Victoria Belogolovkin

Super-obesity and risk for early and late pre-eclampsia

Please cite this paper as: Mbah A, Kornosky J, Kristensen S, August E, Alio A, Marty P, Belogolovkin V, Bruder K, Salihu H. Super‐obesity and risk for early and late pre‐eclampsia. BJOG 2010;117:997–1004.

Maternal alcohol use and medically indicated vs. spontaneous preterm birth outcomes: a population-based study

BACKGROUND The aetiology of preterm birth remains poorly understood. The purpose of this study is to investigate if an association exists between prenatal alcohol consumption and preterm birth and to determine if such an association differs by subcategories of preterm birth. METHODS We employed vital statistics data from the state of Missouri covering the period 1989-2005 (n = 1 221 677 singleton records). The outcome of interest was preterm birth, subclassified into medically indicated and spontaneous phenotypes. Multivariate logistic regression was used to generate adjusted odds ratios, with non-drinking mothers as the referent category. RESULTS Prenatal alcohol use was associated with elevated risk for preterm birth. The strength of association was more prominent for spontaneous preterm delivery {adjusted odds ratio (AOR) [95% confidence interval (CI)] = 1.34 (1.28-1.41)} than for medically indicated preterm birth [AOR (95% CI) = 1.16 (1.05-1.28)]. The overall risk for drinking-related spontaneous preterm birth increased with incremental rise in the number of drinks consumed per week (P for trend < 0.01). CONCLUSIONS Prenatal alcohol use is a risk factor for preterm delivery, and especially for spontaneous preterm birth. These findings enhance our understanding of the aetiology of preterm birth and could be utilized in the development of appropriate prevention strategies that will assist in decreasing perinatal mortality and morbidity associated with preterm delivery.

The effect of low body mass index on the development of gestational hypertension and preeclampsia

Objectives. To evaluate the relationship between low maternal body mass index (BMI) as calculated in the first trimester and the risk of preeclampsia and gestational hypertension. Methods. Patients enrolled in the First And Second Trimester Evaluation of Risk for aneuploidy (FASTER) trial were grouped into three weight categories: low BMI (BMI <19.8 kg/m2), normal BMI (BMI 19.8 – 26 kg/m2), and overweight BMI (26.1 – 29 kg/m2). The incidences of gestational hypertension and preeclampsia were ascertained for each group. Tests for differences in crude incidence proportions were performed using Chi-square tests. Multiple logistic regression was used to adjust for maternal age, race, parity, obesity, use of assisted reproductive technology (ART), in vitro fertilization (IVF), gestational diabetes, pre-gestational diabetes, cocaine use, and smoking. Results. The proportion of patients having gestational hypertension in the low BMI group was 2.0% compared to 3.2% for normal BMI and 6.0% for overweight BMI (p < 0.0001). Women with low BMI were also less likely to develop preeclampsia, 1.1% vs. 1.9% for normal BMI and 2.8% for overweight BMI (p < 0.0001). Conclusions. We found that women with low BMI in the first trimester were significantly less likely to develop gestational hypertension or preeclampsia than women with a normal BMI.

Postpartum eclampsia complicated by reversible cerebral herniation

BACKGROUND: Preeclampsia and eclampsia have been associated with significant morbidity and mortality. Posterior reversible encephalopathy syndrome is a neuroradiologic entity that has been previously reported to occur in patients with preeclampsia and eclampsia. We present, to our knowledge, the first reported case of late postpartum eclampsia complicated by posterior reversible encephalopathy syndrome and reversible cerebral herniation. CASE: A 39-year-old woman (para 1) presented with late postpartum preeclampsia on postpartum day 4. She developed eclampsia and posterior reversible encephalopathy syndrome, which was diagnosed by magnetic resonance imaging. She subsequently developed clinical and radiologic evidence of reversible cerebral herniation. CONCLUSION: Postpartum preeclampsia and eclampsia that is complicated by posterior reversible encephalopathy syndrome can result in cerebral herniation. Neuroradiologic imaging may be a useful adjunctive diagnostic tool in the setting of preeclampsia and eclampsia to predict disease severity.

Maternal and neonatal outcomes based on the gestational age of midtrimester preterm premature rupture of membranes

Objectives. Determine neonatal and maternal outcomes based on the gestational age (GA) that midtrimester preterm premature rupture of membranes (mtPPROM) occurs. Study design. A retrospective chart review was conducted on pregnancies with mtPPROM between 180/7 and 236/7 weeks gestation from January 2000 to December 2007. Antenatal complications, maternal morbidity, and neonatal survival and morbidity were analysed by the specific GA of mtPPROM. Statistical analysis was performed using Chi-square, Fishers Exact, and Kruskal–Wallis tests. Results. A total of 105 patients met inclusion criteria. There was a trend for longer latency with earlier GA of mtPPROM (p = 0.05). Neonatal survival to discharge was 26.6%, with an overall morbidity of 86%. Survival was significantly higher with mtPPROM at 22 0/7–23 6/7 weeks compared to 18 0/7–19 6/7 (p = 0.01) and 20 0/7–21 6/7 weeks (p = 0.01). There was no difference in neonatal morbidity based on the GA of mtPPROM. Conclusions. While neonatal survival improves at later GAs of mtPPROM, morbidity continues to be high.

