Does light-to-moderate alcohol consumption during pregnancy increase the risk for renal anomalies among offspring?

Risks of obstructive genitourinary birth defects in relation to trihalomethane and haloacetic acid exposures: expanding disinfection byproduct mixtures analyses using relative potency factors

BACKGROUND

Some disinfection byproducts (DBPs) are teratogens based on toxicological evidence. Conventional use of predominant DBPs as proxies for complex mixtures may result in decreased ability to detect associations in epidemiological studies.

OBJECTIVE

We assessed risks of obstructive genitourinary birth defects (OGDs) in relation to 12 DBP mixtures and 13 individual component DBPs.

METHODS

We designed a nested registry-based case-control study (210 OGD cases; 2100 controls) in Massachusetts towns with complete quarterly 1999-2004 data on four trihalomethanes (THMs) and five haloacetic acids (HAAs). We estimated temporally-weighted average DBP exposures for the first trimester of pregnancy. We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for OGD in relation to individual DBPs, unweighted mixtures, and weighted mixtures based on THM/HAA relative potency factors (RPF) from animal toxicology data for full-litter resorption, eye defects, and neural tube defects.

RESULTS

We detected elevated aORs for OGDs for the highest of bromodichloromethane (aOR = 1.75; 95% CI: 1.15-2.65), dibromochloromethane (aOR = 1.71; 95% CI: 1.15-2.54), bromodichloroacetic acid (aOR = 1.56; 95%CI: 0.97-2.51), chlorodibromoacetic acid (aOR = 1.97, 95% CI: 1.23-3.15), and tribromoacetic acid (aOR = 1.90; 95%CI: 1.20-3.03). Across unweighted mixture sums, the highest aORs were for the sum of three brominated THMs (aOR = 1.74; 95% CI: 1.15-2.64), the sum of six brominated HAAs (aOR = 1.43; 95% CI: 0.89-2.31), and the sum of nine brominated DBPs (aOR = 1.80; 95% CI: 1.05-3.10). Comparing eight RPF-weighted to unweighted mixtures, the largest aOR differences were for two HAA metrics, which both were higher with RPF weighting; other metrics had reduced or minimally changed ORs in RPF-weighted models.

Increased incidence of renal and urinary tract anomalies among individuals with fetal alcohol spectrum disorders (FASD)

BACKGROUND

Fetal alcohol spectrum disorders (FASD) in a spectrum of neurodevelopmental conditions resulting from prenatal alcohol exposure (PAE). Animal models have confirmed the toxic effects of PAE on the kidneys and urinary tract, yet the evidence from human studies is contradictory. The purpose of this study was to establish the incidence of renal and urinary tract anomalies (RUTA), impaired kidney function, and hypertension among patients with FASD.

METHODS

Children from the FASD Diagnostic Center with FASD diagnosis (FAS, pFAS, or ARND) were offered participation in the study. The control group consisted of patients from the Gastroenterology Department of the same hospital. The patients underwent renal and urinary tract ultrasound examination. The serum creatinine level was also evaluated and the blood pressure was taken twice. Polish OLAF charts were used to determine the percentiles of blood pressure.

RESULTS

The incidence of kidney and urinary tract defects in the study group was significantly higher than in the control group (OR: 2.64 [1.60-4.34]). The kidney size among FASD patients was significantly lower (73 mm [60-83] vs. 83 mm [70-96]; p < .001) when compared to the control group. No differences were observed in the estimated glomerular filtration rate. In the study group, significantly lower systolic blood, diastolic blood pressure, percentile of systolic pressure, and diastolic pressure were observed.

CONCLUSIONS

RUTA occurred more frequently among patients with FASD compared to the control group, and decreased kidney size was also demonstrated among patients with FASD. However, impaired kidney function and the risk of hypertension were not observed.

Environmental and parental risk factors for congenital solitary functioning kidney - a case-control study

BACKGROUND

The etiology of congenital solitary functioning kidney (CSFK) is largely unknown but likely includes various risk factors. We performed a case-control study to compare exposure to environmental and parental risk factors during embryonic kidney development between children with CSFK and healthy controls.

METHODS

We included 434 children with CSFK and 1302 healthy controls from the AGORA data- and biobank matched on year of birth. Exposure to potential risk factors was investigated using parental questionnaire data. Crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated for each potential risk factor. Multiple imputation was used to deal with missing values. Confounders for each potential risk factor were selected using directed acyclic graphs.

