Preconception Phthalate Exposure and Women's Reproductive Health: Pregnancy, Pregnancy Loss, and Underlying Mechanisms

BACKGROUND

Phthalates are endocrine-disrupting chemicals linked to adverse pregnancy outcomes. Despite the sensitivity of female reproductive processes to oxidation-reduction reaction stress and endocrine disruption, evidence for the impact of women's phthalate exposure on the ability to establish and maintain pregnancy has been inconclusive.

OBJECTIVES

We aimed to determine the relationship of preconception phthalate metabolite exposure with a) fecundability and pregnancy loss and b) markers of potential biological mechanisms, including reproductive hormones, inflammation, and oxidative stress.

METHODS

Data were collected from the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial, a preconception study following 1,228 women who were attempting pregnancy, for up to six menstrual cycles and throughout pregnancy if they became pregnant. Twenty phthalate metabolites were measured in a consecutive 3-d pooled urine sample at enrollment. Pregnancy was determined through urinary human chorionic gonadotropin (hCG) at the expected date of menses during each cycle and pregnancy loss as an observed loss following positive hCG. Highly sensitive C-reactive protein (hsCRP) and isoprostanes were measured at enrollment, and reproductive hormones were measured during the follicular phase, ovulation, and luteal phase. Discrete-time Cox proportional hazards models evaluated the relationship of phthalate metabolites with fecundability and weighted Poisson models with robust variance evaluated the risk of pregnancy loss.

RESULTS

An interquartile range (IQR) higher mono-(2-ethylhexyl) phthalate [fecundability odds ratio  ( FOR ) = 0.88 ; 95% confidence interval (CI): 0.78, 1.00], mono-butyl phthalate (FOR = 0.82 ; 95% CI: 0.70, 0.96), and mono-benzyl phthalate (FOR = 0.85 ; 95% CI: 0.74, 0.98) was associated with lower fecundability. No consistent associations were observed with pregnancy loss. Preconception phthalates were consistently associated with higher hsCRP and isoprostanes, as well as lower estradiol and higher follicle-stimulating hormone across the menstrual cycle.

DISCUSSION

Women's preconception exposure to phthalates was associated with lower fecundability, changes in reproductive hormones, and increased inflammation and oxidative stress. The pre- and periconception periods may represent sensitive windows for intervening to limit the reproductive toxicity of phthalate exposure. https://doi.org/10.1289/EHP12287.

The Relationship of Preconception and Early Pregnancy Isoprostanes with Fecundability and Pregnancy Loss

BACKGROUND

Although redox stress likely plays an important role in reproductive health, the utility of peripheral biomarkers of oxidative stress, such as isoprostanes, during the periconception period remains underexplored. We evaluated the relationship between isoprostanes during preconception and gestational week 4 and women's reproductive health outcomes.

METHODS

The Effects of Aspirin in Gestation and Reproduction trial (2007-2011) enrolled 1228 women attempting pregnancy and followed them for up to 6 menstrual cycles and throughout pregnancy if they became pregnant. We measured creatinine-adjusted, log-transformed isoprostanes 8-iso-prostaglandin F 2α (8-iso-PGF2α), its metabolite 2,3-dinor-iPF2α-III, and stereoisomers 5-iso-PGF2α-VI and 8,12-iso-iPF2α-VI in urine during preconception and 4 weeks gestation. We evaluated pregnancy among participants in each menstrual cycle using human chorionic gonadotropin (hCG) and defined pregnancy loss as observed loss following positive hCG. We calculated fecundability odds ratios (FOR) and 95% confidence intervals (CI) using discrete-time Cox proportional hazards models and relative risk of pregnancy loss using adjusted log-binomial models.

RESULTS

Higher preconception isoprostane levels were associated with lower fecundability [e.g., FOR = 0.89; 95% CI = 0.81, 0.97 per interquartile range (IQR) increase in 8-iso-PGF2α]. Among 797 pregnancies, isoprostane levels increased from preconception to 4 weeks gestation (e.g., mean difference = 0.12; 95% CI = 0.10, 0.14 ng/mL for 8-iso-PGF2α) and higher isoprostanes at 4 weeks gestation were associated with lower risk of pregnancy loss (e.g., RR = 0.79; 95% CI = 0.62, 1.00 per IQR increase in 8-iso-PGF2α).

CONCLUSIONS

Preconception urinary isoprostanes may identify redox stress pathways associated with lower fecundability. However, the increase in isoprostanes into gestational week 4 and the associated lower risk of pregnancy loss may suggest confounding by latent factors in early pregnancy.

The Safety of Low-Dose Aspirin on the Mode of Delivery: Secondary Analysis of the Effect of Aspirin in Gestation and Reproduction Randomized Controlled Trial

OBJECTIVE

This study aimed to examine whether prenatal low-dose aspirin (LDA) therapy affects risk of cesarean versus vaginal delivery.

STUDY DESIGN

This study is a secondary analysis of the randomized clinical effects of aspirin in gestation and reproduction (EAGeR) trial. Women received 81-mg daily aspirin or placebo from preconception to 36 weeks of gestation. Mode of delivery and obstetric complications were abstracted from records. Log-binomial regression models estimated relative risk (RR) of cesarean versus vaginal delivery. Data were analyzed among the total preconception cohort, as well as restricted to women who had a live birth.

RESULTS

Among 1,228 women, 597 had a live birth. In the intent-to-treat analysis, preconception-initiated LDA was not associated with risk of cesarean (RR = 1.02; 95% confidence interval [CI]: 0.98-1.07) compared with placebo. Findings were similar in just women with a live birth and when accounting prior cesarean delivery and parity.

CONCLUSION

Preconception-initiated daily LDA was not associated with mode of delivery among women with one to two prior losses.

