Kim Boggess

Progressive Periodontal Disease and Risk of Very Preterm Delivery

OBJECTIVE: The goal was to estimate whether maternal periodontal disease was predictive of preterm (less than 37 weeks) or very preterm (less than 32 weeks) births. METHODS: A prospective study of obstetric outcomes, entitled Oral Conditions and Pregnancy (OCAP), was conducted with 1,020 pregnant women who received both an antepartum and postpartum periodontal examination. Predictive models were developed to estimate whether maternal exposure to either periodontal disease at enrollment (less than 26 weeks) and/or periodontal disease progression during pregnancy, as determined by comparing postpartum with antepartum status, were predictive of preterm or very preterm births, adjusting for risk factors including previous preterm delivery, race, smoking, social domain variables, and other infections. RESULTS: Incidence of preterm birth was 11.2% among periodontally healthy women, compared with 28.6% in women with moderate-severe periodontal disease (adjusted risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1–2.3). Antepartum moderate-severe periodontal disease was associated with an increased incidence of spontaneous preterm births (15.2% versus 24.9%, adjusted RR 2.0, 95% CI 1.2–3.2). Similarly, the unadjusted rate of very preterm delivery was 6.4% among women with periodontal disease progression, significantly higher than the 1.8% rate among women without disease progression (adjusted RR 2.4, 95% CI 1.1–5.2). CONCLUSION: The OCAP study demonstrates that maternal periodontal disease increases relative risk for preterm or spontaneous preterm births. Furthermore, periodontal disease progression during pregnancy was a predictor of the more severe adverse pregnancy outcome of very preterm birth, independently of traditional obstetric, periodontal, and social domain risk factors. LEVEL OF EVIDENCE: II-2

Fetal Growth Restriction and Chronic Lung Disease Among Infants Born Before the 28th Week of Gestation

OBJECTIVE: Improvement in survival of extremely premature infants over the past several decades has resulted in an increase in the number of infants with chronic lung disease (CLD). Historical neonatal exposures associated with CLD now less frequently precede the disease. There is now increasing interest in exposures and events before delivery that predict CLD. The objective of this study was to identify current prenatal predictors of CLD. METHODS: We collected data about prenatal, placental, and neonatal characteristics of 1241 newborns who were delivered before completion of the 28th week of gestation. Associations between prenatal factors, microbiologic and histologic characteristics of the placenta, and selected neonatal characteristics and CLD risk were first evaluated in univariate analyses. Subsequent multivariate analyses investigated the contribution of prenatal factors, particularly fetal growth restriction (FGR), to CLD risk. RESULTS: Among the prenatal factors, birth weight z scores, used as a marker of FGR, provided the most information about CLD risk. Indicators of placental inflammation and infection were not associated with increased risk of CLD. Within nearly all strata of prenatal, placental, and neonatal variables, growth-restricted infants were at increased CLD risk, compared with infants who were not growth-restricted. FGR was the only maternal or prenatal characteristic that was highly predictive of CLD after adjustment for other risk factors. CONCLUSIONS: FGR is independently associated with the risk of CLD. Thus, factors that control fetal somatic growth may have a significant impact on vulnerability to lung injury and in this way increase CLD risk.

Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age

By addressing the reproductive intentions and contraceptive practices and needs of every patient, providers may be able to decrease womens chances of experiencing unintended pregnancies and support women in achieving planned and well-timed pregnancies. By addressing the health promotion needs of every patient and examining and addressing her health profile for reproductive risks, irrespective of her desires for pregnancy, it is likely that more women will enter pregnancy with high levels of preconception wellness and that healthier women and healthier pregnancies and infants will result. The importance of the integration of reproductive planning and health promotion into womens routine healthcare is further emphasized when the potentially far-reaching effects of reproductive outcomes (such as unintended pregnancies, adverse pregnancy outcomes, pregnancy complications, and sexually transmitted infections) on womens health, well-being, and life circumstances are considered.

