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Carter S, Lin JC, Chow T, Martinez MP, Qiu C, Feldman RK, McConnell R, Xiang AH. Preeclampsia Onset, Days to Delivery, and Autism Spectrum Disorders in Offspring: Clinical Birth Cohort Study. JMIR Public Health Surveill 2024; 10:e47396. [PMID: 38630528 PMCID: PMC11063875 DOI: 10.2196/47396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 12/08/2023] [Accepted: 03/01/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring. OBJECTIVE This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery. METHODS This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery. RESULTS Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset. CONCLUSIONS Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.
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Affiliation(s)
- Sarah Carter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Jane C Lin
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ting Chow
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Mayra P Martinez
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Chunyuan Qiu
- Department of Anesthesiology and Perioperative Medicine, Baldwin Park Medical Center, Kaiser Permanente Southern California, Baldwin Park, CA, United States
| | - R Klara Feldman
- Department of Obstetrics and Gynecology, Baldwin Park Medical Center, Kaiser Permanente Southern California, Baldwin Park, CA, United States
| | - Rob McConnell
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Anny H Xiang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
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Qiu C, Carter SA, Lin JC, Shi JM, Chow T, Desai VN, Nguyen VT, Spitzer J, Feldman RK, Xiang AH. Association of Labor Epidural Analgesia, Oxytocin Exposure, and Risk of Autism Spectrum Disorders in Children. JAMA Netw Open 2023; 6:e2324630. [PMID: 37477919 PMCID: PMC10362468 DOI: 10.1001/jamanetworkopen.2023.24630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Importance Maternal labor epidural analgesia (LEA) and oxytocin use for labor and delivery have been reported to be associated with child autism spectrum disorders (ASD). However, it remains unclear whether these 2 common medications used during labor and delivery have synergistic associations with ASD risk in children. Objective To assess the independent associations of LEA and oxytocin during labor and delivery with ASD, as well as outcome modification associated with the concurrent use of both interventions. Design, Setting, and Participants Data for this cohort study included 205 994 singleton births with vaginal deliveries in a single integrated health care system in Southern California from calendar years 2008 to 2017. Children were followed up to December 31, 2021. Data on use of LEA and oxytocin, covariates, and ASD outcome in children were obtained from electronic medical records. Cox proportional hazards regression was used to estimate the hazard ratios (HRs) adjusting for covariates. Exposures Labor epidural analgesia and/or oxytocin use during labor and delivery. Main Outcomes and Measures A child's clinical diagnosis of ASD during follow-up and at age of diagnosis. Results Among the cohort, 153 880 children (74.7%) were exposed to maternal LEA and 117 808 children (57.2%) were exposed to oxytocin during labor and delivery. The population of children was approximately half boys and half girls. The median (IQR) age of the mothers was 30.8 (26.8-34.5) years for those not exposed to LEA, 30.0 (25.9-33.8) years for those exposed to LEA, 30.4 (26.5-34.1) years for those unexposed to oxytocin, and 30.0 (25.9-33.9) years for those exposed to oxytocin during labor and delivery. A total of 5146 children (2.5%) had ASD diagnosed during follow-up. Oxytocin exposure was higher among LEA-exposed (67.7%) than -unexposed (26.1%) children. The ASD risk associated with LEA was independent of oxytocin exposure (HR, 1.28; 95% CI, 1.18-1.38); however, the ASD risk associated with oxytocin was not significant after adjusting for LEA exposure (HR, 1.05; 95% CI, 0.99-1.12). A significant interaction of LEA and oxytocin on child ASD risk was found (P = .02 for interaction). Compared with no exposure, HRs were 1.20 (95% CI, 1.09-1.32) for LEA alone, 1.30 (95% CI, 1.20-1.42) for both LEA and oxytocin, and 0.90 (95% CI, 0.78-1.04) for oxytocin alone. Conclusions and Relevance The findings of this cohort study suggest an association between maternal LEA and ASD risk in children, and the risk appeared to be further increased if oxytocin was also administered. Oxytocin exposure without LEA exposure was not associated with ASD risk in children. These findings must be interpreted with caution. Further studies are needed to replicate or refute the study results and examine biological plausibility.
