Inflammatory markers in serum and placenta in a randomized controlled trial of group prenatal care

BACKGROUND

Racial and socioeconomic disparities in preterm birth and small for gestational age births are growing in the United States, increasing the burden of morbidity and mortality particularly among Black women and birthing persons and their infants. Group prenatal care is one of the only interventions to show potential to reduce the disparity, but the mechanism is unclear.

OBJECTIVE

The goal of this project was to identify if group prenatal care, when compared with individual prenatal care, was associated with a reduction in systemic inflammation during pregnancy and a lower prevalence of inflammatory lesions in the placenta at delivery.

STUDY DESIGN

The Psychosocial Intervention and Inflammation in Centering Study was a prospective cohort study that exclusively enrolled participants from a large randomized controlled trial of group prenatal care (the Cradle study, R01HD082311, ClinicalTrials.gov: NCT02640638) that was performed at a single site in Greenville, South Carolina, from 2016 to 2020. In the Cradle study, patients were randomized to either group prenatal care or individual prenatal care, and survey data were collected during the second and third trimesters. The Psychosocial Intervention and Inflammation in Centering Study cohort additionally provided serum samples at these 2 survey time points and permitted collection of placental biopsies for inflammatory and histologic analysis, respectively. We examined associations between group prenatal care treatment and a composite of z scored serum inflammatory biomarkers (C-reactive protein, interleukin-6, interleukin-1 receptor antagonist, interleukin-10, and tumor necrosis factor α) in both the second and third trimesters and the association with the prevalence of acute and chronic maternal placental inflammatory lesions. Analyses were conducted using the intent to treat principle, and the results were also examined by attendance of visits in the assigned treatment group (modified intent to treat and median or more number of visits) and were stratified by race and ethnicity.

RESULTS

A total of 1256 of 1375 (92%) Cradle participants who were approached enrolled in the Psychosocial Intervention and Inflammation in Centering Study, which included 54% of all the Cradle participants. The Psychosocial Intervention and Inflammation in Centering Study cohort did not differ from the Cradle cohort by demographic or clinical characteristics. Among the 1256 Psychosocial Intervention and Inflammation in Centering Study participants, 1133 (89.6%) had placental data available for analysis. Among those, 549 were assigned to group prenatal care and 584 of 1133 were assigned to individual prenatal care. In the intent to treat and modified intent to treat cohorts, participation in group prenatal care was associated with a higher serum inflammatory score, but it was not associated with an increased prevalence of placental inflammatory lesions. In the stratified analyses, group prenatal care was associated with a higher second trimester inflammatory biomarker composite (modified intent to treat: B=1.17; P=.02; and median or more visits: B=1.24; P=.05) among Hispanic or Latine participants.

CONCLUSION

Unexpectedly, group prenatal care was associated with higher maternal serum inflammation during pregnancy, especially among Hispanic or Latine participants.

Discrimination and Adverse Perinatal Health Outcomes: A Latent Class Analysis

INTRODUCTION

An intersectionality framework recognizes individuals as simultaneously inhabiting multiple intersecting social identities embedded within systems of disadvantage and privilege. Previous research links perceived discrimination with worsened health outcomes yet is limited by a focus on racial discrimination in isolation. We applied an intersectional approach to the study of discrimination to examine the association with adverse perinatal health outcomes.

METHODS

We analyzed data from a cohort of 2,286 pregnant participants (Black, n = 933; Hispanic, n = 471; White, n = 853; and Other, n = 29) from the Centering and Racial Disparities trial. Perceived discrimination was assessed via the Everyday Discrimination Scale (EDS) and perinatal health outcomes collected via electronic medical record review. Latent class analysis was used to identify subgroups of discrimination based on EDS item response and the rate of adverse perinatal health outcomes compared between subgroups using a Bolck, Croon and Hagenaars 3-step approach.

RESULTS

Four discrimination subgroups were identified: no discrimination, general discrimination, discrimination attributed to one or several social identities, and discrimination attributed to most or all social identities. Experiencing general discrimination was associated with postpartum depression symptoms when compared with experiencing no discrimination among Black (9% vs 5%, P = .04) and White participants (18% vs 9%, P = .01). White participants experiencing general discrimination gave birth to low birthweight infants at a higher rate than those experiencing no discrimination (11% vs 6%, P = .04). No significant subgroup differences were observed among Hispanic participants.

CONCLUSION

Perceived discrimination may play an influential role in shaping perinatal health. More research applying an intersectional lens to the study of discrimination and perinatal health outcomes is needed.

