Cohort profile: the Environmental Reproductive and Glucose Outcomes (ERGO) Study (Boston, Massachusetts, USA) - a prospective pregnancy cohort study of the impacts of environmental exposures on parental cardiometabolic health.

PURPOSE: Pregnancy and the postpartum period are increasingly recognised as sensitive windows for cardiometabolic disease risk. Growing evidence suggests environmental exposures, including endocrine-disrupting chemicals (EDCs), are associated with an increased risk of pregnancy complications that are associated with long-term cardiometabolic risk. However, the impact of perinatal EDC exposure on subsequent cardiometabolic risk post-pregnancy is less understood. The Environmental Reproductive and Glucose Outcomes (ERGO) Study was established to investigate the associations of environmental exposures during the perinatal period with post-pregnancy parental cardiometabolic health. PARTICIPANTS: Pregnant individuals aged ≥18 years without pre-existing diabetes were recruited at <15 weeks of gestation from Boston, Massachusetts area hospitals. Participants completed ≤4 prenatal study visits (median: 12, 19, 26, 36 weeks of gestation) and 1 postpartum visit (median: 9 weeks), during which we collected biospecimens, health histories, demographic and behavioural data, and vitals and anthropometric measurements. Participants completed a postpartum fasting 2-hour 75 g oral glucose tolerance test. Clinical data were abstracted from electronic medical records. Ongoing (as of 2024) extended post-pregnancy follow-up visits occur annually following similar data collection protocols. FINDINGS TO DATE: We enrolled 653 unique pregnancies and retained 633 through delivery. Participants had a mean age of 33 years, 10% (n=61) developed gestational diabetes and 8% (n=50) developed pre-eclampsia. Participant pregnancy and postpartum urinary phthalate metabolite concentrations and postpartum glycaemic biomarkers were quantified. To date, studies within ERGO found higher exposure to phthalates and phthalate mixtures, and separately, higher exposure to radioactive ambient particulate matter, were associated with adverse gestational glycaemic outcomes. Additionally, certain personal care products used in pregnancy, notably hair oils, were associated with higher urinary phthalate metabolite concentrations, earlier gestational age at delivery and lower birth weight. FUTURE PLANS: Future work will leverage the longitudinal data collected on pregnancy and cardiometabolic outcomes, environmental exposures, questionnaires, banked biospecimens and paediatric data within the ERGO Study.

Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

STUDY AIM: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach. BACKGROUND: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described. METHODS: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements. RESULTS: We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC. CONCLUSION: This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study. APPLICATION: We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Fractal approaches to scaling transformations to sustainability.

Responses to sustainability challenges are not delivering results at the scale and speed called for by science, international agreements, and concerned citizens. Yet there is a tendency to underestimate the large-scale impacts of small-scale, local, and contextualized actions, and particularly the role of individuals in scaling transformations. Here, we explore a fractal approach to scaling sustainability transformations based on "universal values." Universal values are proposed as intrinsic characteristics that connect humans and nature in a coherent, acausal way. Drawing on the Three Spheres of Transformation framework, we consider how enacting universal values can generate fractal-like patterns of sustainability that repeat recursively across scales. Fractal approaches shift the focus from scaling through "things" (e.g., technologies, behaviors, projects) to scaling through a quality of agency based on values that apply to all. We discuss practical steps involved in fractal approaches to scaling transformations to sustainability, provide examples, and conclude with questions for future research.

Use of personal care products during pregnancy and birth outcomes - A pilot study.

