Association Between Maternal-Perceived Psychological Stress and Fetal Telomere Length.

OBJECTIVE: Our study aimed to investigate the association between maternal-perceived psychological stress and fetal telomere length. METHODS: We recruited women in labor upon hospital delivery admission. Based on responses to the Perceived Stress Scale, we categorized participants as having "high," "normal," or "low" perceived stress. We collected umbilical cord blood samples (N = 71) and isolated genomic DNA from cord blood leukocytes using quantitative polymerase chain reaction. We used a ratio of relative telomere length derived by telomere-to-single-copy gene ratio (T/S ratio). We applied analysis of variance and bootstrapping statistical procedures. RESULTS: Sixteen (22.5%) women were classified as having low perceived stress, 42 (59.2%) were classified as having normal perceived stress, and 13 (18.3%) were classified as having high perceived stress. Fetal telomere length differed significantly across the three stress groups in a dose-response pattern (T/S ratio of those with low perceived stress was greater than those with normal perceived stress, which was greater than those with high perceived stress [P < 0.05]). CONCLUSIONS: Our findings support our hypothesis that maternal-perceived psychological stress during pregnancy is associated with shorter fetal telomere length and suggest maternal stress as a possible marker for early intrauterine programming for accelerated chromosomal aging.

Impact of intrauterine tobacco exposure on fetal telomere length.

OBJECTIVE: We sought to investigate whether maternal smoking during pregnancy affects telomere length of the fetus. STUDY DESIGN: Pregnant women were recruited on hospital admission at delivery. A self-report questionnaire and salivary cotinine test were used to confirm tobacco exposure. Neonatal umbilical cord blood samples were collected, and genomic DNA was isolated from cord blood leukocytes and was analyzed for fetal telomere length based on quantitative polymerase chain reaction. A ratio of relative telomere length was determined by telomere repeat copy number and single copy gene copy number (T/S ratio) and used to compare the telomere length of active, passive, and nonsmokers. Bootstrap and analysis of variance statistical methods were used to evaluate the relationship between prenatal smoking status and fetal telomere length. RESULTS: Of the 86 women who were included in this study, approximately 69.8% of the participants were covered by Medicaid, and 55.8% of the participants were black or Hispanic. The overall mean T/S ratio was 0.8608 ± 1.0442. We noted an inverse relationship between smoking and fetal telomere length in a dose-response pattern (T/S ratio of nonsmokers that was more than passive smokers that was more than active smokers). Telomere length was significantly different for each pairwise comparison, and the greatest difference was between active and nonsmokers. CONCLUSION: Our results provide the first evidence to demonstrate a positive association between shortened fetal telomere length and smoking during pregnancy. Our findings suggest the possibility of early intrauterine programming for accelerated aging that is the result of tobacco exposure.

Association between maternal symptoms of sleep disordered breathing and fetal telomere length.

STUDY OBJECTIVES: Our investigation aims to assess the impact of symptoms of maternal sleep-disordered breathing, specifically sleep apnea risk and daytime sleepiness, on fetal leukocyte telomere length. PARTICIPANTS AND SETTING: Pregnant women were recruited upon hospital delivery admission. INTERVENTIONS: Sleep exposure outcomes were measured using the Berlin Questionnaire to quantify sleep apnea and the Epworth Sleepiness Scale to measure daytime sleepiness. Participants were classified as "High Risk" or "Low Risk" for sleep apnea based on responses to the Berlin, while "Normal" or "Abnormal" daytime sleepiness was determined based on responses to the Epworth. DESIGN: Neonatal umbilical cord blood samples (N = 67) were collected and genomic DNA was isolated from cord blood leukocytes using Quantitative PCR. A ratio of relative telomere length was derived by telomere repeat copy number and single copy gene copy number (T/S ratio) and used to compare telomere lengths. Bootstrap and ANOVA statistical procedures were employed. MEASUREMENTS AND RESULTS: On the Berlin, 68.7% of participants were classified as Low Risk while 31.3% were classified as High Risk for sleep apnea. According to the Epworth scale, 80.6% were determined to have Normal daytime sleepiness, and 19.4% were found to have Abnormal daytime sleepiness. The T/S ratio among pregnant women at High Risk for sleep apnea was significantly shorter than for those at Low Risk (P value < 0.05), and the T/S ratio among habitual snorers was significantly shorter than among non-habitual snorers (P value < 0.05). Although those with Normal Sleepiness had a longer T/S ratio than those with Abnormal Sleepiness, the difference was not statistically significant. CONCLUSION: Our results provide the first evidence demonstrating shortened telomere length among fetuses exposed to maternal symptoms of sleep disordered breathing during pregnancy, and suggest sleep disordered breathing as a possible mechanism of accelerated chromosomal aging.

