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Lueth AJ, Allshouse AA, Silver RM, Hawkins MS, Grobman WA, Redline S, Zee P, Manchada S, Pien G. Allostatic load in early pregnancy and sleep-disordered breathing. J Matern Fetal Neonatal Med 2024; 37:2305680. [PMID: 38253519 DOI: 10.1080/14767058.2024.2305680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES To assess the association between allostatic load in early pregnancy and sleep-disordered breathing (SDB) during pregnancy. METHODS High allostatic load in the first trimester was defined as ≥ 4 of 12 biomarkers (systolic blood pressure, diastolic blood pressure, body mass index, cholesterol, low-density lipoprotein, high-density lipoprotein, high sensitivity C-reactive protein, triglycerides, insulin, glucose, creatinine, and albumin) in the unfavorable quartile. SDB was objectively measured using the Embletta-Gold device and operationalized as "SDB ever" in early (6-15 weeks) or mid-pregnancy (22-31 weeks); SDB at each time point was analyzed as secondary outcomes. Multivariable logistic regression was used to test the association between high allostatic load and SDB, adjusted for confounders. Moderation and sensitivity analyses were conducted to assess the role of allostatic load in racial disparities of SDB and obesity affected the relationship between allostatic load and SDB. RESULTS High allostatic load was present in 35.0% of the nuMoM2b cohort. The prevalence of SDB ever occurred among 8.3% during pregnancy. After adjustment, allostatic load remained significantly associated with SDB ever (aOR= 5.3; 3.6-7.9), in early-pregnancy (aOR= 7.0; 3.8-12.8), and in mid-pregnancy (aOR= 5.8; 3.7-9.1). The association between allostatic load and SDB was not significantly different for people with and without obesity. After excluding BMI from the allostatic load score, the association decreased in magnitude (aOR= 2.6; 1.8-3.9). CONCLUSION The association between allostatic load and SDB was independent of confounders including BMI. The complex and likely bidirectional relationship between chronic stress and SDB deserves further study in reducing SDB.
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Affiliation(s)
- Amir J Lueth
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Marquis S Hawkins
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, USA
| | - Susan Redline
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, USA
| | - Phyllis Zee
- Department of Obstetrics and Gynecology, Northwestern University, Evanston, IL, USA
| | - Shalini Manchada
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University, Bloomington, IN, USA
| | - Grace Pien
- Department of Obstetrics and Gynecology, School of Medicine, John Hopkins University, Baltimore, MD, USA
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Einerson BD, Allshouse AA, Sandoval G, Nelson RE, Esplin MS, Varner M, Grobman WA, Metz TD. Source of variation in cost of obstetrical care for low-risk nulliparas at term. Am J Obstet Gynecol 2024; 230:e99-e100. [PMID: 38191018 PMCID: PMC11070294 DOI: 10.1016/j.ajog.2023.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, 30N 1900 East, Room 2B200, Salt Lake City, UT 84132; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT.
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Grecio Sandoval
- George Washington University Biostatistics Center, Washington, DC
| | - Richard E Nelson
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT; IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - M Sean Esplin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
| | - Michael Varner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
| | - William A Grobman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
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Page JM, Allshouse AA, Gaffney JE, Roberts VHJ, Thorsten V, Gibbins KJ, Dudley DJ, Saade G, Goldenberg RL, Stoll BJ, Hogue CJ, Bukowski R, Parker C, Conway D, Reddy UM, Varner MW, Frias AE, Silver RM. DLK1: A Novel Biomarker of Placental Insufficiency in Stillbirth and Live Birth. Am J Perinatol 2024; 41:e221-e229. [PMID: 35709732 DOI: 10.1055/a-1877-6191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Delta-like homolog 1 (DLK1) is a growth factor that is reduced in maternal sera in pregnancies with small for gestational age neonates. We sought to determine if DLK1 is associated with stillbirth (SB), with and without placental insufficiency. STUDY DESIGN A nested case-control study was performed using maternal sera from a multicenter case-control study of SB and live birth (LB). SB and LB were stratified as placental insufficiency cases (small for gestational age <5% or circulatory lesions on placental histopathology) or normal placenta controls (appropriate for gestational age and no circulatory lesions). Enzyme-linked immunosorbent assay (ELISA) was used to measure DLK1. The mean difference in DLK1 was compared on the log scale in an adjusted linear regression model with pairwise differences, stratified by term/preterm deliveries among DLK1 results in the quantifiable range. In exploratory analysis, geometric means were compared among all data and the proportion of "low DLK1" (less than the median value for gestational age) was compared between groups and modeled using linear and logistic regression, respectively. RESULTS Overall, 234 SB and 234 LB were analyzed; 246 DLK1 values were quantifiable within the standard curve. Pairwise comparisons of case and control DLK1 geometric means showed no significant differences between groups. In exploratory analysis of all data, adjusted analysis revealed a significant difference for the LB comparison only (SB: 71.9 vs. 99.1 pg/mL, p = 0.097; LB: 37.6 vs. 98.1 pg/mL, p = 0.005). In exploratory analysis of "low DLK1," there was a significant difference between the odds ratio of having "low DLK1" between preterm cases and controls for both SB and LB. There were no significant differences in geometric means nor "low DLK1" between SB and LB. CONCLUSION In exploratory analysis, more placental insufficiency cases in preterm SB and LB had "low DLK1." However, low DLK1 levels were not associated with SB. KEY POINTS · Maternally circulating DLK1 is correlated with placental insufficiency.. · Maternally circulating DLK1 is not correlated with SB.. · DLK1 is a promising marker for placental insufficiency..
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Affiliation(s)
- Jessica M Page
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal-Fetal Medicine, Intermountain Health Care, Murray, Utah
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah
| | - Jessica E Gaffney
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center Oregon Health and Science University, Portland, Oregon
| | - Victoria H J Roberts
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center Oregon Health and Science University, Portland, Oregon
| | | | - Karen J Gibbins
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Donald J Dudley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia
| | - George Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Barbara J Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Carol J Hogue
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Radek Bukowski
- Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Corette Parker
- RTI International, Research Triangle Park, North Carolina
| | - Deborah Conway
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Uma M Reddy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut
| | - Michael W Varner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal-Fetal Medicine, Intermountain Health Care, Murray, Utah
| | - Antonio E Frias
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal-Fetal Medicine, Intermountain Health Care, Murray, Utah
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Bridges AG, Allshouse AA, Canfield DR, Grover BW, Son SL, Einerson BD, Silver RM, Haas DM, Grobman WA, Simhan HN, Day RC, Blue NR. Association of Prostaglandin Use for Cervical Ripening with Mode of Delivery in Small for Gestational Age versus Non-Small for Gestational Age Neonates. Am J Perinatol 2024; 41:e456-e464. [PMID: 35863371 DOI: 10.1055/a-1906-8919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Prostaglandins (PGs) use for cervical ripening with small for gestational age (SGA) fetuses is controversial since it remains uncertain if use increases the chance of cesarean delivery (CD). We aimed to assess the association between PG use for cervical ripening and mode of delivery between SGA and appropriate for gestational age (AGA) neonates. STUDY DESIGN Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective observational cohort study of 10,038 nulliparas. We included women undergoing induction with nonanomalous fetuses in the cephalic presentation. Women with >2 cm cervical dilation or prior uterine scar were excluded. We assessed the association of PG use with CD among women with SGA and AGA neonates. SGA was defined as birth weight <10th percentile for gestational age and sex. Multivariable logistic regression was used to adjust for potential confounders and test for interaction. Secondary outcomes included adverse neonatal outcomes, indication for CD, maternal hemorrhage, and chorioamnionitis. RESULTS Among 2,353 women eligible, PGs were used in 54.8%, SGA occurred in 15.1%, and 35.0% had CD. The association between PG use and CD differed significantly (interaction p = 0.018) for SGA versus AGA neonates; CD occurred more often in SGA neonates exposed to PGs than not (35 vs. 22%, p = 0.009). PG use was not associated with CD among AGA neonates (36 vs. 36%, p = 0.8). This effect remained significant when adjusting for body mass index, race/ethnicity, and cervical dilation. Among SGA neonates, CD for "nonreassuring fetal status" was similar between PG groups. Among SGA neonates, PG use was not associated with adverse neonatal outcomes or postpartum hemorrhage but had a higher rate of chorioamnionitis (7.0 vs. 2.1%, p = 0.048). CONCLUSION PG use was associated with a higher rate of CD in SGA but not AGA neonates; however, further studies are needed before PG use is discouraged with SGA neonates. KEY POINTS · PGs are commonly used for cervical ripening.. · PG use was associated with increased risk of cesarean delivery in SGA neonates.. · PG use was not associated with adverse neonatal outcomes..
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Affiliation(s)
- Alexis G Bridges
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Dana R Canfield
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Bryan W Grover
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Shannon L Son
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Hyagriv N Simhan
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Day
- Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
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5
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Hendrickson WK, Allshouse AA, Nygaard IE, Swenson CW. Overactive Bladder in Late Pregnancy to 1 Year After First Vaginal Delivery. Urogynecology (Phila) 2024; 30:433-442. [PMID: 37903370 PMCID: PMC10987286 DOI: 10.1097/spv.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
IMPORTANCE Understanding overactive bladder (OAB) during pregnancy and postpartum may increase our knowledge of pathophysiology. OBJECTIVES The purpose of this study was to understand the prevalence and severity of OAB during pregnancy through 1 year postpartum as well as the associated factors. STUDY DESIGN This is a secondary analysis of a prospective cohort study evaluating primiparous women with a singleton term vaginal delivery assessed at the third trimester, 8 weeks postpartum, and 1 year postpartum. Overactive bladder was defined as urinary urgency plus nocturia or frequency, or urgency urinary incontinence (UUI). Overactive bladder severity was defined using average visual analog scores (0-100) from OAB symptoms on the Epidemiology of Prolapse and Incontinence Questionnaire. We evaluated associations with OAB at each time point using logistic regression. RESULTS Among 579 participants, mean age was 29 years. Overactive bladder prevalence was higher at 8 weeks postpartum (23%) than at the third trimester (18%, P = 0.03) and 1 year postpartum (19%, P = 0.03). Overactive bladder severity was higher at the third trimester (42.2) than at 8 weeks postpartum (23.3, P = 0.008), but not at 1 year postpartum (29.1, P = 0.1). In those with OAB, UUI severity was higher at 1 year postpartum compared with that at the third trimester ( P = 0.02). Younger age was associated with third trimester OAB. At 8 weeks postpartum, OAB was associated with older age, urinary tract infection after delivery, birth weight ≥3,500 g, and third trimester OAB. At 1 year postpartum, OAB was associated with birth weight ≥3,500 g and third trimester OAB. CONCLUSIONS Overactive bladder affects 1 in 5 primiparous women during pregnancy or after vaginal delivery. The increased severity of UUI postpartum and the association between higher birth weight and OAB postpartum suggest an effect of delivery.
