Catherine J. Vladutiu

Perceived stress, reproductive hormones, and ovulatory function: a prospective cohort study

Background: Stress has been shown to suppress ovulation in experimental models, but its effect on human reproduction at the population level is unclear. Methods: Healthy women (n = 259), aged 18–44 years from Western New York, were followed for 2 menstrual cycles (2005–2007). Women completed daily perceived stress assessments, a 4-item Perceived Stress Scale (PSS-4) up to 4 times each cycle, and a 14-item PSS at baseline. Mixed model analyses were used to assess effects of stress on log reproductive hormone concentrations and sporadic anovulation. Results: High versus low daily stress was associated with lower estradiol (−9.5% [95% confidence interval (CI) = −15.6% to −3.0%]), free estradiol (−10.4% [−16.5% to −3.9%]), and luteinizing hormone (−14.8% [−21.3% to −7.7%]) and higher follicle-stimulating hormone (6.2% [95% CI = 2.0% to 10.5%]) after adjusting for age, race, percent body fat, depression score, and time-varying hormones and vigorous exercise. High versus low daily stress was also associated with lower luteal progesterone (−10.4% [95% CI = −19.7% to −0.10%]) and higher odds of anovulation (adjusted odds ratio = 2.2 [95% CI = 1.0 to 4.7]). For each unit increase in daily stress level, women had a 70% higher odds of an anovulatory episode (odds ratio = 1.7 [1.1 to 2.4]). Similar but attenuated results were found for the association between the PSS-4 and reproductive hormones, while null findings were found for the baseline PSS. Conclusion: Daily perceived stress does appear to interfere with menstrual cycle function among women with no known reproductive disorders, warranting further research to explore potential population-level impacts and causal biologic mechanisms.

Teen workers' exposures to occupational hazards and use of personal protective equipment

BACKGROUND Prior research indicates that working adolescents seek care for the toxic effects of on-the-job chemical and environmental hazard exposures. METHODS This cross-sectional survey of a nationally representative sample of 866 adolescent workers in the retail and service sector examines their exposures, personal protective equipment (PPE) use, and training. RESULTS Two-thirds of respondents were exposed to continuous, very loud noise, 55% to thermal hazards and 54% to chemical hazards. Few teens reported using any PPE, though those who had been trained reported somewhat higher usage. CONCLUSIONS Teens working in the retail and service sectors experience a variety of chemical, thermal, biologic and noise exposures. Efforts to eradicate such exposures need to be complemented by increased provision of PPE and appropriate training in their use by employers.

Parity and Components of the Metabolic Syndrome Among US Hispanic/Latina Women: Results From the Hispanic Community Health Study/Study of Latinos.

Background—Physiological adaptations occurring across successive pregnancies may increase the risk of adverse cardiovascular health outcomes in later life. Methods and Results—The association between parity and metabolic syndrome was examined among 7467 Hispanic/Latina women of diverse backgrounds, aged 18 to 74 years, who participated in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) from 2008 to 2011. Metabolic syndrome components were defined according to American Heart Association/National Heart, Lung, and Blood Institute criteria and included abdominal obesity, elevated triglycerides, low high-density lipoprotein cholesterol, high blood pressure, and elevated fasting glucose. Logistic regression models estimated odds ratios (ORs) adjusting for sociodemographic, behavioral, and reproductive characteristics. At HCHS/SOL baseline, women reported none (21.1%), 1 (19.9%), 2 (25.7%), 3 (18.6%), 4 (8.8%), and ≥5 (5.9%) live births. When compared with women with 1 birth, those with 4 births had the highest odds of abdominal obesity (OR, 2.0; 95% confidence interval, 1.5–2.8) and overall metabolic syndrome (OR, 1.4; 95% confidence interval, 1.0–2.0) and those with ≥5 births had the highest odds of low high-density lipoprotein cholesterol (OR, 1.5; 95% confidence interval, 1.2–2.0) and elevated fasting glucose (OR, 1.6; 95% confidence interval, 1.1–2.4), after adjusting for age, background, education, marital status, income, nativity, smoking, physical activity, menopause, oral contraceptive use, hormone therapy, and field center. Further adjustment for percent body fat attenuated these associations. No associations were observed between parity and elevated triglycerides or high blood pressure. Conclusions—Higher parity is associated with an increased prevalence of selected components of the metabolic syndrome among Hispanic/Latina women in the US. High parity among Hispanics/Latinas with a high prevalence of abdominal obesity suggests high risk for metabolic dysregulation.

