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Ramji N, Corsi DJ, Gad M, Dimanlig-Cruz S, Miao Q, Guo Y, Rybak N, White RR, Wen SW, Walker MC, Gaudet LM. The impact of isolated obesity compared with obesity and other risk factors on risk of stillbirth: a retrospective cohort study. CMAJ 2024; 196:E250-E259. [PMID: 38438153 PMCID: PMC10911866 DOI: 10.1503/cmaj.221450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Maternal obesity is associated with stillbirth, but uncertainty persists around the effects of higher obesity classes. We sought to compare the risk of stillbirth associated with maternal obesity alone versus maternal obesity and additional or undiagnosed factors contributing to high-risk pregnancy. METHODS We conducted a retrospective cohort study using the Better Outcomes Registry and Network (BORN) for singleton hospital births in Ontario between 2012 and 2018. We used multivariable Cox proportional hazard regression and logistic regression to evaluate the relationship between prepregnancy maternal body mass index (BMI) class and stillbirth (reference was normal BMI). We treated maternal characteristics and obstetrical complications as independent covariates. We performed mediator analyses to measure the direct and indirect effects of BMI on stillbirth through major common-pathway complications. We used fully adjusted and partially adjusted models, representing the impact of maternal obesity alone and maternal obesity with other risk factors on stillbirth, respectively. RESULTS We analyzed data on 681 178 births between 2012 and 2018, of which 1956 were stillbirths. Class I obesity was associated with an increased incidence of stillbirth (adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.35-1.78). This association was stronger for class III obesity (adjusted HR 1.80, 95% CI 1.44-2.24), and strongest for class II obesity (adjusted HR 2.17, 95% CI 1.83-2.57). Plotting point estimates for odds ratios, stratified by gestational age, showed a marked increase in the relative odds for stillbirth beyond 37 weeks' gestation for those with obesity with and without other risk factors, compared with those with normal BMI. The impact of potential mediators was minimal. INTERPRETATION Maternal obesity alone and obesity with other risk factors are associated with an increased risk of stillbirth. This risk increases with gestational age, especially at term.
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Affiliation(s)
- Naila Ramji
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont.
| | - Daniel J Corsi
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Monica Gad
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Sheryll Dimanlig-Cruz
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Qun Miao
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Yanfang Guo
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Natalie Rybak
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Ruth Rennicks White
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Shi Wu Wen
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Mark C Walker
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Laura M Gaudet
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
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Andrade CBV, Lopes LVA, Ortiga-Carvalho TM, Matthews SG, Bloise E. Infection and disruption of placental multidrug resistance (MDR) transporters: Implications for fetal drug exposure. Toxicol Appl Pharmacol 2023; 459:116344. [PMID: 36526072 DOI: 10.1016/j.taap.2022.116344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
P-glycoprotein (P-gp, encoded by the ABCB1 gene) and breast cancer resistance protein (BCRP/ABCG2) are efflux multidrug resistance (MDR) transporters localized at the syncytiotrophoblast barrier of the placenta and protect the conceptus from drug and toxin exposure throughout pregnancy. Infection is an important modulator of MDR expression and function. This review comprehensively examines the effect of infection on the MDR transporters, P-gp and BCRP in the placenta. Infection PAMPs such as bacterial lipopolysaccharide (LPS) and viral polyinosinic-polycytidylic acid (poly I:C) and single-stranded (ss)RNA, as well as infection with Zika virus (ZIKV), Plasmodium berghei ANKA (modeling malaria in pregnancy - MiP) and polymicrobial infection of intrauterine tissues (chorioamnionitis) all modulate placental P-gp and BCRP at the levels of mRNA, protein and or function; with specific responses varying according to gestational age, trophoblast type and species (human vs. mice). Furthermore, we describe the expression and localization profile of Toll-like receptor (TLR) proteins of the innate immune system at the maternal-fetal interface, aiming to better understand how infective agents modulate placental MDR. We also highlight important gaps in the field and propose future research directions. We conclude that alterations in placental MDR expression and function induced by infective agents may not only alter the intrauterine biodistribution of important MDR substrates such as drugs, toxins, hormones, cytokines, chemokines and waste metabolites, but also impact normal placentation and adversely affect pregnancy outcome and maternal/neonatal health.
