John C. Smulian

Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery.

OBJECTIVEnThe purpose of this study was to determine the wound complication rates and patient satisfaction for subcuticular suture vs staples for skin closure at cesarean delivery.nnnSTUDY DESIGNnThis was a randomized prospective trial. Subjects who underwent cesarean delivery were assigned randomly to stainless steel staples or subcuticular 4.0 Monocryl sutures. The primary outcomes were composite wound complication rate and patient satisfaction.nnnRESULTSnA total of 435 patients were assigned randomly. Staple closure was associated with a 4-fold increased risk of wound separation (adjusted odds ratio [aOR], 4.66; 95% confidence interval [CI], 2.07-10.52; P < .001). Having a wound complication was associated with a 5-fold decrease in patient satisfaction (aOR, 0.18; 95% CI, 0.09-0.37; P < .001). After confounders were controlled for, there was no difference in satisfaction between the treatment groups (aOR, 0.71; 95% CI, 0.34-1.50; P = .63).nnnCONCLUSIONnUse of staples for cesarean delivery closure is associated with an increased risk of wound complications. Occurrence of a wound complication is the most important factor that influenced patient satisfaction.

Pesticide Concentrations in Maternal and Umbilical Cord Sera and Their Relation to Birth Outcomes in a Population of Pregnant Women and Newborns in New Jersey

We evaluated in utero exposures to pesticides by measuring maternal and cord serum biomarkers in a New Jersey cohort of pregnant women and the birth outcomes of their neonates. The study was based on 150 women that underwent an elective cesarean delivery at term in a hospital in central New Jersey. We evaluated the following pesticide compounds in both maternal and umbilical cord sera: chlorpyrifos, diazinon, carbofuran, chlorothalonil, dacthal, metolachlor, trifluralin and diethyl-m-toluamide (DEET). Of these compounds, chlorpyrifos, carbofuran, chlorothalonil, trifluralin, metolachlor and DEET were the pesticides most frequently detected in the serum samples. We found high (> or =75th percentile) metolachlor concentrations in cord blood that were related to birth weight (3605 g in upper quartile vs 3399 g; p=0.05). We also observed an increase in abdominal circumference with increasing cord dichloran concentrations (p=0.031). These observations suggest that in utero exposures to certain pesticides may alter birth outcomes.

Maternal anaemia and preterm birth: a prospective cohort study

BACKGROUNDnThe role of maternal anaemia in preterm birth remains poorly defined, and the association between anaemia and preterm birth clinical subtypes remain unclear. We examined if maternal anaemia exposure both within and across trimesters during gestation is associated with preterm birth.nnnMETHODSnThis was a secondary analysis of data from a population-based prospective cohort study in 13 counties of East China (1993-96). All singleton live births delivered at 20-44 weeks to women with at least one haemoglobin measure during pregnancy were included (n = 160 700). Risk of preterm birth (<37 weeks) was examined by clinical subtypes, namely, preterm premature rupture of membranes (PROM), spontaneous preterm labour and medically indicated preterm birth. Haemoglobin changes across trimesters were assessed as proxy of haemo-dilution and haemo-concentration. Multivariable Cox proportional hazards regression models were fitted.nnnRESULTSnPreterm birth rates of preterm birth were 4.1% for anaemic and 5% for non-anaemic women (P < 0.05). Compared with haemoglobin of 11 g/dl (reference), values <or=5 g/dl in the first trimester were associated with increased risk for preterm PROM [hazard ratio (HR) 3.3, 95% confidence interval (CI) 1.4-7.7], whereas low haemoglobin in the third trimester was associated with reduced risk of spontaneous preterm labour. Haemodilution was associated with reduced risk for preterm birth.nnnCONCLUSIONSnAnaemia in early pregnancy was found to be associated with increased risk for preterm PROM, whereas exposure in late pregnancy was associated with reduced risk for spontaneous preterm labour.

Phthalates Biomarker Identification and Exposure Estimates in a Population of Pregnant Women