Paternal involvement and fetal morbidity outcomes in HIV/AIDS: a population-based study.

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers (N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (<35 years old), and unmarried with at least a high school education (p<.01). They were also more likely to have a history of drug (p<.01) and alcohol (p=.02) abuse. These differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal involvement during pregnancy had elevated risks for adverse fetal outcomes (LBW: OR=1.30, 95% confidence interval [CI]=1.05-1.60; VLBW: OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; VPTB: OR=1.81, 95% CI=1.13-2.90). Absence of fathers increases the likelihood of adverse fetal morbidity outcomes in women with HIV infection. These findings underscore the importance of paternal involvement during pregnancy, especially as an important component of programs for prevention of mother-to-child transmission of HIV.

Socio-ecological Model as a Framework for Overcoming Barriers and Challenges in Randomized Control Trials in Minority and Underserved Communities.

BACKGROUND: Numerous barriers and challenges can hinder the successful enrollment and retention of study participants in clinical trials targeting minority populations. To conduct quality research, it is important to investigate these challenges, determine appropriate strategies that are evidence-based and continue seeking methods of improvement. METHODS: In this paper, we report such experiences in a registered clinical trial in an underserved minority population in the Southern part of United States. This research study is a randomized double-blind controlled clinical trial that tests the efficacy of higher-strength as compared to low-strength/standard of care folic acid to prevent fetal body and brain size reduction in pregnant women who smoke. A unique approach in this socio-behavioral, genetic-epigenetic clinical trial is that we have adopted the socio-ecological model as a functional platform to effectively achieve and maintain high participant recruitment and retention rates. RESULTS: We highlight the barriers we have encountered in our trial and describe how we have successfully applied the socio-ecological model to overcome these obstacles. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: Our positive experience will be of utility to other researchers globally. Our fi ndings have far-reaching implications as the socio-ecological model approach is adaptable to developed and developing regions and has the potential to increase recruitment and retention of hard-to-reach populations who are typically under-represented in clinical trials.

HIV infection and its impact on fetal outcomes among women of advanced maternal age: a propensity score weighted matching approach.

Advanced maternal age (AMA) and HIV status have been investigated separately for their influence on infant outcomes. Both are associated with adverse fetal growth outcomes, including low birth weight (LBW) and preterm birth (PTB). However, the impact of the cooccurrence of these factors in relation to birth outcomes remains relatively understudied. We analyzed Florida hospital discharge data linked to vital records. The study population consisted of women who had a singleton live birth between 1998 and 2007 (N=1,687,176). The exposure variables were HIV infection and maternal age, while the outcomes of interest were LBW, PTB, and small for gestational age (SGA). We matched HIV-positive women to HIV-negative women on selected variables using propensity scores. To approximate relative risks, we computed adjusted odds ratios (AOR) and 95% confidence intervals (CI) generated from logistic regression models and accounted for the matched design using the generalized estimating equations framework. After adjusting for demographic variables, clinical conditions, and route of birth, the risks of LBW, PTB, and SGA remained significant for HIV-positive women, regardless of age. HIV-positive women of AMA (≥35 years) were more likely to have infants of LBW (AOR=1.73, 95% CI=1.37-2.18), PTB (AOR=1.35, 95% CI: 1.06-1.71), and SGA (AOR=1.52, 95% CI=1.22-1.89), compared to uninfected mothers of younger age (<35 years). For women of advanced age, HIV positivity elevates their risk for LBW and PTB. The interplay of HIV status and age should be considered by healthcare providers when determining appropriate interconception strategies for women and their families.

Placental abruption, offspring sex, and birth outcomes in a large cohort of mothers.

