Phthalate and phthalate replacement concentrations in relationship to adiposity in a multi-racial cohort of children.

BACKGROUND/OBJECTIVE: Phthalates and phthalate replacements are used in multiple everyday products, making many of them bioavailable to children. Experimental studies suggest that phthalates and their replacements may be obesogenic, however, epidemiologic studies remain inconsistent. Therefore, our objective was to examine the association between phthalates, phthalate replacements and childhood adiposity/obesity markers in children. SUBJECTS/METHODS: A cross-sectional study was conducted in 630 racial/ethnically diverse children ages 4-8 years. Urinary oxidative metabolites of DINCH and DEHTP, three low molecular weight (LMW) phthalates, and eleven high molecular weight (HMW) phthalates were measured. Weight, height, waist circumference and % body fat were measured. Composite molar sum groups (nmol/ml) were natural log-transformed. Linear regression models adjusted for urine specific gravity, sex, age, race-ethnicity, birthweight, breastfeeding, reported activity level, mother's education and pre-pregnancy BMI. RESULTS: All children had LMW and HMW phthalate metabolites and 88% had DINCH levels above the limit of detection. One unit higher in the log of DINCH was associated with 0.106 units lower BMI z-score [ß = -0.106 (95% CI: -0.181, -0.031)], 0.119 units lower waist circumference z-score [ß = -0.119 (95% CI: -0.189, -0.050)], and 0.012 units lower percent body fat [ß = -0.012 (95% CI: -0.019, -0.005)]. LMW and HMW group values were not associated with adiposity/obesity. CONCLUSIONS: We report an inverse association between child urinary DINCH levels, a non-phthalate plasticizer that has replaced DEHP in several applications, and BMI z-score, waist circumference z-score and % body fat in children. Few prior studies of phthalates and their replacements in children have been conducted in diverse populations. Moreover, DINCH has not received a great deal of attention or regulation, but it is a common exposure. In summary, understanding the ubiquitous nature of these chemical exposures and ultimately their sources will contribute to our understanding of their relationship with obesity.

Multiethnic growth standards for fetal body composition and organ volumes derived from 3D ultrasonography.

BACKGROUND: A major goal of contemporary obstetrical practice is to optimize fetal growth and development throughout pregnancy. To date, fetal growth during prenatal care is assessed by performing ultrasonographic measurement of 2-dimensional fetal biometry to calculate an estimated fetal weight. Our group previously established 2-dimensional fetal growth standards using sonographic data from a large cohort with multiple sonograms. A separate objective of that investigation involved the collection of fetal volumes from the same cohort. OBJECTIVE: The Fetal 3D Study was designed to establish standards for fetal soft tissue and organ volume measurements by 3-dimensional ultrasonography and compare growth trajectories with conventional 2-dimensional measures where applicable. STUDY DESIGN: The National Institute of Child Health and Human Development Fetal 3D Study included research-quality images of singletons collected in a prospective, racially and ethnically diverse, low-risk cohort of pregnant individuals at 12 U.S. sites, with up to 5 scans per fetus (N=1730 fetuses). Abdominal subcutaneous tissue thickness was measured from 2-dimensional images and fetal limb soft tissue parameters extracted from 3-dimensional multiplanar views. Cerebellar, lung, liver, and kidney volumes were measured using virtual organ computer aided analysis. Fractional arm and thigh total volumes, and fractional lean limb volumes were measured, with fractional limb fat volume calculated by subtracting lean from total. For each measure, weighted curves (fifth, 50th, 95th percentiles) were derived from 15 to 41 weeks' using linear mixed models for repeated measures with cubic splines. RESULTS: Subcutaneous thickness of the abdomen, arm, and thigh increased linearly, with slight acceleration around 27 to 29 weeks. Fractional volumes of the arm, thigh, and lean limb volumes increased along a quadratic curvature, with acceleration around 29 to 30 weeks. In contrast, growth patterns for 2-dimensional humerus and femur lengths demonstrated a logarithmic shape, with fastest growth in the second trimester. The mid-arm area curve was similar in shape to fractional arm volume, with an acceleration around 30 weeks, whereas the curve for the lean arm area was more gradual. The abdominal area curve was similar to the mid-arm area curve with an acceleration around 29 weeks. The mid-thigh and lean area curves differed from the arm areas by exhibiting a deceleration at 39 weeks. The growth curves for the mid-arm and thigh circumferences were more linear. Cerebellar 2-dimensional diameter increased linearly, whereas cerebellar 3-dimensional volume growth gradually accelerated until 32 weeks followed by a more linear growth. Lung, kidney, and liver volumes all demonstrated gradual early growth followed by a linear acceleration beginning at 25 weeks for lungs, 26 to 27 weeks for kidneys, and 29 weeks for liver. CONCLUSION: Growth patterns and timing of maximal growth for 3-dimensional lean and fat measures, limb and organ volumes differed from patterns revealed by traditional 2-dimensional growth measures, suggesting these parameters reflect unique facets of fetal growth. Growth in these three-dimensional measures may be altered by genetic, nutritional, metabolic, or environmental influences and pregnancy complications, in ways not identifiable using corresponding 2-dimensional measures. Further investigation into the relationships of these 3-dimensional standards to abnormal fetal growth, adverse perinatal outcomes, and health status in postnatal life is warranted.