Obesity in older mothers, gestational weight gain, and risk estimates for preterm phenotypes

OBJECTIVE To assess whether advanced maternal age modifies the relationship between maternal pregravid weight status, gestational weight gain patterns, and the occurrence of spontaneous preterm birth (SPB) and medically indicated preterm birth (MIPB). METHODS Retrospective cohort analysis of vital statistics data from the state of Florida for the period 2004 through 2007 comprising 311,422 singleton pregnancies (two age groups: 20-24 years old or younger women and >or=35 years or older women). Mothers were classified into five clusters based on their pre-pregnancy body mass index (BMI) values: non-obese (less than 30), class I obese (30.0<or=BMI<or=34.9), class II obese (35.0<or=BMI<or=39.9), class III obese (40<or=BMI<or=49.9), and super-obese (BMI>or=50.0). RESULTS MIPB occurred more frequently among older than younger women [11.8% vs. 6.4%, respectively (p<0.0001)) whereas SPB occurred more frequently among younger women [11.3% vs. 10.5%, respectively (p<0.0001)). Maternal obesity increased the risk for MIPB but not for SPB. Regardless of BMI status, the risk of MIPB was elevated among older mothers, particularly among those with suboptimal (<0.23 kg/week) and supraoptimal (>0.68 kg/week) gestational weight gain. A dose-response relationship with increasing gestational weight gain was evident (p<0.01); the greatest risk for MIPB occurred among older mothers with weekly gestational weight gain in excess of 0.79 kg (OR=7.76, 95% CI=5.73-10.5). CONCLUSION The occurrence of medically indicated preterm birth is positively associated with increased maternal pregravid body weight, older maternal age and extremes of gestational weight gain. Targeted pre- and inter-conception weight management efforts should be particularly encouraged in older mothers.

Success of programming fetal growth phenotypes among obese women.

OBJECTIVE: To estimate the distribution and success of programmed fetal growth phenotypes among obese women. METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978–1997). Maternal body mass index was classified as Normal (18.5–24.9) (referent group), Obese (class 1, 30.0–34.9; class 2, 35.0–39.9; and extreme or class 3, 40 or more). Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA). We used adjusted odds ratio with correction for intracluster correlation to estimate the risk of neonatal mortality for each fetal growth phenotype. RESULTS: As compared with normal weight mothers, obese gravidas tended to program LGA infants at a higher and increasing rate with ascending obesity severity. The opposite effect was observed with respect to AGA and SGA programming patterns. Neonatal mortality among LGA infants was similar for obese (6.2 in 1,000) and normal (4.9 in 1,000) weight mothers (OR 1.05, 95% confidence interval [CI] 0.75–1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32–1.59; SGA OR 1.72, 95% CI 1.49–1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants. LEVEL OF EVIDENCE: II

Successful Management of a Consecutive Cervical Pregnancy by Sonographically Guided Transvaginal Local Injection Case Report and Review of the Literature

The purpose of this study was to describe the successful management of a recurrent cervical pregnancy with local injection and to review similarly treated cases to determine adverse outcomes.

Nulliparity and preterm birth in the era of obesity epidemic

Objective. To assess the impact of obesity on preterm birth among nulliparous women. Methods. Retrospective cohort study of nulliparous mothers delivering infants in Florida between 2004 and 2007. Women were classified as non-obese (pre-pregnancy body mass index (BMI) <30) or obese (BMI ≥ 30). The main outcomes assessed were preterm birth, very preterm birth and extremely preterm birth. Risk estimates were obtained using logistic regression. Multiparous non-obese mothers were the referent group for all analyses. Results. As compared to multiparous women, nulliparous mothers had an increased risk of very preterm and extremely preterm birth with the highest risk observed for extremely preterm birth (odds ratios (OR) = 1.37, 95% CI = 1.28, 1.47) (p for trend <0.01). Obese nulliparous mothers had an elevated risk of preterm, very preterm and extremely preterm birth, with the risk of extremely preterm birth being the most pronounced (OR = 1.97, 95% CI = 1.75–2.22) [p for trend <0.05]. The heightened risk associated with obesity among nulliparous women was observed across all racial/ethnic sub-populations, with black nulliparous obese mothers being at greatest risk of all preterm birth-subtypes. Conclusions. Obesity is a risk marker for preterm, very preterm and extremely preterm birth among first-time mothers and particularly among blacks and Hispanics.

The association of prepregnancy body mass index with pregnancy outcomes in triplet gestations.

The impact of obesity on triplet gestations is poorly understood. In this study, we investigate the association of obesity with birth outcomes in triplets. Triplet births in the state of Missouri from 1989 through 1997 were analyzed. Obesity was defined as maternal prepregnancy body mass index (BMI) >or=30 kg/m(2). We assessed the association between obesity and the following outcomes: stillbirth, preeclampsia, very preterm, small for gestational age (SGA), and a composite adverse birth outcome. We employed logistic regression with further correction for intracluster correlation to obtain adjusted estimates. A total of 667 triplet gestations were analyzed. As compared with normal-weight mothers, the likelihood of stillbirth and preeclampsia was higher among obese mothers (odds ratio[OR] = 3.70; 95% confidence interval [CI] = 1.37 to 9.97 and OR = 3.02; 95% CI = 1.69 to 5.40 respectively). Obese mothers were also about twice as likely to experience at least one of the adverse birth outcomes considered. Obese women with triplet gestations have about four- and threefold elevated risks for stillbirth and preeclampsia as compared with their counterparts with normal weight. This observation may be of utility in the preconceptional counseling of women considering the use of assisted reproductive technology.