Society for Pediatric and Perinatal Epidemiologic Research (SPER): Annual Meeting

MINNEAPOLIS – Shifting the timing of elective repeat cesareans to late term may have the unintended consequence of increasing the proportion of women needing an emergency cesarean section, results of a new study suggest.

Moreover, these emergency deliveries were associated with a twofold increased risk of adverse maternal and neonatal outcomes after adjustment for confounders, Jennifer Hutcheon, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

Previous studies have established that elective repeat cesarean sections performed at early-term gestation, 37-38 weeks, have higher rates of neonatal respiratory complications than late-term deliveries at 39-41 weeks.

The American College of Obstetricians and Gynecologists (ACOG) discourages elective cesarean delivery before 39 weeks of gestation unless there is evidence of fetal lung maturity.

A recent report from the United States and a report from the Netherlands, however, indicate that 35%-55% of elective repeat cesarean deliveries are performed before 39 weeks, said Dr. Hutcheon, an epidemiologist in obstetrics and gynecology at the University of British Columbia, Vancouver.

"A better understanding of potential risks and their mechanisms is needed in order to make sure we implement preventive measures," she said.

To explore this, the researchers used the birth records of 9,206 low-risk women undergoing a planned repeat cesarean delivery in the British Columbia Perinatal Database Registry for 2008-2011, and calculated the correlation between institutional rates of early-term delivery and rates of emergency cesarean delivery for each of the 13 major obstetrical centers in British Columbia. Early term was defined as 37 weeks, 0 days, to 38 weeks, 6 days.

Adverse maternal outcome was defined as any occurrence of maternal mortality, cardiac arrest, obstetric shock, postpartum hemorrhage requiring transfusion or hysterectomy, mechanical ventilation through endotracheal tube, or severe medical morbidity. Adverse neonatal outcome was defined as any in-hospital newborn death, neonatal seizures, or respiratory morbidity requiring positive-pressure ventilation.

The analysis excluded women with suspected intrauterine growth restriction, multiples, congenital anomalies, diabetes, hypertension, or cardiac or renal disease.

In British Columbia, 55% of the elective repeat C-section deliveries were done before 39 weeks, Dr. Hutcheon said. There was considerable variation between institutions, with some centers performing only 35% of cases before 39 weeks and others 72%.

Overall, 15% of repeat cesarean deliveries in the province were performed under emergency timing. Once again, rates ranged between 35% and 72% at the different institutions.

There was a strong negative correlation between institutional rates of early-term delivery and emergency cesareans (r = –0.86; P less than .001), she said. For example, the institution with 72% of its elective repeat cesareans delivered before 39 weeks had fewer than 10% of women needing an emergency cesarean. On the other hand, the institution doing only 35% of elective cesareans before 39 weeks had one in three women going into labor and requiring emergency cesarean delivery.

In a univariate analysis, emergency cesarean delivery was associated with a significantly increased risk of adverse maternal outcome (odds ratio 2.1) and adverse neonatal outcome (OR 2.3), and a modest, nonsignificant increase in obstetrical wound infection (OR 1.4) and use of general anesthesia (OR 1.7), Dr. Hutcheon said.

In a multivariate analysis that adjusted for maternal age, body mass index, number of previous cesareans, and institutional obstetrical volume, the odds ratios were 2.1, 2.5, 1.2, and 1.8, for adverse maternal outcome, adverse neonatal outcome, obstetrical wound infection, and use of general anesthesia, respectively. All differences were significant except for obstetrical wound infection.

Dr. Hutcheon acknowledged that identifying the planned mode of delivery was challenging, and that some of the cesareans performed for an indication of "repeat" or "maternal request/VBAC [vaginal birth after cesarean] declined" may actually have been attempted vaginal deliveries.

To get a handle on this, the investigators looked at the time between hospital admission and when the delivery was actually performed. What they found was that the median interval was less than 3 hours, and was less than 4 hours for all of the cases with adverse outcomes.

"This is certainly more suggestive of a planned cesarean delivery rather than a failed VBAC attempt, where we would expect that interval to be quite a bit longer, although we can’t be sure," she said.

During a discussion of the results, an attendee asked whether it’s possible from the data to identify a "gestational sweet spot" that would reduce the risk of an emergency cesarean and yet be late enough to minimize the risk of adverse neonatal outcomes. Dr. Hutcheon said that is not possible from their data, and that this requires weighing two competing risks.

"You’re weighing a baby in the NICU [neonatal intensive care unit] and the potential for maternal complications, and those risks may be weighed differently by different people," she said, adding that this risk also varies depending on whether the delivery is at an academic center or a community hospital.

Finally, another attendee said the finding that institutions with high rates of repeat cesareans before 39 weeks are doing fewer emergency cesarean deliveries implies that obstetricians should be performing more cesareans before 39 weeks.

Dr. Hutcheon said, "I’m not trying to make the case that we should be doing more early-term elective cesarean deliveries. I think the point is more that we need to be more aware that if we’re introducing policies to try to shift the timing of delivery, this is going to be a side effect. And we need to plan for it better ... and to evaluate our policies to see if there are any adverse effects."

Perinatal Services BC sponsored the study. Dr. Hutcheon and her coauthors reported no conflicts.

MINNEAPOLIS – Shifting the timing of elective repeat cesareans to late term may have the unintended consequence of increasing the proportion of women needing an emergency cesarean section, results of a new study suggest.

Moreover, these emergency deliveries were associated with a twofold increased risk of adverse maternal and neonatal outcomes after adjustment for confounders, Jennifer Hutcheon, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

Previous studies have established that elective repeat cesarean sections performed at early-term gestation, 37-38 weeks, have higher rates of neonatal respiratory complications than late-term deliveries at 39-41 weeks.

The American College of Obstetricians and Gynecologists (ACOG) discourages elective cesarean delivery before 39 weeks of gestation unless there is evidence of fetal lung maturity.

A recent report from the United States and a report from the Netherlands, however, indicate that 35%-55% of elective repeat cesarean deliveries are performed before 39 weeks, said Dr. Hutcheon, an epidemiologist in obstetrics and gynecology at the University of British Columbia, Vancouver.

"A better understanding of potential risks and their mechanisms is needed in order to make sure we implement preventive measures," she said.

To explore this, the researchers used the birth records of 9,206 low-risk women undergoing a planned repeat cesarean delivery in the British Columbia Perinatal Database Registry for 2008-2011, and calculated the correlation between institutional rates of early-term delivery and rates of emergency cesarean delivery for each of the 13 major obstetrical centers in British Columbia. Early term was defined as 37 weeks, 0 days, to 38 weeks, 6 days.

Adverse maternal outcome was defined as any occurrence of maternal mortality, cardiac arrest, obstetric shock, postpartum hemorrhage requiring transfusion or hysterectomy, mechanical ventilation through endotracheal tube, or severe medical morbidity. Adverse neonatal outcome was defined as any in-hospital newborn death, neonatal seizures, or respiratory morbidity requiring positive-pressure ventilation.

The analysis excluded women with suspected intrauterine growth restriction, multiples, congenital anomalies, diabetes, hypertension, or cardiac or renal disease.

In British Columbia, 55% of the elective repeat C-section deliveries were done before 39 weeks, Dr. Hutcheon said. There was considerable variation between institutions, with some centers performing only 35% of cases before 39 weeks and others 72%.

Overall, 15% of repeat cesarean deliveries in the province were performed under emergency timing. Once again, rates ranged between 35% and 72% at the different institutions.

There was a strong negative correlation between institutional rates of early-term delivery and emergency cesareans (r = –0.86; P less than .001), she said. For example, the institution with 72% of its elective repeat cesareans delivered before 39 weeks had fewer than 10% of women needing an emergency cesarean. On the other hand, the institution doing only 35% of elective cesareans before 39 weeks had one in three women going into labor and requiring emergency cesarean delivery.

In a univariate analysis, emergency cesarean delivery was associated with a significantly increased risk of adverse maternal outcome (odds ratio 2.1) and adverse neonatal outcome (OR 2.3), and a modest, nonsignificant increase in obstetrical wound infection (OR 1.4) and use of general anesthesia (OR 1.7), Dr. Hutcheon said.

In a multivariate analysis that adjusted for maternal age, body mass index, number of previous cesareans, and institutional obstetrical volume, the odds ratios were 2.1, 2.5, 1.2, and 1.8, for adverse maternal outcome, adverse neonatal outcome, obstetrical wound infection, and use of general anesthesia, respectively. All differences were significant except for obstetrical wound infection.

Dr. Hutcheon acknowledged that identifying the planned mode of delivery was challenging, and that some of the cesareans performed for an indication of "repeat" or "maternal request/VBAC [vaginal birth after cesarean] declined" may actually have been attempted vaginal deliveries.

To get a handle on this, the investigators looked at the time between hospital admission and when the delivery was actually performed. What they found was that the median interval was less than 3 hours, and was less than 4 hours for all of the cases with adverse outcomes.

"This is certainly more suggestive of a planned cesarean delivery rather than a failed VBAC attempt, where we would expect that interval to be quite a bit longer, although we can’t be sure," she said.

During a discussion of the results, an attendee asked whether it’s possible from the data to identify a "gestational sweet spot" that would reduce the risk of an emergency cesarean and yet be late enough to minimize the risk of adverse neonatal outcomes. Dr. Hutcheon said that is not possible from their data, and that this requires weighing two competing risks.

"You’re weighing a baby in the NICU [neonatal intensive care unit] and the potential for maternal complications, and those risks may be weighed differently by different people," she said, adding that this risk also varies depending on whether the delivery is at an academic center or a community hospital.

Finally, another attendee said the finding that institutions with high rates of repeat cesareans before 39 weeks are doing fewer emergency cesarean deliveries implies that obstetricians should be performing more cesareans before 39 weeks.

Dr. Hutcheon said, "I’m not trying to make the case that we should be doing more early-term elective cesarean deliveries. I think the point is more that we need to be more aware that if we’re introducing policies to try to shift the timing of delivery, this is going to be a side effect. And we need to plan for it better ... and to evaluate our policies to see if there are any adverse effects."

Perinatal Services BC sponsored the study. Dr. Hutcheon and her coauthors reported no conflicts.

MINNEAPOLIS – Shifting the timing of elective repeat cesareans to late term may have the unintended consequence of increasing the proportion of women needing an emergency cesarean section, results of a new study suggest.

Moreover, these emergency deliveries were associated with a twofold increased risk of adverse maternal and neonatal outcomes after adjustment for confounders, Jennifer Hutcheon, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

Previous studies have established that elective repeat cesarean sections performed at early-term gestation, 37-38 weeks, have higher rates of neonatal respiratory complications than late-term deliveries at 39-41 weeks.

The American College of Obstetricians and Gynecologists (ACOG) discourages elective cesarean delivery before 39 weeks of gestation unless there is evidence of fetal lung maturity.

A recent report from the United States and a report from the Netherlands, however, indicate that 35%-55% of elective repeat cesarean deliveries are performed before 39 weeks, said Dr. Hutcheon, an epidemiologist in obstetrics and gynecology at the University of British Columbia, Vancouver.

"A better understanding of potential risks and their mechanisms is needed in order to make sure we implement preventive measures," she said.

To explore this, the researchers used the birth records of 9,206 low-risk women undergoing a planned repeat cesarean delivery in the British Columbia Perinatal Database Registry for 2008-2011, and calculated the correlation between institutional rates of early-term delivery and rates of emergency cesarean delivery for each of the 13 major obstetrical centers in British Columbia. Early term was defined as 37 weeks, 0 days, to 38 weeks, 6 days.

Adverse maternal outcome was defined as any occurrence of maternal mortality, cardiac arrest, obstetric shock, postpartum hemorrhage requiring transfusion or hysterectomy, mechanical ventilation through endotracheal tube, or severe medical morbidity. Adverse neonatal outcome was defined as any in-hospital newborn death, neonatal seizures, or respiratory morbidity requiring positive-pressure ventilation.

The analysis excluded women with suspected intrauterine growth restriction, multiples, congenital anomalies, diabetes, hypertension, or cardiac or renal disease.

In British Columbia, 55% of the elective repeat C-section deliveries were done before 39 weeks, Dr. Hutcheon said. There was considerable variation between institutions, with some centers performing only 35% of cases before 39 weeks and others 72%.

Overall, 15% of repeat cesarean deliveries in the province were performed under emergency timing. Once again, rates ranged between 35% and 72% at the different institutions.

There was a strong negative correlation between institutional rates of early-term delivery and emergency cesareans (r = –0.86; P less than .001), she said. For example, the institution with 72% of its elective repeat cesareans delivered before 39 weeks had fewer than 10% of women needing an emergency cesarean. On the other hand, the institution doing only 35% of elective cesareans before 39 weeks had one in three women going into labor and requiring emergency cesarean delivery.

