Risk of spontaneous preterm birth in relation to maternal experience of serious life events during pregnancy

The Association Between Pre-Pregnancy and First-Trimester Hair Cortisol and Preterm Birth: A Causal Inference Model

Background Adverse life events and chronic psychological distress before and during pregnancy have frequently been associated with preterm birth (PTB) but the biological underpinnings remain unclear. We investigated the association between corticosteroid levels in pre-pregnancy and first-trimester hair and the risk of PTB. Methods We followed 1,808 pregnant women from a prospective pre-birth cohort study in Lima, Perú. Hair samples were taken at the end of the first pregnancy trimester. The two most proximal 3cm segments to the scalp (representing pre-pregnancy and first-trimester) were analyzed to obtain hair cortisol and cortisone concentrations (HCC and HCNC). PTB was defined as birth < 37 completed gestational weeks. We constructed four generalized propensity scores for pre-pregnancy and first-trimester HCC and HCNC to create corresponding inverse probability weights before fitting marginal structural models for estimating the effect of HCC and HCNC on PTB risk. Results Pre-pregnancy Log HCC was not independently associated with PTB risk (RR = 0.97; 95%CI: 0.79, 1.19). In contrast, one SD increase from the mean first-trimester Log HCC was independently associated with a 37% (95%CI: 1.11, 1.69) increased risk of PTB. Although imprecise, pre-pregnancy Log HCNC was negatively associated with PTB risk (RR = 0.84; 95%CI: 0.58, 1.20), whereas the association between first-trimester Log HCNC and PTB risk was positive (RR = 1.20; 95%CI: 0.87, 1.65). Conclusions Our findings show that chronic corticosteroid levels in early pregnancy are causally linked to PTB risk in pregnant Peruvian women. This finding contributes to understanding the biological underpinnings of PTB better to enhance PTB prevention.

Magnitude and associated factors of stillbirth among women who gave birth at Hiwot Fana Specialized University Hospital, Harar, eastern Ethiopia

INTRODUCTION

According to WHO, there are nearly 2 million stillbirths every year, one every 16 seconds. The objective of our study was to assess the frequency and associated factors of stillbirth among women who gave birth at Hiwot Fana Specialized University Hospital, Harar, eastern Ethiopia, 2021.

METHODS

An institution-based retrospective cross-sectional study of medical records was conducted among 336 women who gave birth from 1 January 2020 to 31 December 2020. Maternal medical records were selected by systematic random sampling technique and a pre-tested checklist was used to collect data. Data entry and analysis were done using SPSS-version 20. Bivariate and multivariate logistic regressions were performed to identify factors associated with stillbirth. Adjusted odds ratios with 95% confidence intervals are reported.

RESULTS

The frequency of stillbirth was 12.5% (95% CI: 8.1–14.6). Preterm delivery (AOR=8.10; 95% CI: 3.01–21.79), non-booking for antenatal care (AOR=2.8; 95% CI: 1.14–6.88), antepartum hemorrhage (AOR=3.16; 95% CI: 1.10–9.04), obstructed labor (AOR=2.56; 95% CI: 1.85–7.93) and eclampsia (AOR=2.84; 95% CI: 1.45–6.98) were found to be statistically significantly associated with stillbirth.

CONCLUSIONS

The frequency of stillbirth in this study was high. Prematurity, non-booking for antenatal care, ante-partum hemorrhage, obstructed labor and eclampsia were independently associated for stillbirth. Therefore, we recommend that the health professionals should better work on prevention of preterm birth, active emergency obstetrical and neonatal care by boosting focused antenatal care follow-up with health education on danger signs.

Maternal exposure to life events during pregnancy and congenital heart disease in offspring: a case-control study in a Chinese population

Background

Previous studies have suggested that maternal stress could increase the risk of some adverse pregnancy outcomes, but evidence on congenital heart disease (CHD) is limited. We aimed to explore the association between maternal exposure to life events during pregnancy and CHD in offspring.

Methods

The data was based on an unmatched case-control study about CHD conducted in Shaanxi province of China from 2014 to 2016. We included 2280 subjects, 699 in the case group and 1581 in the control group. The cases were infants or fetuses diagnosed with CHD, and the controls were infants without any birth defects. The life events were assessed by the Life Events Scale for Pregnant Women, and were divided into positive and negative events for synchronous analysis. A directed acyclic graph was drawn to screen the confounders. Logistic regression was employed to estimate the odds ratio and 95% confidence interval for the effects of life events on CHD.

