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Mappa I, Marra MC, Pietrolucci ME, Angela Lu JL, D'Antonio F, Rizzo G. Effects of umbilical vein flow on midbrain growth and cortical development in late onset fetal growth restricted fetuses: a prospective cross-sectional study. J Perinat Med 2024; 52:423-428. [PMID: 38296222 DOI: 10.1515/jpm-2023-0487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/23/2023] [Indexed: 05/04/2024]
Abstract
OBJECTIVES To investigate midbrain growth, including corpus callusum (CC) and cerebellar vermis (CV) and cortical development in late fetal growth restricted (FGR) subclassified according to the umbilical vein blood flow (UVBF) values. METHODS This was a prospective study on singleton fetuses late FGR with abnormal placental cerebral ratio (PCR). FGR fetuses were further subdivided into normal (≥fifth centile) and abnormal ( RESULTS The study cohort included 60 late FGR, 31 with normal UVBF/AC and 29 with abnormal UVBF/AC values. The latter group showed significant differences in CC (median (interquartile range (IQR) normal 0.96 (0.73-1.16) vs. abnormal UVBF/AC 0.60 (0.47-0.87); p<0.0001)), CV (normal 1.04 (0.75-1.26) vs. abnormal UVBF (AC 0.76 (0.62-1.18)); p=0.0319), SF (normal 0.83 (0.74-0.93) vs. abnormal UVBF/AC 0.56 (0.46-0.68); p<0.0001), POF (normal 0.80 (0.71-0.90) vs. abnormal UVBF/AC l 0.49 (0.39-0.90); p≤0.0072) and CF (normal 0.83 (0.56-1.01) vs. abnormal UVBF/AC 0.72 (0.53-0.80); p<0.029). CONCLUSIONS Late onset FGR fetuses with of reduced umbilical vein flow showed shorter CC and CV length and a delayed cortical development when compared to those with normal umbilical vein hemodynamics. These findings support the existence of a link between abnormal brain development and changes in umbilical vein circulation.
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Affiliation(s)
- Ilenia Mappa
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Maria Chiara Marra
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Maria Elena Pietrolucci
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Jia Li Angela Lu
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
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Marra MC, Mappa I, Pietrolucci ME, Lu JLA, D' Antonio F, Rizzo G. Fetal brain development in pregnancies complicated by gestational diabetes mellitus. J Perinat Med 2024; 52:310-316. [PMID: 38231478 DOI: 10.1515/jpm-2023-0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/23/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVES Gestational diabetes mellitus (GDM) carries an increased risk of neurocognitive impairment in offsprings. However, the contribution of maternal hyperglycemia in affecting fetal brain development is not fully elucidated yet. The aim of this study was to evaluate fetal brain and sulci development in pregnancies complicated by GDM. METHODS Prospective observational study including 100 singleton pregnancies complicated by GDM and 100 matched controls. All fetuses underwent neurosonography at 29-34 weeks of gestation, including the assessment of the length of the corpus callosum (CC), cerebellar vermis (CV), Sylvian (SF), parieto-occipital (POF) and calcarine fissures (CF). Sub-group analysis according to the specific treatment regimen adopted (n 67 diet vs. 33 insulin therapy) was also performed. RESULTS Fetuses from mothers with GDM under insulin therapy had a smaller CC (35.54 mm) compared to both controls (40 mm; p<0.001) and women with GDM under diet (39.26 mm; p=0.022) while there was no difference in the HC between the groups. Likewise, when corrected for HC, CV depth was smaller in fetuses with GDM both under insulin therapy (7.03 mm) and diet (7.05 mm,) compared to controls (7.36 mm; p=0.013). Finally, when assessing the sulci development of the brain SF (p≤0.0001), POF (p≤0.0001) and CF (p≤0.0001) were significantly smaller in fetuses with maternal GDM. Post-hoc analysis showed that fetuses of GDM mothers requiring insulin therapy had significantly lower values of SF (p=0.032), POF (p=0.016) and CF (p=0.001). CONCLUSIONS Pregnancies complicated by GDM showed a peculiar pattern of fetal brain growth and cortical development and these changes, which are more evident in those requiring insulin supplementation.
