Shilpa Babbar

The oral microbiome and adverse pregnancy outcomes

Significant evidence supports an association between periodontal pathogenic bacteria and preterm birth and preeclampsia. The virulence properties assigned to specific oral pathogenic bacteria, for example, Fusobacterium nucleatum, Porphyromonas gingivalis, Filifactor alocis, Campylobacter rectus, and others, render them as potential collaborators in adverse outcomes of pregnancy. Several pathways have been suggested for this association: 1) hematogenous spread (bacteremia) of periodontal pathogens; 2) hematogenous spread of multiple mediators of inflammation that are generated by the host and/or fetal immune response to pathogenic bacteria; and 3) the possibility of oral microbial pathogen transmission, with subsequent colonization, in the vaginal microbiome resulting from sexual practices. As periodontal disease is, for the most part, preventable, the medical and dental public health communities can address intervention strategies to control oral inflammatory disease, lessen the systemic inflammatory burden, and ultimately reduce the potential for adverse pregnancy outcomes. This article reviews the oral, vaginal, and placental microbiomes, considers their potential impact on preterm labor, and the future research needed to confirm or refute this relationship.

The clinical significance of an estimated fetal weight below the 10th percentile: a comparison of outcomes of <5th vs 5th–9th percentile

BACKGROUND: The association between small‐for‐gestational‐age (birthweight <10th percentile for gestational age) and neonatal morbidity is well established. Yet, there is a paucity of data on the relationship between suspected small for gestational age (sonographic‐estimated fetal weight <10th percentile) at 2 thresholds and subsequent neonatal morbidity. OBJECTIVE: The objective of this study was to determine the relationship between sonographic‐estimated fetal weight <5th percentile vs 5–9th percentile and neonatal morbidity. STUDY DESIGN: This retrospective study involved 5 centers and included nonanomalous, singletons with sonographic‐estimated fetal weight <10th percentile for gestational age who delivered from 2009–2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis, thrombocytopenia, seizures, or death. Odd ratios were adjusted for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs, and neonatal gender. RESULTS: Of 834 women with suspected small‐for‐gestational‐age fetuses, 513 (62%) had sonographic‐estimated fetal weight <5th percentile, and 321 (38%) had sonographic‐estimated fetal weight of 5–9th percentile for gestational age. At delivery, 81% of women with a suspected small‐for‐gestational‐age fetus had a confirmed small‐for‐gestational‐age fetus. In the group with a sonographic‐estimated fetal weight <5th percentile, 59% of neonates had birthweight <5th percentile; in the group with a sonographic‐estimated fetal weight 5–9th percentile, 41% had birthweight <5th percentile, and 36% had birthweight at 5–9th percentile. Neonatal intensive care unit admission differed significantly for those fetuses at <5th percentile (29%) compared with those fetuses at 5–9th percentile (15%; P<.001). The composite neonatal morbidity among the sonographic‐estimated fetal weight <5th percentile group was higher than the sonographic‐estimated fetal weight of 5–9th percentile group (31% vs 13%; adjusted odds ratio, 2.41; 95% confidence interval, 1.53–3.80). Similar findings were noted when the analysis was limited to sonographic‐estimated fetal weight within 28 days of delivery (adjusted odds ratio, 2.22; 95% confidence interval, 1.34–3.67). CONCLUSION: Eight of 10 suspected small‐for‐gestational‐age fetuses had birthweight <10th percentile for gestational age; the prediction of actual birthweight was more accurate in the <5th percentile group. Neonates with sonographic‐estimated fetal weight of <5th percentile were more likely to be admitted to the neonatal intensive care unit and have complications than were those neonates with sonographic‐estimated fetal weight of 5–9th percentile.

Exercise and yoga during pregnancy: a survey

Abstract The primary objective of this survey was to ascertain the opinions, practices and knowledge about exercise, including yoga, during pregnancy; the secondary objective to compare the responses among women with body mass index (BMI) <30 kg/m2 versus ≥30 kg/m2. Survey consisted of 20 multiple choice questions assessing demographics and exercise practices, and five questions testing their knowledge about it during pregnancy (ACOG Committee Opinion # 267). Of the 500 surveys distributed, 84% (422) responses were analyzed. While 86% of women responded that exercise during pregnancy is beneficial, 83% felt it was beneficial to start prior to pregnancy, and walking was considered the most beneficial (62%). The majority (64%) of respondents were currently exercising during pregnancy and 51% exercised 2–3 times/week. Among the five questions testing knowledge about prenatal exercise, majority (range 60 to 92%) were aware of ACOG recommendations. About half had a BMI ≥30. Knowledge about benefits of exercise during pregnancy did not differ significantly between obese and non-obese. Yoga was tried significantly more among non-obese, 65% believed it is beneficial, and 40% had attempted yoga before pregnancy. In our population, the majority believes that exercise, including yoga, is beneficial and they are active.