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Affiliation(s)
- Whitney K. Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Amanda A. Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Ingrid E. Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Carolyn W. Swenson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
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Nicola-Ducey L, Allshouse AA, Canfield D, Nygaard IE. Pelvic Floor Symptoms 4 Years After Elective Labor Induction: A Randomized Clinical Trial. Urogynecology (Phila) 2024:02273501-990000000-00190. [PMID: 38498772 DOI: 10.1097/spv.0000000000001482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
IMPORTANCE Pelvic floor disorders are common and burdensome. Data on the effect of induction of labor on pelvic floor disorders are sparse and results are mixed. OBJECTIVE Our aim was to evaluate whether elective labor induction in nulliparous women increases the risks of symptomatic urinary incontinence (UI), anal incontinence (AI), or pelvic organ prolapse (POP) 4 years after delivery. STUDY DESIGN In this single-site follow-up study of "A Randomized Trial of Induction Versus Expectant Management" (ARRIVE) that randomized low-risk nulliparous women with a singleton fetus to elective induction of labor versus expectant management, we compared pelvic floor symptoms between groups at a median of 4 years (interquartile range, 3.5-5.3) after first delivery using validated questionnaires. RESULTS Seventy hundred sixty-six of 1,042 (74%) original participants responded, and 647 participants (62%) were included in the analysis after exclusions. The overall prevalence rates of symptomatic moderate to severe UI, AI, and POP were 21%, 14%, and 8%, respectively. There were no significant differences in any of the outcomes between women randomized to induction of labor and those to expectant management, either in unadjusted or adjusted analyses. There were also no differences in secondary outcomes, including subtypes of UI or flatal versus stool incontinence. CONCLUSIONS In this single-site study, we found no significant differences in any UI, AI, and POP symptoms between nulliparous women randomized to elective induction of labor and to expectant management; however, for the least frequent outcome (POP), meaningful differences cannot be ruled out.
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Affiliation(s)
- Lauren Nicola-Ducey
- From the Department of Obstetrics and Gynecology, Oregon Health Science University, Portland, OR
| | | | - Dana Canfield
- Department of Obstetrics and Gynecology, University of California, San Diego, San Diego, CA
| | - Ingrid E Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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Swenson CW, Hendrickson WK, Allshouse AA, Nygaard IE. Older maternal age at first vaginal delivery is associated with increased genital hiatus size at 1 year postpartum. Am J Obstet Gynecol 2024:S0002-9378(24)00062-0. [PMID: 38307470 DOI: 10.1016/j.ajog.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/18/2023] [Accepted: 01/20/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Carolyn W Swenson
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112.
| | - Whitney K Hendrickson
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
| | - Ingrid E Nygaard
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
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Smid MC, Allshouse AA, Metz TD, Debbink MP, Charron E, Campbell K, Cochran G. Co-occurring opioid and methamphetamine use disorder and severe maternal morbidity and mortality in Utah. Am J Obstet Gynecol MFM 2024; 6:101221. [PMID: 37949409 DOI: 10.1016/j.ajogmf.2023.101221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Marcela C Smid
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT.
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Michelle P Debbink
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Schusterman Center, Tulsa, OK
| | - Kristine Campbell
- Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Metz TD, Allshouse AA, McMillin GA, Greene T, Chung JH, Grobman WA, Haas DM, Mercer BM, Parry S, Reddy UM, Saade GR, Simhan HN, Silver RM. Cannabis Exposure and Adverse Pregnancy Outcomes Related to Placental Function. JAMA 2023; 330:2191-2199. [PMID: 38085313 PMCID: PMC10716715 DOI: 10.1001/jama.2023.21146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 12/18/2023]
Abstract
Importance Cannabis use is increasing among reproductive-age individuals and the risks associated with cannabis exposure during pregnancy remain uncertain. Objective To evaluate the association between maternal cannabis use and adverse pregnancy outcomes known to be related to placental function. Design, Setting, and Participants Ancillary analysis of nulliparous individuals treated at 8 US medical centers with stored urine samples and abstracted pregnancy outcome data available. Participants in the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort were recruited from 2010 through 2013; the drug assays and analyses for this ancillary project were completed from June 2020 through April 2023. Exposure Cannabis exposure was ascertained by urine immunoassay for 11-nor-9-carboxy-Δ9-tetrahydrocannabinol using frozen stored urine samples from study visits during the pregnancy gestational age windows of 6 weeks and 0 days to 13 weeks and 6 days (visit 1); 16 weeks and 0 days to 21 weeks and 6 days (visit 2); and 22 weeks and 0 days to 29 weeks and 6 days (visit 3). Positive results were confirmed with liquid chromatography tandem mass spectrometry. The timing of cannabis exposure was defined as only during the first trimester or ongoing exposure beyond the first trimester. Main Outcome and Measure The dichotomous primary composite outcome included small-for-gestational-age birth, medically indicated preterm birth, stillbirth, or hypertensive disorders of pregnancy ascertained by medical record abstraction by trained perinatal research staff with adjudication of outcomes by site investigators. Results Of 10 038 participants, 9257 were eligible for this analysis. Of the 610 participants (6.6%) with cannabis use, 32.4% (n = 197) had cannabis exposure only during the first trimester and 67.6% (n = 413) had ongoing exposure beyond the first trimester. Cannabis exposure was associated with the primary composite outcome (25.9% in the cannabis exposure group vs 17.4% in the no exposure group; adjusted relative risk, 1.27 [95% CI, 1.07-1.49]) in the propensity score-weighted analyses after adjustment for sociodemographic characteristics, body mass index, medical comorbidities, and active nicotine use ascertained via urine cotinine assays. In a 3-category cannabis exposure model (no exposure, exposure only during the first trimester, or ongoing exposure), cannabis use during the first trimester only was not associated with the primary composite outcome; however, ongoing cannabis use was associated with the primary composite outcome (adjusted relative risk, 1.32 [95% CI, 1.09-1.60]). Conclusions and Relevance In this multicenter cohort, maternal cannabis use ascertained by biological sampling was associated with adverse pregnancy outcomes related to placental dysfunction.
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Affiliation(s)
| | | | - Gwendolyn A McMillin
- University of Utah Health, Salt Lake City
- ARUP Laboratories, Salt Lake City, Utah
| | - Tom Greene
- University of Utah Health, Salt Lake City
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Bruno AM, Allshouse AA, Benson AE, Yost CC, Metz TD, Varner MW, Silver RM, Branch DW. Thrombotic Markers in Pregnant Patients with and without SARS-CoV-2 Infection. Am J Perinatol 2023. [PMID: 37967868 DOI: 10.1055/a-2211-5052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with coagulation abnormalities and increased risk for venous and arterial thrombi. This study aimed to evaluate D-dimer levels and lupus anticoagulant (LAC) positivity in pregnant individuals with and without Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. STUDY DESIGN This was a prospective cohort study of pregnant individuals delivering at a single academic institution from April 2020 to March 2022. Individuals with a positive SARS-CoV-2 result during pregnancy were compared with a convenience sample of those without a positive SARS-CoV-2 result. For individuals with SARS-CoV-2 infection, severity was assessed based on the National Institutes of Health classification system. The primary outcome was D-dimer level measured during delivery admission. The secondary outcomes were LAC positivity and thromboembolic events. Outcomes were compared between individuals with and without a positive SARS-CoV-2 result, and further by disease severity. RESULTS Of 98 participants, 77 (78.6%) were SARS-CoV-2 positive during pregnancy. Among individuals with SARS-CoV-2 infection, severity was asymptomatic in 20 (26.0%), mild in 13 (16.9%), moderate in 4 (5.2%), severe in 38 (49.4%), and critical in 2 (2.6%). The D-dimer concentration at delivery did not significantly differ between those with a SARS-CoV-2 positive result compared with those without (mean 2.03 µg/mL [95% confidence interval {CI} 1.72-2.40] vs. 2.37 µg/mL [95% CI 1.65-3.40]; p = 0.43). Three individuals (4%) with SARS-CoV-2 infection and none (0%) without infection were LAC positive (p = 0.59). There were no clinically apparent thromboses in either group. D-dimer concentrations and LAC positive results did not differ by COVID-19 severity. CONCLUSION Thrombotic markers did not differ in pregnant individuals by SARS-CoV-2 infection; however, high rates of LAC positivity were detected. KEY POINTS · Thrombotic markers did not differ in pregnant individuals by SARS-CoV-2 infection.. · Higher than expected rates of LAC positivity were detected.. · There were no clinically apparent thromboses..