Results

After controlling for the potential confounders, the pregnant women experiencing the positive events during pregnancy had lower risk of CHD in offspring than those without positive events (OR = 0.38, 95%CI: 0.30 ~ 0.48). The risk of CHD in offspring could increase by 62% among the pregnant women experiencing the negative events compared to those without (OR = 1.62, 95%CI: 1.29 ~ 2.03). Both effects showed a certain dose-response association. Besides, the positive events could weaken the risk impact of negative events on CHD.

Conclusion

It may suggest that maternal exposure to negative life events could increase the risk of CHD in offspring, while experiencing positive events could play a potential protective role.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04154-0.

Adverse Pregnancy Outcomes Following the Assassination of John F. Kennedy in 1963

INTRODUCTION

Women exposed to stressful events during pregnancy are thought to be at increased risk of adverse birth outcomes. However, studies investigating stressful events are often unable to control for important confounders, such as behavioral and genetic characteristics, or to isolate the impact of the stressor from other secondary effects. We used a discordant-sibling design, which provides stronger inferences about causality, to examine whether a widespread stressor with limited impact on day-to-day life (John F. Kennedy assassination) resulted in an increased risk of adverse birth outcomes.

METHODS

Data were obtained from the Collaborative Perinatal Project, a prospective, multi-site cohort study conducted in the US from 1959 to 1965. Our analysis was restricted to singleton live births ≥24 weeks born before the assassination (n = 24,406) or in utero at the time (n = 5833). We also evaluated associations within siblings discordant for exposure (n = 1144). We used survival analysis to evaluate associations between exposure and preterm birth and marginal models to evaluate associations with birthweight and placental pathology.

RESULTS

First trimester exposure was associated with preterm birth (hazard ratio (HR): 1.17; 95% CI: 1.05, 1.31). In the discordant-sibling model, the point estimate was similar (HR: 1.22; 95% CI: 0.36, 4.06). Third trimester exposure was associated with increased odds of fetal acute inflammation in the placenta (odds ratio (OR): 1.34, 95% CI: 1.05, 1.71).

CONCLUSIONS FOR PRACTICE

First trimester exposure to an acute stressor was associated with preterm birth. We did not observe increased odds of placental pathology with first trimester exposure; however, stress may increase preterm birth risk through chronic placental inflammation, which was not evaluated in this sample.

Integrative Review of Pregnancy and Birth Outcomes After Exposure to a Hurricane

OBJECTIVE

To appraise and analyze published research on the relationships among hurricane exposure and adverse pregnancy and birth outcomes.

DATA SOURCES

A literature search was conducted in four electronic databases: CINAHL Plus, Embase, PubMed, and Web of Science. The following search terms were used: "cyclonic storms," "cesarean section," "premature birth," "fetal mortality," "low birth weight," "infant mortality," "pregnancy complications," and "pregnancy outcome."

STUDY SELECTION

Documents were included if they were peer-reviewed, full-text articles or government documents published in English through February 2020 that focused on the associations among exposure to hurricanes and adverse pregnancy and birth outcomes. The initial search yielded 211 articles, and one article was identified through a hand search. After 48 duplicates were removed, we screened the titles and abstracts of 164 articles. We conducted a full-text review of 57 articles, and 19 articles were included in the integrative review.

DATA EXTRACTION

We extracted data from the full text of each article into a standardized table with the following headings: author, year of publication, location, hurricane and year, population studied, study design, outcomes, data source, and results.

DATA SYNTHESIS

We analyzed study findings based on the outcomes of pregnancy complications, preterm birth, cesarean birth, labor and birth complications, low birth weight, abnormal newborn conditions, and fetal mortality. We synthesized data in a narrative format, and the synthesis indicated that hurricane exposure was frequently associated with pregnancy complications, preterm birth, low birth weight, cesarean birth, and abnormal newborn conditions. However, these associations were not always consistent. Extant research is limited by inconsistency among study designs and the type of hurricane exposure.

CONCLUSION

Interdisciplinary teams that include nurses, midwives, obstetricians and gynecologists, and other health care professionals should ensure that hurricane preparedness and response efforts specifically address the needs of pregnant women to mitigate adverse outcomes.

The Effect of Perceived Stress During Pregnancy on Preterm Birth

Background

Preterm birth is one of the most common problems in pregnancy globally, often leading to neonatal death. The rate of preterm birth is increasing every year. The etiology of preterm birth is multifactorial; preventable maternal psychosocial stress is one of the causes of preterm birth. There has not yet been a report of maternal psychosocial stress and preterm birth in Thailand. This study aimed to explore the relationship between maternal perceived stress and preterm birth.

Objective

To study the effects of maternal perceived stress on preterm birth.

