Browsing by Subject "Perinatal"

Now showing 1 - 8 of 8
  • Thumbnail Image
    Item
    Adequacy of glycemic control in early pregnancy with Type 2 diabetes and perinatal outcomes
    (2023-02-09) Izewski, Joanna; Tang, Rachel; Crites, Kundai; Campbell, Meredith; Pelton, Sarah; Saiko-Blair, Morgan; Scifres, Christina
    Objective In non-pregnant individuals with type 2 DM (T2DM), an HbA1c target < 7% is recommended. We sought to assess if an HbA1c < 7% in early pregnancy is associated with a lower risk for adverse pregnancy outcomes. Study Design We conducted a retrospective cohort study of individuals with T2DM and a singleton gestation who delivered at 2 health systems between 2018-2020. Demographics, markers of health care utilization, and perinatal outcomes were abstracted from the medical record. Race and ethnicity were self-reported. The primary exposure was levels of glycemic control at less than 20 weeks’ gestation using recommended HbA1c targets in non-pregnant individuals (HbA1c < 7% vs. HbA1c ≥7%). Patients without documentation of HbA1c prior to 20 weeks were excluded. Perinatal outcomes were abstracted from the medical record, and logistic regression was used to adjust for covariates. Results Of the individuals who had a documented HbA1c < 20 weeks of gestation, 128/281 (46%) had a HbA1c < 7%, and 153/281 (54%) had a HbA1c ≥7%. Patients with HbA1c < 7% were more likely to be of White race and have private insurance. They also had the first HbA1c measured earlier in pregnancy, a lower mean HbA1c across gestation, less overall weight gain, and were less likely to require insulin at the time of delivery. There were no significant differences in other demographics or markers of healthcare utilization (Table 1). Outcomes are shown in Table 2. After adjusting for covariates, those with a HbA1c ≥7% were more likely to have a preterm birth < 37 weeks (aOR 2.3, 95% CI 1.3-4.0), cesarean delivery (aOR 1.9, 95% CI 1.1-3.3), and a neonate requiring NICU admission (aOR 2.9, 95% CI 1.7-4.9). Conclusion Adverse perinatal outcomes are common among individuals with T2DM even when early pregnancy HbA1c values are within recommended targets for non-pregnant individuals. Those who present with a HbA1c ≥7% are at even higher risk for several outcomes. We observed important disparities in HbA1c values in early pregnancy that likely represent barriers in accessing medical care prior to pregnancy.
  • Thumbnail Image
    Item
    Delay in sexual maturation in perinatally HIV-infected youths is mediated by poor growth
    (Lippincott, Williams & Wilkins, 2017-06-01) Bellavia, Andrea; Williams, Paige L.; DiMeglio, Linda A.; Hazra, Rohan; Abzug, Mark J.; Patel, Kunjal; Jacobson, Denise L.; Van Dyke, Russell B.; Geffner, Mitchell E.; International Maternal Pediatric and Adolescent AIDS Clinical Trials (IMPAACT) P219/219C Study; Pediatric HIV/AIDS Cohort Study (PHACS); Pediatrics, School of Medicine
    OBJECTIVE: To evaluate the association between HIV infection and sexual maturation, and mediation of this association by HIV effects on growth. DESIGN: Pooled data were analyzed from two longitudinal cohort studies, the International Maternal Pediatric Adolescent AIDS Clinical Trials P219/219C Study (1993-2007) and the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol (2007-2015), including perinatally HIV-infected (PHIV) and HIV-exposed uninfected (PHEU) youths. METHODS: We evaluated age at sexual maturity among 2539 PHIV and PHEU adolescents based on annual physician-assessed pubertal staging measures. Interval-censored regression models were used to evaluate associations of HIV infection with age at maturity. Mediation analyses accounting for height and BMI Z-scores at specific ages were used to estimate direct and indirect effects of HIV infection on age at sexual maturity. RESULTS: Mean ages at sexual maturity for PHIV girls (n = 1032) were 15.5 years for both female breast and pubic hair and 15.9 and 15.8 years for PHIV boys (n = 1054) for genitalia and pubic hair, respectively. PHIV youths matured approximately 6 months later on average than PHEU (n = 221 girls and 232 boys), and this difference persisted after adjustment for race/ethnicity and birth cohort. BMI and height Z-scores mediated the association between HIV infection and later maturation in girls, accounting for up to 74% of the total HIV effect. Only height Z-scores mediated the effect of HIV on male age at maturity, accounting for up to 98% of the HIV effect. CONCLUSION: PHIV youths attain sexual maturity later on average than PHEU youths. Much of this difference may be attributable to deficient growth, suggesting directions for future interventions.