Acute feTal behavioral Response to prenatal Yoga: a single, blinded, randomized controlled trial (TRY yoga)

BACKGROUND In 2012, yoga was practiced by 20 million Americans, of whom 82% were women. A recent literature review on prenatal yoga noted a reduction in some pregnancy complications (ie, preterm birth, lumbar pain, and growth restriction) in those who practiced yoga; to date, there is no evidence on fetal response after yoga. OBJECTIVES We aimed to characterize the acute changes in maternal and fetal response to prenatal yoga exercises using common standardized tests to assess the well-being of the maternal-fetal unit. STUDY DESIGN We conducted a single, blinded, randomized controlled trial. Uncomplicated pregnancies between 28 0/7 and 36 6/7 weeks with a nonanomalous singleton fetus of women who did not smoke, use narcotics, or have prior experience with yoga were included. A computer-generated simple randomization sequence with a 1:1 allocation ratio was used to randomize participants into the yoga or control group. Women in the yoga group participated in a 1-time, 1 hour yoga class with a certified instructor who taught a predetermined yoga sequence. In the control group, each participant attended a 1-time, 1 hour PowerPoint presentation by an obstetrician on American Congress of Obstetricians and Gynecologists recommendations for exercise, nutrition, and obesity in pregnancy. All participants underwent pre- and postintervention testing, which consisted of umbilical and uterine artery Doppler ultrasound, nonstress testing, a biophysical profile, maternal blood pressure, and maternal heart rate. A board-certified maternal-fetal medicine specialist, at a different tertiary center, interpreted all nonstress tests and biophysical profile data and was blinded to group assignment and pre- or postintervention testing. The primary outcome was a change in umbilical artery Doppler systolic to diastolic ratio. Sample size calculations indicated 19 women per group would be sufficient to detect this difference in Doppler indices (alpha, 0.05; power, 80%). Data were analyzed using a repeated-measures analysis of variance, a χ(2), and a Fisher exact test. A value of P < .05 was considered significant. RESULTS Of the 52 women randomized, 46 (88%) completed the study. There was no clinically significant change in umbilical artery systolic to diastolic ratio (P = .34), pulsatility index (P = .53), or resistance index (P = .66) between the 2 groups before and after the intervention. Fetal and maternal heart rate, maternal blood pressure, and uterine artery Dopplers remained unchanged over time. When umbilical artery indices were individually compared with gestational age references, there was no difference between those who improved or worsened between the groups. CONCLUSION There was no significant change in fetal blood flow acutely after performing yoga for the first time in pregnancy. Yoga can be recommended for low-risk women to begin during pregnancy.

Effect of Obesity on Breastfeeding

INTRODUCTION: Obesity presents mechanical challenges and may reduce breastfeeding rates. We examined the relationship of obesity and breastfeeding, adjusting for factors that are known to affect breastfeeding. METHODS: This is a retrospective cohort study using survey data (2009–2010) from the Pregnancy Risk Assessment Monitoring System. The outcome was breastfeeding at any time (breastfeeding ever). Independent variables included maternal smoking, age, race, education, depressed mood, gestational age (preterm or term), and stressful life events. RESULTS: Of 66,508 women, 79% had ever breastfed. Fewer women in the underweight, overweight, and obese body mass index (BMI) groups ever breastfed compared with normal BMI groups (77% compared with 79% compared with 75% compared with 81%, respectively, P<.001). On multivariable logistic regression, the odds (odds ratio, 95% confidence interval) of ever breastfeeding were significantly lower for the obese compared with normal BMI, 0.84 (0.76–0.92). Smoking, African American race, preterm delivery, depressed mood, and public insurance were associated with lower odds of ever breastfeeding. CONCLUSIONS: Obesity significantly reduces a womans chances of ever breastfeeding. Therefore, identification of obesity as a high-risk groups for not breastfeeding may assist clinicians in designing future interventions.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: A Comparison

OBJECTIVE To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). STUDY DESIGN We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. RESULTS We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). CONCLUSION Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Doppler Sonography in Early Pregnancy

This chapter provides a review of the three major areas of the use of Doppler ultrasound imaging for fetal and maternal risk assessment in early pregnancy. Ductus venosus and tricuspid flow assessments have now become an essential part of prenatal diagnostic workup in the first trimester. Uterine artery Doppler offers early prediction of preeclampsia and other pregnancy complications that can lead to prevention of some of these disorders through prophylactic therapeutics such as low-dose aspirin. Further research in this field holds exciting opportunities for improving perinatal care and outcome.