Maternal smoking during pregnancy and long-term neurological morbidity of the offspring

OBJECTIVE

To evaluate the long-term pediatric neurological morbidity of children born to mothers who reported smoking during pregnancy as compared with children born to non-smoking mothers.

STUDY DESIGN

A population-based cohort analysis was performed comparing all deliveries of mothers who reported smoking during pregnancy and non-smoking mothers between 1991 and 2014 at a single tertiary medical center. Hospitalizations of the offspring up to the age of 18 years involving neurological morbidities were evaluated according to a predefined set of ICD-9 codes, including autism, development and movement disorders, cerebral palsy and more. A Kaplan-Meier survival curve was used to compare cumulative hospitalization rate in exposed and unexposed offspring and a Cox proportional hazards model was used to control for confounders.

RESULTS

During the study period, 242,342 deliveries met the inclusion criteria. Of them, 2861 (1.2%) were children of smoking mothers. Neurological-related hospitalizations were significantly higher in children born to smoking mothers, as compared with the non-smoking group (5.3% vs. 3.1%, p < 0.01). Specifically, these children had higher rates of movement, eating and developmental disorders as well as attention deficit hyperactive disorder. The Kaplan-Meier survival curve demonstrated a significant higher cumulative incidence of neurological-related hospitalizations in the smoking group (log rank p < 0.01). Using a Cox proportional hazards model, controlling for potential confounders, maternal tobacco use was found to be independently associated with long-term neurological morbidity of the offspring (adjusted HR = 1.58, CI 1.33-1.89, p value < 0.01).

CONCLUSION

Maternal smoking during pregnancy is an independent risk factor for long-term neurological morbidity of the offspring.

Pediatric Cardiovascular Morbidity of the Early Term Newborn

OBJECTIVE

To determine whether early term delivery (at 37^0/7-38^6/7 weeks of gestation) is associated with long-term pediatric cardiovascular morbidity of the offspring.

STUDY DESIGN

A population-based cohort analysis was performed including all term deliveries occurring between 1991 and 2014 at a single tertiary medical center. Gestational age at delivery was subdivided into early term (37^0/7-38^6/7), full term (39^0/7-40^6/7), late term (41^0/7-41^6/7) and post term (≥42^0/7) delivery. Hospitalizations of children up to the age of 18 years involving cardiovascular morbidity were evaluated, including structural valvular disease, hypertension, arrhythmias, rheumatic fever, ischemic heart disease, pulmonary heart disease, perimyoendocarditis, congestive heart failure, and others. Kaplan-Meier survival curves were used to compare cumulative hospitalization incidence between groups. A multivariable Weibull parametric model was used to control for confounders.

RESULTS

During the study period, 223 242 term singleton deliveries met the inclusion criteria. Of them, 24% (n = 53 501) occurred at early term. Hospitalizations involving cardiovascular morbidity were significantly more common in children delivered at early term (0.7%) as compared with those born at full (0.6%), late (0.6%), or post term (0.5%; P = .01). The survival curve demonstrated a significantly higher cumulative incidence of cardiovascular-related hospitalizations in the early term group (log-rank P <.001). In the Weibull model, early term delivery was found to be an independent risk factor for cardiovascular-related hospitalization as compared with full term delivery (adjusted HR, 1.16; 95% CI, 1.01-1.32; P = .02).

CONCLUSION

Early term delivery is independently associated with pediatric cardiovascular morbidity of the offspring as compared with offspring born at full term.

Maternal urinary tract infection during pregnancy and long-term infectious morbidity of the offspring

BACKGROUND

Urinary tract infection (UTI) is a common bacterial infection in pregnant women and is associated with adverse perinatal outcomes. We sought to investigate the long-term infectious outcomes of children to mothers who were diagnosed with UTI during their pregnancy.

METHODS

A population-based cohort analysis was conducted at a single tertiary medical center. The study included all singleton deliveries between the years 1991-2014, comparing offspring born to mothers diagnosed with UTI during their pregnancy with those born to non-exposed mothers. Infectious-related hospitalizations of the offspring up to the age of 18 years were assessed according to a predefined set of ICD-9 codes. A Kaplan-Meier survival curve was conducted to compare cumulative hospitalization incidence between the groups. A Cox regression model was used to adjust for confounders.

