Dawn P. Misra

Prepregnancy body mass index and gestational age-dependent changes in lipid levels during pregnancy.

OBJECTIVE: To examine the effect of maternal prepregnancy overweight and obesity on gestational age-dependent variation in lipid levels during pregnancy. METHODS: Women between 6 and 10 weeks of gestation who carry a single, live intrauterine pregnancy were eligible to participate in a prospective pregnancy study (N=142). The exposure, maternal prepregnancy body mass index (BMI), was classified as: normal weight (BMI 18.5–26.0 kg/m2) and overweight or obese (BMI over 26.0 kg/m2). Our outcomes of interest, total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol were measured at 6–10, 10–14, 16–20, 22–26, and 32–36 weeks of gestation. Mixed linear models were used to examine how the trajectory of lipid levels during pregnancy differs between overweight or obese and normal-weight women. RESULTS: Levels of total cholesterol, triglycerides, LDL cholesterol, and HDL choloesterol increased over the prenatal period. The rate of change in LDL cholesterol (P<.001) and total cholesterol (P=.01) levels was lower for overweight or obese women than for normal-weight women in late-second and early-third trimester. As a result, overweight or obese women had significantly lower total cholesterol and LDL cholesterol levels than their normal-weight counterparts between 32–36 weeks of gestation. CONCLUSION: Overweight and obese women have different lipid profiles during pregnancy than their normal-weight peers. This difference may be the result of metabolic dysregulation associated with maternal overweight and obesity that mediates the increased risk of adverse outcomes found in these women. LEVEL OF EVIDENCE: II

Effects of social and psychosocial factors on risk of preterm birth in black women.

Our objective was to examine how social and psychosocial factors may influence the risk of preterm birth. The design of the study was a hybrid retrospective and prospective cohort. African-American women residing in Baltimore, Maryland, were enrolled prenatally if they received care at one of three Johns Hopkins Medical Institution prenatal clinics (n=384) or enrolled post-partum if they delivered at Johns Hopkins Medical Institution with late, none or intermittent prenatal care (N=459). Preterm birth was defined as less than 37 weeks completed gestation. Interview data were collected on 832 enrolled women delivering singletons between March 2001 and July 2004. The preterm birth rate was 16.4%. In both unadjusted and adjusted models, exposure to racism over a womans lifetime had no effect on risk of preterm birth in our sample. However, we found evidence of a three-way interaction between reported lifetime experiences of racism, depressive symptoms during pregnancy and stress during pregnancy on preterm birth risk. Racism scores above the median (more racism) were associated with an increased risk of preterm birth in three subgroups with the effect moderated by depressive symptoms and stress. Social and psychosocial factors may operate in a complex manner related to risk of preterm birth.

Vaginal and oral microbes, host genotype and preterm birth

Preterm birth (PTB) is a leading cause of infant mortality and morbidity in the US and across the globe. Infection and associated inflammation are important initiators for PTB pathways; an estimated 40% of PTBs are attributed to amniochorionic-decidual or systemic inflammation. Historically, intrauterine infections have been implicated in PTB; recent evidence suggests that infections remote from the fetal site may also be causative. There is strong epidemiological evidence that bacterial vaginosis and periodontitis--two syndromes characterized by perturbations in the normal vaginal and oral bacterial microflora, respectively--are linked to infection-associated PTB. Oral and vaginal environments are similar in their bacterial microbiology; identical bacterial species have been independently isolated in periodontitis and bacterial vaginosis. Periodontitis and bacterial vaginosis also share many behavioral and sociodemographic risk factors suggesting a possible common pathophysiology. Genetic polymorphisms in host inflammatory responses to infection are shared between bacterial vaginosis, periodontitis and PTB, suggesting common mechanisms through which host genotype modify the effect of abnormal bacterial colonization on preterm birth. We review the state of knowledge regarding the risk of PTB attributable to perturbations in bacterial flora in oral and vaginal sites and the role of host genetics in modifying the risk of infection-related PTB. We posit that bacterial species that are common in perturbed vaginal and oral sites are associated with PTB through their interaction with the host immune system.

The consequences of foreclosure for depressive symptomatology.