In a univariate analysis, emergency cesarean delivery was associated with a significantly increased risk of adverse maternal outcome (odds ratio 2.1) and adverse neonatal outcome (OR 2.3), and a modest, nonsignificant increase in obstetrical wound infection (OR 1.4) and use of general anesthesia (OR 1.7), Dr. Hutcheon said.

In a multivariate analysis that adjusted for maternal age, body mass index, number of previous cesareans, and institutional obstetrical volume, the odds ratios were 2.1, 2.5, 1.2, and 1.8, for adverse maternal outcome, adverse neonatal outcome, obstetrical wound infection, and use of general anesthesia, respectively. All differences were significant except for obstetrical wound infection.

Dr. Hutcheon acknowledged that identifying the planned mode of delivery was challenging, and that some of the cesareans performed for an indication of "repeat" or "maternal request/VBAC [vaginal birth after cesarean] declined" may actually have been attempted vaginal deliveries.

To get a handle on this, the investigators looked at the time between hospital admission and when the delivery was actually performed. What they found was that the median interval was less than 3 hours, and was less than 4 hours for all of the cases with adverse outcomes.

"This is certainly more suggestive of a planned cesarean delivery rather than a failed VBAC attempt, where we would expect that interval to be quite a bit longer, although we can’t be sure," she said.

During a discussion of the results, an attendee asked whether it’s possible from the data to identify a "gestational sweet spot" that would reduce the risk of an emergency cesarean and yet be late enough to minimize the risk of adverse neonatal outcomes. Dr. Hutcheon said that is not possible from their data, and that this requires weighing two competing risks.

"You’re weighing a baby in the NICU [neonatal intensive care unit] and the potential for maternal complications, and those risks may be weighed differently by different people," she said, adding that this risk also varies depending on whether the delivery is at an academic center or a community hospital.

Finally, another attendee said the finding that institutions with high rates of repeat cesareans before 39 weeks are doing fewer emergency cesarean deliveries implies that obstetricians should be performing more cesareans before 39 weeks.

Dr. Hutcheon said, "I’m not trying to make the case that we should be doing more early-term elective cesarean deliveries. I think the point is more that we need to be more aware that if we’re introducing policies to try to shift the timing of delivery, this is going to be a side effect. And we need to plan for it better ... and to evaluate our policies to see if there are any adverse effects."

Perinatal Services BC sponsored the study. Dr. Hutcheon and her coauthors reported no conflicts.

MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.

From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.

During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.

"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."

The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.

The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.

During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.

There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.

The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.

The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.

Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.

In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.

In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).

Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.

A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.

"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.

Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.

Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).

The authors report no conflicts of interest.

MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.

From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.

During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.

"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."

The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.

The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.

During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.

There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.

The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.

The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.

Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.

In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.

In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).

Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.

A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.

"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.

Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.

Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).

The authors report no conflicts of interest.

MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.

From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.

During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Patrice Wendling/IMNG Medical Media

After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.

"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."

The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.

The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.

During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.

There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.

The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.

The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.

Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.

In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.

In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).

Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.

A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.

"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.

Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.

Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).

The authors report no conflicts of interest.

MINNEAPOLIS – Black women who conceive using in vitro fertilization are at a markedly increased risk of any type of preterm birth, compared with other races, a retrospective cohort study indicates.

Hispanic women had a significantly lower rate of preterm births than did black women, and similar or slightly higher rates than did white women.

Native American women were not at an increased risk of any type of preterm birth, compared with whites, whereas Asians were at a reduced risk of preterm twin births.

"There exist notable racial and ethnic disparities in preterm births in infants conceived by IVF, with the highest rate in black women," Dr. Xu Xiong of the school of public health and tropical medicine at Tulane University in New Orleans reported at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Racial disparities in preterm birth may reflect biological differences resulting from genetic background or from variations in social demographics, socioeconomic status (SES), environmental exposures, lifestyles, cultural factors, and access to care and treatment, he said. SES factors (such as income, education, and occupation) were not available in the data set, although all of the women were able to finance expensive and time-consuming IVF treatment.

"In this study of relatively higher income women [who] conceived by IVF, our findings of an even greater difference in preterm births between black and white women than in the general population indicate that SES may not be as solely important a determinant for the racial gaps of preterm birth than previously postulated," Dr. Xiong said in an interview.

The investigators conducted a retrospective cohort study of 56,465 singleton and 23,748 twin pregnancies resulting from fresh nondonor IVF cycles in 82,519 women, using 2006-2008 data from the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System).

Among singleton births, 3.3% of black women had a very early preterm birth at less than 28 weeks, compared with 0.7% of white women, 1% of Hispanics, 0.7% of Asians, and 1% of Native Americans (P less than .05).

The pattern was similar for early preterm birth at less than 32 weeks (5.8% vs. 1.6%, 2.2%, 1.4%, and 1.4%, respectively), and for preterm birth at less than 37 weeks (13.3% vs. 6.6%, 8%, 6%, and 8%, respectively) (both P less than .05), Dr. Xiong reported.

In multivariate analysis with adjustment for confounding variables including maternal age; gravida status; smoking status; day of embryo transfer; number of embryos transferred; number of gestational sacs with heart rate; body mass index; prior spontaneous abortions; and infertility diagnosis, black women remained at significantly increased risk of very early preterm birth (odds ratio, 4.5), early preterm birth (OR, 3.7) and preterm birth (OR, 2.0), compared with white women (all P less than .05).

As expected, twin pregnancies increased preterm births for all groups, but once again, blacks had the highest rate of very early preterm birth at 7.7%, compared with 2.5% of whites, 3.7% of Hispanics, 2.3% of Asians, and 3% of Native Americans (P less than .05), he said.

Rates were also significantly higher for black women for early preterm twin birth (13.6% vs. 6.6%, 7%, 5.8%, and 5.8%, respectively) and for preterm twin birth (46.5% vs. 37.6%, 37.5%, 33%, and 41%, respectively; P less than .05).

In the adjusted analysis, black women delivering twins had a significantly increased risk of very early preterm twin births (OR, 3.3), early preterm birth (OR, 2.2) and preterm birth (OR, 1.4), compared with whites (P less than .05), reported Dr. Xiong and his coauthors.

At baseline, black women were more likely to be at least 40 years of age than were whites, Hispanics, Asians, and Native Americans (10.3% vs. 7.4%, 6.3%, 6.7%, and 6.6%, respectively), more likely to be obese (14.6%, 7.5%, 7.5%, 3%, and 9.5%, respectively), and more likely to report a prior preterm birth (69% vs. 59%, 60%, 58%, and 55.4%, respectively).

Roughly 7% of blacks and Native Americans and 6% of Asians smoked, compared with nearly 10% of white and Hispanic mothers. The majority of all women (57%) had two fresh embryos transferred, and 63.5% reported no prior use of IVF/assisted reproductive technology, with rates comparable across racial groups.

Dr. Xiong and his coauthors reported no conflicts of interest.

MINNEAPOLIS – Black women who conceive using in vitro fertilization are at a markedly increased risk of any type of preterm birth, compared with other races, a retrospective cohort study indicates.

Hispanic women had a significantly lower rate of preterm births than did black women, and similar or slightly higher rates than did white women.

Native American women were not at an increased risk of any type of preterm birth, compared with whites, whereas Asians were at a reduced risk of preterm twin births.

"There exist notable racial and ethnic disparities in preterm births in infants conceived by IVF, with the highest rate in black women," Dr. Xu Xiong of the school of public health and tropical medicine at Tulane University in New Orleans reported at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Racial disparities in preterm birth may reflect biological differences resulting from genetic background or from variations in social demographics, socioeconomic status (SES), environmental exposures, lifestyles, cultural factors, and access to care and treatment, he said. SES factors (such as income, education, and occupation) were not available in the data set, although all of the women were able to finance expensive and time-consuming IVF treatment.

"In this study of relatively higher income women [who] conceived by IVF, our findings of an even greater difference in preterm births between black and white women than in the general population indicate that SES may not be as solely important a determinant for the racial gaps of preterm birth than previously postulated," Dr. Xiong said in an interview.

The investigators conducted a retrospective cohort study of 56,465 singleton and 23,748 twin pregnancies resulting from fresh nondonor IVF cycles in 82,519 women, using 2006-2008 data from the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System).

Among singleton births, 3.3% of black women had a very early preterm birth at less than 28 weeks, compared with 0.7% of white women, 1% of Hispanics, 0.7% of Asians, and 1% of Native Americans (P less than .05).

The pattern was similar for early preterm birth at less than 32 weeks (5.8% vs. 1.6%, 2.2%, 1.4%, and 1.4%, respectively), and for preterm birth at less than 37 weeks (13.3% vs. 6.6%, 8%, 6%, and 8%, respectively) (both P less than .05), Dr. Xiong reported.

In multivariate analysis with adjustment for confounding variables including maternal age; gravida status; smoking status; day of embryo transfer; number of embryos transferred; number of gestational sacs with heart rate; body mass index; prior spontaneous abortions; and infertility diagnosis, black women remained at significantly increased risk of very early preterm birth (odds ratio, 4.5), early preterm birth (OR, 3.7) and preterm birth (OR, 2.0), compared with white women (all P less than .05).

As expected, twin pregnancies increased preterm births for all groups, but once again, blacks had the highest rate of very early preterm birth at 7.7%, compared with 2.5% of whites, 3.7% of Hispanics, 2.3% of Asians, and 3% of Native Americans (P less than .05), he said.

Rates were also significantly higher for black women for early preterm twin birth (13.6% vs. 6.6%, 7%, 5.8%, and 5.8%, respectively) and for preterm twin birth (46.5% vs. 37.6%, 37.5%, 33%, and 41%, respectively; P less than .05).

In the adjusted analysis, black women delivering twins had a significantly increased risk of very early preterm twin births (OR, 3.3), early preterm birth (OR, 2.2) and preterm birth (OR, 1.4), compared with whites (P less than .05), reported Dr. Xiong and his coauthors.

At baseline, black women were more likely to be at least 40 years of age than were whites, Hispanics, Asians, and Native Americans (10.3% vs. 7.4%, 6.3%, 6.7%, and 6.6%, respectively), more likely to be obese (14.6%, 7.5%, 7.5%, 3%, and 9.5%, respectively), and more likely to report a prior preterm birth (69% vs. 59%, 60%, 58%, and 55.4%, respectively).

Roughly 7% of blacks and Native Americans and 6% of Asians smoked, compared with nearly 10% of white and Hispanic mothers. The majority of all women (57%) had two fresh embryos transferred, and 63.5% reported no prior use of IVF/assisted reproductive technology, with rates comparable across racial groups.

Dr. Xiong and his coauthors reported no conflicts of interest.

MINNEAPOLIS – Black women who conceive using in vitro fertilization are at a markedly increased risk of any type of preterm birth, compared with other races, a retrospective cohort study indicates.

Hispanic women had a significantly lower rate of preterm births than did black women, and similar or slightly higher rates than did white women.

Native American women were not at an increased risk of any type of preterm birth, compared with whites, whereas Asians were at a reduced risk of preterm twin births.

"There exist notable racial and ethnic disparities in preterm births in infants conceived by IVF, with the highest rate in black women," Dr. Xu Xiong of the school of public health and tropical medicine at Tulane University in New Orleans reported at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Racial disparities in preterm birth may reflect biological differences resulting from genetic background or from variations in social demographics, socioeconomic status (SES), environmental exposures, lifestyles, cultural factors, and access to care and treatment, he said. SES factors (such as income, education, and occupation) were not available in the data set, although all of the women were able to finance expensive and time-consuming IVF treatment.

"In this study of relatively higher income women [who] conceived by IVF, our findings of an even greater difference in preterm births between black and white women than in the general population indicate that SES may not be as solely important a determinant for the racial gaps of preterm birth than previously postulated," Dr. Xiong said in an interview.

The investigators conducted a retrospective cohort study of 56,465 singleton and 23,748 twin pregnancies resulting from fresh nondonor IVF cycles in 82,519 women, using 2006-2008 data from the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System).

Among singleton births, 3.3% of black women had a very early preterm birth at less than 28 weeks, compared with 0.7% of white women, 1% of Hispanics, 0.7% of Asians, and 1% of Native Americans (P less than .05).

The pattern was similar for early preterm birth at less than 32 weeks (5.8% vs. 1.6%, 2.2%, 1.4%, and 1.4%, respectively), and for preterm birth at less than 37 weeks (13.3% vs. 6.6%, 8%, 6%, and 8%, respectively) (both P less than .05), Dr. Xiong reported.

In multivariate analysis with adjustment for confounding variables including maternal age; gravida status; smoking status; day of embryo transfer; number of embryos transferred; number of gestational sacs with heart rate; body mass index; prior spontaneous abortions; and infertility diagnosis, black women remained at significantly increased risk of very early preterm birth (odds ratio, 4.5), early preterm birth (OR, 3.7) and preterm birth (OR, 2.0), compared with white women (all P less than .05).

