Chloe Zera

Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study

Objective To examine whether delivery by caesarean section is a risk factor for childhood obesity. Design Prospective prebirth cohort study (Project Viva). Setting Eight outpatient multi-specialty practices based in the Boston, Massachusetts area. Participants We recruited women during early pregnancy between 1999 and 2002, and followed their children after birth. We included 1255 children with body composition measured at 3 years of age. Main outcome measures BMI score, obesity (BMI for age and sex ≥95th percentile), and sum of triceps plus subscapular skinfold thicknesses at 3 years of age. Results 284 children (22.6%) were delivered by caesarean section. At age 3, 15.7% of children delivered by caesarean section were obese compared with 7.5% of children born vaginally. In multivariable logistic and linear regression models adjusting for maternal prepregnancy BMI, birth weight, and other covariates, birth by caesarean section was associated with a higher odds of obesity at age 3 (OR 2.10, 95% CI 1.36 to 3.23), higher mean BMI z-score (0.20 units, 95% CI 0.07 to 0.33), and higher sum of triceps plus subscapular skinfold thicknesses (0.94 mm, 95% CI 0.36 to 1.51). Conclusions Infants delivered by caesarean section may be at increased risk of childhood obesity. Further studies are needed to confirm our findings and to explore mechanisms underlying this association.

A Web-Based Lifestyle Intervention for Women With Recent Gestational Diabetes Mellitus: A Randomized Controlled Trial

OBJECTIVE: To test the feasibility and effectiveness of a Web-based lifestyle intervention based on the Diabetes Prevention Program modified for women with recent gestational diabetes mellitus to reduce postpartum weight retention. METHODS: We randomly allocated 75 women with recent gestational diabetes mellitus to either a Web-based lifestyle program (Balance after Baby) delivered over the first postpartum year or to a control group. Primary outcomes were change in body weight at 12 months from 1) first postpartum measured weight; and 2) self-reported prepregnancy weight. RESULTS: There were no significant differences in baseline characteristics between groups including age, body mass index, race, and income status. Women assigned to the Balance after Baby program (n=36, three lost to follow-up) lost a mean of 2.8 kg (95% confidence interval –4.8 to −0.7) from 6 weeks to 12 months postpartum, whereas the control group (n=39, one lost to follow-up) gained a mean of 0.5 kg (−1.4 to +2.4) (P=.022). Women in the intervention were closer to prepregnancy weight at 12 months postpartum (mean change −0.7 kg; −3.5 to +2.2) compared with women in the control arm (+4.0 kg; +1.3 to +6.8) (P=.035). CONCLUSION: A Web-based lifestyle modification program for women with recent gestational diabetes mellitus decreased postpartum weight retention. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01158131. LEVEL OF EVIDENCE: I

Differential Associations of Leptin with Adiposity Across Early Childhood

To examine associations of perinatal and 3‐year leptin with weight gain and adiposity through 7 years.

Barriers to follow-up for women with a history of gestational diabetes.

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening. We surveyed primary care providers (PCPs) and obstetric and gynecology care providers (OBCPs) in a large health system. We also assessed documentation of GDM history in the health care systems electronic medical record. Four hundred seventy-eight clinicians were surveyed, among whom 207 responded. Most participants (81.1%) gave an accurate estimate of risk of progression to T2DM. PCPs were less likely than OBCPs to ask patients about history of GDM (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20 to 0.90), but they were far more likely to indicate that they order glucose screening for women with a known history (OR 4.31, 95% CI 2.01 to 9.26). Providers identified poor communication between OBCPs and PCPs as a major barrier to screening. Fewer than half (45.8%) of 450 women with GDM by glucose tolerance test criteria had that history documented on their electronic problem list. Clinicians are aware that women with GDM are at high risk of developing type 2 diabetes, but they do not routinely assess and screen patients, and communication between OBCPs and PCPs can be improved.

A Multi-State Analysis of Early-Term Delivery Trends and the Association With Term Stillbirth.