KEY POINTS

· Aspirin was not associated with risk of cesarean section.. · Aspirin was not associated with mode of delivery.. · No increased risk of bleeding with use of aspirin..

A Data-Based Approach to Evaluating Representation by Gender and Affiliation in Key Presentation Formats at the Annual Meeting of the Society for Epidemiologic Research

The annual meeting of the Society for Epidemiologic Research (SER) is a major forum for sharing new research and promoting the career development of participants. Because of this, evaluating representation in key presentation formats is critical. For the 3,257 presentations identified at the 2015-2017 SER annual meetings, we evaluated presenter characteristics, including gender, affiliation, subject area, and h-index, and representation in 3 highlighted presentation formats: platform talks (n = 382), invited symposium talks (n = 273), and chairing a concurrent contributed session or symposium (n = 188). Data were abstracted from SER records, abstract booklets, and programs. Gender was assessed using GenderChecker software, and h-index was determined using the Scopus application programming interface. Log-binomial models were adjusted for participant characteristics and conference year. In adjusted models, women were less likely than men to present an invited symposium talk (relative risk = 0.60, 95% confidence interval: 0.45, 0.81) compared with all participants with accepted abstracts. Researchers from US public universities, US government institutions, and international institutions were less likely to present a symposium talk or to chair a concurrent contributed session or symposium than were researchers from US private institutions. The research areas that were most represented in platform talks were epidemiologic methods, social epidemiology, and cardiovascular epidemiology. Our findings suggest differences in representation by gender, affiliation, and subject area after accounting for h-index.

Low Intake of Vegetable Protein is Associated With Altered Ovulatory Function Among Healthy Women of Reproductive Age

CONTEXT

Diets high in plant-based protein have gained popularity due to increasing health concerns regarding consumption of animal products. Though links between intakes of certain protein-rich foods and reproductive disorders have been suggested, the relationship of overall animal and vegetable proteins with reproductive hormones among reproductive-aged women is unknown.

OBJECTIVE

To evaluate the associations between the intake of dietary protein with reproductive hormones and sporadic anovulation among reproductive-aged women.

DESIGN

A prospective cohort study, 2005-2007.

SETTING

University at Buffalo, western New York, United States.

PARTICIPANTS

A total of 259 premenopausal women (18-44 years) without dietary restrictions.

MAIN OUTCOME MEASURE(S)

Serum reproductive hormones were determined up to 8 times per cycle for 2 cycles. Protein intake was assessed the day prior to hormone assessment at 4 visits/cycle using 24-hour recalls.

RESULTS

Overall, 84% of participants met the recommended dietary allowance for total protein set for reproductive-aged women. Neither total nor animal protein intake were associated with reproductive hormones or anovulation. However, vegetable protein intake in the lowest tertile was associated with lower luteal phase progesterone (-18.0%, 95% confidence interval [CI] -30.2, -3.6), higher follicle-stimulating hormone (3.8%, 95% CI 0.2, 7.6), and a higher risk of anovulation (risk ratio [RR] 2.53, 95% CI 1.21, 5.26), compared with the middle tertile. Nuts and seeds were the only protein-rich foods associated with an elevated risk of anovulation (RR 2.12, 95% CI 1.17, 3.85).

CONCLUSIONS

Findings suggest that among women who meet the recommended dietary allowance for total protein, low intake of vegetable, but not animal, protein may disturb normal ovulatory function.

Associations between blood cadmium and endocrine features related to PCOS-phenotypes in healthy women of reproductive age: a prospective cohort study

BACKGROUND

Cadmium is an endocrine disrupting chemical that affects the hypothalamic-pituitary-gonadal axis. Though evidence suggests its potential role in altering androgen synthesis and metabolic pathways that are characteristic of polycystic ovary syndrome (PCOS), its relation in healthy women of reproductive age is largely unknown. As women with mild sub-clinical features of PCOS who do not meet the diagnostic criteria of PCOS may still experience reduced fecundability, investigating associations between cadmium and PCOS-phenotypes among healthy women may provide unique insight into the reproductive implications for many on the PCOS spectrum. Therefore, the objective of this study was to evaluate associations between cadmium and androgens, anti-Müllerian hormone (AMH), and metabolic markers in women of reproductive age.

METHODS

This was a prospective cohort study of 251 healthy premenopausal women without self-reported PCOS (mean age 27.3 years and BMI 24.1 kg/m²). Cadmium was measured in blood collected at baseline. Reproductive hormones and metabolic markers were measured in fasting serum 8 times per menstrual cycle for 2 cycles. Linear mixed models and Poisson regression with a robust error variance were used to examine associations between cadmium and reproductive hormones and metabolic markers and anovulation, respectively.

RESULTS

Median (interquartile range) blood cadmium concentrations at baseline were 0.30 (0.19-0.43) µg/L. Higher levels of testosterone (2.2 %, 95 % confidence interval [CI] 0.4, 4.1), sex hormone-binding globulin (2.9 %, 95 % CI 0.5, 5.5), and AMH (7.7 %, 95 % CI 1.1, 14.9) were observed per 0.1 µg/L increase in cadmium concentrations. An 18 % higher probability of a mild PCOS-phenotype (95 % CI 1.06, 1.31), defined by a menstrual cycle being in the highest quartile of cycle-averaged testosterone and AMH levels, was also found per 0.1 µg/L increase in cadmium levels. No associations were observed for insulin and glucose. These findings were consistent even after analyses were restricted to non-smokers or further adjusted for dietary factors to account for potential sources of exposure.

CONCLUSIONS

Overall, among healthy reproductive-aged women, cadmium was associated with endocrine features central to PCOS, but not with metabolic markers. These suggest its potential role in the hormonal milieu associated with PCOS even at low levels of exposure.

