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    <recommendedItem id="20100101_19_471"
                     title="Early Pregnancy Determines Late Outcomes (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18405?impressionId=1265815685032"
                     
      &lt;p&gt;Growth of the fetus during the first trimester  --  when essential organ development is completed  --  lays the foundation for important outcomes in pregnancy and early childhood, Dutch researchers found.&lt;/p&gt;
&lt;p&gt;Restricted first-trimester growth appeared to more than double the risk of preterm birth, low birth weight, and small size for gestational age at birth in a prospective study led by Vincent W.V. Jaddoe, MD, PhD, of Erasmus Medical Center in Rotterdam.&lt;/p&gt;
&lt;p&gt;Infants who didn&apos;t grow as much as expected during the first trimester also showed accelerated &quot;catch-up&quot; growth up to their second birthday  --  a well-established risk factor for later metabolic and cardiovascular disease.&lt;/p&gt;
&lt;p&gt;&quot;It could be that growth as early as in the first trimester of pregnancy is associated with disease in adulthood, although longer follow-up studies are necessary to examine this relationship,&quot; the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This and prior studies suggest that women at high risk of problems late in pregnancy could be identifiable in the first trimester, with the potential for trials of screening and early intervention, according to an accompanying editorial by Gordon C.S. Smith, MD, PhD, of the University of Cambridge, England.&lt;/p&gt;
&lt;p&gt;The challenge, Smith wrote, will be to &quot;produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk.&quot;&lt;/p&gt;
&lt;p&gt;The researchers&apos; population-based, prospective Generation R Study included 1,631 pregnant women in Rotterdam with a known and reliable first day of their last menstrual period and a regular menstrual cycle.&lt;/p&gt;
&lt;p&gt;Fetal crown-to-rump length, measured by ultrasound between the gestational age of 10 weeks 0 days and 13&lt;/p&gt;
&lt;p&gt;weeks 6 days, is typically used to determine gestational age. But in this study it served as the main parameter of first-trimester fetal growth.&lt;/p&gt;
&lt;p&gt;Predictors of restricted fetal growth in multivariate analyses included the following (given as standard deviation growth score): &lt;ul&gt; &lt;li&gt;Younger maternal age (0.10 per 4.68-year standard deviation increase, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) &lt;/li&gt; &lt;li&gt;Higher maternal diastolic blood pressure (&amp;#8722;0.05 per 9.52-mm Hg standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;li&gt;Higher hematocrit level (&amp;#8722;0.07 per 2.50% standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.02) &lt;/li&gt; &lt;li&gt;Smoking (&amp;#8722;0.13, &lt;em&gt;P&lt;/em&gt;=0.03)&lt;/li&gt; &lt;li&gt;Folic acid supplement use (0.17, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;After adjustment for multiple testing, only hematocrit and maternal age remained significant factors, but smoking and nonoptimal use of folic acid supplements together produced a significant reduction in first-trimester fetal growth (SD score &amp;#8722;0.52, 95% CI &amp;#8722;0.78 to &amp;#8722;0.25, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction).&lt;/p&gt;
&lt;p&gt;Higher hematocrit levels may indicate lower circulating plasma volume. That in turn could lead to suboptimal placental perfusion, the researchers suggested as a possible explanation for the importance of this factor.&lt;/p&gt;
&lt;p&gt;The impact on pregnancy outcomes was significant for all adverse birth outcomes assessed. Compared with normal first-trimester fetal growth, growth restriction was associated with the following risks: &lt;ul&gt; &lt;li&gt;2.12-fold higher adjusted odds of preterm birth before 37 weeks&apos; gestation (4.0% versus 7.2%, &lt;em&gt;P&lt;/em&gt;=0.006).&lt;/li&gt; &lt;li&gt;2.42-fold higher adjusted odds of low birth weight, defined as less than 2,500 g or 5 lb 8 oz (3.5% versus 7.5%, &lt;em&gt;P&lt;/em&gt;=0.001).&lt;/li&gt; &lt;li&gt;2.64-fold higher adjusted odds of being small for gestational age at birth, defined as in the lowest 20% (4.0% versus 10.6%, &lt;em&gt;P&lt;/em&gt;=0.001). &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Independent of birth weight, fetal growth restriction in the first trimester accelerated postnatal growth until age 2 years (0.139 standard deviation score increase over two years per standard deviation fetal-crown-to-rump length decrease, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Even though they included only women with reliable menstrual cycles, the authors noted, misclassification of gestational age might still have been an issue, depending on timing of ovulation and implantation.&lt;/p&gt;
&lt;p&gt;&quot;Further studies are needed to assess the associations of first-trimester growth variation on the risks of disease in later childhood and adulthood,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The first phase of the Generation R Study was financially supported by the Erasmus Medical Center, the Erasmus University Rotterdam, and the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;Jaddoe reported receipt of funding from the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Smith reported having been a member of preterm labor advisory boards for GlaxoSmithKline. He also reported funding from Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge University Hospitals, NHS Foundation Trust.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_235"