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Affiliation(s)
- Maria Chiara Marra
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Maria Elena Pietrolucci
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Jia Li Angela Lu
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | | | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
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Shah JS, Figueras F, Blàzquez A, Brazal S, Buratini J, Buscà R, Canto MD, Iemmello R, Jacobs CK, Lorenzon AR, Renzini MM, Ripero M, Sakkas D. Perinatal outcomes in 13,626 singleton pregnancies after autologous IVF across three continents over 7 years. J Assist Reprod Genet 2023; 40:2649-2657. [PMID: 37700077 PMCID: PMC10643744 DOI: 10.1007/s10815-023-02931-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023] Open
Abstract
PURPOSE Are trends in singleton autologous IVF perinatal outcomes consistent over time among five international infertility centers? METHODS This was a retrospective cohort study from January 1, 2012, to December 31, 2018. This study was performed through a large infertility network at five international infertility centers in which patients who had a singleton live birth resulting from fresh and frozen autologous IVF cycles were included. The primary outcome was live birth weight (BW) with secondary outcomes of preterm birth (PTB), large for gestational age (LGA), small for gestational age (SGA), and gestational age at delivery. RESULTS The entire cohort (n = 13,626) consisted of 6941 fresh and 6685 frozen autologous IVF cycles leading to singleton deliveries. Maternal age, parity, body mass index, neonatal sex, and GA at delivery were similar for fresh and frozen IVF cycles in the entire cohort and within each infertility center. Four centers had a trend of decreased BW and three centers had decreased rates of PTB before 32 and 28 weeks and LGA newborns annually, although significance was not reached. Three IVF centers had annual increased trends of PTB before 37 weeks and four centers had increased rates of SGA newborns, although significance was not reached. CONCLUSION Similar trends in perinatal outcomes were present across five international infertility centers over 7 years. Additional studies are crucial to further assess and optimize perinatal outcomes at an international level.
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Affiliation(s)
- Jaimin S Shah
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA.
- Boston IVF - Eugin Group, 130 Second Ave, Waltham, MA, 02451, USA.
- Current address: Shady Grove Fertility, 2255 E Mossy Oaks Rd, Suite 620, Spring, Houston, TX, 77389, USA.
| | - Francesc Figueras
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic, Universitat de Barcelona, 08950, Barcelona, Spain
| | | | | | - Jose Buratini
- Biogenesi Reproductive Medicine Centre - Gruppo Eugin, Istituti Clinici Zucchi, Monza, Italy
| | | | - Mariabeatrice Dal Canto
- Biogenesi Reproductive Medicine Centre - Gruppo Eugin, Istituti Clinici Zucchi, Monza, Italy
| | - Roberta Iemmello
- Biogenesi Reproductive Medicine Centre - Gruppo Eugin, Istituti Clinici Zucchi, Monza, Italy
| | | | - Aline R Lorenzon
- Huntington Medicina Reproductiva - Eugin Group, São Paulo, SP, Brazil
| | - Mario Mignini Renzini
- Biogenesi Reproductive Medicine Centre - Gruppo Eugin, Istituti Clinici Zucchi, Monza, Italy
| | | | - Denny Sakkas
- Boston IVF - Eugin Group, 130 Second Ave, Waltham, MA, 02451, USA.
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Celentano C, Matarrelli B, Pavone G, Vitacolonna E, Mattei PA, Berghella V, Liberati M. The influence of different inositol stereoisomers supplementation in pregnancy on maternal gestational diabetes mellitus and fetal outcomes in high-risk patients: a randomized controlled trial. J Matern Fetal Neonatal Med 2018; 33:743-751. [PMID: 30558466 DOI: 10.1080/14767058.2018.1500545] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: To identify the effects of different dietary inositol stereoisomers on insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk for this disorder.Design: A preliminary, prospective, randomized, placebo controlled clinical trial.Participants: Nonobese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy.Intervention: Supplementation with myo-inositol, d-chiro-inositol, combined myo- and d-chiro-inositol or placebo.Main outcome measure: Development of GDM on a 75 grams oral glucose tolerance test at 24-28 weeks' gestation. Secondary outcome measures were increase in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia.Results: The group of women allocated to receive myo-inositol alone had a lower incidence of abnormal oral glucose tolerance test (OGTT). Nine women in the control group (C), one of the myo-inositol (MI), five in d-chiro-inositol (DCI), three in the myo-inositol/D-chiro-inositol group (MI/DCI) required insulin (p = .134). Basal, 1-hour, and 2 hours glycemic controls were significantly lower in exposed groups (p < .001, .011, and .037, respectively). The relative risk reduction related to primary outcome was 0.083, 0.559, and 0.621 for MI, DCI, and MI/DCI groups.Conclusions: This study compared the different inositol stereoisomers in pregnancy to prevent GDM. Noninferiority analysis demonstrated the largest benefit in the myo-inositol group. The relevance of our findings is mainly related to the possibility of an effective approach in GDM. Our study confirmed the efficacy of inositol supplementation in pregnant women at risk for GDM.
