The Impact of the New Hypertension Guidelines to Low-Dose Aspirin Prophylaxis Eligibility for the Prevention of Preeclampsia: A Cost-Benefit Analysis.

OBJECTIVE: American College of Cardiology and American Heart Association (ACC/AHA) published new guidelines which lower the cut-off for hypertension. We sought to evaluate the impact of these guidelines to cost and benefit of various low-dose aspirin prophylaxis approaches. STUDY DESIGN: Decision tree analysis was created using R software to evaluate four approaches to aspirin prophylaxis in the United States: no aspirin, United States Preventive Service Task Force (USPSTF) with Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines, USPSTF with ACC/AHA hypertension guidelines, as well as universal aspirin prophylaxis. This model was executed to simulate a hypothetical cohort of 4 million pregnant women in the United States. RESULTS: The new guidelines would expand the aspirin eligibility by 8% (76,953 women) in the USPSTF guidelines. Even with this increased eligibility, the USPSTF guidelines continue to be the approach with the most cost savings ($386.5 million) when compared with universal aspirin and no aspirin prophylaxis. The new hypertension guidelines are projected to increase the cost savings of the USPSTF approach by $9.4 million. CONCLUSION: Despite the small change in aspirin prophylaxis, using ACC/AHA definition of hypertension still results in an annual cost-saving of $9.4 million in the United States when compared with JNC7.

Starting a regional collaborative research group for COVID-19 in pregnancy: the Southern Michigan experience.

The outbreak of the SARS-CoV-2 elicited a surge in publications. Obstetric reports were with few exceptions characterized by small sample sizes with potentially limited generalizability. In this review, evidence suggests increased susceptibility to COVID-19 in pregnancy; common pregnancy comorbidities may help explain worse outcomes. While the risk of death is low, pregnancy may be associated with increased need for ventilation. Prematurity rates seem to be increased but may be accounted for in part by higher cesarean rates, to a large degree accounted for by elective decision to shorten the course of the labor. Though fetal/neonatal complication rates may be higher in the presence of COVID-19 infection, survival rates seem unaffected and vertical transmission is rare. As the outbreak continues in the USA with resurgence in many other western countries that achieved initial success in suppressing the virus, much remains to be learned. For example, the question related to the degree to pregnancy modifying symptomatology remains open. Currently, routine polymerase chain reaction testing remains limited by supply shortages possibly delaying diagnosis until later in the course of the disorder and thus altering the symptom complex at presentation. To add to the knowledge base, we initiated a regional COVID-19 in pregnancy collaborative observational study with a coordinating center, standardized data collection and a shared database. This was facilitated by a longstanding tradition of collaboration among regional obstetric services. Over an anticipated two-year study duration, we expect to study 400 documented and suspected COVID-19 pregnancies with time and site of services controls for cohort effect and high power to detect several adverse maternal/infant outcomes. We include a complete listing of variables in our database, which, along with our experience in setting up our regional collaborative, we hope and believe will be of use in other settings.

Prenatal Alcohol Screening During Pregnancy by Midwives and Nurses.

BACKGROUND: Alcohol use during pregnancy can have a variety of harmful consequences on the fetus. Lifelong effects include growth restriction, characteristic facial anomalies, and neurobehavioral dysfunction. This range of effects is known as fetal alcohol spectrum disorders (FASD). There is no amount, pattern, or timing of alcohol use during pregnancy proven safe for a developing embryo or fetus. Therefore, it is important to screen patients for alcohol use, inform them about alcohol's potential effects during pregnancy, encourage abstinence, and refer for intervention if necessary. However, how and how often nurses and midwives inquire about alcohol drinking during pregnancy or use recommended screening tools and barriers they perceive to alcohol screening has not been well established. METHODS: This survey was sent to about 6,000 American midwives, nurse practitioners, and nurses who provide prenatal care about their knowledge of the effects of prenatal alcohol exposure, the prevalence of alcohol use during pregnancy, and practices for screening patients' alcohol use. Participants were recruited by e-mail from the entire membership roster of the American College of Nurse-Midwives. RESULTS: There were 578 valid surveys returned (about 9.6%). Analyses showed that 37.7% of the respondents believe drinking alcohol is safe during at least one trimester of pregnancy. Only 35.2% of respondents reported screening to assess patient alcohol use. Only 23.3% reported using a specific screening tool, and few of those were validated screens recommended for use in pregnant women. Respondents who believe alcohol is safe at some point in pregnancy were significantly less likely to screen their patients. CONCLUSIONS: Respondents who reported that pregnancy alcohol use is unsafe felt more prepared to educate and intervene with patients regarding alcohol use during pregnancy and FASD than respondents who reported drinking in pregnancy was safe. Perceived alcohol safety and perceived barriers to screening appeared to influence screening practices. Improving prenatal care provider knowledge about the effects of prenatal alcohol exposure and the availability of valid alcohol screening tools will improve detection of drinking during pregnancy, provide more opportunities for meaningful intervention, and ultimately reduce the incidence of FASD.