  • Thumbnail Image
    Item
    Impact of exposure to cooking fuels on stillbirths, perinatal, very early and late neonatal mortality - a multicenter prospective cohort study in rural communities in India, Pakistan, Kenya, Zambia and Guatemala
    (Springer (Biomed Central Ltd.), 2015) Patel, Archana B.; Meleth, Sreelatha; Pasha, Omrana; Goudar, Shivaprasad S.; Esamai, Fabian; Garces, Ana L.; Chomba, Elwyn; McClure, Elizabeth M.; Wright, Linda L.; Koso-Thomas, Marion; Moore, Janet L.; Saleem, Sarah; Liechty, Edward A.; Goldenberg, Robert L.; Derman, Richard J.; Hambidge, K. Michael; Carlo, Waldemar A.; Hibberd, Patricia L.; Department of Pediatrics, IU School of Medicine
    BACKGROUND: Consequences of exposure to household air pollution (HAP) from biomass fuels used for cooking on neonatal deaths and stillbirths is poorly understood. In a large multi-country observational study, we examined whether exposure to HAP was associated with perinatal mortality (stillbirths from gestation week 20 and deaths through day 7 of life) as well as when the deaths occurred (macerated, non-macerated stillbirths, very early neonatal mortality (day 0-2) and later neonatal mortality (day 3-28). Questions addressing household fuel use were asked at pregnancy, delivery, and neonatal follow-up visits in a prospective cohort study of pregnant women in rural communities in five low and lower middle income countries participating in the Global Network for Women and Children's Health's Maternal and Newborn Health Registry. The study was conducted between May 2011 and October 2012. Polluting fuels included kerosene, charcoal, coal, wood, straw, crop waste and dung. Clean fuels included electricity, liquefied petroleum gas (LPG), natural gas and biogas. RESULTS: We studied the outcomes of 65,912 singleton pregnancies, 18 % from households using clean fuels (59 % LPG) and 82 % from households using polluting fuels (86 % wood). Compared to households cooking with clean fuels, there was an increased risk of perinatal mortality among households using polluting fuels (adjusted relative risk (aRR) 1.44, 95 % confidence interval (CI) 1.30-1.61). Exposure to HAP increased the risk of having a macerated stillbirth (adjusted odds ratio (aOR) 1.66, 95%CI 1.23-2.25), non-macerated stillbirth (aOR 1.43, 95 % CI 1.15-1.85) and very early neonatal mortality (aOR 1.82, 95 % CI 1.47-2.22). CONCLUSIONS: Perinatal mortality was associated with exposure to HAP from week 20 of pregnancy through at least day 2 of life. Since pregnancy losses before labor and delivery are difficult to track, the effect of exposure to polluting fuels on global perinatal mortality may have previously been underestimated. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073475.