Adverse Pregnancy Outcomes Following Motor Vehicle Crashes

BACKGROUND Motor vehicle crashes are a leading cause of serious trauma during pregnancy, but little is known about their relationships with pregnancy outcomes. PURPOSE To estimate the association between motor vehicle crashes and adverse pregnancy outcomes. METHODS A retrospective cohort study of 878,546 pregnant women, aged 16-46 years, who delivered a singleton infant in North Carolina from 2001 to 2008. Pregnant drivers in crashes were identified by probabilistic linkage of vital records and crash reports. Poisson regression modeled the association among crashes, vehicle safety features, and adverse pregnancy outcomes. Analyses were conducted in 2012. RESULTS In 2001-2008, 2.9% of pregnant North Carolina women were drivers in one or more crashes. After a single crash, compared to not being in a crash, pregnant drivers had slightly elevated rates of preterm birth (adjusted rate ratio [aRR]=1.23, 95% CI=1.19, 1.28); placental abruption (aRR=1.34, 95% CI=1.15, 1.56); and premature rupture of the membranes (PROM; aRR=1.32, 95% CI=1.21, 1.43). Following a second or subsequent crash, pregnant drivers had more highly elevated rates of preterm birth (aRR=1.54, 95% CI=1.24, 1.90); stillbirth (aRR=4.82, 95% CI=2.85, 8.14); placental abruption (aRR=2.97, 95% CI=1.60, 5.53); and PROM (aRR=1.95, 95% CI=1.27, 2.99). Stillbirth rates were elevated following crashes involving unbelted pregnant drivers (aRR=2.77, 95% CI=1.22, 6.28) compared to belted pregnant drivers. CONCLUSIONS Crashes while driving during pregnancy were associated with elevated rates of adverse pregnancy outcomes, and multiple crashes were associated with even higher rates of adverse pregnancy outcomes. Crashes were especially harmful if drivers were unbelted.

Parental Involvement With Their Working Teens

Adolescents work in varied environments and are exposed to hazards. Parents of these working adolescents have an opportunity to help them select jobs and address worker safety issues with employers. The present study conducted telephonic interviews among a national sample of 922 working adolescents along with one parent of each to examine the involvement of parents in their childrens employment and safety issues. Over 70% of parents were found who helped their children identify job opportunities, consider questions about work hours or tasks, fill out job applications, prepare for interviews, or handle difficult safety issues. Parents suggested stronger actions in response to hypothetical situations than when confronted with real problems. Mean level of parental involvement did not vary by the number of hazards reported by teen workers. Parents were involved in helping their teens with work. Further research should explore how to enhance parental effectiveness by making work safe for teens.

Disability and risk of non-fatal residential injuries among adults.

Objective: Many unintentional injuries occur in the home, but little research has considered the specific vulnerability of people with disabilities. Design: Cross-sectional study examining nationally representative data from the 2004–2006 National Health Interview Surveys. Subjects: Adults aged 18 and older who reported having an unintentional, non-motor vehicle-related injury in the home (n = 2189) or outside the home (n = 2072) and those who reported no injuries (n = 81 919) 3 months before their interview. Main outcome measure: Non-fatal, unintentional, non-motor vehicle-related injuries. Results: Among respondents experiencing a residential injury, 21.2% reported one type of disability, 11.2% reported two disabilities, and 9.1% reported three or more disabilities. As the number of disabilities increased, the odds of reporting a residential injury increased. Adults with three or more disabilities had three times the odds of reporting a residential injury (adjusted odds ratio  = 3.2, 95% CI 2.7 to 3.9), compared with adults reporting no injury. Conclusion: The risk of injury in the residential environment among adults with disabilities increases with increasing numbers of disabilities. Attention to home safety issues for residents with disabilities is needed.