RESULTS

Maternal stress was newly identified as a risk factor for CSFK (aOR 2.1, 95% CI 1.2-3.5). Known associations with conception using in vitro fertilization/intracytoplasmic sperm injection (aOR 1.8, 95% CI 1.0-3.2), maternal infections during pregnancy (aOR 2.5, 95% CI 1.4-4.7), smoking during pregnancy (aOR 1.4, 95% CI 1.0-2.0), and parental CAKUT (aOR 6.6, 95% CI 2.9-15.1) were confirmed, but previous associations with diabetes and obesity could not be replicated. Folic acid supplement use and younger maternal age seemed to reduce the risk of CSFK (aORs 0.7, 95% CI 0.5-1.0, and 0.8, 95% CI 0.6-1.0, respectively).

CONCLUSIONS

Environmental and parental risk factors are likely to be involved in the development of CSFK and future studies should combine genetic, environmental, and gene-environment interaction analyses. Women wanting to become pregnant should consider optimizing their health and lifestyle. A higher-resolution version of the Graphical abstract is available as Supplementary information.

Birth Defects Associated with Prenatal Alcohol Exposure-A Review

Since the recognition of fetal alcohol syndrome, alcohol has been accepted as a human teratogen. However, little is known about the relation between prenatal alcohol exposure and the spectrum of associated major birth defects. The objective of this review was to summarize data on the association of major congenital abnormalities and prenatal alcohol exposure. We included all major birth defects according to ICD-10 classification. We found that the strongest evidence to date lies in the research examining herniation (gastroschisis and omphalocele), oral clefts (cleft lip with or without palate and cleft palate) and cardiac defects. There is less consistent evidence supporting the association between prenatal alcohol exposure and anomalies of gastrointestinal system, diaphragmatic hernia, genitourinary system and neural tube defects. We found no material support for PAE and choanal atresia, biliary atresia or clubfoot.

Fetal Programming Is Deeply Related to Maternal Selenium Status and Oxidative Balance; Experimental Offspring Health Repercussions

Nutrients consumed by mothers during pregnancy and lactation can exert permanent effects upon infant developing tissues, which could represent an important risk factor for diseases during adulthood. One of the important nutrients that contributes to regulating the cell cycle and tissue development and functionality is the trace element selenium (Se). Maternal Se requirements increase during gestation and lactation. Se performs its biological action by forming part of 25 selenoproteins, most of which have antioxidant properties, such as glutathione peroxidases (GPxs) and selenoprotein P (SELENOP). These are also related to endocrine regulation, appetite, growth and energy homeostasis. In experimental studies, it has been found that low dietary maternal Se supply leads to an important oxidative disruption in dams and in their progeny. This oxidative stress deeply affects gestational parameters, and leads to intrauterine growth retardation and abnormal development of tissues, which is related to endocrine metabolic imbalance. Childhood pathologies related to oxidative stress during pregnancy and/or lactation, leading to metabolic programing disorders like fetal alcohol spectrum disorders (FASD), have been associated with a low maternal Se status and intrauterine growth retardation. In this context, Se supplementation therapy to alcoholic dams avoids growth retardation, hepatic oxidation and improves gestational and breastfeeding parameters in FASD pups. This review is focused on the important role that Se plays during intrauterine and breastfeeding development, in order to highlight it as a marker and/or a nutritional strategy to avoid diverse fetal programming disorders related to oxidative stress.

Programming of Renal Development and Chronic Disease in Adult Life

Chronic kidney disease (CKD) can have an insidious onset because there is a gradual decline in nephron number throughout life. There may be no overt symptoms of renal dysfunction until about two thirds or more of the nephrons have been destroyed and glomerular filtration rate (GFR) falls to below 25% of normal (often in mid-late life) (Martinez-Maldonaldo et al., 1992). Once End Stage Renal Disease (ESRD) has been reached, survival depends on renal replacement therapy (RRT). CKD causes hypertension and cardiovascular disease; and hypertension causes CKD. Albuminuria is also a risk factor for cardiovascular disease. The age of onset of CKD is partly determined during fetal life. This review describes the mechanisms underlying the development of CKD in adult life that results from abnormal renal development caused by an adverse intrauterine environment. The basis of this form of CKD is thought to be mainly due to a reduction in the number of nephrons formed in utero which impacts on the age dependent decline in glomerular function. Factors that affect the risk of reduced nephron formation during intrauterine life are discussed and include maternal nutrition (malnutrition and obesity, micronutrients), smoking and alcohol, use of drugs that block the maternal renin-angiotensin system, glucocorticoid excess and maternal renal dysfunction and prematurity. Since CKD, hypertension and cardiovascular disease add to the disease burden in the community we recommend that kidney size at birth should be recorded using ultrasound and those individuals who are born premature or who have small kidneys at this time should be monitored regularly by determining GFR and albumin:creatinine clearance ratio. Furthermore, public health measures aimed at limiting the prevalence of obesity and diabetes mellitus as well as providing advice on limiting the amount of protein ingested during a single meal, because they are all associated with increased glomerular hyperfiltration and subsequent glomerulosclerosis would be beneficial.