PURPOSE We tested whether experiencing the stressful event of a home mortgage foreclosure was associated with depressive symptomatology. METHODS Data derive from a cohort study of 662 new mothers in the Life-course Influences on Fetal Environment (LIFE) Study. Eligibility included black/African-American mothers, ages 18 to 45 years, who had just given birth to a singleton baby. Mothers enrolled June 2009 to December 2010 were interviewed immediately after giving birth. Our outcome measure was depressive symptoms based on the Center for Epidemiologic Studies-Depression Scale, dichotomized to measure severe depressive symptomatology during the week prior to the interview. RESULTS A total of 8% of the sample experienced foreclosure in the past 2 years. Covariate-adjusted Poisson regression models showed that women experiencing a recent foreclosure had 1.76 times greater risk for severe depressive symptoms during the week prior to birth compared to women not experiencing foreclosure (95% confidence interval 1.25-2.47, p = .001); foreclosure was also associated with higher excess absolute risk for depressive symptoms (adjusted risk difference 0.173, 95% confidence interval 0.044-0.301, p = .008). CONCLUSIONS Women who have recently experienced foreclosure are at risk for severe depressive symptoms. The mental health needs of pregnant women experiencing foreclosure or other housing stressors should be considered in clinical practice.

Prognosis and treatment of desquamative inflammatory vaginitis.

OBJECTIVE: Desquamative inflammatory vaginitis is a clinical syndrome frequently unrecognized, characterized by vaginal rash and purulent discharge. We describe patient outcomes and treatment at follow-up in a case series of 98 women diagnosed with this syndrome. METHODS: We performed a chart review of 130 patients diagnosed with desquamative inflammatory vaginitis between 1996 and 2007 in a referral university-based vaginitis clinic. Clinical findings, laboratory findings, and treatment were documented during the first 12 months and at 2 and 4 years. RESULTS: Of the 98 patients reviewed, 97 were white; mean age was 48.6 years (plus or minus 10.2 years), and 50% were postmenopausal. All patients were symptomatic with vaginal inflammation and 72% had vestibular findings. Treatment with topical 2% clindamycin (54%) or 10% hydrocortisone (46%) dramatically relieved symptoms within 3 weeks (median) in 86% of patients. Treatment was discontinued (median 8 weeks) in 53 patients experiencing clinical remission accompanied by normal wet mount appearance; however, 17 (32%) relapsed within 6 weeks. At 1 year, cure was achieved in 25 patients (26%), 57 (58%) were asymptomatic but remained dependent on maintenance treatment, and 16 (16%) were partially controlled only. A favorable initial response to therapy was associated with positive clinical prognosis by 20 weeks of follow-up (P=.01). CONCLUSION: Desquamative inflammatory vaginitis is a chronic inflammatory process involving both vagina and vestibule, occurring almost exclusively in white women, that responds well to topical anti-inflammatory therapy, although long-term maintenance therapy frequently is required. LEVEL OF EVIDENCE: III

The impact of neighborhood quality, perceived stress, and social support on depressive symptoms during pregnancy in African American women

Living in a lower-quality neighborhood is associated with higher levels of depressive symptoms in the general population as well as among pregnant and postpartum women. However, little is known of the important pathways by which this association occurs. We proposed a model in which perceived stress and social support mediated the effects of neighborhood quality on depressive symptoms during pregnancy (measured by the 20-item Center for Epidemiologic Studies-Depression, CES-D, scale) in a sample of 1383 African American women from the Detroit metropolitan area interviewed during their delivery hospitalization. Using structural equation modeling (SEM), we built a latent variable of neighborhood quality using 4 measures (neighborhood disorder, neighborhood safety/danger, walking environment, overall rating). We then tested two SEM mediation models. We found that lower neighborhood quality was associated with higher prevalence of depressive symptoms during pregnancy (standardized total effect = .16, p = .011). We found that perceived stress partially mediated the neighborhood quality association with depressive symptoms. Although the association of social support with depressive symptoms was negligible, social support mediated associations of neighborhood quality with perceived stress [standardized path coefficient = .38 (.02), p = .009]. Our results point to the need for public health, health care, as well as non-health related interventions (e.g. crime prevention programs) to decrease overall exposure to stressors, as well as stress levels of women living in poor quality neighborhoods. Interventions that increase the levels of social support of women during pregnancy are also needed for their potential to decrease stress and ultimately improve mental health at this important time in the life course.

