Associations of Maternal Prenatal Stress and Depressive Symptoms With Childhood Neurobehavioral Outcomes in the ECHO Cohort of the NICHD Fetal Growth Studies: Fetal Growth Velocity as a Potential Mediator.

OBJECTIVE: Maternal prenatal stress and mood symptoms are associated with risk for child psychopathology. Within the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies (ECHO-FGS), a racially and ethnically diverse cohort, we studied associations between prenatal stress and depressive symptoms with child neurobehavior, and potential mediation by fetal growth velocity (FGV) in low-risk pregnancies. METHOD: For 730 mother-child pairs, we had serial ultrasound measurements, self-reports of prenatal stress and depression, observations of child executive functions and motor skills from 4 to 8 years, and maternal reports of child psychiatric problems. We tested associations between prenatal stress and depressive symptoms with child neurobehavior in regression analyses, and associations with FGV in mixed effect models. Post hoc we tested severity of prenatal symptoms; FGV at 25th, 50th, and 75th percentiles; and moderation by biological sex and by race and ethnicity. RESULTS: Prenatal stress and depressive symptoms were associated with child psychiatric problems, and prenatal depressive symptoms with decrements in executive functions and motor skills, especially in biological male children. Neither prenatal stress nor depressive symptoms were associated with FGV. CONCLUSION: In one of the largest cohorts with observed child outcomes, and the first with broad representation of race and ethnicity in the United States, we found that prenatal stress and depressive symptoms were associated with greater reports of child psychiatric symptoms. Only prenatal depressive symptoms were associated with observed decrements in cognitive abilities, most significantly in biological male children. Stress during low-risk pregnancies may be less detrimental than theorized. There was no mediation by FGV. These findings support the need to attend to even small changes in prenatal distress, as these may have long-lasting implications.

Early vs expectant artificial rupture of membranes following Foley catheter ripening: a randomized controlled trial.

BACKGROUND: Early amniotomy shortens the duration of spontaneous labor, yet there is no clear evidence on the optimal timing of amniotomy following cervical ripening. There are limited high-quality studies on the use of early amniotomy intervention following labor induction. OBJECTIVE: This study aimed to evaluate whether amniotomy within 1 hour of Foley catheter expulsion reduces the duration of labor among individuals undergoing combined misoprostol and Foley catheter labor induction at term. STUDY DESIGN: This was a randomized clinical trial conducted from November 2020 to May 2021 comparing amniotomy within 1 hour of Foley catheter expulsion (early artificial rupture of membranes) with expectant management. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction at ≥37 weeks with a singleton gestation and needing cervical ripening were eligible. Our primary outcome was time to delivery. Wilcoxon rank sum, Pearson chi-square, and Cox survival analyses with intent-to-treat principles were performed adjusting for age, body mass index, parity, mode of delivery, Bishop score, and the interaction between randomization group and parity. A sample size of 160 was planned to detect a 4-hour reduction in delivery time. RESULTS: A total of 160 patients (79 early artificial rupture of membranes, 81 expectant management) were randomized. Early artificial rupture of membranes achieved a faster median time to delivery than expectant management (early artificial rupture of membranes: 11.1 hours; interquartile range, 6.25-17.1 vs expectant management: 19.8 hours; interquartile range, 13.2-26.2; P<.001). A greater percentage of individuals in the early artificial rupture of membranes group delivered within 24 hours (86% vs 70%; P=.03). There was no difference in the cesarean delivery rate between the 2 groups (22% vs 31%; P=.25). Individuals delivered 2.3 times faster following early artificial rupture of membranes (hazard ratio, 2.3; 95% confidence interval, 1.5-3.4; P<.001). There were no significant differences in maternal and neonatal outcomes. CONCLUSION: Amniotomy within 1 hour of Foley catheter expulsion resulted in 2.3 times faster delivery than expectant management. Therefore, early artificial rupture of membranes should be considered in individuals undergoing mechanical cervical ripening at term.

Incremental risk of clinical chorioamnionitis associated with cervical examination.

BACKGROUND: Clinical chorioamnionitis is associated with significant maternal and neonatal morbidity, yet there is no clear evidence on the association between cervical examinations and infection. OBJECTIVE: We sought to assess the association between the number of cervical examinations performed during term labor management and the risk of clinical chorioamnionitis. STUDY DESIGN: This is a retrospective cohort study of term (≥37 weeks of gestation), singleton pregnancies who labored at our tertiary care center from 2014 to 2018. The primary outcome of clinical chorioamnionitis was defined as maternal intrapartum fever (single oral temperature of >39°C or 38°C-38.9°C for 30 minutes) and 1 or more of the following: maternal leukocytosis, purulent cervical drainage, or fetal tachycardia. The primary exposure was the number of digital cervical exams documented in the medical record. Log-binomial regression was used to model the effect of cervical examinations on the risk of clinical chorioamnionitis while adjusting for potential confounders. RESULTS: A total of 20,029 individuals met the inclusion criteria and 1028 (5%) patients experienced clinical chorioamnionitis. The number of cervical exams was associated with increased risk of developing infection after adjusting for potential confounders. Individuals with ≥8 cervical exams had 1.7 times the risk of developing clinical chorioamnionitis compared with those with 1 to 3 exams. Prolonged rupture time, nulliparity, Black race, Medicaid insurance, higher gestational age, and higher body mass index were associated with increased risk of clinical chorioamnionitis, whereas smoking and group B Streptococcus colonization were associated with a lower risk. CONCLUSION: Our study found that the number of cervical exams performed during labor is an independent risk factor for developing clinical chorioamnionitis. Unnecessary cervical exams should be avoided during labor management at term.