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Affiliation(s)
- Claudio Celentano
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Barbara Matarrelli
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Giulia Pavone
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Ester Vitacolonna
- Department of Medicine and Science of Aging, University of Chieti, Chieti, Italy
| | - Peter A Mattei
- ITAB Institute of Advanced Biomedical Technologies, University of Chieti, Chieti, Italy
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marco Liberati
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
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Size at birth by gestational age and hospital mortality in very preterm infants: results of the area-based ACTION project. Early Hum Dev 2015; 91:77-85. [PMID: 25555236 DOI: 10.1016/j.earlhumdev.2014.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Size at birth is an important predictor of neonatal outcomes, but there are inconsistencies on the definitions and optimal cut-offs. AIMS The aim of this study is to compute birth size percentiles for Italian very preterm singleton infants and assess relationship with hospital mortality. STUDY DESIGN Prospective area-based cohort study. SUBJECTS All singleton Italian infants with gestational age 22-31 weeks admitted to neonatal care in 6 Italian regions (Friuli Venezia-Giulia, Lombardia, Marche, Tuscany, Lazio and Calabria) (n. 1605). OUTCOME MEASURE Hospital mortality. METHODS Anthropometric reference charts were derived, separately for males and females, using the lambda (λ) mu (μ) and sigma (σ) method (LMS). Logistic regression analysis was used to estimate mortality rates by gestational age and birth weight centile class, adjusting for sex, congenital anomalies and region. RESULTS At any gestational age, mortality decreased as birth weight centile increased, with lowest values observed between the 50th and the 89th centiles interval. Using the 75th-89th centile class as reference, adjusted mortality odds ratios were 7.94 (95% CI 4.18-15.08) below 10th centile; 3.04 (95% CI 1.63-5.65) between the 10th and 24th; 1.96 (95% CI 1.07-3.62) between the 25th and the 49th; 1.25 (95% CI 0.68-2.30) between the 50(h) and the 74th; and 2.07 (95% CI 1.01-4.25) at the 90th and above. CONCLUSIONS Compared to the reference, we found significantly increasing adjusted risk of death up to the 49th centile, challenging the usual 10th centile criterion as risk indicator. Continuous measures such as the birthweight z-score may be more appropriate to explore the relationship between growth retardation and adverse perinatal outcomes.
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Visentin S, Londero AP, Grumolato F, Trevisanuto D, Zanardo V, Ambrosini G, Cosmi E. Timing of delivery and neonatal outcomes for small-for-gestational-age fetuses. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1721-1728. [PMID: 25253817 DOI: 10.7863/ultra.33.10.1721] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To investigate whether antenatal recognition of small-for-gestational-age (SGA) fetuses with normal maternal and fetal Doppler values delivered after 34 weeks' gestation is associated with changes in the risk of adverse maternal and neonatal outcomes. METHODS In this retrospective study, we included 313 singleton SGA fetuses and 313 appropriate-for-gestational-age control fetuses born between 34 and 42 weeks' gestation from 2009 to 2012. Small-for-gestational-age fetuses identified before delivery (n = 124), for whom antenatal surveillance was performed until delivery (estimated fetal weight twice weekly and Doppler evaluation of the fetal compartment once weekly), were compared to those not identified at delivery (n = 189). The latter group did not undergo antenatal surveillance for several reasons (women for whom a sonographic evaluation or gynecologic consultation was not performed in the third trimester and incorrect sonographic biometric evaluation in the third trimester). Main outcome measures were mode of delivery, perinatal complications, and neonatal intensive care unit admission. The risk of serious fetal complications was assessed by cross-tabulation analysis adjusted for gestational age and degree of SGA. RESULTS Prenatally recognized SGA fetuses were smaller and delivered earlier than unrecognized SGA fetuses (P< .05). Fetal acidemia (pH <7.10) was significantly more common in unrecognized SGA fetuses (3.7% versus 0%). Small-for-gestational-age fetuses at or below the 3rd percentile were more commonly recognized prenatally and hospitalized in the neonatal intensive care unit. Unrecognized SGA fetuses also had worse fetal outcomes compared to controls (P< .05). Recognized and unrecognized SGA fetuses were born significantly more frequently by cesarean delivery (P < .05). No significant differences in perinatal outcomes were found between recognized SGA deliveries with or without medical induction. CONCLUSIONS Antenatal recognition of SGA fetuses delivered after 34 weeks' gestation might improve perinatal outcomes. Medical induction of labor did not modify neonatal outcomes among prenatally recognized SGA fetuses.
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Affiliation(s)
- Silvia Visentin
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Ambrogio Pietro Londero
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Francesca Grumolato
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Vincenzo Zanardo
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Guido Ambrosini
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.)
| | - Erich Cosmi
- Department of Woman's and Child's Health, Maternal-Fetal Medicine Unit, University of Padua School of Medicine, Padua, Italy (S.V., F.G., D.T., V.Z., G.A., E.C.); and Clinic of Obstetrics and Gynecology, Department of Experimental Clinical and Medical Sciences, University of Udine, Udine, Italy (A.P.L.).