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Affiliation(s)
- Ann M Bruno
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics & Gynecology, Intermountain Health, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Ashley E Benson
- Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Christian Con Yost
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
- Molecular Medicine Program, Molecular Medicine Program, University of Utah, Salt Lake City, Utah
| | - Torri D Metz
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics & Gynecology, Intermountain Health, Salt Lake City, Utah
| | - Michael W Varner
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
| | - D Ware Branch
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics & Gynecology, Intermountain Health, Salt Lake City, Utah
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Merriam AA, Metz TD, Allshouse AA, Silver RM, Haas DM, Grobman WA, Simhan HN, Wapner RJ, Wing D, Mercer BM, Parry S, Reddy UM. Reply: The Risk Factor for Maternal Morbidity is Racism, Not Race. Am J Perinatol 2023. [PMID: 37863072 DOI: 10.1055/a-2195-6914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
- Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, Connecticut
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Hyagriv N Simhan
- Department of Obstetrics and Gynecology, The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Deborah Wing
- Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
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12
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Canfield DR, Allshouse AA, Smith J, Metz TD, Grobman WA, Silver RM. Labour agentry and subsequent adverse mental health outcomes: A follow-up study of the ARRIVE Trial. BJOG 2023. [PMID: 37968788 DOI: 10.1111/1471-0528.17703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 10/04/2023] [Accepted: 10/19/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Labour can be traumatic for women who perceive they are not involved in decisions affecting their care during labour. Our objective was to assess the relation between labour agentry and subsequent mental health. DESIGN Follow-up cohort study. SETTING U.S. Tertiary care center. POPULATION Participants from Utah who participated in the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial. METHODS During the ARRIVE trial, participants completed the Labor Agentry Scale twice, a validated questionnaire measuring perceived control of patients during childbirth. ARRIVE participants from Utah subsequently were asked to complete questions about mental health history and stressful events occurring since the trial, as well as surveys including the Primary Care Posttraumatic Stress Disorder (PC-PTSD) screen, Edinburgh Postnatal Depression Scale (EPDS) and Generalised Anxiety Disorder-7 (GAD-7) screen. The lower quartile of both agentry measurements defined a person's ordinal agentry category, used for assessing cohort characteristics by exposure category. Continuous minimum agentry was included in adjusted modelling. MAIN OUTCOME MEASURES The primary outcome was a mental health composite including a positive screen for depression, anxiety, or PTSD or self-report of a diagnosis or exacerbation since their delivery. RESULTS In all, 766 of 1042 (74%) people responded to the survey (median 4.4, range 2.5-6.4 years after delivery) and 753 had complete data for analysis. In unadjusted comparisons across ordinal agentry category, lower agentry was significantly associated with the primary composite endpoint, and depressive symptoms (test of trend p = 0.003 primary, p = 0.004 depression). Lower labour agentry scores were associated with incremental odds of the primary endpoint (1 SD [24 units], adjusted odds ratio [aOR] 1.21, 95% CI 1.41-1.03), driven by depressive symptoms or self-reported diagnosis (aOR 1.25, 95% CI 1.47-1.05). CONCLUSIONS Lower labour agentry at the time of birth was associated with a greater risk for mental health conditions years after delivery, indicating a potential opportunity for primary prevention of subsequent depression.
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Affiliation(s)
- Dana R Canfield
- Department of Obstetrics and Gynecology, Univeristy of California, San Diego, California, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Jessica Smith
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
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13
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Dalton SE, Workalemahu T, Allshouse AA, Page JM, Reddy UM, Saade GR, Pinar H, Goldenberg RL, Dudley DJ, Silver RM. Copy number variants and fetal growth in stillbirths. Am J Obstet Gynecol 2023; 228:579.e1-579.e11. [PMID: 36356697 PMCID: PMC10149588 DOI: 10.1016/j.ajog.2022.11.1274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fetal growth abnormalities are associated with a higher incidence of stillbirth, with small and large for gestational age infants incurring a 3 to 4- and 2 to 3-fold increased risk, respectively. Although clinical risk factors such as diabetes, hypertension, and placental insufficiency have been associated with fetal growth aberrations and stillbirth, the role of underlying genetic etiologies remains uncertain. OBJECTIVE This study aimed to assess the relationship between abnormal copy number variants and fetal growth abnormalities in stillbirths using chromosomal microarray. STUDY DESIGN A secondary analysis utilizing a cohort study design of stillbirths from the Stillbirth Collaborative Research Network was performed. Exposure was defined as abnormal copy number variants including aneuploidies, pathogenic copy number variants, and variants of unknown clinical significance. The outcomes were small for gestational age and large for gestational age stillbirths, defined as a birthweight <10th percentile and greater than the 90th percentile for gestational age, respectively. RESULTS Among 393 stillbirths with chromosomal microarray and birthweight data, 16% had abnormal copy number variants. The small for gestational age outcome was more common among those with abnormal copy number variants than those with a normal microarray (29.5% vs 16.5%; P=.038). This finding was consistent after adjusting for clinically important variables. In the final model, only abnormal copy number variants and maternal age remained significantly associated with small for gestational age stillbirths, with an adjusted odds ratio of 2.22 (95% confidence interval, 1.12-4.18). Although large for gestational age stillbirths were more likely to have an abnormal microarray: 6.2% vs 3.3% (P=.275), with an odds ratio of 2.35 (95% confidence interval, 0.70-7.90), this finding did not reach statistical significance. CONCLUSION Genetic abnormalities are more common in the setting of small for gestational age stillborn fetuses. Abnormal copy number variants not detectable by traditional karyotype make up approximately 50% of the genetic abnormalities in this population.
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Affiliation(s)
- Susan E Dalton
- University of Utah Health, Salt Lake City, UT; Intermountain Healthcare, Salt Lake City, UT
| | | | | | | | | | - George R Saade
- University of Texas Medical Branch at Galveston, Galveston, TX
| | - Halit Pinar
- Brown University School of Medicine, Providence, RI
| | | | | | - Robert M Silver
- University of Utah Health, Salt Lake City, UT; Intermountain Healthcare, Salt Lake City, UT.
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14
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Lueth AJ, Allshouse AA, Blue NM, Grobman WA, Levine LD, Catov J, Saade G, Yee LM, Wilson FA, Murtaugh M, Merz N, Chung J, Ray M, Scifres C, Silver RM. Can allostatic load in pregnancy explain the association between race and subsequent cardiovascular disease risk: A cohort study. BJOG 2023. [PMID: 37069728 DOI: 10.1111/1471-0528.17486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVE To assess the relationship between allostatic load, a measure of cumulative chronic stress in early pregnancy and cardiovascular disease risk, 2-7 years postpartum, and pathways contributing to racial disparities in cardiovascular disease risk. DESIGN Secondary analysis of a prospective cohort study. SETTING MULTICENTER POPULATION Pregnant women. METHODS Our primary exposure was high allostatic load in the first trimester, defined as at least 4 of 12 biomarkers (systolic blood pressure, diastolic blood pressure, body mass index, cholesterol, low-density lipoprotein, high-density lipoprotein, high-sensitivity C-reactive protein, triglycerides, insulin, glucose, creatinine and albumin) in the unfavourable quartile. Logistic regression was used to test the association between high allostatic load and main outcome adjusted for confounders: time from index pregnancy and follow up, age, education, smoking, gravidity, bleeding in the first trimester, index adverse pregnancy outcomes, and health insurance. Each main outcome component and allostatic load were analysed secondarily. Mediation and moderation analyses assessed the role of high allostatic load in racial disparities of cardiovascular disease risk. MAIN OUTCOME MEASURE Incident cardiovascular disease risk: hypertension, or metabolic disorders. RESULTS Cardiovascular disease risk was identified in 1462/4022 individuals (hypertension: 36.6%, metabolic disorder: 15.4%). After adjustment, allostatic load was associated with cardiovascular disease risk (adjusted odds ratio [aOR] 2.0, 95% CI 1.8-2.3), hypertension (aOR 2.1, 95% CI 1.8-2.4) and metabolic disorder (aOR 1.7, 95% CI 1.5-2.1). Allostatic load was a partial mediator between race and cardiovascular disease risk. Race did not significantly moderate this relationship. CONCLUSIONS High allostatic load during pregnancy is associated with cardiovascular disease risk. The relationships between stress, subsequent cardiovascular risk and race warrant further study.
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Affiliation(s)
- Amir J Lueth
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathan M Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio, USA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janet Catov
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University, Evanston, Illinois, USA
| | - Fernando A Wilson
- Intermountain Health Department of Population Health Sciences, University of Utah Health, Utah, Salt Lake City, USA
| | - Maureen Murtaugh
- Intermountain Health Department of Population Health Sciences, University of Utah Health, Utah, Salt Lake City, USA
| | - Noel Merz
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Judith Chung
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, California, USA
| | - Mitali Ray
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christina Scifres
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University, Bloomington, Indiana, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
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15
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Rosett HA, Allshouse AA, Nygaard IE, Hill AJ, Swenson CW. Association Between Genital Hiatus Size 8 Weeks Postpartum and Pelvic Organ Prolapse 1 Year After the First Vaginal Delivery. Urogynecology (Phila) 2023:02273501-990000000-00091. [PMID: 37093569 DOI: 10.1097/spv.0000000000001354] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
IMPORTANCE Evidence suggests that genital hiatus (GH) enlargement precedes pelvic organ prolapse development remote from delivery. However, the association of postpartum GH enlargement and prolapse is unknown. OBJECTIVE The aim of this study was to determine the association between enlarged GH at 8 weeks postpartum and prolapse 1 year after first vaginal delivery. STUDY DESIGN This is a secondary analysis of the Motherhood and Pelvic Health study, a prospective cohort of women after their first vaginal delivery. Enlarged GH was defined as ≥4 cm. Prolapse was defined as Pelvic Organ Prolapse Quantification points Ba, Bp, or C at or beyond the hymen. Kaplan-Meier analysis and proportional hazards modeling were used to analyze the association between enlarged GH at 8 weeks postpartum and prolapse at 1 year postpartum. Diagnostic test characteristics of enlarged GH were calculated. RESULTS Five hundred eighty women were included. At 1 year postpartum, the prevalence of prolapse was 3 times higher in women with, versus without, an enlarged GH at 8 weeks postpartum (16% vs 5%, P < 0.001). This was confirmed in a Cox proportional hazards model while adjusting for age, body mass index, and early postpartum prolapse (adjusted hazard ratio, 3.3; 95% confidence interval, 1.85-6.06; P < 0.001). The diagnostic properties of postpartum GH to predict prolapse at 1 year are as follows: sensitivity, 0.63; specificity, 0.67; positive predictive value, 0.17; and negative predictive value, 0.95. CONCLUSIONS Women with an enlarged GH at 8 weeks postpartum have a 3.3-fold increased risk of prolapse at 1 year. As a screening tool, GH <4 cm at 8 weeks postpartum has high negative predictive value.