Patients and Methods

An unmatched case–control study was conducted in postpartum women, between January 17, 2019, and September 30, 2019, at the Department of Obstetrics and Gynecology, Faculty of Medicine, Vajira Hospital. A total of 200 participants were enrolled and divided into case and control groups in a 1:1 ratio. The case group consisted of postpartum women with preterm birth and the control group consisted of consecutive postpartum women with term birth. Perceived stress was measured by using the Thai Perceived Stress Scale-10 (T-PSS-10).

Results

Maternal perceived stress during pregnancy was significantly greater in preterm birth compared with term birth in both means score (19.43±4.48 vs 14.08±4.06, p<0.001) and moderate to high stress level (92 vs 51, p<0.001). Perceived stress score and stress level were significant predictive factors for preterm birth (AOR 1.31, 95% CI 1.20–1.44, P < 0.001 and AOR 8.66, 95% CI 3.64–20.63, P < 0.001, respectively).

Conclusion

Maternal perceived stress during pregnancy was statistically greater in preterm birth. Perceived stress score and stress level were significant predictive factors for preterm birth.

Interleukin-17A and Chronic Stress in Pregnant Women at 24-28 Weeks Gestation

BACKGROUND

Allostatic load (AL) is a biopsychosocial model that suggests chronic psychosocial stress leads to physiological dysregulation and poor outcomes. The purpose of this study was to examine AL in pregnant women operationalized using proinflammatory cytokines and psychosocial indicators and perinatal outcomes.

OBJECTIVES

The aim of the study was to identify relationships between circulating cytokines/chemokines and the Prenatal Distress Questionnaire, the Maternal Antenatal Attachment Scale, the Emotional Quotient Inventory, the Life Experiences Scale, and demographics in pregnant women.

METHODS

A cross-sectional design was used to recruit pregnant women between 24 and 28 weeks of gestation. Blood and stress/emotional indicators were obtained after informed consent. Plasma was abstracted to simultaneously measure 29 cytokines/chemokines using a multiplex array. Cytokine/chemokine levels were compared with continuous variables using Spearman's rho and with categorical variables using Mann-Whitney U.

RESULTS

Twenty-five women with medically high-risk (n = 16) and low-risk (n = 9) pregnancies consented. Most women were White (68%) with a mean age of 29 years (SD = 5.9). Although several cytokines and chemokines showed significant correlations with the stress/emotional indicators, only interleukin-17A (IL-17A) was significantly associated with all of the indicators (Prenatal Distress Questionnaire: rs = .528, p = .012; Maternal Antenatal Attachment Scale: rs = -.439, p = .036; Emotional Quotient Inventory total: rs = -.545, p = .007), Life Experiences Scale (rs = .458, p = .032), birth weight (rs = -.499, p = .013), and race (p = .01).

DISCUSSION

Increased levels of IL-17A, a known cytokine associated with chronic stress and with poor perinatal outcomes, were associated with high prenatal distress, low maternal attachment, and lower emotional intelligence in pregnant women. Increased levels of IL-17A also were associated with lower birth weight and non-White race. Results support the model of AL in pregnant women and highlight IL-17A as a potential biomarker of AL during pregnancy.

At the forefront of psychoneuroimmunology in pregnancy: Implications for racial disparities in birth outcomes PART 1: Behavioral risks factors

Birth prior to full term is a substantial public health issue. In the US, ˜400,000 babies per year are born preterm (<37 weeks), while>1 million are early term (37-38^6/7 weeks). Birth prior to full term confers risk both immediate and long term, including neonatal intensive care, decrements in school performance, and increased mortality risk from infancy through young adulthood. Risk for low birth weight and preterm birth are 1.5-2 times greater among African Americans versus Whites. Psychosocial stress related to being a member of a discriminated racial minority group contributes substantially to these racial disparities. Providing promising targets for intervention, depressed mood, anxiety, and poor sleep are each linked with exposure to chronic stress, including racial discrimination. A rigorous transdisciplinary approach addressing these gaps holds great promise for clinical impact in addressing racial disparities as well as ameliorating effects of stress on perinatal health more broadly. As will be reviewed in a companion paper, the mechanistic roles of physiological sequelae to stress - including neuroendocrine, inflammatory regulation, biological aging, and the microbiome - also require delineation.

Prenatal stress and child development: A scoping review of research in low- and middle-income countries

INTRODUCTION

Past research has shown relationships between stress during pregnancy, and related psychosocial health measures such as anxiety and depressive symptoms, with infant, child, and adult outcomes. However, most research is from high-income countries. We conducted a scoping review to identify research studies on prenatal stress and outcomes of the pregnancy or offspring in low- and middle-income countries (LMICs), and to synthesize the stress measures and outcomes assessed, the findings observed, and directions for future research.