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Wesselink A, Warner M, Samuels S, Parigi A, Brambilla P, Mocarelli P, Eskenazi B. Maternal dioxin exposure and pregnancy outcomes over 30 years of follow-up in Seveso. ENVIRONMENT INTERNATIONAL 2014; 63:143-8. [PMID: 24291766 PMCID: PMC3891592 DOI: 10.1016/j.envint.2013.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/23/2013] [Accepted: 11/05/2013] [Indexed: 05/09/2023]
Abstract
Animal evidence suggests an association between exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and adverse pregnancy outcomes. Epidemiologic studies report inconsistent results, but are limited by narrow range of exposure, small sample size, and lack of a biologic measure of highest lifetime exposure. On July 10, 1976, a chemical explosion in Seveso, Italy resulted in the highest known residential exposure to TCDD. In 1996, we initiated the Seveso Women's Health Study (SWHS), a retrospective cohort of TCDD exposure and reproductive health. Individual-level TCDD was measured in serum collected soon after the explosion. After 20years of follow-up, we found no association between maternal TCDD in 1976 serum or estimated at pregnancy and spontaneous abortion (SAB), fetal growth, or gestational length. Here, we present an updated analysis of TCDD exposure and adverse pregnancy outcomes from a subsequent follow-up of the SWHS cohort in 2008-2009. SWHS women had 1211 post-explosion pregnancies through the 2008-2009 follow-up. We found no association between TCDD estimated at pregnancy and SAB, fetal growth, or gestational length. However, we found a non-significant inverse association between maternal 1976 serum TCDD and birthweight (adjusted β=-22.8, 95% CI: -80.1, 34.6). The association was stronger among first post-explosion births, but remained non-significant (adjusted β=-47.7, 95% CI: -107.3, 11.9). SWHS is the first study to be able to consider two potentially relevant measures of TCDD exposure: highest lifetime dose and in utero. Our results, although non-significant, suggest that highest dose may be more relevant in epidemiologic studies of TCDD and pregnancy outcomes.
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Affiliation(s)
- Amelia Wesselink
- Center for Environmental Research and Children's Health, School of Public Health, University of California at Berkeley, Berkeley, CA, United States.
| | - Marcella Warner
- Center for Environmental Research and Children's Health, School of Public Health, University of California at Berkeley, Berkeley, CA, United States.
| | - Steven Samuels
- School of Public Health, University of Albany, The State University of New York, Albany, NY, United States.
| | - Aliza Parigi
- University of Milano-Bicocca School of Medicine, Hospital of Desio, Desio-Milano, Italy.
| | - Paolo Brambilla
- University of Milano-Bicocca School of Medicine, Hospital of Desio, Desio-Milano, Italy.
| | - Paolo Mocarelli
- University of Milano-Bicocca School of Medicine, Hospital of Desio, Desio-Milano, Italy.
| | - Brenda Eskenazi
- Center for Environmental Research and Children's Health, School of Public Health, University of California at Berkeley, Berkeley, CA, United States.
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Milne E, Greenop KR, Metayer C, Schüz J, Petridou E, Pombo-de-Oliveira MS, Infante-Rivard C, Roman E, Dockerty JD, Spector LG, Koifman S, Orsi L, Rudant J, Dessypris N, Simpson J, Lightfoot T, Kaatsch P, Baka M, Faro A, Armstrong BK, Clavel J, Buffler PA. Fetal growth and childhood acute lymphoblastic leukemia: findings from the childhood leukemia international consortium. Int J Cancer 2013; 133:2968-79. [PMID: 23754574 DOI: 10.1002/ijc.28314] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/18/2013] [Accepted: 05/14/2013] [Indexed: 11/07/2022]
Abstract
Positive associations have been reported between the measures of accelerated fetal growth and risk of childhood acute lymphoblastic leukemia (ALL). We investigated this association by pooling individual-level data from 12 case-control studies participating in the Childhood Leukemia International Consortium. Two measures of fetal growth-weight-for-gestational-age and proportion of optimal birth weight (POBW)-were analysed. Study-specific odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression, and combined in fixed effects meta-analyses. Pooled analyses of all data were also undertaken using multivariable logistic regression. Subgroup analyses were undertaken when possible. Data on weight for gestational age were available for 7,348 cases and 12,489 controls from all 12 studies and POBW data were available for 1,680 cases and 3,139 controls from three studies. The summary ORs from the meta-analyses were 1.24 (95% CI: 1.13, 1.36) for children who were large for gestational age relative to appropriate for gestational age, and 1.16 (95% CI: 1.09, 1.24) for a one-standard deviation increase in POBW. The pooled analyses produced similar results. The summary and pooled ORs for small-for-gestational-age children were 0.83 (95% CI: 0.75, 0.92) and 0.86 (95% CI: 0.77, 0.95), respectively. Results were consistent across subgroups defined by sex, ethnicity and immunophenotype, and when the analysis was restricted to children who did not have high birth weight. The evidence that accelerated fetal growth is associated with a modest increased risk of childhood ALL is strong and consistent with known biological mechanisms involving insulin-like growth factors. © 2013 UICC.