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Affiliation(s)
| | | | - Ingrid E Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - A Jolyn Hill
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Carolyn W Swenson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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16
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Bruno AM, Allshouse AA, Metz TD, Theilen LH. Hypertensive disorders of pregnancy pre- and postaspirin guideline publication in individuals with pregestational diabetes mellitus. Am J Obstet Gynecol MFM 2023; 5:100877. [PMID: 36708967 PMCID: PMC10108661 DOI: 10.1016/j.ajogmf.2023.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND The US Preventive Services Taskforce published guidelines in 2014 recommending that low-dose aspirin be initiated between 12 and 28 weeks of gestation among high-risk patients for preeclampsia prophylaxis. Moreover, low-dose aspirin is recommended by some clinicians for the prevention of preterm birth. OBJECTIVE This study aimed to evaluate whether there is an association between the US Preventive Services Taskforce aspirin guideline hypertensive disorders of pregnancy and the rates of hypertensive disorders of pregnancy and preterm birth in individuals with pregestational diabetes mellitus. STUDY DESIGN This was a repeated cross-sectional analysis of individuals with pregestational diabetes mellitus and at least 1 singleton delivery at >20 weeks of gestation with records available in the National Vital Statistics System between 2010 and 2018. The primary outcome was hypertensive disorders of pregnancy, and the secondary outcome was preterm birth. Demographics and clinical characteristics among individuals in the pre-US Preventive Services Taskforce guideline cohort (2010-2013) were compared with that of individuals in the post-US Preventive Services Taskforce guideline cohort (2015-2018). Multivariable regression estimated the odds ratios and 95% confidence intervals for the association between guideline publication and the selected endpoints. Effect modification was assessed for access to prenatal care using the Kotelchuck Index (<80% vs ≥80%). Furthermore, a sensitivity analysis limited to nulliparas was performed. RESULTS Overall, 224,065 individuals were included. Individuals in the post-US Preventive Services Taskforce guideline cohort were more likely to be older, be obese, and have a history of preterm birth. In unadjusted and adjusted modeling, delivery in the post-US Preventive Services Taskforce guideline cohort was associated with hypertensive disorders of pregnancy (adjusted odds ratio, 1.25; 95% confidence interval, 1.22-1.28) and preterm birth (adjusted odds ratio, 1.10; 95% confidence interval, 1.08-1.12). The adjusted odds ratios for hypertensive disorders of pregnancy and preterm birth were more pronounced among those with less than adequate access to care. The findings were similar in the sensitivity analysis of only nulliparas. CONCLUSION Delivery after US Preventive Services Taskforce aspirin guideline publication was associated with higher rates of hypertensive disorders of pregnancy and preterm birth in a population of individuals with diabetes mellitus. It is unknown whether patient or practitioner factors, or other changes in obstetrical care, contributed to these findings.
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Affiliation(s)
- Ann M Bruno
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Bruno, Ms Allshouse, and Drs Metz and Theilen); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT (Drs Bruno, Metz, and Theilen).
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Bruno, Ms Allshouse, and Drs Metz and Theilen)
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Bruno, Ms Allshouse, and Drs Metz and Theilen); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT (Drs Bruno, Metz, and Theilen)
| | - Lauren H Theilen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Bruno, Ms Allshouse, and Drs Metz and Theilen); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT (Drs Bruno, Metz, and Theilen)
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Bruno AM, Horns JJ, Allshouse AA, Metz TD, Debbink ML, Smid MC. Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders. Obstet Gynecol 2023; 141:395-402. [PMID: 36657144 PMCID: PMC10477003 DOI: 10.1097/aog.0000000000005050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/27/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum. METHODS We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed. RESULTS Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66). CONCLUSION Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.
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Affiliation(s)
- Ann M Bruno
- University of Utah Health, Salt Lake City, and Intermountain Healthcare, Murray, Utah
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Bruno AM, Benson AE, Allshouse AA, Yost CC, Metz TD, Varner MW, Silver RM, Branch D. Thrombotic markers in pregnant patients with and without SARS-CoV-2 infection. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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19
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Moyle K, Peterson LK, Guerra MM, Kim M, Allshouse AA, Benson AE, Salmon JE, Branch D. Anti-β2 glycoprotein-I domain 1 antiphospholipid antibodies as a marker for adverse pregnancy outcomes. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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20
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Einerson BD, Allshouse AA, Shainker SA, Khandelwal M, Nieto-Calvache AJ, Fitzgerald G, Subramaniam A, Shrivastava V, Zuckerwise LC, Warrick CM, Fox KA, Carusi DA, Shamshirsaz A, Lyell DJ, Silver BM. Severe morbidity for placenta accreta spectrum has decreased over time in referral centers. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Adesomo A, Allshouse AA, Theilen LH. Are hypertensive disorders of pregnancy associated with vasomotor symptoms? Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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22
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Lendrum TL, Allshouse AA, Kim P, McMillin GA, Silver RM, Metz TD. Association of prenatal cannabis use with severe depressive symptoms. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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23
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Bruno AM, Allshouse AA, Metz TD. Trends in Attempted and Successful Trial of Labor After Cesarean Delivery in the United States From 2010 to 2020. Obstet Gynecol 2023; 141:173-175. [PMID: 36701618 PMCID: PMC10477004 DOI: 10.1097/aog.0000000000004998] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 12/23/2022]
Abstract
The vaginal birth after cesarean (VBAC) delivery rate was last reported as 13.8% in 2019. However, contemporary trends in attempted and successful trial of labor after cesarean (TOLAC) delivery among individuals with prior cesarean delivery have not been evaluated. We performed a repeated cross-sectional analysis of singleton, cephalic, term deliveries in individuals with a history of one or two cesarean deliveries in the National Vital Statistics System from 2010 to 2020. Temporal trends in attempted and successful TOLAC, as well as VBAC, were characterized using joinpoint regression. Overall, 4,277,800 deliveries were included. Attempted TOLAC increased from 15.3% in 2010 to 21.7% in 2020, with an annual percent increase (relative) of 4.25% (95% CI 2.9-5.6%). Successful TOLAC increased from 69.8% to 74.7%, with an annual percent change (relative) of 0.91% (95% CI 0.7-1.2%). The VBAC rate similarly increased such that, by 2020, it was 16.2%.
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Affiliation(s)
- Ann M Bruno
- University of Utah Health, Salt Lake City, and Intermountain Healthcare, Murray, Utah
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Canfield DR, Allshouse AA, Smith J, Metz TD, Grobman WA, Silver RM. The ARRIVE Trial: Impact of Elective Induction on Subsequent Pregnancy Occurrence and Mode of Delivery. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Gimbel LA, Allshouse AA, Neff D, Silver RM, Conradt E, Crowell SE. Mental health symptom changes in pregnant individuals across the COVID-19 pandemic: a prospective longitudinal study. BMC Pregnancy Childbirth 2022; 22:897. [PMID: 36463120 PMCID: PMC9719623 DOI: 10.1186/s12884-022-05144-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Initial studies found that mental health symptoms increased in pregnant and postpartum individuals during the COVID-19 pandemic. Less research has focused on if these putative increases persist over time and what factors influence these changes. We examined the longitudinal change in mental health symptoms in pregnant and postpartum individuals and investigated moderation by maternal emotion dysregulation and the incidence of coronavirus. METHODS Pregnant and postpartum individuals at the University of Utah were invited to join the COVID-19 and Perinatal Experiences (COPE) Study. Beginning on April 23, 2020 participants were sent a survey comprised of demographics, medical and social history, pregnancy information and self-assessments (Time 1). Participants were contacted 90 days later and invited to participate in a follow-up questionnaire (Time 2). Daily coronavirus case counts were accessed from the state of Utah and a 7-day moving average calculated. Within-subject change in mental health symptom scores, as measured by the Brief Symptom Inventory, was calculated. Linear mixed effects regression modeling adjusted for history of substance abuse and mental health disorders. RESULTS 270 individuals responded between April 23rd, 2020 and July 15th, 2021. Mental health symptom scores improved by 1.36 points (0.7-2.0 p < 0.001). The decrease in mental health symptoms was not moderated by the prevalence of COVID-19 cases (p = 0.19) but was moderated by emotion dysregulation (p = 0.001) as defined by the Difficulties in Emotion Regulation Scale short form. Participants with higher emotion dysregulation also had higher mental health symptom scores. CONCLUSION Mental health symptoms improved over the course of the pandemic in the same pregnant or postpartum participant. Our findings do not negate the importance of mental health care during the pandemic. Rather, we believe this identifies some aspect of resiliency and adaptability. Examining emotion dysregulation, or asking about a history of mental health, may be helpful in identifying persons at higher risk of heightened responses to stressors.