OBJECTIVE: To investigate stillbirth, neonatal, and perinatal death outcomes in pregnancies complicated by placental abruption, according to fetal sex. METHODS: We utilized maternally linked cohort data files of singleton live births to mothers diagnosed with placental abruption during the period 1989 through 2005 (n = 10,014). Logistic regression models were employed to generate adjusted odd ratios and their 95% confidence intervals. Male babies served as the referent category. RESULTS: The sex ratio at birth was 1.18. The overall prevalence of stillbirth, neonatal mortality, and perinatal mortality was 7.2%, 4.5%, and 11.8%, respectively. Placental abruption was less likely to occur in mothers carrying female pregnancies than mothers of male infants (adjusted odds ratio [95% confidence interval] = 0.89 [0.86-0.93]). There were no significant sex differences with regards to stillbirth, neonatal mortality, and perinatal mortality. Similar findings were observed for preterm and term infants. CONCLUSIONS: Although a preponderance of male infants was discernable among mothers with placental abruption, no sex difference in fetal survival was observed among the offspring of the mothers affected by placental abruption.

Fetal sex and differential survival in preeclampsia and eclampsia.

PURPOSE: We investigate sex differences in the incidence of stillbirth, neonatal mortality, and perinatal mortality among singletons born to mothers with preeclampsia or eclampsia. METHODS: Retrospective cohort analysis of a population-based sample of singleton births covering the period 1989 through 2005 (n = 56,313). RESULTS: The study population comprised 26,931 female (47.8%) and 29,382 male infants (52.2%; referent group). Overall, the prevalence of stillbirth, neonatal mortality and perinatal mortality were 0.68, 0.52 and 1.2%, respectively. There was no sex difference in the incidence of stillbirth, neonatal or perinatal mortality among offspring of mothers in this study. CONCLUSION: Although there was a preponderance of male infants among mothers with preeclampsia or eclampsia, we did not observe any sex-associated differences in fetal or neonatal survival among offspring of mothers with preeclampsia or eclampsia.

Temporal trends in cardiomyopathy in pregnancy and association with feto-infant morbidity outcomes.

OBJECTIVE: To examine temporal trends of cardiomyopathy in pregnancy and its association with feto-infant morbidity outcomes. DESIGN AND METHODS: We performed a population-based retrospective cohort analysis utilizing the Florida hospital discharge data linked to vital statistics for 1998 to 2007 (N = 1 738 860). Prevalence rates and trend statistics of cardiomyopathy were computed. Conditional logistic regression models were used to generate adjusted odds ratios (AOR) and 95% confidence intervals (CI). RESULTS: The annual prevalence of cardiomyopathy in pregnancy increased from 8.5/100 000 births to 32.7/100 000 (p for trend <0.0001), representing an absolute increase of 24% and a relative increase of 300% over the decade. Infants born to women with cardiomyopathy were at higher risk for feto-infant morbidities, including low birth weight (AOR = 3.49, 95% CI: 2.97-4.11), very low birth weight (AOR = 4.43, 95% CI: 2.98-6.60), preterm birth (AOR = 3.33, 95% CI: 2.88-3.85), very preterm birth (AOR = 5.22, 95% CI: 3.92-6.97) and small for gestational age (AOR = 1.57, 95% CI: 1.26-1.96). CONCLUSION: The observed increasing prevalence of cardiomyopathy during pregnancy over the decade is of concern, as it is related to elevated risk for feto-infant morbidities. There is a need to delineate risk factors for this condition and to formulate appropriate preconception counseling for women with elevated risk for this diagnosis.

Interpregnancy body mass index changes and risk of stillbirth.

BACKGROUND/AIMS: To examine the association between interpregnancy body mass index (BMI) change and stillbirth. METHODS: Retrospective study using Missouri maternally linked cohort files (1978-2005). A total of 218,389 women were used in the analysis. BMI was classified as: underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), or obese (≥30.0). Weight change was defined based on BMI category (i.e. normal-normal, normal-obese, etc.). Cox proportional hazard regression models were used to generate adjusted hazard ratios (HR) and 95% CI for the risk of stillbirth in the second pregnancy. RESULTS: Significant findings were associated with interpregnancy BMI changes involving overweight mothers becoming obese (HR = 1.4, 95% CI 1.1-1.7), normal-weight mothers becoming overweight (HR = 1.2, 95% CI 1.0-1.4) or obese (HR = 1.5, 95% CI 1.1-2.1), or obese mothers maintaining their obesity status across the two pregnancies (HR = 1.4, 95% CI 1.2-1.7). Other weight change categories did not show significant risk elevation for stillbirth. CONCLUSIONS: BMI change appears to play an important role in subsequent stillbirth risk.

Recurrent versus isolated pre-eclampsia and risk of feto-infant morbidity outcomes: racial/ethnic disparity.