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Affiliation(s)
- C B V Andrade
- Instituto de Biofisica Carlos Chagas Filho, Laboratorio de Endocrinologia Translacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Departamento de Histologia e Embriologia, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - L V A Lopes
- Departamento de Morfologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - T M Ortiga-Carvalho
- Instituto de Biofisica Carlos Chagas Filho, Laboratorio de Endocrinologia Translacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - S G Matthews
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Department of Obstetrics & Gynecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sinai Health System, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - E Bloise
- Departamento de Morfologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
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Musana J, Cohen CR, Kuppermann M, Gerona R, Wanyoro A, Aguilar D, Santos N, Temmerman M, Weiss SJ. Obstetric risk in pregnancy interacts with hair cortisone levels to reduce gestational length. Front Glob Womens Health 2022; 3:878538. [PMID: 35936818 PMCID: PMC9354598 DOI: 10.3389/fgwh.2022.878538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background Maternal psychological stress has been linked to preterm birth. However, the differential contribution of psychological stress versus stress hormones is not clear. Studies focus primarily on perceived stress and cortisol, with few assessing its inter-convertible hormone cortisone. Furthermore, little is known about the potential moderating roles of obstetric risk and fetal sex in the relationship between maternal stress and gestational length. This gap in knowledge is particularly evident for rural women who typically experience chronic multiple stressors during pregnancy. We explored the relationship of hormonal and psychological stress to gestational length and the effects of obstetric risks and fetal sex on this relationship among Kenyan pregnant women. Methods The sample included 130 women recruited between 22 to 28 weeks gestation. They completed a clinical and sociodemographic questionnaire together with the Perceived Stress Scale and provided a hair sample for cortisol and cortisone assay. Women underwent an ultrasound to assess weeks of gestation. At delivery, their pregnancy-related health problems were identified using information extracted from medical records to compile each woman's number of pregnancy risks on the Obstetric Medical Risk Index (OMRI). Results Perceived stress and hair cortisol were not significant predictors of gestational length. However, a greater number of obstetric risks on the OMRI was associated with shorter gestational length. This effect was further explained by the interaction between obstetric risk and hair cortisone (B = 0.709, p = 0.02). Hair cortisone levels of mothers who had a shorter gestation were significantly higher in mothers with 2 or more risks on the OMRI but not among mothers with only one or no risks (t = 2.39, p = 0.02). Fetal sex had no relationship to gestational length and also had no moderating effect on the relationship between any stress-related metric and gestational length. Conclusion Cortisone levels may increase in anticipation of shorter gestation as a compensatory response to increased obstetric risk. Elevated cortisone may be a more sensitive marker of risk for early delivery than cortisol or psychological stress, with salience for both the male and female fetus.