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Affiliation(s)
- Lauren A Gimbel
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, USA.
| | - Amanda A Allshouse
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, USA
| | - Dylan Neff
- Department of Psychology, University of Utah, Salt Lake City, USA
| | - Robert M Silver
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, USA
| | - Elisabeth Conradt
- Departments of Psychiatry and Pediatrics, Duke University, Durham, USA
| | - Sheila E Crowell
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, USA
- Department of Psychology, University of Utah, Salt Lake City, USA
- Department of Psychiatry, University of Utah, Salt Lake City, USA
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Lueth AJ, Allshouse AA, Blue NM, Grobman WA, Levine LD, Simhan HN, Kim JK, Johnson J, Wilson FA, Murtaugh M, Silver RM. Allostatic Load and Adverse Pregnancy Outcomes. Obstet Gynecol 2022; 140:974-982. [PMID: 36357956 PMCID: PMC9712159 DOI: 10.1097/aog.0000000000004971] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the association between allostatic load, as an estimate of chronic stress, and adverse pregnancy outcomes. METHODS This was a secondary analysis of nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be), a prospective observational cohort study. Our primary exposure was dichotomous high allostatic load in the first trimester, defined as 4 or more of 12 biomarkers in the "worst" quartile. The primary outcome was a composite adverse pregnancy outcome: hypertensive disorders of pregnancy (HDP), preterm birth, small for gestational age (SGA), and stillbirth. Secondary outcomes included components of the composite. Multivariable logistic regression was used to test the association between high allostatic load and adverse pregnancy outcomes, adjusted for potential confounders. Mediation and moderation analyses were conducted to assess the role of allostatic load along the causal pathway between racial disparities and adverse pregnancy outcomes. RESULTS Among 4,266 individuals, 34.7% had a high allostatic load. Composite adverse pregnancy outcome occurred in 1,171 (27.5%): 14.0% HDP, 8.6% preterm birth (48.0% spontaneous and 52.2% indicated), 11.0% SGA, and 0.3% stillbirth. After adjustment for maternal age, gravidity, smoking, bleeding in the first trimester, and health insurance, high allostatic load was significantly associated with a composite adverse pregnancy outcome (adjusted odds ratio [aOR] 1.5, 95% CI 1.3, 1.7) and HDP (aOR 2.5, 95% CI 2.0-2.9), but not preterm birth or SGA. High allostatic load partially mediated the association between self-reported race and adverse pregnancy outcomes. The association between allostatic load and HDP differed by self-reported race, but not for a composite adverse pregnancy outcome, preterm birth, or SGA. CONCLUSION High allostatic load in the first trimester is associated with adverse pregnancy outcomes, particularly HDP. Allostatic load was a partial mediator between race and adverse pregnancy outcomes. The association between allostatic load and HDP differed by self-reported race.
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Affiliation(s)
- Amir J. Lueth
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Amanda A. Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Nathan M. Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - William A. Grobman
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio
| | - Lisa D. Levine
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hyagriv N. Simhan
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jin Kyung Kim
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, California
| | - Jasmine Johnson
- Department of Obstetrics and Gynecology, School of Medicine, Indiana University
| | - Fernando A. Wilson
- Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah
| | - Maureen Murtaugh
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
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Bruno AM, Blue NR, Allshouse AA, Haas DM, Shanks AL, Grobman WA, Simhan H, Reddy UM, Silver RM, Metz TD. Marijuana use, fetal growth, and uterine artery Dopplers. J Matern Fetal Neonatal Med 2022; 35:7717-7724. [PMID: 34470115 PMCID: PMC9080638 DOI: 10.1080/14767058.2021.1960973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Marijuana (MJ) use is associated with adverse effects on fetal growth. We aimed to investigate the timing of suboptimal fetal growth onset in MJ-exposed pregnancies. In addition, we aimed to explore the relationship between MJ-exposure and both abnormal uterine artery (UtA) Doppler parameters and small for gestational age (SGA). STUDY DESIGN This was a secondary analysis of a prospective multicenter cohort that enrolled nulliparous individuals delivering non-anomalous fetuses beyond 20 weeks' gestation. Marijuana exposure was ascertained by self-report or clinical urine toxicology testing. Ultrasound estimated fetal weights (EFWs) were assessed in participants at both 16w0d-21w6d and 22w0d-29w6d. EFWs and birth weight (BW) were converted to weight percentiles (wPCT). EFW and BW wPCTs were calculated using population-based standards. Additionally, a customized standard designed to be applicable to both EFWs and BWs within the same model was also used to allow for EFW to BW percentile trajectories. The primary outcome, longitudinal wPCT, was compared between individuals with and without MJ use in a linear mixed-effects regression model adjusting for tobacco. For modeling, wPCT was smoothed across gestational age; MJ was estimated as an intercept and linear difference in the slope of gestational age. UtA Doppler notching, resistance index (RI), and pulsatility index (PI) at 16w0d-21w6d were compared using t-test and χ2. SGA at delivery was also compared. RESULTS Nine thousand one hundred and sixty-three individuals met inclusion criteria; 136 (1.5%) used MJ during pregnancy. Individuals who used MJ were more likely to be younger, identify as non-Hispanic Black, and have had less education. Fetuses exposed to MJ had lower wPCT beginning at 28 weeks using population-based and customized standards, when compared to those without exposure. UtA notching, PI, and RI were similar between groups. SGA was more frequent in neonates exposed to MJ using both population-based (22 vs. 9%, p<.001) and customized (25 vs. 14%, p<.001) curves. CONCLUSIONS MJ-exposed fetuses were estimated to be smaller than unexposed fetuses starting at 28 weeks' gestation across both growth standards without a difference in UtA Doppler parameters.
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Affiliation(s)
- Ann M. Bruno
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, Intermountain Healthcare, Murray, UT, USA
| | - Nathan R. Blue
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, Intermountain Healthcare, Murray, UT, USA
| | - Amanda A. Allshouse
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - David M. Haas
- Department of Obstetrics & Gynecology, Indiana University, Indianapolis, IN, USA
| | - Anthony L. Shanks
- Department of Obstetrics & Gynecology, Indiana University, Indianapolis, IN, USA
| | - William A. Grobman
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL, USA
| | - Hyagriv Simhan
- Department of Obstetrics & Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Uma M. Reddy
- Department of Obstetrics & Gynecology, Yale University, New Haven, CT, USA
| | - Robert M. Silver
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, Intermountain Healthcare, Murray, UT, USA
| | - Torri D. Metz
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, Intermountain Healthcare, Murray, UT, USA
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Gimbel LA, Blue NR, Allshouse AA, Silver RM, Gimbel B, Grobman WA, Haas DM, Simhan HN, Mercer BM, Hatfield T. Pregnancy outcomes and anxiety in nulliparous women. J Matern Fetal Neonatal Med 2022; 35:8681-8690. [PMID: 34747312 PMCID: PMC9097789 DOI: 10.1080/14767058.2021.1998441] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine pregnancy outcomes in women with treated and untreated anxiety in a well-characterized cohort. STUDY DESIGN Secondary analysis of the NuMoM2b study, a prospective multi-center cohort of nulliparous women. Anxiety was assessed at 6 weeks 0 days - 13 weeks 6 days using the State Trait Anxiety Inventory (STAI-T). Women were divided into three groups: anxiety and medical treatment, anxiety and no medical treatment, and no anxiety (controls). The primary outcome was a composite of preterm birth, small for gestational age infant, placental abruption (clinically diagnosed), and hypertensive disorders of pregnancy. Multivariable logistic regression was used to adjust for potential confounding variables. RESULTS Among 8293 eligible women, 24% (n = 1983) had anxiety; 311 were treated medically. The composite outcome (preterm birth, small for gestational age infant, placental abruption, hypertensive disorders of pregnancy) occurred more often in women with untreated anxiety than controls (28.6% vs 25.9%, p=.02), with no difference between treated anxiety and controls (27.7% vs 25.9%, p=.49). After adjustment for confounders, including controlling for depression, there were no differences in the primary outcome among groups. Untreated anxiety remained associated with increased odds of neonatal intensive care unit admission. CONCLUSION Anxiety occurred in almost a quarter of nulliparas. There was no association between treated or untreated anxiety and our primary outcome of adverse pregnancy outcomes after adjustment for confounders. However, neonates born to women with untreated anxiety were at increased risk for NICU admission.
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Affiliation(s)
- Lauren A. Gimbel
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Nathan R. Blue
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Amanda A. Allshouse
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Robert M. Silver
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Bruce Gimbel
- Psychiatry, Saint Mary Mercy Hospital, Livonia, MI, USA
| | | | - David M. Haas
- Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hyagriv N. Simhan
- Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian M. Mercer
- Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Tamera Hatfield
- Obstetrics and Gynecology, University of California Irvine College of Health Sciences, Irvine, CA, USA
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Blue NR, Allshouse AA, Grobman WA, Day RC, Haas DM, Simhan HN, Parry S, Saade GR, Silver RM. Developing a predictive model for perinatal morbidity among small for gestational age infants. J Matern Fetal Neonatal Med 2022; 35:8462-8471. [PMID: 34582307 PMCID: PMC8958182 DOI: 10.1080/14767058.2021.1980533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND While neonates with birth weight <10th percentile are at increased risk of morbidity and mortality, most of these are constitutionally small and not at increased risk. There are no current strategies that reliably distinguish constitutionally small neonates from small neonates at the highest risk of morbidity, so additional tools for risk stratification are needed. OBJECTIVE Our objectives were to identify factors that are independently associated with perinatal morbidity among neonates with birth weight <10th percentile (small for gestational age, SGA) and to create predictive models of perinatal morbidity among SGA neonates based on the timing of information availability. STUDY DESIGN This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, was a nested case-control study. Participants were prospectively enrolled at eight U.S. centers, with data collection occurring at three standard time points during pregnancy and again after delivery. Our analysis included neonates with birth weights <10th percentile and excluded those with major congenital malformations or suspected or confirmed aneuploidy. The primary outcome was a composite of perinatal morbidity, defined as NICU admission >48 h, NEC, sepsis, RDS, mechanical ventilation, retinopathy of prematurity, seizures, grade 3 or 4 IVH, stillbirth, or death before discharge. Cases were SGA neonates that experienced the primary outcome, and controls were SGA neonates that did not. Maternal factors for potential inclusion in predictive modeling were drawn from a broad list of variables collected as part of the NuMoM2B study, including demographic, anthropometric, clinical, ultrasound, social/behavioral, dietary, and psychological variables. Characteristics that were different in bivariate analysis between cases and controls then underwent further evaluation and refinement. Continuous and multi-category variables were assessed using multiple approaches, including as continuous variables, using standard categories (such as for BMI) as well as empirically-derived cut-points identified by receiver-operating characteristics methodology. The approach for each variable that resulted in the best performance was selected for use in modeling. After variable optimization, multivariable analysis was used to derive prediction models using factors known at mid-pregnancy (Model 1) and delivery (Model 2). RESULTS Of the original cohort, 865 were eligible and analyzed, with 134 (15.5%) experiencing the primary outcome. After bivariable and multivariable analysis, these variables were included in Model 1: BMI, stress level, diastolic blood pressure, narcotic use (all in 1st trimester), and uterine artery pulsatility index at 16-21 weeks. Model 2 added the following variables to Model 1: preterm delivery, preeclampsia, and suspected fetal growth restriction. When models 1 and 2 were empirically tested and compared to predicted performance to demonstrate calibration, observed morbidity rates approximately followed expected rates within deciles. Models 1 and 2 had respective areas under the receiver-operating characteristic curve of 0.72 (95% CI 0.67-0.76) and 0.84 (0.80-0.88), to predict the composite morbidity. CONCLUSION Using a deeply phenotyped cohort of nulliparous women, we created two models with the moderate-good prediction of perinatal morbidity among SGA neonates. TRIAL REGISTRATION clinicaltrials.gov ID: NCT01322529.
