Impact of being underweight before pregnancy on preterm birth by race/ethnicity and insurance status in California: an analysis of birth records

BACKGROUND

The US still has a high burden of preterm birth (PTB), with important disparities by race/ethnicity and poverty status. There is a large body of literature looking at the impact of pre-pregnancy obesity on PTB, but fewer studies have explored the association between underweight status on PTB, especially with a lens toward health disparities. Furthermore, little is known about how weight, specifically pre-pregnancy underweight status, and socio-economic-demographic factors such as race/ethnicity and insurance status, interact with each other to contribute to risks of PTB.

OBJECTIVES

The objective of this study was to measure the association between pre-pregnancy underweight and PTB and small for gestational age (SGA) among a large sample of births in the US. Our secondary objective was to see if underweight status and two markers of health disparities - race/ethnicity and insurance status (public vs. other) - on PTB.

STUDY DESIGN

We used data from all births in California from 2011 to 2017, which resulted in 3,070,241 singleton births with linked hospital discharge records. We ran regression models to estimate the relative risk of PTB by underweight status, by race/ethnicity, and by poverty (Medi-cal status). We then looked at the interaction between underweight status and race/ethnicity and underweight and poverty on PTB.

RESULTS

Black and Asian women were more likely to be underweight (aRR = 1.0, 95% CI: 1.01, 1.1 and aRR = 1.4, 95% CI: 1.4, 1.5, respectively), and Latina women were less likely to be underweight (aRR = 0.7, 95% CI: 0.7, 0.7). Being underweight was associated with increased odds of PTB (aRR = 1.3, 95% CI 1.3-1.3) and, after controlling for underweight, all nonwhite race/ethnic groups had increased odds of PTB compared to white women. In interaction models, the combined effect of being both underweight and Black, Indigenous and People of Color (BIPOC) statistically significantly reduced the relative risk of PTB (aRR = 0.9, 95% CI: 0.8, 0.9) and SGA (aRR = 1.0, 95% CI: 0.9, 1.0). The combined effect of being both underweight and on public insurance increased the relative risk of PTB (aRR = 1.1, 95% CI: 1.1, 1.2) but there was no additional effect of being both underweight and on public insurance on SGA (aRR = 1.0, 95% CI: 1.0, 1.0).

CONCLUSIONS

We confirm and build upon previous findings that being underweight preconception is associated with increased risk of PTB and SGA - a fact often overlooked in the focus on overweight and adverse birth outcomes. Additionally, our findings suggest that the effect of being underweight on PTB and SGA differs by race/ethnicity and by insurance status, emphasizing that other factors related to inequities in access to health care and poverty are contributing to disparities in PTB.

Can we improve the outcome of pregnancies with low serum PAPP-A in the first trimester?

OBJECTIVE

This study aimed to assess the impact of micronized progesterone (VMP4) supplementation on pregnancies with low serum pregnancy-associated plasma protein-A (PAPP-A) multiples of the median (MoM) values during first-trimester screening.

METHODS

Out of 8933 patients evaluated, 116 pregnant women with low PAPP-A concentrations in their blood and no fetal chromosomal anomalies (CAs) were included. Three groups were formed: group 1 received VMP4 from 11 to 16 weeks (29 women, 25%), group 2 received VMP4 from 11 to 36 weeks (25 women, 21.5%), and group 3 (62 women, 53.5%) served as controls without receiving progesterone.

RESULTS

Results indicated that group 3 had higher rates of complications, including miscarriages (16.37%), preterm delivery (17.8%), and fetal developmental abnormalities (19.4%). Birthweight variations were elevated in pregnancies without progesterone, contrasting with lower variations in VMP4 groups. Group 2, receiving VMP4 until 36 weeks, reported the lowest incidence of abortion and preterm birth (PB), along with the highest mean birth weight.

CONCLUSIONS

The conclusion suggests that 200 mg per day of VMP4 up to 36 weeks of supplementation led to fewer placental-related complications in women with very low PAPP-A at first-trimester screening (0.399 MoM). By reporting lower rates of miscarriages, PBs, and fetal developmental abnormalities in the micronized progesterone-treated groups, the study suggests a potential reduction in complications.

Prenatal exposure to intra-amniotic infection with Ureaplasma species increases the prevalence of bronchopulmonary dysplasia

OBJECTIVES

The present study investigated the relationship between bronchopulmonary dysplasia (BPD) and intra-amniotic infection with Ureaplasma species.

METHODS

This was a single-center, retrospective cohort study. Patients with singleton pregnancies who underwent inpatient management at our department for preterm premature rupture of membranes (PPROM), preterm labor, cervical insufficiency, and asymptomatic cervical shortening at 22-33 gestational weeks were included. Amniocentesis was indicated for patients with PPROM or an elevated maternal C-reactive protein level (≥0.58 mg/dL). Patients with an amniotic fluid IL-6 concentration ≥3.0 ng/mL were diagnosed with intra-amniotic inflammation, while those with positive aerobic, anaerobic, M. hominis, and Ureaplasma spp. cultures were diagnosed with microbial invasion of the amniotic cavity (MIAC). Patients who tested positive for both intra-amniotic inflammation and MIAC were considered to have intra-amniotic infection. An umbilical vein blood IL-6 concentration >11.0 pg/mL indicated fetal inflammatory response syndrome (FIRS). The maternal inflammatory response (MIR) and fetal inflammatory response (FIR) were staged using the Amsterdam Placental Workshop Group Consensus Statement.

RESULTS

Intra-amniotic infection with Ureaplasma spp. was diagnosed in 37 patients, intra-amniotic infection without Ureaplasma spp. in 28, intra-amniotic inflammation without MIAC in 58, and preterm birth without MIR/FIR and FIRS in 86 as controls. Following an adjustment for gestational age at birth, the risk of BPD was increased in patients with intra-amniotic infection with Ureaplasma spp. (adjusted odds ratio: 10.5; 95% confidence interval: 1.55-71.2), but not in those with intra-amniotic infection without Ureaplasma spp. or intra-amniotic inflammation without MIAC.

CONCLUSION

BPD was only associated with intra-amniotic infection with Ureaplasma species.

Equilibrium Mechanical Properties of the Nonhuman Primate Cervix

Cervical remodeling is critical for a healthy pregnancy. Premature tissue changes can lead to preterm birth (PTB), and the absence of remodeling can lead to post-term birth, causing significant morbidity. Comprehensive characterization of cervical material properties is necessary to uncover the mechanisms behind abnormal cervical softening. Quantifying cervical material properties during gestation is challenging in humans. Thus, a nonhuman primate (NHP) model is employed for this study. In this study, cervical tissue samples were collected from Rhesus macaques before pregnancy and at three gestational time points. Indentation and tension mechanical tests were conducted, coupled with digital image correlation (DIC), constitutive material modeling, and inverse finite element analysis (IFEA) to characterize the equilibrium material response of the macaque cervix during pregnancy. Results show, as gestation progresses: (1) the cervical fiber network becomes more extensible (nonpregnant versus pregnant locking stretch: 2.03 ± 1.09 versus 2.99 ± 1.39) and less stiff (nonpregnant versus pregnant initial stiffness: 272 ± 252 kPa versus 43 ± 43 kPa); (2) the ground substance compressibility does not change much (nonpregnant versus pregnant bulk modulus: 1.37 ± 0.82 kPa versus 2.81 ± 2.81 kPa); (3) fiber network dispersion increases, moving from aligned to randomly oriented (nonpregnant versus pregnant concentration coefficient: 1.03 ± 0.46 versus 0.50 ± 0.20); and (4) the largest change in fiber stiffness and dispersion happen during the second trimester. These results, for the first time, reveal the remodeling process of a nonhuman primate cervix and its distinct regimes throughout the entire pregnancy.

Association between adverse pregnancy outcome and placental biomarkers in the first trimester: A prospective cohort study

OBJECTIVE

To determine the inter-relationships between five first-trimester biomarkers (pregnancy associated plasma protein A [PAPP-A], alpha-fetoprotein [AFP], beta human chorionic gonadotrophin [beta-hCG], placenta growth factor [PlGF] and soluble fms-like tyrosine kinase receptor-1 [sFlt-1]) and a range of adverse pregnancy outcomes (APOs).

DESIGN

Prospective cohort study of nulliparous singleton pregnancy.

SETTING

Cambridge, UK.

POPULATION OR SAMPLE

4056 pregnancy outcome prediction study participants.

METHODS

The biomarker concentrations were measured in maternal serum at ~12 weeks of gestation. Univariable analysis of APOs was performed using logistic regression. Multivariable analysis used best subsets logistic regression with cross-validation.

MAIN OUTCOME MEASURES

Pre-eclampsia (PE), small for gestational age (SGA), including severe SGA (birthweight <3rd), fetal growth restriction (FGR), preterm birth (PTB, both induced and spontaneous [iPTB and sPTB, respectively]), pre-viable loss and stillbirth, plus combinations of outcomes.

RESULTS

Lower values of PAPP-A, PlGF and sFlt-1 and higher values of AFP were associated with FGR (OR for 1 SD higher value 0.59 [95% CI 0.48-0.74], OR 0.56 [95% CI 0.44-0.70], OR 0.68 [95% CI 0.54-0.87] and OR 1.53 [95% CI 1.25-1.88]), severe SGA (OR 0.59 [95% CI 0.49-0.72], OR 0.71 [95% CI 0.57-0.87], OR 0.74 [95% CI 0.60-0.91] and OR 1.41 [95% CI 1.17-1.71]), sPTB (OR  0.61 [95% CI 0.50-0.73], OR 0.79 [95% CI 0.66-0.96], OR 0.57 [95% CI 0.47-0.70] and OR 1.41 [95% CI 1.18-1.67]) and iPTB (OR  0.72 [95% CI 0.57-0.91], OR 0.62 [95% CI 0.49-0.78], OR 0.71 [95% CI 0.56-0.90] and OR 1.44 [95% CI 1.16-1.78]), respectively. When combinations of biomarkers were assessed, PAPP-A and AFP were independently associated with severe SGA; PAPP-A alone with PE + PTB; PlGF alone with severe PE; PlGF, beta-hCG, AFP and PAPP-A with the combination of PE and SGA; AFP and sFlt-1 with sPTB; and AFP and PlGF with iPTB.

CONCLUSIONS

Combinations of first-trimester placental biomarkers are associated with APOs. However, the patterns vary for different types of APO, indicating heterogeneity in the underlying pathophysiological pathways.

Risk of adverse pregnancy outcomes in twin- and singleton-born women: An inter-generational cohort study

OBJECTIVE

To compare the risk of adverse pregnancy outcomes between twin-born and singleton-born women. We also evaluated whether in utero exposure to pre-eclampsia or preterm delivery affected adverse pregnancy outcomes in women's own pregnancies.

DESIGN

Population-based cohort study.

SETTING

Medical Birth Registry of Norway 1967-2020.

POPULATION

9184 twin-born and 492 894 singleton-born women during 1967-2005, with their later pregnancies registered during 1981-2020.

METHODS

Data from an individual's birth were linked to their later pregnancies. We used generalised linear models with log link binomial distribution to obtain exponentiated regression coefficients that estimated relative risks (RRs) with 95% confidence intervals (CIs) for associations between twin- or singleton-born women and later adverse pregnancy outcomes.