Adiposity is associated with anovulation independent of serum free testosterone: A prospective cohort study

BACKGROUND

Obesity, a body mass index (BMI) ≥30 kg/m2 , is linked to infertility, potentially through a greater risk of anovulation due to elevated androgens. Yet, previous studies have not directly assessed the impact of adiposity, or body fat, on anovulation in the absence of clinical infertility.

OBJECTIVE

To characterise the associations between adiposity and anovulation among women menstruating on a regular basis.

METHODS

Women from the EAGeR trial (n = 1200), a randomised controlled trial of low-dose aspirin and pregnancy loss among women trying to conceive, were used to estimate associations between adiposity and incident anovulation. Participants completed baseline questionnaires and anthropometry, and provided blood specimens. Women used fertility monitors for up to six consecutive menstrual cycles, with collection of daily first morning voids for hormone analysis in the first two menstrual cycles for prospective assessment of anovulation. Anovulation was assessed by urine pregnanediol glucuronide or luteinising hormone concentration or the fertility monitor. Weighted mixed-effects log-binomial regression was used to estimate associations between measures of adiposity and incident anovulation, adjusted for free (bioavailable) testosterone, anti-Mullerian hormone (AMH), serum lipids, and demographic and life style factors.

RESULTS

343 (28.3%) women experienced at least one anovulatory cycle. Anovulation risk was higher per kg/m2 greater BMI (relative risk [RR] 1.03, 95% confidence interval (CI) 1.01, 1.04), cm waist circumference (RR 1.01, 95% CI 1.00, 1.02), mm subscapular skinfold (RR 1.02, 95% CI 1.01, 1.03), and mm middle upper arm circumference (RR 1.04, 95% CI 1.01, 1.06) adjusted for serum free testosterone, AMH, lipids, and other factors.

CONCLUSIONS

Adiposity may be associated with anovulation through pathways other than testosterone among regularly menstruating women. This may account in part for reported associations between greater adiposity and infertility among women having menstrual cycles regularly. Understanding the association between adiposity and anovulation might lead to targeted interventions for preventing infertility.

Does maternal race or ethnicity modify the association between maternal psychiatric disorders and preterm birth?

PURPOSE

Preterm birth risk has been linked to maternal racial and ethnic background, particularly African American heritage; however, the association of maternal race and ethnicity with psychiatric disorders and preterm birth has received relatively limited attention.

METHODS

The Consortium on Safe Labor (2002-2008) is a nationwide U.S. cohort study with 223,394 singleton pregnancies. Clinical data were obtained from electronic medical records, including maternal diagnoses of psychiatric disorders. Relative risk (RR) and 95% confidence intervals (CI) were estimated for the association between maternal psychiatric disorders and preterm birth (<37 completed weeks) using log-binomial regression with generalized estimating equations. The interaction effect of maternal psychiatric disorders with race and ethnicity was also evaluated.

RESULTS

Non-Hispanic White (RR, 1.42; 95% CI, 1.35-1.49), Hispanic (RR, 1.44; 95% CI, 1.29-1.60), and non-Hispanic Black (RR, 1.21, 95% CI, 1.13-1.29) women with any psychiatric disorder were at increased risk for delivering preterm infants, compared with women without any psychiatric disorder. However, non-Hispanic Black women with any psychiatric disorder, depression, bipolar disorder, and schizophrenia had a significantly lower increase in preterm birth risk than non-Hispanic White women.

CONCLUSIONS

Despite the significant association between maternal psychiatric disorders and preterm birth risk, psychiatric disorders did not appear to contribute to racial and ethnic disparities in preterm birth.

Recalled maternal lifestyle behaviors associated with anti-müllerian hormone of adult female offspring

Anti-müllerian hormone (AMH) is an established marker of ovarian reserve that decreases with age. Though the pool of ovarian follicles is established during fetal development, impacts of in utero exposures on AMH are uncertain. Thus, we sought to evaluate associations of in utero exposures with AMH of adult daughters with a prospective cohort study of adult daughters at university medical centers. Women noted their mother's reported use of diethylstilbestrol (DES), vitamins, tobacco, alcohol, and caffeine during pregnancy, and their mother's occupation during pregnancy. All participants were reproductive age women (18-40 years) enrolled in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. Serum AMH concentrations were measured at baseline prior to conception and categorized using clinical guidelines. Multinomial regression models estimated associations between each exposure and high (>3.5 ng/mL) and low (<1.0 ng/mL) versus normal AMH (1.0-3.5 ng/mL), adjusting for participant's age, mother's age, mother's history of fertility treatment, and mother's use of vitamins. In 1202 women with available data, maternal caffeine use was associated with an increased risk of low AMH, compared to normal (relative risk [RR] 1.90, 95 % confidence interval [CI] 1.09, 3.30). Vitamins were associated with an increased risk of high AMH compared to normal (RR 1.93, 95 % CI 1.24, 3.00). Other exposures were not associated with AMH concentrations in offspring. Maternal caffeine and vitamin use during pregnancy may be associated with ovarian reserve in adult offspring, highlighting the potential importance of pregnancy lifestyle on the reproductive health of daughters.

Low-dose aspirin in reproductive health: effects on menstrual cycle characteristics

OBJECTIVE

To estimate the effect of daily 81 mg low-dose aspirin (LDA) on menstrual cycle length and hormone profiles.

DESIGN

Secondary analysis of a trial evaluating the effect of daily LDA or placebo on live birth among women with one or two previous pregnancy losses.

SETTING

University medical centers.

PATIENT(S)

A total of 915 regularly menstruating women who had at least one menstrual cycle (3,190 total cycles) in which pregnancy did not occur.

INTERVENTION(S)

Randomized allocation to LDA versus placebo.