Lack of Uptake of Prophylactic Human Papilloma Virus Vaccine Among Women With Systemic Lupus Erythematosus Seen at a Regional Medical Center.

BACKGROUND/OBJECTIVE: Women with systemic lupus erythematosus (SLE) are at increased risk for cervical neoplasia likely due to infection with high-risk human papillomavirus (HR-HPV) and should be considered for HPV vaccination. We sought to determine the frequency of HR-HPV infection and uptake of HPV vaccination in our regional female lupus population. METHODS: For this medical records review study, data were analyzed from our electronic health records EPIC for women with International Classification of Diseases-10 or International Classification of Diseases -9 billing codes for SLE seen June 6, 2007, to May 1, 2017. This study was approved by the Central Michigan University/Covenant Medical Center institutional review board. Statistical analyses consisted of Student t test, χ, and Z test for proportions using SPSS v. 24 software. RESULTS: A total of 1349 women with SLE were identified, mean age of 53 years, 70.8% white, 20.8% African American, with 49% exposed to cigarette smoke. High-risk HPV testing performed in 195 (14.5%; mean age, 50 years) showed 16.9% (33/195) were positive, with those testing positive for HR-HPV being slightly younger (p < 0.05).Comparing our proportion testing positive for HR-HPV (0.169) versus National Health and Nutrition Examination Survey (0.088), we calculated a Z = 3.99 (p < 0.001) indicating HPV infection is significantly higher (2×) in our female SLE cohort. Only 16.0% (38/238) of the 238 women eligible to receive an HPV vaccine were tested for HR-HPV with 9 being positive and only 4.6% (11/238) vaccinated. CONCLUSIONS: Human papillomavirus infection is a serious health issue in women with SLE, but HPV testing and vaccination rates remain low. Efforts should be directed to promote awareness of the importance of HPV vaccination in this high-risk population.

Risk of Expectant Management and Optimal Timing of Delivery in Low-Risk Term Pregnancies: A Population-Based Study.

OBJECTIVE: The benefits of the 39-week rule have been questioned and concerns of increased stillbirth after adoption of this rule have been raised. Whether expectant management risks outweigh the benefits of awaiting 39 weeks has not been studied. We analyze the risks of expectant management at term and the optimal timing for delivery. STUDY DESIGN: All U.S. nonanomalous singleton term deliveries in 2013 were selected, excluding diabetes/hypertension, and low birth weight. Maternal/neonatal complications and stillbirth/infant death were compared among expectant management versus deliveries at each term gestational age. Logistic regression was used to calculate adjust odds ratios of complications according to delivery plan at each gestational age. RESULTS: From approximately 3 million deliveries, maternal complications during expectant management were lower at early term, and became higher at 39 weeks, relative risk [RR] (95% confidence interval [CI]) = 1.18 (1.16-1.19). Neonatal complications during expectant management were lower during early term, and became higher at ≥39 weeks, RR (95% CI) = 1.09 (1.08-1.09). The risk of perinatal mortality in the expectant management group was lower during early term, and became higher at ≥39 weeks, 18.93 (17.83-20.10) versus 17.37 (16.61-18.16), p = 0.010. CONCLUSION: Complications during expectant management occurring while awaiting full term do not outweigh the benefits of better outcomes from reaching 39 weeks. However, extending beyond 39 weeks may put these pregnancies at an increased risk.