Group vs Individual Prenatal Care and Gestational Diabetes Outcomes: A Secondary Analysis of a Randomized Clinical Trial

Importance

The impact of group-based prenatal care (GPNC) model in the US on the risk of gestational diabetes (GD) and related adverse obstetric outcomes is unknown.

Objective

To determine the effects of the GPNC model on risk of GD, its progression, and related adverse obstetric outcomes.

Design, Setting, and Participants

This is a single-site, parallel-group, randomized clinical trial conducted between February 2016 and March 2020 at a large health care system in Greenville, South Carolina. Participants were individuals aged 14 to 45 years with pregnancies earlier than 21 weeks' gestational age; follow-up continued to 8 weeks post partum. This study used an intention-to-treat analysis, and data were analyzed from March 2021 to July 2022.

Interventions

Eligible participants were randomized to receive either CenteringPregnancy, a widely used GPNC model, with 10 group-based sessions or traditional individual prenatal care (IPNC).

Main Outcomes and Measures

The primary outcome was the incidence of GD diagnosed between 24 and 30 weeks of gestation. The secondary outcomes included progression to A2 GD (ie, GD treated with medications) and GD-related adverse obstetric outcomes (ie, preeclampsia, cesarean delivery, and large for gestational age). Log binomial models were performed to estimate risk differences (RDs), 95% CIs, and P values between GPNC and IPNC groups, adjusting for all baseline covariates.

Results

Of all 2348 participants (mean [SD] age, 25.1 [5.4] years; 952 Black participants [40.5%]; 502 Hispanic participants [21.4%]; 863 White participants [36.8%]), 1176 participants were randomized to the GPNC group and 1174 were randomized to the IPNC group. Among all participants, 2144 (91.3%) completed a GD screening (1072 participants [91.3%] in GPNC vs 1071 [91.2%] in IPNC). Overall, 157 participants (6.7%) developed GD, and there was no difference in GD incidence between the GPNC (83 participants [7.1%]) and IPNC (74 participants [6.3%]) groups, with an adjusted RD of 0.7% (95% CI, -1.2% to 2.7%). Among participants with GD, GPNC did not reduce the risk of progression to A2 GD (adjusted RD, -6.1%; 95% CI, -21.3% to 9.1%), preeclampsia (adjusted RD, -7.9%; 95% CI, -17.8% to 1.9%), cesarean delivery (adjusted RD, -8.2%; 95% CI, -12.2% to 13.9%), and large for gestational age (adjusted RD, -1.2%; 95% CI, -6.1% to 3.8%) compared with IPNC.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial among medically low-risk pregnant individuals, the risk of GD was similar between participants who received GPNC intervention and traditional IPNC, indicating that GPNC may be a feasible treatment option for some patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02640638.

Well Child Visit Attendance for Group Prenatal Care Participants

OBJECTIVES

Participation in group prenatal care (GPNC) has been associated with increased attendance at prenatal, family planning and postpartum visits. We explored whether GPNC participation is associated with pediatric care engagement by measuring well-child visit (WCV) attendance among infants whose births were covered by Medicaid.

METHODS

We used Medicaid claims and vital statistics from the South Carolina Department of Health and Human Services and GPNC site participation records (2013-2018). We compared WCV attendance of CenteringPregnancy GPNC patients to a propensity-score matched cohort of individual prenatal care patients (IPNC) across 21 prenatal care practices using linear probability models. The primary outcome measure was attending 6 or more WCVs in the first 15 months, a Healthcare Effectiveness Data and Information Set (HEDIS) performance measure.

RESULTS

No differences in WCV were observed when comparing any exposure to GPNC (one or more sessions) to IPNC. We identified 3191 patients who participated in GPNC and matched these with 5184 in IPNC. Participation in 5 or more GPNC sessions compared to 5 or more prenatal visits was associated with higher rates of WCV compliance over the first 15 months (4.7 percentage point difference [95% CI 3.1-6.3%, P < .001]), with stronger associations between GPNC and WCV attendance for low birthweight infants, for Black infants, and for infants of mothers with no previous live births.

CONCLUSIONS

This study suggests GPNC may modestly influence WCV attendance. The potential mechanisms and dose response require further investigation. Gaps in WCV attendance compared to benchmarks persist regardless of PNC model.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

BACKGROUND

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.

OBJECTIVE

This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.

STUDY DESIGN

This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.

RESULTS

A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).