Selected Vaginal Bacteria and Risk of Preterm Birth: An Ecological Perspective

We examined the community ecology of vaginal microbial samples taken from pregnant women with previous preterm birth experience to investigate whether targeted pathogenic and commensal bacteria are related to risk of preterm birth in the current pregnancy. We found a significant correlation between the community structure of selected bacteria and birth outcome, but the correlation differed among self-reported racial/ethnic groups. Using a community ordination analysis, we observed infrequent co-occurrence of Mycoplasma and bacteria vaginosis associated bacteria 3 (BVAB3) among black and Hispanic participants. In addition, we found that the vaginal bacteria responded differently in different racial/ethnic groups to modifications of maternal behavioral (ie, douching and smoking) and biological traits (ie, body mass index [BMI]). Even after accounting for these maternal behaviors and traits, the selected vaginal bacteria was significantly associated with preterm birth among black and Hispanic participants. By contrast, white participants did not exhibit significant correlation between microbial community and birth outcome. Findings from this study affirm the necessity of considering womens race/ethnicity when evaluating the correlation between vaginal bacteria and preterm birth. The study also illustrates the importance of studying the vaginal microbiota from an ecological perspective, and demonstrates the power of ecological community analysis to improve understanding of infectious disease.

Preconception Predictors of Birth Outcomes: Prospective Findings from the Central Pennsylvania Women's Health Study

ObjectiveTo examine maternal pre-pregnancy (preconception) predictors of birthweight and fetal growth for singleton live births occurring over a 2-year period in a prospective study.MethodsData are from a population-based cohort study of 1,420 women who were interviewed at baseline and 2-years later; self-report data and birth records were obtained for incident live births during the followup period. The analytic sample includes 116 singleton births. Baseline preconception maternal health status and health-related behaviors were examined as predictors of birthweight and fetal growth, controlling for prenatal and sociodemographic variables, using multiple regression analysis.ResultsPreconception BMI (overweight or obese) and vegetable consumption (at least one serving per day) had statistically significant independent and positive effects on birthweight and fetal growth. Maternal weight gain during pregnancy, a prenatal variable, was an additional independent predictor of birthweight and fetal growth. Sociodemographic variables were not significant predictors after controlling for preconception and prenatal maternal characteristics.ConclusionsFindings confirm that preconception maternal health status and health-related behaviors can affect birthweight and fetal growth independent of prenatal and socioeconomic variables. Implications for preconception care are discussed.

The Influence of Personal and Group Racism on Entry Into Prenatal Care Among-African American Women

BACKGROUND Racism has been hypothesized as a barrier to accessing health care. No quantitative study has directly assessed its influence on womens initiation of prenatal care (PNC). We examined the relationship between PNC entry and experiences of personal and group racism among low-income, African-American (AA) women. We also examined whether the use of denial of racism as a coping mechanism was associated with a delay in accessing PNC. METHODS Using a prospective/retrospective cohort design we collected data from 872 AA women (prenatally, n = 484; postpartum, n = 388). Multinomial logistic regression was used to assess the relationship between the overall denial of racism index and PNC initiation. FINDINGS PNC entry was not associated with personal experiences of racism (p = .33); it was significantly associated with group experiences (p < .01). CONCLUSION Denial of racism experienced by other AAs was a barrier to early PNC among low-income, AA women. Delayed access to PNC may be rooted in the avoidance of racialized experiences among less empowered women when faced with discrimination. Our findings have important implication for the engagement of AA women into the PNC delivery system and the health care system postpartum.

Reducing Exposure to Environmental Toxicants Before Birth: Moving from Risk Perception to Risk Reduction

In this study, we considered approaches to reducing maternal exposure to hazardous environmental toxicants, focusing on risk communication to pregnant women and providers, but also considering identification of environmental toxicants in the community and reduction of environmental toxicants. We addressed the following questions: (1) What do pregnant women and their providers know about environmental toxicants and perinatal health? and (2) What policy strategies are needed (should be considered) to move forward in risk reduction in this area? We reviewed the literature on knowledge of pregnant women and providers regarding these issues. While there is limited research on what pregnant women and their providers know about environmental toxicants and perinatal health, there is evidence of reproductive and perinatal toxicity. This article describes a wide range of policy strategies that could be implemented to address environmental toxicants in the context of perinatal health. Effective leadership in this area will likely require collaboration of both environmental health and maternal and child health leaders and organizations.