Audrey F. Saftlas

Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987-2004.

BACKGROUND Few studies have reported on population-level incidence of or trends in the hypertensive disorders of pregnancy, and none report on data through 2004. We describe population trends in the incidence rates of preeclampsia, eclampsia, and gestational hypertension in the United States for 1987-2004. METHODS We analyzed public-use data from the National Hospital Discharge Survey (NHDS), which has been conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics since 1965. We calculated crude and age-adjusted incidence rates and estimated the risk associated with available demographic variables using Cox regression modeling. RESULTS Rates of preeclampsia and gestational hypertension increased significantly (by 25 and 184%, respectively) over the study period; in contrast, the rate of eclampsia decreased by 22% (nonsignificant). Women under the age of 20 were at significantly greater risk for all three outcomes. Women in the south of the country were at significantly greater risk for preeclampsia and gestational hypertension when compared to those in the Northeast. CONCLUSIONS The increase in gestational hypertension may be exaggerated because of the revised clinical guidelines published in the 1990s; these same revisions would likely have reduced diagnoses of preeclampsia. Therefore, our observation of a small but consistent increase in preeclampsia is a conservative indication of a true population-level change.

Physical and mental health outcomes of prenatal maternal stress in human and animal studies: a review of recent evidence

Prenatal maternal stress (PNMS) has been linked with adverse health outcomes in the offspring through experimental studies using animal models and epidemiological studies of human populations. The purpose of this review article is to establish a parallel between animal and human studies, while focusing on methodological issues and gaps in knowledge. The review examines the quality of recent evidence for prevailing PNMS theoretical models, namely the biopsychosocial model for adverse pregnancy outcomes and the fetal programming model for chronic diseases. The investigators used PubMed (2000-06) to identify recently published original articles in the English language literature. A total of 103 (60 human and 43 animal) studies were examined. Most human studies originated from developed countries, thus limiting generalisability to developing nations. Most animal studies were conducted on non-primates, rendering extrapolation of findings to pregnant women less straightforward. PNMS definition and measurement were heterogeneous across studies examining similar research questions, thus precluding the conduct of meta-analyses. In human studies, physical health outcomes were often restricted to birth complications while mental health outcomes included postnatal developmental disorders and psychiatric conditions in children, adolescents and adults. Diverse health outcomes were considered in animal studies, some being useful models for depression, schizophrenia or attention deficit hyperactivity disorder in human populations. The overall evidence is consistent with independent effects of PNMS on perinatal and postnatal outcomes. Intervention studies and large population-based cohort studies combining repeated multi-dimensional and standardised PNMS measurements with biomarkers of stress are needed to further understand PNMS aetiology and pathophysiology in human populations.

Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies.

OBJECTIVE To prospectively examine in pregnant women whether asthma or asthma therapy influenced preterm delivery, intrauterine grown restriction (IUGR), or birthweight. METHODS We enrolled 873 pregnant women with a history of asthma, of whom 778 experienced asthma symptoms or took medication, and 1333 women with no asthma history, including 884 women with neither asthma diagnosis nor symptoms and 449 with symptoms but no diagnosis. Asthma symptoms, medication, and severity were classified according to 2002 Global Initiative for Asthma guidelines. RESULTS Preterm delivery was not associated with asthma diagnosis, severity, or symptoms but was associated with use of controller medications, independent of symptoms, specifically oral steroids and theophylline. Gestation was reduced by 2.22 weeks in women using oral steroids daily (P =.001) and 1.11 weeks after theophylline (P =.002). We observed a 24% (5-47%) increased risk for IUGR with each increased symptom step, which increased further in symptomatic women with no asthma diagnosis (31%, 4-65%) compared with women with neither asthma nor symptoms. CONCLUSIONS We found no effect of asthma symptoms or severity on preterm delivery but observed increased risks associated with use of oral steroid and theophylline. Intrauterine growth restriction was associated with asthma severity, which possibly reflects a hypoxic fetal effect. Women with asthma symptoms but no diagnosis were at particular risk of undermedication and delivering IUGR infants. These observations support guidelines that advocate active management of pregnant patients with mild or moderate asthma with beta(2) agonists, with oral steroids added only if severity increases. Symptomatic patients without an asthma diagnosis might need to be equally managed.

Low-to-moderate gestational alcohol use and intrauterine growth retardation, low birthweight, and preterm delivery

PURPOSE Heavy drinking during pregnancy is an established risk factor for fetal alcohol syndrome and other adverse perinatal outcomes. However, there is still debate as to the effects of low-to-moderate drinking during pregnancy. METHODS This prospective investigation was based on 2714 singleton live births at Yale-New Haven Hospital during 1988-1992. Alcohol drinking during pregnancy was evaluated with respect to intrauterine growth retardation (IUGR), preterm delivery, and low birthweight. RESULTS Mild drinking, defined as > 0.10-0.25 oz of absolute alcohol per day, during the first month of pregnancy was associated with a protective effect on IUGR (OR, 0.39; 95% confidence interval (CI), 0.20-0.76). Overall, drinking during month 1 of pregnancy suggested a curvilinear effect on growth retardation, with consumption of > 1.00 oz of absolute alcohol per day showing increased risk. Drinking during month 7 was associated with a uniform increase in the odds of preterm delivery; the ORs were 2.88 (95% CI, 1.64-5.05) for light drinking and 2.96 (95% CI, 1.32-6.67) for mild-to-moderate alcohol consumption. CONCLUSIONS Differences in the risk estimates for IUGR and preterm delivery may indicate etiological differences that warrant further investigation of these outcomes and critical periods of exposure. Low birthweight is not a useful neonatal outcome for this exposure because it is a heterogeneous mix of preterm delivery and IUGR. Despite the observed protective effects of mild drinking on IUGR, the increased risk of preterm delivery with alcohol use supports a policy of abstinence during pregnancy.