MAIN OUTCOME MEASURES

Pre-eclampsia, preterm delivery or perinatal loss in twin-born compared with singleton-born women.

RESULTS

There was no increased risk for adverse outcomes in twin-born compared with singleton-born women: adjusted RRs for pre-eclampsia were 1.00 (95% CI 0.93-1.09), for preterm delivery 0.96 (95% CI 0.90-1.02) and for perinatal loss 1.00 (95% CI 0.84-1.18). Compared with singleton-born women exposed to pre-eclampsia in utero, twin-born women exposed to pre-eclampsia had lower risk of adverse outcomes in their own pregnancies; the aRR for pre-eclampsia was 0.73 (95% CI 0.58-0.91) and for preterm delivery was 0.71 (95% CI 0.56-0.90). Compared with preterm singleton-born women, preterm twin-born women did not differ in terms of risk of pre-eclampsia (aRR 1.05, 95% CI 0.92-1.21) or perinatal loss (aRR 0.99, 95% CI 0.71-1.37) and had reduced risk of preterm delivery (RR 0.83, 95% CI 0.74-0.94).

CONCLUSIONS

Twin-born women did not differ from singleton-born women in terms of risk of adverse pregnancy outcomes. Twin-born women exposed to pre-eclampsia in utero, had a lower risk of pre-eclampsia and preterm delivery compared with singleton-born women exposed to pre-eclampsia.

Biomarkers associated with cardiovascular disease in women with spontaneous preterm birth: A case-control study

INTRODUCTION

Women with spontaneous preterm birth have an increased risk of cardiovascular disease later in life. Studies suggest potential pathophysiological mechanisms in common, but whether these could be identified by measurement of soluble circulating protein biomarkers in women with spontaneous preterm birth is unknown. The aim of this study was to determine if protein biomarkers associated with cardiovascular disease distinguish women with spontaneous preterm birth from healthy controls, both at pregnancy and at follow up.

MATERIAL AND METHODS

Study participants were identified in the population-based Uppsala biobank of pregnant women in Sweden, where plasma samples were collected in mid-pregnancy. In a first screening phase, we identified participants who subsequently experienced spontaneous preterm birth (<37 weeks) in the index pregnancy (N = 13) and controls (N = 6). In these samples, differences in protein expression were examined by comparative mass spectrometry. In a second validation phase, we invited 100 cases with previous spontaneous preterm birth in the index pregnancy and 100 controls (matched for age, body mass index, and year of delivery) from the same source population, to a follow-up visit 4-15 years after pregnancy. At follow up, we collected plasma samples and data on cardiovascular risk factors. We measured concentrations of selected biomarkers identified in the screening phase, as well as lipid profiles in samples both from pregnancy (biobank) and follow up.

CLINICALTRIALS

gov registration NCT05693285.

RESULTS

In the screening phase, fibrinogen, cadherin-5, complement C5, factor XII, plasma kallikrein, apolipoprotein M, and vitamin D-binding protein differed significantly at pregnancy. In the validation phase, 65 women agreed to participate (35 cases and 30 controls), with a median follow-up time of 11.8 years since pregnancy. The concentration of fibrinogen (p = 0.02) and triglycerides (p = 0.03) were slightly higher in cases compared with matched controls at follow up.

CONCLUSIONS

Compared with women without preterm birth, those with spontaneous preterm birth had slightly higher concentrations of fibrinogen, both at mid-pregnancy and a decade after pregnancy. Additionally, we found slightly higher concentration of triglycerides at follow up in women with previous spontaneous preterm birth. The relevance of this finding is uncertain but might indicate potential pathophysiological mechanisms in common between spontaneous preterm birth and cardiovascular disease.

Histological chorioamnionitis and pathological stages on very preterm infant outcomes

AIMS

Histological chorioamnionitis (HCA) is a condition linked to preterm birth and neonatal infection and its relationship with various pathological stages in extremely preterm neonates, and with their associated short- and long-term consequences, remains a subject of research. This study investigated the connection between different pathological stages of HCA and both short-term complications and long-term outcomes in preterm infants born at or before 32 weeks of gestational age.

METHODS

Preterm infants born at ≤ 32 weeks of gestation who underwent placental pathology evaluation and were followed-up at 18-24 months of corrected age were included. Neonates were classified based on their exposure to HCA and were further subdivided into different groups according to maternal inflammatory responses (MIR) and fetal inflammatory responses (FIR) stages. We compared short-term complications during their hospital stay between the HCA-exposed and -unexposed groups and examined the influence of HCA stages on long-term outcomes.

RESULTS

The HCA group exhibited distinct characteristics such as higher rates of premature rupture of membranes > 18 h, reduced amniotic fluid, early-onset sepsis, bronchopulmonary dysplasia and intraventricular haemorrhage (IVH) grades III-IV (P < 0.05). The moderate-severe HCA group displayed lower gestational age, lower birth weight and higher incidence of IVH (grades III-IV) and preterm sepsis compared with the mild HCA group (P < 0.05). After adjusting for confounders, the MIR stages 2-3 group showed associations with cognitive impairment and cerebral palsy (P < 0.05), and the FIR stages 2-3 group also showed poor long-term outcomes and cognitive impairment (P < 0.05).

CONCLUSIONS

Moderate-severe HCA was associated with increased early-onset sepsis, severe IVH and poor long-term outcomes, including cognitive impairment and cerebral palsy. Vigilant prevention strategies are warranted for severe HCA cases in order to mitigate poorer clinical outcomes.

Adverse perinatal events and maternal interpregnancy weight change: A population-based observational study

OBJECTIVE

Mothers whose newborn experiences adversity may neglect their own health to care for their affected infant or following a perinatal death. Weight gain after pregnancy is one measure of maternal self-care. We measured interpregnancy weight gain among women whose child had an adverse perinatal event.

METHODS

This population-based observational study included 192 154 primigravid women with two consecutive singleton births in Ontario, Canada. Outcomes included net weight gain, and adjusted odds ratios (aOR) of moving to a higher body mass index (BMI) category between pregnancies, comparing women whose child did versus did not experience either a perinatal death, prematurity, severe neonatal morbidity, major congenital anomaly, or severe neurologic impairment.

RESULTS

Perinatal death was associated with a +3.5 kg (95% confidence interval [CI]: 2.1-4.9) net higher maternal weight gain in the subsequent pregnancy. Relative to term births, preterm birth <32 weeks (+3.2 kg, 95% CI: 1.9-4.6), 32-33 weeks (+1.8 kg, 95% CI: 0.7-2.8) and 34-36 weeks (+0.9 kg, 95% CI: 0.6-1.3) were associated with higher net weight gain. Having an infant with severe neonatal morbidity was associated with a +1.2 kg (95% CI: 0.3-2.1) weight gain. Likewise, the aOR of moving to a higher BMI category was 1.27 (95% CI, 1.14-1.42) following a perinatal death, 1.21 (95% CI: 1.04-1.41) after a preterm birth <32 weeks, and 1.11 (95% CI: 1.02-1.22) with severe neonatal morbidity.

CONCLUSION

Greater interpregnancy weight gain, and movement to a higher BMI category, are each more likely in a woman whose first-born was affected by certain major adverse perinatal events.

Maternal biomarkers in predicting neonatal sepsis after preterm premature rupture of membranes in preterm infants

AIM

This retrospective cohort study aimed to assess the utility of maternal C-reactive protein (CRP) and leukocyte levels in predicting neonatal sepsis after preterm premature rupture of membranes (pPROM).

METHODS

We conducted a retrospective cohort study (2009-2021), encompassing preterm infants born ≤29 + 6 weeks of gestation following pPROM. The primary outcome was early-onset neonatal sepsis within the initial 72 h of life.

RESULTS

We analysed data from 706 patients with a median gestational age at pPROM of 25.1 weeks and a median gestational age at birth of 26.4 weeks. Overall survival rate was 86.1%, with 65.7% survival without severe morbidities. These rates were significantly worse in preterm infants with sepsis. Maternal CRP and leukocyte levels correlated significantly with neonatal infection markers and sepsis. However, their predictive values, correlation coefficients, and area under the curve values were generally low. Using maternal CRP ≥2 mg/dL to predict neonatal sepsis yielded a positive predictive value of 18.5%, negative predictive value of 91.5%, AUC of 0.589, 45.5% sensitivity, and 74.5% specificity.

CONCLUSION

Maternal CRP and leukocyte levels were ineffective as a tool for predicting early-onset neonatal sepsis following early pPROM. Consequently, these biomarkers lack the reliability required for clinical decision-making in this context.

Development and validation of models for predicting preterm birth and gestational latency following emergency cervical cerclage: A multicenter cohort study

INTRODUCTION

Emergency cervical cerclage is a recognized method for preventing mid-trimester pregnancy loss and premature birth; however, its benefits remain controversial. This study aimed to establish preoperative models predicting preterm birth and gestational latency following emergency cervical cerclage in singleton pregnant patients with a high risk of preterm birth.

MATERIAL AND METHODS

We retrospectively reviewed data from patients who received emergency cerclage between 2015 and 2023 in three institutions. Patients were grouped into a derivation cohort (n = 141) and an independent validation cohort (n = 61). Univariate and multivariate logistic and Cox regression analyses were used to identify independent predictive variables and establish the models. Harrell's C-index, time-dependent receiver operating characteristic curves and areas under the curves, calibration curve, and decision curve analyses were performed to assess the models.

RESULTS

The models incorporated gestational weeks at cerclage placement, history of prior second-trimester loss and/or preterm birth, cervical dilation, and preoperative C-reactive protein level. The C-index of the model for predicting preterm birth before 28 weeks was 0.87 (95% CI: 0.82-0.93) in the derivation cohort and 0.82 (95% CI: 0.71-0.92) in the independent validation cohort; The C-index of the model for predicting gestational latency was 0.70 (95% CI: 0.66-0.75) and 0.78 (95% CI: 0.71-0.84), respectively. In the derivation set, the areas under the curves were 0.84, 0.81, and 0.84 for predicting 1-, 3- and 5-week pregnancy prolongation, respectively. The corresponding values for the external validation were 0.78, 0.78, and 0.79, respectively. Calibration curves showed a good homogeneity between the observed and predicted ongoing pregnant probabilities. Decision curve analyses revealed satisfactory clinical usefulness.

CONCLUSIONS

These novel models provide reliable and valuable prognostic predictions for patients undergoing emergency cerclage. The models can assist clinicians and patients in making personalized clinical decisions before opting for the cervical cerclage.

Taking a chance on outcome standardisation: A cross-sectional analysis assessing the uptake of the prevention of preterm birth core outcome set in randomised controlled trials

OBJECTIVE

Analyse uptake of the core outcome set (COS) within preterm birth (PTB) clinical trials.

DESIGN

On 26 June 2023, we conducted a systematic search of phase III/IV trial registry entries regarding PTB interventions via ClinicalTrials.gov and the International Clinical Trial Registry Platform. These trials were analysed for the outcomes measured.

SETTING

N/A.