Oral Health in Women During Preconception and Pregnancy: Implications for Birth Outcomes and Infant Oral Health

The mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontal disease, that is, a chronic infection of the gingiva and supporting tooth structures, has been associated with preterm birth, development of preeclampsia, and delivery of a small-for-gestational age infant. Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in the mother predisposes the infant to the development of caries. It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve womens oral and general health, pregnancy outcomes, and their childrens dental health. However, given the relationship between oral health and general health, oral health care should be a goal in its own right for all individuals. Regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded so that their own oral and general health is safeguarded and their childrens risk of caries is reduced. Oral health promotion should include education of women and their health care providers ways to prevent oral disease from occurring, and referral for dental services when disease is present.

Maternal periodontal disease, systemic inflammation, and risk for preeclampsia

OBJECTIVE Maternal periodontal disease, a chronic oral infectious and inflammatory disorder, is associated with an increased risk for preeclampsia. Our objective was to determine the relationship between maternal periodontal disease, maternal systemic inflammation, and the development of preeclampsia. STUDY DESIGN A secondary analysis of data from the Oral Conditions and Pregnancy Study was performed. A cohort of healthy pregnant women enrolled at less than 26 weeks underwent an oral health examination, serum sampling, and delivery follow-up. Periodontal disease was categorized clinically as present or absent. Maternal serum was assayed for C-reactive protein by high-sensitivity enzyme-linked immunosorbent assay and stratified as elevated (> or = 75th percentile) or not elevated (< 75th percentile). Preeclampsia was defined as blood pressure > 140/90 mmHg and at least 1+ proteinuria on a catheterized urine specimen. Risk ratios (RR) for preeclampsia were calculated, stratified by periodontal disease and C-reactive protein level. RESULTS Thirty-one (4%) of 775 women with complete data developed preeclampsia. Women with CRP > or = 75th percentile were more likely than those with CRP < 75th percentile to develop preeclampsia (7% vs 3%, P < .03; RR, 95% CI 2.2, 1.1-4.4). Women with periodontal disease and CRP > or = 75th percentile were at increased risk for preeclampsia (adjusted RR 5.8, 1.2-26.9), compared to women without periodontal disease and either CRP < 75th or > or = 75th percentile. CONCLUSION Maternal periodontal disease with systemic inflammation as measured by C-reactive protein is associated with an increased risk for preeclampsia.

First‐trimester maternal vitamin D status and risk for gestational diabetes (GDM) a nested case‐control study

Vitamin D deficiency may contribute to impaired glucose metabolism. There are sparse data regarding vitamin D and the development of gestational diabetes (GDM). The objective of this study was to assess if first‐trimester vitamin D deficiency is more prevalent in women later diagnosed with GDM compared with women with uncomplicated pregnancies.

Maternal oral health in pregnancy

Oral diseases are prevalent conditions; dental caries is the most common chronic childhood disease, and adult periodontal infection affects up to 40% of reproductive-aged women. Childhood caries is a preventable infectious disease, and maternal oral flora is one of the greatest predictors of the oral flora of her offspring. Periodontal infection is also preventable and has received recent attention as a risk factor for cardiovascular disease, diabetes, and respiratory infection. Periodontal infection has also been associated with adverse pregnancy outcome. Effective preventive and treatment measures to reduce the morbidity of oral diseases exist, yet both caries and periodontal infection remain prevalent, particularly among racial and ethnic minorities and disadvantaged individuals. Given the evident relationships between oral and general health and between maternal and infant oral health, oral health care should be a goal for all individuals. Pregnancy offers an opportunity to educate women regarding oral health and treat them where appropriate. Research is ongoing to delineate the role of maternal oral health care in pregnancy outcomes and opportunities for positive intervention.