As expected, twin pregnancies increased preterm births for all groups, but once again, blacks had the highest rate of very early preterm birth at 7.7%, compared with 2.5% of whites, 3.7% of Hispanics, 2.3% of Asians, and 3% of Native Americans (P less than .05), he said.

Rates were also significantly higher for black women for early preterm twin birth (13.6% vs. 6.6%, 7%, 5.8%, and 5.8%, respectively) and for preterm twin birth (46.5% vs. 37.6%, 37.5%, 33%, and 41%, respectively; P less than .05).

In the adjusted analysis, black women delivering twins had a significantly increased risk of very early preterm twin births (OR, 3.3), early preterm birth (OR, 2.2) and preterm birth (OR, 1.4), compared with whites (P less than .05), reported Dr. Xiong and his coauthors.

At baseline, black women were more likely to be at least 40 years of age than were whites, Hispanics, Asians, and Native Americans (10.3% vs. 7.4%, 6.3%, 6.7%, and 6.6%, respectively), more likely to be obese (14.6%, 7.5%, 7.5%, 3%, and 9.5%, respectively), and more likely to report a prior preterm birth (69% vs. 59%, 60%, 58%, and 55.4%, respectively).

Roughly 7% of blacks and Native Americans and 6% of Asians smoked, compared with nearly 10% of white and Hispanic mothers. The majority of all women (57%) had two fresh embryos transferred, and 63.5% reported no prior use of IVF/assisted reproductive technology, with rates comparable across racial groups.

Dr. Xiong and his coauthors reported no conflicts of interest.

MINNEAPOLIS – Evidence suggests that two novel fastidious bacteria linked to bacterial vaginosis are also associated with pelvic inflammatory disease.

Ureaplasma urealyticum biovar 2 (UU-2) and Leptotrichia sanguiengens/Leptotrichia amnionii (LS/LA) were significantly associated with PID after adjustment for age, race, chlamydia, and gonorrhea.

Ureaplasma parvum (UP), however, was not associated with PID in a substudy of women participating in the PEACH (PID Evaluation and Clinical Health) study.

Patrice Wendling/IMNG Medical Media

"This is the first study to demonstrate that [LS/LA] and UU-2, but not UP, are associated with PID," lead author Catherine Haggerty, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The results are consistent with studies showing that UU-2 is associated with nongonococcal urethritis in men, whereas UP is not. UU-2 and UP, also known as biovar 1, were recently designated as two distinct biovars. UP has not been consistently associated with bacterial vaginosis (BV) or PID.

The investigators used polymerase chain reaction (PCR) to measure select BV-associated, fastidious bacteria in cervical and endometrial specimens from 607 of 831 women recruited from emergency department and outpatient clinics during 1996-1999 for PEACH. The multicenter, randomized study compared the effectiveness of inpatient and outpatient treatment for PID.

The PEACH cohort was largely (75%) African-American, 40% were aged 20-24 years, half had an upper genital infection or inflammation, and 35% had gonorrhea or chlamydia.

Among the women in the subset, 22% had LS/LA only, 17% UP, 4% UU-2, 46% were coinfected with two or more bacteria, and 11% had no infection, said Dr. Haggerty, a reproductive epidemiologist with the University of Pittsburgh.

In adjusted logistic regression analysis, women who tested positive for LS/LA, UP, or UU-2 in the lower genital tract (cervix) were approximately 10, 13, and 20 times as likely, respectively, to test positive in the upper genital tract (endometrium).

Contamination during sampling is one possible explanation, but "still, the data provide intriguing evidence that there may be an upward transmission of these bacteria that may lead to the development of [PID]," she said.

Indeed, the likelihood of a woman having endometritis was significantly increased if she tested positive for UU-2 (adjusted odds ratio, 1.4) or LS/LA (OR, 2.2) in the endometrium, but not UP (OR, 0.8).

Among those women without gonorrheal or chlamydial infection, the risk of PID (histologically confirmed endometritis) was further increased with UU-2 (OR, 2.5) and LS/LA (OR, 2.7), but not UP (OR, 0.8).

The results may be important in guiding PID treatment, which currently consists of broad-spectrum antibiotics that may not target all the bacteria associated with the disorder, Dr. Haggerty said. UU-2 expresses tetracycline resistance in up to 45% of patients, while antimicrobial resistance to Leptotrichia is largely unknown because of the difficulty in culturing fastidious bacteria in vitro.

In addition, resistance to vaginal metronidazole has been reported among pregnant women with BV who carry the Leptotrichia or Sneathia species or BV-associated bacterium 1 (BVAB₁) (BMC Infect. Dis. 2009;9:89). Metronidazole is a mainstay of BV treatment, but the Centers for Disease Control and Prevention still lists it as optional for PID, despite the frequent coexistence of the two conditions, Dr. Haggerty said.

"Studies are needed to determine treatment of these bacteria in general, as well as among PID patients," she said.

During a discussion of the study, an audience member questioned whether PCR is taking over as the diagnostic criterion for PID because many of the bacteria cannot be identified without it. Dr. Haggerty replied that we are moving in that direction, as a result of the "landmark study" by Dr. David Fredricks et al., reporting high sensitivities and specificities for several bacteria or combinations of bacteria identified using targeted PCR versus the Amsel (clinical) or Nugent (Gram stain) criteria (J. Clin. Microbiol. 2007;45:3270-6).

Dr. Haggerty and her coauthors reported no conflicts of interest. The substudy was funded by the National Institutes of Health/National Institute of Allergy and Infectious Diseases. PEACH was funded by the Agency for Health Care Policy and Research, now known as the Agency for Healthcare Research and Quality.

MINNEAPOLIS – Evidence suggests that two novel fastidious bacteria linked to bacterial vaginosis are also associated with pelvic inflammatory disease.

Ureaplasma urealyticum biovar 2 (UU-2) and Leptotrichia sanguiengens/Leptotrichia amnionii (LS/LA) were significantly associated with PID after adjustment for age, race, chlamydia, and gonorrhea.

Ureaplasma parvum (UP), however, was not associated with PID in a substudy of women participating in the PEACH (PID Evaluation and Clinical Health) study.

Patrice Wendling/IMNG Medical Media

"This is the first study to demonstrate that [LS/LA] and UU-2, but not UP, are associated with PID," lead author Catherine Haggerty, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The results are consistent with studies showing that UU-2 is associated with nongonococcal urethritis in men, whereas UP is not. UU-2 and UP, also known as biovar 1, were recently designated as two distinct biovars. UP has not been consistently associated with bacterial vaginosis (BV) or PID.

The investigators used polymerase chain reaction (PCR) to measure select BV-associated, fastidious bacteria in cervical and endometrial specimens from 607 of 831 women recruited from emergency department and outpatient clinics during 1996-1999 for PEACH. The multicenter, randomized study compared the effectiveness of inpatient and outpatient treatment for PID.

The PEACH cohort was largely (75%) African-American, 40% were aged 20-24 years, half had an upper genital infection or inflammation, and 35% had gonorrhea or chlamydia.

Among the women in the subset, 22% had LS/LA only, 17% UP, 4% UU-2, 46% were coinfected with two or more bacteria, and 11% had no infection, said Dr. Haggerty, a reproductive epidemiologist with the University of Pittsburgh.

In adjusted logistic regression analysis, women who tested positive for LS/LA, UP, or UU-2 in the lower genital tract (cervix) were approximately 10, 13, and 20 times as likely, respectively, to test positive in the upper genital tract (endometrium).

Contamination during sampling is one possible explanation, but "still, the data provide intriguing evidence that there may be an upward transmission of these bacteria that may lead to the development of [PID]," she said.

Indeed, the likelihood of a woman having endometritis was significantly increased if she tested positive for UU-2 (adjusted odds ratio, 1.4) or LS/LA (OR, 2.2) in the endometrium, but not UP (OR, 0.8).

Among those women without gonorrheal or chlamydial infection, the risk of PID (histologically confirmed endometritis) was further increased with UU-2 (OR, 2.5) and LS/LA (OR, 2.7), but not UP (OR, 0.8).

The results may be important in guiding PID treatment, which currently consists of broad-spectrum antibiotics that may not target all the bacteria associated with the disorder, Dr. Haggerty said. UU-2 expresses tetracycline resistance in up to 45% of patients, while antimicrobial resistance to Leptotrichia is largely unknown because of the difficulty in culturing fastidious bacteria in vitro.

In addition, resistance to vaginal metronidazole has been reported among pregnant women with BV who carry the Leptotrichia or Sneathia species or BV-associated bacterium 1 (BVAB₁) (BMC Infect. Dis. 2009;9:89). Metronidazole is a mainstay of BV treatment, but the Centers for Disease Control and Prevention still lists it as optional for PID, despite the frequent coexistence of the two conditions, Dr. Haggerty said.

"Studies are needed to determine treatment of these bacteria in general, as well as among PID patients," she said.

During a discussion of the study, an audience member questioned whether PCR is taking over as the diagnostic criterion for PID because many of the bacteria cannot be identified without it. Dr. Haggerty replied that we are moving in that direction, as a result of the "landmark study" by Dr. David Fredricks et al., reporting high sensitivities and specificities for several bacteria or combinations of bacteria identified using targeted PCR versus the Amsel (clinical) or Nugent (Gram stain) criteria (J. Clin. Microbiol. 2007;45:3270-6).

Dr. Haggerty and her coauthors reported no conflicts of interest. The substudy was funded by the National Institutes of Health/National Institute of Allergy and Infectious Diseases. PEACH was funded by the Agency for Health Care Policy and Research, now known as the Agency for Healthcare Research and Quality.

MINNEAPOLIS – Evidence suggests that two novel fastidious bacteria linked to bacterial vaginosis are also associated with pelvic inflammatory disease.

Ureaplasma urealyticum biovar 2 (UU-2) and Leptotrichia sanguiengens/Leptotrichia amnionii (LS/LA) were significantly associated with PID after adjustment for age, race, chlamydia, and gonorrhea.

Ureaplasma parvum (UP), however, was not associated with PID in a substudy of women participating in the PEACH (PID Evaluation and Clinical Health) study.

Patrice Wendling/IMNG Medical Media

"This is the first study to demonstrate that [LS/LA] and UU-2, but not UP, are associated with PID," lead author Catherine Haggerty, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The results are consistent with studies showing that UU-2 is associated with nongonococcal urethritis in men, whereas UP is not. UU-2 and UP, also known as biovar 1, were recently designated as two distinct biovars. UP has not been consistently associated with bacterial vaginosis (BV) or PID.

The investigators used polymerase chain reaction (PCR) to measure select BV-associated, fastidious bacteria in cervical and endometrial specimens from 607 of 831 women recruited from emergency department and outpatient clinics during 1996-1999 for PEACH. The multicenter, randomized study compared the effectiveness of inpatient and outpatient treatment for PID.

The PEACH cohort was largely (75%) African-American, 40% were aged 20-24 years, half had an upper genital infection or inflammation, and 35% had gonorrhea or chlamydia.

Among the women in the subset, 22% had LS/LA only, 17% UP, 4% UU-2, 46% were coinfected with two or more bacteria, and 11% had no infection, said Dr. Haggerty, a reproductive epidemiologist with the University of Pittsburgh.

In adjusted logistic regression analysis, women who tested positive for LS/LA, UP, or UU-2 in the lower genital tract (cervix) were approximately 10, 13, and 20 times as likely, respectively, to test positive in the upper genital tract (endometrium).

Contamination during sampling is one possible explanation, but "still, the data provide intriguing evidence that there may be an upward transmission of these bacteria that may lead to the development of [PID]," she said.

Indeed, the likelihood of a woman having endometritis was significantly increased if she tested positive for UU-2 (adjusted odds ratio, 1.4) or LS/LA (OR, 2.2) in the endometrium, but not UP (OR, 0.8).

Among those women without gonorrheal or chlamydial infection, the risk of PID (histologically confirmed endometritis) was further increased with UU-2 (OR, 2.5) and LS/LA (OR, 2.7), but not UP (OR, 0.8).

The results may be important in guiding PID treatment, which currently consists of broad-spectrum antibiotics that may not target all the bacteria associated with the disorder, Dr. Haggerty said. UU-2 expresses tetracycline resistance in up to 45% of patients, while antimicrobial resistance to Leptotrichia is largely unknown because of the difficulty in culturing fastidious bacteria in vitro.

In addition, resistance to vaginal metronidazole has been reported among pregnant women with BV who carry the Leptotrichia or Sneathia species or BV-associated bacterium 1 (BVAB₁) (BMC Infect. Dis. 2009;9:89). Metronidazole is a mainstay of BV treatment, but the Centers for Disease Control and Prevention still lists it as optional for PID, despite the frequent coexistence of the two conditions, Dr. Haggerty said.

"Studies are needed to determine treatment of these bacteria in general, as well as among PID patients," she said.