Prenatal exposure to endocrine disrupting chemicals (EDCs) from personal care products may be associated with birth outcomes including preterm birth and low birth weight. There is limited research examining the role of personal care product use during pregnancy on birth outcomes. Our pilot study consisted of 164 participants in the Environmental Reproductive and Glucose Outcomes (ERGO) study (Boston, MA), with data on self-reported personal care product use at four study visits throughout pregnancy (product use in the 48 h before a study visit and hair product use in the month before a study visit). We used covariate-adjusted linear regression models to estimate differences in mean gestational age at delivery, birth length, and sex-specific birth weight-for-gestational age (BW-for-GA) Z-score based on personal care product use. Hair product use in the past month prior to certain study visits was associated with decreased mean sex-specific BW-for-GA Z-scores. Notably, hair oil use in the month prior to study visit 1 was associated with a lower mean BW-for-GA Z-score (V1: -0.71, 95% confidence interval: -1.12, -0.29) compared to non-use. Across all study visits (V1-V4), increased mean birth length was observed among nail polish users vs. non-users. In comparison, decreased mean birth length was observed among shave cream users vs. non-users. Liquid soap, shampoo, and conditioner use at certain study visits were significantly associated with higher mean birth length. Suggestive associations were observed across study visits for other products including hair gel/spray with BW-for-GA Z-score and liquid/bar soap with gestational age. Overall, use of a variety of personal care products throughout pregnancy was observed to be associated with our birth outcomes of interest, notably hair oil use during early pregnancy. These findings may help inform future interventions/clinical recommendations to reduce exposures linked to adverse pregnancy outcomes.

Urinary phthalate metabolite concentrations and personal care product use during pregnancy - Results of a pilot study.

INTRODUCTION: Phthalates are reproductive toxicants commonly found in personal care products (PCPs). These endocrine disrupting chemicals are associated with pregnancy complications, including gestational diabetes. Yet, little is known about PCP use as a contributor to urinary phthalate metabolite concentrations in pregnancy. METHODS: We conducted a pilot study among 108 pregnant participants to examine the associations of self-reported PCP use with 14 phthalate and 2 DINCH (di(isononyl) cyclohexane-1,2-dicarboxylate) metabolite concentrations measured in single spot urine samples during pregnancy (median: 36 weeks of gestation). At the time of urine collection, participants self-reported use of hair products (within the last month) and other PCPs (within the last 48 h). We used linear regression to estimate associations for natural log-transformed, specific gravity-corrected concentrations of common PCP-associated phthalate metabolites (monoethyl phthalate [MEP], mono-n-butyl phthalate [MBP], and mono-isobutyl phthalate [MIBP]) in our primary analyses, and additional phthalate metabolites in secondary analyses. RESULTS: Most urinary metabolites were detected for >90% of participants. Participants who reported using hair oil within the past month had MEP concentrations 125% higher (95% confidence interval [CI]: -0.1, 408) than non-users. For other personal care products, we observed the greatest percent difference in PCP-associated metabolites for MIBP among hair gel users (39.3%, 95% CI: -6.3, 107) and for MEP among conditioner/crème rinse users (-55.4%, 95% CI: -76.4, -15.6) compared to non-users. CONCLUSION: Findings suggest that self-reported use of hair oils during late pregnancy may be associated with higher urinary concentrations of MEP. Hair gel use in late pregnancy may also be associated with higher urinary phthalate metabolite concentrations, while conditioner/crème rinse use may be associated with lower levels if MEP.

Associations of insulin pump and continuous glucose monitoring use with pregnancy-related outcomes in women with type 1 diabetes.

AIMS: To examine insulin pump and continuous glucose monitoring (CGM) use with pregnancy-related outcomes in women with type 1 diabetes. METHODS: We abstracted medical records of 646 pregnancies in 478 women with type 1 diabetes, with information on insulin pump versus multiple daily injection (MDI) use and CGM use. We analyzed the associations of pump vs. MDI use, CGM use vs. non-use and pregnancy-related outcomes using mixed effect models. RESULTS: Pump use was associated with lower HbA1c levels in the first [ß (95% CI) = -0.33 (-0.51, -0.15) %] and second trimester [ß (95% CI) = -0.13 (-0.24, -0.02) %], increased birth weight [ß (95% CI) = 0.14 (0.02, 0.26) kg], birth weight percentile [ß (95% CI) = 4.87 (0.49, 9.26) %], higher odds of large for gestational age [OR (95% CI) = 1.65 (1.06, 2.58)] and macrosomia [OR (95% CI) = 1.81 (1.03, 3.18)]. CGM use was associated with lower first [ß (95% CI) = -0.38 (-0.64, -0.13) %] and third trimester [ß (95% CI) = -0.17 (-0.33, -0.00) %] HbA1c levels. CONCLUSIONS: Women with type 1 diabetes who used pump or CGM had better glycemic control during pregnancy; however, pump use was associated with higher birth weight measures.

