Search

Objective: To assess post-partum inflammation for patients delivering prior to 34 6/7 weeks by birth etiology. Methods: This was an observational study of early preterm birth (PTB) occurring between 20 0/7 and 34 6/7 weeks of gestation. Serum C-reactive protein (CRP) levels were measured 1 month post-partum. CRP measurements were compared by birth etiology. Results: A total of 399 women were analyzed. Distribution of birth etiology was 35% (n = 138) preterm labor (PTL), 28% (n = 115) preterm premature rupture of membranes (pPROM), and 37% (n = 141) indicated preterm birth (IPTB). Serum CRP varied by birth etiology (P = 0.036). Women with pPROM had elevated median CRP levels compared to women with PTL (P = 0.037). IPTB demonstrated elevated CRP levels when compared to PTL (P = 0.019). Pre-eclamptic/eclamptic subjects exhibited increased median CRP levels compared to PTL (P = 0.04). Conclusion: Post-partum inflammation varies by birth etiology. Such variation may serve as identification of subjects whose future pregnancies and, ultimately, overall health status may benefit from inter-pregnancy interventions aimed at reducing inflammatory-associated risk factors. [ABSTRACT FROM AUTHOR]

Preterm birth is a syndrome with many causes and phenotypes. We propose a classification that is based on clinical phenotypes that are defined by ≥1 characteristics of the mother, the fetus, the placenta, the signs of parturition, and the pathway to delivery. Risk factors and mode of delivery are not included. There are 5 components in a preterm birth phenotype: (1) maternal conditions that are present before presentation for delivery, (2) fetal conditions that are present before presentation for delivery, (3) placental pathologic conditions, (4) signs of the initiation of parturition, and (5) the pathway to delivery. This system does not force any preterm birth into a predefined phenotype and allows all relevant conditions to become part of the phenotype. Needed data can be collected from the medical records to classify every preterm birth. The classification system will improve understanding of the cause and improve surveillance across populations. [ABSTRACT FROM AUTHOR]

A comprehensive classification system for preterm birth requires expanded gestational boundaries that recognize the early origins of preterm parturition and emphasize fetal maturity over fetal age. Exclusion of stillbirths, pregnancy terminations, and multifetal gestations prevents comprehensive consideration of the potential causes and presentations of preterm birth. Any step in parturition (cervical softening and ripening, decidual-membrane activation, and/or myometrial contractions) may initiate preterm parturition, and should be recorded for every preterm birth, as should the condition of the mother, fetus, newborn, and placenta, before a phenotype is assigned. [ABSTRACT FROM AUTHOR]

In 2009, the Global Alliance to Prevent Prematurity and Stillbirth Conference charged the authors to propose a new comprehensive, consistent, and uniform classification system for preterm birth. This first article reviews issues related to measurement of gestational age, clinical vs etiologic phenotypes, inclusion vs exclusion of multifetal and stillborn infants, and separation vs combination of pathways to preterm birth. The second article proposes answers to the questions raised here, and the third demonstrates how the proposed system might work in practice. [ABSTRACT FROM AUTHOR]

Background: Recruitment and retention of patients for randomized control trial (RCT) studies can provide formidable challenges, particularly with minority and underserved populations. Data are reported for the Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large RCT targeting risk factors for repeat preterm births among women who previously delivered premature (< 35 weeks gestation) infants. Methods: Design of the PCPPP incorporated strategies to maximize recruitment and retention. These included an advanced database system tracking follow-up status and assessment completion rates; cultural sensitivity training for staff; communication to the community and eligible women of the benefits of participation; financial incentives; assistance with transportation and supervised childcare services; and reminder calls for convenient, flexibly scheduled appointments. Analyses reported here: 1) compare recruitment projections to actual enrollment 2) explore recruitment bias; 3) validate the randomization process 4) document the extent to which contact was maintained and complete assessments achieved 5) determine if follow-up was conditioned upon socio-economic status, race/ethnicity, or other factors. Results: Of eligible women approached, 1,126 (77.7%) agreed to participate fully. Of the 324 not agreeing, 118 (36.4%) completed a short survey. Consenting women were disproportionately from minority and low SES backgrounds: 71.5% consenting were African American, versus 38.8% not consenting. Consenting women were also more likely to report homelessness during their lifetime (14.6% vs. 0.87%) and to be unmarried at the time of delivery (81.6% versus 47.9%). First one-month postpartum assessment was completed for 83.5% (n = 472) of the intervention group (n = 565) and 76% (426) of the control group. Higher assessment completion rates were observed for the intervention group throughout the follow-up. Second, third, fourth and fifth postpartum assessments were 67.6% vs. 57.5%, 60.0% vs. 48.9%, 54.2% vs. 46.3% and 47.3% vs. 40.8%, for the intervention and control group women, respectively. There were no differences in follow-up rates according to race/ethnicity, SES or other factors. Greater retention of the intervention group may reflect the highly-valued nature of the medical and behavior services constituting the intervention arms of the Project. Conclusion: Findings challenge beliefs that low income and minority women are averse to enrolling and continuing in clinical trials or community studies. [ABSTRACT FROM AUTHOR]