Contemporary analysis of maternal and neonatal morbidity after uterine rupture: A nationwide population-based study.

AIM: Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture. METHODS: Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χ2 test, and relative risks were calculated. Logistic regression was used to identify the most significant complications. P < 0.05 indicated statistical significance. RESULTS: From 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold). CONCLUSIONS: Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Contemporary epidemiology and novel predictors of uterine rupture: a nationwide population-based study.

PURPOSE: In spite of several policies aiming to decrease cesarean rates and related complications such as uterine rupture, data show that uterine rupture and associated morbidity are increasing along the years. Whether previously unidentified risk factors are currently playing an important role on these trends is unknown. We analyze current risks of uterine rupture and main preceding factors from more recent years compared to former data. METHODS: All uterine rupture cases in the US from 2011-2012 were selected, with matched non-uterine rupture cases selected as controls. Variables considered for analysis included demographics, maternal morbidity, and obstetric complications. Likelihood forward selection was used to identify main risk factors of uterine rupture. Medians of main factors identified were used to simulate groups at risk and calculate odds ratios of uterine rupture. RESULTS: From ~8 million births, 1925 presented uterine rupture. In patients with no prior cesarean delivery, multiple gestation, chronic hypertension and chorioamnionitis presented the highest odds of uterine rupture, with the combination of these factors increasing the odds of rupture 59 times (~1%). In women with prior cesarean delivery, induction/augmentation and chorioamnionitis were the most significant predictors, with the combination increasing the odds 33 times (~3%). CONCLUSIONS: Despite policies implemented and changes in clinical practice, uterine rupture remains an important issue. Previously unidentified risk factors are playing now an important role, information that should be considered during patient counseling and clinical practice. Combinations of some of these factors may increase the risk of uterine rupture significantly enough to modify clinical care.

Commercial Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) Testing is Not Vulnerable to Incidental Alcohol Exposure in Pregnant Women.

BACKGROUND: Ethyl Glucoronide (EtG) and Ethyl Sulfate (EtS) have shown promise as biomarkers for alcohol and may be sensitive enough for use with pregnant women in whom even low-level alcohol use is important. However, there have been reports of over-sensitivity of EtG and EtS to incidental exposure to sources such as alcohol-based hand sanitizer. Further, few studies have evaluated these biomarkers among pregnant women, in whom the dynamics of these metabolites may differ. OBJECTIVES: This study evaluated whether commercial EtG-EtS testing was vulnerable to high levels of environmental exposure to alcohol in pregnant women. METHODS: Two separate samples of five nurses-one pregnant and the other postpartum, all of whom reported high levels of alcohol-based hand sanitizer use-provided urine samples before and 4-8 hours after rinsing with alcohol-based mouthwash and using hand sanitizer. The five pregnant nurses provided urine samples before, during, and after an 8-hour nursing shift, during which they repeatedly cleansed with alcohol-based hand sanitizer (mean 33.8 uses). The five postpartum nurses used hand sanitizer repeatedly between baseline and follow-up urine samples. RESULTS: No urine samples were positive for EtG-EtS at baseline or follow-up, despite use of mouthwash and-in the pregnant sample-heavy use of hand sanitizer (mean of 33.8 uses) throughout the 8-hour shift. CONCLUSIONS/IMPORTANCE: Current, commercially available EtG-EtS testing does not appear vulnerable to even heavy exposure to incidental sources of alcohol among pregnant and postpartum women.

Computer-Delivered Screening and Brief Intervention for Alcohol Use in Pregnancy: A Pilot Randomized Trial.