Beyond "blah blah blah": exploring the "how" of transformation.

Calls for transformations are clear and multiple pathways and alternative visions for the future have been defined. Yet, there is very little shared understanding of how such transformations come about and how knowledge-action gaps will be filled. This Special Feature focuses on how we can go beyond talking about transformation-the "blah blah blah"-and moving toward action for results. It does so by distinguishing between the means of transformation and the manner of transformation, two key dimensions to answering the question of "how." The means can be understood as the many solutions, technical and practical methods, or actions that are presented as significant to transformative change. The manner, in contrast, represents the ways in which something is done, i.e., ways of acting. It describes the core values, principles, qualities, and relationships that not only underpin and motivate transformative change, but shape the process. Integrating rather than conflating the means and the manner is important to better understand how transformations come about. We then present insights from the collection of papers that focus on the "how" of transformation. The papers describe different ways of integrating the means and the manner in transformation processes. We have organized them thematically as follows: papers that draw on the integration of meaning making, the integration of learning and listening, and the integration of different ways of being and becoming. Drawing on both science and alternative ways of knowing, they weave together new narratives and stories about nature, society, and the future, inviting us to embark on the journey of creating sustainability pathways.

Risk-Factor Based Lead Screening and Correlation with Blood Lead Levels in Pregnancy.

OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 µg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.

Bereaved College Students: Social Support, Coping Style, Continuing Bonds, and Social Media Use as Predictors of Complicated Grief and Posttraumatic Growth.

Many college students experience the death of someone close to them and could be at risk for complicated grieving. Their primary sources of support may be unavailable as family members may live far away and their peers may be unprepared to respond to their grief. In addition, college students are exposed to a variety of stressors that could result in maladaptive coping. Furthermore, although most college-aged students use social media, little is known about its impact on grieving. The purpose of this study was to examine the degree to which social support, coping, continuing bonds, and social media use predicted complicated grief and posttraumatic growth in a sample of college students who had experienced an interpersonal loss. Participants (N = 258; 77.5% female, M age = 19.98, SD = 1.41) completed an online survey assessing the aforementioned constructs using Likert-type scales. Findings from two hierarchical regressions indicated that coping variables accounted for the greatest percentage of variance in grieving outcomes with avoidant-emotional coping being the most robust predictor of complicated grief and problem-focused coping accounting for considerable variance in posttraumatic growth (both were associated positively with the outcomes). As hypothesized, continuing bonds explained variance in both grieving outcomes with externalized continuing bonds and maintaining continuing bonds on social media predicting complicated grief and internalized continuing bonds contributing to posttraumatic growth (also all positively associated). Social support from family also was predictive of posttraumatic growth in the positive direction. Future research directions and implications for practice are discussed with the hope that this research might inform the development of interventions to assist college students who are grieving.

Teaching the "how" of transformation.