Buccal Versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction.

BACKGROUND: Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. OBJECTIVE: Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 µg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery. RESULTS: A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes. CONCLUSION: We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. KEY POINTS: · Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Methods for the induction of labor: efficacy and safety.

This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 µg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.

Nutritional Intake in Dichorionic Twin Pregnancies: A Descriptive Analysis of a Multisite United States Cohort.

INTRODUCTION: Twin gestations have greater nutritional demands than singleton gestations, yet dietary intakes of women with twin gestations have not been well described. METHODS: In a prospective, multi-site US study of 148 women with dichorionic twin gestations (2012-2013), we examined longitudinal changes in diet across pregnancy. Women completed a food frequency questionnaire during each trimester of pregnancy. We examined changes in means of total energy and energy-adjusted dietary components using linear mixed effects models. RESULTS: Mean energy intake (95% CI) across the three trimesters was 2010 kcal/day (1846, 2175), 2177 kcal/day (2005, 2349), 2253 kcal/day (2056, 2450), respectively (P = 0.01), whereas the Healthy Eating Index-2010 was 63.9 (62.1, 65.6), 64.5 (62.6, 66.3), 63.2 (61.1, 65.3), respectively (P = 0.53). DISCUSSION: Women with twin gestations moderately increased total energy as pregnancy progressed, though dietary composition and quality remained unchanged. These findings highlight aspects of nutritional intake that may need to be improved among women carrying twins.

Combination Foley Catheter-Oxytocin versus Oxytocin Alone following Preterm Premature Rupture of Membranes.

OBJECTIVE: The benefit of mechanical ripening agents following preterm premature rupture of membranes (PPROM) has not been established. We sought to compare the time to delivery in women who received transcervical Foley catheter plus oxytocin infusion versus oxytocin infusion alone in patients with unfavorable cervices and PPROM. STUDY DESIGN: This is a retrospective cohort study of patients presenting with PPROM of a live, singleton gestation between 240/7 and 366/7 weeks' gestation from January 2005 to October 2018 at a single, tertiary care institution. Patients with an unfavorable cervical examination (≤2-cm dilation), no contraindication to labor and undergoing labor induction were analyzed. Time to delivery was analyzed using multivariable linear regression adjusting for cervical dilation at induction and nulliparity. Bivariate and multivariate analyses were used where appropriate. RESULTS: A total of 260 participants were included: 109 who received a Foley catheter and oxytocin (Foley/oxytocin) and 151 who had oxytocin alone. Demographic characteristics were similar between the two groups. Unadjusted time to delivery was significantly shorter in the oxytocin only group (Foley/oxytocin: 20.35 hours vs. oxytocin alone: 14.7 hours, p < 0.001). No differences in length of labor were detected after adjusting for cervical dilation at induction and nulliparity (p = 0.5). The unadjusted rate of cesarean delivery was higher in the combination Foley/oxytocin group (Foley/oxytocin: 16.5% vs. oxytocin alone: 7.3%, p = 0.03), but no differences were found in the adjusted analysis (p = 0.06). There were no differences in clinical chorioamnionitis rates between the two groups (Foley/oxytocin: 8.3% vs. oxytocin alone: 9.3%, p = 0.83). Furthermore, no significant differences were found in maternal and neonatal outcomes between the two groups. CONCLUSION: In patients with PROM, the use of a transcervical Foley catheter in addition to oxytocin is not associated with a shorter time to delivery compared with oxytocin alone. KEY POINTS: · Transcervical Foley catheter did not shorten length of labor in PPROM.. · Transcervical Foley catheter did not increase infection risk.. · Pitocin alone can be used in PPROM population..