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Affiliation(s)
- Joseph Musana
- Department of Obstetrics and Gynaecology, Aga Khan University Hospital, Nairobi, Kenya
- *Correspondence: Joseph Musana
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Roy Gerona
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Anthony Wanyoro
- Department of Obstetrics and Gynaecology, Kenyatta University, Nairobi, Kenya
| | - David Aguilar
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California, San Francisco, San Francisco, CA, United States
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University Hospital, Nairobi, Kenya
| | - Sandra J. Weiss
- Department of Community Health Systems, University of California, San Francisco, San Francisco, CA, United States
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Abstract
OBJECTIVE This study was aimed to assess the utility of diagnostic tests of maternal and fetal infection in the evaluation of stillbirth. STUDY DESIGN A single-center retrospective study from January 2011 to December 2016 of all women presenting to the hospital with intrauterine fetal death at or after 20 weeks of gestation. Standard evaluation included review of medical records, clinical and laboratory inflammatory workup, maternal serologies, fetal autopsy, placental pathology, and fetal and placental cultures. A suspected infectious etiology was defined as meeting at least two diagnostic criteria, and only after exclusion of any other identifiable stillbirth cause. RESULTS During the 7-year study period, 228 cases of stillbirth were diagnosed at our center. An infectious etiology was the suspected cause of stillbirth in 35 cases (15.3%). The mean gestational age of infection-related stillbirth was 28 1/7 (range: 22-37) weeks, while for a noninfectious etiology, it was 34 0/7 (range: 25-38) weeks (p = 0.005). Placental histological findings diagnostic of overt chorioamnionitis and funisitis were observed in 31 (88.5%) cases. In 16 (45.7%) cases the placental and fetal cultures were positive for the same pathogen. Serology of acute infection was positive in three (8.5%) of the cases. CONCLUSION Maternal and fetal infectious workup is valuable in the investigation of stillbirth, particularly before 30 weeks of gestation and should be considered a part of standard evaluation.
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Harrison MS, Thorsten VR, Dudley DJ, Parker CB, Koch MA, Hogue CJ, Stoll BJ, Silver RM, Varner MW, Pinar MH, Coustan DR, Saade GR, Bukowski RK, Conway DL, Willinger M, Reddy UM, Goldenberg RL. Stillbirth, Inflammatory Markers, and Obesity: Results from the Stillbirth Collaborative Research Network. Am J Perinatol 2018; 35:1071-1078. [PMID: 29609190 PMCID: PMC6436964 DOI: 10.1055/s-0038-1639340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Obesity is associated with increased risk of stillbirth, although the mechanisms are unknown. Obesity is also associated with inflammation. Serum ferritin, C-reactive protein, white blood cell count, and histologic chorioamnionitis are all markers of inflammation. OBJECTIVE This article determines if inflammatory markers are associated with stillbirth and body mass index (BMI). Additionally, we determined whether inflammatory markers help to explain the known relationship between obesity and stillbirth. STUDY DESIGN White blood cell count was assessed at admission to labor and delivery, maternal serum for assessment of various biomarkers was collected after study enrollment, and histologic chorioamnionitis was based on placental histology. These markers were compared for stillbirths and live births overall and within categories of BMI using analysis of variance on logarithmic-transformed markers and logistic regression for dichotomous variables. The impact of inflammatory markers on the association of BMI categories with stillbirth status was assessed using crude and adjusted odds ratios (COR and AOR, respectively) from logistic regression models. The interaction of inflammatory markers and BMI categories on stillbirth status was also assessed through logistic regression. Additional logistic regression models were used to determine if the association of maternal serum ferritin with stillbirth is different for preterm versus term births. Analyses were weighted for the overall population from which this sample was derived. RESULTS A total of 497 women with singleton stillbirths and 1,414 women with live births were studied with prepregnancy BMI (kg/m2) categorized as normal (18.5-24.9), overweight (25.0-29.9), or obese (30.0 + ). Overweight (COR, 1.48; 95% confidence interval [CI]: 1.14-1.94) and obese women (COR, 1.60; 95% CI: 1.23-2.08) were more likely than normal weight women to experience stillbirth. Serum ferritin levels were higher (geometric mean: 37.4 ng/mL vs. 23.3, p < 0.0001) and C-reactive protein levels lower (geometric mean: 2.9 mg/dL vs. 3.3, p = 0.0279), among women with stillbirth compared with live birth. Elevated white blood cell count (15.0 uL × 103 or greater) was associated with stillbirth (21.2% SB vs. 10.0% live birth, p < 0.0001). Histologic chorioamnionitis was more common (33.2% vs. 15.7%, p < 0.0001) among women with stillbirth compared with those with live birth. Serum ferritin, C-reactive protein, and chorioamnionitis had little impact on the ORs associating stillbirth with overweight or obesity. Adjustment for elevated white blood cell count did not meaningfully change the OR for stillbirth in overweight versus normal weight women. However, the stillbirth OR for obese versus normal BMI changed by more than 10% when adjusting for histologic chorioamnionitis (AOR, 1.38; 95% CI: 1.02-1.88), indicating confounding. BMI by inflammatory marker interaction terms were not significant. The association of serum ferritin levels with stillbirth was stronger among preterm births (p = 0.0066). CONCLUSION Maternal serum ferritin levels, elevated white blood cell count, and histologic chorioamnionitis were positively and C-reactive protein levels negatively associated with stillbirth. Elevated BMIs, both overweight and obese, were associated with stillbirth when compared with women with normal BMI. None of the inflammatory markers fully accounted for the relationship between obesity and stillbirth. The association of maternal serum ferritin with stillbirth was stronger in preterm than term stillbirths.