Prenatal alcohol exposure affects renal function in overweight schoolchildren: birth cohort analysis

BACKGROUND

Prenatal ethanol exposure has been shown to reduce nephron endowment in animal models, but the effect of alcohol during human pregnancy on postnatal kidney function has not been explored. We aim to investigate the potential association of maternal alcohol consumption during pregnancy with the offspring renal function, considering potential confounding by intrauterine growth and children's current nutritional status.

METHODS

Prospective longitudinal study in a random sample of 1093 children from a population-based birth cohort. Anthropometrics and estimated glomerular filtration rate (eGFR) were assessed at 7 years of age. Multiple linear regression models were fitted, adjusting for child's gender, age, birthweight, and maternal age, education, prepregnancy nutritional status, and smoking.

RESULTS

Thirteen percent of mothers consumed alcohol during pregnancy. At 7 years of age, eGFR was significantly lower in children with prenatal alcohol exposure (134 ± 17 vs.138 ± 16 mL/min/1.73m², p = 0.014). The effect was dose dependent and only present in overweight and obese children, among whom adjusted eGFR was -6.6(-12.0 to -1.1)mL/min/1.73m² and -11.1(-21.3 to -1.2)mL/min/1.73m² in those exposed to ≤ 40 g and to > 40 g of alcohol per week, respectively, compared to no consumption (p_trend = 0.002).

CONCLUSIONS

Prenatal alcohol exposure has a dose-dependent adverse effect on renal function at school age in overweight and obese children.

Moderate prenatal ethanol exposure in the rat promotes kidney cell apoptosis, nephron deficits, and sex-specific kidney dysfunction in adult offspring

Alcohol during pregnancy can impair fetal development and result in offspring with neurodevelopmental deficits. Less is known about how low to moderate alcohol exposure can affect other organs, such as the kidney. Here, the effects of moderate ethanol exposure throughout pregnancy on kidney development were examined using a rat model. Rats were fed a liquid diet containing 6% ethanol (vol/vol) or control (0% ethanol) throughout pregnancy. Kidneys were collected at embryonic day (E) 20 or postnatal day (PN) 30 and total glomerular (nephron) number determined using unbiased stereology. Kidney function was examined in offspring at 8 and 19 months. At E20, fetuses exposed to ethanol had fewer nephrons with increased apoptosis. Alcohol exposure caused kidney dysregulation of pro- (Bax) and anti- (Bcl-2) apoptotic factors, and reduced expression of the cell proliferation marker, Ki67. Prenatal alcohol decreased expression of Gdnf and Tgfb1, important regulators of branching morphogenesis, in male fetuses. At PN30, kidney volume and nephron number were lower in offspring exposed to prenatal alcohol. Urine flow and osmolality were normal in offspring exposed to alcohol however sodium excretion tended to be lower in females prenatally exposed to alcohol. Findings suggest exposure to moderate levels of alcohol during pregnancy results in impaired kidney development and leads to a permanent nephron deficit. Although the impact on adult kidney function was relatively minor, these data highlight that even at moderate levels, alcohol consumption during pregnancy can have deleterious long-term outcomes and should be avoided.

The association between gestational use of personal care products and neonatal urological abnormality at birth: The Japan Environment and Children's Study

Congenital anomalies of the kidney and urinary tract (CAKUT) include a broad group of birth defects. Exposure to endocrine disrupting chemicals (EDCs) is suspected to be one of the risk factors for CAKUT, and the use of personal care products (PCPs) is a source of EDC exposure. Therefore, this study aimed to investigate the relationship between CAKUT and the use of PCPs in a large birth cohort study. Data from 86,899 pregnant women included in the Japan Environment and Children's Study (JECS), an ongoing nationwide project, were analyzed. The prevalence of CAKUT in newborns was 0.25 % and almost 90 % of subjects used PCPs during mid-late pregnancy. No association was found between CAKUT and PCP use in a model adjusted for the following covariates: maternal age at delivery. The result was persistent after rigorous sensitivity analyses.