CONCLUSION

There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Mycotoxin ingestion during late gestation alters placentome structure, cotyledon transcriptome, and fetal development in pregnant sheep

Ergot alkaloids, a class of mycotoxins, induce vasoconstriction when consumed by animals and humans. Pregnant ewes (n = 16; 81.2 kg ± 7.7) were assigned fed endophyte-infected tall fescue seed (E+; 4.14 μg ergovaline + ergovalinine/g seed) or a control diet (CON; 0 μg ergovaline + ergovalinine) for increasing duration during late gestation (from gd86 to gd110 or gd133) to examine changes in placentome morphology and mRNA transcriptome, and fetal development. Exposure to E+ fescue reduced serum prolactin concentrations at gd110 and gd133 demonstrating treatment efficacy. For control ewes, cotyledon and total placentome weights decreased with advancing gestation due to remodeling of placental tissues; however, cotyledon and placentome weight did not change with advancing gestation in E+ fed ewes. Fetal brain sparing was evident in E+ exposed fetuses at gd110 and gd133 compared to CON, which demonstrates asymmetrical growth and intrauterine growth restriction. Mycotoxin exposure (E+) resulted in differential expression of 22 genes in the cotyledon tissue at gd110 but only one gene at gd133 compared to CON. These results suggest that the response to mycotoxin exposure in the pregnant sheep model has an immediate impact on placental remodeling and fetal development that persists throughout the duration of the exposure period.

The effect of ergot alkaloid exposure during gestation on the microscopic morphology and vasculature of the ovine placenta

Ergot alkaloids, a class of mycotoxins associated with ergotism, act as agonists on serotonin (5HT) receptors, specifically 5HT2a, which mediate smooth muscle contraction and vasoconstriction. The objective of this study was to examine the impact of ergot alkaloid exposure during mid and late gestation on microscopic placental structure and vascular development. Ewes were fed endophyte-infected tall fescue seed containing ergot alkaloids (E+/E+, 1.77 mg ewe^-1 d^-1) or endophyte-free tall fescue seed (E-/E-, 0 mg ergot alkaloids) during both mid (d 35 to d 85) and late gestation (d 86 to d 133). On d 133 of gestation, a terminal surgery was performed and two placentomes of the type B morphology were collected for microscopic analyses. Amorphous connective tissue regions were larger (p < 0.0001) and more numerous (p = 0.025) in the placentome of ergot alkaloid exposed ewes. Staining showed no difference (p = 0.83) in the number of vessels present, but luminal area of maternal vasculature was 117% greater (p < 0.0001) in ergot alkaloid exposed ewes. Results showed that exposure to ergot alkaloids during gestation slowed maturation of the fetal villi as indicated by greater amorphous connective tissue regions, and altered size and shape of blood vessels to counteract reductions in blood flow caused by vasoconstriction.

Evaluation of oral citrulline administration as a mitigation strategy for fescue toxicosis in sheep

Gestating ewes consuming ergot alkaloids, from endophyte-infected (E+) tall fescue seed, suffer from intrauterine growth restriction and produce smaller lambs. Arginine (Arg) supplementation has been shown to increase birth weight and oral citrulline (Cit) administration is reported to increase arginine concentrations. Two experiments were conducted to: 1) evaluate if oral supplementation with Cit or water, to ewes consuming E+ fescue seed, increases lamb birth weight and 2) determine the effectiveness of Cit and citrulline:malate as an oral drench and elevating circulating levels of Cit to determine levels and dose frequency. In experiment 1, gestating Suffolk ewes (n = 10) were assigned to one of two treatments [oral drench of citrulline-malate 2:1 (CITM; 81 mg/kg/d of citrulline) or water (TOX)] to start on d 86 of gestation and continued until parturition. Ewes on CITM treatment had decreased (P < 0.05) plasma Arg and Cit concentrations during gestation. At birth, lambs from CITM ewes had reduced (P < 0.05) crude fat and total fat but did not differ (P > 0.05) in birth weight from lambs born to TOX ewes. In experiment 2, nonpregnant Suffolk ewes (n = 3) were assigned to either oral citrulline (CIT; 81 mg/kg/d), citrulline-malate 2:1 (CITM; 81 mg/kg/d of citrulline), or water (CON) drench in a Latin Square design for a treatment period of 4 d with a washout period of 3 d. On d 4, blood samples were collected at 0, 0.5, 1, 2, 3, 4, 6, 8, 10, 12, and 18 h post drench. Oral drenching of CIT and CITM increased (P < 0.0001) Cit concentrations within 2 h and levels remained elevated for 6 h. Apparent half-life of elimination for CIT and CITM were 8.484 and 10.392 h, respectively. Our results show that lamb birth weight was not altered with a single oral drench of citrulline-malate; however, lamb body composition was altered. The level and frequency of citrulline dosing may need to be greater in order to observe consistent elevation of Cit/Arg concentrations to determine its effectiveness in mitigating fescue toxicosis.