SAMPLE

After searching the two databases, 5257 randomised controlled trials (RCTs) were screened, resulting in 92 RCTs for analysis.

METHODS

Inclusion criteria were the following: subjects were patients receiving an intervention for PTB, study enrolment began within 5 years prior to publication of PTB COS to 26 June 2023, and evaluated the efficacy of interventions. Authors screened and extracted data in masked, duplicate fashion, then performed an interrupted time series analysis, analysis of variance and correlation analysis.

MAIN OUTCOME MEASURES

We extracted outcomes measured by each clinical trial in our sample. Trials were analysed for the percentage of adopted outcomes from PTB COS.

RESULTS

After COS publication, there was no significant change in percentage of COS outcomes measured. The most measured outcome was 'offspring mortality' (54.34%, 50/92) and the least measured outcome was 'late neonatal neurodevelopment morbidity' (3.26%, 3/92). Additionally, 22.83% (21/92) of trials measured zero outcomes related to the PTB COS.

CONCLUSION

Our results demonstrated no significant change in outcome measurement before or after PTB COS publication. We recommend focusing on both the measurement of outcomes and the assessments that are used.

Preterm birth and subsequent intelligence and academic performance in youth: A cohort study

INTRODUCTION

Worldwide, more children than before survive preterm birth. Preterm birth can affect long-term cognitive outcomes. The aim of our study was to investigate the association between preterm birth and academic performance and intelligence in youth.

MATERIAL AND METHODS

This cohort study included all liveborn children in Denmark from 1978 to 2000. We used uni- and multivariable logistic and linear regressions to analyze associations between gestational age and school graduation, grade point average (GPA), attending conscription, and male intelligence scores at conscription. We adjusted for a priori defined potential confounders.

RESULTS

The study included 1 450 681 children and found an association between preterm birth and lower academic performance, with children born extremely preterm having the lowest odds of graduating from lower- and upper secondary education (LSE and USE) and appearing before the conscription board (odds ratios of 0.45 [0.38-0.54], 0.52 [0.46-0.59], and 0.47 [0.39-0.56] for LSE, USE, and conscription, respectively, compared to the term group). Statistically significant differences were observed in LSE for total GPA and core subject GPA with higher GPAs in the term group, which were considered clinically relevant for mathematics with a 0.71 higher grade point for the term compared to the extremely preterm. Conversely, USE differences were less evident, and in linear regression models we found that preterm birth was associated with higher GPAs in the adjusted analyses; however, this was not statistically significant. We demonstrated statistically significant differences in intelligence scores at conscription with lower scores in the three preterm groups (-5.13, -2.73, and - 0.76, respectively) compared to the term group.

CONCLUSIONS

Low gestational age at birth was associated with not graduating from LSE and USE, achieving lower GPAs in LSE, not attending conscription, and lower intelligence scores in young adulthood. The findings remained significant after adjusting for potential confounders.

Prediction and prevention of preterm birth: Quality assessment and systematic review of clinical practice guidelines using the AGREE II framework

BACKGROUND

Prediction of pregnancies at risk of preterm birth (PTB) may allow targeted prevention strategies.

OBJECTIVES

To assess quality of clinical practice guidelines (CPGs) and identify areas of agreement and contention in prediction and prevention of spontaneous PTB.

SEARCH STRATEGY

We searched for CPGs regarding PTB prediction and prevention in asymptomatic singleton pregnancies without language restriction in January 2024.

SELECTION CRITERIA

CPGs included were published between July 2017 and December 2023 and contained statements intended to direct clinical practice.

DATA COLLECTION AND ANALYSIS

CPG quality was assessed using the AGREE-II tool. Recommendations were extracted and grouped under domains of prediction and prevention, in general populations and high-risk groups.

MAIN RESULTS

We included 37 CPGs from 20 organizations; all were of moderate or high quality overall. There was consensus in prediction of PTB by identification of risk factors and cervical length screening in high-risk pregnancies and prevention of PTB by universal screening and treatment for asymptomatic bacteriuria, screening and treatment for BV in high-risk pregnancies, and use of preventative progesterone and cerclage. Areas of contention or limited consensus were the role of PTB clinics, universal cervical length measurement, biomarkers and cervical pessaries.

CONCLUSIONS

This review identified strengths and limitations of current PTB CPGs, and areas for future research.

Size and multiplicity of placental lakes on 20-week fetal anatomy ultrasound and obstetrical outcomes

Our objective was to determine if placental lake presence or size are associated with adverse pregnancy outcomes. This was a retrospective cohort of patients who had fetal anatomy ultrasounds at 18-22 weeks and delivered between 2018 and 2022. Placental lakes were classified as small (>2.0-3.9 cm) or large (>4 cm). Multiple gestations, placenta previas, and placenta accretas were excluded. Outcomes included low birthweight, cesarean delivery, primary cesarean for non-reassuring fetal heart tracing, fetal growth restriction, preterm birth, and severe preeclampsia. A total of 1052 patients were included; 294 had placental lakes (204 small, 90 large). No differences in pregnancy outcomes were observed. RÉSUMÉ: Notre objectif était de déterminer si la présence d'un lac placentaire et sa taille sont associées à des issues de grossesse défavorables. Il s'agit d'une étude de cohorte rétrospective portant sur des patientes ayant eu une échographie morphologique entre 18 et 22 semaines d'aménorrhée et ayant accouché dans la période de 2018 à 2022. Les lacs placentaires ont été classés comme petits (>2,0-3,9 cm) ou grands (>4 cm). Les cas de grossesse multiple, de placenta prævia et de placenta accreta ont été exclus. Les critères de jugement étaient le faible poids à la naissance, la césarienne, la césarienne primaire pour un tracé cardiaque fœtal non rassurant, le retard de croissance intra-utérin, l'accouchement prématuré et la pré-éclampsie sévère. Au total, 1052 patientes ont été incluses; 294 avaient un lac placentaire (204 petits, 90 grands). Aucune différence n'a été observée dans les issues de grossesse.

[Risk of neonatal acidosis in preterm induction of labor for fetal growth restriction]

OBJECTIVE

If a small for gestational age (SGA) foetus needs to be delivered because of severity (< 3rd centile) attempting induction of labor theoretically increases the risk of caesarean section and neonatal acidosis, but these risks are poorly understood. This article aims to assess the risk of caesarean section and neonatal acidosis in attempted vaginal birth of a moderately preterm foetus in the setting of severe SGA.

METHOD

A single-centre hospital-based observational study conducted over a period of 17 consecutive years in mothers with a single foetus in cephalic presentation with severe SGA (< 3rd centile) needing foetal extraction. Neonatal acidosis was considered moderate if pH<7.10 and severe if pH<7.0. The degree of severity of SGA was estimated according to the birth weight ratio.

RESULTS

Four hundred and thirty-fourfoetuses with severe SGA were included during the period, 140 of whom were born after induction (32.3%). In this group, 66.4 % of women achieved a vaginal birth (66.4% CI95[58.0-74.2]) and the risk of moderate or severe acidosis was doubled compared with the group of foetuses who had undergone a planned caesarean section (7.9% vs 3.1%, OR=2.7 [1.1-6.7]). Neither gestational age nor the degree of growth restriction was significantly related to the risk of caesarean section or to the risk of moderate or severe neonatal acidosis Conclusion: In cases of severe SGA before 37 weeks' gestation, induction of labour allows vaginal delivery in two-thirds of cases. It is accompanied by a doubling of the risk of moderate or severe neonatal acidosis.

Association of Pregnant Women's Perinatal Depression with Sociodemographic, Anthropometric and Lifestyle Factors and Perinatal and Postnatal Outcomes: A Cross-Sectional Study

Background: In recent decades, the incidence of depression has gradually increased in the general population globally. Depression is also common during gestation and could result in detrimental gestational complications for both the mother and the fetus. The survey presented aimed to evaluate whether pregnant women's perinatal depression could be associated with socio-demographic, anthropometry and lifestyle factors, and perinatal and postnatal outcomes. Methods: This is a cross-sectional survey conducted on 5314 pregnant women. Socio-demographic and lifestyle factors were recorded by relevant questionnaires via face-to-face interviews. Anthropometric parameters were measured by qualified personnel. Perinatal depressive symptomatology status was evaluated by Beck's Depression Inventory (BDI-II) questionnaire. Results: Depressive symptoms throughout gestation were found in 35.1% of the enrolled women. Perinatal depression was significantly associated with lower educational and economic level, pre-pregnancy regular smoking and reduced levels of Mediterranean diet adherence levels, a higher prevalence of gestational diabetes and preterm birth, as well as a higher incidence of delivering by caesarean section and abnormal childbirth weight. Perinatal depression was also significantly associated with a higher prevalence of maternal postpartum depression and lower prevalence of exclusive breastfeeding practices, as well as with a higher incidence of childhood asthma. Conclusions: Pregnant women's perinatal depression appears to be associated with various socio-demographic, anthropometry, and lifestyle characteristics and with a higher frequency of several adverse pregnancy complications. The present findings emphasize the importance of pregnant women's perinatal mental health, highlighting the need to develop and apply public strategies and policies for psychological counseling and support of future mothers to minimize probable risk factors that may trigger perinatal depression. Novel well-organized, follow-up surveys of enhanced validity are highly recommended to establish more definitive conclusions.

Perinatal outcomes in patients undergoing repeat cerclage: A retrospective case series study

OBJECTIVE

This study aimed to describe the pregnancy outcomes of a case series of patients with probable cerclage failure who received repeat cerclage (RC) with potential indications.

METHODS

We retrospectively collected a case series of 55 singleton pregnancies with RC from 2019 to 2022 in Shanghai, China. All included women provided written informed consent, and the study was approved by the ethics committees of the two hospitals. We compared pregnancy outcomes between pregnancies with RC for different indications.

RESULTS

Among the case series, nine patients underwent RC for the indication of protruding membranes below the previous suture loop (group A), and the other 46 patients for painless cervix dilation (group B). Gestational age at delivery was shorter in group B than in group A (30.7 vs 37.6 weeks, P = 0.009). Rates of preterm birth <32 weeks (63.0% vs 22.2%, P = 0.033) and < 37 weeks (76.1% vs 33.3%, P = 0.002) were significantly higher in group B than in group A. Of the 46 patients who underwent RC for painless cervical dilation, 28 had cervical dilation of 1 to 2 cm (group C) and the other 18 had cervical dilation of 3 to 6 cm (group D). The gestational age at delivery was shorter in group D than in group C (27.4 vs 31.5 weeks, P = 0.037). However, rates of preterm birth <32 or <37 weeks were similar between the groups.

CONCLUSION

RC may constitute a rescue strategy for patients with probable cerclage failure. Protrusion of membranes below the cerclage loop or cervical dilation <3 cm may be an indicator of better pregnancy outcome.