Propensity Score-Matched Analysis on the Association Between Pregnancy Infections and Adverse Birth Outcomes in Rural Northwestern China

The purpose of this study is to examine the relationship between infections and birth outcomes in pregnant Chinese women by using propensity score (PS) matching. The data used here was from a large population-based cross-sectional epidemiological survey on birth defects in Shaanxi province, Northwest China. The babies born during 2010–2013 and their mothers were selected with a stratified multistage sampling method. We used PS-matched (1:1) analysis to match participants with infections to participants without infections. Of 22916 rural participants, the overall prevalence of infection was about 39.96%. 5381 pairs were matched. We observed increased risks of birth defects with infections, respiratory infections and genitourinary infections during the pregnancy (OR, 1.59; 95% CI: 1.21–2.08; OR, 1.44; 95% CI: 1.10–1.87; OR, 3.11; 95% CI: 1.75–5.54). There was also a significant increase of low birth weight associated with respiratory infections (1.13(1.01–1.27)). The association of birth defect with the infection could be relatively stable but the effect could be mediated by some important factors such as mother’s age, education level and economic level. The infection during pregnancy is common in Chinese women and might increase the risk of offspring birth defects and low birth weight, especially in younger, lower education, poor pregnant women.

Maternal risk factors involved in specific congenital anomalies of the kidney and urinary tract: A case-control study

BACKGROUND

Congenital anomalies of the kidney and urinary tract (CAKUT) comprise a heterogeneous group of birth defects with a variety of genetic and nongenetic factors suspected of involvement in the etiology. However, little is known about risk factors in specific CAKUT phenotypes. Therefore, we studied potential maternal risk factors in individual phenotypes within the CAKUT spectrum.

METHODS

Questionnaire data were collected from parents of 562 children with CAKUT and 2139 healthy controls within the AGORA data- and biobank. Potential maternal risk factors investigated included folic acid use, overweight and obesity, smoking, alcohol consumption, subfertility, and diabetes mellitus. We performed logistic regression analyses to assess associations between these potential risk factors and CAKUT phenotypes.

RESULTS

Increased risks of CAKUT were observed for folic acid use and maternal obesity, while fertility treatment by in vitro fertilization or intrauterine insemination and diabetes diagnosed during pregnancy also seem to be associated with CAKUT. Use of multivitamins reduced the risk (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-1.0) as opposed to use of folic acid supplements only (OR, 1.3; 95% CI, 1.0-1.8). Folic acid use was associated with duplex collecting systems (OR, 1.8; 95% CI, 1.0-3.4) and vesicoureteral reflux (OR, 1.8; 95% CI, 1.1-2.9) in particular. A relatively strong association was observed between diabetes during pregnancy and posterior urethral valves (OR, 2.6; 95% CI, 1.1-5.9).

CONCLUSION

Use of folic acid only seems to be counterproductive for prevention of CAKUT, in contrast to multivitamin use. Furthermore, we observed differences in risk factor patterns among CAKUT phenotypes, which stress the importance of separate analyses for each phenotype. Birth Defects Research (Part A) 106:596-603, 2016. © 2016 Wiley Periodicals, Inc.

Selenium or selenium plus folic acid-supplemented diets ameliorate renal oxidation in ethanol-exposed pups

BACKGROUND

Ethanol (EtOH) exposure during gestation and lactation induces an oxidative stress in offspring. In kidney, the oxidative damage is the primary pathway to alcohol-induced injury. In this study, we have demonstrated that a diet supplemented with selenium (Se) (0.5 ppm) or with Se (0.5 ppm) + folic acid (8 ppm) administered to EtOH-exposed (20% v/v) dams during gestation and lactation prevents the oxidative EtOH-provoked effects in their offspring's kidneys.

METHODS

All the studies were performed on 21-day-old pups. Serum, urine, and kidney Se levels were assessed by graphite-furnace atomic absorption spectrometry. Se and creatinine clearance, antioxidant enzyme activities, and lipid and protein peroxidation were determined by a spectrophotometric method in kidney.

RESULTS

Dietary supplementation treatments used could not improve the glomerular filtration function altered by EtOH exposure during gestation and lactation; however, they did improve renal Se deposits, renal development, and renal protein content while decreasing lipid and protein oxidation and modifying antioxidant enzymes' activity.