OBJECTIVE: We examined the association between recurrent versus isolated pre-eclampsia and feto-infant morbidity outcomes. STUDY DESIGN: This is a population-based retrospective study on Florida hospital discharge data linked to the birth cohort files from 1998 through 2007. The study population comprised women with singleton first and second births who experienced pre-eclampsia in both pregnancies, and a comparison group consisting of women who were normotensive during their first pregnancy but developed pre-eclampsia in their second pregnancy. Feto-infant morbidities (low birth weight, very low birth weight, preterm, very preterm and small for gestational age) were the outcome of interest. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between recurrent pre-eclampsia and feto-infant morbidity outcomes were obtained from logistic regression models. RESULT: Women who experienced recurrent pre-eclampsia were at elevated risk for low birth weight, very low birth weight, preterm and very preterm. The risk was most pronounced for preterm infants (OR=1.58 CL=1.42-1.76). Subgroup analysis demonstrated that infants born to black mothers with recurrent pre-eclampsia experienced the most elevated risk across all the racial/ethnic subgroups and this was most pronounced for very low birth weight and very preterm with a more than three-fold increase in risk (OR=3.77, 95% CI=2.77-5.13 and OR=3.66, 95% CI=2.66-5.03, respectively) as compared to the referent category (white mothers who were normotensive in first pregnancy but developed pre-eclampsia in their second pregnancy). CONCLUSION: Pre-eclampsia is very severe when it recurs and black women are affected more than white or Hispanic women.

The impact of obesity on maternal morbidity and feto-infant outcomes among macrosomic infants.

OBJECTIVE: To estimate the contribution of obesity to maternal complications, neonatal morbidity and mortality among macrosomic births. DESIGN: A population-based retrospective cohort design using State of Missouri maternally linked birth cohort files. METHODS: Using pre-gravid body mass index (BMI), we categorized mothers of 116,976 singleton macrosomic live births as non-obese (BMI < 30) or obese (BMI ≥ 30). We used logistic regression models to generate adjusted odd ratios for pregnancy and neonatal complications. We also estimated the proportion of potentially preventable excess maternal and neonatal complications that could be eliminated among obese women with infant macrosomia at various levels of pre-pregnancy obesity reduction. RESULT: Obese mothers with macrosomic infants were at elevated risk for chronic hypertension (odds ratio (OR) = 6.78 [95% confidence interval (CI): 5.82-7.88]), insulin-dependent diabetes mellitus, (OR = 2.60 [CI: 2.34-2.88]) other types of diabetes mellitus (OR = 2.83 [CI: 2.65-3.02]) and preeclampsia (OR = 2.49 [CI: 2.33-2.67]). Macrosomic infants of obese mothers were at greater risk for hyaline membrane disease (OR = 2.14 [CI: 1.73-2.66]), extended assisted ventilation (OR = 1.71 [CI: 1.44-2.04]), birth injury (OR = 1.58 [CI: 1.37-1.84]) and meconium aspiration syndrome (OR = 1.42 [CI: 1.09-1.87]). The proportion of preventable excess maternal morbidity was 60%, 45%, 30% and 15%, assuming an effective pre-conception intervention that could reduce obesity down to 0%, 25%, 50% and 75% of its current level, respectively. The corresponding proportion of preventable excess neonatal complications would be 40%, 30%, 20% and 10%, respectively. CONCLUSION: Among obese mothers with macrosomic births, a substantial proportion of maternal and neonatal morbidity could be averted through effective pre-conception interventions.

Association between intimate partner violence and induced abortion in Cameroon.

OBJECTIVE: To examine the association between intimate partner violence (IPV; physical, sexual, and emotional violence) and induced abortion in Cameroon. METHODS: We used data from the 2004 Cameroon Demographic Health Survey (DHS) and hierarchic multivariate modeling to compare the rates of induced abortion by IPV type. RESULTS: In 2004, 2570 women were administered the domestic violence module of the DHS. Of those women, 126 (4.9%) reported having had at least 1 induced abortion. Cameroonian women reported high rates of IPV: physical violence (995 [38.7%]); emotional violence (789 [30.7%]); and sexual violence (381 [14.8%]). After adjusting for covariates, physical and sexual IPV increased the risk for induced abortion, whereas the association between emotional violence and induced abortion was not significant in multivariate models. CONCLUSION: Given the increased risk for maternal morbidity and mortality following unsafe induced abortions in Cameroon, the association between induced abortion and IPV is of interest in terms of public health. Programs targeted at preventing IPV might reduce the rate of maternal morbidity and mortality.