Association between intracervical Foley balloon and clinical chorioamnionitis among patients with group B streptococcus colonization undergoing induction with standardized labor management.

BACKGROUND: Intracervical Foley balloons are commonly used for cervical ripening, but there has been a historical concern regarding an increased risk of clinical chorioamnionitis with Foley balloon use in patients with group B streptococcus. OBJECTIVE: This study aimed to determine whether intracervical Foley balloon use in patients with group B streptococcus is associated with an increased risk of clinical chorioamnionitis. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial Mechanical and Pharmacologic Methods of Labor Induction: A Randomized Controlled Trial that compared cervical ripening agents within a standardized labor protocol. Foley balloon (alone, with oxytocin, or with misoprostol) was compared with misoprostol only to evaluate the primary outcome of clinical chorioamnionitis, defined based on the American College of Obstetricians and Gynecologists guidelines. Patients with a term, singleton pregnancy with intact membranes and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) and a known group B streptococcus status were included. The secondary outcomes included a composite postpartum maternal infectious outcome consisting of any occurrence of endometritis, wound infection, postpartum urinary tract infection, or maternal sepsis; additional secondary outcomes included neonatal outcomes. Binomial regression with robust error variance was used to evaluate whether group B streptococcus status modified the relationship between Foley balloon use and clinical chorioamnionitis and to adjust for confounders. RESULTS: A total of 491 patients were enrolled in the original trial. Of these patients, 467 had a known group B streptococcus status and underwent cervical ripening: 182 (39.0%) had group B streptococcus, and 285 (61.0%) did not have group B streptococcus. Moreover, 73.0% of patients received a Foley balloon, and 27.0% of patients did not receive a Foley balloon. There was no difference in the demographic or clinical characteristics between groups. The overall rate of clinical chorioamnionitis was 12.2%, with no difference between those with and without a Foley balloon (12.6% vs 11.1%, respectively; P=.66). Group B streptococcus status did not modify the association between Foley balloon use and clinical chorioamnionitis (relative risk, 0.93; 95% confidence interval, 0.50-1.72). This remained unchanged after adjusting for gestational age (adjusted relative risk, 0.87; 95% confidence interval, 0.45-1.67). Furthermore, other maternal and neonatal outcomes were similar between groups. CONCLUSION: In this secondary analysis of a large randomized trial using a standardized labor protocol, there was no increased risk of infectious morbidity with Foley balloon use in patients overall and in patients with group B streptococcus. Our findings support that a Foley balloon can be safely used for cervical ripening in patients with group B streptococcus colonization.

The "30-minute rule" for expedited delivery: fact or fiction?

Initially developed from hospital feasibility data from the 1980s, the "30-minute rule" has perpetuated the belief that the decision-to-incision time in an emergency cesarean delivery should be <30 minutes to preserve favorable neonatal outcomes. Through a review of the history, available data on delivery timing and associated outcomes, and consideration of feasibility across several hospital systems, the use and applicability of this "rule" are explored, and its reconsideration is called for. Moreover, we have advocated for balanced consideration of maternal safety with rapidity of delivery, encouraged process-based approaches, and proposed standardization of terminology regarding delivery urgency. Furthermore, a standardized 4-tier classification system for delivery urgency, from class I, for a perceived threat to maternal or fetal life, to class IV, a scheduled delivery, and a call for further research with a standardized structure to facilitate comparison have been proposed.

Leiomyomata, neonatal anthropometry, and pregnancy outcomes in singleton pregnancies.