During a discussion of the study, an audience member questioned whether PCR is taking over as the diagnostic criterion for PID because many of the bacteria cannot be identified without it. Dr. Haggerty replied that we are moving in that direction, as a result of the "landmark study" by Dr. David Fredricks et al., reporting high sensitivities and specificities for several bacteria or combinations of bacteria identified using targeted PCR versus the Amsel (clinical) or Nugent (Gram stain) criteria (J. Clin. Microbiol. 2007;45:3270-6).

Dr. Haggerty and her coauthors reported no conflicts of interest. The substudy was funded by the National Institutes of Health/National Institute of Allergy and Infectious Diseases. PEACH was funded by the Agency for Health Care Policy and Research, now known as the Agency for Healthcare Research and Quality.

MINNEAPOLIS – Young black women who are obese or heavy through the hips were less likely to become pregnant, according to a substudy of the ongoing, prospective Black Women’s Health Study.

Fecundity was significantly reduced in a dose-response fashion for women who were overweight (fecundity ratio, 0.89), obese (FR, 0.75) and very obese (FR, 0.68) after adjustment for age, education, smoking history, alcohol intake, physical activity, parity, region, and waist-to-hip ratio.

Patrice Wendling/IMNG Medical Media

A large waist-to-hip ratio (defined as 0.8 or greater), also was significantly associated with lower fecundity (FR, 0.73), with fecundity ratios less than 1 indicating reduced fecundity or longer time to pregnancy (TTP).

"Overall and central adiposity are associated with reduced fecundability in black women," Lauren Wise, Sc.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The substudy is the first TTP study in black women, and its results largely agree with previous studies consistently linking high body mass index and reduced fertility in white women.

Little is known about the determinants of fertility in black women, who are disproportionately affected by the obesity epidemic in the United States. Studies of central adiposity and fertility in whites have been inconclusive, with some suggesting that adiposity may interfere with estrogen metabolism, increase insulin resistance, and change the quality and pH of cervical mucus, said Dr. Wise of the Slone Epidemiology Center at Boston University.

The substudy cohort was drawn from 59,000 women in the Black Women’s Health Study, the largest study of U.S. black women’s health yet conducted and now in its 17th year of follow-up. A total of 15,500 women completed a Web-based survey in 2011 reporting the TTP for each planned pregnancy. There were 10,272 births, of which only 4,315 births (43%) were planned. The researchers excluded both the unplanned pregnancies and women who had incomplete data, a history of infertility, and age older than 40 years either in 1995 or while they attempted pregnancy; the final sample included 2,084 births and 209 unsuccessful pregnancy attempts among 1,706 women, aged 21-40 years.

The average age was 34 years for all BMI groups including those classified as overweight (BMI, 25-29 kg/m²), obese (BMI, 30-34) and very obese (BMI, 35 or greater).

BMI was inversely associated with education and vigorous exercise, and was positively associated with waist-to-hip ratio, waist circumference, and current smoking status, reported Dr. Wise and her colleagues.

After adjusting for all previous covariates plus BMI, researchers found that a waist circumference of 33-35 inches – but not beyond – was significantly associated with lower fecundity.

Fecundity was not lower in women who were underweight (BMI less than 18.5; FR, 1.11).

During a discussion of the results, one attendee pointed out that asking participants about marital status, which the investigators did, is not the same as asking about relationship status or frequency of intercourse.

Another audience member observed that male obesity is proving to be just as important as female obesity in terms of a couple’s inability to conceive.

Indeed, a recent systematic review involving 14 studies and 9,779 men reported that overweight and obese men are at increased risk of oligozoospermia or azoospermia, compared with normal-weight men (Arch. Intern. Med. 2012;172:440-2). Possible hypotheses for this relationship include hypogonadotropic hyperestrogenic hypogonadism due to aromatization of steroids in estrogens in peripheral tissue; direct alterations of spermatogenesis and Sertoli cell function; hip, abdominal and scrotal fat-tissue accumulation, leading to increased scrotal temperature; and accumulation of toxins and liposoluble endocrine disruptors in fatty tissue.

The analysis and the Black Women’s Health Study are sponsored by the National Institutes of Health. Dr. Wise and her coauthors reported no disclosures.

MINNEAPOLIS – Young black women who are obese or heavy through the hips were less likely to become pregnant, according to a substudy of the ongoing, prospective Black Women’s Health Study.

Fecundity was significantly reduced in a dose-response fashion for women who were overweight (fecundity ratio, 0.89), obese (FR, 0.75) and very obese (FR, 0.68) after adjustment for age, education, smoking history, alcohol intake, physical activity, parity, region, and waist-to-hip ratio.

Patrice Wendling/IMNG Medical Media

A large waist-to-hip ratio (defined as 0.8 or greater), also was significantly associated with lower fecundity (FR, 0.73), with fecundity ratios less than 1 indicating reduced fecundity or longer time to pregnancy (TTP).

"Overall and central adiposity are associated with reduced fecundability in black women," Lauren Wise, Sc.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The substudy is the first TTP study in black women, and its results largely agree with previous studies consistently linking high body mass index and reduced fertility in white women.

Little is known about the determinants of fertility in black women, who are disproportionately affected by the obesity epidemic in the United States. Studies of central adiposity and fertility in whites have been inconclusive, with some suggesting that adiposity may interfere with estrogen metabolism, increase insulin resistance, and change the quality and pH of cervical mucus, said Dr. Wise of the Slone Epidemiology Center at Boston University.

The substudy cohort was drawn from 59,000 women in the Black Women’s Health Study, the largest study of U.S. black women’s health yet conducted and now in its 17th year of follow-up. A total of 15,500 women completed a Web-based survey in 2011 reporting the TTP for each planned pregnancy. There were 10,272 births, of which only 4,315 births (43%) were planned. The researchers excluded both the unplanned pregnancies and women who had incomplete data, a history of infertility, and age older than 40 years either in 1995 or while they attempted pregnancy; the final sample included 2,084 births and 209 unsuccessful pregnancy attempts among 1,706 women, aged 21-40 years.

The average age was 34 years for all BMI groups including those classified as overweight (BMI, 25-29 kg/m²), obese (BMI, 30-34) and very obese (BMI, 35 or greater).

BMI was inversely associated with education and vigorous exercise, and was positively associated with waist-to-hip ratio, waist circumference, and current smoking status, reported Dr. Wise and her colleagues.

After adjusting for all previous covariates plus BMI, researchers found that a waist circumference of 33-35 inches – but not beyond – was significantly associated with lower fecundity.

Fecundity was not lower in women who were underweight (BMI less than 18.5; FR, 1.11).

During a discussion of the results, one attendee pointed out that asking participants about marital status, which the investigators did, is not the same as asking about relationship status or frequency of intercourse.

Another audience member observed that male obesity is proving to be just as important as female obesity in terms of a couple’s inability to conceive.

Indeed, a recent systematic review involving 14 studies and 9,779 men reported that overweight and obese men are at increased risk of oligozoospermia or azoospermia, compared with normal-weight men (Arch. Intern. Med. 2012;172:440-2). Possible hypotheses for this relationship include hypogonadotropic hyperestrogenic hypogonadism due to aromatization of steroids in estrogens in peripheral tissue; direct alterations of spermatogenesis and Sertoli cell function; hip, abdominal and scrotal fat-tissue accumulation, leading to increased scrotal temperature; and accumulation of toxins and liposoluble endocrine disruptors in fatty tissue.

The analysis and the Black Women’s Health Study are sponsored by the National Institutes of Health. Dr. Wise and her coauthors reported no disclosures.

MINNEAPOLIS – Young black women who are obese or heavy through the hips were less likely to become pregnant, according to a substudy of the ongoing, prospective Black Women’s Health Study.

Fecundity was significantly reduced in a dose-response fashion for women who were overweight (fecundity ratio, 0.89), obese (FR, 0.75) and very obese (FR, 0.68) after adjustment for age, education, smoking history, alcohol intake, physical activity, parity, region, and waist-to-hip ratio.

Patrice Wendling/IMNG Medical Media

A large waist-to-hip ratio (defined as 0.8 or greater), also was significantly associated with lower fecundity (FR, 0.73), with fecundity ratios less than 1 indicating reduced fecundity or longer time to pregnancy (TTP).

"Overall and central adiposity are associated with reduced fecundability in black women," Lauren Wise, Sc.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The substudy is the first TTP study in black women, and its results largely agree with previous studies consistently linking high body mass index and reduced fertility in white women.

Little is known about the determinants of fertility in black women, who are disproportionately affected by the obesity epidemic in the United States. Studies of central adiposity and fertility in whites have been inconclusive, with some suggesting that adiposity may interfere with estrogen metabolism, increase insulin resistance, and change the quality and pH of cervical mucus, said Dr. Wise of the Slone Epidemiology Center at Boston University.

The substudy cohort was drawn from 59,000 women in the Black Women’s Health Study, the largest study of U.S. black women’s health yet conducted and now in its 17th year of follow-up. A total of 15,500 women completed a Web-based survey in 2011 reporting the TTP for each planned pregnancy. There were 10,272 births, of which only 4,315 births (43%) were planned. The researchers excluded both the unplanned pregnancies and women who had incomplete data, a history of infertility, and age older than 40 years either in 1995 or while they attempted pregnancy; the final sample included 2,084 births and 209 unsuccessful pregnancy attempts among 1,706 women, aged 21-40 years.

The average age was 34 years for all BMI groups including those classified as overweight (BMI, 25-29 kg/m²), obese (BMI, 30-34) and very obese (BMI, 35 or greater).

BMI was inversely associated with education and vigorous exercise, and was positively associated with waist-to-hip ratio, waist circumference, and current smoking status, reported Dr. Wise and her colleagues.

After adjusting for all previous covariates plus BMI, researchers found that a waist circumference of 33-35 inches – but not beyond – was significantly associated with lower fecundity.

Fecundity was not lower in women who were underweight (BMI less than 18.5; FR, 1.11).

During a discussion of the results, one attendee pointed out that asking participants about marital status, which the investigators did, is not the same as asking about relationship status or frequency of intercourse.

Another audience member observed that male obesity is proving to be just as important as female obesity in terms of a couple’s inability to conceive.

Indeed, a recent systematic review involving 14 studies and 9,779 men reported that overweight and obese men are at increased risk of oligozoospermia or azoospermia, compared with normal-weight men (Arch. Intern. Med. 2012;172:440-2). Possible hypotheses for this relationship include hypogonadotropic hyperestrogenic hypogonadism due to aromatization of steroids in estrogens in peripheral tissue; direct alterations of spermatogenesis and Sertoli cell function; hip, abdominal and scrotal fat-tissue accumulation, leading to increased scrotal temperature; and accumulation of toxins and liposoluble endocrine disruptors in fatty tissue.

The analysis and the Black Women’s Health Study are sponsored by the National Institutes of Health. Dr. Wise and her coauthors reported no disclosures.

MINNEAPOLIS – Prenatal exposure to traffic-related toxins may increase the risk for Wilms tumor, the most common form of childhood kidney cancer, the results of a study suggest.

Furthermore, findings suggest that different toxins may be potent at different pregnancy periods, Anshu Shrestha reported in a poster presentation at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The main culprits – formaldehyde, lead, and chromium VI – all have been shown to increase the risk of kidney cancer in adults, but little is known about their relationship to childhood renal cancers.

Wilms tumor occurs in 1 in 200,000-250,000 children, typically striking at about 3 years and rarely developing after age 8 years. The cure rate is about 90%, if the tumor has not metastasized.

The population-based, case-control study included 84 children in the California Cancer Registry who were aged 5 years and younger at the time of diagnosis with Wilms tumor, and 25,222 controls who were randomly selected from a birth registry and matched by birth year. Cases and controls lived within a 5-mile radius of a California Air Resources Board monitoring site, which measures 24-hour averages of air toxic concentrations every 12 days. Trimester-specific averages were calculated for 20 air toxins that were selected for carcinogenic property and sufficient sample size. Logistic regression analysis was adjusted for birth year, maternal age, maternal race/ethnicity and census-based socioeconomic status.

Third-trimester exposure to formaldehyde increased the risk of Wilms tumor by nearly 1.5-fold (odds ratio, 1.43), said Ms. Shrestha, an epidemiology doctoral student at the school of public health, University of California, Los Angeles.

Exposure to chromium VI in the first trimester and to lead in the second trimester also increased the odds of Wilms tumor, although to a lesser degree (OR, 1.10 and 1.27).

Positive associations were suggested for first-trimester exposure to lead, selenium, and benzene, but not for 1,3-butadiene, styrene, and ortho-dichlorobenzene.

Ms. Shrestha said that the data are preliminary and require more work to confirm that they are not due to chance alone.

Nearly half (47.6%) of the cases were Hispanic, 52.4% lived at the two lowest socioeconomic levels, and 55% had mothers aged 20-29 years at the time of their birth. Only 10.7% of cases lived at the highest socioeconomic level (defined by a combination of seven census indicators, including education and median household income).