MAIN OUTCOME MEASURE(S)

Menstrual cycle length and follicular and luteal phases were measured. Urinary pregnanediol glucuronide, follicle-stimulating hormone, luteinizing hormone, and estrone-3-glucuronide were assessed up to six times during the first two cycles. Generalized estimating equations estimated relative risk of short (<25th percentile: <27 days) and long (>75th percentile: ≥32 days) versus normal cycle length. Linear mixed models estimated mean hormone level differences with weights used to account for multiple cycles contributed per participant.

RESULT(S)

There were no significant differences in total menstrual cycle, follicular phase, or luteal phase length between LDA and placebo groups. LDA posed no greater risk of having a short versus normal-length or long versus normal-length follicular phase, or having a short versus normal-length or long versus normal-length luteal phase. There were no significant differences in hormone levels across the menstrual cycle between the LDA and placebo groups.

CONCLUSION(S)

Daily LDA use did not result in any changes to menstrual cycle, follicular phase, or luteal phase length or hormone levels across the menstrual cycle compared with placebo.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00467363.

Family history of autoimmune disease in relation to time-to-pregnancy, pregnancy loss, and live birth rate

Several autoimmune conditions have adverse effects on reproductive outcomes, but the relationship between family history of autoimmune disease in women without these conditions and pregnancy is uncertain. The objective of this study was to determine if there is an association between a family history of an autoimmune condition and time-to-pregnancy (TTP), pregnancy loss, and live birth. This was a prospective cohort study from a RCT of 1228 adult women ages 18-40, who were healthy, had no history of infertility, were actively attempting to conceive, and had one or two prior pregnancy losses. Of these, 1172 women had data available regarding family history of autoimmune conditions. Women with an affected first-degree relative had similar TTP when compared to those without a FHx (fecundability odds ratio 0.90, 95% confidence interval [CI] 0.70, 1.15). Women with an affected first-degree relative had a lower likelihood of live birth (relative risk [RR] 0.83, 95% CI 0.69, 0.99). Among women who achieved pregnancy, FHx of autoimmune disease was associated with a higher likelihood of pregnancy loss (RR 1.49, 95% CI 1.10, 2.03). Women who had a first-degree relative with an autoimmune disease had a similar TTP as unaffected women but a lower likelihood of live birth and higher risk of pregnancy loss. This information may encourage clinicians to evaluate women with a family history of autoimmune conditions prior to pregnancy and highlights the need for further studies to ascertain the effects of autoimmunity and pregnancy.

Preconception Blood Pressure and Its Change Into Early Pregnancy: Early Risk Factors for Preeclampsia and Gestational Hypertension

Preeclampsia and gestational hypertension are common complications of pregnancy associated with significant maternal and infant morbidity. Despite extensive research evaluating risk factors during pregnancy, most women who develop a hypertensive disorder of pregnancy are not considered high-risk and strategies for prevention remain elusive. We evaluated preconception blood pressure and its change into early pregnancy as novel risk markers for development of a hypertensive disorder of pregnancy. The EAGeR (Effects of Aspirin in Gestation and Reproduction) trial (2007-2011) randomized 1228 healthy women with a history of pregnancy loss to preconception-initiated low-dose aspirin versus placebo and followed participants for up to 6 menstrual cycles attempting pregnancy and throughout pregnancy if they became pregnant. Blood pressure was measured during preconception and throughout early gestation. The primary outcomes, preterm preeclampsia, term preeclampsia, and gestational hypertension, were abstracted from medical records. Among 586 women with a pregnancy >20 weeks' gestation, preconception blood pressure levels were higher for preterm preeclampsia (87.3±6.7 mm Hg mean arterial pressure), term preeclampsia (88.3±9.8 mm Hg), and gestational hypertension (87.9±9.1 mm Hg) as compared with no hypertensive disorder of pregnancy (83.9±8.6 mm Hg). Change in blood pressure from preconception into very early pregnancy was associated with development of preeclampsia (relative risk, 1.13 [95% CI, 1.02-1.25] per 2 mm Hg increase in mean arterial pressure at 4 weeks' gestation), particularly preterm preeclampsia (relative risk, 1.21 [95% CI, 1.01-1.45]). Randomization to aspirin did not alter blood pressure trajectory or risk of hypertension in pregnancy. Preconception blood pressure and longitudinal changes during early pregnancy are underexplored but crucial windows in the detection and prevention of hypertensive disorders of pregnancy. Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00467363.

Maternal preconception lipid profile and gestational lipid changes in relation to birthweight outcomes

In 575 women with 1–2 prior pregnancy losses; total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were evaluated preconception and throughout pregnancy to evaluate whether previously observed associations between third trimester maternal lipid profile and birthweight outcomes are driven by preconception lipids or lipid changes during pregnancy. Lipid trajectories were compared by pre-pregnancy body mass index (BMI) <25 or ≥25 kg/m²; logistic regression models evaluated preconception lipid concentration and change from preconception to 28 weeks with adjusted odds of large- or small-for-gestational age (LGA or SGA) neonate by BMI group. Preconception lipid concentrations and gestational lipid trajectories varied by BMI group (P < 0.001). Preconception lipids were not associated with LGA or SGA in either group. A 10 mg/dL increase in HDL-C change from preconception to 28 weeks was associated with decreased odds of LGA (odds ratio (OR) = 0.63, 95% confidence interval (CI): 0.46, 0.86) and 10 mg/dL increase in TG change associated with increased odds of LGA (OR = 1.05, 95% CI: 1.01, 1.1) overall. For ≥25 BMI only, 10 mg/dL increase in HDL-C change was associated with decreased SGA odds (OR = 0.35, 95% CI: 0.19, 0.64). Gestational lipid trajectories differed by BMI group and were differentially associated with birthweight outcomes, with HDL-C more strongly associated with healthy birthweight in women with BMI ≥25.