ABSTRACT Phthalates are known reproductive and developmental toxicants in experimental animals. However, in humans, there are few data on the exposure of pregnant women that can be used to assess the potential developmental exposure experienced by the fetus. We measured several phthalate metabolites in maternal urine, maternal serum, and cord serum samples collected at the time of delivery from 150 pregnant women from central New Jersey. The urinary concentrations of most metabolites were comparable to or less than among the U.S. general population, except for mono(2-ethylhexyl) phthalate (MEHP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), and mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), three metabolites of di(2-ethylhexyl) phthalate (DEHP). The median urinary concentrations of MEHHP (109 μ g/l) and MEOHP (95.1 μ g/l) were more than 5 times their population-based concentrations, whereas the median urinary concentration of MEHP was more than 20 times higher. High concentration of MEHP may indicate a recent exposure to the parent chemical DEHP in the hospital shortly before the collection of the samples. Calculation of daily intakes using the urinary biomarker data reveals that none of the pregnant women tested had integrated exposures to DEHP greater than the Agency for Toxic Substances and Disease Registrys minimal risk levels (MRLs chronic 60, intermediate 100 μ g/kg/day). No abnormal birth outcomes (e.g., birth weight, Apgar Score, and gestational age) were noted in those newborns whose mothers had relatively greater exposure to DEHP during the perinatal period than others in this study. Significantly greater concentrations and detection frequencies in maternal urine than in maternal serum and cord serum suggest that the urinary concentrations of the phthalate metabolites may be more reliable biomarkers of exposure than their concentrations in other biological specimens.

Food Cravings and Intake of Sweet Foods in Healthy Pregnancy and Mild Gestational Diabetes Mellitus. A Prospective Study

Pregnancy is associated with increased sweet food cravings, but the relationship between sweet cravings and dietary intake remains uncertain. Gestational diabetes mellitus (GDM) is glucose intolerance first recognized during pregnancy. GDM may further perpetuate sweet food cravings and intake in pregnancy, although this has not been investigated. This study longitudinally assessed sweet food cravings across pregnancy in women who developed mild GDM (n = 15), normal glucose tolerant pregnant women (NGT; n = 93) and nonpregnant controls (n = 19). Food frequency questionnaires and craving surveys were completed 3 times during pregnancy, and again during postpartum. While 55% of NGT women reported sweet cravings at 24-28 wk; this percentage fell significantly at term. Sweet cravings in these women coincided with higher reported sweet food and beverage intake. Only 40% of GDM women reported sweet cravings at 24-28 wk. However, at 34-38 wk, this subset of GDM women reported twice the frequency of sweet cravings than NGT women (12.1 ± 2.8 times/wk vs. 5.9 ± 1.0 times/wk, respectively). Sweet cravings appear to be a feature of late pregnancy in GDM, but may not threaten dietary adherence in women with mild GDM. Future studies should investigate sweet cravings in women with more severe GDM.

Ischemic Placental Disease: Maternal Versus Fetal Clinical Presentations by Gestational Age

Objective.u2003Preeclampsia, small for gestational age (SGA), and abruption are considered ischemic placental diseases (IPD), and are major contributors to both maternal and fetal morbidity and mortality. Although the placenta is considered a fetal organ, these conditions can present clinically with either maternal or fetal manifestations, but their relationship to preterm births is largely unexplored. Methods.u2003We designed a population-based study to assess the origins of IPD. IPD was classified as maternal (preeclampsia only), fetal (SGA only), or both (abruption only, preeclampsia with either SGA or abruption, or all 3). The study was based on 90,500 women that delivered singleton live births at 22–44 weeks gestation. Results.u2003Among 77,275 term births with IPD, 23.2% presented as maternal disease only, 68.9% as fetal disease, and 7.9% as both. In contrast, among 12,906 preterm births with IPD, the proportions were roughly equal (maternal 32.9%, fetal 36.5%, and both 30.6%). Among spontaneous preterm births with IPD, a greater proportion had a fetal presentation (43.0%), whereas among indicated preterm births with IPD, a greater proportion (43.4%) had both maternal and fetal presentations. Conclusions.u2003IPD at preterm gestations is more likely to involve both the mother and fetus than at term. The differing clinical presentations by gestational age suggest different pathways between term and preterm births. This may reflect heterogeneous processes for IPD at early vs. late gestations, regardless of the effects of differing gestational age thresholds for interventions.

Neonatal hypoglycemia in term, nondiabetic pregnancies

OBJECTIVEnTo define the incidence of hypoglycemia and identify risk factors in neonates from term, singleton, nondiabetic pregnancies.nnnSTUDY DESIGNnWe conducted a matched case-control study of term, singleton infants weighing more than 2500 g in nondiabetic pregnancies. Cases with hypoglycemia (glucose < 50 mg/dL) were identified by International Classification of Diseases, ninth revision, codes. Two controls per case were matched on race, maternal age, and birthweight. Conditional logistic regression analyses were performed.nnnRESULTSnThere were 116 cases and 232 controls studied. The incidence density of neonatal hypoglycemia was 24.7 per 1000 infant-days at risk. Hypoglycemia was less commonly associated with later gestational age (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.53-0.85 per week of gestation). Maternal fever during labor was more common with hypoglycemia (OR, 4.08; 95% CI, 1.39-11.79). Public insurance was more than twice as common with hypoglycemia compared with those privately insured (OR, 2.31; 95% CI, 1.17-4.58).nnnCONCLUSIONnNeonatal hypoglycemia was associated with earlier gestational age, intrapartum fever, and public insurance.