The preterm birth rate in the USA is nearing 13%. The recent rise has been attributed to increased indicated preterm births and multiple births following artificial conceptions. There are few obstetrical interventions that successfully delay or prevent spontaneous preterm birth or reduce the risk factors leading to indicated preterm birth. On the other hand, there are many strategies that have improved outcomes for those infants who are born preterm. These include the use of corticosteroids for fetal maturation and regionalization of perinatal care for high-risk mothers and their infants. Several interventions, including progesterone use and cerclage, demonstrate promise in reducing spontaneous preterm births. The most pressing need is to better define the populations of pregnant women for whom these and other interventions will effectively reduce preterm birth. [ABSTRACT FROM AUTHOR]

This article presents the first in a series about preterm birth. Preterm birth is the leading cause of infant mortality and morbidity in the developed world. Babies delivered under the age of 37 weeks' gestation are considered preterm. Pre-eclampsia and eclampsia are both causes as are infections, inflammation, vascular disease and uterine overdistension. Mothers who are black and have had a previous preterm baby are most likely to have spontaneous preterm births. A short cervix and a raised cervical-vaginal fetal fibronectin concentration are the strongest predictors of preterm delivery.

Examines the role of psychosocial and nutritional stress on poor pregnancy outcomes. Susceptibility of pregnant women to infection and pathological consequences of infection; Increase risk of preterm birth; Influence on the timing of delivery and the birth weight of the fetus.

Preterm birth is currently the most important problem in maternal-child health in the United States. Epidemiological studies have suggested that two factors, maternal stress and maternal urogenital tract infection, are significantly and independently associated with an increased risk of spontaneous preterm birth. These factors are also more prevalent in the population of sociodemographically disadvantaged women who are at increased risk for preterm birth. Studies of the physiology of parturition suggest that neuroendocrine and immune processes play important roles in the physiology and pathophysiology of normal and preterm parturition. However, not all women with high levels of stress and/or infection deliver preterm, and little is understood about factors that modulate susceptibility to pathophysiological events of the endocrine and immune systems in pregnancy. We present here a comprehensive, biobehavioural model of maternal stress and spontaneous preterm delivery. According to this model, chronic maternal stress is a significant and independent risk factor for preterm birth. The effects of maternal stress on preterm birth may be mediated through biological and/or behavioural mechanisms. We propose that maternal stress may act via one or both of two physiological pathways: (a) a neuroendocrine pathway, wherein maternal stress may ultimately result in premature and/or greater degree of activation of the maternal-placental-fetal endocrine systems that promote parturition; and (b) an immune/inflammatory pathway, wherein maternal stress may modulate characteristics of systemic and local (placental-decidual) immunity to increase susceptibility to intrauterine and fetal infectious-inflammatory processes and thereby promote parturition through pro-inflammatory mechanisms. We suggest that placental corticotropin-releasing hormone may play a key role in orchestrating the effects of endocrine and inflammatory/immune processes on preterm birth. Moreover, because... [ABSTRACT FROM AUTHOR]

A growing literature suggests that maternal psychological and social stress is a significant and independent risk factor for a range of adverse reproductive outcomes including preterm birth. Several issues remain to be addressed about stress and vulnerability to stress during pregnancy. Of these, perhaps one of the most important questions relates to biologic plausibility. Parturition, the process that results in birth, is a biological phenomenon. Very little empirical research to date, however, has examined the role of biological processes, if any, as mediators of the relationship between stress and preterm birth. In this paper we discuss the maternal, placental, and fetal neuroendocrine, immune/inflammatory, and vascular processes that may bridge the experience of social adversity before and during pregnancy and the biological outcome of preterm birth. [ABSTRACT FROM AUTHOR]