OBJECTIVE: To investigate whether reduction in early-term deliveries was associated with increasing rates of term stillbirth. METHODS: This is a retrospective descriptive analysis of variation in term delivery timing and stillbirth from 2005 to 2011 based on birth certificate and fetal death data. Early-term deliveries (37 0/7–38 6/7 weeks of gestation) as a percentage of total term delivery and term stillbirth rates were calculated for each state, both overall and for low- and high-risk women. We analyzed whether state-level changes in early-term deliveries and term stillbirth were correlated using Pearson correlation coefficients. States were also categorized as high or low reduction (above or below the national average) and changes in stillbirth rates for these groups were analyzed using a Cochrane-Armitage test for linear trend. RESULTS: There was a decline in early-term deliveries across the United States: 1,123,467 of 3,533,233 term, singleton births occurred in the early term in 2005 (31.8%) as compared with 978,294 of 3,429,172 (28.5%) in 2011. Reductions varied widely by state. There was no change in the term stillbirth rate (123/100,000 births in 2005 compared with 130/100,000 in 2011; P=.189) nor change in the high reduction states alone. There was no correlation between state-level changes in early-term deliveries and term stillbirth. There was an increase in term stillbirths among women with diabetes (from 238/100,000 to 300/100,000 births; P=.010), independent of changes in early-term delivery timing. CONCLUSION: The reduction in early-term deliveries across the United States between 2005 and 2011 was not associated with an increase in the rate of term stillbirth. LEVEL OF EVIDENCE: II

Urinary tract infection during pregnancy, angiogenic factor profiles, and risk of preeclampsia

BACKGROUND Despite decades of research, and much progress in discernment of biomarkers in the maternal circulation, the pathogenesis of preeclampsia (PE) remains elusive. The pathophysiology of PE is believed to involve aberrant placentation and an associated increase in systemic inflammation. In this conceptualization, PE becomes more likely when the level of systemic inflammatory burden inherent in pregnancy itself exceeds the maternal capacity to compensate for this additional stress. If this is the case, then it is possible to hypothesize that conditions, such as infectious disease, that increase systemic inflammatory burden should also increase the risk of PE. As urinary tract infection (UTI) represents a common source of inflammation during pregnancy, we tested whether presence of UTI during pregnancy increased the odds of developing PE. Prior work has documented this association. However many of these studies were limited by small cohort sizes and insufficient control for covariates. OBJECTIVE The present study is a secondary analysis of a robust contemporary obstetrical cohort recruited to examine the ability of longitudinally sampled maternal angiogenic concentrations to predict PE. We hypothesize that the occurrence of UTI during a pregnancy is associated with the later occurrence of PE in that pregnancy. As PE is believed to be associated with aberrations in systemic angiogenic levels (placental growth factor and soluble isoform of VEGF receptor), we further hypothesize that there will be significant interactions between maternal angiogenic protein levels and the occurrence of UTI. STUDY DESIGN Women aged ≥18 years (n = 2607) were recruited and followed up prospectively from the initiation of prenatal care through delivery at 3 regional academic centers. PE was defined by American Congress of Obstetricians and Gynecologists criteria and was independently validated by a panel of physicians. UTI was defined by the presence of clinical symptoms necessitating treatment in addition to supportive laboratory evidence. Multivariate logistic regression models were used and controlled for maternal age, race, parity, body mass index, hypertension, diabetes, in vitro fertilization, and smoking status. RESULTS There were 129 women with diagnosed UTIs and 235 with PE. Patients with UTI in pregnancy had higher rates of PE (31.1% vs 7.8%, P < .001) compared to those without reported UTI. The mean gestational age (SD) for UTI diagnosis in PE cases and controls was 25.6 (10.4) and 21.9 (10.9) weeks, respectively (P = .08). The unadjusted odds ratio for PE in the setting of UTI was 5.29 (95% confidence interval, 3.54-7.89). After controlling for confounders, UTI was associated with an odds ratio for PE of 3.2 (95% confidence interval, 2.0-5.1). CONCLUSION Presence of UTI in pregnancy, particularly in the third trimester, is strongly associated with PE. This association supports the hypothesis that the risk of PE is enhanced by an increased maternal inflammatory burden. Prophylaxis against UTI represents a potentially low-cost global intervention to slow or halt the development of PE.