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Affiliation(s)
- Elizabeth Milne
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, WA, Australia, On behalf of the Aus-ALL Consortium (Australia)
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Boshari T, Urquia ML, Sgro M, De Souza LR, Ray JG. Differences in birthweight curves between newborns of immigrant mothers vs. infants born in their corresponding native countries: systematic overview. Paediatr Perinat Epidemiol 2013; 27:118-30. [PMID: 23374056 DOI: 10.1111/ppe.12038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Newborn weight may vary between ethnic groups, but it is not known if birthweight differences exist between term babies born to immigrant mothers compared with those born in their corresponding native countries. METHODS We completed a systematic review of all birthweight curves published between 1980 and 2012, based on at least 100 singleton deliveries. We compared the 10th, 50th and 90th percentile birthweight values at 40 weeks gestation for male and female infants born in their native country vs. those infants born to mothers who had emigrated from their native country to Ontario, Canada. For the 50th percentile values, we also calculated a standardised pooled weighted difference and 95% confidence interval [CI] for both sexes. We also assessed whether birthweight differed over time, or if the differences varied by the Human Development Index (HDI) value for the native country. RESULTS A total of 31 studies from 21 different countries met the inclusion criteria, comprising 13 317 578 males and 12 859 119 females born at 40 weeks gestation. There was a small non-significant rise in reported birthweight percentile values between 1983 and 2006. Nearly all infants born to women in their native country had lower birthweights than those born to mothers who had emigrated from the same country to Canada at the 10th, 50th and 90th percentiles. Overall, the 50th percentile weights differed by 115 g [95% CI 74, 156] for males and 122 g [95% CI 95, 150] for females. As HDI or median birthweight increased, birthweight differences were less pronounced, but not significantly so. CONCLUSIONS Term birthweight percentiles are typically higher among term infants born to mother who immigrate to Canada than those of infants born in their respective native country.
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Affiliation(s)
- Talia Boshari
- Undergraduate Studies, McGill University, Montreal, Quebec, Canada
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10
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Matarrelli B, Vitacolonna E, D'Angelo M, Pavone G, Mattei PA, Liberati M, Celentano C. Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: a randomized controlled trial. J Matern Fetal Neonatal Med 2013; 26:967-72. [PMID: 23327487 DOI: 10.3109/14767058.2013.766691] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To test the hypothesis that dietary myo-inositol may improve insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk of this disorder. DESIGN A prospective, randomized, double-blind, placebo controlled clinical trial, pilot study. PARTICIPANTS Non-obese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy. INTERVENTION Supplementation with myo-inositol or placebo during pregnancy. MAIN OUTCOME MEASURE Development of GDM on a 75 g oral glucose tolerance test at 24-28 weeks' gestation. Secondary outcome measures were increased in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia. RESULTS Thirty-six women were allocated to receive myo-inositol and 39 placebo. The incidence of GDM in mid-pregnancy was significantly reduced (p = 0.001) in women randomized to receive myo-inositol compared to placebo (relative risk 0.127). Women randomized to receive myo-inositol also required less insulin therapy, delivered at a later gestational age, had significantly smaller babies with fewer episodes of neonatal hypoglycemia. CONCLUSIONS Myo-inositol supplementation in pregnancy reduced the incidence of GDM in women at high risk of this disorder. The reduction in incidence of GDM in the treatment arm was accompanied by improved outcomes.