Assessing the impact of paternal involvement on racial/ethnic disparities in infant mortality rates.

We sought to assess the contribution of paternal involvement to racial disparities in infant mortality. Using vital records data from singleton births in Florida between 1998 and 2005, we generated odds ratios (OR), 95% confidence intervals (CI), and preventative fractions to assess the association between paternal involvement and infant mortality. Paternal involvement status was based on presence/absence of paternal first and/or last name on the birth certificate. Disparities in infant mortality were observed between and within racial/ethnic subpopulations. When compared to Hispanic (NH)-white women with involved fathers, NH-black women with involved fathers had a two-fold increased risk of infant mortality whereas infants born to black women with absent fathers had a seven-fold increased risk of infant mortality. Elevated risks of infant mortality were also observed for Hispanic infants with absent fathers (OR = 3.33. 95%CI = 2.66-4.17). About 65-75% of excess mortality could be prevented with increased paternal involvement. Paternal absence widens the black-white gap in infant mortality almost four-fold. Intervention programs to improve perinatal paternal involvement may decrease the burden of absent father-associated infant mortality.

Association between tobacco use in pregnancy and placenta-associated syndromes: a population-based study.

INTRODUCTION: Cigarette smoking is an established risk factor for adverse perinatal outcomes. The purpose of this study is to examine the association between maternal smoking in pregnancy and the occurrence of placental-associated syndromes (PAS). METHODS: We analyzed data from a population-based retrospective cohort of singleton deliveries that occurred in the state of Missouri from 1989 through 2005 (N = 1,224,133). The main outcome was PAS, a composite outcome defined as the occurrence of placental abruption, placenta previa, preeclampsia, small for gestational age, preterm or stillbirth. We used logistic regression models to generate adjusted odd ratios and their 95 percent confidence intervals. Non-smoking gravidas served as the referent category. RESULTS: The overall prevalence of prenatal smoking was 19.6%. Cigarette smoking in pregnancy was associated with the composite outcome of placental syndromes (odds ratio, 95% confidence interval = 1.59, 1.57-1.60). This association showed a dose-response relationship, with the risk of PAS increasing with increased quantity of cigarettes smoked. Similar results were observed between smoking in pregnancy and independent risks for abruption, previa, SGA, stillbirth, and preterm delivery. CONCLUSION: Maternal smoking in pregnancy is a risk factor for the development of placenta-associated syndrome. Smoking cessation interventions in pregnancy should continue to be encouraged in all maternity care settings.

The psychosocial impact of vesico-vaginal fistula in Niger.

PURPOSE: To explore the psycho-social impact of vesico-vaginal fistula (VVF) on women in Niger. STUDY DESIGN: We conducted a qualitative study on 21 women in convalescence at the DIMOL Reproductive Health Center in Niamey, Niger, in 2008 and 2009. The women had undergone 1-3 fistula repair operations and all had stillborn infants. RESULTS: Women reported many psychological consequences of VVF including depression, feelings of shame, and loneliness. Others reported feeling devalued as a woman and wanting to end their lives. Social consequences of fistula reported by these women included rejection from society, isolation, rejection from husband and/or divorce. Almost half of the women reported of having lost their social network and support as a result of the fistula. Women with VVF were deemed unworthy, and their illness was often attributed to some fault of their own. CONCLUSIONS: Our findings support the notion that socio-economic factors, though they certainly contribute to obstetric fistula, are not the primary reason for fistula, particularly in Niger. Fistula is a direct result of lack of access to skilled birth attendants and emergency obstetric care.

Changes in prepregnancy body mass index between pregnancies and risk of preterm phenotypes.

We examined whether the risk of preterm birth and its subtypes (medically indicated and spontaneous preterm) are influenced by changes in prepregnancy body mass index (BMI) between the first and second pregnancies. A population-based, retrospective cohort analysis was performed using the Missouri (1978 to 2005) longitudinally linked cohort data sets. Women with their first two successive singleton live births ( N = 436,502) were analyzed. The risks for preterm birth and its subtypes were evaluated using multivariate logistic regression modeling. Compared with women who maintained normal interpregnancy BMI, women who lowered their weight from normal to underweight were more likely to experience preterm and spontaneous preterm birth (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4 to 1.6). Women with BMI changes from normal weight to obese (OR 1.4, 95% CI 1.2 to 1.6) and normal weight to overweight (OR 1.2, 95% CI 1.1 to 1.3) were at increased risk of medically indicated preterm birth. A decrease in prepregnancy BMI from normal to underweight is associated with increased risk of spontaneous preterm birth, and prepregnancy BMI increases from normal to overweight or to obese BMI are associated with increased risk of medically indicated preterm birth.