  • Thumbnail Image
    Item
    Maternal weight gain among individuals with Type 2 diabetes and associated perinatal outcomes
    (2023-02-10) Izewski, Joanna; Crites, Kundai; Tang, Rachel; Saiko-Blair, Morgan; Campbell, Meredith; Pelton, Sarah; Scifres, Christina
    Objective The prevalence of type 2 Diabetes Mellitus (T2DM) in pregnancy is increasing, and adverse perinatal outcomes are common. We sought to assess whether higher or lower weight gain is associated with adverse perinatal outcomes in T2DM. Study Design This was a retrospective cohort study of patients with T2DM and a singleton gestation who delivered at 2 health systems between 2018-2020. Demographics, markers of health care utilization, and various perinatal outcomes were abstracted from the medical record. Race and ethnicity were self-reported. Our primary exposure was weight gain < 5 kilograms(kg) across gestation compared to those who gained ≥5kg. We excluded patients for whom weight gain could not be calculated. We assessed multiple perinatal outcomes, and we used multinomial logistic regression to adjust for covariates. Results We included 341 individuals with T2DM. There were 216/341 (63%) in the ≥5kg group, and 125/341 (37%) in the < 5kg group. The < 5kg group was more likely to be of Black race. The ≥5kg group initiated prenatal care earlier in gestation, were more likely to have ≥12 total prenatal visits, and be on insulin at the time of delivery. There were no significant differences in other demographics or markers of healthcare utilization (Table 1). Perinatal outcomes are shown in Table 2. Those with < 5kg of weight gain were less likely to develop a hypertensive disorder of pregnancy (aOR 0.3, 95% CI 0.2-0.5), or undergo a cesarean delivery (aOR 0.6, 95% CI 0.4-0.9). Stillbirth was more common among those who gained < 5kg (7 vs. 2%, p=0.02). There was a statistical difference in neonatal birthweight category (AGA vs. SGA vs. LGA) (p=0.04) between the 2 groups that did not persist after adjusting for covariates. Conclusion Weight gain is associated with adverse perinatal outcomes among individuals with T2DM. While weight gain < 5kg is associated with a reduced risk for certain outcomes, the increased risk for stillbirth deserves further study.
  • Thumbnail Image
    Item
    Perinatal smoking and its related factors
    (2018-07-12) Jones, Ashley; Shieh, Carol; Staten, Lisa; Carter-Harris, Lisa; Stiffler, Deborah; Macy, Jon
    The smoking rate of low-income pregnant women is almost 4 times the rate for higher-income women. A better understanding of smoking within the low-income population is needed. The purpose of this dissertation was to study smoking and related factors for pregnant and postpartum women living in poverty. The first component used Rodger’s evolutionary concept analysis method and uncovered three attributes, four antecedents, and three consequences for smoking cessation. The second (N = 1,554) and third (N = 71,944) components were a secondary data analysis of first-pregnancy Medicaid-eligible women enrolled in the Nurse-Family Partnership program from 2011-2016. The second component explored patterns of smoking and depression and their associations. Eight distinct patterns of smoking and depression were found. Smokers were more likely than nonsmokers to have depressive symptoms at the end of pregnancy (OR = 1.37 [1.04, 1.81] and 12 months post-delivery (OR = 1.93 [1.47, 2.51]. The third component investigated covariates present during early pregnancy and their relationships with smoking status and sought to find best fitting predictive models. Multivariable logistic regression showed cigarette use in the 3 months prior to pregnancy and at program intake were significant predictors for smoking status at the end of pregnancy and 12 months post-delivery. Interactive Matrix Language, Structured Query Language, and iterations of logistic regression identified 5 covariates (high school education, cigarette use prior to pregnancy, smoking status at pregnancy baseline, depression, and self-mastery) for the best fitting model at the end of pregnancy and three additional covariates (post-secondary education, marital status, and race) for the 12 months post-delivery model. The area under the receiver operator characteristic curve was 0.9681 for the end of pregnancy model and 0.9269 for 12 months post-delivery model, indicating excellent prediction ability of the models. Results can be integrated in smoking prevention education, screening, and cessation intervention programs.
