Maternal urinary concentrations of organophosphate ester metabolites: associations with gestational weight gain, early life anthropometry, and infant eating behaviors among mothers-infant pairs in Rhode Island.

BACKGROUND: Organophosphate esters (OPEs)-used as flame retardants and plasticizers-are associated with adverse pregnancy outcomes such as reduced fecundity and live births and increased preterm delivery. OPEs may interfere with growth and metabolism via endocrine-disruption, but few studies have investigated endocrine-related outcomes. The objective of this pilot study (n = 56 mother-infant pairs) was to evaluate associations of OPEs with gestational weight gain (GWG), gestational age at delivery, infant anthropometry, and infant feeding behaviors. METHODS: We quantified OPE metabolites (bis-2-chloroethyl phosphate [BCEP], bis (1,3-dichloro-2-propyl) phosphate [BDCPP], diphenyl phosphate [DPHP]) in pooled maternal spot urine collected throughout pregnancy (~ 12, 28, and 35 weeks' gestation). We obtained maternal sociodemographic characteristics from questionnaires administered at enrollment and perinatal characteristics from medical record abstraction. Trained research assistants measured infant weight, length, head and abdominal circumferences, and skinfold thicknesses at birth and 6 weeks postpartum. Mothers reported infant feeding behavior via the Baby Eating Behavior Questionnaire (BEBQ). Using multiple linear regression, we assessed associations of log2-transformed maternal urinary OPE metabolites with GWG, gestational age at delivery, infant anthropometry at birth, weekly growth rate, and BEBQ scores at 6 weeks postpartum. We used linear mixed effects (LME) models to analyze overall infant anthropometry during the first 6 weeks of life. Additionally, we considered effect modification by infant sex. RESULTS: We observed weak positive associations between all OPE metabolites and GWG. In LME models, BDCPP was associated with increased infant length (ß = 0.44 cm, 95%CI = 0.01, 0.87) and weight in males (ß = 0.14 kg, 95%CI = 0.03, 0.24). BDCPP was also associated with increased food responsiveness (ß = 0.23, 95%CI = 0.06, 0.40). DPHP was inversely associated with infant abdominal circumference (ß = - 0.50 cm, 95%CI = - 0.86, - 0.14) and female weight (ß = - 0.19 kg, 95%CI = - 0.36, - 0.02), but positively associated with weekly growth in iliac skinfold thickness (ß = 0.10 mm/wk., 95%CI = 0.02, 0.19). Further, DPHP was weakly associated with increased feeding speed. BCEP was associated with greater infant thigh skinfold thickness (ß = 0.34 mm, 95%CI = 0.16, 0.52) and subscapular skinfold thickness in males (ß = 0.14 mm, 95%CI = 0.002, 0.28). CONCLUSIONS: Collectively, these findings suggest that select OPEs may affect infant anthropometry and feeding behavior, with the most compelling evidence for BDCPP and DPHP.

Factors Associated with Attempted External Cephalic Version for Fetal Malpresentation at Term.

Objective To assess differences in patient characteristics between women who did and did not undergo attempted external cephalic version (ECV) for fetal malpresentation at term. Study Design This was a retrospective cohort study of women with a singleton gestation and noncephalic presentation at > 37.0 weeks between October 2014 and October 2015. We compared demographic and clinical characteristics of women who did and did not undergo attempted ECV and assessed the reasons that women did not attempt ECV. Results Among 215 women, only 51 (24%) attempted ECV. There were no differences in age, race, insurance type, or body mass index between women who underwent attempted ECV and those who did not. Women who underwent ECV were significantly more likely to have had a prior vaginal delivery (69 vs. 36%, p < 0.001). Seventy-six women (46%) declined ECV. Women who declined ECV were more likely to be nulliparous than those who accepted the procedure (66 vs. 29%, p < 0.001). Among women who had ECV, the success rate was 55%. There were no adverse events after attempted ECV in this cohort. Conclusion Among women with fetal malpresentation at term, those without a prior vaginal delivery were significantly less likely to undergo attempted ECV.

Improving Obstetric Hypertensive Emergency Treatment in a Tertiary Care Women's Emergency Department.