The study was supported by grants from the National Institute of Environmental Health Sciences. Ms. Shrestha did not provide conflict of interest information.

MINNEAPOLIS – Prenatal exposure to traffic-related toxins may increase the risk for Wilms tumor, the most common form of childhood kidney cancer, the results of a study suggest.

Furthermore, findings suggest that different toxins may be potent at different pregnancy periods, Anshu Shrestha reported in a poster presentation at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The main culprits – formaldehyde, lead, and chromium VI – all have been shown to increase the risk of kidney cancer in adults, but little is known about their relationship to childhood renal cancers.

Wilms tumor occurs in 1 in 200,000-250,000 children, typically striking at about 3 years and rarely developing after age 8 years. The cure rate is about 90%, if the tumor has not metastasized.

The population-based, case-control study included 84 children in the California Cancer Registry who were aged 5 years and younger at the time of diagnosis with Wilms tumor, and 25,222 controls who were randomly selected from a birth registry and matched by birth year. Cases and controls lived within a 5-mile radius of a California Air Resources Board monitoring site, which measures 24-hour averages of air toxic concentrations every 12 days. Trimester-specific averages were calculated for 20 air toxins that were selected for carcinogenic property and sufficient sample size. Logistic regression analysis was adjusted for birth year, maternal age, maternal race/ethnicity and census-based socioeconomic status.

Third-trimester exposure to formaldehyde increased the risk of Wilms tumor by nearly 1.5-fold (odds ratio, 1.43), said Ms. Shrestha, an epidemiology doctoral student at the school of public health, University of California, Los Angeles.

Exposure to chromium VI in the first trimester and to lead in the second trimester also increased the odds of Wilms tumor, although to a lesser degree (OR, 1.10 and 1.27).

Positive associations were suggested for first-trimester exposure to lead, selenium, and benzene, but not for 1,3-butadiene, styrene, and ortho-dichlorobenzene.

Ms. Shrestha said that the data are preliminary and require more work to confirm that they are not due to chance alone.

Nearly half (47.6%) of the cases were Hispanic, 52.4% lived at the two lowest socioeconomic levels, and 55% had mothers aged 20-29 years at the time of their birth. Only 10.7% of cases lived at the highest socioeconomic level (defined by a combination of seven census indicators, including education and median household income).

The study was supported by grants from the National Institute of Environmental Health Sciences. Ms. Shrestha did not provide conflict of interest information.

MINNEAPOLIS – Prenatal exposure to traffic-related toxins may increase the risk for Wilms tumor, the most common form of childhood kidney cancer, the results of a study suggest.

Furthermore, findings suggest that different toxins may be potent at different pregnancy periods, Anshu Shrestha reported in a poster presentation at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The main culprits – formaldehyde, lead, and chromium VI – all have been shown to increase the risk of kidney cancer in adults, but little is known about their relationship to childhood renal cancers.

Wilms tumor occurs in 1 in 200,000-250,000 children, typically striking at about 3 years and rarely developing after age 8 years. The cure rate is about 90%, if the tumor has not metastasized.

The population-based, case-control study included 84 children in the California Cancer Registry who were aged 5 years and younger at the time of diagnosis with Wilms tumor, and 25,222 controls who were randomly selected from a birth registry and matched by birth year. Cases and controls lived within a 5-mile radius of a California Air Resources Board monitoring site, which measures 24-hour averages of air toxic concentrations every 12 days. Trimester-specific averages were calculated for 20 air toxins that were selected for carcinogenic property and sufficient sample size. Logistic regression analysis was adjusted for birth year, maternal age, maternal race/ethnicity and census-based socioeconomic status.

Third-trimester exposure to formaldehyde increased the risk of Wilms tumor by nearly 1.5-fold (odds ratio, 1.43), said Ms. Shrestha, an epidemiology doctoral student at the school of public health, University of California, Los Angeles.

Exposure to chromium VI in the first trimester and to lead in the second trimester also increased the odds of Wilms tumor, although to a lesser degree (OR, 1.10 and 1.27).

Positive associations were suggested for first-trimester exposure to lead, selenium, and benzene, but not for 1,3-butadiene, styrene, and ortho-dichlorobenzene.

Ms. Shrestha said that the data are preliminary and require more work to confirm that they are not due to chance alone.

Nearly half (47.6%) of the cases were Hispanic, 52.4% lived at the two lowest socioeconomic levels, and 55% had mothers aged 20-29 years at the time of their birth. Only 10.7% of cases lived at the highest socioeconomic level (defined by a combination of seven census indicators, including education and median household income).

The study was supported by grants from the National Institute of Environmental Health Sciences. Ms. Shrestha did not provide conflict of interest information.

MINNEAPOLIS – Increased levels of the stress biomarker alpha-amylase, but not cortisol, are significantly associated with a lower chance of conception, a couple-based, prospective study has shown.

The odds of pregnancy were slashed 31% for women whose salivary levels of alpha-amylase were in the highest tertile, compared with women whose levels were in the lowest tertile after adjustment for such important confounders as the difference between partners’ ages, intercourse during the fertile window and the woman’s age, income, race, parity, smoking, caffeine intake, and alcohol use (odds ratio, 0.69).

Patrice Wendling/IMNG Medical Media

This study is the first in the United States to prospectively examine the association between physiologic stress and fecundity among couples trying to conceive, lead author Courtney D. Lynch, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

"We previously published similar results in a population in the U.K., and we were quite astounded that we found exactly the same thing," she said.

In that study (Fertil. Steril. 2011;95:2184-9), alpha-amylase was negatively associated with fecundity in the first cycle of attempting pregnancy (OR, 0.85) after adjustment for the couples’ age, intercourse frequency during the fertile window, and female alcohol use.

The current analysis was based on 501 couples in Michigan and Texas who were attempting pregnancy and were followed for up to 12 months and then through pregnancy, if pregnancy occurred, as part of the LIFE (Longitudinal Investigation of Fertility and the Environment) study. Cortisol and alpha-amylase concentrations were determined by enzyme immunoassay from salivary samples collected by the women on the day following enrollment and the day following the start of their first menses in the study.

The women, aged 18-40 years, were mostly white (78%), college graduates (75%), and nonsmokers (73%). Their mean age was 30 years, 53% were nulliparous, and 55% were overweight or obese.

Of the 401 couples who completed the protocol, 87% achieved pregnancy and 13% did not.

Complete data evaluable on 393 couples showed no significant differences between women who did or did not become pregnant in mean levels of cortisol (0.46 μg/dL vs. 0.36 μg/dL) or alpha-amylase (23.6 U/mL vs. 32.0 U/mL), said Dr. Lynch, an epidemiologist at Ohio State University in Columbus.

The adjusted odds of pregnancy were similar for women with salivary cortisol in the lowest tertile (0.02-0.30 μg/dL; OR, 1.0), middle tertile (0.31-0.42 μg/dL; OR, 0.90), or highest tertile (0.43-15.60 μg/dL; OR, 0.91).

The adjusted odds of pregnancy were significantly diminished, however, for women with alpha-amylase levels in the middle (10.5-23.6 U/mL; OR, 0.89) or highest tertile (23.7-379.0 U/mL; OR, 0.69), compared with the lowest tertile (0.4-10.4 U/mL; OR, 1.0), she said.

The investigators also used Bayesian statistical techniques to identify the fertile window and estimate day-specific probabilities of conception, taking into account the relevant covariates. Based on this analysis, the probability of pregnancy on day 1 of the fertility window for a 30-year-old, nonsmoking white woman with a partner 2 years older than she and all other covariates centered at the mean, was 26% for women in the lowest alpha-amylase tertile, 24% in the middle tertile, and 20% in the highest tertile, Dr. Lynch said.

The results of a similar analysis in the U.K. cohort showed that conception probabilities increased with increasing quartiles of cortisol for each day during the fertile window, but that the opposite was true for alpha-amylase, as increasing quartiles reduced all day-specific probabilities of conception. The opposing direction of fecundity odds ratios provides evidence that the reduction in fecundity associated with alpha-amylase was mediated via the sympathetic nervous system rather than through the hypothalamic-pituitary-adrenal axis, Dr. Lynch said.

Although the U.S. analysis could not assess the effect of stress over time with only two salivary samples, the data lend further support to the existence and directionality of the stress and fecundity association, she said.

Despite a plethora of evidence that stress negatively impacts pregnancy outcomes, empiric data on stress and conception are surprisingly sparse. A small prospective Australian study involving 13 women found no significant difference in urinary epinephrine, norepinephrine, or cortisol concentrations between conception and nonconception cycles (Hum. Reprod. 1997;12:2324-9).

A newly published study by Dr. Lynch and her colleagues also found no association between self-reported stress, anxiety and depression, and pregnancy after several confounders were controlled for in 339 women, aged 18-40, attempting to conceive (Fertil. Steril. 2012 June 13 [epub ahead of print]).

When asked by the audience how her two studies could come to such different conclusions, Dr. Lynch replied that "when you ask people if they are stressed, if people are chronically stressed they’re not going to perceive this day as any worse than another day in their situation, but that doesn’t mean the body doesn’t respond."

Indeed, the U.K. investigators concluded that alpha-amylase, the principal salivary protein secreted from the parotid gland, may be a "novel biomarker for assessing psychosocial stressors and reproductive end points, as mediated via the sympathetic nervous system." They pointed out that because alpha-amylase is produced locally in the oral cavity, it remains in relatively high concentrations compared with other salivary markers such as cortisol that is released elsewhere in the body by the adrenal gland and transported to the saliva via ultrafiltration.

Dr. Lynch and her colleagues reported no relevant financial disclosures.

MINNEAPOLIS – Increased levels of the stress biomarker alpha-amylase, but not cortisol, are significantly associated with a lower chance of conception, a couple-based, prospective study has shown.

The odds of pregnancy were slashed 31% for women whose salivary levels of alpha-amylase were in the highest tertile, compared with women whose levels were in the lowest tertile after adjustment for such important confounders as the difference between partners’ ages, intercourse during the fertile window and the woman’s age, income, race, parity, smoking, caffeine intake, and alcohol use (odds ratio, 0.69).

Patrice Wendling/IMNG Medical Media

This study is the first in the United States to prospectively examine the association between physiologic stress and fecundity among couples trying to conceive, lead author Courtney D. Lynch, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

"We previously published similar results in a population in the U.K., and we were quite astounded that we found exactly the same thing," she said.

In that study (Fertil. Steril. 2011;95:2184-9), alpha-amylase was negatively associated with fecundity in the first cycle of attempting pregnancy (OR, 0.85) after adjustment for the couples’ age, intercourse frequency during the fertile window, and female alcohol use.

The current analysis was based on 501 couples in Michigan and Texas who were attempting pregnancy and were followed for up to 12 months and then through pregnancy, if pregnancy occurred, as part of the LIFE (Longitudinal Investigation of Fertility and the Environment) study. Cortisol and alpha-amylase concentrations were determined by enzyme immunoassay from salivary samples collected by the women on the day following enrollment and the day following the start of their first menses in the study.

The women, aged 18-40 years, were mostly white (78%), college graduates (75%), and nonsmokers (73%). Their mean age was 30 years, 53% were nulliparous, and 55% were overweight or obese.

Of the 401 couples who completed the protocol, 87% achieved pregnancy and 13% did not.

Complete data evaluable on 393 couples showed no significant differences between women who did or did not become pregnant in mean levels of cortisol (0.46 μg/dL vs. 0.36 μg/dL) or alpha-amylase (23.6 U/mL vs. 32.0 U/mL), said Dr. Lynch, an epidemiologist at Ohio State University in Columbus.

The adjusted odds of pregnancy were similar for women with salivary cortisol in the lowest tertile (0.02-0.30 μg/dL; OR, 1.0), middle tertile (0.31-0.42 μg/dL; OR, 0.90), or highest tertile (0.43-15.60 μg/dL; OR, 0.91).

The adjusted odds of pregnancy were significantly diminished, however, for women with alpha-amylase levels in the middle (10.5-23.6 U/mL; OR, 0.89) or highest tertile (23.7-379.0 U/mL; OR, 0.69), compared with the lowest tertile (0.4-10.4 U/mL; OR, 1.0), she said.

The investigators also used Bayesian statistical techniques to identify the fertile window and estimate day-specific probabilities of conception, taking into account the relevant covariates. Based on this analysis, the probability of pregnancy on day 1 of the fertility window for a 30-year-old, nonsmoking white woman with a partner 2 years older than she and all other covariates centered at the mean, was 26% for women in the lowest alpha-amylase tertile, 24% in the middle tertile, and 20% in the highest tertile, Dr. Lynch said.

The results of a similar analysis in the U.K. cohort showed that conception probabilities increased with increasing quartiles of cortisol for each day during the fertile window, but that the opposite was true for alpha-amylase, as increasing quartiles reduced all day-specific probabilities of conception. The opposing direction of fecundity odds ratios provides evidence that the reduction in fecundity associated with alpha-amylase was mediated via the sympathetic nervous system rather than through the hypothalamic-pituitary-adrenal axis, Dr. Lynch said.