RESULTS

During the study period, 243,725 deliveries met the inclusion criteria. Of them, 8034 (3.3%) were exposed to maternal UTI during pregnancy. Infectious-related hospitalizations were significantly prevalent in offspring to exposed mothers (12.3% vs. 11.0%, OR = 1.125, 95% CI 1.051-1.204, Kaplan-Meier log rank p < 0.001). In the Cox regression model, while controlling for clinically relevant confounders, maternal UTI (adjuster HR = 1.240), as well as preterm delivery (adjusted HR = 1.385) and cesarean delivery (adjusted HR = 1.198) were noted as independent risk factors for long-term infectious morbidity of the offspring.

CONCLUSIONS

Maternal UTI in pregnancy may influence offspring susceptibility to pediatric infections, as it was found to be an independent risk factor for long-term infectious morbidity of the offspring.

Reproductive Effects of Exposure to Low-Dose Ionizing Radiation: A Long-Term Follow-Up of Immigrant Women Exposed to the Chernobyl Accident

The Chernobyl accident in 1986 spread ionizing radiation over extensive areas of Belarus and Ukraine, leading to adverse health effects in exposed children. More than 30 years later, exposed children have grown and became parents themselves. This retrospective study from Israel was aimed to evaluate whether Chernobyl-exposed women are at higher risk for adverse reproductive outcomes. Exposed immigrants were identified as high or low exposure based on Caesium-137 soil contamination levels registered in the town they lived in. The exposed group was age matched with three comparison groups: non-exposed immigrant women from the Former Soviet Union (FSU) excluding Belarus and the Ukraine, immigrants from other countries (Non FSU) and Israeli-born women at a ratio of 1:10. Chernobyl-exposed women were more likely to be nulliparous and have fewer children (2.1 + 0.8 vs. 3.1 + 1.8, p < 0.001), were more likely to undergo fertility treatments (8.8% vs. 5.8%, adjusted OR = 1.8, 95%CI 1.04-3.2, p = 0.036), and were also more likely to have anemia after delivery (49.4% vs. 36.6%, OR = 1.7, 95%CI 1.2-2.3, p = 0.001), compared to women in the combined comparison groups. The overall fertility of Chernobyl-exposed women seems to be reduced as reflected by the lower number of children and their greater need for fertility treatments.

Does nuchal cord at birth increase the risk for cerebral palsy?

BACKGROUND

Nuchal cord is a common finding in pregnancy. It is unclear whether a nuchal cord at birth causes birth asphyxia and raises the risk for developing cerebral palsy of the offspring.

AIM

To evaluate the incidence of cerebral palsy in children born with and without nuchal cord.

STUDY DESIGN

A population-based cohort analysis including all singleton deliveries over >20 years at a single tertiary medical center was conducted. The incidence of cerebral palsy in children up to 18 years of age was evaluated. Kaplan-Meier survival curve was used to compare cumulative incidence between the groups, and a Cox proportional hazards model was used to control for confounders.

RESULTS

During the study period, 243,682 singleton deliveries met the inclusion criteria. Of them, 14.1% (n = 34,332) were diagnosed with nuchal cord at birth. Rates of cerebral palsy were comparable between the groups (0.1% vs. 0.1%, OR = 1.03, 95% CI 0.69-1.52, p = 0.89). The Kaplan-Meier survival curve demonstrated no significant differences in cumulative incidence of cerebral palsy for children born with or without nuchal cord (log rank p = 0.92, Fig. 1). The Cox proportional hazards model, controlled for preterm delivery, maternal age, diabetes and hypertensive disorders, showed no association between nuchal cord and cerebral palsy (adjusted HR = 1.06; 95% CI 0.71-1.57; p = 0.77).

CONCLUSION

In our population, nuchal cord at birth was not associated with higher risk for cerebral palsy.

Maternal hypothyroidism and future pediatric neurological morbidity of the offspring

BACKGROUND

Maternal hypothyroidism in pregnancy has been associated with neurocognitive impairment in exposed children, ranging from psychomotor-developmental delay to lower IQ scores.

OBJECTIVE

To investigate the long-term neurological morbidity of children to hypothyroid mothers during pregnancy.