Differential Effect of Ambient Air Pollution Exposure on Risk of Gestational Hypertension and Preeclampsia

Although ambient air pollution may increase hypertension risk through endothelial damage and oxidative stress, evidence is inconsistent regarding its effect on hypertension in pregnancy. Prior research has evaluated a limited scope of pollution species and often not differentiated preeclampsia, which may have a placental origin, from gestational hypertension. Among 49 607 women with at least 2 singleton deliveries in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Consecutive Pregnancies Study (2002-2010), we estimated criteria pollutant and volatile organic compound levels during pregnancy using Community Multiscale Air Quality models and abstracted gestational hypertension and preeclampsia diagnoses from medical records. Generalized estimating equations accounted for repeat pregnancies and adjusted for ambient temperature and maternal age, race/ethnicity, body mass index, smoking, alcohol, parity, insurance, marital status, and asthma. Air pollution levels were low to moderate (eg, median 41.6 ppb [interquartile range, 38.9-43.7 ppb] for ozone and 35.1 ppb [28.9-40.3 ppb] for nitrogen oxides). Higher levels of most criteria pollutants during preconception and the first trimester were associated with lower preeclampsia risk, while higher second-trimester levels were associated with greater gestational hypertension risk. For example, an interquartile increase in first-trimester carbon monoxide was associated with a relative risk of 0.88 (95% CI, 0.81-0.95) for preeclampsia and second-trimester carbon monoxide a relative risk of 1.14 (95% CI, 1.07-1.22) for gestational hypertension. Volatile organic compounds, conversely, were not associated with gestational hypertension but consistently associated with higher preeclampsia risk. These findings further suggest air pollution may affect the development of hypertension in pregnancy, although differing causes of preeclampsia and gestational hypertension may alter these relationships.

Ambient air pollution and fetal growth restriction: Physician diagnosis of fetal growth restriction versus population-based small-for-gestational age

BACKGROUND

Ambient air pollution may affect fetal growth restriction (FGR) through several mechanisms. However, prior studies of air pollution and small-for-gestational age (SGA), a common proxy for FGR, have reported inconsistent findings.

OBJECTIVE

We assessed air pollution in relation to physician-diagnosed FGR and population-based SGA in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Consecutive Pregnancy Study (2002-2010).

METHODS

Among 50,005 women (112,203 singleton births), FGR was captured from medical records and ICD-9 codes, and SGA determined by population standards for birthweight <10th, <5th and <3rd percentile. Community Multiscale Air Quality models estimated ambient levels of seven criteria pollutants for whole pregnancy, 3-months preconception, and 1st, 2nd and 3rd trimesters. Generalized estimating equations with robust standard errors accounted for interdependency of pregnancies within participant. Models adjusted for maternal age, race/ethnicity, pre-pregnancy body mass index, smoking, alcohol, parity, insurance, marital status, asthma and temperature.

RESULTS

FGR was diagnosed in 1.5% of infants, and 6.7% were <10th, 2.7% <5th and 1.5% <3rd percentile for SGA. Positive associations of SO2, NO2 and PM10 and negative associations of O3 with FGR were observed throughout preconception and pregnancy. For example, an interquartile increase in whole pregnancy SO2 was associated with 16% (95% CI 8%, 25%) increased FGR risk, 17% for NO2 (95% CI 9%, 26%) and 12% for PM10 (95% CI 6%, 19%). Associations with SGA were less clear.

CONCLUSIONS

Chronic exposure to air pollution may be associated with FGR but not SGA in this low-risk population.

Time-varying cycle average and daily variation in ambient air pollution and fecundability

STUDY QUESTION

Does ambient air pollution affect fecundability?

SUMMARY ANSWER

While cycle-average air pollution exposure was not associated with fecundability, we observed some associations for acute exposure around ovulation and implantation with fecundability.

WHAT IS KNOWN ALREADY

Ambient air pollution exposure has been associated with adverse pregnancy outcomes and decrements in semen quality.

STUDY DESIGN, SIZE, DURATION

The LIFE study (2005-2009), a prospective time-to-pregnancy study, enrolled 501 couples who were followed for up to one year of attempting pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Average air pollutant exposure was assessed for the menstrual cycle before and during the proliferative phase of each observed cycle (n = 500 couples; n = 2360 cycles) and daily acute exposure was assessed for sensitive windows of each observed cycle (n = 440 couples; n = 1897 cycles). Discrete-time survival analysis modeled the association between fecundability and an interquartile range increase in each pollutant, adjusting for co-pollutants, site, age, race/ethnicity, parity, body mass index, smoking, income and education.

MAIN RESULTS AND THE ROLE OF CHANCE

Cycle-average air pollutant exposure was not associated with fecundability. In acute models, fecundability was diminished with exposure to ozone the day before ovulation and nitrogen oxides 8 days post ovulation (fecundability odds ratio [FOR] 0.83, 95% confidence interval [CI]: 0.72, 0.96 and FOR 0.84, 95% CI: 0.71, 0.99, respectively). However, particulate matter ≤10 microns 6 days post ovulation was associated with greater fecundability (FOR 1.25, 95% CI: 1.01, 1.54).

LIMITATIONS, REASONS FOR CAUTION

Although our study was unlikely to be biased due to confounding, misclassification of air pollution exposure and the moderate study size may have limited our ability to detect an association between ambient air pollution and fecundability.

WIDER IMPLICATIONS OF THE FINDINGS

While no associations were observed for cycle-average ambient air pollution exposure, consistent with past research in the United States, exposure during critical windows of hormonal variability was associated with prospectively measured couple fecundability, warranting further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Longitudinal Investigation of Fertility and the Environment study contract nos. #N01-HD-3-3355, NO1-HD-#-3356, N01-HD-3-3358 and the Air Quality and Reproductive Health Study Contract No. HHSN275200800002I, Task Order No. HHSN27500008). We declare no conflict of interest.