BACKGROUND: Although screening and brief intervention (SBI) for unhealthy alcohol use has demonstrated efficacy in some trials, its implementation has been limited. Technology-delivered approaches are a promising alternative, particularly during pregnancy when the importance of alcohol use is amplified. The present trial evaluated the feasibility and acceptability of an interactive, empathic, video-enhanced, and computer-delivered SBI (e-SBI) plus 3 tailored mailings, and estimated intervention effects. METHODS: We recruited 48 pregnant women who screened positive for alcohol risk at an urban prenatal care clinic. Participants were randomly assigned to the e-SBI plus mailings or to a control session on infant nutrition, and were re-evaluated during their postpartum hospitalization. The primary outcome was 90-day period prevalence abstinence as measured by timeline follow-back interview. RESULTS: Participants rated the intervention as easy to use and helpful (4.7 to 5.0 on a 5-point scale). Blinded follow-up evaluation at childbirth revealed medium-size intervention effects on 90-day period prevalence abstinence (OR = 3.4); similarly, intervention effects on a combined healthy pregnancy outcome variable (live birth, normal birthweight, and no neonatal intensive care unit stay) were also of moderate magnitude in favor of e-SBI participants (OR = 3.3). As expected in this intentionally underpowered pilot trial, these effects were nonsignificant (p = 0.19 and 0.09, respectively). CONCLUSIONS: This pilot trial demonstrated the acceptability and preliminary efficacy of e-SBI plus tailored mailings for alcohol use in pregnancy. These findings mirror the promising results of other trials using a similar approach and should be confirmed in a fully powered trial.

Optimal timing for term delivery of twin pregnancies: a population-based study.

OBJECTIVE: The objective of this study was to examine the risk of adverse neonatal outcomes after twin delivery according to gestational age. MATERIALS AND METHODS: The U.S. Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were twin deliveries and gestational age of 37 to 42 weeks. Exclusion criteria were congenital anomalies and missing/incomplete data. Cases were subdivided by gestational age into early term, term, and late term. Singleton pregnancies matched by delivery time and location were selected as controls. Outcome variables included were low Apgar score, assisted ventilation, neonatal intensive care unit admission, surfactant/antibiotic use, seizures, and birth injury. Logistic regression analysis was used to calculate adjusted odds ratios according to gestational age and plurality, using singleton term as reference. RESULTS: A total of 220,169 twin and 270,540 singleton deliveries were identified. The risk of adverse neonatal outcomes for twins was higher than for singletons. For twins, the distribution of the risks of the composite of adverse neonatal outcomes was linear, being the lowest at early term and the highest at late term, whereas the distribution for singletons was u-shaped being lowest at term compared with early and late term. CONCLUSIONS: Twins are at higher risk of suboptimal neonatal outcomes than singletons, but do better when delivered at early term rather than term or late term.

Institute of Medicine Guidelines for Appropiate Pregnancy Weight Gain for Obese Women May Be Too High.

OBJECTIVE: To investigate how the 2009 Institute of Medicine (IOM) guidelines for pregnancy weight gain for obese women relate to the longer-term outcome of childhood obesity. STUDY DESIGN: Maternal, neonatal, soioeconomic, and nutritional histories were collected for mothers with children age 2-5 years old. Women in each body mass index (BMI) category were categorized based on under, appropriate (AG), and over weight gain per IOM guidelines and compared with rates of childhood obesity in each category. RESULTS: A total of 502 mother-child pairs were enrolled; 36.4% of women were obese at the start of pregnancy. Obese women who were AG by IOM guidelines were more likely than underweight, normal weight, and overweight women to have obese offspring (29.5% vs. 14.2%, p = 0.04). The BMI percentiles of the offspring of obese AG women were 10 percentile points higher than the 55th percentile of the other groups. CONCLUSION: The 2009 IOM pregnancy weight gain guidelines for obese women may still be too high when considering longer-term outcomes such as childhood obesity. Further studies are needed.

Acceptability of a computerized brief intervention for alcohol among abstinent but at-risk pregnant women.

BACKGROUND: Limitations in time and training have hindered widespread implementation of alcohol-based interventions in prenatal clinics. Also, despite the possibility of underreporting or relapse, many at-risk women report that they quit drinking after pregnancy confirmation so that interventions focusing on current drinking may seem unnecessary. The Computerized Brief Intervention for Alcohol Use in Pregnancy (C-BIAP) was designed to (a) be implemented via a handheld device in prenatal clinics, and (b) use a modified brief intervention strategy with women who screen at-risk but report no current drinking. METHODS: The authors administered the C-BIAP to 18 T-ACE (Tolerance, Annoyance, Cut Down, and Eye Opener)-positive pregnant African American women who provided quantitative and qualitative feedback. RESULTS: The C-BIAP received high ratings of acceptability; qualitative feedback was also positive overall and suggested good acceptance of abstinence themes. CONCLUSIONS: Technology may be a feasible and acceptable method for brief intervention delivery with pregnant women who do not report current drinking.