Obstetrical outcomes are unchanged after hysteroscopic myomectomy in women with submucosal fibroids.

BACKGROUND: Previous studies have demonstrated increased rates of poor obstetrical outcomes including preterm delivery, placental abruption, and intrauterine growth restriction in women with uterine leiomyomas. Currently, preconception myomectomy has not been reported to improve pregnancy rates or pregnancy outcomes in women with subserosal leiomyomas, and the data remain inconclusive for intramural fibroids. Pregnancy rates have been found to improve after the removal of submucosal fibroids. However, the effect of preconception myomectomy for submucosal fibroids on birth outcomes has yet to be examined. OBJECTIVE: This study aimed to determine whether hysteroscopic excision of submucosal leiomyomas affects the rate of preterm delivery, among other obstetrical outcomes. STUDY DESIGN: We performed a retrospective case-control study of women who underwent hysteroscopic resection of leiomyomas (cases) and controls of women who had submucosal fibroids at the time of their first-trimester ultrasounds. Women were included if they delivered a nonanomalous fetus beyond 20 weeks' gestation. A total of 73 cases were identified and matched with 219 controls (case-to-control ratio, 1:3). Subsequently, owing to multiple-gestation pregnancy, 11 patients were excluded from the case population and 4 patients from the control group. The final analysis included 277 women-62 cases and 215 controls. Our primary outcome was preterm delivery before 37 weeks' gestation. Prespecified secondary outcomes of interest were preterm delivery before 34 weeks' gestation, placental abruption, fetal malpresentation, intrauterine growth restriction, and rate of cesarean delivery. Data analysis was performed using univariate and multivariate statistics. RESULTS: Cases and controls were similar with respect to age, race, body mass index, and mode of delivery. Cases were more likely to be primiparous (66% cases [42 of 62] vs 37% controls [80 of 215]; P=.00) and use assisted reproductive technology to conceive (22.6% cases [14 of 62] vs 7.0% controls [15 of 215]; P<.001). No differences were found in the rate of preterm delivery at <37 weeks' gestation (12.9% cases [8 of 62] vs 13.5% controls [29 of 215]; P=.89), preterm delivery at <34 weeks' gestation (4.84% cases [3 of 62] vs 6.97% controls [15 of 215]; P=.77), or other obstetrical outcomes. CONCLUSION: Overall, women with submucosal uterine leiomyomas who undergo hysteroscopic removal have similar birth outcomes to those who do not.

Examining the relationship between food environment and gestational diabetes.

BACKGROUND: Studies have shown an association between the incidence of gestational diabetes and living in neighborhoods oversaturated with unhealthy foods. OBJECTIVE: This study sought to determine if the food environment also affects the management of gestational diabetes. We hypothesized that living in areas with a higher quality of food decreased the risk of requiring medication to treat gestational diabetes. STUDY DESIGN: This was a retrospective cohort study of singleton births at the Christiana Care Health System between 2015 and 2018. Patients with gestational diabetes who live in Delaware (N=1327) were geocoded and classified according to their census tract food environment. The food environment was assessed using the modified Retail Food Environment Index, which measures the percentage of healthy food retailers among all food retailers within a half-mile radius of the census tract boundaries. The modified Retail Food Environment Index scores were divided into 3 categories: poor (modified Retail Food Environment Index score, 0-3), average (modified Retail Food Environment Index score, 4-10), and good or above average (modified Retail Food Environment Index score, ≥11) food environments. The primary outcome was the prevalence of A2 gestational diabetes mellitus. Several neonatal and obstetrical outcomes were also examined including type II diabetes mellitus (defined as a 2-hour glucose tolerance test with at least 1 value above the threshold), cesarean delivery, shoulder dystocia, admission to the neonatal intensive care unit, neonatal hypoglycemia, neonatal hyperbilirubinemia, neonatal respiratory distress syndrome, and macrosomia. RESULTS: A total of 689 (52%) women were diagnosed as having A2 gestational diabetes mellitus. Women in the average or good or above average food environment groups had a lower prevalence of A2 gestational diabetes mellitus than women in the poor food environment group (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.92] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.56; 95% confidence interval, 0.40-0.82]). They also had a lower prevalence of type II diabetes mellitus (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.25; 95% confidence interval, 0.09-0.72] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.48; 95% confidence interval, 0.27-0.86]). There were no differences in the other secondary outcomes of interest. CONCLUSION: The food environment affects the requirement for medication to obtain glycemic levels that are within the target range for those with gestational diabetes.