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Affiliation(s)
- Chunyuan Qiu
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Sarah A Carter
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jane C Lin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jiaxiao M Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Ting Chow
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Vimal N Desai
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Vu T Nguyen
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
- Department of Internal Medicine, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Joseph Spitzer
- Department of Pediatrics, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - R Klara Feldman
- Department of Obstetrics & Gynecology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Anny H Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
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Qiu C, Lin JC, Shi JM, Chow T, Desai VN, Nguyen VT, Riewerts RJ, Feldman RK, Segal S, Xiang AH. Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring. JAMA Pediatr 2020; 174:1168-1175. [PMID: 33044486 PMCID: PMC7551212 DOI: 10.1001/jamapediatrics.2020.3231] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Although the safety of labor epidural analgesia (LEA) for neonates has been well documented, the long-term health effects of LEA on offspring remain to be investigated. OBJECTIVE To assess the association between maternal LEA exposure and risk of autism spectrum disorders (ASDs) in offspring. DESIGN, SETTING, AND PARTICIPANTS Data for this retrospective longitudinal birth cohort study were derived from electronic medical records from a population-based clinical birth cohort. A total of 147 895 singleton children delivered vaginally between January 1, 2008, and December 31, 2015, in a single integrated health care system were included. Children were followed up from the age of 1 year until the first date of the following occurrences: clinical diagnosis of ASD, last date of health plan enrollment, death, or the study end date of December 31, 2018. EXPOSURES Use and duration of LEA. MAIN OUTCOMES AND MEASURES The main outcome was clinical diagnosis of ASD. Cox proportional hazards regression analysis was used to estimate the hazard ratio (HR) of ASD associated with LEA exposure. RESULTS Among the cohort of 147 895 singleton children (74 425 boys [50.3%]; mean [SD] gestational age at delivery, 38.9 [1.5] weeks), 109 719 (74.2%) were exposed to maternal LEA. Fever during labor was observed in 13 055 mothers (11.9%) in the LEA group and 510 of 38 176 mothers (1.3%) in the non-LEA group. Autism spectrum disorders were diagnosed in 2039 children (1.9%) in the LEA group and 485 children (1.3%) in the non-LEA group. After adjusting for potential confounders, including birth year, medical center, maternal age at delivery, parity, race/ethnicity, educational level, household income, history of comorbidity, diabetes during pregnancy, smoking during pregnancy, preeclampsia or eclampsia, prepregnancy body mass index, gestational weight gain, gestational age at delivery, and birth weight, the HR associated with LEA vs non-LEA exposure was 1.37 (95% CI, 1.23-1.53). Relative to the unexposed group, the adjusted HR associated with LEA exposure of less than 4 hours was 1.33 (95% CI, 1.17-1.53), with LEA exposure of 4 to 8 hours was 1.35 (95% CI, 1.20-1.53), and with LEA exposure of more than 8 hours was 1.46 (95% CI, 1.27-1.69). Within the LEA group, there was a significant trend of ASD risk associated with increasing duration of LEA exposure after adjusting for covariates (HR for linear trend, 1.05 [95% CI, 1.01-1.09] per 4 hours). Adding fever to the model did not change the HR estimate associated with LEA exposure (adjusted HR for LEA vs non-LEA, 1.37 [95% CI, 1.22-1.53]). CONCLUSIONS AND RELEVANCE This study suggests that maternal LEA may be associated with increased ASD risk in children. The risk appears to not be directly associated with epidural-related maternal fever.
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Affiliation(s)
- Chunyuan Qiu
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Jane C. Lin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jiaxiao M. Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ting Chow
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Vimal N. Desai
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Vu T. Nguyen
- Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California,Department of Internal Medicine, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Robert J. Riewerts
- Department of Pediatrics, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - R. Klara Feldman
- Department of Obstetrics & Gynecology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
| | - Scott Segal
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anny H. Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
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Abstract
This cohort study uses electronic health record data to examine associations between maternal diabetes (preexisting type 1, type 2, and gestational) and autism spectrum disorder in children.