Cell‑free fetal DNA at 11‑13 weeks of gestation is not altered in complicated pregnancies

Non-invasive maternal cell-free fetal DNA (cffDNA) is a promising biomarker for screening common genetic syndromes. Alterations in the expression levels of cffDNA in the maternal circulation have been demonstrated in abnormal pregnancies. However, the results are conflicting. The present study aimed to investigate whether cffDNA levels are associated with pregnancy complications. The study group comprised pregnant women who presented with pregnancy complications, such as preterm birth, gestational hypertension, intrauterine growth retardation, gestational diabetes, polyhydramnios, oligohydramnios, vaginal bleeding and placental abruption. The control group comprised women who had a normal pregnancy course. Blood samples were obtained from 500 pregnant women between 11-13 weeks of gestation. cffDNA was amplified, sequenced and analyzed using the next-generation aneuploidy test of a Panorama-Natera kit. Nuchal translucency (NT) thickness as well as pregnancy associated plasma protein-A (PAPP-A) and β-human chorionic gonadotropin (β-hCG) levels were also assessed. Statistical analysis was performed in 494 out of the 500 samples collected with SPSS v.26 using non-parametric methods. The parameters were normalized by the multiples of median (MoM) method. The expression levels of PAPP-A, β-hCG, and the NT mean MoM values were significantly different between the study and control groups (P=0.005, P<0.001 and P=0.007, respectively). However, the expression levels of cffDNA and the mean MoM values were not significantly different between these two groups (P=0.687). The findings of the present study support the conclusion that cffDNA expression is not altered in a series of pregnancy complications. The prognostic value of cffDNA in predicting adverse pregnancy outcomes requires further investigation.

Diving into CDC pregnancy data in the United States: longitudinal study and interactive application

Objective

Preterm birth (PTB) is a major determinant of neonatal mortality, morbidity, and childhood disability. In this article, we present a longitudinal analysis of the risk factors associated with PTB and how they have varied over the years: starting from 1968 when the CDC first started, reporting the natality data, up until 2021. Along with this article, we are also releasing an RShiny web application that will allow for easy consumption of this voluminous dataset by the research community. Further, we hope this tool can aid clinicians in the understanding and prevention of PTB.

Materials and Methods

This study used the CDC Natality data from 1968 to 2021 to analyze trends in PTB outcomes across the lens of various features, including race, maternal age, education, and interval length between pregnancies. Our interactive RShiny web application, CDC NatView, allows users to explore interactions between maternal risk factors and maternal morbidity conditions and the aforementioned features.

Results

Our study demonstrates how CDC data can be leveraged to conduct a longitudinal analysis of natality trends in the United States. Our key findings reveal an upward trend in late PTBs, which is concerning. Moreover, a significant disparity exists between African American and White populations in terms of PTB. These disparities persist in other areas, such as education, body-mass index, and access to prenatal care later in pregnancy.

Discussion

Another notable finding is the increase in maternal age over time. Additionally, we confirm that short interpregnancy intervals (IPIs) are a risk factor for PTBs. To facilitate the exploration of pregnancy risk factors, infections, and maternal morbidity, we developed an open-source RShiny tool called CDC NatView. This software offers a user-friendly interface to interact with and visualize the CDC natality data, which constitutes an invaluable resource.

Conclusion

In conclusion, our study has shed light on the rise of late PTBs and the persistent disparities in PTB rates between African American and White populations in the US. The increase in maternal age and the confirmation of a short IPI as a risk factor for PTB are noteworthy findings. Our open-source tool, CDC NatView, can be a valuable resource for further exploration of the CDC natality data to enhance our understanding of pregnancy risk factors and the interaction of PTB outcomes and maternal morbidities.

Maternal outcomes of a cohort of pregnancies affected by non-immune hydrops fetalis

OBJECTIVE

To describe the maternal outcomes of a prospective cohort of non-immune hydrops fetalis (NIHF) pregnancies with negative standard-of-care evaluations.

METHODS

This study was a secondary analysis of a prospective cohort study of NIHF pregnancies with negative work-ups (infection, alloimmune anemia, fetomaternal hemorrhage, and chromosomal disorders). Outcomes were obstetric complications, including pre-eclampsia, mirror syndrome, preterm birth, polyhydramnios, postpartum hemorrhage, and maternal mental health.

RESULTS

Forty pregnancies were included. Four patients developed pre-eclampsia (4/40, 10.0%); three occurred postpartum. None was diagnosed with mirror syndrome. Of the 31 continued pregnancies, 16 (51.6%) resulted in early fetal death or stillbirth and 15 (48.4%) resulted in live births. Of the 15 live births, 8 (53.3%) were delivered by primary cesarean delivery; 5 (62.5%) were for hydrops fetalis. Eleven live births (73.3%) were delivered preterm; 9 (81.8%) were indicated, most commonly for fetal indications (7/9, 77.8%). Polyhydramnios occurred in 14/40 (35.0%) cases. Where EBL was recorded (n=37), there were 5 (13.5%) cases of postpartum hemorrhage and an additional 3 (8.1%) had uterine atony without hemorrhage. Eighteen patients (18/40, 45.0%) had new-onset or exacerbated depression or anxiety symptoms.

CONCLUSION

Our study identified several important adverse outcomes of pregnancies complicated by NIHF with negative standard-of-care evaluations, including a high rate of postpartum pre-eclampsia and worsened mental health. We identified a higher rate of cesarean delivery and preterm birth, both primarily for fetal indications. We also observed the known relationship between polyhydramnios, hemorrhage, and atony, but noted that this risk included pregnancies concluding in dilation and evacuation. Counseling after a diagnosis of NIHF should include these adverse outcomes.

Cognition, mental health and quality of life amongst siblings of preterm born children: A systematic review

AIM

Globally, 1 in 10 babies are born preterm. Families with preterm born infants may suffer strains related to the presence of a preterm child. To date, most evidence focuses on the outcome of children born preterm and of their parents. Our objective was to investigate the evidence on the impact of having a preterm born sibling on cognitive function, mental health and quality of life of term-born siblings and critically appraise the evidence.

METHODS

We searched five electronic databases, Google Scholar and reference lists. Two reviewers independently conducted screening, data extraction and critical appraisal.

RESULTS

We retrieved 9121 articles. After duplicates, titles, abstract and full text review, seven studies met the inclusion criteria. One study reported higher anxiety and depression scores on index cases in the term born comparison group, compared to the index cases in the preterm born sibling group. Another study reported more feelings of reduced parental attention, and more interpersonal problems in the preterm born sibling group, than the comparison group.

CONCLUSIONS

Although two studies reported a difference in outcomes between index cases in preterm born sibling groups and comparison groups, the scarce evidence did not allow us to delineate an effect or lack of it.

Clinical Chorioamnionitis and Neurodevelopment at 5 Years of Age in Children Born Preterm: The EPIPAGE-2 Cohort Study

OBJECTIVE

To assess the association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born preterm.

STUDY DESIGN

EPIPAGE 2 is a national, population-based cohort study of children born before 35 weeks of gestation in France in 2011. We included infants born alive between 240/7 and 346/7 weeks after preterm labor or preterm premature rupture of membranes. Clinical chorioamnionitis was defined as maternal fever before labor (>37.8°C) with ≥2 of the following criteria: maternal tachycardia, hyperleukocytosis, uterine contractions, purulent amniotic fluid, or fetal tachycardia. The primary outcome was a composite, including cerebral palsy, coordination disorders, cognitive disorders, sensory disorders, or behavioral disorders. We also analyzed each of these disorders separately as secondary outcomes. We performed a multivariable analysis using logistic regression models. We accounted for the nonindependence of twins and missing data by generalized estimating equation models and multiple imputations, respectively.

RESULTS

Among 2927 children alive at 5 years of age, 124 (3%) were born in a context of clinical chorioamnionitis. Overall, 8.2% and 9.6% of children exposed and unexposed, respectively, to clinical chorioamnionitis had moderate-to-severe neurodevelopmental disorders. After multiple imputations and multivariable analysis, clinical chorioamnionitis was not associated with the occurrence of moderate-to-severe neurodevelopmental disorders (aOR, 0.9; 95% CI, 0.5-1.8).

CONCLUSIONS

We did not find any association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born at <35 weeks of gestation after preterm labor or preterm premature rupture of membrane.

An innovative low-cost breast pump-hire program to enhance breastfeeding rates in a neonatal intensive care unit

AIM

To evaluate the outcomes of a low-cost hospital-grade breast pump hire program for women experiencing financial hardship with infants in neonatal intensive care.

DESIGN

A multi-method evaluation including data audits and surveys.

METHODS

Twenty-four electric breast pumps were purchased and rented to mothers at a cost of $1/day. To be eligible, mothers needed to have given birth to an infant <32 weeks and/or <1500 g and self-identified as experiencing financial hardship. Data were collected by (1) a retrospective audit to evaluate infant feeding and clinical outcomes at hospital discharge; (2) prospective telephone surveys to evaluate women's satisfaction with the program; and (3) analysis of the breast pump register to determine any loss or damages.

RESULTS

Twenty-four mothers of 26 infants participated in the program. More than half of the infants were exclusively breastmilk fed at hospital discharge, and more than three-quarters were fed a combination of breastmilk and formula. Women who intended to formula feed were supported to provide breastmilk to their infants in the first few weeks of life. Most participants were highly satisfied with the program. Women reported that accessibility to a hospital-grade breast pump improved their ability to provide expressed breastmilk to their infants. Most participants were 'extremely satisfied' with the performance of the breast pump. One-quarter of the women reported that they would have exclusively formula-fed if they did not have access to the breast pump hire program. The audit of the equipment register showed no reported technical issues, loss or damages.

CONCLUSION

The findings suggested that the low-cost breast pump hire program supported equitable care, increasing women's ability to provide expressed breastmilk for their infants.

IMPACT

Providing access to low-cost hospital-grade breast pumps to mothers of vulnerable infants is likely to prevent poor infant clinical outcomes and improve women's care satisfaction.

PUBLIC OR PATIENT CONTRIBUTION

Nil.

Xenobiotic metabolites modify immune responses of the cervicovaginal epithelium: potential mechanisms underlying barrier disruption

OBJECTIVE

Xenobiotic metabolites are exogenous biochemicals that can adversely impact reproductive health. We previously identified xenobiotics in cervicovaginal fluid during pregnancy in association with short cervix. In other organ systems, xenobiotics can modify epithelial barrier function. We hypothesise that xenobiotics dysregulate epithelial cell and macrophage immune responses as a mechanism to disrupt the cervicovaginal barrier.

DESIGN

In vitro cell culture system.

SETTING

Laboratory within academic institution.

SAMPLE

Vaginal, ectocervical and endocervical epithelial cell lines and primary macrophages.

METHODS

Cells were treated with diethanolamine (2.5 mM), ethyl glucoside (5 mM) or tartrate (2.5 mM) for 24 h.

MAIN OUTCOME MEASURES

Cytokines and matrix metalloproteinases were measured in cell supernatants (n = 3 per condition). One-way analysis of variance (ANOVA) with Dunnett's test for multiple comparisons was performed.

RESULTS

Diethanolamine induces inflammatory cytokines, whereas ethyl glucoside and tartrate generally exert anti-inflammatory effects across all cells. Diethanolamine increases interleukin 6 (IL-6), IL-8, interferon γ-induced protein 10 kDa (IP-10), growth-regulated oncogene (GRO), fractalkine, matrix metalloproteinase 1 (MMP-1), MMP-9 and MMP-10 (p < 0.05 for all), factors involved in acute inflammation and recruitment of monocytes, neutrophils and lymphocytes. Ethyl glucoside and tartrate decrease multiple cytokines, including RANTES and MCP-1 (p < 0.05 for all), which serve as chemotactic factors. Vaginal cells exhibit heightened inflammatory tone compared with cervical cells and macrophages, with a greater number of differentially expressed analytes after xenobiotic exposure.

