevant migration data and, where needed, relevant toxicity data for the alternative substances, in order to be able to conduct a benefit-risk analysis of DEHP and the alternatives as obligatory in the new European Union Medical Device Regulation.

Unwitting Accomplices: Endocrine Disruptors Confounding Clinical Care

Burgeoning evidence over the last 25 years has identified myriad synthetic chemicals with the capacity to alter various aspects of hormone synthesis and action. These endocrine-disrupting chemicals (EDCs) have been linked to various diseases, including reproductive disorders, metabolic diseases, and developmental abnormalities, among others. Exposure to EDCs arises from industrial activity, use of personal and home care products, and consumption of contaminated food and water; however, the role of healthcare in exposing individuals to EDCs is grossly underappreciated. Indeed, through the use of medications as well as medical equipment and devices, healthcare providers are unknowing mediators of exposure to EDCs, chemicals that might not only promote disease but that may also antagonize the efficacy of treatments. The ethical implications of provider-dependent exposure are profound. A failure to disclose the endocrine-disrupting properties of medical interventions violates core principles of nonmaleficence, patient autonomy, and justice as well as the practice of informed consent. Furthermore, physicians' lack of knowledge regarding EDCs in medical practice artificially skews risk-benefit calculations that are fundamental to informed medical decision-making. To combat this underappreciated ethical challenge, urgent action is required. Healthcare providers must be educated about endocrine disruption. Known EDCs, defined by endocrinologists, should be clearly labeled on all medical products, and all medication components and devices should be screened for endocrine-disrupting properties. Finally, communication strategies must be devised to empower patients with knowledge about these risks. Providing ethically competent care requires an open acknowledgment of endocrine risks imposed by the medical community that have heretofore been ignored.

New SPE-LC-MS/MS method for the simultaneous determination in urine of 22 metabolites of DEHP and alternative plasticizers from PVC medical devices

DiEthylHexylPhthalate (DEHP) can leach out of plasticized PVC medical devices (MD) and may enter into contact with patients. This phthalate is known for its reprotoxic and endocrine disrupting effects. Its use in medical devices (MD) has been restricted and alternative plasticizers have been developed. Nevertheless, no published clinical studies exist concerning patient exposure to these alternative plasticizers during medical care. This is particularly worrisome when high-risk populations, such as newborns, are exposed to these new plasticizers in intensive care units. Our study aimed to develop a novel sensitive and selective method to simultaneously identify and quantify DEHP and 17 other plasticizer metabolites (free or glucuronide conjugates), which are specific biomarkers of DEHTP, TOTM, DINP, DINCH and DEHA exposure in human urine. This robust method uses turbulent-flow online extraction technology coupled to high performance liquid chromatography - tandem mass spectrometry. Special care was taken to address two major problems in plasticizer analysis: contamination and chromatographic separation of interfering analogue structures. The validation was assessed in synthetic urine and the linearity of response was demonstrated for all compounds (R² > 0.99), with limits of quantification from 0.01 to 0.1 ng/ml. Accuracies ranged from 86% to 117% and inter- and intra-day precisions were <20%. The clinical applicability and suitability of our new method was assessed in patients in a neonatal intensive care unit to measure urinary concentrations of DEHP and alternative plasticizer metabolites. These metabolites were found in the majority of urine samples, with a median detection frequency of 95.2% (ranging from 12.5% to 100%). The high sensitivity, selectivity and ruggedness make the method suitable for large-scale biomonitoring studies of high-risk and general populations.

Phthalates exposure and uterine fibroid burden among women undergoing surgical treatment for fibroids: a preliminary study

OBJECTIVES

To examine the association between phthalate exposure and two measures of uterine fibroid burden: diameter of largest fibroid and uterine volume.

DESIGN

Pilot, cross-sectional study.

SETTING

Academic medical center.

PATIENT(S)

Fifty-seven premenopausal women undergoing either hysterectomy or myomectomy for fibroids.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The diameter of the largest fibroid and uterine dimensions were abstracted from medical records. Spot urine samples were analyzed for 14 phthalate biomarkers using mass spectrometry. We estimated associations between fibroid outcomes and individual phthalate metabolites, sum of di(2-ethylhexyl) phthalate metabolites (∑DEHP), and a weighted sum of anti-androgenic phthalate metabolites (∑AA Phthalates) using linear regression, adjusting for age, race/ethnicity, and body mass index. Fibroid outcomes were also examined dichotomously (divided at the median) using logistic regression.

RESULTS

Most women were of black ethnicity, overweight or obese, and college educated. In multivariable models, higher levels of mono-hydroxyisobutyl phthalate, monocarboxyoctyl phthalate, monocarboxynonyl phthalate, mono(2-ethylhexyl) phthalate, mono(2-ethyl-5-hydroxyhexyl phthalate) (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), ∑DEHP, and ∑AA Phthalates were positively associated with uterine volume. Associations were most pronounced for individual DEHP metabolites (MEHHP, MEOHP, MECPP), ∑DEHP, and ∑AA Phthalates. For example, a doubling in ∑DEHP and ∑AA Phthalates was associated with 33.2% (95% confidence interval 6.6-66.5) and 26.8% (95% confidence interval 2.2-57.4) increase in uterine volume, respectively. There were few associations between phthalate biomarkers and fibroid size.

CONCLUSIONS

Exposure to some phthalate biomarkers was positively associated with uterine volume, which further supports the hypothesis that phthalate exposures may be associated with fibroid outcomes. Additional studies are needed to confirm these relationships.

Impacts of bisphenol A (BPA) and phthalate exposures on epigenetic outcomes in the human placenta

The placenta guides fetal growth and development. Bisphenol A (BPA) and phthalates are widespread environmental contaminants and endocrine disruptors, and the placental epigenetic response to these chemicals is an area of growing research interest. Therefore, our objective was to summarize research linking BPA or phthalate exposure to placental outcomes in human pregnancies, with a particular focus on epigenetic endpoints. In PubMed, studies were selected for review (without limiting start date and ending on 1 May 2018) if they reported any direct effects of BPA or phthalates on the placenta in humans. Collectively, available studies suggest that BPA and phthalate exposures are associated with changes to placental micro-RNA expression, DNA methylation, and genomic imprinting. Furthermore, several studies suggest that fetal sex may be an important modifier of placental outcomes in response to these chemicals. Studies in humans demonstrate associations of BPA and phthalate exposure with adverse placental outcomes. Moving forward, more studies should consider sex differences (termed "placental sex") in the measured outcomes, and should utilize appropriate statistical approaches to assess modification by fetal sex. Furthermore, more consistent sample collection and molecular outcome assessment paradigms will be indispensable for making progress in the field. These advances, together with improved non-invasive tools for measuring placental function and outcomes across pregnancy, will be critical for understanding the mechanisms driving placental epigenetic disruption in response to BPA and phthalates, and how these disruptions translate into placental and fetal health.