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Affiliation(s)
- Anny H. Xiang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Xinhui Wang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Mayra P. Martinez
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Kathleen Page
- Division of Endocrinology and Diabetes, University of Southern California Keck School of Medicine, Los Angeles
| | - Thomas A. Buchanan
- Division of Endocrinology and Diabetes, University of Southern California Keck School of Medicine, Los Angeles
| | - R. Klara Feldman
- Department of Obstetrics and Gynecology, Kaiser Permanente Southern California, Pasadena
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Du Pen SL, Williams AR, Feldman RK. Epidurograms in the management of patients with long-term epidural catheters. Reg Anesth 1996; 21:61-7. [PMID: 8826026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Standardized test doses have been established in the practice of anesthesiology to determine the location of the epidural catheter tip. The resulting data obtained after test dosing is open to interpretation, and comparison is difficult. A more objective method of catheter verification and epidural space measurement is indicated in long-term epidural catheterization. The goal of this review is to define a standard procedure for epidurography, explore the use of an epidurogram algorithm in differential diagnosis, and review the temporal relationship of a series of epidurograms. METHODS A standard epidurogram procedure was defined and used for the study. Routine postoperative epidurograms were obtained following epidural catheter placement. Serial epidurograms were obtained when clinically indicated, as described in the epidurogram algorithm. Radiographs taken after injection of the dye were used for determination of epidural catheter tip location and volume dye flow. Two cases are presented to demonstrate the effectiveness of the epidurogram algorithm. RESULTS Epidurograms show dye dispersion within the space, allowing for visualization of anomalies, resulting in a permanent record for later review. Case reports demonstrate the use of epidurograms in determining the cause of changes in epidural analgesia. CONCLUSIONS The review of repeated epidurograms and presented case reports support the use of epidurograms as a diagnostic tool for clinical practice. Abnormal epidurograms helped determine epidural space infection, tumor obstruction, space compression from vertebral compression fractures, and epidural fibrosis. The addition of a contrast computed tomographic scan after epidurography allows for more accurate diagnostic interpretation of epidural space pathology. The use of a standard epidurogram technique allows this procedure to be used in the differential diagnosis of suspected problems in the epidural space.
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Affiliation(s)
- S L Du Pen
- Tumor Institute Pain Service, Swedish Medical Center, Seattle, WA 98104, USA
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Abstract
Percutaneous tunable dye laser lithotripsy was used in two patients to successfully fragment a 2-cm left hepatic duct calculus and a 5-mm main pancreatic duct calculus. Tunable dye laser lithotripsy may prove to be a more effective alternative to mechanical lithotripsy.
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Affiliation(s)
- R K Feldman
- Department of Radiology, Virginia Mason Clinic, Seattle, WA 98111
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Krupski WC, Feldman RK, Rapp JH. Recombinant human tissue-type plasminogen activator is an effective agent for thrombolysis of peripheral arteries and bypass grafts: preliminary report. J Vasc Surg 1989; 10:491-8; discussion 499-500. [PMID: 2509737 DOI: 10.1067/mva.1989.15220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The efficacy, safety, and effects on hemostasis and coagulation of two doses of human tissue-type plasminogen activator in patients with acute and subacute peripheral arterial occlusion were compared. Seven patients with lower extremity ischemia and one patient with upper extremity ischemia had peripheral arterial thromboses (five arteries, three grafts) confirmed by clinical history, physical examination, and angiography. The duration of occlusion ranged from 31 hours to 30 days (mean 11.9 days). Tissue-type plasminogen activator was infused via a catheter directly into the thrombus at a randomly assigned dose of 0.05 mg/kg/hr (n = 4) or 0.025 mg/kg/hr (n = 4). Thrombolysis was complete in seven patients and partial in one. Duration of infusion ranged from 1 hour to 21 hours (mean 7.4 hours). The low dose required a longer infusion than did the high dose, but they were both successful in achieving thrombolysis. The one patient with partial thrombolysis had abrupt discontinuation of infusion when extravasation through a recently endarterectomized femoral artery developed. Otherwise there were no significant complications from tissue-type plasminogen activator therapy. Secondary procedures to correct underlying arterial disease were performed in five of the seven patients (71%) who had complete thrombolysis. Even at low dosages, infusion of tissue-type plasminogen activator into arteries or bypass graft thrombus produced complete thrombolysis, and no major complications occurred. This allowed more systematic effects to diagnose and treat underlying arterial disease.
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Affiliation(s)
- W C Krupski
- Surgical and Radiological Services, San Francisco Veterans Administration Medical Center, CA 94121
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