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Affiliation(s)
- Barbara Matarrelli
- Departments of Obstetrics and Gynaecology, University G. d’Annunzio, Chieti, Italy
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Severi FM, Bocchi C, Imperatore A, Boni C, Ferrata C, Florio P, Reis FM, Petraglia F. Ultrasound estimated fetal weight slightly below the median is associated with increased risk of spontaneous preterm birth. Prenat Diagn 2012; 32:588-91. [DOI: 10.1002/pd.3865] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 01/27/2012] [Accepted: 01/29/2012] [Indexed: 12/23/2022]
Affiliation(s)
- Filiberto M. Severi
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Caterina Bocchi
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Alberto Imperatore
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Carlotta Boni
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Chiara Ferrata
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Pasquale Florio
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Fernando M. Reis
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
| | - Felice Petraglia
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynaecology; University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100; Siena; Italy
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De Bonis M, Sabatini L, Galeazzi LR, Torricelli M, Calzoni P, Fineschi D, Novembri R, Severi FM, Petraglia F. Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction. Eur J Obstet Gynecol Reprod Biol 2012; 160:142-6. [DOI: 10.1016/j.ejogrb.2011.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 05/26/2011] [Accepted: 10/19/2011] [Indexed: 11/26/2022]
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Ghi T, Kuleva M, Youssef A, Maroni E, Nanni M, Pilu G, Rizzo N, Pelusi G. Maternal cardiac function in complicated twin pregnancy: a longitudinal study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:581-585. [PMID: 21225666 DOI: 10.1002/uog.8915] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate longitudinally a cohort of twin pregnancies and to assess whether the occurrence of adverse pregnancy outcome may be related to specific maternal cardiac findings. METHODS Women with twin pregnancies were enrolled prospectively and underwent serial maternal echocardiography at 20-23 weeks, 26-29 weeks and 30-33 weeks of gestation. Patients were excluded if delivery took place prior to 34 weeks. Cardiac findings were compared between patients with uneventful pregnancy outcome and those who developed one of the following complications: pre-eclampsia or gestational hypertension; small-for-gestational age (SGA) neonates (birth weight of one or both twins < 5(th) centile for gestational age). RESULTS A group of 28 twin gestations was obtained for analysis, including eight complicated cases. At each visit, mean ± SD cardiac output (CO) was significantly higher in uncomplicated than complicated twin pregnancies (6.55 ± 0.82 vs 4.99 ± 0.67 L/min, P < 0.001 at 20-23 weeks; 7.31 ± 0.74 vs 5.66 ± 1.17 L/min, P < 0.001 at 26-29 weeks; 7.50 ± 0.89 vs 5.32 ± 0.74 L/min, P < 0.001 at 30-33 weeks), as was stroke volume (83.4 ± 12.2 vs 64.5 ± 9.2 mL, P = 0.001 at 20-23 weeks; 84.4 ± 15.6 vs 64.5 ± 12.0 mL, P = 0.003 at 26-29 weeks; 85.0 ± 19.2 vs 65.6 ± 10.7 mL, P = 0.013 at 30-33 weeks), whereas total vascular resistance (TVR) was lower (1005 ± 137 vs 1406 ± 159 dynes × s/cm(5) , P < 0.001 at 20-23 weeks; 924 ± 100 vs 1249 ± 231 dynes × s/cm(5) , P < 0.001 at 26-29 weeks; 929 ± 96 vs 1400 ± 244 dynes × s/cm(5) , P < 0.001 at 30-33 weeks). Moreover, CO, blood pressure (BP), heart rate (HR) and TVR remained stable throughout the assessed pregnancy interval in women developing a complication, whereas significant changes (rise in CO, HR and BP; fall in TVR) were noted in the uncomplicated group. CONCLUSIONS Maternal cardiac function in twin pregnancies complicated by pre-eclampsia or SGA neonates apparently does not undergo the profound longitudinal changes that occur in uneventful twin pregnancies.
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Affiliation(s)
- T Ghi
- Department of Obstetrics and Gynecology, S.Orsola Malpighi Hospital, University of Bologna, Bologna, Italy.
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Kuleva M, Youssef A, Maroni E, Contro E, Pilu G, Rizzo N, Pelusi G, Ghi T. Maternal cardiac function in normal twin pregnancy: a longitudinal study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:575-580. [PMID: 21240915 DOI: 10.1002/uog.8936] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To investigate maternal cardiac function in a cohort of uncomplicated twin gestations assessed longitudinally. METHODS Women with twin pregnancies were enrolled prospectively and underwent serial maternal echocardiography at 20-23 weeks, 26-29 weeks and 30-33 weeks of gestation. Patients were excluded if any of these complications occurred after recruitment: delivery < 34 weeks; pre-eclampsia or gestational hypertension; small-for-gestational age neonates (birth weight of one or both twins < 5(th) centile for gestational age). Cardiac findings were compared with those obtained at the same gestational age periods in a group of singleton gestations. RESULTS A group of 20 uncomplicated twin gestations was obtained for analysis and 10 singleton pregnancies were then selected as controls. At each visit, mean ± SD cardiac output (CO) was significantly higher in twins than in singletons (6.55 ± 0.82 vs 5.62 ± 0.82 L/min, P = 0.007 at 20-23 weeks; 7.31 ± 0.74 vs 6.39 ± 0.74 L/min, P = 0.003 at 26-29 weeks; 7.50 ± 0.89 vs 6.68 ± 0.65 L/min, P = 0.015 at 30-33 weeks), whereas total vascular resistance (TVR) was lower (1005 ± 137 vs 1179 ± 199 dynes × s/cm(5) , P = 0.009 at 20-23 weeks; 924 ± 100 vs 1070 ± 138 dynes × s/cm(5), P = 0.003 at 26-29 weeks; 929 ± 96 vs 1031 ± 122 dynes × s/cm(5), P = 0.018 at 30-33 weeks). In both twins and singletons, CO showed a significant increase while TVR decreased significantly throughout the assessed pregnancy time period. CONCLUSION In twin gestation, maternal cardiac function apparently undergoes more profound changes compared with in singleton gestation, as testified by higher CO and lower TVR values at each stage of pregnancy starting from the mid-trimester.