CONCLUSIONS

Xenobiotic metabolites present in the cervicovaginal space during pregnancy modify immune responses, unveiling potential pathways through which environmental exposures may contribute to the pathogenesis of cervical remodelling preceding preterm birth. Future work identifying xenobiotic sources and routes of exposure offers the potential to modify environmental risks to improve pregnancy outcomes.

Association between maternal cigarette smoking cessation and risk of preterm birth in Western New York

BACKGROUND

Although many studies suggested the benefit of smoking cessation among pregnant women in reducing the risk of preterm birth (PTB), the timing of the effect of the cessation remains inconclusive.

OBJECTIVES

To examine the association of trimester-specific smoking cessation behaviours with PTB risk.

METHODS

We included 199,453 live births in Western New York between 2004 and 2018. Based on self-reported cigarette smoking during preconception and in each trimester, we created six mutually exclusive groups: non-smokers, quitters in each trimester, those who smoked throughout pregnancy, and inconsistent smokers. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using Poisson regression to examine the association between smoking cessation and PTB. Effect modification by illegal drug use, maternal age, race and ethnicity and pre-pregnancy body mass index (BMI) was investigated multiplicatively by ratio of relative risk and additively by relative excess risk due to interaction (RERI).

RESULTS

Overall, 6.7% of women had a PTB; 14.1% smoked throughout pregnancy and 3.4%, 1.8% and 0.8% reported quitting smoking during the first, second and third trimesters, respectively. Compared to non-smokers, third-trimester cessation (RR 1.20, 95% CI 1.01, 1.43) and smoking throughout pregnancy (RR 1.27, 95% CI 1.21, 1.33) were associated with a higher PTB risk, while quitting smoking during the first or second trimester, or inconsistent smoking was not associated with PTB. A positive additive interaction was identified for maternal age and late smoking cessation or smoking throughout pregnancy on PTB risk (RERI 0.17, 95% CI 0.00, 0.36), and a negative interaction was observed for pre-pregnancy BMI ≥30 kg/m2 (ratio of relative risk 0.70, 95% CI 0.63, 0.78; RERI -0.42, 95% CI -0.56, -0.30).

CONCLUSION

Compared to non-smokers, smoking throughout pregnancy and third-trimester smoking cessation are associated with an increased risk of PTB, while quitting before the third trimester may not increase PTB risk.

The timing, duration, and severity of nausea and vomiting of pregnancy and adverse birth outcomes among controls without birth defects in the National Birth Defects Prevention Study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) occurs in approximately 70% of pregnant people, with varying severity and duration. Treatments include pharmacologic and herbal/natural medications. The associations between NVP and birth outcomes, including preterm birth, small for gestational age (SGA), and low birth weight are inconclusive.

OBJECTIVE

To determine whether NVP and reported medications are associated with adverse birth outcomes.

METHODS

We used data from the population-based, multisite National Birth Defects Prevention Study (1997-2011) to evaluate whether self-reported NVP according to timing, duration, and severity or its specific treatments were associated with preterm birth, SGA, and low birth weight among controls without birth defects. Odds ratios (aOR) and 95% confidence intervals (CI) were adjusted for sociodemographic, reproductive, and medical factors. For any NVP, duration, treatment use, and severity score analyses, the comparison group was participants with no reported NVP. For timing analyses, the comparison group was women with no reported NVP in the same trimester of pregnancy.

RESULTS

Among 6018 participants, 4339 (72.1%) reported any NVP. Among those with NVP, moderate or severe symptoms were more common than mild symptoms. Any versus no NVP was not associated with any of the outcomes of interest. NVP in months 4-6 (aOR 1.21, 95% CI: 1.00, 1.47) and 7-9 (aOR 1.57, 95% CI: 1.22, 2.01) of pregnancy were associated with an increase in the risk of preterm birth. NVP lasting one trimester in duration was associated with decrease in risk of SGA (aOR: 0.74, 95% CI: 0.58, 0.95), and NVP present in every trimester of pregnancy had a 50% increase in risk of preterm birth (aOR: 1.50, 95% CI: 1.11, 2.05). For NVP in months 7-9 and preterm birth, ORs were elevated for moderate (aOR: 1.82, 95% CI: 1.26, 2.63), and severe (aOR: 1.53, 95% CI: 1.06, 2.19) symptoms. NVP was not significantly associated with low birth weight. Our analyses of medications were limited by small numbers, but none suggested increased risk of adverse outcomes associated with use of the medication.

CONCLUSION

Mild NVP and NVP limited to early pregnancy appear to have no effect or a small protective effect on birth outcomes. Long-lasting NVP, severe NVP, and NVP later in pregnancy may increase risk of preterm birth and SGA.

Cannabis Use in Pregnancy and Neonatal Outcomes: A Systematic Review and Meta-Analysis

Objective: To determine whether prenatal cannabis use alone increases the likelihood of fetal and neonatal morbidity and mortality. Study Design: We searched bibliographic databases, such as PubMed, Embase, Scopus, Cochrane reviews, PsycInfo, MEDLINE, Clinicaltrials.gov, and Google Scholar from inception through February 14, 2022. Cohort or case-control studies with prespecified fetal or neonatal outcomes in pregnancies with prenatal cannabis use. Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small-for-gestational-age (SGA), birthweight (grams), and perinatal mortality. Two independent reviewers screened studies. Studies were extracted by one reviewer and confirmed by a second using a predefined template. Risk of bias assessment of studies, using the Newcastle-Ottawa Quality Assessment Scale, and Grading of Recommendations Assessment, Development, and Evaluation for evaluating the certainty of evidence for select outcomes were performed by two independent reviewers with disagreements resolved by a third. Random effects meta-analyses were conducted, using adjusted and unadjusted effect estimates, to compare groups according to prenatal exposure to cannabis use status. Results: Fifty-three studies were included. Except for birthweight, unadjusted and adjusted meta-analyses had similar results. We found very-low- to low-certainty evidence that cannabis use during pregnancy was significantly associated with greater odds of PTB (adjusted odds ratio [aOR], 1.42; 95% confidence interval [CI], 1.19 to 1.69; I2, 93%; p=0.0001), SGA (aOR, 1.76; 95% CI, 1.52 to 2.05; I2, 86%; p<0.0001), and perinatal mortality (aOR, 1.5; 95% CI, 1.39 to 1.62; I2, 0%; p<0.0001), but not significantly different for birthweight (mean difference, -40.69 g; 95% CI, -124.22 to 42.83; I2, 85%; p=0.29). Because of substantial heterogeneity, we also conducted a narrative synthesis and found comparable results to meta-analyses. Conclusion: Prenatal cannabis use was associated with greater odds of PTB, SGA, and perinatal mortality even after accounting for prenatal tobacco use. However, our confidence in these findings is limited. Limitations of most existing studies was the failure to not include timing or quantity of cannabis use. This review can help guide health care providers with counseling, management, and addressing the limited existing safety data. Protocol Registration: PROSPERO CRD42020172343.

Ongoing effects of preterm birth on the dopaminergic and noradrenergic pathways in the frontal cortex and hippocampus of guinea pigs

Children born preterm have an increased likelihood of developing neurobehavioral disorders such as attention-deficit hyperactivity disorder (ADHD) and anxiety. These disorders have a sex bias, with males having a higher incidence of ADHD, whereas anxiety disorder tends to be more prevalent in females. Both disorders are underpinned by imbalances to key neurotransmitter systems, with dopamine and noradrenaline in particular having major roles in attention regulation and stress modulation. Preterm birth disturbances to neurodevelopment may affect this neurotransmission in a sexually dimorphic manner. Time-mated guinea pig dams were allocated to deliver by preterm induction of labor (gestational age 62 [GA62]) or spontaneously at term (GA69). The resultant offspring were randomized to endpoints as neonates (24 h after term-equivalence age) or juveniles (corrected postnatal day 40, childhood equivalence). Relative mRNA expressions of key dopamine and noradrenaline pathway genes were examined in the frontal cortex and hippocampus and quantified with real-time PCR. Myelin basic protein and neuronal nuclei immunostaining were performed to characterize the impact of preterm birth. Within the frontal cortex, there were persisting reductions in the expression of dopaminergic pathway components that occurred in preterm males only. Conversely, preterm-born females had increased expression of key noradrenergic receptors and a reduction of the noradrenergic transporter within the hippocampus. This study demonstrated that preterm birth results in major changes in dopaminergic and noradrenergic receptor, transporter, and synthesis enzyme gene expression in a sex- and region-based manner that may contribute to the sex differences in susceptibility to neurobehavioral disorders. These findings highlight the need for the development of sex-based treatments for improving these conditions.

Ambient temperature and preterm birth: A case-crossover study

OBJECTIVE

To investigate the association between ambient temperature and preterm birth (PTB) and to estimate the population attributable fraction (PAF) of PTBs due to low and high temperatures.

DESIGN

Time-stratified case-crossover design.

SETTING

Japan (46 prefectures, excluding Okinawa), 2011-2020.

SAMPLE

214 050 PTBs registered in the Japan Perinatal Registry Network database among 1 908 168 singleton live births.

METHODS

A quasi-Poisson regression model with a distributed lag nonlinear model was employed to assess the associations between daily mean temperature and PTBs for a lag of 0-27 days in each prefecture. A random effects meta-analysis was conducted by combining effect estimates from the 46 prefectures to estimate pooled relative risks (RRs). The PAFs of the PTBs due to below or above the mean of the 46 median temperatures (16.0°C) were calculated.

MAIN OUTCOME MEASURES

Preterm singleton live births.

RESULTS

The association between daily mean temperature and PTB risk exhibited a U-shaped curve. The adjusted RRs were 1.15 (95% confidence interval [CI] 1.05-1.25) at the mean of the 1st percentiles (0.8°C) and 1.08 (95% CI 1.00-1.17) at the mean of the 99th percentiles (30.2°C) of 46 prefectures, with 16.0°C as the reference temperature. Approximately 2.3% (95% CI 0.6-4.0) of PTBs were attributable to low temperatures.

CONCLUSIONS

Both low and possibly high temperatures were associated with an increased risk of PTBs. These findings may help to inform preventive measures for pregnant women.

Effect of low-molecular-weight heparin on placenta-mediated fetal growth restriction in a tertiary referral hospital: A 7-year retrospective cohort study

OBJECTIVE

To investigate the effect of low-molecular-weight heparin (LMWH) on placenta-mediated fetal growth restriction (FGR).