Vitamin D Status and Periodontal Disease Among Pregnant Women

BACKGROUND Maternal periodontal disease is found in < or = 40% of pregnant women and is associated with adverse pregnancy outcomes. Vitamin D deficiency may play a role in periodontal disease and tooth loss, and insufficient vitamin D status is common among pregnant women. The objective of this study is to examine the relationship between maternal vitamin D status and periodontal disease. METHODS A case-control study was conducted. Cases were defined as pregnant women with clinical moderate to severe periodontal disease; controls were pregnant women who were periodontally healthy. Maternal data were chart abstracted and serum was collected between 14 and 26 weeks of gestation. Serum 25-hydroxyvitamin D (25[OH]D) levels were measured using liquid chromatography-tandem mass spectrometry. Median serum 25(OH)D levels and prevalence of vitamin D insufficiency (defined as <75 nmol/l) were compared between cases and controls. The odds ratio and 95% confidence interval for moderate to severe periodontal disease among women with vitamin D insufficiency was calculated using multivariable logistic regression, adjusting for maternal race, season of blood draw, and other potential confounders. RESULTS A total of 117 cases were compared to 118 controls. Cases had lower median 25(OH)D levels than controls (59 versus 100 nmol/l; P <0.001) and were more likely to have vitamin D insufficiency (65% versus 29%; P <0.001). The adjusted odds ratio (95% confidence interval) for moderate to severe periodontal disease among women with vitamin D insufficiency was 2.1 (0.99 to 4.5). CONCLUSIONS Vitamin D insufficiency (serum 25[OH]D <75 nmol/l) is associated with maternal periodontal disease during pregnancy. Vitamin D supplementation represents a potential therapeutic strategy to improve maternal oral health.

A nested case-control study of first-trimester maternal vitamin D status and risk for spontaneous preterm birth

We assessed if first-trimester vitamin D deficiency is more prevalent in women who experienced a spontaneous preterm birth compared with women who delivered at term. We conducted a nested case-control study of pregnant women who had previously given blood for first-trimester combined screening for trisomy 21 and subsequently delivered at a tertiary hospital between November 2004 and July 2009. From an overall cohort of 4225 women, 40 cases of spontaneous preterm birth (≥ 23 (0/7) and ≤ 34 (6/7) weeks) were matched by race/ethnicity with 120 women delivering at term (≥ 37 (0/7) weeks) with uncomplicated pregnancies. Banked maternal serum was used to measure maternal 25-hydroxyvitamin D [25(OH)D]. The prevalence of first-trimester maternal vitamin D deficiency [25(OH)D < 50 nmol/L] was comparable among women who subsequently delivered preterm compared with controls (7.5% versus 6.7%, P  = 0.90). The median 25(OH)D level for all subjects was 89 nmol/L (interquartile range, 73 to 106 nmol/L). Seventy-three percent (117/160) of the cohort had sufficient vitamin D levels [25(OH)D ≥ 75 nmol/L]. In a cohort of pregnant women with mostly sufficient levels of first-trimester serum 25(OH)D, vitamin D deficiency was not associated with spontaneous preterm birth.

Bacteremia shortly after placental separation during cesarean delivery.

Objective To assess frequency, risk factors, and microbiology of bacteremia within 15 minutes of placental separation during cesarean delivery. Methods Ninety-three women undergoing cesarean delivery afte a minimum of 4 hours of labor or ruptured membranes were compared with 26 women not in labor undergoing cesarean. Blood cultures for aerobic and anaerobic bacteria were obtained within 15 minutes of delivery of the placenta and before prophylactic antibiotic administration. Chorioamnionic membranes were also cultured. Demographic, labor, delivery, and postpartum characteristics were abstracted from the medical record. Results Bacteremia was detected in 13 (11%) of 119 women. Bacteremia occurred in 13 (14%) of 93 women after labor or rupture of membranes compared with zero of 26 women not in labor (P = .02). Isolates included group B streptococcus (n = 5), Gardnerella vaginalis (n = 5), Streptococcus pneumoniae (n = 1), Peptostreptococcus sp (n = 1), and mixed flora of Prevotella bivia, G vaginalis, and viridans streptococci (n = 1). Bacteremia was associated with earlier median gestational age, lower median birth weight, and a positive chorioamnionic membrane culture. After adjustment for gestational age, intrauterine monitoring was also significantly associated with bacteremia. Conclusion Bacteremia was common after labor in this population, especially in preterm deliveries and those with positive chorioamnionic-placental culture. Many of the isolates are capable of cuasing endocarditis. Appraisal of the risk of bacteremia and the risk of bacterial endocarditis should be made in individual patients to assess the need for antibiotic prophylaxis.