PURPOSE: To investigate the relationship of fibroids in pregnancy, preterm birth, and neonatal anthropometry. METHODS: Pregnant women (n = 2578) in the National Institute of Child Health and Human Development Fetal Growth Studies-Singletons cohort had up to six ultrasounds across pregnancy. Sonographers recorded fibroid number and volume of the three largest fibroids. Trained personnel measured neonatal anthropometry. Linear and logistic regression compared neonatal anthropometry and pregnancy outcomes among pregnancies with versus without fibroids. Causal mediation analysis evaluated preterm birth as a mediator. RESULTS: Average birthweight did not differ by fibroid status. However, compared with pregnancies without fibroids, neonates from pregnancies with single fibroids had 0.3- (95% confidence interval [CI], 0.0, 0.5) cm larger head circumferences; those with multiple fibroids had 0.3- (95% CI, 0.0, 0.6) cm larger arm circumferences; and those with small fibroid volume had 0.7- (95% CI, 0.3, 1.2) cm larger head, 0.4- (95% CI, 0.0, 0.8) cm larger arm, and 0.7- (95% CI, 0.1, 1.3) cm larger thigh circumferences. Presence versus absence of fibroids was associated with 1.73-2.65 times higher odds of preterm birth. Differences in preterm birth did not explain fibroid-anthropometry results. CONCLUSIONS: We found no evidence that fibroids negatively impacted fetal growth; instead, fibroids were associated with increased head, arm, and thigh circumferences. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT00912132.

Longitudinal Changes in Physical Activity during Pregnancy: National Institute of Child Health and Human Development Fetal Growth Studies.

INTRODUCTION: Exercise in pregnancy is associated with many perinatal benefits, but patterns of home, work, and commuting activity are not well described. We investigated longitudinal activity in singleton and twin pregnancy by activity domain and maternal characteristics. METHODS: In the National Institute of Child Health and Human Development Fetal Growth Studies cohorts, 2778 women with singleton and 169 women with twin gestations reported activity using the Pregnancy Physical Activity Questionnaire at up to six or seven study visits, respectively. Metabolic equivalent of task-hours per week (MET-h·wk -1 ) was calculated from reported activity. Baseline measurements (obtained between 10 and 13 wk) reflected past year activity. Linear mixed models estimated MET-h·wk -1 by domain (household/childcare, occupational, inactive, transportation, sports/exercise), self-reported race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander), prepregnancy body mass index (<25, 25 to < 30, ≥30 kg·m -2 ), parity (0, ≥1), baseline activity (quartiles), and plurality (singleton, twin). RESULTS: Household/caregiving activity made up the largest fraction of reported MET-h·wk -1 at baseline (42%), followed by occupational activity (28%). Median summed activity declined 47%, from 297 to 157 MET-h·wk -1 , between 10 and 40 wk, largely driven by changes in household/caregiving (44% decline), and occupational activity (63% decline). Sports/exercise activity declined 55% but constituted only 5% of reported MET-h·wk -1 at baseline. At baseline, non-Hispanic Black women reported significantly higher activity than non-Hispanic White or Hispanic women, but differences did not persist across pregnancy. Across gestation nulliparous women reported significantly lower activity than parous women. Women with singleton gestations reported significantly more activity than women with twins from weeks 26 to 38. Baseline activity level was strongly associated with later activity levels. CONCLUSIONS: Measuring domains of activity beyond exercise, and collecting longitudinal measurements, is necessary to fully describe activity in diverse populations of pregnant women.

Validation of a novel mobile phone application for type 2 diabetes screening following gestational diabetes mellitus.

Background: We sought to determine if using fasting blood glucose (FBG) through text-based care is an effective screening tool for type 2 diabetes in the postpartum period compared to in-person, 2-hour oral glucose tolerance testing (2hr OGTT). Methods: This was a single-center interventional study that included individuals diagnosed with gestational diabetes. Patients were enrolled in standard, office-based 2hr OGTT in combination with text-based remote diabetes screening. Study participants were instructed to record FBG for 3 consecutive days using a mobile application. We assessed agreement with 2hr OGTT using sensitivity, specificity, positive and negative predictive value with exact binomial 95% confidence intervals. Results: A total of 446 individuals diagnosed with gestational diabetes met inclusion criteria, 239 of which were enrolled in standard office-based screening and 207 were enrolled in dual screening using standard 2hr OGTT testing combined with text-based remote FBG screening. A FBG value less than 100 mg/dL had 100% sensitivity (86-100%), 86% specificity (77-93%) with a 100% (94-100%) negative predictive value and 71% (54-85%) positive predictive value. Follow-up was significantly higher among individuals enrolled in remote text-based screening compared to standard in-office screening (48% vs. 25%, respectively; P<0.001). Conclusions: Text-based screening may be a feasible alternative to in-office screening. A mobile-based system using FBG successfully screened all patients with type 2 diabetes in the postpartum period with 100% sensitivity and negative predictive value. Remote telehealth screening significantly increased follow-up with type 2 diabetes screening.