CONCLUSIONS

Se or Se + folic acid supplementations improve renal development and protein content and modify antioxidant enzymes' activity, decreasing lipid and protein oxidation after EtOH exposure. In this context, a double-supplemented diet appears to reduce protein peroxidation more efficiently than the Se-only-supplemented one, probably via superoxide dismutase and catalase.

Maternal risk factors for congenital urinary anomalies: results of a population-based case-control study

OBJECTIVE

Epidemiologic data addressing maternal risk factors for congenital urinary tract anomalies (CUTA) are limited, with conflicting results for preexisting diabetes mellitus, gestational diabetes, and tobacco and alcohol use. The purpose of this study was to examine the association between maternal risk factors and CUTA in a population-based case-control study.

METHODS

A case-control analysis was performed using linked birth-hospital discharge records from Washington state for 1987-2007 to evaluate the association between maternal risk factors and CUTA. Cases were children with International Classification of Diseases, Ninth Revision, Clinical Modification codes for urinary anomalies. Controls without urinary tract anomalies were selected from Washington State birth records and matched by birth year in a ratio of 4:1. Logistic regression was performed to evaluate the association between maternal factors and CUTA.

RESULTS

A total of 4673 cases and 18,692 controls were studied. In the multivariate analysis, gestational diabetes (OR 1.42, 95% CI 1.09-1.85), preexisting diabetes (OR 3.46, 95% CI 2.17-5.54), and maternal renal disease (OR 5.31, 95% CI 2.40-11.72) were all associated with an increased risk of kidney anomalies. Advanced maternal age (OR 1.20, 95% CI 1.06-1.35), gestational diabetes (OR 1.25, 95% CI 1.01-1.56), maternal renal disease (OR 4.06, 95% CI 1.95-8.46), and non-Caucasian race (OR 0.82, 95% CI .74-.91) were all associated with the risk of ureter, bladder, and urethra anomalies in multivariate analysis.

CONCLUSION

Several maternal factors are associated with the risk of CUTA, including diabetes mellitus and maternal renal disease. This information can be used for prenatal counseling and management of women with these risk factors.

[Alcohol and pregnancy]

Alcohol consumption during pregnancy is a major cause of mental retardation in Western countries. Fetal alcohol syndrome (FAS) is mainly characterized by pre- and postnatal stunted growth, neurocognitive disorders, and facial dysmorphism. It compromises the intellectual and behavioral prognosis of the child. Prevention tools exist, through better information of health professionals, for optimal care of high-risk women before, during, and after pregnancy, which would decrease the incidence of SAF in the future.

Effects of light ethanol consumption during pregnancy: increased frequency of minor anomalies in the newborn and altered contractility of umbilical cord artery

This study explores the effects of light maternal ethanol consumption during pregnancy on the appearance of minor malformations in neonates as well as on the contractile properties of their umbilical cord arteries (UCAs). Clinical external findings of newborns of women declaring light ethanol consumption during any period of their pregnancies [ethanol-exposed group (E group), n=79] were compared with those of nonexposed mothers [nonexposed to ethanol group (NE group), n=100]. Women who smoked or had any associated pathology were excluded. E group mothers consumed, on average, 200-250 mL ethanol/trimester (upper limit 700 mL/trimester). Sixty-six percent of the neonates in the E group presented at least one minor malformation (retromicrognathia and minor anomalies of the auricular/preauricular area were the more common), whereas only 16% of the NE group did (p=0.0000). The percentage of children exhibiting Apgar scores <7 was significantly greater in the E group (11% versus 2%, p=0.0119). UCAs from the E group developed significantly less contractile force (p<0.05) than those of the NE group when exposed to 1 microM serotonin (5-HT) or to a high K+ depolarizing solution. This difference persisted after inhibition of endothelial release of nitric oxide (NO) and prostacyclin. In conclusion, even light drinking should be considered a risk during pregnancy.