METHODS

A cohort of 570 pregnant women diagnosed with placenta-mediated FGR were enrolled from January 1, 2015 through to December 31, 2021. A birth database, including demographic data, antenatal complications, and detailed delivery and newborn data, was created to collect variables from the Hospital Information System (HIS) Database. The unique personal registration number, assigned to each patient on first registration with HIS in the West China Second University Hospital, was used to link these patients. LMWH use was defined as at least 1-week prescription from diagnosis of placenta-mediated FGR. Pregnant women received LMWH (Enoxaparin 4000 IU/day) by self-administered subcutaneous injection only when they agreed and signed informed consent. Primary outcome was intrauterine fetal death after 20 weeks of pregnancy. Secondary outcomes included preterm birth (PB), Apgar score less than 7 at 1 min, admission to neonatal intensive care unit (NICU), and birth weight. Logistic regression analysis was conducted to compute adjusted odds ratio (aOR) with 95% confidence intervals (CI) for outcomes.

RESULTS

After controlling for confounders, LMWH use was associated with a decreased risk of intrauterine fetal death (aOR 2.49, 95% CI 1.35-4.57, P = 0.003), PB before 37 weeks of pregnancy (aOR 3.35, 95% CI 2.14-5.23, P < 0.001), PB before 34 weeks of pregnancy (aOR 2.25, 95% CI 1.36-3.74, P = 0.002), Apgar score less than 7 at 1 min (aOR 2.25, 95% CI 1.36-3.74, P = 0.002), NICU admission (aOR 2.29, 95% CI 1.48-3.55, P < 0.001). Using LMWH increased the mean birth weight in PB before 32 weeks of pregnancy (mean ± standard deviation [SD] 1126.4 ± 520.0 g, P = 0.020), PB before 37 weeks of pregnancy (mean ± SD 1563.9 ± 502.7 g, P = 0.019), early-onset FGR (mean ± SD 2125.2 ± 665.7 g, P < 0.001), late-onset FGR (mean ± SD 2343.4 ± 507.9, P < 0.001), and non-severe FGR (mean ± SD 2231.1 ± 607.2 g, P < 0.001).

CONCLUSION

Use of LMWH can significantly improve the fetal and neonatal outcomes among pregnant women with placenta-mediated FGR, particularly reducing the risk of intrauterine fetal death.

Prevalence of hepatitis C among pregnant women in an Appalachian population

The opioid crisis has adversely affected West Virginia's pregnant and infant populations. With high rates of opioid use disorder and neonatal abstinence syndrome, West Virginia has the highest rates of Hepatitis C (HCV) acute infection among pregnant women. To better understand how HCV impacts an already high-risk population, the study purpose was to (1) describe its prevalence among women receiving prenatal care at a single tertiary care clinic in Appalachia and compare with state and national rates, and (2) determine whether it is associated with preterm birth (gestation <37 weeks). Data were collected on a retrospective cohort of pregnant patients universally screened for HCV between 2017 and 2021. The study cohort had an HCV infection rate of 119/988 = 11.94% or 119.4 per 1000. This is five times the rate of 22.6 per 1000 live births in West Virginia in 2014 and 35 times the national rate of 3.4 per 1000 live births (MMWR Morb Mortal Wkly Rep 66, 2017 and 470). Viral loads were detected in 63 (6.38%) of patients. The study cohort with birth outcome data had high rates of tobacco use (326/720; 45.3%) and substance abuse (209/720; 29.0%). The preterm birth rate was 17.8% (128/720), almost double the national average (10.09%) (Natl Vital Stat Rep 70, 2021 and 1). There was no statistically significant difference in preterm birth between HCV-positive (15/92; 16.3%) and HCV-negative (113/628; 18.0%) patients. HCV infection in our population presents a significant public health issue and missed opportunity for treatment in a population with continuity of care challenges. These findings could be used to justify a pilot program for early postpartum referral for treatment.

Impact of preeclampsia on infant and maternal health among women with rheumatic diseases

OBJECTIVES

We sought to identify the impact of preeclampsia on infant and maternal health among women with rheumatic diseases.

METHODS

A retrospective single-center cohort study was conducted to describe pregnancy and infant outcomes among women with systemic lupus erythematosus (SLE) with and without preeclampsia as compared to women with other rheumatic diseases with and without preeclampsia.

RESULTS

We identified 263 singleton deliveries born to 226 individual mothers (mean age 31 years, 35% non-Hispanic Black). Overall, 14% of women had preeclampsia; preeclampsia was more common among women with SLE than other rheumatic diseases (27% vs 8%). Women with preeclampsia had a longer hospital stay post-delivery. Infants born to mothers with preeclampsia were delivered an average of 3.3 weeks earlier than those without preeclampsia, were 4 times more likely to be born preterm, and twice as likely to be admitted to the neonatal intensive care unit. The large majority of women with SLE in this cohort were prescribed hydroxychloroquine and aspirin, with no clear association of these medications with preeclampsia.

CONCLUSIONS

We found preeclampsia was an important driver of adverse infant and maternal outcomes. While preeclampsia was particularly common among women with SLE in this cohort, the impact of preeclampsia on the infants of all women with rheumatic diseases was similarly severe. In order to improve infant outcomes for women with rheumatic diseases, attention must be paid to preventing, identifying, and managing preeclampsia.

Effects of Levothyroxine Treatment on Fertility and Pregnancy Outcomes in Subclinical Hypothyroidism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Subclinical hypothyroidism, defined by elevated thyrotropin (TSH) and normal free thyroxine levels, is associated with adverse pregnancy outcomes, including preterm birth, pre-eclampsia, and small for gestational age. Despite the uncertainty regarding the effectiveness of levothyroxine (LT4) treatment on pregnancy outcomes in subclinical hypothyroidism, LT4 is widely administered with a pre-treatment threshold TSH level of 2.5 mU/L. The aim of this study is to investigate the efficacy of periconceptional LT4 treatment for subclinical hypothyroidism, including TSH levels >2.5 mU/L, and identify the characteristics of subclinical hypothyroidism that can benefit from LT4 treatment. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials from inception to February 2023. We analyzed the pooled effects of LT4 on subclinical hypothyroidism before and during pregnancy. The main outcomes before pregnancy were live birth, pregnancy, and miscarriage. The main outcomes during pregnancy were live birth, miscarriage, and preterm birth. We conducted subgroup analyses to compare the effects of LT4 on subclinical hypothyroidism with TSH levels of 2.5-4.0 and >4.0 mU/L. Results: Of the 888 studies identified, 27 full-text articles were screened for eligibility. Five studies on pre-conception treatment with 768 participants and eight studies on treatment during early pregnancy with 2622 participants were analyzed. One of the two studies on pre-conception treatment in subclinical hypothyroidism with TSH >4.0 mU/L had high risk of bias and the other was composed of 64 participants. Pre-conception LT4 treatment had no significant effect in improving rates of live births and pregnancies, or reducing miscarriages (risk ratio [RR], 95% confidence interval): 1.41 (0.84-2.36), 1.73 (0.88-3.39), and 0.46 (0.11-2.00), respectively. LT4 treatment during pregnancy was not significantly associated with higher rates of live births (RR 1.03, 0.98-1.09) nor decreased miscarriage rates (RR 1.01, 0.66-1.53). The effect of LT4 treatment on preterm birth during pregnancy was significantly different depending on the TSH values (p = 0.04); a positive effect was shown in the subclinical hypothyroidism subgroup with TSH >4.0 mU/L (RR 0.47, 0.20-1.10), while no significant effect was observed in the subgroup with TSH 2.5-4.0 mU/L (RR 1.35, 0.79-2.31). Conclusions: Pre-conceptional LT4 treatment for subclinical hypothyroidism does not improve fertility or decrease the incidence of miscarriages. However, further well-designed studies are needed for pre-conceptional treatment, especially in TSH >4.0 mU/L. LT4 treatment during pregnancy had a positive effect on preterm birth; nevertheless, this was only applicable to subclinical hypothyroidism with TSH >4.0 mU/L.

Noninvasive factors predicting the maintenance of pregnancy for more than 4 weeks after rescue cerclage in singleton pregnancies with cervical dilatation and prolapsed membrane

Studies on noninvasive factors and predicting the maintenance of pregnancy, and those comparing the usefulness of these factors with invasive amniotic fluid markers in predicting the maintenance of pregnancy following rescue cerclage, are lacking. Therefore, this study aimed to determine whether C-reactive protein (CRP) levels, White blood cell (WBC) count, absolute neutrophil count (ANC), and platelet-to-lymphocyte ratio (PLR) in maternal blood, which are noninvasive and readily available clinical markers, can predict the maintenance of pregnancy following rescue cerclage in patients with cervical insufficiency (CI). A total of 142 singleton pregnant women (15-28 wk) who underwent rescue cerclage for CI were retrospectively evaluated. The interleukin (IL)-6 concentration in the amniotic fluid; CRP levels, WBC count, ANC, and PLR in the maternal peripheral blood; and degree of cervical dilatation were evaluated before cerclage. The primary outcome was whether the pregnancy was maintained for >4 weeks after rescue cerclage. Among the 142 patients, prolonged pregnancy for >4 weeks following emergent cerclage was observed in 107 (75.35%), while 35 (24.65%) gave birth within 4 weeks. This study demonstrated that the degree of cervical dilatation at diagnosis; WBC count, ANC, and CRP levels in the maternal peripheral blood; and IL-6 concentration in the amniotic fluid significantly differed between the successful and failure groups (all P < .05). The area under the curve (AUC) of the amniotic fluid IL-6 concentration was .795 for the prediction of spontaneous preterm birth within 4 weeks after rescue cerclage. Additionally, the AUC of the CRP level, cervical dilatation, WBC count, ANC, and PLR were .795, .703, .695, .682, and .625, respectively. These findings suggest that the preoperative CRP levels can be considered a useful noninvasive marker comparable to amniotic fluid IL-6 concentration for identifying pregnant women with CI at high risk of spontaneous preterm birth following rescue cerclage.

Value of Non-Coding RNA Expression in Biofluids to Identify Patients at Low Risk of Pathologies Associated with Pregnancy

Pregnancy-related complications (PRC) impact maternal and fetal morbidity and mortality and place a huge burden on healthcare systems. Thus, effective diagnostic screening strategies are crucial. Currently, national and international guidelines define patients at low risk of PRC exclusively based on their history, thus excluding the possibility of identifying patients with de novo risk (patients without a history of disease), which represents most women. In this setting, previous studies have underlined the potential contribution of non-coding RNAs (ncRNAs) to detect patients at risk of PRC. However, placenta biopsies or cord blood samples are required, which are not simple procedures. Our review explores the potential of ncRNAs in biofluids (fluids that are excreted, secreted, or developed because of a physiological or pathological process) as biomarkers for identifying patients with low-risk pregnancies. Beyond the regulatory roles of ncRNAs in placental development and vascular remodeling, we investigated their specific expressions in biofluids to determine favorable pregnancy outcomes as well as the most frequent pathologies of pregnant women. We report distinct ncRNA panels associated with PRC based on omics technologies and subsequently define patients at low risk. We present a comprehensive analysis of ncRNA expression in biofluids, including those using next-generation sequencing, shedding light on their predictive value in clinical practice. In conclusion, this paper underscores the emerging significance of ncRNAs in biofluids as promising biomarkers for risk stratification in PRC. The investigation of ncRNA expression patterns and their potential clinical applications is of diagnostic, prognostic, and theragnostic value and paves the way for innovative approaches to improve prenatal care and maternal and fetal outcomes.