Disability and home hazards and safety practices in US households

BACKGROUND Individuals with disabilities have an elevated risk of residential injury. However, the prevalence of home hazards and safety practices among households where an individual with a disability resides is unknown. METHODS This study examined patterns of home hazards and safety practices among 1003 households across the United States in 2002. RESULTS Households with at least 1 resident with a disability had a lower prevalence of household hazards than those without a resident with a disability, including living in a 2-story dwelling (34.6% vs 50.7%) and having stairs inside the home (48.1% vs 58.4%). They were more likely to implement fall prevention strategies, such as handrails or grab bars in the bathroom (40.4% vs 21.8%) and mats or nonskid strips in the tub or shower (71.7% vs 61.5%). CONCLUSION There is room for improvement in safety practices among households where an individual with a disability resides.

Pregnant driver-associated motor vehicle crashes in North Carolina, 2001-2008

BACKGROUND Motor vehicle crashes are the leading cause of maternal injury-related mortality during pregnancy in the United States, yet pregnant women remain an understudied population in motor vehicle safety research. METHODS We estimated the risk of being a pregnant driver in a crash among 878,546 pregnant women, 16-46 years, who reached the 20th week of pregnancy in North Carolina (NC) from 2001 to 2008. We also examined the circumstances surrounding the crash events. Pregnant drivers in crashes were identified by probabilistic linkage of live birth and fetal death records and state motor vehicle crash reports. RESULTS During the 8-year study period, the estimated risk of being a driver in a crash was 12.6 per 1000 pregnant women. Pregnant women at highest risk of being drivers in serious crashes were 18-24 years old (4.5 per 1000; 95% confidence interval, CI,4.3, 4.7), non-Hispanic black (4.8 per 1000; 95% CI=4.5, 5.1), had high school diplomas only (4.5 per 1000; 95% CI=4.2, 4.7) or some college (4.1 per 1000; 95% CI=3.9, 4.4), were unmarried (4.7 per 1000; 95% CI=4.4, 4.9), or tobacco users (4.5 per 1000; 95% CI=4.1, 5.0). A high proportion of crashes occurred between 20 and 27 weeks of pregnancy (45%) and a lower proportion of crashes involved unbelted pregnant drivers (1%) or airbag deployment (10%). Forty percent of crashes resulted in driver injuries. CONCLUSIONS NC has a relatively high pregnant driver crash risk among the four U.S. states that have linked vital records and crash reports to examine pregnancy-associated crashes. Crash risks were especially elevated among pregnant women who were young, non-Hispanic black, unmarried, or used tobacco. Additional research is needed to quantify pregnant womens driving frequency and patterns.

Gestational age at initiation of 17-alpha hydroxyprogesterone caproate and recurrent preterm birth