Rural Disparity in Domestic Violence Prevalence and Access to Resources

OBJECTIVE Intimate partner violence (IPV) against women is a significant health issue in the United States and worldwide. The majority of studies on IPV have been conducted in urban populations. The objectives of this study are to determine if prevalence, frequency, and severity of IPV differ by rurality and to identify variance in geographic access to IPV resources. METHODS A cross-sectional clinic-based survey of 1478 women was conducted to measure the 1-year prevalence of physical, sexual, and psychologic IPV. IPV intervention programs in the state were inventoried and mapped, and the distance to the closest program was estimated for each participant based on an innovative algorithm developed for use when only ZIP code location is available. RESULTS Women in small rural and isolated areas reported the highest prevalence of IPV (22.5% and 17.9%, respectively) compared to 15.5% for urban women. Rural women reported significantly higher severity of physical abuse than their urban counterparts. The mean distance to the nearest IPV resource was three times greater for rural women than for urban women, and rural IPV programs served more counties and had fewer on-site shelter services. Over 25% of women in small rural and isolated areas lived >40 miles from the closest program, compared with <1% of women living in urban areas. CONCLUSIONS Rural women experience higher rates of IPV and greater frequency and severity of physical abuse yet live much farther away from available resources. More IPV resources and interventions targeting rural women are needed.

Association of asthma diagnosis, severity, symptoms, and treatment with risk of preeclampsia

OBJECTIVE: Existing studies relating asthma and preeclampsia provide conflicting results, perhaps due to differences in study populations, varying definitions of asthma, and inadequate control for confounding, particularly asthma medication use. This prospective study examines associations between aspects of asthma (diagnosis, severity, symptoms, and medication use) and risk of preeclampsia. METHODS: A total of 1,708 pregnant women, of whom 656 had asthma diagnosis and 1,052 had no asthma diagnosis, were included in this analysis. Asthma symptoms, treatment, and severity were classified according to Global Initiative for Asthma guidelines. Hospital records were abstracted, and strict criteria were applied to classify women as preeclamptic based on National Heart, Lung, and Blood Institute guidelines. RESULTS: There were 568 of 656 women with diagnosed asthma and 353 of 1,052 women without asthma diagnosis who had symptoms or took asthma medication during pregnancy. Separate adjusted logistic regression models were run for different measures of asthma status: 1) asthma diagnosis; 2) overall Global Initiative for Asthma severity; 3) Global Initiative for Asthma symptom and treatment steps; and 4) Global Initiative for Asthma symptom step and medication type. Women at increased risk of preeclampsia were those classified as Global Initiative for Asthma symptom step 3/4 compared with no symptoms (odds ratio 3.36, 95% confidence interval 1.24–9.14) and theophylline users (odds ratio 1.16 for every dose/month increase in use, 95% confidence interval 1.02–1.33). In contrast, neither a history of physician-diagnosed asthma nor Global Initiative for Asthma treatment step was associated with preeclampsia status. CONCLUSION: Our findings suggest that women with moderate to severe asthma symptoms, regardless of asthma diagnosis or treatment, are at increased risk of preeclampsia compared with women with no symptoms. LEVEL OF EVIDENCE: II-2

Trends in obstetric operative procedures, 1980 to 1987.

OBJECTIVES Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. METHODS We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. RESULTS The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. CONCLUSIONS As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.

Maternal caffeine intake and intrauterine growth retardation.

This study estimates the effect of maternal caffeine consumption throughout pregnancy on fetal growth. We studied 2,714 women who delivered a liveborn infant between 1988 and 1991. Detailed information regarding coffee, tea, and soda drinking during the first and third trimesters of pregnancy was obtained. Average caffeine intake during month 1 of pregnancy was higher than for month 7 (72.4 vs 54.0 mg per day). Consumption of >300 mg caffeine per day during month 1 (adjusted odds ratio = 0.91; 95% confidence interval = 0.44–1.90) and during month 7 (adjusted odds ratio = 1.00; 95% confidence interval = 0.37–2.70) was not associated with intrauterine growth retardation. There was little evidence for any effect modification due to cigarette smoking on the caffeine associations. This study provides evidence that antenatal caffeine consumption has no adverse effect on fetal growth.

Hospitalization for pregnancy complications, United States, 1986 and 1987

OBJECTIVE The purpose of our analysis was to provide a national overview of the magnitude of the public health burden associated with inpatient care for pregnancy complications. STUDY DESIGN We analyzed data from the National Hospital Discharge Survey for 1986 and 1987. We calculated ratios of hospitalizations for pregnancy complications for every 100 hospitalizations involving a birth. Standard errors for these ratios were calculated with RATIOEST, and relative ratios with 95% confidence intervals were calculated for subgroups of interest. RESULTS We found that for every 100 hospitalizations involving a birth, there were 22.2 nondelivery hospitalizations for pregnancy complications (14.6 antenatal complications, 7.6 pregnancy loss complications). These ratios were higher for black than for white women (relative ratio 1.4, 95% confidence interval 1.2 to 1.6). The effects of marital status, age, and insurance coverage differed between black and white women, and mean length of stay was longer for black than for white women. CONCLUSION Hospitalization for pregnancy complications is far more common than is widely appreciated and is more frequent among black than white women.

Maternal lipid levels during pregnancy and gestational diabetes: a systematic review and meta-analysis.

Lipid levels during pregnancy in women with gestational diabetes mellitus (GDM) have been extensively studied; however, it remains unclear whether dyslipidaemia is a potential marker of preexisting insulin resistance.