Reported multivitamin consumption and the occurrence of multiple congenital anomalies

The purpose of this case-control study was to determine whether multivitamin use is associated with the occurrence of multiple congenital anomalies (MCA). MCA case-infants were infants with two or more major birth defects affecting at least two different organ systems, with no recognized chromosome abnormality or single gene disorder. Control-infants were a random sample of live births with no major birth defects from the same population (metropolitan Atlanta) and time period (1993-1997) as the case-infants. Exposure to multivitamins, cereals, and supplements was ascertained from a maternal telephone interview and classified based on folic acid content. We compared women who used multivitamins three or more times per week with women who were not exposed to vitamins/cereals/supplements during the periconceptional period (3 months before pregnancy through the first trimester), adjusting for maternal age, education, race/ethnicity, first degree family history of a major birth defect, pre-pregnancy maternal body mass index, gravidity, and first trimester alcohol use and cigarette smoking. Periconceptional multivitamin use was associated with MCA among all infants (adjusted odds ratio [aOR]=2.4, 95% confidence interval [CI] 0.9-6.7), and especially when analysis was limited to those with no family history of major defects (aOR=4.0, 95% CI 1.3-12.8). MCA-infants with urinary obstructive defects were more common among multivitamin-exposed infants than among unexposed infants, but this defect did not occur within a consistent pattern of defects. While these findings provide some support for one previous study, the interpretation remains unclear given the proven protective effect of multivitamins containing folic acid on isolated neural tube defects and possibly other types of defects.

Fetal alcohol spectrum disorders prevention: An exploratory study of women's use of, attitudes toward, and knowledge about alcohol

PURPOSE

The incidence of fetal alcohol spectrum disorders (FASD) is increasing, even though it is 100% preventable. This study examined use of, knowledge about, and attitudes toward alcohol of women requesting emergency contraception (EC) and/or a pregnancy test, and evaluated whether a brief intervention would be effective in educating them about the risks of FASD.

DATA SOURCES

Fifty women from two outpatient clinics participated. Information was collected on demographic and personal health habits, alcohol use, and knowledge of and attitudes toward alcohol. As a brief intervention to increase knowledge about FASD, participants read a short pamphlet about the risks of alcohol exposure in pregnancy and then completed a post-test questionnaire. Descriptive statistics, including means, standard deviations, and skewness, were calculated for all variables. Pearson correlations were computed to assess relationships between demographic/lifestyle variables and attitudes toward and knowledge about alcohol. Paired t-tests were used to analyze the relationship between pretest and post-test knowledge scores.

CONCLUSIONS

The majority of participants were single (76%), college educated (94%), and received EC at the clinic visit (60%). The average age was 24 years. Slightly over half (52%) reported drinking beer at least once a week, with one to six cans on occasion. Younger women expressed more tolerant attitudes toward alcohol use (p= .02) and drank significantly more beer on occasion (p= .015). Women who reported drinking alcohol when they last had sex were significantly (p= .017) less tolerant in their attitudes toward alcohol use. The intervention used in this study was effective in communicating knowledge about FASD to this population (p < .0001).

IMPLICATIONS FOR PRACTICE

These findings suggest that young women may be engaging in behaviors that could put potential offspring at risk for exposure to alcohol. Clinicians are advised to take a thorough history to determine alcohol use in all women of childbearing age and to provide information regarding FASD prevention.

Maternal age and non-chromosomal birth defects, Atlanta--1968-2000: teenager or thirty-something, who is at risk?

OBJECTIVE

This investigation explored the association between maternal age and non-chromosomal birth defects to assess any increased risk associated with maternal age.

METHODS

Birth defect cases were ascertained by the Metropolitan Atlanta Congenital Defects Program (MACDP), denominator information was obtained using birth certificate data. Infants with any chromosomal diagnosis were excluded. Effect estimates were calculated using 5-year maternal age categories with 25-29 years as the referent. Multiple logistic regression was used to adjust for maternal race, parity, infant sex, and birth year.

RESULTS

A total of 1,050,616 singleton infants, born after > or = 20 weeks gestation in the five counties of metropolitan Atlanta from 1968 through 2000 who did not have a chromosomal abnormality and whose mother was 14 to 40 years old, were included in the analyses, 32,816 of them were identified with birth defects by the MACDP. Young maternal age (14-19 years) was associated with anencephaly (OR = 1.81, 95% CI = 1.30-2.52), hydrocephaly without neural tube defect (OR = 1.56, 95% CI = 1.23-1.96), all ear defects (OR = 1.28, 95% CI = 1.10-1.49), cleft lip (OR = 1.88, 95% CI = 1.30-2.73), female genital defects (OR = 1.57, 95% CI = 1.12-2.19), hydronephrosis (OR = 1.42, 95% CI = 1.11-1.82), polydactyly (OR = 1.29, 95% CI = 1.09-1.52), omphalocele (OR = 2.08, 95% CI = 1.39-3.12), and gastroschisis (OR = 7.18, 95% CI = 4.39-11.75). Advanced maternal age (35-40 years) was associated with all heart defects (OR = 1.12, 95% CI = 1.03-1.22), tricuspid atresia (OR = 1.24, 95% CI = 1.02-1.50), right outflow tract defects (OR = 1.28, 95% CI = 1.10-1.49), hypospadias 2nd degree or higher (OR = 1.85, 95% CI = 1.33-2.58), male genital defects excluding hypospadias (OR = 1.25, 95% CI = 1.08-1.45) and craniosynostosis (OR = 1.65, 95% CI = 1.18-2.30).