Ambient air pollution and semen quality

BACKGROUND

Ambient air pollution is associated with systemic increases in oxidative stress, to which sperm are particularly sensitive. Although decrements in semen quality represent a key mechanism for impaired fecundability, prior research has not established a clear association between air pollution and semen quality. To address this, we evaluated the association between ambient air pollution and semen quality among men with moderate air pollution exposure.

METHODS

Of 501 couples in the LIFE study, 467 male partners provided one or more semen samples. Average residential exposure to criteria air pollutants and fine particle constituents in the 72 days before ejaculation was estimated using modified Community Multiscale Air Quality models. Generalized estimating equation models estimated the association between air pollutants and semen quality parameters (volume, count, percent hypo-osmotic swollen, motility, sperm head, morphology and sperm chromatin parameters). Models adjusted for age, body mass index, smoking and season.

RESULTS

Most associations between air pollutants and semen parameters were small. However, associations were observed for an interquartile increase in fine particulates ≤2.5 µm and decreased sperm head size, including -0.22 (95% CI -0.34, -0.11) µm2 for area, -0.06 (95% CI -0.09, -0.03) µm for length and -0.09 (95% CI -0.19, -0.06) µm for perimeter. Fine particulates were also associated with 1.03 (95% CI 0.40, 1.66) greater percent sperm head with acrosome.

CONCLUSIONS

Air pollution exposure was not associated with semen quality, except for sperm head parameters. Moderate levels of ambient air pollution may not be a major contributor to semen quality.

Preconception Blood Pressure Levels and Reproductive Outcomes in a Prospective Cohort of Women Attempting Pregnancy

Elevated blood pressure in young adulthood is an early risk marker for cardiovascular disease. Despite a strong biological rationale, little research has evaluated whether incremental increases in preconception blood pressure have early consequences for reproductive health. We evaluated preconception blood pressure and fecundability, pregnancy loss, and live birth in the EAGeR trial (Effects of Aspirin on Gestational and Reproduction; 2007-2011), a randomized clinical trial of aspirin and reproductive outcomes among 1228 women attempting pregnancy with a history of pregnancy loss. Systolic and diastolic blood pressure were measured during preconception in the first observed menstrual cycle and in early pregnancy and used to derive mean arterial pressure. Fecundability was assessed as number of menstrual cycles until pregnancy, determined through human chorionic gonadotropin testing. Pregnancy loss included both human chorionic gonadotropin-detected and clinical losses. Analyses adjusted for treatment assignment, age, body mass index, race, marital status, smoking, parity, and time since last loss. Mean preconception systolic and diastolic blood pressure were 111.6 mm Hg (SD, 12.1) and 72.5 (SD, 9.4) mm Hg. Risk of pregnancy loss increased 18% per 10 mm Hg increase in diastolic blood pressure (95% confidence interval, 1.03-1.36) and 17% per 10 mm Hg increase in mean arterial pressure (95% confidence interval, 1.02-1.35) in adjusted analyses. Findings were similar for early pregnancy blood pressure. Preconception blood pressure was not related to fecundability or live birth in adjusted analyses. Findings suggest that preconception blood pressure among healthy women is associated with pregnancy loss, and lifestyle interventions targeting blood pressure among young women may favorably impact reproductive health.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00467363.

C-Reactive protein in relation to fecundability and anovulation among eumenorrheic women

OBJECTIVE

To assess systemic inflammation in relation to fecundability and anovulation.

DESIGN

Prospective cohort study among participants in the Effects of Aspirin in Gestation and Reproduction trial who were assigned to the placebo.

SETTING

Academic medical centers.

PATIENT(S)

Healthy eumenorrheic women (n = 572), 18-40 years of age, with one or two pregnancy losses, attempting spontaneous pregnancy.

INTERVENTION(S)

Baseline serum high-sensitivity C-reactive protein (hsCRP) values <10 mg/L were categorized into tertiles.

MAIN OUTCOME MEASURE(S)

Discrete Cox proportional hazards models estimated the fecundability odds ratio (FOR) and 95% confidence interval (CI) and adjusted for potential confounders. Log-binomial regression estimated the risk ratio (RR) and 95% CI of anovulation. The algorithm to define anovulation used data on urinary concentrations of hCG, pregnanediol-3-glucuronide, and LH as well as fertility monitor readings.

RESULT(S)

Higher hsCRP was associated with reduced fecundability but not with an increased risk of anovulation.

CONCLUSION(S)

Among healthy women attempting pregnancy after one or two pregnancy losses, we found preliminary evidence that systemic inflammation is associated with reduced fecundability, but not independently from adiposity. Sporadic anovulation did not appear to drive this association.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT00467363.

The association of posttraumatic stress disorder and chronic medical conditions by ethnicity

Our study extends the literature on associations between posttraumatic stress disorder (PTSD) and chronic medical conditions by assessing differences in the magnitude of these relations by ethnicity. We examined group differences in the magnitude of the relation between PTSD and chronic medical conditions (cardiovascular disease [CVD], hypertension, obesity, diabetes). We obtained data from Latino (n = 3,224) and non-Latino white (n = 4,180) respondents from the Collaborative Psychiatric Epidemiology Surveys. Logistic regression models were constructed to test for the modification of the effect of PTSD on chronic medical conditions by ethnicity, and then by nativity. Unadjusted models revealed significant interactions between Latino ethnicity and PTSD for odds of diabetes (OR = 2.18 [Latino] v. 0.81 [non-Latino white]), CVD (OR = 3.23 [Latino] v. 1.28 [non-Latino white]), and hypertension (OR = 1.61 [Latino] v. 0.98 [non-Latino white]). Among U.S.-born Latinos, we found a significant interaction between ethnicity and PTSD for odds of CVD (OR = 4.18 [Latino] v. 1.28 [non-Latino white]) and diabetes (OR = 2.27 [Latino] v. 0.81 [non-Latino white]). These findings attenuated in adjusted models with the exception of differences in PTSD and odds of diabetes among Latinos (including aggregated group & U.S.-born) compared to non-Latino whites. Our findings support the need for further research on the complex relations between PTSD and chronic conditions, including the investigation of conditional risk by Latino sub-groups.