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Affiliation(s)
| | | | | | | | | | | | - Barbara J. Stoll
- University of Texas Health McGovern Medical School, Houston, Texas
| | | | | | | | | | | | | | - Deborah L. Conway
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Marian Willinger
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
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O'Driscoll DN, Greene CM, Molloy EJ. Immune function? A missing link in the gender disparity in preterm neonatal outcomes. Expert Rev Clin Immunol 2018; 13:1061-1071. [PMID: 28972799 DOI: 10.1080/1744666x.2017.1386555] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In neonatology, males exhibit a more severe disease course and poorer prognosis in many pathological states when compared to females. Perinatal brain injury, respiratory morbidity, and sepsis, among other complications, preferentially affect males. Preterm neonates (born <37 weeks gestation) display a particularly marked sexual disparity in pathology, especially at the borders of viability. The sex biases in preterm neonatal outcomes and underlying multifactorial mechanisms have been incompletely explored. Sex-specific clinical phenomena may be partially explained by intrinsic differences in immune function. The distinct immune system of preterm neonates renders this patient population vulnerable, and it is increasingly important to consider biological sex in disease processes and to strive for improved outcomes for both sexes. Areas covered: We discuss the cellular responses and molecular intermediates in immune function which are strongly dependent on sex-specific factors such as the genetic and hormonal milieu of premature birth and consider novel findings in a clinical context. Expert commentary: The role of immune function in the manifestation of sex-specific disease manifestations and outcomes in preterm neonates is a critical prognostic variable. Further mechanistic elucidation will yield valuable translational and clinical information of disease processes in preterm neonates which may be harnessed for modulation.
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Affiliation(s)
- David N O'Driscoll
- a Neonatology , National Maternity Hospital , Dublin , Ireland.,b Pediatrics, Trinity College, Trinity Centre for Health Sciences , The University of Dublin, National Children's Hospital, AMNCH , Dublin , Ireland
| | - Catherine M Greene
- c Clinical Microbiology , Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
| | - Eleanor J Molloy
- a Neonatology , National Maternity Hospital , Dublin , Ireland.,b Pediatrics, Trinity College, Trinity Centre for Health Sciences , The University of Dublin, National Children's Hospital, AMNCH , Dublin , Ireland.,d Neonatology , Coombe Women and Infants' University Hospital , Dublin , Ireland.,e Neonatology , Our Lady's Children's Hospital Crumlin , Dublin , Ireland
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Chaiworapongsa T, Romero R, Erez O, Tarca AL, Conde-Agudelo A, Chaemsaithong P, Kim CJ, Kim YM, Kim JS, Yoon BH, Hassan SS, Yeo L, Korzeniewski SJ. The prediction of fetal death with a simple maternal blood test at 20-24 weeks: a role for angiogenic index-1 (PlGF/sVEGFR-1 ratio). Am J Obstet Gynecol 2017; 217:682.e1-682.e13. [PMID: 29037482 PMCID: PMC5951183 DOI: 10.1016/j.ajog.2017.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fetal death is an obstetrical syndrome that annually affects 2.4 to 3 million pregnancies worldwide, including more than 20,000 in the United States each year. Currently, there is no test available to identify patients at risk for this pregnancy complication. OBJECTIVE We sought to determine if maternal plasma concentrations of angiogenic and antiangiogenic factors measured at 24-28 weeks of gestation can predict subsequent fetal death. STUDY DESIGN A case-cohort study was designed to include 1000 randomly selected subjects and all remaining fetal deaths (cases) from a cohort of 4006 women with a singleton pregnancy, enrolled at 6-22 weeks of gestation, in a pregnancy biomarker cohort study. The placentas of all fetal deaths were histologically examined by pathologists who used a standardized protocol and were blinded to patient outcomes. Placental growth factor, soluble endoglin, and soluble vascular endothelial growth factor receptor-1 concentrations were measured by enzyme-linked immunosorbent assays. Quantiles of the analyte concentrations (or concentration ratios) were estimated as a function of gestational age among