Large for gestational age and long-term cognitive function.

OBJECTIVE: As we have previously published, small-for-gestational-age (<3% birthweight [BW]) newborns exhibit catch-up cognitive functioning by age 2 years. Our objective was to compare cognitive functioning in children born with ≥90% vs 5-89% BW for gestational age (WGA) between 9 months and kindergarten. STUDY DESIGN: Nonanomalous singletons from Early Childhood Longitudinal Study-Birth Cohort with BW ≥90% vs 5-89% were compared. Cognitive and academic functioning was measured at 4 time points: 9 months, and 2, 3.5, and 5.5 years. Associations between WGA and cognitive functioning at each time point was examined using confounder-adjusted general linear model-based methods. RESULTS: Of 2930 cases, 271 (9.2%) were ≥90% WGA. In terms of cognitive performance, children ≥90% WGA were not statistically different (P = .068) from normal WGA at any time point, nor did they change at different rates across early childhood. CONCLUSION: There is no difference in cognitive function in children with BW 5-89% vs ≥90% for GA.

Increased cut-point of the TACER-3 screen reduces false positives without losing sensitivity in predicting risk alcohol drinking in pregnancy.

BACKGROUND: Detection of in-pregnancy maternal risk alcohol drinking is an essential first step in preventing fetal alcohol spectrum disorders, and the widely used T-ACE screen was developed for that purpose. We recently reported that increasing the total T-ACE score cut-point from 2 to 3 doubled specificity of detecting risk drinking in pregnancy and identified 4-year-old children with neurobehavioral effects associated with prenatal alcohol exposure. METHODS: In this study, the TACER-3 was further validated in another prospectively identified high-risk urban cohort. Women were categorized as follows: (i) Not At-Risk Group (negative on T-ACE and TACER-3); (ii) At-Risk Group (positive on T-ACE and TACER-3); and (iii) Change Risk Group (positive on T-ACE but negative on TACER-3). RESULTS: The TACER-3 total score cut-point of 3 yielded fewer "false positives" than the T-ACE cut-point of 2. Based on relative risk scores, women in the TACER-3-positive At-Risk Group were more likely to drink alcohol during pregnancy than women in the Change Risk Group. In contrast, women in the Not At-Risk Group were largely not different in their drinking from women in the Change Risk Group. The largest increases in relative risk of the At-Risk Group compared to the Change Risk Group were for the amount of drinking per day across pregnancy (RR = 11.4) and for the amount of drinking per drinking day at the first prenatal visit (RR = 12.7). For both of these measures, the relative risk of at-risk alcohol consumption in the At-Risk Group was over >10 times that of the Change Risk Group. CONCLUSIONS: Thus, the TACER-3 was more effective at selectively identifying women drinking at fetal risk levels than the original T-ACE. The TACER-3 allows for more efficient use of healthcare provider time in directing targeted clinical interventions with pregnant women identified as drinking at fetal risk levels.

Alcohol, tobacco, cocaine, and marijuana use: relative contributions to preterm delivery and fetal growth restriction.

BACKGROUND: Pregnancy substance use is linked to low birth weight. However, less is known about relative contributions of various substances and whether effects are due to decreased gestational duration, restriction of fetal growth, or both. The study goal was to use causal modeling to evaluate the individual impact of alcohol, tobacco, cocaine, and marijuana on gestational duration and fetal growth. METHODS: Participants were 3164 urban black women recruited at entry to prenatal care and followed to delivery, with all gestational dating ultrasound supported. Pregnancy substance use was assessed via self-report (alcohol, tobacco, cocaine, and marijuana). RESULTS: Alcohol, cigarette, and cocaine use were all individually and negatively related to gestational age at delivery. However, only alcohol, cigarette, and marijuana use predicted fetal growth, with effects for alcohol and cigarette greater and more discrepant for older women. Overall, heavy cigarette smoking had the greatest individual impact on birth weight (up to 431 g). Heavy levels of use of all 4 substances by older women decreased birth weight by 26% (806 g). CONCLUSIONS: For perhaps the first time, reduced birth weight is apportioned both by type of substance and mechanism of effect. The use of alcohol and/or cigarettes was clearly more harmful to fetal growth than cocaine use. Findings demonstrate the need for continued emphasis on intervention efforts to address legal and illicit pregnancy substance use.