Usual Course of Treatment and Predictors of Treatment Utilization for Patients With Posttraumatic Stress Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric illness that frequently remains undiagnosed and untreated. While extensive research has been conducted among veterans, little research has evaluated course of treatment for PTSD in a general hospital setting.

METHODS

We utilized data from the Partners HealthCare Research Patient Data Registry to evaluate mental health treatment utilization, including psychotherapy and pharmacotherapy, by patients with recently diagnosed primary PTSD following DSM-IV criteria between January 1, 2002, and June 30, 2011. We additionally evaluated predictors of treatment utilization 6 months postdiagnosis.

RESULTS

Among 2,475 patients with recently diagnosed primary PTSD, approximately half (55.7%) had any therapy visit and 10% had at least 12 therapy visits in the 6 months following diagnosis. Approximately half (47.0%) received a psychiatric prescription, with 29.3% receiving a selective serotonin reuptake inhibitor (SSRI), 11.8% receiving an atypical antipsychotic, and 24.4% receiving a benzodiazepine. Latinos were 25% (95% CL = 1.09, 1.43) more likely to have an SSRI prescription, 35% (95% CL = 1.05, 1.75) more likely to have an atypical antipsychotic prescription, and 28% (95% CL = 1.19, 1.38) more likely to receive any psychotherapy. Women were 49% (95% CL = 0.42, 0.63) less likely to have an atypical antipsychotic prescription. Patients with Medicare were 23% (95% CL = 0.67, 0.88) less likely to have any psychotherapy, and patients with Medicaid were 35% (95% CL = 0.46, 0.92) less likely to have 12 or more therapy visits.

CONCLUSIONS

Many patients with a primary diagnosis of PTSD do not receive psychotherapy, and psychiatric prescriptions, including atypical antipsychotics and benzodiazepines, are common. Future research is needed to determine the quality of care received and explore subpopulation-specific barriers limiting access to care.

Residential segregation and mental health among Latinos in a nationally representative survey

BACKGROUND

Among Latinos, living in a locality with greater Latino ethnic density may be protective for mental health, although findings vary by Latino subgroup, gender and birthplace. Although little studied, Latino residential segregation may capture different pathways linking risk and protective environmental factors to mental health than local ethnic density.

METHODS

This study evaluated the association between residential segregation and mental distress as measured by the Kessler-10 (K10) among Latino participants in the National Latino and Asian American Study (NLAAS). Census data from 2000 was used to calculate metropolitan statistical area (MSA) residential segregation using the dissimilarity and isolation indices, as well as census tract ethnicity density and poverty. Latino subgroup (Puerto Rican, Mexican American, Cuban American and other Latino subgroup), gender and generation status were evaluated as moderators.

RESULTS

Among 2554 Latino participants in NLAAS, residential segregation as measured by the isolation index was associated with less mental distress (β -0.14, 95% CI -0.26 to -0.03 log(K10)) among Latinos overall after adjustment for ethnic density, poverty and individual covariates. Residential segregation as measured by the dissimilarity index was significantly associated with less mental distress among men (β -0.56, 95% CI -1.04 to -0.08) but not among women (β -0.20, 95% CI -0.45 to 0.04, p-interaction=0.019). No modification was observed by Latino subgroup or generation.

CONCLUSIONS

Among Latinos, increasing residential segregation was associated with less mental distress, and this association was moderated by gender. Findings suggest that MSA-level segregation measures may capture protective effects associated with living in Latino communities for mental health.

Association of premenstrual syndrome and premenstrual dysphoric disorder with bulimia nervosa and binge-eating disorder in a nationally representative epidemiological sample

OBJECTIVE

Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with significant health impairment. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) comprise both psychological (disturbances in mood and affect) and physiological (bloating and changes in appetite) symptoms that may trigger binge-eating and/or purging.

METHOD

Female participants were drawn from the Collaborative Psychiatric Epidemiological Surveys, conducted from 2001 to 2003. Weighted multivariable logistic regression modeled the association between lifetime PMS and PMDD and lifetime odds of BN or BED.

RESULTS

Among 8,694 participants, 133 (1.0%) had BN and 185 (1.8%) BED. Additionally, 366 (4.2%) had PMDD and 3,489 (42.4%) had PMS. Prevalence of PMDD and PMS were 17.4 and 55.4% among those with BN, 10.7 and 48.9% among those with BED and 3.4 and 59.1% among those with subthreshold BED. After adjustment for age, race/ethnicity, income, education, body mass index, age at menarche, birth control use, and comorbid mental health conditions, PMDD was associated with seven times the odds of BN (OR 7.2, 95% CI 2.3, 22.4) and PMS with two times the odds of BN (OR 2.5, 95% CI 1.1, 5.7). Neither PMDD nor PMS were significantly associated with BED.

DISCUSSION

Women with PMS and PMDD have a higher odds of BN, independent of comorbid mental health conditions. PMS and PMDD may be important comorbidities to BN to consider in clinical settings, and future research should investigate whether PMS and PMDD affect the onset and duration of bulimic symptoms as well as the potential for shared risk factors across disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:641-650).

Black-white disparities in the association between posttraumatic stress disorder and chronic illness

OBJECTIVE

Non-Latino blacks experience a higher proportion of chronic illness and associated disabilities than non-Latino whites. Posttraumatic stress disorder (PTSD) is associated with a greater risk of chronic illness, although few studies have investigated whether the interaction of PTSD with racial disparities may lead to a greater risk of chronic illness among blacks with PTSD than among whites with PTSD.