STUDY DESIGN

A population-based cohort study was performed including all deliveries occurring in a period of 20 years at a tertiary medical center. We excluded multiple pregnancies, fetuses with congenital malformations, perinatal mortality cases and women lacking prenatal care from the study. Neurological-related hospitalizations of children (up to 18 years) were evaluated using neurological morbidities that were predefined by ICD-9 codes. Kaplan-Meier survival curve was used to compare cumulative hospitalization rate in exposed and unexposed children. A Cox regression model was used to control for confounders.

RESULTS

During the study period, 217,910 deliveries met the inclusion criteria. Of them, 1.1% (n = 2403) were in mothers with known hypothyroidism during pregnancy. The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of neurological-related hospitalizations in the hypothyroidism group (log rank p = 0.007). Total hospitalization rate per person years was significantly higher in the maternal hypothyroidism group (5.5 vs. 3.1, HR =1.37, 95% CI 1.10-1.73, p = 0.007). The Cox regression model controlled for various possible confounders including maternal age, maternal obesity, birth weight, preterm birth, maternal diabetes, hypertensive disorders, induction of labor and mode of delivery, found maternal hypothyroidism to be independently associated with pediatric neurological morbidity in these children (adjusted HR =1.33, 95% CI 1.05-1.68, p = 0.01).

CONCLUSION

Maternal hypothyroidism in pregnancy is independently associated with long-term pediatric neurological morbidity of the offspring.

Long-term pediatric hematological morbidity of the early-term newborn

Children born at early term (37 0/7 to 38 6/7 weeks' gestation) are at an increased risk for long-term respiratory, cardiovascular, neurological, and developmental morbidities as compared with children born at full term (39 0/7 to 40 6/7 weeks' gestation). In this population-based cohort analysis, we sought to evaluate the long-term hematological morbidity of early-term born children. The cohort consisted of 223,242 term singleton deliveries. Hospitalizations of the offspring up to 18 years of age involving hematological morbidity were evaluated, including hereditary and acquired anemias, immunodeficiency disorders, coagulation disorders, white blood cell disorders, cytopenias, polycythemia, and myelodysplastic syndrome. Hematological hospitalizations were significantly more common in children delivered at early term as compared with those born at later gestational ages. A Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of hematological-related hospitalizations in the early-term born group (logrank p < 0.001). Using a Cox regression model, early-term delivery was found to be an independent risk factor for childhood hematological morbidity with an adjusted hazard ratio of 1.15 (95%CI 1.01-1.30, p=0.027).Conclusion: Early-term delivery appears to be independently associated with pediatric long-term hematological morbidity of the offspring. What is Known? • It has been shown that children born at early term are at increased risk for short-term adverse outcomes including perinatal mortality. • Early-term infants are also at increased risk for long-term morbidity, mainly respiratory. What is New? • Early-term delivery is also independently associated with long-term hematological morbidity of the offspring.

Maternal prenatal smoking and long-term gastrointestinal morbidity of the offspring: A population-based cohort analysis

Tobacco consumption in the form of cigarette smoking is one of the most prevalent controllable risk factors for adverse health outcomes and is a known reproductive toxin. We aimed to study the effect of maternal cigarette smoking during pregnancy on the risk of long-term gastrointestinal (GI) morbidity of their offspring. A population-based cohort analysis was performed comparing long-term GI-related hospitalizations among offspring of smoking mothers compared with offspring of non-smoking mothers up to the age of 18. The analysis included all singletons born between the years 1999-2014 at a single tertiary medical center. A Kaplan-Meier survival curve was used to compare the cumulative GI morbidity, and a Cox proportional hazards model was constructed to adjust for confounders. The study population included 242,342 children who met the inclusion criteria, 2861(1.2 %) of them were born to smokers. Offspring of smoking mothers were found to have higher rates of GI-related hospitalizations (7.2 % vs. 5.4 %, p < 0.01). Furthermore, the cumulative incidence of long-term GI morbidity was higher compared with those born to non-smoking mothers (log-rank p < 0.01). Specifically, an increased risk for inflammatory bowel disease was noted (OR = 1.48, 95 % CI 1.2-1.8, P < 0.01). Using a Cox proportional hazards model, controlling for confounders including maternal age, ethnicity, maternal diabetes mellitus and hypertensive disorders of pregnancy, birth weight, prematurity and mode of delivery, the association between maternal smoking during pregnancy and long-term GI morbidity of the offspring remained significant (adjusted HR = 1.54, 95 % CI 1.3-1.8, P < 0.01). In-utero exposure to maternal smoking is associated with an increased risk for long-term GI morbidity of the offspring.