COVID-19 is associated with early emergence of preeclampsia: results from a large regional collaborative.

Objective: To investigate the relationship between preeclampsia and SARS-CoV-2 infection during pregnancy. Methods: This was a retrospective cohort study of pregnant women between March and October 2020. Pregnant patients admitted to 14 obstetrical centers in Michigan, USA formed the study population. Of the N = 1458 participants, 369 had SARS-CoV-2 infection (cases). Controls were uninfected pregnancies that were delivered in the same obstetric unit within 30 days of the index case. Robust Poisson regression was used to estimate relative risk (RR) of preterm and term preeclampsia and preeclampsia involving placental lesions. The analysis included adjustment for relevant clinical and demographic risk factors.Results: SARS-CoV-2 infection during pregnancy increased the risk of preeclampsia [adjusted aRR = 1.69 (1.26-2.26)], preeclampsia involving placental lesions [aRR = 1.97(1.14-3.4)] and preterm preeclampsia 2.48(1.48-4.17). Although the highest rate of preeclampsia was observed in patients infected with SARS-CoV-2 who were symptomatic (18.4%), there was increased risk even in asymptomatic SARS-CoV-2 infected patients (14.2%) relative to non-infected controls (8.7%) (p < 0.05). This association with symptomatology was also noted with preterm preeclampsia for which the rate doubled from 2.7% in controls to 5.2% in asymptomatic cases and reached 11.8% among symptomatic cases (p < 0.05). The rate of preterm preeclampsia among cases of pregnant people self-identified as Black reached 10.1% and was almost double the rate of the reminder of the group of infected pregnancies (5.3%), although the rate among uninfected was almost the same (2.7%) for both Black and non-Black groups (interaction p = 0.05).Conclusions: Infection with SARS-CoV-2 increases the risk of preeclampsia even in the absence of symptoms, although symptomatic persons are at even higher risk. Racial disparities in the development of preterm preeclampsia after SARS-CoV-2 infection may explain discrepancies in prematurity between different populations.

Fetal alcohol-related growth restriction from birth through young adulthood and moderating effects of maternal prepregnancy weight.

BACKGROUND: Fetal alcohol-related growth restriction persists through infancy, but its impact later in life is less clear. Animal studies have demonstrated important roles for maternal nutrition in fetal alcohol spectrum disorders, but the impact of prenatal maternal body composition has not been studied in humans. This study examined the effects of prenatal alcohol exposure on longitudinal growth from birth through young adulthood and the degree to which maternal weight and body mass index (BMI) moderate these effects. METHODS: Nearly 480 mothers were recruited at their first prenatal clinic visit to overrepresent moderate-to-heavy use of alcohol during pregnancy, including a 5% random sample of low-level drinkers and abstainers. They were interviewed at every prenatal visit about their alcohol consumption using a timeline follow-back approach. Their children were examined for weight, length/height, and head circumference at birth, 6.5 and 13 months, and 7.5, 14, and 19 years. RESULTS: In multiple regression models with repeated measures (adjusted for confounders), prenatal alcohol exposure was associated with longitudinal reductions in weight, height, and weight-for-length/BMI that were largely determined at birth. At low-to-moderate levels of exposure, these effects were more severe in infancy than in later childhood. By contrast, effects persisted among children whose mothers drank at least monthly and among those born to women with alcohol abuse and/or dependence who had consumed ≥ 4 drinks/occasion. In addition, effects on weight, height, and head circumference were markedly stronger among children born to mothers with lower prepregnancy weight. CONCLUSIONS: These findings confirm prior studies demonstrating alcohol-related reductions in weight, height, weight-for-height/BMI, and head circumference that persist through young adulthood. Stronger effects were seen among children born to mothers with smaller prepregnancy weight, which may have been because of attainment of higher blood alcohol concentrations in smaller mothers for a given amount of alcohol intake or to increased vulnerability in infants born to women with poorer nutrition.