Objectives: Maternal infection, particularly bacterial vaginosis (BV) in pregnancy, is one of the leading causes of adverse perinatal outcomes. The determinants of individual differences in susceptibility, or vulnerability, to maternal infections are poorly understood. This study examines whether chronic maternal stress predisposes women to infection during pregnancy, and if so, whether the effects of chronic stress on infection are independent of other established risk factors. Methods: We conducted a cross-sectional, clinical prevalence study of chronic maternal stress and BV status in a sample of 454 pregnant women at 14.3 ± 0.3 weeks gestation (±SEM). BV was diagnosed by Gram-stain of vaginal fluid samples; chronic maternal stress was assessed using the Cohen Perceived Stress Scale. Other established risk factors for BV, including maternal age, race/ethnicity, marital status, SES, and behaviors related to feminine hygiene, sexual practices, and substance use, were measured using a structured interview. Results: Of the 454 women enrolled in this study, 224 (49%) were BV positive (Nugent score 7–10), 64 (14%) had intermediate vaginal flora (Nugent score 4–6), and 166 (37%) were BV negative (Nugent score 0–3). BV+ women had significantly higher chronic stress levels than BV- women (24.6 ± 0.5 vs. 22.2 ± 0.6 units (±SEM), respectively; t = 3.19; p < .01). Maternal sociodemographic variables (African-American race/ethnicity) and behavioral characteristics (vaginal douching, number of lifetime sexual partners, and use of illicit drugs) also were significantly associated with the presence of BV. After controlling for the effects of these variables, using a multivariable logistic regression model, chronic maternal stress remained a significant and independent predictor of BV status. Women in the moderate-stress group (third quartile) and high-stress (fourth quartile) group were 2.3 times (95% CI = 1.2–4.3) and 2.2 times (95% CI = 1.1–4.2) more likely to be BV+ than women in the low-stress group (bottom quartile). Conclusions: High levels of chronic stress during pregnancy are associated with bacterial vaginosis. The effect of chronic maternal stress is independent of the effects of other established sociodemographic and behavioral risk factors for BV. [ABSTRACT FROM AUTHOR]

Background: The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care.Objective: We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency.Study Design: We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders.Results: Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86).Conclusion: Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines. [ABSTRACT FROM AUTHOR]

This article focuses on prepregnancy health status and the risk of preterm delivery. In the United States and most developed countries, during the previous 4 or 5 decades, the preterm birth rate has either remained stable or, more commonly, risen slowly. This rise has occurred despite increasing knowledge of risk factors and mechanisms and the introduction of numerous public health and medical interventions designed to reduce PTB. Preterm birth has 3 obstetrical antecedents: (1) spontaneous preterm labor and (2) spontaneous membrane rupture, which taken together result in spontaneous PTB, and (3) the decision of the physician to induce labor or perform a cesarean delivery because of fetal distress or maternal illness, resulting in an indicated PTB.

The article discusses the results of a study regarding the correspondence between periodontal disease and premature birth. The results of the study are also published in this issue, on page 1885. Statistics relating to the incidence of premature births and periodontal disease, treated both during and after pregnancy, are provided. The author suggests that periodontal disease is also related to miscarriage and stillbirth. The author suggests that if periodontal disease and premature birth are related, the periodontal disease may require treatment prior to pregnancy.

Neighborhood socioeconomic effects on health have been estimated using multiple variables and indices. This inconsistent estimation approach makes comparison across geographic areas challenging. In this paper, we developed indices representing specific socioeconomic domains that can be reproduced in other areas to estimate elements of the neighborhood socioeconomic environment on health outcomes, specifically preterm birth. Using year 2000 U.S. census data and principal components analysis, socioeconomic indices were developed representing a priori – defined domains of education, employment, housing, occupation, poverty and residential stability. These socioeconomic indices were subsequently used in race-stratified multilevel logistic regression models of preterm birth in eight socioeconomically distinct study areas in the U.S. Maternal residence was obtained from birth records and was geocoded to census tracts. In maternal age and education adjusted models, living in tracts with high unemployment, low education, poor housing, low proportion of managerial or professional occupation and high poverty was associated with increased odds of preterm birth for non-Hispanic white women at most sites. Among non-Hispanic black women, similar associations were noted for tract-level low education, high unemployment, low occupation, and high poverty, but the effect estimates were generally smaller than those seen for white women. Increasing amounts of residential stability were not associated with preterm birth in these analyses. We combined the domain estimates across the eight study sites to produce pooled effect estimates for the socioeconomic domains on preterm birth. The research reported here suggests that specific neighborhood-level socioeconomic features may be especially influential to health outcomes. These socioeconomic domains represent potential targets for intervention or policy efforts designed to improve maternal and child health and reduce health disparities. [Copyright &y& Elsevier]