College and university students are eager to engage with transformative solutions to the climate crisis, but often struggle to see openings or possibilities where they can leverage their actions and really "make a difference." While climate change education often focuses on the physical dimensions of climate change and the evaluation of political, technological, and behavioral solutions, less attention has been directed to questions of how large-scale transformations to sustainability occur and how educators can help students to perceive an active role for themselves in these efforts. This paper describes an integrative learning process for teaching the "how" of transformation. This process, which we use in our undergraduate courses on climate change and society, combines the "Three Spheres" model of transformation with an active learning change experiment. A pilot assessment, conducted via student surveys and focus groups during spring semester 2020, indicated that the learning process: (1) increased the students' understanding of transformation and their sense that transformative change is possible; (2) enhanced the students' sense of their own agency and ability to make a difference; and, (3) helped students to articulate a role for themselves in processes of transformative change. These initial findings suggest that teaching the "how" of transformation is possible and that both understanding and experiential realization of the connection between individual and collective change are vital elements for student learning and engagement. While these early findings need to be replicated in other courses and educational settings, they offer promising indications about how universities and climate change educators can play a more prominent role in generating transformative change.

Getting to the heart of transformation.

Climate change, biodiversity loss, the COVID-19 pandemic, and growing inequity and poverty are some of the key global challenges facing us today. These multiple and interacting crises have elicited growing appeals to the need for transformation. Yet while the scholarly literature on transformations is expanding rapidly, the concept risks becoming an empty buzzword or an alibi for superficial interventions and business-as-usual responses within research, policy and practice communities. In this perspective, we look more closely at what is needed to generate the deep and enduring changes that are called for to address multiple, interacting challenges. We do this by focusing on the prefix 'trans-', which signifies moving "across, over, or beyond" the current state of affairs, and we consider how the potential for equitable and sustainable transformations lies in our capacity to transcend entrenched boundaries and limits. Focusing on transdisciplinary, transgressive, and transcendent approaches, we reflect on how individuals, groups, and organizations can plant seeds and help to nurture the potential for radical transformative change at all scales.

Endocrine disrupting chemical-associated hair product use during pregnancy and gestational age at delivery: a pilot study.

BACKGROUND: Prenatal endocrine disrupting chemical (EDC) exposure has been associated with increased risk of preterm birth. Non-Hispanic Black women have higher incidence of preterm birth compared to other racial/ethnic groups and may be disproportionately exposed to EDCs through EDC-containing hair products. However, research on the use of EDC-associated hair products during pregnancy and risk of preterm birth is lacking. Therefore, the objective of this pilot study was to estimate associations of prenatal hair product use with gestational age at delivery in a Boston, Massachusetts area pregnancy cohort. METHODS: The study population consisted of a subset of participants enrolled in the Environmental Reproductive and Glucose Outcomes (ERGO) Study between 2018 and 2020. We collected self-reported data on demographics and hair product use using a previously validated questionnaire at four prenatal visits (median: 12, 19, 26, 36 weeks' gestation) and abstracted gestational age at delivery from medical records. We compared gestational age and hair product use by race/ethnicity and used linear regression to estimate covariate-adjusted associations of product use and frequency of use at each study visit with gestational age at delivery. Primary models were adjusted for maternal age at enrollment and delivery method. RESULTS: Of the 154 study participants, 7% delivered preterm. Non-Hispanic Black participants had lower mean gestational age at delivery compared to non-Hispanic White participants (38.2 vs. 39.2 weeks) and were more likely to report ever and more frequent use of hair products. In regression models, participants reporting daily use of hair oils at visit 4 had lower mean gestational age at delivery compared to non-users (ß: -8.3 days; 95% confidence interval: -14.9, -1.6). We did not find evidence of associations at earlier visits or with other products. CONCLUSIONS: Frequent use of hair oils during late pregnancy may be associated with shorter gestational duration. As hair oils are more commonly used by non-Hispanic Black women and represent potentially modifiable EDC exposure sources, this may have important implications for the known racial disparity in preterm birth.

Ambient PM gross ß-activity and glucose levels during pregnancy.