Feeding Tall Fescue Seed during Mid and Late Gestation Influences Subsequent Postnatal Growth, Puberty, and Carcass Quality of Offspring

Weaned lambs (n = 82), born to ewes fed endophyte-free (E-) or endophyte-infected (E+; 1.77 mg hd-1 d-1 ergovaline + ergovalinine) tall fescue seed from d 35 to 85 of gestation (MID) and/or d 86 of gestation to parturition (LATE), were used to examine how ergot alkaloid exposure during fetal development altered subsequent puberty attainment or carcass quality. Lambs were weaned at 75 d of age and separated by sex to assess puberty in ewe lambs (n = 39) and to evaluate growth, carcass and meat quality in wethers (n = 43). Data were analyzed with maternal fescue treatment, stage of gestation, and two-way interaction in the model. Age at puberty tended (P = 0.06) to be longer for ewe lambs born to dams fed E+ fescue during LATE gestation versus those fed E-. Post-weaning average daily gain tended to be higher (P = 0.07) for wether lambs born to dams fed E+ fescue seed during MID gestation compared to E-. Exposure to ergot alkaloids during fetal growth altered (P < 0.10) longissimus muscle weight and color, lipid deposition, fatty acid composition, and shear force values of semimembranosus muscle in wether lambs. These results indicate that exposure to ergot alkaloids in utero does alter subsequent post-weaning puberty attainment and body composition in offspring.

Differentially expressed genes in cotyledon of ewes fed mycotoxins

BACKGROUND

Ergot alkaloids (E+) are mycotoxins produced by the endophytic fungus, Epichloë coenophiala, in tall fescue that are associated with ergotism in animals. Exposure to ergot alkaloids during gestation reduces fetal weight and placental mass in sheep. These reductions are related to vasoconstrictive effects of ergot alkaloids and potential alterations in nutrient transport to the fetus. Cotyledon samples were obtained from eight ewes that were fed E+ (n = 4; E+/E+) or E- (endophyte-free without ergot alkaloids; n = 4; E-/E-) seed during both mid (d 35 to 85) and late (d 85-133) gestation to assess differentially expressed genes associated with ergot alkaloid induced reductions in placental mass and fetal weight, and discover potential adaptive mechanisms to alter nutrient supply to fetus.

RESULTS

Ewes fed E+/E+ fescue seed during both mid and late gestation had 20% reduction in fetal body weight and 33% reduction in cotyledon mass compared to controls (E-/E-). Over 13,000 genes were identified with 110 upregulated and 33 downregulated. Four genes had a |log2FC| > 5 for ewes consuming E+/E+ treatment compared to controls: LECT2, SLC22A9, APOC3, and MBL2. REViGO revealed clusters of upregulated genes associated glucose, carbohydrates, lipid, protein, macromolecular and cellular metabolism, regulation of wound healing and response to starvation. For downregulated genes, no clusters were present, but all enriched GO terms were associated with anion and monocarboxylic acid transport. The complement and coagulation cascade and the peroxisome proliferator-activated receptor signaling pathway were found to be enriched for ewes consuming E+/E+ treatment.

CONCLUSIONS

Consumption of ergot alkaloids during gestation altered the cotyledonary transcriptome specifically related to macronutrient metabolism, wound healing and starvation. These results show that ergot alkaloid exposure upregulates genes involved in nutrient metabolism to supply the fetus with additional substrates in attempts to rescue fetal growth.

Ergot alkaloid exposure during gestation alters: 3. Fetal growth, muscle fiber development, and miRNA transcriptome1