METHODS

We evaluated data from the population-based National Survey of American Life and the National Comorbidity Survey Replication to investigate the association between race, lifetime PTSD and self-reported chronic illness. Weighted linear and Poisson regression models assessed differences in the magnitude of association between PTSD and chronic illness by race on both the additive and multiplicative scales.

RESULTS

The magnitude of the association between lifetime PTSD and diabetes was greater among blacks (RD 0.07, 95% CI 0.02, 0.11; RR 1.9, 95% CI 1.4, 2.5) than whites (RD 0.004, 95% CI -0.02, 0.03; RR 1.2, 95% CI 0.7, 1.9) on the additive (p=0.017) scale. The magnitude of the association between lifetime PTSD and heart disease was greater among blacks (RD 0.09, 95% CI 0.05, 0.13) than whites (RD 0.04, 95% CI 0.01, 0.07) on the additive scale at a level approaching significance (p=0.051).

CONCLUSION

A lifetime history of PTSD was associated with a significantly greater risk of diabetes among blacks as compared to whites. These findings suggest that continuous exposure to racial inequalities may be associated with a greater risk of PTSD-related health sequela.

Longitudinal Study of Mental Health and Pain-Related Functioning Following a Motor Vehicle Collision

OBJECTIVE

Relations between mental and physical health symptoms are well-established in the literature on recovery following motor vehicle collisions (MVCs). To understand the temporal sequencing and evolution of these relations, we examined the bidirectional association between mental and physical health symptoms at 4 and 16 weeks following a MVC.

METHODS

The sample consisted of 103 participants recruited through public MVC police reports. The study included self-report assessments for posttraumatic stress symptoms, depressive symptoms, bodily pain, and role limitations attributable to physical health. A series of multivariable linear regression analyses were conducted to estimate the associations between these mental and physical health outcomes.

RESULTS

The analysis revealed that mental health symptoms at 4 weeks post-MVC were associated with higher bodily pain at 16 weeks post-MVC (PTSD symptoms: β = -0.74, 95% CI: -1.06, -0.42; depressive symptoms: β = -1.34, 95% CI: -1.90, -0.78), but not higher health-related role limitations. Physical health symptoms at 4 weeks post-MVC were not associated with PTSD or depressive symptoms at 16 weeks post-MVC.

CONCLUSIONS

The results indicate the predictive strength of mental health symptoms at 4 weeks post-MVC in identifying individuals at risk for bodily pain at 16 weeks and shed light on the temporal sequencing of how relations between physical and mental health symptoms emerge over time. This suggests that early assessment of mental health symptoms may have significant implications for the treatment of these patients. (PsycINFO Database Record

Early pregnancy vitamin D status and risk for adverse maternal and infant outcomes in a bi-ethnic cohort: the Behaviors Affecting Baby and You (B.A.B.Y.) Study

Vitamin D deficiency is common during pregnancy and higher in Hispanic as compared with non-Hispanic white women. However, the association between vitamin D deficiency and adverse pregnancy outcomes remains unclear and may vary across ethnic groups, in part because of genetic variation in the metabolism of vitamin D. Few studies have included Hispanic women. Therefore, we investigated this association among 237 participants in the Behaviors Affecting Baby and You Study, a randomised trial of an exercise intervention among ethnically diverse prenatal care patients in Massachusetts. Baseline serum 25-hydroxyvitamin D (25(OH)D) was measured at 15·2 (sd 4·7) weeks' gestation. Information on adverse pregnancy outcomes was abstracted from medical records. Mean 25(OH)D was 30·4 (sd 12·0) ng/ml; 53·2 % of participants had insufficient (<30 ng/ml) and 20·7 % had deficient (<20 ng/ml) 25(OH)D levels. After adjusting for month of blood draw, gestational age at blood draw, gestational age at delivery, age, BMI and Hispanic ethnicity, women with insufficient and deficient vitamin D had infants with birth weights 139·74 (se 69·16) g (P=0·045) and 175·52 (se 89·45) g (P=0·051) lower compared with women with sufficient vitamin D levels (≥30 ng/ml). Each 1 ng/ml increase in 25(OH)D was associated with an increased risk for gestational diabetes mellitus among Hispanic women only (relative risk 1·07; 95 % CI 1·03, 1·11) in multivariable analysis. We did not observe statistically significant associations between maternal vitamin D status and other pregnancy outcomes. Our findings provide further support for an adverse impact of vitamin D deficiency on birth weight in Hispanic women.

At-home oral care for adults with developmental disabilities: a survey of caregivers

BACKGROUND

Little is known about effective at-home oral care methods for people with developmental disabilities (DDs) who are unable to perform personal preventive practices themselves and rely on caregivers for assistance.

METHODS

A convenience sample of 808 caregivers (84.5 percent paid, 15.5 percent family members) who accompanied adults with DDs (20 years or older) to appointments at a specialized statewide dental care system completed computer-assisted personal interview surveys. The authors used these data to investigate caregivers' at-home oral care experiences and to explore differences between caregivers who were paid and those who were family members.

RESULTS

Caregivers reported that a high proportion (85 percent) of dentate adults with DDs received assistance with tooth cleaning. They also reported a high prevalence of dental problems, and low adherence to brushing (79 percent) and flossing (22 percent) recommendations. More caregivers reported that they felt confident assisting with brushing than with flossing (85 percent versus 54 percent). Family members and paid caregivers differed with respect to confidence and training.

CONCLUSIONS

At-home oral care, particularly flossing, presents substantial challenges for adults with DDs. Solutions must be tailored to address the different experiences and distinct needs of the family members and paid caregivers who assist these adults.

PRACTICAL IMPLICATIONS

Caregivers play an important role in providing at-home oral care, and they must be included in efforts to improve oral health outcomes for people with DDs.