women who delivered a live neonate but did not develop preeclampsia or deliver a small-for-gestational-age newborn. A positive test was defined as analyte concentrations (or ratios) <2.5th and 10th centiles (placental growth factor, placental growth factor/soluble vascular endothelial growth factor receptor-1 [angiogenic index-1] and placental growth factor/soluble endoglin) or >90th and 97.5th centiles (soluble vascular endothelial growth factor receptor-1 and soluble endoglin). Inverse probability weighting was used to reflect the parent cohort when estimating the relative risk. RESULTS There were 11 fetal deaths and 829 controls with samples available for analysis between 24-28 weeks of gestation. Three fetal deaths occurred <28 weeks and 8 occurred ≥28 weeks of gestation. The rate of placental lesions consistent with maternal vascular underperfusion was 33.3% (1/3) among those who had a fetal death <28 weeks and 87.5% (7/8) of those who had this complication ≥28 weeks of gestation. The maternal plasma angiogenic index-1 value was <10th centile in 63.6% (7/11) of the fetal death group and in 11.1% (92/829) of the controls. The angiogenic index-1 value was <2.5th centile in 54.5% (6/11) of the fetal death group and in 3.7% (31/829) of the controls. An angiogenic index-1 value <2.5th centile had the largest positive likelihood ratio for predicting fetal death >24 weeks (14.6; 95% confidence interval, 7.7-27.7) and a relative risk of 29.1 (95% confidence interval, 8.8-97.1), followed by soluble endoglin >97.5th centile and placental growth factor/soluble endoglin <2.5th, both with a positive likelihood ratio of 13.7 (95% confidence interval, 7.3-25.8) and a relative risk of 27.4 (95% confidence interval, 8.2-91.2). Among women without a fetal death whose plasma angiogenic index-1 concentration ratio was <2.5th centile, 61% (19/31) developed preeclampsia or delivered a small-for-gestational-age neonate; when the 10th centile was used as the cut-off, 37% (34/92) of women had these adverse outcomes. CONCLUSION (1) A maternal plasma angiogenic index-1 value <2.5th centile (0.126) at 24-28 weeks of gestation carries a 29-fold increase in the risk of subsequent fetal death and identifies 55% of subsequent fetal deaths with a false-positive rate of 3.5%; and (2) 61% of women who have a false-positive test result will subsequently experience adverse pregnancy outcomes.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Offer Erez
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Adi L Tarca
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Chong Jai Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon Mee Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Sun Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Bo Hyun Yoon
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sonia S Hassan
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Steven J Korzeniewski
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
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Nijkamp J, Sebire N, Bouman K, Korteweg F, Erwich J, Gordijn S. Perinatal death investigations: What is current practice? Semin Fetal Neonatal Med 2017; 22:167-175. [PMID: 28325580 PMCID: PMC7118457 DOI: 10.1016/j.siny.2017.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Perinatal death (PD) is a devastating obstetric complication. Determination of cause of death helps in understanding why and how it occurs, and it is an indispensable aid to parents wanting to understand why their baby died and to determine the recurrence risk and management in subsequent pregnancy. Consequently, a perinatal death requires adequate diagnostic investigation. An important first step in the analysis of PD is to identify the case circumstances, including relevant details regarding maternal history, obstetric history and current pregnancy (complications are evaluated and recorded). In the next step, placental examination is suggested in all cases, together with molecular cytogenetic evaluation and fetal autopsy. Investigation for fetal-maternal hemorrhage by Kleihauer is also recommended as standard. In cases where parents do not consent to autopsy, alternative approaches such as minimally invasive postmortem examination, postmortem magnetic resonance imaging, and fetal photographs are good alternatives. After all investigations have been performed it is important to combine findings from the clinical review and investigations together, to identify the most probable cause of death and counsel the parents regarding their loss.