CONCLUSIONS

Young and advanced maternal ages are associated with different types of birth defects. Underlying causes for these associations are not clear.

The Metropolitan Atlanta Congenital Defects Program: 35 years of birth defects surveillance at the Centers for Disease Control and Prevention

BACKGROUND

The Metropolitan Atlanta Congenital Defects Program (MACDP) is a population-based birth defects surveillance program administered by the Centers for Disease Control and Prevention (CDC) that has been collecting, analyzing, and interpreting birth defects surveillance data since 1967. This paper presents an overview of MACDP current methods and accomplishments over the past 35 years.

METHODS

MACDP actively monitors major birth defects among infants born to residents of five counties of metropolitan Atlanta, an area with approximately 50,000 annual births. Cases are ascertained from multiple sources, coded using a modified British Pediatric Association six-digit code, and reviewed and classified by clinical geneticists.

RESULTS

MACDP has monitored trends in birth defects rates and has served as a case registry for descriptive, risk factor, and prognostic studies of birth defects, including studies of Agent Orange exposure among Vietnam War veterans, maternal use of multivitamins, diabetes, febrile illnesses, and survival of children with neural tube defects. MACDP has served as a data source for one of the centers participating in the National Birth Defects Prevention Study, and for developing and evaluating neural tube defects prevention strategies related to the periconceptional use of folic acid supplements.

CONCLUSIONS

Since its inception, MACDP has served as a resource for the development of uniform methods and approaches to birth defect surveillance across the United States and in many other countries, monitoring birth defects rates, and as a case registry for various descriptive, etiologic, and survival studies of birth defects. MACDP has also served as a training ground for a large number of professionals active in birth defects epidemiology.

Subfertility and prepregnancy overweight/obesity: possible interaction between these risk factors in the etiology of congenital renal anomalies

BACKGROUND

Maternal subfertility and high body mass index (BMI) are both associated with adverse reproductive outcomes, including some birth defects. One study reported an association between subfertility and renal anomalies (Li, 1999).

METHODS

We defined subfertility as the mother's report that she sought fertility treatment from a doctor/clinic, and high BMI as a prepregnancy BMI > or = 25. We included 169 infants with renal anomalies (renal agenesis [n = 41], obstructive defects [n = 117], and duplication defects [n = 11]) and 2763 infants without defects who were born in 1968-1980 in metropolitan Atlanta, after excluding mothers who reported diabetes. Conditional logistic regression (matching variables: race, birth hospital, and birth period) was used to obtain effect estimates (adjusted for maternal age and gestational age).

RESULTS

Subfertility was more common among case-mothers (11.8%) than control-mothers (7.8%), high BMI was similar among case-mothers (11.2%) and control-mothers (10.9%), and joint exposure (subfertility and high BMI) was reported by 3% case-mothers and 0.7% of control-mothers. Joint exposure to subfertility and high BMI was associated with renal anomalies (odds ratio [OR] = 5.8; 95% confidence interval [CI] = 2.0-16.3). All case-mothers who reported a joint exposure had infants with obstructive renal anomalies (OR = 8.5; 95% CI = 2.9-24.7). There was no association observed for either exposure alone (subfertility and low BMI, or high BMI and no subfertility) for either all renal anomalies or obstructive defects.

CONCLUSIONS

Women who are overweight/obese and experience subfertility may be more likely to have an infant with an obstructive renal anomaly. Further exploration of possible biologic mechanisms is needed.

Maternal febrile illnesses, medication use, and the risk of congenital renal anomalies

BACKGROUND

Renal anomalies occur in about three infants per 1000 live births and have been associated with several environmental risk factors. Researchers have yet to assess the effect of maternal febrile illnesses on renal anomalies, even though febrile illnesses have been associated with other birth defects. Our objective was to determine whether maternal illness, fever, or medication use during the first trimester of pregnancy is associated with the occurrence of renal anomalies.