Meconium stained amniotic fluid exposure and long-term respiratory morbidity in the offspring

OBJECTIVE

Meconium stained amniotic fluid (MSAF) is a well-established risk factor for neonatal short-term respiratory complications. Little is known regarding the long-term morbidity. We investigated the possible association between MSAF and offspring respiratory morbidity.

METHODS

A population-based, cohort study of singleton deliveries occurring between 1991 and 2014 at a sole regional tertiary medical center was performed. Incidence of offspring respiratory related hospitalizations up to the age of 18 years were evaluated and compared to unexposed offspring. A Kaplan-Meier survival curve was used to compare cumulative respiratory morbidity incidence, and a Cox proportional hazards model was used to control for confounders.

RESULTS

During the study period 242,342 deliveries met the inclusion criteria. Of them, 14.7% (n = 35,609) were complicated with MSAF. Incidence of respiratory-related hospitalizations was significantly lower in children exposed to MSAF as compared to the unexposed group (4.5% vs. 4.9%, respectively; p < .01). Specifically, hospitalizations involving pneumonitis were significantly less common among the MSAF group (odds ratio, 0.35; 95% confidence interval [95% CI], 0.13-0.96; p = .03). The Kaplan-Meier survival curve demonstrated significantly lower total cumulative respiratory morbidity rates in the MSAF exposed group (log rank p < .01). In the Cox model, controlled for clinically relevant confounders, MSAF exhibited an independent and significant protective effect on long-term childhood respiratory morbidity (aHR, 0.91; 95% CI, 0.86-0.96; p < .01).

CONCLUSIONS

Fetal exposure to MSAF during labor appears to be associated with lower rates of long-term respiratory related hospitalizations in the offspring. Changes in offspring microbiome, as well as functional and anatomical modulations possibly resulting from MSAF exposure, might offer a plausible explanation of our findings.

Airway pollution and smoking in reproductive health

Environmental exposure refers to contact with chemical, biological, or physical substances found in air, water, food, or soil that may have a harmful effect on a person's health. Almost all of the global population (99%) breathe air that contains high levels of pollutants. Smoking is one of the most common forms of recreational drug use and is the leading preventable cause of morbidity and mortality worldwide. The small particles from either ambient (outdoor) pollution or cigarette smoke are inhaled to the lungs and quickly absorbed into the bloodstream. These substances can affect virtually every organ in our body and have been associated with various respiratory, cardiovascular, endocrine, and also reproductive morbidities, including decreased fertility, adverse pregnancy outcomes, and offspring long-term morbidity. This review summarizes the latest literature reporting the reproductive consequences of women exposed to ambient (outdoor) air pollution and cigarette smoking.

Maternal Anemia and Long-Term Offspring Infectious Morbidity

OBJECTIVE

Anemia of pregnancy is a common condition associated with adverse obstetric outcomes. However, little is known about its long-term effect on the offspring. This study aimed to evaluate a possible association between anemia during pregnancy and the long-term incidence of infectious morbidity in the offspring.

STUDY DESIGN

A large population-based retrospective study was conducted at the Soroka University Medical Center, the sole tertiary medical center in the south of Israel. The study included deliveries between the years 1991 and 2014 and compared long-term infectious morbidity of offspring of women with and without anemia during pregnancy (defined as hemoglobin level below 11 g/dL). The long-term incremental incidence of hospitalizations of offspring up to 18 years of age due to infectious morbidity was evaluated using Kaplan-Meier survival curves, while Cox's regression model was used to control for confounders.

RESULTS

During the study period, 214,244 deliveries met the inclusion criteria, of which 110,775 (51.7%) newborns were born to mothers with anemia during pregnancy. The overall infectious-related hospitalization rate was significantly higher in children from the exposed group (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.04-1.10, p < 0.01). Kaplan-Meier survival curves showed a significantly higher cumulative incidence of hospitalizations due to infectious diseases as compared with children in the unexposed group (log-rank test, p < 0.01). The Cox model demonstrated a significant and independent association between maternal anemia and the long-term risk for hospitalization due to infectious diseases of the offspring (adjusted hazard ratio [aHR]: 1.09, 95% CI: 1.06-1.12, p < 0.01).