Impact of preterm birth on kidney health and development

Preterm birth, defined as birth before the gestational age of 37 weeks, affects 11% of the newborns worldwide. While extensive research has focused on the immediate complications associated with prematurity, emerging evidence suggests a link between prematurity and the development of kidney disease later in life. It has been demonstrated that the normal course of kidney development is interrupted in infants born prematurely, causing an overall decrease in functional nephrons. Yet, the pathogenesis leading to the alterations in kidney development and the subsequent pathophysiological consequences causing kidney disease on the long-term are incompletely understood. In the present review, we discuss the current knowledge on nephrogenesis and how this process is affected in prematurity. We further discuss the epidemiological evidence and experimental data demonstrating the increased risk of kidney disease in these individuals and highlight important knowledge gaps. Importantly, understanding the intricate interplay between prematurity, abnormal kidney development, and the long-term risk of kidney disease is crucial for implementing effective preventive and therapeutic strategies.

Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines

OBJECTIVES

Twin pregnancies are at increased risk of preterm birth (PTB) compared to singletons. Evaluation of cervical length (CL) represents the optimal tool to screen PTB in singleton. Conversely, there is less evidence on the use of CL in twins. Our aim was to evaluate the methodological quality and clinical heterogeneity of clinical practice guidelines (CPGs) on the CL application in twins using AGREE II methodology.

METHODS

MEDLINE, Scopus, and websites of the main scientific societies were examined. The following aspects were evaluated: diagnostic accuracy of CL, optimal gestational age at assessment and interventions in twin pregnancies with reduced CL. The quality of the published CPGs was carried out using "The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)" tool. The quality of guideline was rated using a scoring system. Each considered item was evaluated by the reviewers on a seven-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). A cut-off >60 % identifies a CPGs as recommended.

RESULTS

The AGREE II standardized domain scores for the first overall assessment had a mean of 74 %. The score was more than 60 % in the 66.6 % of CPGs analyzed indicating an agreement between the reviewers on recommending the use of these CPGs. A significant heterogeneity was found; there was no specific recommendation on CL assessment in about half of the published CPGs. There was also significant heterogeneity on the CL cut-off to prompt intervention.

CONCLUSIONS

Despite the fact that the AGREE II analysis showed that the majority of the included guidelines are of good quality, there was a significant heterogeneity among CPGs as regard as the indication, timing, and cut-off of CL in twins as well as in the indication of interventions.

Prediction of outcomes for rescue cerclage in cervical insufficiency: A multicenter retrospective study

Purpose: Cervical insufficiency is a significant risk factor for preterm birth and miscarriage during the second trimester; cervical cerclage is a treatment option. This study seeks to evaluate the predictive roles of various clinical factors and to develop predictive models for immediate and long-term outcomes after rescue cerclage. Methods: We conducted a multicenter retrospective study on patients who underwent rescue cerclage at 14 to 26 weeks of gestation. Data were collected from the Electronic Medical Record systems of participating hospitals. Outcomes were dichotomized into immediate failure (inability to maintain pregnancy for at least 48 hours post-cerclage, gestational latency < 2 days) and long-term success (maintenance of pregnancy until at least 28 weeks of gestation). Clinical factors influencing these outcomes were analyzed. Results: The study included 98 patients. Immediate failure correlated with longer prolapsed membrane lengths, elevated C-reactive protein levels at admission, and extended operation time. The successful maintenance of pregnancy until at least 28 weeks was associated with earlier gestational age at diagnosis, negative AmniSure test results, longer lengths of the functional cervix, and smaller cervical dilatation at the time of cerclage. Binary logistic regression models for immediate failure and long-term success exhibited excellent and good predictive abilities, respectively (AUROC = 0.912, 95% CI: 0.834-0.989; and AUROC = 0.872, 95% CI: 0.788-0.956). Conclusion: The developed logistic regression models offer a valuable tool for the prognostic assessment of patients undergoing rescue cerclage, enabling informed clinical decision-making.

Screening preterm-born infants for autistic traits may help to identify social communication difficulties at five years of age

AIM

This study compared neurodevelopmental screening questionnaires completed when preterm-born children reached 2 years of corrected age with social communication skills at 5.5 years of age.

METHODS

Eligible subjects were born in 2011 at 24-34 weeks of gestation, participated in a French population-based epidemiological study and were free of motor and sensory impairment at 2 years of corrected age. The Ages and Stages Questionnaire (ASQ) and the Modified Checklist for Autism in Toddlers (M-CHAT) were used at 2 years and the Social Communication Questionnaire (SCQ) at 5.5 years of age.

RESULTS

We focused on 2119 children. At 2 years of corrected age, the M-CHAT showed autistic traits in 20.7%, 18.5% and 18.2% of the children born at 24-26, 27-31 and 32-34 weeks of gestation, respectively (p = 0.7). At 5.5 years of age, 12.6%, 12.7% and 9.6% risked social communication difficulties, with an SCQ score ≥90th percentile (p = 0.2). A positive M-CHAT score at 2 years was associated with higher risks of social communication difficulties at 5.5 years of age (odds ratio 3.46, 95% confidence interval 2.04-5.86, p < 0.001). Stratifying ASQ scores produced similar results.

CONCLUSION

Using parental neurodevelopmental screening questionnaires for preterm-born children helped to identify the risk of later social communication difficulties.

Cannabis exposure during pregnancy and perinatal outcomes: A cohort study

INTRODUCTION

Cannabis potency and its use during pregnancy have increased in the last decade. The aim of this study was to investigate the impact of antenatal cannabis use on fetal growth, preterm birth and other perinatal outcomes.

MATERIAL AND METHODS

A propensity score-matched analysis was performed in women with singleton pregnancies attending a tertiary care site in Barcelona. Women in the cannabis group were selected based on the results of a detection test. Primary outcomes were small for gestational age at birth (SGA), low birthweight and preterm birth. Secondary outcomes were other biometric parameters (neonatal length and head circumference), respiratory distress, admission to the neonatal intensive care unit and breastfeeding at discharge. A second propensity score-matched analysis excluding other confounders (use of other recreational drugs and discontinuation of cannabis use during pregnancy) was performed.

RESULTS

Antenatal cannabis was associated with a higher odds ratio of SGA (OR 3.60, 95% CI: 1.68-7.69), low birthweight (OR 3.94, 95% CI: 2.17-7.13), preterm birth at 37 weeks (OR 2.07, 95% CI: 1.12-3.84) and 32 weeks of gestation (OR 4.13, 95% CI: 1.06-16.11), admission to the neonatal intensive care unit (OR 1.95, 95% CI: 1.03-3.71), respiratory distress (OR 2.77, 95% CI: 1.26-6.34), and lower breastfeeding rates at discharge (OR 0.10, 95% CI: 0.05-0.18). When excluding other confounders, no significant association between antenatal cannabis use and SGA was found.

CONCLUSIONS

Antenatal cannabis use increases the risk of SGA, low birthweight, preterm birth and other adverse perinatal outcomes. However, when isolating the impact of cannabis use by excluding women who use other recreational drugs and those who discontinue cannabis during pregnancy, no significant association between antenatal cannabis use and SGA birth was found.

Systemic Lupus Erythematosus is Associated With an Increased Frequency of Spontaneous Preterm Births: Systematic Review and Meta-analysis

OBJECTIVE

Preterm birth (PTB) is one of the most frequent complications of pregnancies in women with systemic lupus erythematosus (SLE). The high indicated PTB proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures as well as screening for early detection are performed. The risk of spontaneous PTB is less well recognized. The purpose of this study is to determine the proportions of spontaneous and indicated PTB in pregnancies of women with SLE DATA SOURCES: A systematic literature search using Pubmed, Embase, Web of Science and Google Scholar was performed in June 2021 STUDY ELIGIBILITY CRITERIA: Studies in pregnant women with SLE reporting spontaneous and indicated PTB rates were selected. Original research articles published from 1995 to June 2021 were included STUDY APPRAISAL AND SYNTHESIS METHODS: Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa Quality Assessment Scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed.

RESULTS

We included 21 articles, containing data of 8157 pregnancies in women with SLE. On average 31% (95% prediction interval [0.14; 0.50]) of the pregnancies resulted in PTB, including 14% (95% prediction interval [0.04; 0.27]) spontaneous, and 16% (95% prediction interval [0.03; 0.35])indicated PTB CONCLUSIONS: In pregnant women with SLE, spontaneous as well as indicated PTB proportions are high. This information should be applied in (pre-pregnancy) counselling and management in pregnancy. The knowledge obtained by this meta-analysis, paves the way for further research of associated risk factors and development of interventions to reduce spontaneous PTB in SLE pregnancies.

Universal cervical length screening and risk of spontaneous preterm birth: a systematic review and meta-analysis

OBJECTIVE

To evaluate the risk of spontaneous preterm birth with or without universal transvaginal ultrasound cervical length screening at the time of midtrimester scan.

DATA SOURCES

Medline, Embase, ClinicalTrials.gov, and Web of Science were systematically searched from the inception of the databases to November 12, 2023, using combinations of the relevant medical subject heading terms, key words, and word variants that were considered suitable for the topic.

STUDY ELIGIBILITY CRITERIA

Studies including individuals with singleton gestations at 16-25 weeks of gestation screened or not screened with universal transvaginal ultrasound cervical length screening were considered eligible. Primary outcome was spontaneous preterm birth <37 weeks; secondary outcomes were spontaneous preterm birth <34 and <32 weeks.

METHODS

Random effect head-to-head analyses were used to directly compare each outcome, expressing the results as summary odds ratio and relative 95% confidence interval. The quality of the included studies was independently assessed by 2 reviewers, using the Newcastle-Ottawa scale for cohort studies and the Cochrane risk-of-bias tool for randomized controlled studies. The study was registered on the prospective register of systematic reviews database (PROSPERO) (registration number: CRD42022385325).

RESULTS

Eight studies, including 447,864 pregnancies, were included in the meta-analysis (213,064 screened with transvaginal ultrasound cervical length and 234,800 unscreened). In the overall analysis, universal transvaginal ultrasound cervical length did not significantly decrease the spontaneous preterm birth rates <37 weeks (odds ratio, 0.92 [95% confidence interval, 0.84-1.01], P=.07) and <34 weeks (odds ratio, 0.87 [95% confidence interval, 0.73-1.04], P=.12), but was significantly associated with a lower risk of spontaneous preterm birth <32 weeks (odds ratio, 0.84 [95% confidence interval, 0.76-0.94], P=.002). Individuals without a prior spontaneous preterm birth had a significantly lower risk of spontaneous preterm birth <37 weeks (odds ratio, 0.88 [95% confidence interval, 0.79-0.97], P=.01) and a lower trend of spontaneous preterm birth <32 weeks (odds ratio, 0.82 [95% confidence interval, 0.66-1.01], P=.06) when screened with transvaginal ultrasound cervical length, compared with no screening.

CONCLUSION

Universal transvaginal ultrasound cervical length screening usually <24 weeks in singletons without a prior spontaneous preterm birth, is associated with a significant reduction in spontaneous preterm birth <37 weeks, compared with no screening.