OBJECTIVE: To assess treatment outcomes associated with an obstetric hypertensive emergency quality improvement intervention instituted in a tertiary care women's emergency department. METHODS: We conducted a cohort study of pregnant (20 weeks of gestation or greater) and postpartum (6 weeks of gestation or less) women treated for hypertensive emergency (systolic blood pressure [BP] 160 mm Hg or greater, diastolic 110 mm Hg or greater, or both) before and after a quality improvement intervention. A multidisciplinary task force revised clinical guidelines and nursing policy, updated electronic order sets, and provided staff education and clinical management aids. Data were collected by electronic chart review. The primary outcome was achieving goal BP (systolic 150 mm Hg or less and diastolic 100 mm Hg or less) within an hour of initial therapy. Secondary outcomes included time from first severe BP to 1) first antihypertensive treatment and 2) goal BP. RESULTS: There were no significant differences in baseline characteristics in the preintervention (n=173; September 2014 to September 2015) and postintervention (n=173; December 2015 to November 2016) groups, including gestational age, days postpartum, maternal age, race-ethnicity, or comorbidities. We found no significant difference in primary outcome frequency: 41% achieved goal BP within 60 minutes preintervention vs 47% postintervention (P=.28). Median time from first severe BP to first treatment was unchanged (30 minutes preintervention vs 29 minutes postintervention, P=.058); however, median time from first severe BP to goal BP decreased significantly (122 vs 95 minutes, P=.04). Confirmation of hypertensive emergency within 15 minutes (recommended) was only achieved in approximately 20% of women in either group. More women initially received intravenous antihypertensive treatment after the intervention (52% preintervention vs 80% postintervention, P<.001). CONCLUSION: A quality improvement initiative was not associated with more women achieving BP control within an hour of obstetric hypertensive emergency treatment, but was associated with decreased time to achieve control. This suggests improved clinical practice after the intervention.

Evaluating the Performance of Ultrasound Screening for Congenital Heart Disease: A Descriptive Cohort Study.

Objective The objective of this study was to evaluate the rate of abnormal fetal echocardiogram after normal detailed anatomy ultrasound when both are performed by maternal-fetal medicine specialists. Study Design Retrospective review of women who underwent detailed anatomy ultrasound and fetal echocardiography between 16 and 26 weeks' gestation at a single center. Women included had at least one indication for fetal echocardiography as recommended by the American Institute of Ultrasound in Medicine and normal cardiac anatomy on initial detailed anatomy ultrasound. Women with previous abnormal ultrasound, extracardiac anomalies, and abnormal or incomplete cardiac anatomy on initial examinations were excluded. The primary outcome was abnormal fetal echocardiogram, defined as a structural cardiac anomaly. Results A total of 1,000 women (1,052 fetuses) were included. The most common indication for echocardiography was family history of congenital heart disease. Five fetuses had an abnormal echocardiogram (0.5%, 95% confidence interval: 0.2-1.1%), only one of which altered care. The other four were suspected ventricular septal defects; of these, three were not seen on postnatal cardiac imaging. Conclusion The rate of abnormal fetal echocardiogram after a normal detailed anatomy ultrasound interpreted by maternal-fetal medicine specialists is low. Fetal echocardiography as a second screening test is of low clinical utility and unlikely to be cost-effective in this setting.

Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term.

OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery. METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500-3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables. RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31-1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01-1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55-2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65-22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g. CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.

The Potential Role for Myoinositol in the Prevention of Gestational Diabetes Mellitus.

More than 9% of overweight and obese women develop gestational diabetes mellitus (GDM) during pregnancy. Myoinositol is a promising supplement that may represent the first GDM-risk modifier that could be implemented on a population-level. It has been shown in animal and small human trials to prevent GDM through its insulin-mimetic properties. In animal studies, it also appears to decrease intra-abdominal adiposity and protect against diabetic embryopathies. In humans, four small randomized trials have demonstrated that myoinositol supplementation can lead to more than a 50% rate reduction in GDM compared with placebo. We now need a large, multicentered randomized controlled trial to demonstrate whether myoinositol has not only the promised impact on GDM rates, but also an effect on important secondary outcomes intricately linked to GDM, such as birth weight and neonatal intensive care unit admission.

An Evidence-Based Approach to Defining Fetal Macrosomia.

OBJECTIVE: This study aims to determine the risk of adverse outcomes associated with the current diagnostic criteria for fetal macrosomia. Study DESIGN: We evaluated three techniques for characterizing birth weight as a predictor of shoulder dystocia or third- or fourth-degree laceration in 79,879 vaginal deliveries. First, we compared deliveries with birth weights above or below 4,500 g. We then performed logistic regression using birth weight as a continuous predictor, both with and without fractional polynomial transformation. Finally, we calculated the number of cesarean sections required to prevent one incident of the interrogated outcomes (number needed to treat [NNT]). RESULTS: Rates of adverse intrapartum outcomes increase incrementally with increasing birth weight and are predicted most accurately with logistic regression following fractional polynomial transformation. The NNT for third- or fourth-degree laceration dropped from 14.3 (95% confidence interval [CI], 13.9-14.7) at a birth weight of 3,500 g to 6.4 (95% CI, 6.1-6.8) at 4,500 g and, for shoulder dystocia, from 54.9 (95% CI, 51.5-58.6) at 3,500 g to 5.6 (95% CI, 5.2-6.0) at 4,500 g. CONCLUSION: The conventional distinction between "normal" and "macrosomic" does not reflect the incremental effect of increasing birth weight on the risk of obstetric morbidity. Outcomes analysis can inform fetal growth standards to better reflect relevant thresholds of risk.