BACKGROUND: Exposure to ionizing radiation has been associated with insulin resistance and type 2 diabetes. In light of recent work showing an association between ambient particulate matter (PM) gross ß-activity and gestational diabetes mellitus (GDM) among pregnant women, we examined pregnancy glucose levels in relation to PM gross ß-activity to better understand this pathway. METHODS: Our study included 103 participants receiving prenatal care at Beth Israel Deaconess Medical Center in Boston, MA. PM gross ß-activity was obtained from US Environmental Protection Agency's RadNet program monitors, and blood glucose levels were obtained from the non-fasting glucose challenge test performed clinically as the first step of the 2-step GDM screening test. For each exposure window we examined (i.e., moving average same-day, one-week, first-trimester, and second-trimester PM gross ß-activity), we fitted generalized additive models and adjusted for clinical characteristics, socio-demographic factors, temporal variables, and PM with an aerodynamic diameter ≤ 2.5 µm (PM2.5). Subgroup analyses by maternal age and by body mass index were also conducted. RESULTS: An interquartile range increase in average PM gross ß-activity during the second trimester of pregnancy was associated with an increase of 17.5 (95% CI: 0.8, 34.3) mg/dL in glucose concentration. Associations were stronger among younger and overweight/obese participants. Our findings also suggest that the highest compared to the lowest quartile of one-week exposure was associated with 17.0 (95% CI: - 4.0, 38.0) mg/dL higher glucose levels. No associations of glucose were observed with PM gross ß-activity during same-day and first-trimester exposure windows. PM2.5 was not associated with glucose levels during any exposure window in our data. CONCLUSIONS: Exposure to higher levels of ambient PM gross ß-activity was associated with higher blood glucose levels in pregnant patients, with implications for how this novel environmental factor could impact pregnancy health.

Reflecting on the Anthropocene: The Call for Deeper Transformations : This article belongs to Ambio's 50th Anniversary Collection. Theme: Anthropocene.

Research on global environmental change has transformed the way that we think about human-environment relationships and Earth system processes. The four Ambio articles highlighted in this 50th Anniversary Issue have influenced the cultural narrative on environmental change, highlighting concepts such as "resilience," "coupled human and natural systems", and the "Anthropocene." In this peer response, I argue that global change research is still paying insufficient attention to how to deliberately transform systems and cultures to avoid the risks that science itself has warned us about. In particular, global change research has failed to adequately integrate the subjective realm of meaning making into both understanding and action. Although this has been an implicit subtext in global change research, it is time to fully integrate research from the social sciences and environmental humanities.

Evaluating a Recovery-Oriented Intensive Outpatient Program for Veterans at Risk for Suicide.

Background: Suicide is the 10th leading cause of death in the United States and suicide risk is elevated among military veterans. Risk for suicide is inherently transdiagnostic, complex, and multifaceted, which means a comprehensive psychotherapeutic approach to risk mitigation is required. Aims: Our aims were to summarize findings from an evaluation of an interdisciplinary, recovery-oriented intensive outpatient program (IR-IOP) that includes evidence-based suicide prevention stategies for veterans with varying psychiatric diagnoses who are at risk for suicide. Method: Veterans completed the Patient Health Questionnaire-9 and the Beck Scale for Suicide Ideation prior to and following their participation in the IR-IOP. Results: A significant decrease in the severity of suicide ideation was found between pre- and posttreatment. Limitations: This program evaluation utilized archival data and, as such, there was not a control group and posttreatment follow-up data were not collected. Conclusion: Preliminary findings suggest an IR-IOP for veterans with heterogenous psychiatric diagnoses utilizing a multifaceted psychotherapeutic approach to suicide prevention may be effective in reducing suicide ideation.

Is It Love or Is It Control? Assessing Warning Signs of Dating Violence.

The purpose of this study was to develop and evaluate the Relationship Red Flags Scale, a measure of ability to recognize warning signs of dating violence. The factor structure and psychometric properties of this measure were tested with independent samples of college women and men, and test-retest reliability was assessed with college women. Specifically, our first study examined the factor structure, validity, and reliability of the Relationship Red Flags measure with a sample of 433 undergraduate women. Confirmatory factor analyses provided support for a 25-item five-factor structure (i.e., Monitoring Behaviors, Controlling Behaviors, Demeaning Behaviors, Threatening and Aggressive Behaviors, and Jealous and Possessive Behaviors). Internal consistency reliability was adequate and the validity of the measure was supported for use with college women (negative correlations were found among measures of warning signs and acceptance of dating violence). Our second study replicated these findings with an independent sample of 330 college men. Finally, a third investigation found that the measure demonstrated adequate test-retest reliability with an independent sample of 47 college women.