Pesticide Concentrations in Matrices Collected in the Perinatal Period in a Population of Pregnant Women and Newborns in New Jersey, USA

ABSTRACT Gestational exposure to pesticides may adversely affect fetal development and birth outcomes. However, data on fetal exposure and associated health effects in newborns remain sparse. We measured a variety of pesticides and metabolites in maternal urine, maternal serum, cord serum, amniotic fluid, and meconium samples collected at the time of cesarean delivery from 150 women in central New Jersey, USA. Women who used pesticides at home had higher concentrations of pesticides or metabolites in cord serum [e.g., dacthal (p = .007), diethyltoluamide (p = .043), and phthalimide (p = .030)] than those who did not use pesticides, suggesting that residential use of pesticides may contribute to overall exposure as assessed by biomonitoring. Except for orthophenylphenol, the concentrations of most pesticides in biological matrices of this study population were either comparable to or lower than the levels reported in previous studies and in the U.S. general population. The daily exposure estimates of two representative organophosphorus insecticides (chlorpyrifos and diazinon) were lower than most regulatory protection limits (USEPA oral benchmark dose10/100, USEPA reference oral dose, or ATSDR minimal risk levels); however, they were near or at the USEPAs population-adjusted doses for children and women. No abnormal birth outcomes or other clinical endpoints were noted in those newborns who had higher concentrations of orthophenylphenol during the perinatal period.

Oxytocin Discontinuation During Active Labor in Women Who Undergo Labor Induction

OBJECTIVEnThe purpose of this study was to determine whether there is an increase in the cesarean delivery rate in women who undergo induction when oxytocin is discontinued in the active phase of labor.nnnSTUDY DESIGNnWe conducted a prospective randomized controlled trial of women who underwent induction of labor at term; they were assigned randomly to either routine oxytocin use (routine) or oxytocin discontinuation (DC) once in active labor. Analysis was by intention to treat.nnnRESULTSnTwo hundred fifty-two patients were eligible for study analysis: 127 patients were assigned randomly to the routine group and 125 patients were assigned randomly to the DC group. Cesarean delivery rate was similar between the groups (routine, 25.2% [n = 32] vs the DC group, 19.2% [n = 24]; P = .25). There was a higher chorioamnionitis rate and slightly longer active phase in those women who were assigned to the DC group. In adjusted analysis, the rate of chorioamnionitis was not different by randomization group but was explained by the duration of membrane rupture and intrauterine pressure catheter placement.nnnCONCLUSIONnDiscontinuation of oxytocin in active labor after labor induction does not increase the cesarean delivery rate significantly.

Changes in Sweet Taste Across Pregnancy in Mild Gestational Diabetes Mellitus: Relationship to Endocrine Factors

Gestational diabetes mellitus (GDM) is glucose intolerance diagnosed during pregnancy. Previous work suggested that women with GDM showed exaggerated preferences for sweet taste, but data were limited to a single time point during pregnancy. This study longitudinally assessed sweet taste changes across pregnancy in women who developed GDM (n = 15) as compared with women with normal glucose tolerance (NGT; n = 93) and nonpregnant controls (n = 19). A second objective was to relate sweet taste changes in GDM to fasting leptin and insulin profiles. Following an overnight fast, subjects evaluated strawberry-flavored milks varying in sucrose and fat content, as well as glucose solutions. Evaluations were made at 3 time points during pregnancy and during early postpartum. At 34-38 weeks gestation, women with GDM gave higher liking ratings to moderately sweetened (5% and 10% sucrose) strawberry milks than women with NGT. These differences were not related to alterations in the perception of the samples. At 24-28 weeks gestation, and in women with GDM only, fasting insulin was correlated with liking of the glucose solutions (R(2) = 0.63, P = 0.004) and fasting leptin was correlated with sweetness liking of the 10% sucrose milk (R(2) = 0.42, P = 0.017). These data suggest that women with GDM exhibit higher liking ratings for a sweet fat milk drink late in pregnancy. Also, higher hedonic ratings for sweet taste in GDM may be related to elevated leptin and insulin concentrations at midpregnancy. GDM may increase the desire for sweet taste that could influence dietary management of this disease.