Pregnancy Complications as Markers for Subsequent Maternal Cardiovascular Disease: Validation of a Maternal Recall Questionnaire

BACKGROUND We designed and tested the validity of a questionnaire to characterize maternal recall of pregnancy complications associated with increased future cardiovascular disease risk, based on the 2011 American Heart Association (AHA) guidelines. METHODS A maternal recall questionnaire of pregnancy history was administered to 971 patients who had participated in a previous cohort study of 1,608 pregnant women. Medical records from the study pregnancy served as the gold standard. Prevalence, sensitivity (sens), specificity (spec), positive predictive value (PPV), negative predictive value (NPV), and/or Spearmans correlation coefficients (r) were calculated for each question. RESULTS A total of 526 (54%) individuals recontacted responded. Respondents were more likely to be older, white, educated, and nulliparous and were less likely to deliver low-birthweight infants in the study pregnancy than were individuals who did not respond. Mean length of recall was 4.35 years (standard deviation [SD] 0.46) postpartum. Maternal recall was most accurate for gestational diabetes (sens: 92%, spec: 98%, PPV: 79%, NPV: 99%), infant birthweight (r=0.95), and gestation length (r=0.85). Maternal recall was modest for preeclampsia (sens: 79%, spec: 97%, PPV: 68%, NPV: 98%) and pregnancy-associated hypertension, including preeclampsia or gestational hypertension (sens: 60%, spec: 95%, PPV: 64%, NPV: 94%). CONCLUSIONS This validation study demonstrated that the majority of women could accurately recall a history of gestational diabetes, infant birthweight, and gestational age at delivery, 4 years postpartum on average. Recall of preeclampsia and pregnancy-associated hypertension overall was modest. Maternal report of these pregnancy conditions may help clinicians identify women at increased risk for cardiovascular disease.

The effect of obstetric practice change to reduce early term delivery on perinatal outcome.

Objective:To investigate whether the national emphasis on attaining ⩾39 weeks gestation has altered obstetric practice, and if so whether this has affected perinatal morbidity.Study Design:We examined trends in gestational age, neonatal morbidity, maternal complications and stillbirth for a retrospective cohort of singleton, live births between 37+0 and 39+6 weeks of gestation over a 5-year period at a single tertiary care center.Result:There were 21 343 eligible deliveries. The proportion of deliveries in the early term (<39 weeks) decreased from 47.8 to 40.2% (P<0.01). The reduction was most pronounced for elective inductions (27.5 to 8.0%; P<0.01) and scheduled cesareans (56.9 to 24.9%; P<0.01), although a similar trend was seen for nonelective inductions (51.2 to 47.9%; P=0.03). In multivariable analysis, there was a 10% decreased odds of early term delivery per year (P<0.01). There were no changes in the rates of neonatal intensive care unit (NICU) evaluation (29.8 to 28.1%; P=0.11), pre-eclampsia (7.6 to 8.5%; P=0.06) or stillbirth (11.5 to 14.4 per 10 000; P=0.55).Conclusion:A 10% annual decline in the odds of early term delivery was not accompanied by significant changes in perinatal morbidity.

Diabetes Screening Reminder for Women With Prior Gestational Diabetes: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether an electronic health record (EHR) reminder improves rates of screening for type 2 diabetes in women with prior gestational diabetes. METHODS: We randomly allocated primary care providers (by clinic site) to a reminder for type 2 diabetes screening within the EHR or to usual care. Women with previous gestational diabetes mellitus were identified through an automated search of laboratory results and the problem list. We compared rates of screening during the study period (2010–2012) in women at intervention sites with those at control sites. With a sample size of 850 participants, we had 80% power to detect a 15% difference in screening rates. RESULTS: We included 847 individuals seen at a participating clinic during the study period, of whom 471 were at a reminder clinic and 376 were at a control clinic. A similar proportion of women were screened for type 2 diabetes in both groups (n=265, 56.3% of the reminder group compared with n=206, 54.8% of the control group, P=.67; adjusted odds ratio [OR] 1.04, 95% confidence interval [CI] 0.79–1.38). Patient characteristics associated with risk for diabetes including body mass index (adjusted OR per kg/m2 1.05, 95% CI 1.01–1.08) and race (adjusted OR for nonwhite race 2.14, 95% CI 1.57–2.92) were significantly associated with screening. CONCLUSION: A simple EHR reminder did not increase the rate of diabetes screening in women with prior gestational diabetes mellitus. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01288144. LEVEL OF EVIDENCE: I

Identification of pathologically small fetuses using customized, ultrasound and population‐based growth norms

Fetal growth restriction is a strong risk factor for stillbirth. We compared the performance of three fetal growth curves – customized, ultrasound (Hadlock) and population – in identifying abnormally grown fetuses at risk of stillbirth.