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Affiliation(s)
- Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert C Day
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
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Scaglione MA, Allshouse AA, Canfield DR, Mclaughlin HD, Bruno AM, Hammad IA, Branch DW, Maurer KA, Dood RL, Debbink MP, Silver RM, Einerson BD. Prophylactic Ureteral Stent Placement and Urinary Injury During Hysterectomy for Placenta Accreta Spectrum. Obstet Gynecol 2022; 140:806-811. [PMID: 36201777 PMCID: PMC10069290 DOI: 10.1097/aog.0000000000004957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between prophylactic ureteral stent placement at the time of hysterectomy for placenta accreta spectrum and genitourinary injury. METHODS We conducted a retrospective cohort study of patients with placenta accreta spectrum who underwent hysterectomy at two referral centers from 2001 to 2021. The exposure was prophylactic ureteral stent placement. The primary outcome, genitourinary injury, was a composite of bladder injury, ureteral injury, or vesicovaginal fistula. Secondary outcomes included components of the primary outcome. We evaluated differences between groups using χ 2 and t test. To evaluate differences in the primary outcome, we reported odds ratios (ORs) and adjusted odds ratios (aORs) using multivariable logistic regression analyses to control for potential confounding variables. We used a Cochran-Armitage χ 2 trend test to evaluate difference in stent use and injury over time. RESULTS In total, 236 patients were included. Prophylactic ureteral stents were used in 156 surgeries (66%). Overall, genitourinary injury occurred less frequently in the stent group compared with the no stent group (28% vs 51%, OR 0.37, 95% CI 0.21-0.65). This association persisted after controlling for urgency of delivery, three or more prior cesarean deliveries, and whether a gynecologic oncologist was present (aOR 0.27, 95% CI 0.14-0.52). Unintentional bladder injury occurred less frequently in the stent group compared with the no stent group (13% vs 25%, P =.018), as did ureteral injury (2% vs 9%, P =.019). CONCLUSION Prophylactic ureteral stent placement was associated with a decreased risk of genitourinary injury during hysterectomy for placenta accreta spectrum.
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Affiliation(s)
- Morgan A Scaglione
- Division of Maternal Fetal Medicine and the Division of Gynecologic Oncology, University of Utah Health, and Intermountain Healthcare, Salt Lake City, Utah
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Bruno AM, Allshouse AA, Campbell HM, Branch DW, Lim MY, Silver RM, Metz TD. Weight-Based Compared With Fixed-Dose Enoxaparin Prophylaxis After Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol 2022; 140:575-583. [PMID: 36075079 PMCID: PMC10473241 DOI: 10.1097/aog.0000000000004937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/14/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate fixed compared with weight-based enoxaparin dosing to achieve prophylactic anti-Xa levels after cesarean delivery. METHODS Individuals meeting institutional criteria for enoxaparin thromboprophylaxis after cesarean delivery were randomly allocated to fixed (40 mg daily for body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] lower than 40; 40 mg every 12 hours for BMI 40 or higher) or weight-based (0.5 mg/kg every 12 hours) enoxaparin dosing. Enoxaparin was initiated during inpatient hospitalization and continued at discharge for 14 days. Those with contraindication to anticoagulation, plan for therapeutic anticoagulation, or known renal impairment were excluded. The trial was unmasked. The primary outcome was prophylactic (0.2-0.6 international units/mL) peak anti-Xa level 4-6 hours after at least the third enoxaparin dose (at steady state). Secondary outcomes included subprophylactic and supraprophylactic peaks, outpatient peak, and venous thromboembolism (VTE) and wound complications in the first 6 weeks postpartum. Sample size of 121 per group was planned. At interim analysis with 50% enrollment, the trial was stopped early for efficacy. Primary analyses followed intention-to-treat principle with worst-case imputation for missing outcomes. Secondary analyses were complete case. RESULTS From June 2020 to November 2021, 74 individuals were randomized to weight-based enoxaparin and 72 to fixed-dose enoxaparin. Those who received weight-based dosing were more likely to achieve prophylactic anti-Xa levels than those who received fixed dosing in primary analysis (49/74 [66%] vs 32/72 [44%], relative risk [RR] 1.49, 95% CI 1.10-2.02) and secondary analysis (49/60 [82%] vs 32/57 [56%], RR 1.45, 95% CI 1.12-1.88). Subprophylactic levels occurred more frequently with fixed dosing; supraprophylactic levels did not differ significantly by dosing. At the outpatient postoperative visit, 52% of participants (15/29) with weight-based dosing compared with 15% (5/33) with fixed dosing achieved prophylactic peak anti-Xa level (RR 3.41, 95% CI 1.42-8.24). There were no VTEs in either group. Wound complications occurred in five individuals (7%) with weight-based enoxaparin dosing compared with one individual (1%) with fixed enoxaparin dosing (RR 4.86, 95% 0.58-40.63). CONCLUSION Weight-based dosing was more effective than fixed enoxaparin dosing in achieving prophylactic peak anti-Xa levels after cesarean delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04305756.
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Affiliation(s)
- Ann M. Bruno
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | | | - Heather M. Campbell
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - D. Ware Branch
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - Ming Y. Lim
- University of Utah Health, Salt Lake City, UT
| | - Robert M. Silver
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - Torri D. Metz
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
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Metz TD, Allshouse AA, McMillin GA, Silver RM, Smid MC, Haas DM, Simhan HN, Saade GR, Grobman WA, Parry S, Chung JH, Jarlenski MP. Association of Cannabis Use With Nausea and Vomiting of Pregnancy. Obstet Gynecol 2022; 140:266-270. [PMID: 35852278 PMCID: PMC9309979 DOI: 10.1097/aog.0000000000004850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
Abstract
Our objective was to evaluate whether cannabis use was associated with nausea and vomiting in early pregnancy. Participants from nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be) enrolled from October 2010 through September 2013 with a PUQE (Pregnancy-Unique Quantification of Emesis) questionnaire and an available stored urine sample from the first study visit (median gestational age 12 weeks) were included. Cannabis exposure was ascertained by urine immunoassay for 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH); positive results were confirmed with liquid chromatography tandem mass spectrometry. The primary outcome was moderate-to-severe nausea by the PUQE score. Overall, 9,250 participants were included, and 5.8% (95% CI 5.4-6.3%) had detectable urine THC-COOH. In adjusted analyses, higher THC-COOH levels were associated with greater odds of moderate-to-severe nausea (20.7% in the group with THC-COOH detected vs 15.5% in the group with THC-COOH not detected, adjusted odds ratio 1.6, 95% CI 1.1-2.2 for a 500 ng/mg Cr THC-COOH increment).
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Affiliation(s)
- Torri D Metz
- University of Utah Health and ARUP Laboratories, Salt Lake City, Utah; Indiana University, Indianapolis, Indiana; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Texas Medical Branch, Galveston, Texas; The Ohio State University, Columbus, Ohio; University of Pennsylvania, Philadelphia, Pennsylvania; University of California Irvine, Irvine, California; and University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Smid MC, Allshouse AA, McMillin GA, Nunez K, Cavin T, Worden J, Buchi K, Muniyappa B, Varner MW, Cochran G, Metz TD. Umbilical Cord Collection and Drug Testing to Estimate Prenatal Substance Exposure in Utah. Obstet Gynecol 2022; 140:153-162. [PMID: 35852263 PMCID: PMC9373719 DOI: 10.1097/aog.0000000000004868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our primary objective was to estimate statewide prenatal substance exposure based on umbilical cord sampling. Our secondary objectives were to compare prevalence of prenatal substance exposure across urban, rural, and frontier regions, and to compare contemporary findings to those previously reported. METHODS We performed a cross-sectional prevalence study of prenatal substance exposure, as determined by umbilical cord positivity for 49 drugs and drug metabolites, through the use of qualitative liquid chromatography-tandem mass spectrometry. All labor and delivery units in Utah (N=45) were invited to participate. Based on a 2010 study using similar methodology, we calculated that a sample size of at least 1,600 cords would have 90% power to detect 33% higher rate of umbilical cords testing positive for any substance. Deidentified umbilical cords were collected from consecutive deliveries at participating hospitals. Prevalence of prenatal substance exposure was estimated statewide and by rurality using weighted analysis. RESULTS From November 2020 to November 2021, 1,748 cords (urban n=988, rural n=384, frontier n=376) were collected from 37 hospitals, representing 92% of hospitals that conduct 91% of births in the state. More than 99% of cords (n=1,739) yielded results. Statewide, 9.9% (95% CI 8.1-11.7%) were positive for at least one substance, most commonly opioids (7.0%, 95% CI 5.5-8.5%), followed by cannabinoid (11-nor-9-carboxy-delta-9-tetrahydrocannabinol [THC-COOH]) (2.5%, 95% CI 1.6-3.4%), amphetamines (0.9%, 95% CI 0.4-1.5), benzodiazepines (0.5%, 95% CI 0.1-0.9%), alcohol (0.4%, 95% CI 0.1-0.7%), and cocaine (0.1%, 95% CI 0-0.3%). Cord positivity was similar by rurality (urban=10.3%, 95% CI 8.3-12.3%, rural=7.1%, 95% CI 3.5-10.7%, frontier=9.2%, 95% CI 6.2-12.2%, P=.31) and did not differ by substance type. Compared with a previous study, prenatal exposure to any substance (6.8 vs 9.9%, P=.01), opioids (4.7 vs 7.0% vs 4.7%, P=.03), amphetamines (0.1 vs 0.9%, P=.01) and THC-COOH (0.5 vs 2.5%, P<.001) increased. CONCLUSION Prenatal substance exposure was detected in nearly 1 in 10 births statewide.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Department of Pathology, and the Department of Pediatrics, University of Utah Health, the Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, the Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, and ARUP Laboratories, Salt Lake City, Utah
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Bruno AM, Allshouse AA, Einerson BD, Campbell HM, Branch DW, Silver RM, Metz TD. Trends in postpartum venous thromboembolism and chemical prophylaxis among insured US patients. Am J Obstet Gynecol MFM 2022; 4:100620. [PMID: 35358739 PMCID: PMC10497236 DOI: 10.1016/j.ajogmf.2022.100620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/08/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ann M Bruno
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Health, 30 N 1900 E, Ste. 2B200, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT.