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.

Fetal Growth Biometry as Predictors of Shoulder Dystocia in a Low-Risk Obstetrical Population.

OBJECTIVE: This study aimed to evaluate fetal biometrics as predictors of shoulder dystocia (SD) in a low-risk obstetrical population. STUDY DESIGN: Participants were enrolled as part of a U.S.-based prospective cohort study of fetal growth in low-risk singleton gestations (n = 2,802). Eligible women had liveborn singletons ≥2,500 g delivered vaginally. Sociodemographic, anthropometric, and pregnancy outcome data were abstracted by research staff. The diagnosis of SD was based on the recorded clinical impression of the delivering physician. Simple logistic regression models were used to examine associations between fetal biometrics and SD. Fetal biometric cut points, selected by Youden's J and clinical determination, were identified to optimize predictive capability. A final model for SD prediction was constructed using backward selection. Our dataset was randomly divided into training (60%) and test (40%) datasets for model building and internal validation. RESULTS: A total of 1,691 women (98.7%) had an uncomplicated vaginal delivery, while 23 (1.3%) experienced SD. There were no differences in sociodemographic or maternal anthropometrics between groups. Epidural anesthesia use was significantly more common (100 vs. 82.4%; p = 0.03) among women who experienced SD compared with those who did not. Amniotic fluid maximal vertical pocket was also significantly greater among SD cases (5.8 ± 1.7 vs. 5.1 ± 1.5 cm; odds ratio = 1.32 [95% confidence interval: 1.03,1.69]). Several fetal biometric measures were significantly associated with SD when dichotomized based on clinically selected cut-off points. A final prediction model was internally valid with an area under the curve of 0.90 (95% confidence interval: 0.81, 0.99). At a model probability of 1%, sensitivity (71.4%), specificity (77.5%), positive (3.5%), and negative predictive values (99.6%) did not indicate the ability of the model to predict SD in a clinically meaningful way. CONCLUSION: Other than epidural anesthesia use, neither sociodemographic nor maternal anthropometrics were significantly associated with SD in this low-risk population. Both individually and in combination, fetal biometrics had limited ability to predict SD and lack clinical usefulness. KEY POINTS: · SD unpredictable in low-risk women.. · Fetal biometry does not reliably predict SD.. · Epidural use associated with increased SD risk.. · SD prediction models clinically inefficient..

The association between maternal pre-pregnancy BMI, gestational weight gain and child adiposity: A racial-ethnically diverse cohort of children.

BACKGROUND: The prevalence of obesity in US children has more than tripled in the past 40 years; hence, it is critical to identify potentially modifiable factors that may mitigate the risk. OBJECTIVES: To examine the association between maternal pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and child adiposity as measured by BMI, waist circumference and percent body fat in a racial-ethnically diverse cohort. METHODS: In a prospective cohort study of healthy women without chronic disease, we examined the association between pre-pregnancy BMI, GWG and child adiposity. Children ages 4-8 years (n = 816) in the Environmental Influences on Child Health Outcomes-NICHD Fetal Growth Studies were assessed. Trained study staff ascertained maternal pre-pregnancy BMI, GWG and child adiposity. RESULTS: The odds of child obesity (≥95th BMI percentile) increased independently for each unit increase in maternal pre-pregnancy BMI [OR = 1.12 (95% CI: 1.08, 1.17)] and for each 5-kg increase in GWG [OR = 1.25 (95% CI: 1.07, 1.47)]. The odds of child waist circumference (≥85th percentile) also increased independently for pre-pregnancy BMI [OR = 1.09 (95% CI: 1.05, 1.12)] and GWG [OR = 1.18 (95% CI: 1.04, 1.34)]. CONCLUSIONS: Maternal pre-pregnancy BMI and GWG were each independently and positively associated with child obesity and high child waist circumference.

Early Exposure to Animals and Childhood Body Mass Index Percentile and Percentage Fat Mass.