  • Thumbnail Image
    Item
    Risk Factors for Postpartum Relapse in Women at Risk of Postpartum Psychosis: The Role of Psychosocial Stress and the Biological Stress System
    (Elsevier, 2021) Hazelgrove, Katie; Biaggi, Alessandra; Waites, Freddie; Fuste, Montserrat; Osborne, Sarah; Conroy, Susan; Howard, Louise M.; Mehta, Mitul A.; Miele, Maddalena; Nikkheslat, Naghmeh; Seneviratne, Gertrude; Zunszain, Patricia A.; Pawlby, Susan; Pariante, Carmine M.; Dazzan, Paola; Psychiatry, School of Medicine
    Background: Postpartum psychosis is the most severe psychiatric disorder associated with childbirth, and the risk is particularly high for women with a history of bipolar disorder, schizoaffective disorder or those who have suffered a previous episode of postpartum psychosis. Whilst there is a lot of evidence linking stress to psychosis unrelated to childbirth, the role of stress in the onset of postpartum psychosis has not been fully investigated. Methods: A prospective longitudinal study of 112 pregnant women, 51 at risk of postpartum psychosis because of a DSM-IV diagnosis of bipolar disorder (n = 41), schizoaffective disorder (n = 6) or a previous postpartum psychosis (n = 4) and 61 healthy women with no past or current DSM-IV diagnosis and no family history of postpartum psychosis. Women were followed up from the third trimester of pregnancy to 4 weeks' post partum. Women at risk who had a psychiatric relapse in the first 4 weeks' post partum (AR-unwell) (n = 22), were compared with those at risk who remained well (AR-well) (n = 29) on measures of psychosocial stress (severe childhood maltreatment and stressful life events) and biological stress (cortisol and inflammatory biomarkers). Results: Logistic regression analyses revealed that severe childhood maltreatment (OR = 4.9, 95% CI 0.5-49.2) and higher daily cortisol in the third trimester of pregnancy (OR=3.7, 95% CI 1.2-11.6) predicted psychiatric relapse in the first 4 weeks' post partum in women at risk of postpartum psychosis after adjusting for clinical and sociodemographic covariates. Conclusion: The current study provides evidence for the role of psychosocial stress and the biological stress system in the risk of postpartum relapse in women at risk of postpartum psychosis.
  • Thumbnail Image
    Item
    Screening for Perinatal Depression with the Patient Health Questionnaire Depression Scale (PHQ-9): A Systematic Review and Meta-analysis
    (Elsevier, 2021) Wang, Larry; Kroenke, Kurt; Stump, Timothy E.; Monahan, Patrick O.; Medicine, School of Medicine
    Objectives: Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND. Methods: The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity. Results: A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate. Conclusions: The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.
  • Thumbnail Image
    Item
    The role of etravirine in the management of treatment-experienced pediatric patients with HIV
    (Dove Press, 2013-04-10) Osterholzer, Danielle; Pediatrics, School of Medicine
    Pediatric patients infected with human immunodeficiency virus (HIV) are now living longer, healthier lives due to the advent of combined antiretroviral (ARV) therapy, including regimens that often contain non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, first-generation NNRTIs such as nevirapine (NVP) and efavirenz (EFV) have a low genetic barrier to resistance, and both drugs can become ineffective with a single viral point mutation. New agents with activity against resistant viral strains must be available to salvage children and adolescents with virologic failure after NNRTI use. One such drug, etravirine, an oral second-generation NNRTI approved for use in the US in heavily treatment-experienced HIV-1-infected adults in 2008, is accumulating data in this younger population. Etravirine became approved by the US Food and Drug Administration in early 2012 to be used in combination with other ARV medications in HIV-1-infected children aged 6 years to <18 years who are failing their regimens with HIV-1 strains resistant to NNRTIs and other ARVs. This approval was largely based on data from a prospective, open-label, phase II clinical trial in this age group prescribed etravirine at 5.2 mg/kg twice daily (up to the adult dose of 200 mg twice daily) in combination with an investigator-selected optimized background regimen. Currently available 48-week follow-up data show complete viral suppression (<50 copies/mL) in 56% of the patients, with relatively few serious adverse events attributed to the drug. Additional studies and case reports from the field suggest its utility in clinical practice. This review is designed to increase the background understanding of this drug in pediatric HIV providers, to lay out the current pediatric data to support its use, and to define its practical role in the treatment of HIV-infected children now and in the future.