METHODS

We searched PubMed, Scopus, and PsycINFO for English-language abstracts published from Jan 1960-Jan 2017. Search terms were related to stress and psychosocial health; pregnancy; infant or child development; and LMICs.

RESULTS

48 articles were identified. Sixty percent of studies were in upper-middle, 25% in lower-middle, and 15% in low income countries. Most studies used questionnaires, either existing or tailor-made, to assess stress. Eight assessed cortisol. Most studies (n = 31) assessed infant outcomes at birth, particularly gestational age or preterm birth (n = 22, 12 showing significant relationships), and birthweight (n = 21, 14 showing significant relationships). Five studies analyzed outcomes later in infancy such as temperament and motor development, all showing significant results; and nine in childhood such as behavioral development, asthma, and physical growth, with eight showing significant results.

CONCLUSIONS

Results highlight the importance of prenatal stress on infant and child outcomes in LMICs. Methods used in high-income countries are successfully employed in LMICs, but tailored tools remain necessary. Careful assessment of covariates is needed to foster analyses of interactive effects and pathways. Studies including longer-term follow-up should be prioritized.

Prenatal Stress, Prematurity, and Asthma

Asthma is the most common chronic disease of childhood, affecting millions of children in the United States and worldwide. Prematurity is a risk factor for asthma, and certain ethnic or racial minorities such as Puerto Ricans and non-Hispanic blacks are disproportionately affected by both prematurity and asthma. In this review, we examine current evidence to support maternal psychosocial stress as a putative link between prematurity and asthma, while also focusing on disruption of the hypothalamic-pituitary-adrenal (HPA) axis and immune responses as potential underlying mechanisms for stress-induced "premature asthma." Prenatal stress may cause not only abnormalities in the HPA axis but also epigenetic changes in the fetal glucocorticoid receptor gene (NR3C1), leading to impaired glucocorticoid metabolism. Moreover, maternal stress can alter fetal cytokine balance, favoring TH2 (allergic) immune responses characteristic of atopic asthma: interleukin 6 (IL-6), which has been associated with premature labor, can promote TH2 responses by stimulating production of IL-4 and IL-13. Given a link among stress, prematurity, and asthma, future research should include birth cohorts aimed at confirming and better characterizing "premature asthma." If confirmed, clinical trials of prenatal maternal stress reduction would be warranted to reduce the burden of these common comorbidities. While awaiting the results of such studies, sound policies to prevent domestic and community violence (eg, from firearms) are justified, not only by public safety but also by growing evidence of detrimental effects of violence-induced stress on psychiatric and somatic health.

Withholding Information to Protect a Loved One

Parents respond to the death of a child in very different ways. Some parents may be violent or angry, some sad and tearful, some quiet and withdrawn, and some frankly delusional. We present a case in which a father's reaction to his daughter's death is a desire to protect his wife from the stressful information. The wife is in the second trimester of a high-risk pregnancy and so is particularly fragile. We asked pediatricians and bioethicists to discuss the ways in which they might respond to the father's understandable but troubling request.

Maternal bereavement and the risk of preterm delivery: the importance of gestational age and of the precursor of preterm birth

BACKGROUND

Maternal stress during pregnancy may increase the risk of preterm delivery (PD), but the associations between stress and subtypes of PD are not clear. We investigated maternal loss of a close relative and risks of very and moderately PD (<32 and 32-36 weeks, respectively) and spontaneous and medically indicated PD.

METHOD

We studied 4 940 764 live singleton births in Denmark (1978-2008) and Sweden (1973-2006). We retrieved information on death of women's family members (children, partner, siblings, parents), birth outcomes and maternal characteristics from nationwide registries.

RESULTS

Overall, the death of a close family member the year before pregnancy or in the first 36 weeks of pregnancy was associated with a 7% increased risk of PD [95% confidence interval (CI) 1.04-1.10]. The highest hazard ratios (HR) for PD were found for death of an older child [HR (95% CI) 1.20 (1.10-1.31)] and for death of a partner [HR (95% CI) 1.31 (1.03-1.66)]. These losses were associated with higher risks of very preterm [HR (95% CI) 1.61 (1.29-2.01) and 2.07 (1.15-3.74), respectively] than of moderately preterm [HR (95% CI) 1.14 (1.03-1.26) and 1.22 (0.94-1.58), respectively] delivery. There were no substantial differences in the association between death of a child or partner and the risk of spontaneous v. medically indicated PD.

CONCLUSIONS

Death of a close family member the year before or during pregnancy was associated with an increased risk of PD, especially very PD. Possible mechanisms include both spontaneous and medically indicated preterm birth.