CONCLUSION

Offspring of anemic mothers are at a greater risk for infectious-related hospitalizations in their first 18 years of life.

KEY POINTS

· Anemia is highly common in pregnancy.. · Maternal anemia has multiple short-term implications.. · Our study shows anemia of pregnancy is independently associated with long-term offspring infectious morbidity..

Assessing the impact of medically assisted reproduction on autism spectrum disorder risk

PURPOSE

Techniques of medically assisted reproduction interact with the embryo at crucial developmental stages, yet their impact on the fetus and subsequent child's health remains unclear. Given rising infertility rates and more frequent use of fertility treatments, we aimed to investigate if these methods heighten the risk of autism spectrum disorder (ASD) in children.

METHODS

A population-based cohort study was conducted at Soroka University Medical Center, a tertiary referral hospital, encompassing singleton births. The incidence of ASD in offspring, incorporating either hospital or community-based diagnoses, was compared in relation to the conception method. To examine the cumulative incidence of ASD, a Kaplan-Meier survival curve was utilized. Cox proportional hazards model was employed to adjust for confounders.

RESULTS

Among 115,081 pregnancies, 0.5% involved ovulation induction (OI) and 1.7% in vitro fertilization (IVF), with the rest conceived naturally. Fertility treatments were more common in older patients and linked to more diabetes, hypertensive disorders, preterm, and cesarean deliveries. Out of 767 ASD diagnoses, offspring from OI and IVF had higher initial ASD rates (2.1% and 1.3%) than natural conceptions (0.6%). In a Cox model accounting for maternal age, ethnicity, and gender, neither OI nor IVF was significantly associated with ASD. The adjusted hazard ratios were 0.83 (95% CI 0.48-1.43) for OI and 1.34 (95% CI 0.91-1.99) for IVF. When considering fertility treatments combined, the association with ASD remained non-significant (aHR 1.11, 95% CI 0.80-1.54, p = 0.52).

CONCLUSION

Fertility treatments, including OI and IVF, do not exhibit a significant association with heightened ASD risk in offspring.

Chronic Hypertension in Pregnancy and Placenta-Mediated Complications Regardless of Preeclampsia

BACKGROUND

The prevalence of chronic hypertension in women of reproductive age is on the rise mainly due to delayed childbearing. Maternal chronic hypertension, prevailing prior to conception or manifesting within the early gestational period, poses a substantial risk for the development of preeclampsia with adverse maternal and fetal outcomes, specifically as a result of placental dysfunction. We aimed to investigate whether chronic hypertension is associated with placenta-mediated complications regardless of the development of preeclampsia in pregnancy.

METHODS

This was a population-based, retrospective cohort study from 'Soroka' university medical center (SUMC) in Israel, of women who gave birth between 1991 and 2021, comparing placenta-mediated complications (including fetal growth restriction (FGR), placental abruption, preterm delivery, and perinatal mortality) in women with and without chronic hypertension. Generalized estimating equation (GEE) models were used for each outcome to control for possible confounding factors.

RESULTS

A total of 356,356 deliveries met the study's inclusion criteria. Of them, 3949 (1.1%) deliveries were of mothers with chronic hypertension. Women with chronic hypertension had significantly higher rates of all placenta-mediated complications investigated in this study. The GEE models adjusting for preeclampsia and other confounding factors affirmed that chronic hypertension is independently associated with all the studied placental complications except placental abruption.

CONCLUSIONS

Chronic hypertension in pregnancy is associated with placenta-mediated complications, regardless of preeclampsia. Therefore, early diagnosis of chronic hypertension is warranted in order to provide adequate pregnancy follow-up and close monitoring for placental complications, especially in an era of advanced maternal age.

Maternal condyloma acuminata infection in pregnancy and offspring long-term respiratory and infectious outcome

BACKGROUND

Maternal condyloma acuminata infection may be vertically transmitted to the offspring during pregnancy and childbirth. Our study aimed to investigate the possible impact of maternal condyloma acuminata infection in pregnancy on offspring respiratory and infectious morbidity.