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Affiliation(s)
- J.W. Nijkamp
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,Corresponding author. Department of Obstetrics and Gynecology, University Medical Centre Groningen, CB 21, P.O. box 30001, 9700 RB Groningen, The Netherlands.
| | - N.J. Sebire
- Department of Pediatric Pathology, Clinical Molecular Genetics, Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, UK
| | - K. Bouman
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - F.J. Korteweg
- Department of Obstetrics and Gynecology, Martini Hospital, Groningen, The Netherlands
| | - J.J.H.M. Erwich
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - S.J. Gordijn
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kindinger LM, MacIntyre DA, Lee YS, Marchesi JR, Smith A, McDonald JAK, Terzidou V, Cook JR, Lees C, Israfil-Bayli F, Faiza Y, Toozs-Hobson P, Slack M, Cacciatore S, Holmes E, Nicholson JK, Teoh TG, Bennett PR. Relationship between vaginal microbial dysbiosis, inflammation, and pregnancy outcomes in cervical cerclage. Sci Transl Med 2016; 8:350ra102. [DOI: 10.1126/scitranslmed.aag1026] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/23/2016] [Indexed: 12/20/2022]
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Lindam A, Johansson S, Stephansson O, Wikström AK, Cnattingius S. High Maternal Body Mass Index in Early Pregnancy and Risks of Stillbirth and Infant Mortality-A Population-Based Sibling Study in Sweden. Am J Epidemiol 2016; 184:98-105. [PMID: 27358265 PMCID: PMC4945704 DOI: 10.1093/aje/kww046] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/26/2016] [Indexed: 12/16/2022] Open
Abstract
In a population-based case-control study, we investigated whether familial confounding influenced the associations between maternal overweight/obesity and risks of stillbirth and infant mortality by including both population and sister controls. Using nationwide data from the Swedish Medical Birth Register (1992–2011), we included all primiparous women with singleton births who also had a sister with a first birth during that time period. We used logistic regression analyses to calculate odds ratios (and 95% confidence intervals) adjusted for maternal age, height, smoking habits, education, and time period (5-year groups) of child's birth. Body mass index (BMI) was calculated as weight (kg)/height (m)2. Compared with population controls with a normal BMI (18.5–24.9), stillbirth risk increased with increasing BMI (BMI 25–29.9: odds ratio (OR) = 1.51 (95% confidence interval (CI): 1.21, 1.89); BMI 30–34.9: OR = 1.77 (95% CI: 1.24, 2.50); BMI ≥35: OR = 3.16 (95% CI: 2.10, 4.76)). The sister case-control analyses revealed similar results. Offspring of obese women (BMI ≥30) had an increased risk of infant mortality when population controls were used (OR = 2.41, 95% CI: 1.83, 3.16), and an even higher risk was obtained when sister controls were used (OR = 4.04, 95% CI: 2.25, 7.25). We conclude that obesity in early pregnancy is associated with increased risks of stillbirth and infant mortality independently of genetic and early environmental risk factors shared within families.
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Affiliation(s)
| | | | | | | | - Sven Cnattingius
- Correspondence to Prof. Sven Cnattingius, Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden (e-mail: )
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