Exploring the Psychosocial Predictors of Gestational Diabetes and Birth Weight

OBJECTIVE

To determine the best sociodemographic and behavioral predictors for gestational diabetes mellitus (GDM) and birth weight (BW) and whether stress, depression, or abuse influences GDM and BW after controlling for sociodemographic variables.

DESIGN

Retrospective correlational.

SETTING

Utah Pregnancy Risk Monitoring System and birth certificate data.

PARTICIPANTS

We analyzed data from the birth certificates of 4,682 women with live births between 2009 and 2011 in Utah. During that time, a total of 143,373 live births occurred in the state. Data were predominantly from non-Hispanic White, married, or partnered women with average age of 27.5 years and average body mass index (BMI) of 25.1.

METHODS

Stress, cumulative depression, and abuse were operationalized based on previous analysis, and control and covariate data (e.g., age, BMI, race, ethnicity, education, marital status) were collected. Bivariate analysis was used to identify associations between variables, and a hierarchical stepwise logistical regression was conducted to identify best predictors of GDM and BW.

RESULTS

We did not find that cumulative depression, stress, or abuse was a predictor of GDM, and only cumulative stress was a predictor of BW. More incidences of GDM were observed in women who were poor, older, less educated, non-White, obese, or experienced depression during pregnancy.

CONCLUSION

Unlike depression or abuse, stress is often overlooked by providers. This finding represents an unmet opportunity for nurses to screen for and assist women with stressors to positively affect birth weight.

Neutrophil elastase and fetal fibronectin levels as predictors of single-birth prematurity

The aim of this study was to investigate the predictive values (PVs) of neutrophil elastase (NE) and fetal fibronectin (fFN) in cervical secretions for single-birth premature delivery. Samples of cervical secretions were obtained from 144 women with high-risk singleton pregnancies at 20-34 weeks' gestation and premature Creasy scores of >12 points for NE and fFN level testing, and the PVs of the two indicators for premature birth (PB) were retrospectively analyzed. NE and fFN had high negative PVs (NPVs) for PB; the NPV of NE and fFN for delivery 7 days after detection was significantly higher than the positive PV (P<0.01). In addition, the sensitivity of the combined use of NE and fFN levels for PB prediction was high if both were present, and the PB rate of the double-positive group was higher than that of the single-positive group (P<0.01). Clinical intervention could turn the NE and fFN values negative in certain cases; in these cases, the PB rate was significantly lower than that in the sustained-positive group. In conclusion, NE and fFN in cervical secretions could be used as objective predictors of premature delivery, and their combined application could improve the prediction sensitivity. Effective clinical intervention could then reduce the incidence of PB.

Sleep duration, vital exhaustion, and odds of spontaneous preterm birth: a case-control study

BACKGROUND

Preterm birth is a leading cause of perinatal morbidity and mortality worldwide, resulting in a pressing need to identify risk factors leading to effective interventions. Limited evidence suggests potential relationships between maternal sleep or vital exhaustion and preterm birth, yet the literature is generally inconclusive.

METHODS

We examined the relationship between maternal sleep duration and vital exhaustion in the first six months of pregnancy and spontaneous (non-medically indicated) preterm birth among 479 Peruvian women who delivered a preterm singleton infant (<37 weeks gestation) and 480 term controls who delivered a singleton infant at term (≥37 weeks gestation). Maternal nightly sleep and reports of vital exhaustion were ascertained through in-person interviews. Spontaneous preterm birth cases were further categorized as those following either spontaneous preterm labor or preterm premature rupture of membranes. In addition, cases were categorized as very (<32 weeks), moderate (32-33 weeks), and late (34- <37 weeks) preterm birth for additional analyses. Logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

After adjusting for confounders, we found that short sleep duration (≤6 hours) was significantly associated with preterm birth (aOR = 1.56; 95% CI 1.11-2.19) compared to 7-8 hours of sleep. Vital exhaustion was also associated with increased odds of preterm birth (aOR = 2.41; 95% CI 1.79-3.23) compared to no exhaustion (Ptrend <0.001). These associations remained significant for spontaneous preterm labor and preterm premature rupture of membranes. We also found evidence of joint effects of sleep duration and vital exhaustion on the odds of spontaneous preterm birth.

CONCLUSIONS

The results of this case-control study suggest maternal sleep duration, particularly short sleep duration, and vital exhaustion may be risk factors for spontaneous preterm birth. These findings call for increased clinical attention to maternal sleep and the study of potential intervention strategies to improve sleep in early pregnancy with the aim of decreasing risk of preterm birth.