Understanding the Relationship Between Gender Representation in County Government and Perinatal Outcomes to Black, White, and Hispanic Birthing People in Georgia

Objective

To characterize the association between percent of county-level elected officials who were female-presenting and perinatal outcomes in Georgia and variation by individual race, 2020-2021.

Materials and Methods

We gathered data on the gender composition of county-level elected officials for all Georgia counties (n = 159) in 2022 and calculated the percent of female elected officials (percent female, 0-100). We linked this to data from 2020 to 2021 birth certificates (n = 238,795) to identify preterm birth (PTB, <37 weeks), low birthweight (LBW, <2500 grams), hypertensive disorders of pregnancy, and cesarean delivery. We fit multilevel log binomial models with generalized estimating equations, with percent female as the primary independent variable. We adjusted for individual and county-level potential confounders and individual race/ethnicity as an effect modifier.

Results

County median percent female elected officials was 22.2% (interquartile range: 15.5). Overall, 14.6% of births were PTB and 10.1% LBW. A 15 percentage point increase in percent female elected officials was associated with lower risk of hypertensive disorders of pregnancy for white (adjusted risk ratio [RR]: 0.94, 95% confidence interval [CI]: 0.88-0.99), and possibly Hispanic (adjusted RR: 0.95, 95% CI: 0.89-1.0) and non-Hispanic other (adjusted RR: 0.94 (0.87-1.01), but not black birthing people (adjusted RR: 1.0, 95% CI: 0.95-1.05). There was not a clear pattern for PTB, birthweight, or cesarean delivery.

Conclusion

Greater female representation in county government was associated with improved maternal health for some racial/ethnic groups in Georgia.

Pregnancy Outcomes among Pregnant Persons after COVID-19 Vaccination: Assessing Vaccine Safety in Retrospective Cohort Analysis of U.S. National COVID Cohort Collaborative (N3C)

COVID-19 vaccines have been shown to be effective in preventing severe illness, including among pregnant persons. The vaccines appear to be safe in pregnancy, supporting a continuously favorable overall risk/benefit profile, though supportive data for the U.S. over different periods of variant predominance are lacking. We sought to analyze the association of adverse pregnancy outcomes with COVID-19 vaccinations in the pre-Delta, Delta, and Omicron SARS-CoV-2 variants' dominant periods (constituting 50% or more of each pregnancy) for pregnant persons in a large, nationally sampled electronic health record repository in the U.S. Our overall analysis included 311,057 pregnant persons from December 2020 to October 2023 at a time when there were approximately 3.6 million births per year. We compared rates of preterm births and stillbirths among pregnant persons who were vaccinated before or during pregnancy to persons vaccinated after pregnancy or those who were not vaccinated. We performed a multivariable Poisson regression with generalized estimated equations to address data site heterogeneity for preterm births and unadjusted exact models for stillbirths, stratified by the dominant variant period. We found lower rates of preterm birth in the majority of modeled periods (adjusted incidence rate ratio [aIRR] range: 0.42 to 0.85; p-value range: <0.001 to 0.06) and lower rates of stillbirth (IRR range: 0.53 to 1.82; p-value range: <0.001 to 0.976) in most periods among those who were vaccinated before or during pregnancy compared to those who were vaccinated after pregnancy or not vaccinated. We largely found no adverse associations between COVID-19 vaccination and preterm birth or stillbirth; these findings reinforce the safety of COVID-19 vaccination during pregnancy and bolster confidence for pregnant persons, providers, and policymakers in the importance of COVID-19 vaccination for this group despite the end of the public health emergency.

Development and validation of a risk prediction model for preterm birth in women with gestational diabetes mellitus

OBJECTIVES

This study aims to develop and validate a prediction model for preterm birth in women with gestational diabetes mellitus (GDM).

DESIGN

We conducted a retrospective study on women with GDM who gave birth at the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, between November 2017 and July 2021. We divided 1879 patients into a development set (n = 1346) and a validation set (n = 533). The development set was used to construct the prediction model for preterm birth using the stepwise logistic regression model. A nomogram and a web calculator were established based on the model. Discrimination and calibration were assessed in both sets.

PATIENTS AND MEASUREMENTS

Patients were women with GDM. Data were collected from medical records. GDM was diagnosed with 75-g oral glucose tolerance test during 24-28 gestational weeks. Preterm birth was definied as gestational age at birth <37 weeks.

RESULTS

The incidence of preterm birth was 9.4%. The predictive model included age, assisted reproductive technology, hypertensive disorders of pregnancy, reproductive system inflammation, intrahepatic cholestasis of pregnancy, high-density lipoprotein, homocysteine, and fasting blood glucose of 75-g oral glucose tolerance test. The area under the receiver operating characteristic curve for the development and validation sets was 0.722 and 0.632, respectively. The model has been adequately calibrated using a calibration curve and the Hosmer-Lemeshow test, demonstrating a correlation between the predicted and observed risk.

CONCLUSION

This study presents a novel, validated risk model for preterm birth in pregnant women with GDM, providing an individualized risk estimation using clinical risk factors in the third trimester of pregnancy.

Pre-pregnancy body mass index, gestational diabetes mellitus, and gestational weight gain: individual and combined effects on fetal growth

Background

Pre-pregnancy body mass index (BMI), gestational diabetes mellitus (GDM), and gestational weight gain (GWG) are interlinked and may play a complex role in fetal growth. We aimed to examine the relationship between pre-pregnancy BMI, GDM, GWG, and fetal growth outcomes and explore the contribution of GDM and GWG to the relationship between Pre-pregnancy obesity/overweight and large-for-gestational-age (LGA) in a prospective cohort.

Methods

We prospectively recruited women in the first trimester and having one-step GDM screened with a 75-g oral glucose tolerance test between 24 and 28 weeks of gestation (n = 802). Outcomes included LGA, small-for-gestational-age (SGA), and preterm birth. To assess the individual and cumulative associations between pre-pregnancy BMI, GDM, GWG, and these outcomes, we used multivariate logistic regression analysis. Furthermore, we employed structural equation modeling (SEM) to investigate the mediating role of GDM and excessive GWG in the correlation between pre-pregnancy overweight/obesity and LGA.

Results

Pre-pregnancy obesity, GDM, and excessive GWG were all independently associated with increased odds of LGA. Inadequate GWG was associated with higher odds of preterm birth. Compared with women unexposed to pre-pregnancy overweight/obesity, GDM, or excessive GWG, women exposed any two conditions had higher odds for LGA (AOR 3.18, 95% CI 1.25-8.11) and women with coexistence of all had the highest odds for LGA (AOR 8.09, 95% CI 2.18-29.97). The mediation analysis showed that GDM explained 18.60% (p < 0.05) of the total effect of pre-pregnancy overweight/obesity on LGA, and GWG explained 17.44% (p < 0.05) of the total effect.

Conclusion

Pre-pregnancy obesity/overweight, GDM, and excessive GWG are associated with higher odds of fetal growth disturbances as individual factors and when they co-exist. The effect of pre-pregnancy overweight/obesity on LGA is partially achieved through GDM and excessive GWG.

Pentaerythrityl tetranitrate improves the outcome of children born to mothers with compromised uterine perfusion-12-months follow-up and safety data of the double-blind randomized PETN trial

BACKGROUND

This is a follow-up study to the pentaerythrityl tetranitrate randomized controlled multicenter trial that reports neonatal outcome data of newborns admitted to neonatal intensive care units and outcome data of the offspring at 12 months of age.

OBJECTIVE

We present data on adverse events reported during the study to document the safety of pentaerythrityl tetranitrate treatment during pregnancy. To further evaluate the effects of pentaerythrityl tetranitrate on neonatal and long-term outcomes, we present follow up data from of 240 children at 12 months of age, including information on height, weight, head circumference, developmental milestones, and the presence of chronic disease and of 144 newborns admitted to the neonatal intensive care unit during the trial.

STUDY DESIGN

The pentaerythrityl tetranitrate trial was a randomized, double-blind, placebo-controlled study designed to assess the efficacy and safety of the nitric oxide-donor pentaerythrityl tetranitrate in the prevention of fetal growth restriction and perinatal death in pregnancies complicated by abnormal placental perfusion.

RESULTS

Results at 12 months demonstrated that significantly more children were age appropriately developed without impairments in the pentaerythrityl tetranitrate group (P=.018). In addition, the presence of chronic disease was lower in the pentaerythrityl tetranitrate group (P=.041). Outcome data of the 144 newborns admitted to the neonatal intensive care unit did not reveal differences between the treatment and placebo groups. There were no differences in the number or nature of reported adverse events between the study groups.

CONCLUSION

The analysis shows that study children born in the pentaerythrityl tetranitrate cohort have a clear advantage compared with the placebo group at the age of 12 months, as evidenced by the increased incidence of normal development without the presence of chronic disease. Although safety has been proven, further follow-up studies are necessary to justify pentaerythrityl tetranitrate treatment during pregnancies complicated by impaired uterine perfusion.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BACKGROUND

An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth.

OBJECTIVE

We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery.

STUDY DESIGN

We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity.

RESULTS

A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42).

CONCLUSION

Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.

Impact of Genital Infections and Antibiotic Use on Incidence of Preterm Birth: A Retrospective Observational Study

This study investigates the complex interplay among genital infections, antibiotic usage, and preterm birth. This study aims to identify common genital pathogens associated with preterm births, assess the impact of various antibiotic treatments on pregnancy outcomes, and understand antibiotic resistance patterns among these pathogens. This study included 71 pregnant women who experienced preterm birth and 94 women with genital infections who delivered at term. Various maternal characteristics, medical history, signs and symptoms, gestational weight, gestational age, type of birth, vaginal pH, Nugent scores, and vaginal flora were analyzed. Antibiotic resistance patterns of isolated microorganisms were also examined. The prevalence of sexually transmitted diseases (STDs) and genital herpes was significantly higher in the preterm group. Preterm births were associated with fever, pelvic pain, vaginal spotting, and fatigue. Vaginal pH levels and Nugent scores were significantly higher in the preterm group, indicating disturbed vaginal flora. The presence of Extended-Spectrum Beta-Lactamases (ESBLs) was a particularly strong risk factor, increasing by more than four times the odds of preterm birth (OR = 4.45, p = 0.001). Vancomycin-Resistant Enterococci (VRE) presence was another critical factor, with a four-fold increase in the odds of preterm birth (OR = 4.01, p = 0.034). The overall presence of Multidrug-Resistant (MDR) organisms significantly increased the odds of preterm birth (OR = 3.73, p = 0.001). Specific pathogens like Chlamydia trachomatis (OR = 3.12, p = 0.020) and Mycoplasma hominis (OR = 3.64, p = 0.006) were also identified as significant risk factors. Ureaplasma urealyticum also showed a significantly higher risk of preterm birth (OR = 2.76, p = 0.009). This study highlights the importance of screening for and treating genital infections during pregnancy, especially STDs and genital herpes, as they can significantly increase the risk of preterm birth. Additionally, the presence of specific microorganisms and antibiotic resistance patterns plays an essential role in preterm birth risk. Early detection and targeted antibiotic treatment may help mitigate this risk and improve pregnancy outcomes.