METHODS

A population-based cohort analysis including all singleton deliveries occurring between 1991 and 2014 at a tertiary medical center. Long-term infectious and respiratory morbidities were compared between children with and without exposure to maternal condyloma infection during pregnancy. A Kaplan-Meier survival curve was used to compare cumulative hospitalization rate and a Cox regression analyses to control for confounders.

RESULTS

No significant differences were found in total respiratory and infectious related hospitalizations between the study groups. The survival curves demonstrated no difference in the cumulative incidence between the two groups in both respiratory hospitalizations (log-rank, p = 0.18) and infectious hospitalizations (log-rank, p = 0.95). Cox multivariable analyses demonstrated that exposure to maternal condyloma infection during pregnancy is not a risk factor for neither infectious (aHR 0.91, [CI] 0.49-1.69) nor respiratory (aHR 0.37, [CI] 0.09-1.51) morbidity during childhood and adolescence.

CONCLUSION

Exposure to maternal condyloma infection during pregnancy does not appear to be an independent risk factor for later respiratory or infectious morbidity throughout childhood and adolescence.

[RISK FACTORS, COMPLICATIONS AND OUTCOMES OF PREGNANCIES WITH VELAMENTOUS CORD INSERTION]

INTRODUCTION

A velamentous cord insertion (VCI) describes a peripheral umbilical cord insertion to the placenta with blood vessels from the cord traversing fetal membranes before reaching the placental margin. These vessels remain unprotected and exposed to pressure and injury during pregnancy and labor.

OBJECTIVES

To determine the risk factors for VCI, and assess the risk for complications and adverse outcomes of pregnancies with VCI.

METHODS

A retrospective cohort study of women who gave birth at Soroka Medical Center between the years 1988 to 2011. We examined the risk factors, complications and adverse outcomes of pregnancies with VCI compared to those without VCI.

RESULTS

During the study period there were 246,488 births, of which 200 had VCI. Multifetal gestation (OR = 9.2), infertility treatments (OR = 4.3) and chronic hypertension (OR = 2.2 were found as independent risk factors for VCI. In addition, intrauterine growth retardation (OR = 4.3), polyhydramnion (OR = 2.3), fetal malformations (OR = 2.2), placental abruption (OR = 8.2), preterm birth (OR = 4.6), cesarean delivery (OR = 3.3) and low Apgar score (OR = 2.3) had significant correlation to VCI. Finally, the presence of VCI was found as an independent risk factor (OR = 4.07) for perinatal mortality.

CONCLUSION

Multifetal gestation and infertility treatments were the most important risk factors for VCI. These pregnancies had more complications and perinatal mortality. Given the results, we should consider close monitoring of pregnancies with the mentioned risk factors for the presence of VCI.

The Association between Term Chorioamnionitis during Labor and Long-Term Infectious Morbidity of the Offspring

Background: Chorioamnionitis during labor exposes the fetus to an intrauterine state that may alter the future immune response and may expose the offspring to future susceptibility to infectious disease. We evaluated the long-term pediatric infectious morbidity of children born at term to mothers who have chorioamnionitis during labor. Methods: This was a population-based cohort analysis including only term singleton deliveries at a regional tertiary hospital between the years 1991 and 2021. Offspring to mothers with and without a diagnosis of chorioamnionitis during labor were compared. Offspring hospitalizations up to the age of 18 years involving infectious morbidity were evaluated using the Kaplan-Meier survival curve and a Cox regression model to control possible confounders. Results: A total of 331,598 deliveries were included, 988 (0.3%) of which were of mothers diagnosed with chorioamnionitis during labor. All infectious morbidity rates included in the analysis were comparable between groups. The Kaplan-Meier survival curves were similar for both groups (log-rank = 0.881) and the multivariable analysis ascertained that chorioamnionitis during labor was not a risk factor for offspring's long-term infectious morbidity (HR 0.929, 95%CI 0.818-1.054, p = 0.254). Conclusions: In our cohort, term chorioamnionitis during labor was not associated with a higher risk of pediatric hospitalization due to infections. The infectious/inflammatory state during labor did not expose nor increase the susceptibility of the term offspring to future infectious morbidity.