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Affiliation(s)
- M Kuleva
- Department of Obstetrics and Gynecology, S.Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
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Bellomo G, Venanzi S, Saronio P, Verdura C, Narducci PL. Prognostic significance of serum uric acid in women with gestational hypertension. Hypertension 2011; 58:704-8. [PMID: 21876075 DOI: 10.1161/hypertensionaha.111.177212] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim of our study was to ascertain, prospectively, whether serum uric acid is a suitable predictor of preeclampsia and/or the delivery of small-for-gestational-age infants in women with gestational hypertension. We screened 206 primiparas, with a singleton pregnancy, referred for recent onset of hypertension. At presentation, we measured serum uric acid, creatinine, blood glucose, hemoglobin and platelet level, and 24-hour proteinuria, as well as office and 24-hour blood pressures. We followed the women until 1 month after delivery and recorded pregnancy outcome. After logistic regression analysis, uric acid resulted a significant predictor of preeclampsia, with an unadjusted odds ratio of 9.1 (95% CI: 4.8 to 17.4; P<0.001); after adjustment for age, gestation week, hemoglobin and platelet levels, serum creatinine, office and 24-hour average systolic and diastolic blood pressures, it was 7.1 (95% CI: 3.2 to 15.7; P<0.001). Regarding the association between maternal serum uric acid and the chance of giving birth to a small-for-gestational-age infant, the unadjusted odds ratio was 1.7 (95% CI: 1.4 to 2.2; P<0.001), and it was 1.6 (95% CI: 1.1 to 2.4; P=0.02) after adjustment. Receiver operating characteristic analysis showed that serum uric acid, at a 309-μmol/L cutoff, predicted the development of preeclampsia (area under the curve: 0.955), with 87.7% sensitivity and 93.3% specificity, and the delivery of small-for-gestational-age infants (area under the curve: 0.784) with 83.7% sensitivity and 71.7% specificity. In conclusion, the results of our study show that serum uric acid is a reliable predictor of preeclampsia in women referred for gestational hypertension.
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Affiliation(s)
- Gianni Bellomo
- Department of Nephrology, San Giovanni Battista Hospital, Foligno, Italy.
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Montes-Núñez S, Chávez-Corral DV, Reza-López S, Sanin LH, Acosta-Maldonado B, Levario-Carrillo M. Birth weight in children with birth defects. ACTA ACUST UNITED AC 2011; 91:102-7. [PMID: 21254364 DOI: 10.1002/bdra.20751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 08/16/2010] [Accepted: 09/18/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Birth defects (BDs) are a serious public health problem in Mexico. The objective of this paper was to identify the frequency of newborns (NBs) that are born small for gestational age with a birth defect. MATERIALS AND METHODS A cross-sectional study of NBs from hospitals part of the Mexican Institute of Social Security in Chihuahua, Mexico, was conducted. NBs were classified according to the presence or absence of a BD and according to their weight percentile using regional standards of birth weight. RESULTS NBs diagnosed with (n = 263) or without BDs (n = 64,626) were included in this study. A greater proportion of NBs small for gestational age were identified in cases involving BDs (20%), compared with NBs without BDs (9%). Moreover, the average decrease in birth weights of NBs with BDs associated with their digestive system was 210 grams (95% confidence interval [CI], -436/-12), with their genital organs 440 grams (95% CI, -730/-151), involving chromosomal abnormalities 230 grams (95% CI, -435/-26), or with their musculoskeletal system 289 grams (95% CI, -43/-147) according to the gestational age, sex, and condition of the NB (p < 0.05). CONCLUSIONS A greater proportion of NBs with BDs were associated with a low birth rate for their gestational age. In addition, some BDs were found to be associated with an impaired birth weight more often than others This suggests that clinical decisions regarding NBs with congenital defects and a lower birth weight for their gestational age should be diagnosed and treated for additional nutritional considerations as needed. Birth Defects Research (Part A), 2011. © 2011 Wiley-Liss, Inc.