Pregnancy recruitment for population research: the National Children's Study vanguard experience in Wayne County, Michigan.

BACKGROUND: To obtain a probability sample of pregnancies, the National Children's Study conducted door-to-door recruitment in randomly selected neighbourhoods in randomly selected counties in 2009-10. In 2011, an experiment was conducted in 10 US counties, in which the two-stage geographic sample was maintained, but participants were recruited in prenatal care provider offices. We describe our experience recruiting pregnant women this way in Wayne County, Michigan, a county where geographically eligible women attended 147 prenatal care settings, and comprised just 2% of total county pregnancies. METHODS: After screening for address eligibility in prenatal care offices, we used a three-part recruitment process: (1) providers obtained permission for us to contact eligible patients, (2) clinical research staff described the study to women in clinical settings, and (3) survey research staff visited the home to consent and interview eligible women. RESULTS: We screened 34,065 addresses in 67 provider settings to find 215 eligible women. Providers obtained permission for research contact from 81.4% of eligible women, of whom 92.5% agreed to a home visit. All home-visited women consented, giving a net enrolment of 75%. From birth certificates, we estimate that 30% of eligible county pregnancies were enrolled, reaching 40-50% in the final recruitment months. CONCLUSIONS: We recruited a high fraction of pregnancies identified in a broad cross-section of provider offices. Nonetheless, because of time and resource constraints, we could enrol only a fraction of geographically eligible pregnancies. Our experience suggests that the probability sampling of pregnancies for research could be more efficiently achieved through sampling of providers rather than households.

Alcohol use in pregnancy: insights in screening and intervention for the clinician.

Alcohol consumption during pregnancy remains a common occurrence and is associated with a multitude of adverse birth and long-term outcomes. Binge drinking in particular is shown to be particularly harmful to the developing fetus. Effects include full fetal alcohol syndrome, with characteristic facial dysmorphology, growth restriction, and developmental to delays. Exposed children may also have partial fetal alcohol syndrome, alcohol-related birth defects, and alcohol-related neurodevelopmental disorders. These effects are preventable, and efforts must begin with accurate identification of women who consume alcohol during pregnancy. Several screening tools have been developed and validated for use in prenatal care settings, and the most recently proposed brief and easy to use T-ACER3 has demonstrated high sensitivity and specificity in both identifying risk drinking during pregnancy and predicting long-term neurobehavioral outcomes in exposed children. Once identified, effective interventions are available for use with pregnant women consuming alcohol. Brief interventions, which can be delivered by a health professional and involve motivational interviewing, have been demonstrated to significantly reduce alcohol consumption during pregnancy. These approaches, recommended by American College of Obstetricians and Gynecologist (ACOG), help move patients toward increased readiness to positively change their drinking behavior. Ultimately, all prenatal care providers should routinely screen all patients for alcohol use using validated tools, and where appropriate, should offer intervention.

More for less - if only we could get them to do it!

Systems for the provision of healthcare need to be improved, since costs are already high and rising along with the needs of an aging population. In considering evaluations of two programs from opposite ends of the country, inferences can differ depending on the observer. While the demographic-healthcare time bomb we're faced with should have been obvious years ago, the need for positive action is upon us. The difficult issues are not so much errors in the past as they are (1) disingenuous suggestions that this isn't a cost problem, (2) a need to improve team behaviors and functions to increase the value of the care provided (i.e., quality for expenditure), (3) a lack of engagement and enthusiasm by providers for new systems and (4) most importantly, resistance to change brought from outside the care environment and the source and beneficiaries of the change not being primarily the local stakeholders. Care providers and recipients, as well as the governments funding healthcare will need to be convinced that we are successfully increasing healthcare value and improving patient outcomes.