Although the U.S. analysis could not assess the effect of stress over time with only two salivary samples, the data lend further support to the existence and directionality of the stress and fecundity association, she said.

Despite a plethora of evidence that stress negatively impacts pregnancy outcomes, empiric data on stress and conception are surprisingly sparse. A small prospective Australian study involving 13 women found no significant difference in urinary epinephrine, norepinephrine, or cortisol concentrations between conception and nonconception cycles (Hum. Reprod. 1997;12:2324-9).

A newly published study by Dr. Lynch and her colleagues also found no association between self-reported stress, anxiety and depression, and pregnancy after several confounders were controlled for in 339 women, aged 18-40, attempting to conceive (Fertil. Steril. 2012 June 13 [epub ahead of print]).

When asked by the audience how her two studies could come to such different conclusions, Dr. Lynch replied that "when you ask people if they are stressed, if people are chronically stressed they’re not going to perceive this day as any worse than another day in their situation, but that doesn’t mean the body doesn’t respond."

Indeed, the U.K. investigators concluded that alpha-amylase, the principal salivary protein secreted from the parotid gland, may be a "novel biomarker for assessing psychosocial stressors and reproductive end points, as mediated via the sympathetic nervous system." They pointed out that because alpha-amylase is produced locally in the oral cavity, it remains in relatively high concentrations compared with other salivary markers such as cortisol that is released elsewhere in the body by the adrenal gland and transported to the saliva via ultrafiltration.

Dr. Lynch and her colleagues reported no relevant financial disclosures.

MINNEAPOLIS – Increased levels of the stress biomarker alpha-amylase, but not cortisol, are significantly associated with a lower chance of conception, a couple-based, prospective study has shown.

The odds of pregnancy were slashed 31% for women whose salivary levels of alpha-amylase were in the highest tertile, compared with women whose levels were in the lowest tertile after adjustment for such important confounders as the difference between partners’ ages, intercourse during the fertile window and the woman’s age, income, race, parity, smoking, caffeine intake, and alcohol use (odds ratio, 0.69).

Patrice Wendling/IMNG Medical Media

This study is the first in the United States to prospectively examine the association between physiologic stress and fecundity among couples trying to conceive, lead author Courtney D. Lynch, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

"We previously published similar results in a population in the U.K., and we were quite astounded that we found exactly the same thing," she said.

In that study (Fertil. Steril. 2011;95:2184-9), alpha-amylase was negatively associated with fecundity in the first cycle of attempting pregnancy (OR, 0.85) after adjustment for the couples’ age, intercourse frequency during the fertile window, and female alcohol use.

The current analysis was based on 501 couples in Michigan and Texas who were attempting pregnancy and were followed for up to 12 months and then through pregnancy, if pregnancy occurred, as part of the LIFE (Longitudinal Investigation of Fertility and the Environment) study. Cortisol and alpha-amylase concentrations were determined by enzyme immunoassay from salivary samples collected by the women on the day following enrollment and the day following the start of their first menses in the study.

The women, aged 18-40 years, were mostly white (78%), college graduates (75%), and nonsmokers (73%). Their mean age was 30 years, 53% were nulliparous, and 55% were overweight or obese.

Of the 401 couples who completed the protocol, 87% achieved pregnancy and 13% did not.

Complete data evaluable on 393 couples showed no significant differences between women who did or did not become pregnant in mean levels of cortisol (0.46 μg/dL vs. 0.36 μg/dL) or alpha-amylase (23.6 U/mL vs. 32.0 U/mL), said Dr. Lynch, an epidemiologist at Ohio State University in Columbus.

The adjusted odds of pregnancy were similar for women with salivary cortisol in the lowest tertile (0.02-0.30 μg/dL; OR, 1.0), middle tertile (0.31-0.42 μg/dL; OR, 0.90), or highest tertile (0.43-15.60 μg/dL; OR, 0.91).

The adjusted odds of pregnancy were significantly diminished, however, for women with alpha-amylase levels in the middle (10.5-23.6 U/mL; OR, 0.89) or highest tertile (23.7-379.0 U/mL; OR, 0.69), compared with the lowest tertile (0.4-10.4 U/mL; OR, 1.0), she said.

The investigators also used Bayesian statistical techniques to identify the fertile window and estimate day-specific probabilities of conception, taking into account the relevant covariates. Based on this analysis, the probability of pregnancy on day 1 of the fertility window for a 30-year-old, nonsmoking white woman with a partner 2 years older than she and all other covariates centered at the mean, was 26% for women in the lowest alpha-amylase tertile, 24% in the middle tertile, and 20% in the highest tertile, Dr. Lynch said.

The results of a similar analysis in the U.K. cohort showed that conception probabilities increased with increasing quartiles of cortisol for each day during the fertile window, but that the opposite was true for alpha-amylase, as increasing quartiles reduced all day-specific probabilities of conception. The opposing direction of fecundity odds ratios provides evidence that the reduction in fecundity associated with alpha-amylase was mediated via the sympathetic nervous system rather than through the hypothalamic-pituitary-adrenal axis, Dr. Lynch said.

Although the U.S. analysis could not assess the effect of stress over time with only two salivary samples, the data lend further support to the existence and directionality of the stress and fecundity association, she said.

Despite a plethora of evidence that stress negatively impacts pregnancy outcomes, empiric data on stress and conception are surprisingly sparse. A small prospective Australian study involving 13 women found no significant difference in urinary epinephrine, norepinephrine, or cortisol concentrations between conception and nonconception cycles (Hum. Reprod. 1997;12:2324-9).

A newly published study by Dr. Lynch and her colleagues also found no association between self-reported stress, anxiety and depression, and pregnancy after several confounders were controlled for in 339 women, aged 18-40, attempting to conceive (Fertil. Steril. 2012 June 13 [epub ahead of print]).

When asked by the audience how her two studies could come to such different conclusions, Dr. Lynch replied that "when you ask people if they are stressed, if people are chronically stressed they’re not going to perceive this day as any worse than another day in their situation, but that doesn’t mean the body doesn’t respond."

Indeed, the U.K. investigators concluded that alpha-amylase, the principal salivary protein secreted from the parotid gland, may be a "novel biomarker for assessing psychosocial stressors and reproductive end points, as mediated via the sympathetic nervous system." They pointed out that because alpha-amylase is produced locally in the oral cavity, it remains in relatively high concentrations compared with other salivary markers such as cortisol that is released elsewhere in the body by the adrenal gland and transported to the saliva via ultrafiltration.

Dr. Lynch and her colleagues reported no relevant financial disclosures.

MINNEAPOLIS – Extremes in prepregnancy body mass index are linked with slower mental development, an analysis of a large, nationally representative cohort suggests.

 After researchers adjusted for sociodemographics, children whose mothers were obese or underweight were 1.5-times more likely than were children of normal-weight mothers to have delayed mental development at 2 years.

No such association with body mass index (BMI) was observed for motor skills.

Given the obesity epidemic, the findings have implications for pre- and inter-conception care, early intervention programs, and obesity prevention and policy, Stefanie Hinkle, Ph.D., said at the meeting.

"Focusing on obesity in children is a particular concern given they our next generation of mothers," she said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The analysis included 6,850 children from the Early Childhood Longitudinal Study–Birth Cohort, a nationally representative sample of 3.6 million children born in 2001. At about two years of age, certified interviewers used a validated shortened version of the Bayley Scales of Infant Development II to assess mental and psychomotor development.

At 9 months postpartum, 5% of mothers reported a prepregnancy BMI categorized as underweight (less than 18.5 kg/m²); 56% normal weight (18.5-24.9 kg/m²); 25% overweight (25-29.9 kg/m²); 8% class I obese (30-34.9 kg/m²); and 6% class II & III obese (at least 35 kg/m²).

Compared with children of normal-weight mothers, mental development T scores were significantly lower for children of underweight or class II-III obese mothers. The greatest difference, a gap of 2.13 points, was observed among children of mothers with severe obesity or a BMI of 35 kg/m² or more, said Dr. Hinkle, a postdoctoral fellow with the division of reproductive health, Centers for Disease Control and Prevention in Atlanta.

The adjusted odds for the more clinically relevant endpoint of delayed mental development, defined as at least one standard deviation below reference, were 1.48 for children of underweight moms and 1.50 for those of severely obese moms.

T scores for motor development and delayed motor development were not significantly different based on prepregnancy BMI, Dr. Hinkle said.

During a discussion at the meeting, one attendee asked whether the analysis included low birth-weight infants or took into consideration such factors as parenting styles, home environment or neighborhood environment.

"I’m just a little skeptical that obesity, all by itself, has this direct effect because there are a lot of other things that happen during child development in the first few years," said Russell Kirby, Ph.D., professor of community and family health, University of South Florida, Tampa.

Dr. Hinkle said they adjusted the models for maternal age, race/ethnicity, marital status, parity, years of schooling, smoking during pregnancy, and household poverty at the time of the assessment and for the child’s gender. Additional data were collected on factors relating to the home and will be used in a future analysis of the children at 5 years. The investigators also performed an analysis among low birth-weight infants and the findings were similar.

Session moderator Dr. Fiona Stanley, professor of pediatrics at University of Western Australia in Perth, said single-factor analyses are frustrating given that the pathways into obesity are known to be complex and involve several factors that can influence child outcomes such as maternal mental health, self-esteem and poverty.

"There are many pathways into children not doing well on Bayley scores at age 2, and maternal obesity is a marker for a pathway or set of pathways," she said in an interview. "To target just obesity is not the way forward."

Finally, an attendee pointed out that the effect of factors influencing perinatal IQ often disappears as time goes on.

The Oak Ridge (Tenn.) Institute for Science and Education sponsored the analysis. The Department of Education sponsored the Early Childhood Longitudinal Study–Birth Cohort study. Dr. Hinkle and her coauthors report no relevant conflicts of interest.

MINNEAPOLIS – Extremes in prepregnancy body mass index are linked with slower mental development, an analysis of a large, nationally representative cohort suggests.

 After researchers adjusted for sociodemographics, children whose mothers were obese or underweight were 1.5-times more likely than were children of normal-weight mothers to have delayed mental development at 2 years.

No such association with body mass index (BMI) was observed for motor skills.

Given the obesity epidemic, the findings have implications for pre- and inter-conception care, early intervention programs, and obesity prevention and policy, Stefanie Hinkle, Ph.D., said at the meeting.

"Focusing on obesity in children is a particular concern given they our next generation of mothers," she said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The analysis included 6,850 children from the Early Childhood Longitudinal Study–Birth Cohort, a nationally representative sample of 3.6 million children born in 2001. At about two years of age, certified interviewers used a validated shortened version of the Bayley Scales of Infant Development II to assess mental and psychomotor development.

At 9 months postpartum, 5% of mothers reported a prepregnancy BMI categorized as underweight (less than 18.5 kg/m²); 56% normal weight (18.5-24.9 kg/m²); 25% overweight (25-29.9 kg/m²); 8% class I obese (30-34.9 kg/m²); and 6% class II & III obese (at least 35 kg/m²).

Compared with children of normal-weight mothers, mental development T scores were significantly lower for children of underweight or class II-III obese mothers. The greatest difference, a gap of 2.13 points, was observed among children of mothers with severe obesity or a BMI of 35 kg/m² or more, said Dr. Hinkle, a postdoctoral fellow with the division of reproductive health, Centers for Disease Control and Prevention in Atlanta.

The adjusted odds for the more clinically relevant endpoint of delayed mental development, defined as at least one standard deviation below reference, were 1.48 for children of underweight moms and 1.50 for those of severely obese moms.

T scores for motor development and delayed motor development were not significantly different based on prepregnancy BMI, Dr. Hinkle said.

During a discussion at the meeting, one attendee asked whether the analysis included low birth-weight infants or took into consideration such factors as parenting styles, home environment or neighborhood environment.

"I’m just a little skeptical that obesity, all by itself, has this direct effect because there are a lot of other things that happen during child development in the first few years," said Russell Kirby, Ph.D., professor of community and family health, University of South Florida, Tampa.

Dr. Hinkle said they adjusted the models for maternal age, race/ethnicity, marital status, parity, years of schooling, smoking during pregnancy, and household poverty at the time of the assessment and for the child’s gender. Additional data were collected on factors relating to the home and will be used in a future analysis of the children at 5 years. The investigators also performed an analysis among low birth-weight infants and the findings were similar.

Session moderator Dr. Fiona Stanley, professor of pediatrics at University of Western Australia in Perth, said single-factor analyses are frustrating given that the pathways into obesity are known to be complex and involve several factors that can influence child outcomes such as maternal mental health, self-esteem and poverty.

"There are many pathways into children not doing well on Bayley scores at age 2, and maternal obesity is a marker for a pathway or set of pathways," she said in an interview. "To target just obesity is not the way forward."

