Approaching NIH guideline recommended care for maternal-infant health: clinical failures to use recommended antenatal corticosteroids.

To assess the use of antenatal corticosteroids in clinical circumstances for which both the NIH Guideline and local experts recommend their use and to describe characteristics associated with failure to use recommended antenatal steroids. We convened local experts to adapt the NIH statement by identifying clinical circumstances for which they agree antenatal steroids should always be used. We conducted a retrospective chart review on a cohort study of mothers who delivered premature (24-34 weeks) infants between 2000 and 2002 at three New York City hospitals and investigated the association of failure to treat with antenatal steroids with characteristics of the mother, pregnancy, delivery, and hospital. Twenty percent (101/515) of eligible mothers failed to receive indicated antenatal corticosteroid therapy. Of these, 43% delivered more than 2 h after admission, and 33% delivered more than 4 h after admission, indicating sufficient time to have treated them. Lack of prenatal care, longer gestation, advanced cervical exam, and intact membranes at admission were associated with failure to receive the recommended therapy. Antenatal steroids were under-utilized in our sample. If our results our generalizable, opportunities for quality improvement in the antenatal management of mothers in preterm labor exist.

Serum inflammatory mediators in pregnancy: changes after periodontal treatment and association with pregnancy outcomes.

BACKGROUND: The purposes of this study were to determine: 1) if periodontal treatment in pregnant women before 21 weeks of gestation alters levels of inflammatory mediators in serum; and 2) if changes in these mediators are associated with birth outcomes. METHODS: A total of 823 pregnant women with periodontitis were randomly assigned to receive scaling and root planing before 21 weeks of gestation or after delivery. Serum obtained between 13 and 16 weeks, 6 days (study baseline) and 29 to 32 weeks of gestation was analyzed for C-reactive protein; prostaglandin E(2); matrix metalloproteinase-9; fibrinogen; endotoxin; interleukin (IL)-1 beta, -6, and -8, and tumor necrosis factor-alpha. Cox regression, multiple linear regression, and the t, chi(2), and Fisher exact tests were used to examine associations among the biomarkers, periodontal treatment, and gestational age at delivery and birth weight. RESULTS: A total of 796 women had baseline serum data, and 620 women had baseline and follow-up serum and birth data. Periodontal treatment did not significantly alter the level of any biomarker (P >0.05). Neither baseline levels nor the change from baseline in any biomarker were significantly associated with preterm birth or infant birth weight (P >0.05). In treatment subjects, the change in endotoxin was negatively associated with the change in probing depth (P <0.05). CONCLUSIONS: Non-surgical mechanical periodontal treatment in pregnant women, delivered before 21 weeks of gestation, did not reduce systemic (serum) markers of inflammation. In pregnant women with periodontitis, levels of these markers at 13 to 17 weeks and 29 to 32 weeks of gestation were not associated with infant birth weight or a risk for preterm birth.

Change in periodontitis during pregnancy and the risk of pre-term birth and low birthweight.

AIM: Determine whether periodontitis progression during pregnancy is associated with adverse birth outcomes. METHODS: We used clinical data and birth outcomes from the Obstetrics and Periodontal Therapy Study, in which randomly selected women received periodontal treatment before 21 weeks of gestation (N=413) or after delivery (410). Birth outcomes were available for 812 women and follow-up periodontal data for 722, including 75 whose pregnancies ended <37 weeks. Periodontitis progression was defined as >or=3 mm loss of clinical attachment. Birth outcomes were compared between non-progressing and progressing groups using the log rank and t tests, separately in all women and in untreated controls. RESULTS: The distribution of gestational age at the end of pregnancy (p>0.1) and mean birthweight (3295 versus 3184 g, p=0.11) did not differ significantly between women with and without disease progression. Gestational age and birthweight were not associated with change from baseline in percentage of tooth sites with bleeding on probing or between those who did versus did not progress according to a published definition of disease progression (p>0.05). CONCLUSIONS: In these women with periodontitis and within this study's limitations, disease progression was not associated with an increased risk for delivering a pre-term or a low birthweight infant.

Examining the safety of dental treatment in pregnant women.

BACKGROUND: Although clinicians generally consider it safe to provide dental care for pregnant women, supporting clinical trial evidence is lacking. This study compares safety outcomes from a trial in which pregnant women received scaling and root planing and other dental treatments. METHODS: The authors randomly assigned 823 women with periodontitis to receive scaling and root planing, either at 13 to 21 weeks' gestation or up to three months after delivery. They evaluated all subjects for essential dental treatment (EDT) needs, defined as the presence of moderate-to-severe caries or fractured or abscessed teeth; 351 women received complete EDT at 13 to 21 weeks' gestation. The authors used Fisher exact test and a propensity-score adjustment to compare rates of serious adverse events, spontaneous abortions/stillbirths, fetal/congenital anomalies and preterm deliveries (<37 weeks' gestation) between groups, according to the provision of periodontal treatment and EDT. RESULTS: Rates of adverse outcomes did not differ significantly (P> .05) between women who received EDT and those who did not require this treatment, or between groups that received both EDT and periodontal treatment, either EDT or periodontal treatment alone, or no treatment. Use of topical or local anesthetics during root planing also was not associated with an increased risk of experiencing adverse outcomes. CONCLUSIONS: EDT in pregnant women at 13 to 21 weeks' gestation was not associated with an increased risk of experiencing serious medical adverse events or adverse pregnancy outcomes. Data from larger studies and from groups with other treatment needs are needed to confirm the safety of dental care in pregnant women. CLINICAL IMPLICATIONS: This study provides evidence that EDT and use of topical and local anesthetics are safe in pregnant women at 13 to 21 weeks' gestation.

Treatment of periodontal disease and the risk of preterm birth.

BACKGROUND: Maternal periodontal disease has been associated with an increased risk of preterm birth and low birth weight. We studied the effect of nonsurgical periodontal treatment on preterm birth. METHODS: We randomly assigned women between 13 and 17 weeks of gestation to undergo scaling and root planing either before 21 weeks (413 patients in the treatment group) or after delivery (410 patients in the control group). Patients in the treatment group also underwent monthly tooth polishing and received instruction in oral hygiene. The gestational age at the end of pregnancy was the prespecified primary outcome. Secondary outcomes were birth weight and the proportion of infants who were small for gestational age. RESULTS: In the follow-up analysis, preterm birth (before 37 weeks of gestation) occurred in 49 of 407 women (12.0%) in the treatment group (resulting in 44 live births) and in 52 of 405 women (12.8%) in the control group (resulting in 38 live births). Although periodontal treatment improved periodontitis measures (P<0.001), it did not significantly alter the risk of preterm delivery (P=0.70; hazard ratio for treatment group vs. control group, 0.93; 95% confidence interval [CI], 0.63 to 1.37). There were no significant differences between the treatment and control groups in birth weight (3239 g vs. 3258 g, P=0.64) or in the rate of delivery of infants that were small for gestational age (12.7% vs. 12.3%; odds ratio, 1.04; 95% CI, 0.68 to 1.58). There were 5 spontaneous abortions or stillbirths in the treatment group, as compared with 14 in the control group (P=0.08). CONCLUSIONS: Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction. (ClinicalTrials.gov number, NCT00066131 [ClinicalTrials.gov].).