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT
| | - Heather M Campbell
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT
| | - D Ware Branch
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT
| | - Robert M Silver
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT
| | - Torri D Metz
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT; Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT
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Bruno AM, Allshouse AA, Metz TD, Theilen LH. Trends in Hypertensive Disorders of Pregnancy in the United States From 1989 to 2020. Obstet Gynecol 2022; 140:83-86. [PMID: 35849460 PMCID: PMC10472797 DOI: 10.1097/aog.0000000000004824] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
Hypertensive disorders of pregnancy affect up to 8% of pregnancies, but updated national trends are lacking. We performed a repeated cross-sectional analysis of individuals with singleton pregnancies who delivered at greater than 20 weeks of gestation, with data in the U.S. National Vital Statistics System from 1989 to 2020. Temporal trends in hypertensive disorders of pregnancy, chronic hypertension, and eclampsia were characterized using joinpoint regression. Overall, 122,329,914 deliveries were included. Hypertensive disorders of pregnancy increased from 2.79% in 1989 to 8.22% in 2020, representing an average annual percentage change (AAPC) of 3.6% (95% CI 3.0-4.1%). Chronic hypertension increased (AAPC 4.1%, 95% CI 3.3-4.9%), whereas eclampsia decreased (AAPC -2.5%, 95% CI -4.0% to -1.0%). Hypertensive disorders of pregnancy are associated with significant morbidity and mortality; the rising incidence is concerning.
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Affiliation(s)
- Ann M Bruno
- University of Utah Health, Salt Lake City, and Intermountain Healthcare, Murray, Utah
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Blue NR, Allshouse AA, Heerboth S, Grobman W, Mercer B, Shanks A, Bregand-White JM, Simhan H, Reddy UM, Saade G, Parry S, Silver RM. Derivation and assessment of a sex-specific fetal growth standard. J Matern Fetal Neonatal Med 2022; 35:9913-9921. [PMID: 35603475 DOI: 10.1080/14767058.2022.2075696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To derive a prescriptive sex-specific fetal growth standard and assess clinical management and outcomes according to sex-specific growth status. MATERIALS AND METHODS This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective observational study of 10,038 nulliparas from eight U.S. centers who underwent ultrasounds at 14-20 and 22-29 weeks with outcomes ascertained after delivery. From these, we selected a nested cohort of lower risk participants (excluded those with chronic hypertension, pre-gestational diabetes, suspected aneuploidy, and preterm delivery) to derive a sex-specific equation for expected fetal growth using fetal weights by ultrasound and at birth. We compared the male-female discrepancy in the rate of weight <10th (small for gestational age [SGA]) and >90th (large for gestational age [LGA]) percentiles between the sex-specific and sex-neutral (Hadlock) standards. Using the full unselected cohort, we then assessed outcomes and clinical management according to sex-specific SGA and LGA status. RESULTS Overall, 7280 infants in the lower risk nested cohort were used to derive a sex-specific equation with fetal sex included as an equation intercept. The sex-neutral standard diagnosed SGA more often in female newborns (21% vs. 13%, p < .001) and LGA more often in male newborns (5% vs. 3%, p < .001). The sex-specific standard resolved these disparities (SGA: 9% vs. 10%, p = .23; LGA: 13% vs. 13%, p = .58). To approximate an unselected population, 1059 participants initially excluded for risk factors for abnormal growth were then included for our secondary objective (N = 8339). In this unselected cohort, 39% (95% CI 37.0-42.0%) of the 1498 newborns classified as SGA by the sex-neutral standard were reclassified as appropriate for gestational age (AGA) by the sex-specific standard. These reclassified newborns were more likely to be delivered for growth restriction despite having lower risk of morbidity (females) or comparable risk of morbidity (males) compared to newborns considered AGA by both methods. Of the 6485 newborns considered AGA by the sex-neutral standard, 737 (11.4%, 95% CI 10.6-12.2%) were reclassified as LGA by the sex-specific standard. These reclassified newborns had higher rates of cesarean for arrest of descent, cesarean for arrest of dilation, and shoulder dystocia than newborns considered AGA by both methods. None were reclassified from LGA to AGA by the sex-specific standard. CONCLUSION The Hadlock sex-neutral standard generates sex disparities in SGA and LGA at birth. Our sex-specific standard resolves these disparities and has the potential to improve accuracy of growth pathology risk stratification.
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Affiliation(s)
- Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Sarah Heerboth
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - William Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
| | - Brian Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Anthony Shanks
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN, USA
| | - Julia M Bregand-White
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, CA, USA
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Uma M Reddy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT, USA
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
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Metz TD, Allshouse AA, Pinar H, Varner M, Smid MC, Hogue C, Dudley DJ, Bukowski R, Saade GR, Goldenberg RL, Reddy U, Silver RM. Maternal Marijuana Exposure, Feto-Placental Weight Ratio, and Placental Histology. Am J Perinatol 2022; 39:546-553. [PMID: 32971561 PMCID: PMC10506868 DOI: 10.1055/s-0040-1717092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Marijuana use is associated with placenta-mediated adverse pregnancy outcomes including fetal growth restriction, but the mechanism remains uncertain. The objective was to evaluate the association between maternal marijuana use and the feto-placental weight ratio (FPR). Secondarily, we aimed to compare placental histology of women who used marijuana to those who did not. STUDY DESIGN This was a secondary analysis of singleton pregnancies enrolled in a multicenter and case-control stillbirth study. Prior marijuana use was detected by electronic medical record abstraction or cord homogenate positive for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid. Prior tobacco use was detected by self-report or presence of maternal serum cotinine. Stillbirths and live births were considered separately. The primary outcome was FPR. Association of marijuana use with FPR was estimated with multivariable linear modeling adjusted for fetal sex, preterm birth, and tobacco use. Comparisons between groups for placental histology were made using Chi-square and stratified by live birth and stillbirth, term and preterm deliveries, and fetal sex. RESULTS Of 1,027 participants, 224 were stillbirths and 803 were live births. Overall, 41 (4%) women used marijuana during the pregnancy. The FPR ratio was lower among exposed offspring but reached statistical significance only for term stillbirths (mean 6.84 with marijuana use vs. mean 7.8 without use, p < 0.001). In multivariable modeling, marijuana use was not significantly associated with FPR (p = 0.09). There were no differences in histologic placental features among those with and without marijuana use overall or in stratified analyses. CONCLUSION Exposure to marijuana may not be associated with FPR. Similarly, there were no placental histologic features associated with marijuana exposure. Further study of the influence of maternal marijuana use on placental development and function is warranted to better understand the association between prenatal marijuana use and poor fetal growth. KEY POINTS · Maternal marijuana exposure was not associated with the feto-placental weight ratio.. · Marijuana exposure was not associated with differences in placental histology.. · Concerning trend toward lower feto-placental weight ratios among marijuana-exposed stillbirths..