Cesarean delivery versus vaginal delivery: impact on survival and morbidity for the breech fetus at the threshold of viability.

OBJECTIVE: To determine if cesarean delivery is associated with improved survival and morbidity in the breech fetus at the threshold of viability. STUDY DESIGN: The Missouri maternally linked cohort data files covering the period 1989 through 2005 were utilized for analysis. All pregnancies with singleton fetuses in the breech presentation delivered between 23(0) and 24(6) weeks gestation and birth weights between 400 and 750 g were included. Logistic regression was used to compare cesarean to vaginal delivery after controlling for maternal demographics and pregnancy complications. RESULTS: A total of 325 breech singletons were analyzed; cesarean deliveries accounted for 46.1% (150) and vaginal deliveries accounted for 53.9% (175). Cesarean delivery was associated with a survival benefit across all birth weights. Morbidity was higher in cesarean compared to vaginal delivery. CONCLUSION: Although cesarean delivery appears to be associated with an increase in survival at the threshold of viability for the breech fetus, there is a concomitant increase in morbidity. Any benefit that cesarean delivery conveys on survival at the threshold of viability should be weighed against the increased maternal morbidity and high overall neonatal morbidity.

The impact of previous cesarean section on the success of future fetal programming pattern.

PURPOSE: The purpose of this study is to examine whether cesarean section in the first pregnancy is associated with the success or failure of programmed fetal growth phenotypes or patterns in the subsequent pregnancy. METHODS: We analyzed data from a population-based retrospective cohort of singleton deliveries that occurred in the state of Missouri from 1978 to 2005 (n = 1,224,133). The main outcome was neonatal mortality, which was used as an index of the success of fetal programming. Cox proportional hazard and logistic regression models were used to generate point estimates and 95% confidence intervals. RESULTS: Mothers delivering by cesarean section in the first pregnancy were less likely to deliver subsequent appropriate-for-gestational-age (AGA) neonates (OR 0.91, 95% CI 0.89-0.92) when compared with mothers delivering vaginally. Of the 1,457 neonatal deaths in the second pregnancy, 383 early neonatal and 95 late neonatal deaths were to mothers with cesarean section deliveries in the first pregnancy. When compared with women with a previous vaginal delivery, AGA neonates of women with a primary cesarean section had 20% increased risk of both neonatal (OR 1.20, 95% CI 1.05-1.37) and early neonatal (OR 1.23, 95% CI 1.05-1.43) death. CONCLUSION: Our study suggests that previous cesarean section is a risk factor for neonatal mortality among AGA infants of subsequent pregnancy. Future prospective studies are needed to confirm these findings.

Impact of prenatal alcohol consumption on placenta-associated syndromes.

The biology of placental and fetal development suggests that alcohol may play a significant role in increasing the risk of feto-infant morbidity and mortality, but study results are inconsistent and the mechanism remains poorly defined. Previous studies have not examined the risk of placenta-associated syndromes (PASs: defined as the occurrence of either placental abruption, placenta previa, preeclampsia, small for gestational age, preterm, or stillbirth) as a unique entity. Therefore, we sought to examine the relationship between prenatal alcohol use and the risk of PAS among singleton births in the Missouri maternally linked data files covering the period 1989-2005. Logistic regression with adjustment for intracluster correlation was used to generate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Compared with nondrinkers, drinkers were more likely to be smokers, 35 years of age or older, black, and multiparous. Drinkers had an increased risk of PAS (OR=1.26, 95% CI=1.22,1.31) when compared with their nondrinking counterparts. The risk of PAS was progressively amplified with increasing prenatal alcohol consumption (P for trend <.01). Women who reported consuming five or more alcoholic drinks per week had more than twofold increased risk of PASs, whereas women in the lowest drinking category (one to two drinks per week) had only a slight increased risk of PAS (OR=1.09, 95% CI=1.05, 1.14). Enhanced understanding of the mechanism by which prenatal alcohol consumption leads to PAS may aid in the development of more targeted interventions designed to prevent adverse pregnancy outcomes. Screening women for alcohol use may assist providers in protecting developing fetuses from the potential dangers of prenatal alcohol use.