Finally, an attendee pointed out that the effect of factors influencing perinatal IQ often disappears as time goes on.

The Oak Ridge (Tenn.) Institute for Science and Education sponsored the analysis. The Department of Education sponsored the Early Childhood Longitudinal Study–Birth Cohort study. Dr. Hinkle and her coauthors report no relevant conflicts of interest.

MINNEAPOLIS – Extremes in prepregnancy body mass index are linked with slower mental development, an analysis of a large, nationally representative cohort suggests.

 After researchers adjusted for sociodemographics, children whose mothers were obese or underweight were 1.5-times more likely than were children of normal-weight mothers to have delayed mental development at 2 years.

No such association with body mass index (BMI) was observed for motor skills.

Given the obesity epidemic, the findings have implications for pre- and inter-conception care, early intervention programs, and obesity prevention and policy, Stefanie Hinkle, Ph.D., said at the meeting.

"Focusing on obesity in children is a particular concern given they our next generation of mothers," she said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The analysis included 6,850 children from the Early Childhood Longitudinal Study–Birth Cohort, a nationally representative sample of 3.6 million children born in 2001. At about two years of age, certified interviewers used a validated shortened version of the Bayley Scales of Infant Development II to assess mental and psychomotor development.

At 9 months postpartum, 5% of mothers reported a prepregnancy BMI categorized as underweight (less than 18.5 kg/m²); 56% normal weight (18.5-24.9 kg/m²); 25% overweight (25-29.9 kg/m²); 8% class I obese (30-34.9 kg/m²); and 6% class II & III obese (at least 35 kg/m²).

Compared with children of normal-weight mothers, mental development T scores were significantly lower for children of underweight or class II-III obese mothers. The greatest difference, a gap of 2.13 points, was observed among children of mothers with severe obesity or a BMI of 35 kg/m² or more, said Dr. Hinkle, a postdoctoral fellow with the division of reproductive health, Centers for Disease Control and Prevention in Atlanta.

The adjusted odds for the more clinically relevant endpoint of delayed mental development, defined as at least one standard deviation below reference, were 1.48 for children of underweight moms and 1.50 for those of severely obese moms.

T scores for motor development and delayed motor development were not significantly different based on prepregnancy BMI, Dr. Hinkle said.

During a discussion at the meeting, one attendee asked whether the analysis included low birth-weight infants or took into consideration such factors as parenting styles, home environment or neighborhood environment.

"I’m just a little skeptical that obesity, all by itself, has this direct effect because there are a lot of other things that happen during child development in the first few years," said Russell Kirby, Ph.D., professor of community and family health, University of South Florida, Tampa.

Dr. Hinkle said they adjusted the models for maternal age, race/ethnicity, marital status, parity, years of schooling, smoking during pregnancy, and household poverty at the time of the assessment and for the child’s gender. Additional data were collected on factors relating to the home and will be used in a future analysis of the children at 5 years. The investigators also performed an analysis among low birth-weight infants and the findings were similar.

Session moderator Dr. Fiona Stanley, professor of pediatrics at University of Western Australia in Perth, said single-factor analyses are frustrating given that the pathways into obesity are known to be complex and involve several factors that can influence child outcomes such as maternal mental health, self-esteem and poverty.

"There are many pathways into children not doing well on Bayley scores at age 2, and maternal obesity is a marker for a pathway or set of pathways," she said in an interview. "To target just obesity is not the way forward."

Finally, an attendee pointed out that the effect of factors influencing perinatal IQ often disappears as time goes on.

The Oak Ridge (Tenn.) Institute for Science and Education sponsored the analysis. The Department of Education sponsored the Early Childhood Longitudinal Study–Birth Cohort study. Dr. Hinkle and her coauthors report no relevant conflicts of interest.

MINNEAPOLIS – Maternal hypertension and intrapartum fever increase the risk for ischemic stroke in infants, a large retrospective analysis suggests.

Gestational diabetes, a known risk factor for maternal hypertension and neonatal hypoglycemia, does not increase stroke risk.

"Additional research is needed to determine the mechanism underlying these associations and to develop effective preventive methods for high-risk infants," Dr. Joshua R. Mann reported at the meeting.

Approximately 2-4 children per 10,000 births experience ischemic stroke in the first 28 days of life. Roughly 60% of infants present immediately, typically with neonatal seizures. In the remaining 40%, stroke is recognized later in childhood during evaluation for abnormal neurologic or cognitive development.

There were 43 cases of ischemic stroke before 30 days of life and 118 additional cases diagnosed from day 30 through 364 days in the retrospective analysis of 226,117 children (199,934 full-term births) born from 2000 through 2007 and enrolled in the South Carolina Medicaid program.

Of these, 37 cases and 96 cases, respectively, had confirmed ischemic strokes, defined as more than one ICD-9 code for ischemic stroke or a single diagnosis of ischemic stroke plus a neurocognitive condition that could be indicative of stroke.

Compared with infants without stroke, maternal hypertension was significantly more common for infants with ischemic stroke before 30 days (32.5% vs. 14%; P value = .0004) and before 365 days (28% vs. 14%; P less than .0001), reported Dr. Mann of family and preventive medicine at the University of South Carolina, Columbia.

Fever at delivery was significantly more common in mothers of infants with stroke prior to 365 days (4.9% vs. 1.2%; P less than .0001), but not in those with stroke before 30 days (4.6% vs. 1.2%; P = .09).

Maternal diabetes was not significant at either time point.

In a logistic regression analysis that adjusted for a broad range of demographic and other confounding risk factors, infants born to mothers with hypertension had more than twice the risk of any stroke, defined as one or more diagnoses indicating ischemic stroke, before 30 days (odds ratio 2.31; P = .0071), or a confirmed ischemic stroke (OR 2.75; P = .0021), he said.

Maternal fever at delivery more than tripled the risk of any ischemic stroke (OR 3.36; P = .048) and quadrupled the risk of confirmed ischemic stroke (OR 4.02; P = .025), he reported in a poster presentation.

Maternal diabetes did not significantly increase the odds of any stroke (OR 0.35; P = .08) or confirmed stroke (OR 0.40; P = .13).

Although it was not the primary goal of the study, the investigators also found multiple child characteristics to be associated with increased odds of any stroke prior to 365 days. The significant covariates were birth trauma (OR 5.99), birth asphyxia (OR 11.42), sickle cell disease (OR 3.58), sickle cell trait (OR 2.45), congenital infection (OR 5.39), neonatal infection (OR 6.06), meningitis (OR 6.05), encephalitis (OR 3.99) and child thrombophilia, which had a staggering odds ratio of 157.99.

There was also evidence of synergy between maternal hypertension and the presence of at least one other risk factor for stroke diagnosed before 365 days.

A recent study among 44 children indicated that the timing of the stroke has a bearing on outcomes. Children who had a stroke between 1 and 6 years had better neuropsychological outcomes than did children who had a stroke before age 1 or after age 6 (Child Neuropsychol. 2011 Dec. 6 [doi:10.1080/09297049.2011.639756]).

The full paper is in press with the journal Developmental Medicine and Child Neurology, Dr. Mann noted.

Funding for the study was provided by a Health Resources Services Administration Maternal Child Health grant. Dr. Mann and his coauthors reported having no disclosures.

MINNEAPOLIS – Maternal hypertension and intrapartum fever increase the risk for ischemic stroke in infants, a large retrospective analysis suggests.

Gestational diabetes, a known risk factor for maternal hypertension and neonatal hypoglycemia, does not increase stroke risk.

"Additional research is needed to determine the mechanism underlying these associations and to develop effective preventive methods for high-risk infants," Dr. Joshua R. Mann reported at the meeting.

Approximately 2-4 children per 10,000 births experience ischemic stroke in the first 28 days of life. Roughly 60% of infants present immediately, typically with neonatal seizures. In the remaining 40%, stroke is recognized later in childhood during evaluation for abnormal neurologic or cognitive development.

There were 43 cases of ischemic stroke before 30 days of life and 118 additional cases diagnosed from day 30 through 364 days in the retrospective analysis of 226,117 children (199,934 full-term births) born from 2000 through 2007 and enrolled in the South Carolina Medicaid program.

Of these, 37 cases and 96 cases, respectively, had confirmed ischemic strokes, defined as more than one ICD-9 code for ischemic stroke or a single diagnosis of ischemic stroke plus a neurocognitive condition that could be indicative of stroke.

Compared with infants without stroke, maternal hypertension was significantly more common for infants with ischemic stroke before 30 days (32.5% vs. 14%; P value = .0004) and before 365 days (28% vs. 14%; P less than .0001), reported Dr. Mann of family and preventive medicine at the University of South Carolina, Columbia.

Fever at delivery was significantly more common in mothers of infants with stroke prior to 365 days (4.9% vs. 1.2%; P less than .0001), but not in those with stroke before 30 days (4.6% vs. 1.2%; P = .09).

Maternal diabetes was not significant at either time point.

In a logistic regression analysis that adjusted for a broad range of demographic and other confounding risk factors, infants born to mothers with hypertension had more than twice the risk of any stroke, defined as one or more diagnoses indicating ischemic stroke, before 30 days (odds ratio 2.31; P = .0071), or a confirmed ischemic stroke (OR 2.75; P = .0021), he said.

Maternal fever at delivery more than tripled the risk of any ischemic stroke (OR 3.36; P = .048) and quadrupled the risk of confirmed ischemic stroke (OR 4.02; P = .025), he reported in a poster presentation.

Maternal diabetes did not significantly increase the odds of any stroke (OR 0.35; P = .08) or confirmed stroke (OR 0.40; P = .13).

Although it was not the primary goal of the study, the investigators also found multiple child characteristics to be associated with increased odds of any stroke prior to 365 days. The significant covariates were birth trauma (OR 5.99), birth asphyxia (OR 11.42), sickle cell disease (OR 3.58), sickle cell trait (OR 2.45), congenital infection (OR 5.39), neonatal infection (OR 6.06), meningitis (OR 6.05), encephalitis (OR 3.99) and child thrombophilia, which had a staggering odds ratio of 157.99.

There was also evidence of synergy between maternal hypertension and the presence of at least one other risk factor for stroke diagnosed before 365 days.

A recent study among 44 children indicated that the timing of the stroke has a bearing on outcomes. Children who had a stroke between 1 and 6 years had better neuropsychological outcomes than did children who had a stroke before age 1 or after age 6 (Child Neuropsychol. 2011 Dec. 6 [doi:10.1080/09297049.2011.639756]).

The full paper is in press with the journal Developmental Medicine and Child Neurology, Dr. Mann noted.

Funding for the study was provided by a Health Resources Services Administration Maternal Child Health grant. Dr. Mann and his coauthors reported having no disclosures.

MINNEAPOLIS – Maternal hypertension and intrapartum fever increase the risk for ischemic stroke in infants, a large retrospective analysis suggests.

Gestational diabetes, a known risk factor for maternal hypertension and neonatal hypoglycemia, does not increase stroke risk.

"Additional research is needed to determine the mechanism underlying these associations and to develop effective preventive methods for high-risk infants," Dr. Joshua R. Mann reported at the meeting.

Approximately 2-4 children per 10,000 births experience ischemic stroke in the first 28 days of life. Roughly 60% of infants present immediately, typically with neonatal seizures. In the remaining 40%, stroke is recognized later in childhood during evaluation for abnormal neurologic or cognitive development.

There were 43 cases of ischemic stroke before 30 days of life and 118 additional cases diagnosed from day 30 through 364 days in the retrospective analysis of 226,117 children (199,934 full-term births) born from 2000 through 2007 and enrolled in the South Carolina Medicaid program.

Of these, 37 cases and 96 cases, respectively, had confirmed ischemic strokes, defined as more than one ICD-9 code for ischemic stroke or a single diagnosis of ischemic stroke plus a neurocognitive condition that could be indicative of stroke.

Compared with infants without stroke, maternal hypertension was significantly more common for infants with ischemic stroke before 30 days (32.5% vs. 14%; P value = .0004) and before 365 days (28% vs. 14%; P less than .0001), reported Dr. Mann of family and preventive medicine at the University of South Carolina, Columbia.

Fever at delivery was significantly more common in mothers of infants with stroke prior to 365 days (4.9% vs. 1.2%; P less than .0001), but not in those with stroke before 30 days (4.6% vs. 1.2%; P = .09).

Maternal diabetes was not significant at either time point.

In a logistic regression analysis that adjusted for a broad range of demographic and other confounding risk factors, infants born to mothers with hypertension had more than twice the risk of any stroke, defined as one or more diagnoses indicating ischemic stroke, before 30 days (odds ratio 2.31; P = .0071), or a confirmed ischemic stroke (OR 2.75; P = .0021), he said.

Maternal fever at delivery more than tripled the risk of any ischemic stroke (OR 3.36; P = .048) and quadrupled the risk of confirmed ischemic stroke (OR 4.02; P = .025), he reported in a poster presentation.