METHODS

In this population-based case-control study, we evaluated 192 infants with renal anomalies (renal agenesis [n = 44], obstructive defects [n = 134], and renal duplication defects [n = 14]) and 3029 infant without birth defects, all of whom were born in metropolitan Atlanta, Georgia, from 1968 through 1980. Maternal illness was defined as reported flu-like illness and/or episodic illness during the first trimester.

RESULTS

Our adjusted multivariate analyses showed that among the 192 case-infants, 38 had mothers with an illness (adjusted odds ratio [AOR], 1.71; 95% confidence interval [CI], 1.15-2.52), 20 had mothers who reported a fever (AOR, 1.80; 95% CI, 1.07-3.02) and 26 had mothers who reported taking medication (AOR, 1.69; 95% CI, 1.07-2.68). Fifteen mothers reported a fever and medication use (AOR, 1.90; 95% CI, 1.05-3.45). Nonprescription aspirin-containing medication use showed the strongest association (AOR, 3.45; 95% CI, 1.36-8.75) with renal anomalies.

CONCLUSIONS

Our data suggest that maternal exposure to illness, fever, and medication (particularly aspirin) may increase the risk of congenital renal anomalies.

Prevalence of birth defects among infants of Gulf War veterans in Arkansas, Arizona, California, Georgia, Hawaii, and Iowa, 1989-1993

BACKGROUND

Epidemiologic studies of birth defects among infants of Gulf War veterans (GWV) have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. This study was conducted to measure the prevalence of birth defects among infants of GWVs and nondeployed veterans (NDV) in states that conducted active case ascertainment of birth defects between 1989-93.

METHODS

Military records of 684,645 GWVs and 1,587,102 NDVs were electronically linked with 2,314,908 birth certficates from Arizona, Hawaii, Iowa, and selected counties of Arkansas, California, and Georgia; 11,961 GWV infants and 33,052 NDV infants were identified. Of these, 450 infants had mothers who served in the Gulf War, and 3966 had NDV mothers.

RESULTS

Infants conceived postwar to male GWVs had significantly higher prevalence of tricuspid valve insufficicieny (relative risk [RR], 2.7; 95% confidence interval [CI], 1.1-6.6; p = 0.039) and aortic valve stenosis (RR, 6.0; 95% CI, 1.2-31.0; p = 0.026) compared to infants conceived postwar to NDV males. Among infants of male GWVs, aortic valve stenosis (RR, 163; 95% CI, 0.09-294; p = 0.011) and renal agenesis or hypoplasia (RR, 16.3; 95% CI, 0.09-294; p = 0.011) were significantly higher among infants conceived postwar than prewar. Hypospadias was significantly higher among infant sons conceived postwar to GWV women compared to NDV women (RR, 6.3; 95% CI, 1.5-26.3; p = 0.015).

CONCLUSION

We observed a higher prevalence of tricuspid valve insufficiency, aortic valve stenosis, and renal agenesis or hypoplasia among infants conceived postwar to GWV men, and a higher prevalence of hypospadias among infants conceived postwar to female GWVs. We did not have the ability to determine if the excess was caused by inherited or environmental factors, or was due to chance because of myriad reasons, including multiple comparisons. Although the statistical power was sufficient to compare the combined birth defects prevalence, larger sample sizes were needed for less frequent individual component defects.

Follow-up of children of depressed mothers exposed or not exposed to antidepressant drugs during pregnancy

OBJECTIVE

To compare the structural growth and developmental outcome of children born to mothers diagnosed with major depressive disorder during pregnancy who were exposed or not exposed to selective serotonin reuptake inhibitors (SSRIs) in utero.

STUDY DESIGN

Children whose mothers were diagnosed with major depressive disorder in pregnancy and elected not to take medication (n = 13) were compared with children of depressed mothers treated with SSRIs (n = 31) on birth outcomes and postnatal neurodevelopmental functioning between ages 6 and 40 months. Children underwent blinded standardized pediatric and dysmorphology examinations and evaluations of their mental and psychomotor development with the use of the Bayley Scales of Infant Development (BSID II).

RESULTS

The Bayley mental developmental indexes were similar in both groups. Children exposed to SSRIs during pregnancy had lower APGAR scores and scored lower on the Bayley psychomotor development indexes and the motor quality factor of the Bayley Behavioral Rating Scale than unexposed children.

CONCLUSIONS

The findings that SSRIs during fetal development might have subtle effects on motor development and motor control are consistent with the pharmacologic properties of the drugs.