Background Preterm birth is the leading cause of neonatal morbidity and mortality in nonanomalous neonates in the United States. Women with a previous early spontaneous preterm birth are at highest risk for recurrence. Weekly intramuscular 17‐alpha hydroxyprogesterone caproate reduces the risk of recurrent prematurity. Although current guidelines recommend 17‐alpha hydroxyprogesterone caproate initiation between 16 and 20 weeks, in clinical practice, 17‐alpha hydroxyprogesterone caproate is started across a spectrum of gestational ages. Objective The objective of the study was to examine the relationship between the gestational age at 17‐alpha hydroxyprogesterone caproate initiation and recurrent preterm birth among women with a prior spontaneous preterm birth 16–28 weeks’ gestation. Study Design This was a retrospective cohort study of women from a single tertiary care center, 2005–2016. All women with ≥1 singleton preterm births because of a spontaneous onset of contractions, preterm prelabor rupture of membranes, or painless cervical dilation between 16 and 28 weeks followed by a subsequent singleton pregnancy treated with 17‐alpha hydroxyprogesterone caproate were included. Women were grouped based on quartiles of gestational age of 17‐alpha hydroxyprogesterone caproate initiation (quartile 1, 140/7 to 161/7; quartile 2, 162/7 to 170/7; quartile 3, 171/7 to 186/7; and quartile 4, 190/7 to 275/7). Women with a gestational age of 17‐alpha hydroxyprogesterone caproate initiation in quartiles 1 and 2 were considered to have early‐start 17‐alpha hydroxyprogesterone caproate; those in quartiles 3 and 4 were considered to have late‐start 17‐alpha hydroxyprogesterone caproate. The primary outcome was recurrent preterm birth <37 weeks’ gestation. Secondary outcomes included recurrent preterm birth <34 and <28 weeks’ gestation and composite major neonatal morbidity (diagnosis of grade III or IV intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis stage II or III, or death). Gestational age at delivery was compared by quartile of 17‐alpha hydroxyprogesterone caproate initiation using Kaplan‐Meier survival curves and the log‐rank test. Logistic regression models estimated odds ratios for the association between gestational age at 17‐alpha hydroxyprogesterone caproate initiation and preterm birth <37 weeks’ gestation, adjusting for demographics, prior pregnancy and antenatal characteristics. Results A total of 132 women met inclusion criteria; 52 (39.6%) experienced recurrent preterm birth <37 weeks in the studied pregnancy. 17‐Alpha hydroxyprogesterone caproate was initiated at a mean 176/7 ± 2.5 weeks. Demographic and baseline characteristics were similar between women with early‐start 17‐alpha hydroxyprogesterone caproate (quartiles 1 and 2) compared with those with late‐start 17‐alpha hydroxyprogesterone caproate (quartiles 3 and 4). Women with early‐start 17‐alpha hydroxyprogesterone caproate trended toward lower rates of recurrent preterm birth <37 weeks compared with those with late‐start 17‐alpha hydroxyprogesterone caproate (41.3% vs 57.7%, P = .065). Delivery gestational age was inversely proportional to gestational age at 17‐alpha hydroxyprogesterone caproate initiation (quartile 1, 374/7 weeks vs quartile 2, 365/7 vs quartile 3, 361/7 weeks vs quartile 4, 340/7, P = .007). In Kaplan‐Meier survival analyses, these differences in delivery gestational age by 17‐alpha hydroxyprogesterone caproate initiation quartile persisted across pregnancy (log‐rank P < .001). In regression models, later initiation of 17‐alpha hydroxyprogesterone caproate was significantly associated with increased odds of preterm birth <37 weeks. Women with early 17‐alpha hydroxyprogesterone caproate initiation also had lower rates of major neonatal morbidity than those with later 17‐alpha hydroxyprogesterone caproate initiation (1.5% vs 14.3%, P = .005). Conclusion Rates of recurrent preterm birth among women with a prior spontaneous preterm birth 16–28 weeks are high. Women beginning 17‐alpha hydroxyprogesterone caproate early deliver later and have improved neonatal outcomes. Clinicians should make every effort to facilitate 17‐alpha hydroxyprogesterone caproate initiation at 16 weeks.

Operationalizing 17α-hydroxyprogesterone Caproate to Prevent Recurrent Preterm Birth: Definitions, Barriers, and Next Steps

Each year in the United States, more than 500,000 neonates are born before 37 weeks of gestation. Women who have experienced a previous preterm birth are at high risk of recurrence. A weekly prenatal injection of 17α-hydroxyprogesterone caproate decreases the risk of recurrent preterm birth and is recommended from as early as 16 weeks of gestation in women carrying singleton pregnancies who have a history of spontaneous singleton preterm birth. A commonly used metric for public health program effectiveness is population coverage of an intervention. In the case of 17α-hydroxyprogesterone caproate, population coverage can be defined as the proportion of women who are eligible for 17α-hydroxyprogesterone caproate (ie, previous pregnancy complicated by spontaneous singleton preterm birth) who actually receive the intervention. To receive a full course of 17α-hydroxyprogesterone caproate, women must negotiate a complex series of steps that includes presenting early for prenatal care, being identified as eligible for 17α-hydroxyprogesterone caproate, being offered 17α-hydroxyprogesterone caproate, accepting 17α-hydroxyprogesterone caproate, and adhering to the weekly 17α-hydroxyprogesterone caproate dose schedule. We describe this series of steps as well potential solutions to increase 17α-hydroxyprogesterone caproate coverage.