Evaluating the Effectiveness of an Online Intervention to Educate College Students About Dating Violence and Bystander Responses.

The purpose of this study was to conduct a randomized controlled trial to assess the efficacy of STOP Dating Violence, an online intervention developed to educate students about dating violence and appropriate bystander interventions on college campuses. College students (N = 317) were randomly assigned to one of the three conditions: (a) the STOP Dating Violence intervention, (b) a website containing information about dating violence, or (c) a control condition. Participants completed pre- and posttest quantitative and qualitative measures to assess knowledge of warning signs and appropriate bystander behaviors, attitudes about intervening as a bystander, willingness to intervene, and self-efficacy regarding intervening. The results indicated that students who participated in the STOP Dating Violence intervention were the most knowledgeable about jealous warning signs of dating violence and appropriate bystander interventions, had the greatest intent to assist a victim of dating violence, and were the most confident in their ability to intervene in dating violence situations, when compared with participants in the website and control conditions. Those who participated in the intervention also demonstrated greater knowledge regarding appropriate bystander behaviors 1 month following the intervention. No differences were found in attitudes regarding helping someone in an abusive dating relationship or engagement in bystander behaviors at follow-up. Qualitative analyses provided further support for the efficacy of STOP Dating Violence in increasing knowledge of barriers to bystander intervention and appropriate bystander intervention strategies in dating violence situations. Overall, the STOP Dating Violence intervention has the potential to educate undergraduates about dating violence and bystander interventions on college campuses.

Lead exposure and association with angiogenic factors and hypertensive disorders of pregnancy.

OBJECTIVES: Lead exposure has been associated with hypertensive disorders of pregnancy. Angiogenic factors, including soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF), are aberrant in preeclampsia, but have not been correlated with lead levels. We evaluated the association of lead exposure with angiogenic factors. STUDY DESIGN: This cross sectional study utilized a convenience sample of singleton pregnancies ≥34 weeks' gestation. Blood lead and angiogenic factors were measured before delivery; bone lead was measured postpartum. We dichotomized bone and blood lead into the top tertile versus the bottom tertiles and used log-binomial regression to assess the association between lead and a high angiogenic ratio. MAIN OUTCOME MEASURES: The outcomes were high sFlt1 to PlGF ratio and development of a hypertensive disorder of pregnancy. RESULTS: We enrolled 102 participants, of whom 98 had at least one lead measurement and an angiogenic factor result. Median bone lead was 3.8 ug/g (2.0 - 6.6) and median blood lead was 0.2 ug/dL (0.2 - 0.4). Incidence of hypertensive disorders of pregnancy was 31%. When comparing the highest tertile of bone lead to the bottom two tertiles, there was no association with a high sFlt1/PlGF ratio or hypertensive disorders of pregnancy. Similar results were observed for the exposure of blood lead. CONCLUSIONS: Lead exposure was not an important contributor to an elevated angiogenic factor ratio or hypertensive disorders of pregnancy in our U.S. POPULATION: However, lead exposure was modest in our population and we cannot exclude a relationship with hypertensive disorders of pregnancy.

Time trends in pregnancy-related outcomes among women with type 1 diabetes mellitus, 2004-2017.

OBJECTIVE: To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes. STUDY DESIGN: We abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression. RESULTS: HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (P = 0.002). Excessive gestational weight gain increased (P = 0.01). Gestation length also increased (P = 0.01), as did vaginal deliveries (P = 0.03). There were no change in birthweight over time (P = 0.07) and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged. CONCLUSION: Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.