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Affiliation(s)
- Sonia Montes-Núñez
- Unidad de Investigación Médica en Epidemiología Clínica Chihuahua, Ave. Colón 1003, Colonia Obrera, Chihuahua, Mexico
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Neonatal anthropometric charts: the Italian neonatal study compared with other European studies. J Pediatr Gastroenterol Nutr 2010; 51:353-61. [PMID: 20601901 DOI: 10.1097/mpg.0b013e3181da213e] [Citation(s) in RCA: 315] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVE This was a nationwide prospective study carried out in Italy between 2005 and 2007, involving 34 centers with a neonatal intensive care unit. The study reports the Italian Neonatal Study charts for weight, length, and head circumference of singletons born between 23 and 42 gestational weeks, comparing them with previous Italian data and with the most recent data from European countries. PATIENTS AND METHODS Single live born babies with ultrasound assessment of gestational age within the first trimester, and with both parents of Italian origin. Only fetal hydrops and major congenital anomalies diagnosed at birth were excluded. The reference set consists of 22,087 girls and 23,375 boys. RESULTS At each gestational age, boys are heavier than girls by about 4%. Later-born neonates are heavier than firstborn neonates by about 3%. The effects of sex and birth order on length and head circumference are milder. No differences were observed between babies born in central-north Italy and southern Italy. A large variability emerged among European neonatal charts, resulting in huge differences in the percentage of Italian Neonatal Study neonates below the 10th centile, which is traditionally used to define small-for-gestational-age babies. In the last 2 decades prominent changes in the distribution of birth weight emerged in Italy and in the rest of Europe, in both term and preterm neonates. CONCLUSIONS The existing European neonatal charts, based on more or less recent data, were found to be inappropriate for Italy. Until an international standard is developed, the use of national updated reference charts is recommended.
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Ríos JM, Tufiño-Olivares E, Reza-López S, Sanín LH, Levario-Carrillo M. Birthweight percentiles by gestational age and gender for children in the North of Mexico. Paediatr Perinat Epidemiol 2008; 22:188-94. [PMID: 18298694 DOI: 10.1111/j.1365-3016.2007.00898.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective of this study was to determine the 10th, 50th and 90th percentiles of birthweight, by gestational age and sex, for newborns covered by the Mexican Institute of Social Security (IMSS) in the State of Chihuahua. To generate the database, we used IMSS hospitals' records in the State of Chihuahua, covering the period between 1 January 2000 and 31 December 2004. We included singleton live births only, and excluded babies with congenital malformations. The birthweights of 88,368 children born at 21-44 weeks of gestation comprised our data. From these data, we calculated the 10th, 50th and 90th percentiles for each sex, at 32-44 weeks of gestation. The observed cutoffs for the 10th percentile in our population were 40-250 g higher than those reported in other references with Mexican populations. These results constitute an updated birthweight reference that will allow the identification of newborns in the North region of the country with low birthweight-for-gestational age. Such information can be a useful instrument for preventing or diminishing associated risks.
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Affiliation(s)
- Jesús Manuel Ríos
- Unidad de Investigación Médica en Epidemiología Clínica, Instituto Mexicano del Seguro Social en Chihuahua, Chihuahua, Mexico
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Festini F, Taccetti G, Repetto T, Reali MF, Campana S, Mergni G, Marianelli L, de Martino M. Gestational and neonatal characteristics of children with cystic fibrosis: a cohort study. J Pediatr 2005; 147:316-20. [PMID: 16182668 DOI: 10.1016/j.jpeds.2005.04.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Revised: 02/09/2005] [Accepted: 04/13/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To examine whether the birth weight (BW) and the risks of being pre-term, low birth weight (LBW), and small for gestational age (SGA) of children with cystic fibrosis (CF) are different from nonaffected children. STUDY DESIGN Retrospective cohort study. We examined all the children with CF born in Tuscany, Italy, from 1991 to 2002 (n = 70) comparing them to the entire population of non-CF-affected children born in the same period (n = 290,059). RESULTS The mean BW of newborns with CF was 246.2 g lower than the mean BW of the non-CF neonatal population (P = .0003). Children with CF had a higher risk of being born pre-term (RR 2.62, P = .001), LBW (RR 2.66, P = .0009), and SGA (RR = 1.74, P = .04) than the non-CF-affected children. The mean BW of term newborns with CF was 205.7 g lower than that of term non-CF-affected babies (P = .0002). CONCLUSIONS Our data show an association between CF and reduced BW and show a greater risk of being pre-term for babies with CF.
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Affiliation(s)
- Filippo Festini
- Cystic Fibrosis Center of Tuscany, Pediatric Infectious Diseases Department, Meyer Pediatric Hospital, University of Florence, Italy.
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