Maternal diabetes did not significantly increase the odds of any stroke (OR 0.35; P = .08) or confirmed stroke (OR 0.40; P = .13).

Although it was not the primary goal of the study, the investigators also found multiple child characteristics to be associated with increased odds of any stroke prior to 365 days. The significant covariates were birth trauma (OR 5.99), birth asphyxia (OR 11.42), sickle cell disease (OR 3.58), sickle cell trait (OR 2.45), congenital infection (OR 5.39), neonatal infection (OR 6.06), meningitis (OR 6.05), encephalitis (OR 3.99) and child thrombophilia, which had a staggering odds ratio of 157.99.

There was also evidence of synergy between maternal hypertension and the presence of at least one other risk factor for stroke diagnosed before 365 days.

A recent study among 44 children indicated that the timing of the stroke has a bearing on outcomes. Children who had a stroke between 1 and 6 years had better neuropsychological outcomes than did children who had a stroke before age 1 or after age 6 (Child Neuropsychol. 2011 Dec. 6 [doi:10.1080/09297049.2011.639756]).

The full paper is in press with the journal Developmental Medicine and Child Neurology, Dr. Mann noted.

Funding for the study was provided by a Health Resources Services Administration Maternal Child Health grant. Dr. Mann and his coauthors reported having no disclosures.

MINNEAPOLIS – Improved access to health care appears to be contributing to a rise in attention-deficit/hyperactivity disorder diagnoses among poor children, a national study has found.

Although many factors may be contributing to the rise in ADHD diagnoses among poor children, access to health care through public insurance programs may have played a role, according to Patricia Pastor, Ph.D., who was one of the study coauthors. Since 1997, there has been a significant decline in the number of uninsured poor children because of the expansion of the Children’s Health Insurance Program (CHIP) and Medicaid.

Between 1999 and 2010, the percentage of poor children diagnosed with ADHD increased from 8% to 12%. At the same time, public insurance coverage among these children increased significantly from 40% to 69%, noted Dr. Pastor, of the National Center for Health Statistics, Centers for Disease Control and Prevention. The percentage of poor children covered by public insurance and diagnosed with ADHD also increased from 10% to 14%, but this did not reach statistical significance.

The analysis included 35,896 children, aged 7-11 years, who part of the National Health Interview Survey, an ongoing, nationally representative, in-person household survey. Diagnosed ADHD was identified by the following question: "Has a doctor or health professional ever told you that your child had attention deficit hyperactivity disorder or attention deficit disorder?" Poverty status was based on reported and imputed family income and size. "Poor" children had family incomes less than 200% of the poverty level, while those classified as "non-poor" had family incomes 200% or more of the poverty level.

Between 1999 and 2010, there was an upward trend in the percentage of all children diagnosed with ADHD, increasing by 2% annually, reported Dr. Pastor and her coauthor Cynthia A. Reuben, M.A., also with the CDC. The percentage of non-poor children diagnosed with ADHD remained flat at about 7% during this time period, varying by just 0.2% annually. This compares with an annual percent change (APC) of 2.9% among poor children.

Over the same time period, the percentage of poor children with private health insurance coverage dropped significantly from 35% to 20%, Dr. Pastor said. This was offset by the rise in children on public insurance, lowering the overall number of poor children without insurance from 22% to 12% between 1999 and 2010.

Logistic regression analysis – adjusted for such confounders as age, sex, race, and ethnicity – revealed a significant increase over time in diagnosed ADHD among poor children, but not among non-poor children. When the model was further adjusted to include insurance coverage, the increased risk of an ADHD diagnosis among poor children declined to 1.0, but was not totally eliminated.

"So clearly there were other factors associated with this significant upward trend of diagnosed ADHD in poor children," said Dr. Pastor. Future analyses will explore these factors, such as changes in diagnostic practices of health care providers and in special education programs.

A meeting attendee expressed surprise that the increase in ADHD diagnoses was seen only in the public sector, and asked whether a similar rise was not seen among families with private insurance because they still face costly copayments for tests to diagnosis ADHD.

Dr. Pastor said the diagnosis of ADHD was based on parental report and that a different data set would be needed to tease out the influence of copayments on ADHD trends. "We don’t know what parents had to do to get those diagnoses, and I think that is one of the limitations of our data source," she said.

Session moderator Dr. Fiona Stanley, a professor of pediatrics at the University of Western Australia in Perth, said in an interview that she believes the increase in diagnosed ADHD among the poor does not represent a real increase in the incidence of the disorder, but rather that "more families are coming forward because they can."

She said the study is extremely important because the "usual pattern that we see for ADHD and autism is that poor people aren’t in the sample," and that they are also unlikely to be diagnosed with ADHD or autism, even in countries with national insurance like Australia.

Once the diagnosis is made, clinicians need to provide a lot of parental support and education to poor families on how to manage these children, Dr. Stanley advised.

"Many drugs now, particularly psychotropic drugs, are being given off label with no evidence of what they’re doing in children in primary school up to the teenage years when brains are still developing," she said. "I don’t think we have very good trial evidence of whether they’re effective, and the overdiagnosis of mental illness, particularly in the DSM-V, is horrendous."

Dr. Pastor, Ms. Reuben, and Dr. Stanley reported having no disclosures.

MINNEAPOLIS – Improved access to health care appears to be contributing to a rise in attention-deficit/hyperactivity disorder diagnoses among poor children, a national study has found.

Although many factors may be contributing to the rise in ADHD diagnoses among poor children, access to health care through public insurance programs may have played a role, according to Patricia Pastor, Ph.D., who was one of the study coauthors. Since 1997, there has been a significant decline in the number of uninsured poor children because of the expansion of the Children’s Health Insurance Program (CHIP) and Medicaid.

Between 1999 and 2010, the percentage of poor children diagnosed with ADHD increased from 8% to 12%. At the same time, public insurance coverage among these children increased significantly from 40% to 69%, noted Dr. Pastor, of the National Center for Health Statistics, Centers for Disease Control and Prevention. The percentage of poor children covered by public insurance and diagnosed with ADHD also increased from 10% to 14%, but this did not reach statistical significance.

The analysis included 35,896 children, aged 7-11 years, who part of the National Health Interview Survey, an ongoing, nationally representative, in-person household survey. Diagnosed ADHD was identified by the following question: "Has a doctor or health professional ever told you that your child had attention deficit hyperactivity disorder or attention deficit disorder?" Poverty status was based on reported and imputed family income and size. "Poor" children had family incomes less than 200% of the poverty level, while those classified as "non-poor" had family incomes 200% or more of the poverty level.

Between 1999 and 2010, there was an upward trend in the percentage of all children diagnosed with ADHD, increasing by 2% annually, reported Dr. Pastor and her coauthor Cynthia A. Reuben, M.A., also with the CDC. The percentage of non-poor children diagnosed with ADHD remained flat at about 7% during this time period, varying by just 0.2% annually. This compares with an annual percent change (APC) of 2.9% among poor children.

Over the same time period, the percentage of poor children with private health insurance coverage dropped significantly from 35% to 20%, Dr. Pastor said. This was offset by the rise in children on public insurance, lowering the overall number of poor children without insurance from 22% to 12% between 1999 and 2010.

Logistic regression analysis – adjusted for such confounders as age, sex, race, and ethnicity – revealed a significant increase over time in diagnosed ADHD among poor children, but not among non-poor children. When the model was further adjusted to include insurance coverage, the increased risk of an ADHD diagnosis among poor children declined to 1.0, but was not totally eliminated.

"So clearly there were other factors associated with this significant upward trend of diagnosed ADHD in poor children," said Dr. Pastor. Future analyses will explore these factors, such as changes in diagnostic practices of health care providers and in special education programs.

A meeting attendee expressed surprise that the increase in ADHD diagnoses was seen only in the public sector, and asked whether a similar rise was not seen among families with private insurance because they still face costly copayments for tests to diagnosis ADHD.

Dr. Pastor said the diagnosis of ADHD was based on parental report and that a different data set would be needed to tease out the influence of copayments on ADHD trends. "We don’t know what parents had to do to get those diagnoses, and I think that is one of the limitations of our data source," she said.

Session moderator Dr. Fiona Stanley, a professor of pediatrics at the University of Western Australia in Perth, said in an interview that she believes the increase in diagnosed ADHD among the poor does not represent a real increase in the incidence of the disorder, but rather that "more families are coming forward because they can."

She said the study is extremely important because the "usual pattern that we see for ADHD and autism is that poor people aren’t in the sample," and that they are also unlikely to be diagnosed with ADHD or autism, even in countries with national insurance like Australia.

Once the diagnosis is made, clinicians need to provide a lot of parental support and education to poor families on how to manage these children, Dr. Stanley advised.

"Many drugs now, particularly psychotropic drugs, are being given off label with no evidence of what they’re doing in children in primary school up to the teenage years when brains are still developing," she said. "I don’t think we have very good trial evidence of whether they’re effective, and the overdiagnosis of mental illness, particularly in the DSM-V, is horrendous."

Dr. Pastor, Ms. Reuben, and Dr. Stanley reported having no disclosures.

MINNEAPOLIS – Improved access to health care appears to be contributing to a rise in attention-deficit/hyperactivity disorder diagnoses among poor children, a national study has found.

Although many factors may be contributing to the rise in ADHD diagnoses among poor children, access to health care through public insurance programs may have played a role, according to Patricia Pastor, Ph.D., who was one of the study coauthors. Since 1997, there has been a significant decline in the number of uninsured poor children because of the expansion of the Children’s Health Insurance Program (CHIP) and Medicaid.

Between 1999 and 2010, the percentage of poor children diagnosed with ADHD increased from 8% to 12%. At the same time, public insurance coverage among these children increased significantly from 40% to 69%, noted Dr. Pastor, of the National Center for Health Statistics, Centers for Disease Control and Prevention. The percentage of poor children covered by public insurance and diagnosed with ADHD also increased from 10% to 14%, but this did not reach statistical significance.

The analysis included 35,896 children, aged 7-11 years, who part of the National Health Interview Survey, an ongoing, nationally representative, in-person household survey. Diagnosed ADHD was identified by the following question: "Has a doctor or health professional ever told you that your child had attention deficit hyperactivity disorder or attention deficit disorder?" Poverty status was based on reported and imputed family income and size. "Poor" children had family incomes less than 200% of the poverty level, while those classified as "non-poor" had family incomes 200% or more of the poverty level.

Between 1999 and 2010, there was an upward trend in the percentage of all children diagnosed with ADHD, increasing by 2% annually, reported Dr. Pastor and her coauthor Cynthia A. Reuben, M.A., also with the CDC. The percentage of non-poor children diagnosed with ADHD remained flat at about 7% during this time period, varying by just 0.2% annually. This compares with an annual percent change (APC) of 2.9% among poor children.

Over the same time period, the percentage of poor children with private health insurance coverage dropped significantly from 35% to 20%, Dr. Pastor said. This was offset by the rise in children on public insurance, lowering the overall number of poor children without insurance from 22% to 12% between 1999 and 2010.

Logistic regression analysis – adjusted for such confounders as age, sex, race, and ethnicity – revealed a significant increase over time in diagnosed ADHD among poor children, but not among non-poor children. When the model was further adjusted to include insurance coverage, the increased risk of an ADHD diagnosis among poor children declined to 1.0, but was not totally eliminated.

"So clearly there were other factors associated with this significant upward trend of diagnosed ADHD in poor children," said Dr. Pastor. Future analyses will explore these factors, such as changes in diagnostic practices of health care providers and in special education programs.

A meeting attendee expressed surprise that the increase in ADHD diagnoses was seen only in the public sector, and asked whether a similar rise was not seen among families with private insurance because they still face costly copayments for tests to diagnosis ADHD.

Dr. Pastor said the diagnosis of ADHD was based on parental report and that a different data set would be needed to tease out the influence of copayments on ADHD trends. "We don’t know what parents had to do to get those diagnoses, and I think that is one of the limitations of our data source," she said.

Session moderator Dr. Fiona Stanley, a professor of pediatrics at the University of Western Australia in Perth, said in an interview that she believes the increase in diagnosed ADHD among the poor does not represent a real increase in the incidence of the disorder, but rather that "more families are coming forward because they can."

She said the study is extremely important because the "usual pattern that we see for ADHD and autism is that poor people aren’t in the sample," and that they are also unlikely to be diagnosed with ADHD or autism, even in countries with national insurance like Australia.

Once the diagnosis is made, clinicians need to provide a lot of parental support and education to poor families on how to manage these children, Dr. Stanley advised.

"Many drugs now, particularly psychotropic drugs, are being given off label with no evidence of what they’re doing in children in primary school up to the teenage years when brains are still developing," she said. "I don’t think we have very good trial evidence of whether they’re effective, and the overdiagnosis of mental illness, particularly in the DSM-V, is horrendous."

Dr. Pastor, Ms. Reuben, and Dr. Stanley reported having no disclosures.