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Affiliation(s)
| | | | | | | | | | | | - Donald J Dudley
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Radek Bukowski
- University of Texas at Austin, Dell Medical School, Austin, Texas
| | | | | | - Uma Reddy
- Yale University, New Haven, Connecticut
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Bruno AM, Allshouse AA, Metz TD, Theilen LH. Trends in hypertensive disorders of pregnancy in the U.S. from 1989 to 2018. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Moyle K, Allshouse AA, Blue N. Ultrasound detection of nuchal cord tension in a simulated nuchal cord model. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Lueth A, Silver RM, Allshouse AA, Blue N, Wilson F, Murtaugh M. Allostatic Load and Adverse Perinatal Outcomes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Metz TD, McMillin GA, Silver RM, Allshouse AA, Heard K, Jensen TL, Wymore EM, Stickrath E, Conageski C, Kinney GL, Binswanger IA. Quantification of prenatal marijuana use: evaluation of the correlation between self-report, serum, urine and umbilical cord assays among women delivering at two urban Colorado hospitals. Addiction 2022; 117:172-181. [PMID: 34142398 PMCID: PMC8664979 DOI: 10.1111/add.15606] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/01/2021] [Accepted: 06/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS To estimate during pregnancy correlations between frequency of self-reported use of marijuana and quantified marijuana metabolite in biospecimens including urine, sera and umbilical cord homogenate. DESIGN Prospective cohort. SETTING Two urban hospitals in Colorado with legal recreational and medicinal marijuana. PARTICIPANTS Pregnant women (<16 weeks gestation) self-reporting marijuana use. MEASUREMENTS Participants completed a written self-report survey and provided biospecimens at <16 weeks gestation (n = 46), 18 to 22 weeks gestation (n = 43), 32 to 36 weeks gestation (n = 39), and delivery (n = 37). Self-reported marijuana use frequency was calculated based on past-month days of use multiplied by number of daily uses. Maternal urine and sera were tested for presence (>5 ng/mL) of 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH). Liquid chromatography tandem mass spectrometry quantified THC-COOH in umbilical cord homogenate (ng/g). Last marijuana use by any measure was recorded to evaluate the time frame over which THC-COOH remains detectable (>0.10 ng/g) in cord. FINDINGS From December 2017 through May 2019, 51 pregnant women enrolled, and 46 were included in analyses (2 withdrew and 3 had a spontaneous abortion). The majority were normal weight, White or Black race, and insured by Medicaid. At the time of enrollment between 7 to 15 weeks' gestation, 87% had ongoing use by self-report, or positive urine or serum. The majority (33 [66%]) stopped using before delivery. Sera and urine results were strongly correlated with self-reported use frequency (Spearman correlation coefficient [r] range 0.70-0.87 across visits, P < 0.001), and with each other. There was only one positive cord result when use stopped before 22 weeks. Frequency of self-reported marijuana use at delivery had strong correlation with quantified cord THC-COOH (r = 0.80, 95% CI = 0.62-0.89). CONCLUSIONS Quantified umbilical cord THC-COOH appears to strongly correlate with frequency of maternal marijuana use in the last month of pregnancy. Earlier use can be measured by either quantitative urine or serum assay.
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Affiliation(s)
- Torri D Metz
- University of Utah Health, Salt Lake City, UT, USA
| | - Gwendolyn A McMillin
- University of Utah Health, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
| | | | | | - Kennon Heard
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Elaine Stickrath
- University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | | | | | - Ingrid A Binswanger
- University of Colorado School of Medicine, Aurora, CO, USA
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
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Smid M, Allshouse AA, Campbell K, Debbink MP, Cochran G. Neonatal outcomes among pregnant individuals with co-occurring opioid/methamphetamine use disorders and mental health diagnosis. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Heerboth S, Allshouse AA, Nourse SE, Silver BM, Grobman WA, Chung JH, Simhan H, Reddy UM, Saade GR, Shanks A, Blue N. Deriving a sex-specific fetal growth standard. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Scaglione M, Allshouse AA, Canfield DR, Bruno AM, Hammad I, Branch D, Maurer K, Dood R, Debbink MP, Silver RM, Einerson BD. Prophylactic ureteral stent placement and genitourinary injury during hysterectomy in placenta accreta spectrum. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dalton S, Allshouse AA, Clark EA, Manuck TA, Esplin SS, Varner MW. Cumulative Life Stressors are Associated with Preterm Birth. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Metz TD, Allshouse AA, McMillin GA, Silver RM, Jarlenski MP. Association of Marijuana Use with Nausea and Vomiting of Pregnancy. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Son SL, Hosek LL, Stein MC, Allshouse AA, Catino AB, Hoskoppal AK, Cox DA, Whitehead KJ, Lindsay IM, Esplin S, Metz TD. Association between pregnancy and long-term cardiac outcomes in individuals with congenital heart disease. Am J Obstet Gynecol 2022; 226:124.e1-124.e8. [PMID: 34331895 PMCID: PMC8748281 DOI: 10.1016/j.ajog.2021.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND As early life interventions for congenital heart disease improve, more patients are living to adulthood and are considering pregnancy. Scoring and classification systems predict the maternal cardiovascular risk of pregnancy in the context of congenital heart disease, but these scoring systems do not assess the potential subsequent risks following pregnancy. Data on the long-term cardiac outcomes after pregnancy are unknown for most lesion types. This limits the ability of healthcare practitioners to thoroughly counsel patients who are considering pregnancy in the setting of congenital heart disease. OBJECTIVE We aimed to evaluate the association between pregnancy and the subsequent long-term cardiovascular health of individuals with congenital heart disease. STUDY DESIGN This was a retrospective longitudinal cohort study of individuals identifying as female who were receiving care in two adult congenital heart disease centers from 2014 to 2019. Patient data were abstracted longitudinally from a patient age of 15 years (or from the time of entry into the healthcare system) to the conclusion of the study, death, or exit from the healthcare system. The primary endpoint, a composite adverse cardiac outcome (death, stroke, heart failure, unanticipated cardiac surgery, or a requirement for a catheterized procedure), was compared between parous (at least one pregnancy >20 weeks' gestation) and nulliparous individuals. By accounting for differences in the follow-up, the effect of pregnancy was estimated based on the time to the composite adverse outcome in a proportional hazards regression model adjusted for the World Health Organization class, baseline cardiac medications, and number of previous sternotomies. Participants were also categorized according to their lesion type, including septal defects (ventricular septal defects, atrial septal defects, atrioventricular septal defects, or atrioventricular canal defects), right-sided valvular lesions, left-sided valvular lesions, complex cardiac anomalies, and aortopathies, to evaluate if there is a differential effect of pregnancy on the primary outcome when adjusting for lesion type in a sensitivity analysis. RESULTS Overall, 711 individuals were eligible for inclusion; 209 were parous and 502 nulliparous. People were classified according to the World Health Organization classification system with 86 (12.3%) being classified as class I, 76 (10.9%) being classified as class II, 272 (38.9%) being classified as class II to III, 155 (22.1%) being classified as class III, and 26 (3.7%) being classified as class IV. Aortic stenosis, bicuspid aortic valve, dilated ascending aorta or aortic root, aortic regurgitation, and pulmonary insufficiency were more common in parous individuals, whereas dextro-transposition of the great arteries, Turner syndrome, hypoplastic right heart, left superior vena cava, and other cardiac diagnoses were more common in nulliparous individuals. In multivariable modeling, pregnancy was associated with the composite adverse cardiac outcome (36.4%% vs 26.1%%; hazard ratio, 1.83; 95% confidence interval, 1.25-2.66). Parous individuals were more likely to have unanticipated cardiac surgery (28.2% vs 18.1%; P=.003). No other individual components of the primary outcome were statistically different between parous and nulliparous individuals in cross-sectional comparisons. The association between pregnancy and the primary outcome was similar in a sensitivity analysis that adjusted for cardiac lesion type (hazard ratio, 1.61; 95% confidence interval, 1.10-2.36). CONCLUSION Among individuals with congenital heart disease, pregnancy was associated with an increase in subsequent long-term adverse cardiac outcomes. These data may inform counseling of individuals with congenital heart disease who are considering pregnancy.
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Affiliation(s)
- Shannon L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT.
| | - Lauren L Hosek
- University of Utah School of Medicine, Salt Lake City, UT
| | | | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Anna B Catino
- Division of Cardiology, University of Utah Health, Salt Lake City, UT
| | - Arvind K Hoskoppal
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Daniel A Cox
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Kevin J Whitehead
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Ian M Lindsay
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Sean Esplin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
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Scaglione M, Allshouse AA, Silver RM, Campbell H. Adverse pregnancy outcomes in AMA and obese patients associated with advanced reproductive technology (ART). Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Cummins H, Allshouse AA, Metz TD, Debbink MP. Pilot non-inferiority study of group prenatal care versus standard care for pregnant people with diabetes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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El Khoudary SR, Qi M, Chen X, Matthews K, Allshouse AA, Crawford SL, Derby CA, Thurston RC, Kazlauskaite R, Barinas-Mitchell E, Santoro N. Patterns of menstrual cycle length over the menopause transition are associated with subclinical atherosclerosis after menopause. Menopause 2021; 29:8-15. [PMID: 34636354 PMCID: PMC9178927 DOI: 10.1097/gme.0000000000001876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Longer menstrual cycles have been associated with greater risk of cardiovascular disease, supporting a contribution of abnormal ovarian function. We aimed to characterize trajectories of menstrual cycle length over the menopause transition (MT) and test whether these trajectories are associated with postmenopausal markers of subclinical atherosclerosis. METHODS Women from the Study of Women's Health Across the Nation Daily Hormone Study were included if they had an observed date of the final menstrual period (FMP), recorded cycle lengths from ≥2 annual menstrual cycles (mean±SD: 4.22 ± 1.91 cycles), and had measurements of postmenopausal carotid intima-media thickness (cIMT) and/or brachial-ankle pulse wave velocity (baPWV). Trajectories of cycle length over the MT were identified using group-based trajectory modeling and linked with cIMT and baPWV using linear regression. RESULTS We studied 428 women who had 1,808 cycles over the MT (45.1 ± 2.3 y old at baseline visit), and of whom 263 had cIMT, and 213 had baPWV measured postmenopausally (after 13.88 ± 0.42 and 15.25 ± 0.70 y since baseline visit, respectively). Three distinct trajectories of cycle length were identified: stable (no changes in cycle length over the MT among 62.1% of women), late increase (a late increase 2 y before the FMP among 21.8%), and early-increase (an early increase 5 y before the FMP among 16.2%). Women with the late-increase pattern had significantly lower postmenopausal cIMT (0.72 mm) and baPWV (1392 cm/s) levels than the stable group (0.77 mm and 1508 cm/s, respectively) adjusting for race, concurrent age, socioeconomic status, physical activity level, and premenopausal cardiovascular risk profile. CONCLUSIONS Patterns of cycle length over the MT seem to be a marker of future vascular health that may help identify groups at greater or lesser risk of atherosclerosis after menopause.
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Affiliation(s)
| | - Meiyuzhen Qi
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Xirun Chen
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Karen Matthews
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | | | - Rebecca C. Thurston
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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