INTRODUCTION: A few studies have identified childhood animal exposure as associated with adiposity, but results are inconsistent and differ in timing. METHODS: We conducted an observational cohort study of children ages 4-8 in the Environmental Influences on Child Health Outcomes [ECHO] study. The main exposure was having a dog in the home and/or regular contact with farm animals during the first year of life. Outcomes of interest were child BMI percentile (adjusted for gender and age) categorized as normal/underweight (<85th percentile), overweight (85th to <95th), and obese (≥95th), and percent fat mass (continuous). Associations were analyzed using multinomial logistic regression and multivariable linear regression, respectively, with and without multiple imputation. RESULTS: First year animal exposure occurred in 245 of 770 (31.8%) children. Children with early animal exposure had 0.53 (95% CI: 0.28, 0.997) times the odds of being in the obese BMI category compared to those exposed to animals after controlling for covariates: maternal pre-pregnancy BMI, race/ethnicity, reported child activity level, receiving food assistance, age child began daycare (<1 year vs 1+), exclusively breastfed x6 months, and NICU admission (n=721). Children with early animal exposure had, on average, 1.5% (95% CI: -3.0, -0.1) less fat mass than exposed children after adjustment for maternal BMI, race/ethnicity, activity, food assistance, breastfeeding, and maternal education (n=548). Multiple imputation did not alter either result. CONCLUSION: These results provide evidence that exposure to dogs or farm animals in the first year of life is associated with lower odds of obesity and lower percent fat mass in childhood.

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.

Activity restriction and preterm birth prevention.

PURPOSE OF REVIEW: Since the 1900s, activity restriction (AR) has been widely prescribed as a strategy for preventing preterm birth (PTB). Over the past decade, the practice has been called into question as numerous studies have demonstrated that AR does not improve obstetrical and perinatal outcomes but does confer significant physical and psychological risks. The purpose of this review is to offer clinicians a summary of the latest data on the risks, benefits, and efficacy of AR for the prevention of PTB. RECENT FINDINGS: Both retrospective and prospective studies have demonstrated that AR does not significantly prolong pregnancy including those with multiple gestations, short cervices, ruptured membranes, and increased body mass indexes. Several studies have also shown that physical activity during pregnancy is associated with a higher incidence of vaginal delivery, a lower incidence of gestational diabetes mellitus, and a lower incidence of hypertensive disorders without increasing the risk of adverse neonatal outcomes. SUMMARY: The culmination of these data led to the Society for Maternal-Fetal Medicines' release of an updated committee recommendation in August of 2020; AR should not be routinely prescribed as a treatment to prevent PTB.

Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting. DATA SOURCES: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied. METHODS OF STUDY SELECTION: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included. TABULATION, INTEGRATION, AND RESULTS: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths. CONCLUSION: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019140503.

The Compliance of Prescribed Activity Restriction in Women at High Risk for Preterm Birth.

OBJECTIVE: Despite lack of evidence to support efficacy, activity restriction is one of the most commonly prescribed interventions used for the prevention of preterm birth. We have a departmental policy against the use of activity restriction but many practitioners still prescribe it in an effort to prevent preterm birth. We sought to evaluate the rate and compliance of women who are prescribed activity restriction during pregnancy to prevent preterm birth. STUDY DESIGN: This was a single-site retrospective questionnaire study at a tertiary care, academic affiliated medical center. Women with a history of preterm delivery or short cervix were included. Once patients were identified, each patient was contacted and administered a questionnaire. We assessed the rates of activity restriction prescription and compliance. Secondary outcomes included details regarding activity restriction and treatment in pregnancy. Continuous variables were compared with t-test and categorical variables with Chi-square test. The value p < 0.05 was considered significant. RESULTS: Among the 52 women who responded to the questionnaire, 18 reported being placed on activity restriction by a physician, with 1 self-prescribing activity restriction, giving a rate of our primary outcome of 19 of 52 (36.5%). All women reported compliance with prescribed activity restriction (100%). Gestational age at delivery was not different in women placed on activity restriction. CONCLUSION: This questionnaire suggests that approximately one in three high-risk women were placed on activity restriction during their pregnancy despite a departmental policy against its use. The 100% compliance rate in patients placed on activity restriction is a strong reminder of the impact prescribing patterns of physicians can have on patients. KEY POINTS: · One in three women are placed on activity restriction in pregnancy.. · Women are compliant with prescribed activity restriction.. · Activity restriction does not reduce rates of preterm birth..