The objective of this study was to assess how exposure to ergot alkaloids during 2 stages of gestation alters fetal growth, muscle fiber formation, and miRNA expression. Pregnant ewes (n = 36; BW = 83.26 ± 8.14 kg; 4/group; 9 groups) were used in a 2 × 2 factorial arrangement with 2 tall fescue seed treatments [endophyte-infected (E+) vs. endophyte-free (E-)] fed during 2 stages of gestation (MID, days 35 to 85 vs. LATE, days 86 to 133), which created 4 possible treatments (E-/E-, E+/E-, E-/E+, or E+/E+). Ewes were individually fed a total mixed ration containing E+ or E- fescue seed according to treatment assignment. Terminal surgeries were conducted on day 133 of gestation for the collection of fetal measurements and muscle samples. Data were analyzed as a 2 × 2 factorial with fescue treatment, stage of gestation, and 2-way interaction as fixed effects. Fetuses exposed to E+ seed during LATE gestation had reduced (P = 0.0020) fetal BW by 10% compared with E- fetuses; however, fetal body weight did not differ (P = 0.41) with E+ exposure during MID gestation. Fetuses from ewes fed E+ seed during MID and LATE gestation tended to have smaller (P = 0.058) kidney weights compared with E- fetuses. Liver weight was larger (P = 0.0069) in fetuses fed E- during LATE gestation compared with E+. Fetal brain weight did not differ by fescue treatment fed during MID (P = 0.36) or LATE (P = 0.40) gestation. The percentage of brain to empty body weight (EBW) was greater (P = 0.0048) in fetuses from ewes fed E+ fescue seed during LATE gestation, which is indicative of intrauterine growth restriction (IUGR). Primary muscle fiber number was lower (P = 0.0005) in semitendinosus (STN) of fetuses exposed to E+ during MID and/or LATE gestation compared with E-/E-. miRNA sequencing showed differential expression (P < 0.010) of 6 novel miRNAs including bta-miR-652_R+1, mdo-miR-22-3p, bta-miR-1277_R-1, ppy-miR-133a_L+1_1ss5TG, hsa-miR-129-1-3p, and ssc-miR-615 in fetal STN muscle. These miRNA are associated with glucose transport, insulin signaling, intracellular ATP, hypertension, or adipogenesis. This work supports the hypothesis that E+ tall fescue seed fed during late gestation reduces fetal weight and causes asymmetrical growth, which is indicative of IUGR. Changes in primary fiber number and miRNA of STN indicate that exposure to E+ fescue fed during MID and LATE gestation alters fetal muscle development that may affect postnatal muscle growth and meat quality.

Ergot alkaloid exposure during gestation alters. I. Maternal characteristics and placental development of pregnant ewes1

Tall fescue [Lolium arundinaceum (Scheyreb.) Darbysh] is the primary cool season forage grass in the Southeastern United States. Most tall fescue contains an endophytic fungus (Epichloë coenophiala) that produces ergot alkaloids and upon ingestion induces fescue toxicosis. The objective of this study was to assess how exposure to endophyte-infected (E+; 1.77 mg hd-1 d-1 ergovaline and ergovalinine) or endophyte-free (E-; 0 mg hd-1 d-1 ergovaline and ergovalinine) tall fescue seed fed during 2 stages of gestation (MID, days 35-85/LATE, days 86-133) alters placental development. Thirty-six, fescue naïve Suffolk ewes were randomly assigned to 1 of 4 fescue treatments: E-/E-, E-/E+, E+/E-, or E+/E+. Ewes were individually fed the same amount of E+ or E- seed mixed into total mixed ration during MID and LATE gestation. Terminal surgeries were conducted on day 133 of gestation. Ewes fed E+ fescue seed had elevated (P < 0.001) ergot alkaloid excretion and reduced (P < 0.001) prolactin levels during the periods when fed E+ seed. Ewes switched on day 86 from E- to E+ seed had a 4% reduction (P = 0.005) in DMI during LATE gestation, which translated to a 2% reduction (P = 0.07) in DMI overall. Average daily gain was also reduced (P = 0.049) by 64% for E-/E+ ewes during LATE gestation and tended to be reduced (P = 0.06) by 33% overall. Ewes fed E+ seed during LATE gestation exhibited a 14% and 23% reduction in uterine (P = 0.03) and placentome (P = 0.004) weights, respectively. Caruncle weights were also reduced by 28% (P = 0.003) for E-/E+ ewes compared with E-/E- and E+/E-. Ewes fed E+ seed during both MID and LATE gestation exhibited a 32% reduction in cotyledon (P = 0.01) weights, whereas ewes fed E+ seed only during MID gestation (E+/E-) had improved (P = 0.01) cotyledon weights. The percentage of type A placentomes tended to be greater (P = 0.08) for E+/E+ ewes compared with other treatments. Other placentome types (B, C, or D) did not differ (P > 0.05). Total fetal weight per ewe was reduced (P = 0.01) for ewes fed E+ seed during LATE gestation compared with E-; however, feeding E+ seed during MID gestation did not alter (P = 0.70) total fetal weight per ewe. These results suggest that exposure to ergot alkaloids during LATE (days 86-133) gestation has the greatest impact on placental development by reducing uterine and placentome weights. This, in turn, reduced total fetal weight per ewe by 15% in ewes fed E+ seed during LATE gestation (E-/E+ and E+/E+).