                     title="Congenital Anomalies Linked to Mom&apos;s Diabetes (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18065?impressionId=1265815685032"
                     
      &lt;p&gt;Pregestational maternal diabetes was associated with an increased risk of a major congenital anomaly, but obesity itself was not, a cross-sectional study found.&lt;/p&gt;
&lt;p&gt;In a multivariable logistic model, the major contributor to a rising rate of congenital anomalies was maternal pregestational diabetes (OR 3.8, 95% CI 2.1 to 6.6), according to Joseph R. Biggio, Jr., MD, and colleagues from the University of Alabama at Birmingham.&lt;/p&gt;
&lt;p&gt;&quot;Because hyperglycemia is a major contributor to developmental malformations, interventions to address obesity and identify women at risk for diabetes and hyperglycemia should be considered in efforts to reduce the occurrence of congenital anomalies,&quot; they wrote in the February issue of &lt;em&gt;Obstetrics &amp;amp; Gynecology.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Maternal obesity has been linked with numerous problems, including preeclampsia, gestational diabetes, fetal and neonatal death, and birth trauma, but scientists have disagreed over whether it also contributes to the risk of fetal malformations, the researchers noted.&lt;/p&gt;
&lt;p&gt;To help settle the issue, Biggio and colleagues used a perinatal database in their university health system that included all women with singletons delivered between 1991 and 2004.&lt;/p&gt;
&lt;p&gt;They divided the cohort into three time periods  --  1991 to 1994, 1995 to 1999, and 2000 to 2004, with a total of 41,902 pregnancies.&lt;/p&gt;
&lt;p&gt;For their primary analysis, they defined maternal obesity as a first prenatal visit weight greater than 200 lb, because during the earlier epochs many women did not have body mass index (BMI) calculated. For their secondary analyses they used BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt; as the criterion for obesity.&lt;/p&gt;
&lt;p&gt;In each epoch, there were increases in mean maternal weight, mean BMI, the proportion of women weighing more than 200 lb, the proportion with a BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt;, and the prevalence of pregestational diabetes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all).&lt;/p&gt;
&lt;p&gt;Univariable analysis determined that the rate of major anomalies, particularly involving the cardiac and pulmonary systems, also increased during each time period.&lt;/p&gt;
&lt;p&gt;But there was no independent association between congenital anomalies and maternal obesity using either definition, during any of the three time periods or during the study overall.&lt;/p&gt;
&lt;p&gt;Although no direct association was seen between congenital malformations and maternal obesity, the investigators reported that the proportion of anomalies that could be attributed to obesity increased from 0% to 23% during the overall study period.&lt;/p&gt;
&lt;p&gt;The proportion of anomalies that could be attributed to diabetes ranged from 58% to 76%.&lt;/p&gt;
&lt;p&gt;Moreover, for obese women with diabetes the proportion of anomalies attributed to diabetes increased sharply, from 48% in the first epoch to 74% in the third epoch.&lt;/p&gt;
&lt;p&gt;In contrast, for the obstetric population as a whole, the population-attributable risk of congenital malformation related to obesity rose from near zero in the first epoch to 6.1% in the third epoch, while that related to diabetes increased from 3.3% to 9.2%, the investigators reported.&lt;/p&gt;
&lt;p&gt;During the course of the study there was a nearly 15-lb increase in maternal weight and a 30% increase in the proportion of women whose BMI exceeded 29 kg/m&lt;sup&gt;2&lt;/sup&gt;.&lt;/p&gt;
&lt;p&gt;There also was a nearly twofold increase in the rate of major anomalies  --  and a 250% increase in the prevalence of diabetes.&lt;/p&gt;
&lt;p&gt;The authors observed that there has been much interest in the effects of maternal obesity on birth defects.&lt;/p&gt;
&lt;p&gt;Although the pathophysiologic basis for this possible association have not been identified, hypotheses have included increased serum insulin, lower levels of folic acid, chronic hypoxia, and increased inflammatory mediators.&lt;/p&gt;
&lt;p&gt;&quot;Our study provides evidence that the defects may not be due solely to the maternal obesity per se but may be due to undiagnosed diabetes,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;From a public health standpoint, the study findings suggest that efforts to reduce the prevalence of congenital anomalies should be focused less on obesity and aimed more closely at correcting hyperglycemia.&lt;/p&gt;
&lt;p&gt;&quot;If euglycemia could be achieved before pregnancy, or at least embryogenesis and organogenesis, the majority of these anomalies could potentially be avoided,&quot; they observed.&lt;/p&gt;
&lt;p&gt;They also suggested that even women of normal weight, but with other diabetes risk factors, could benefit from closer attention to glycemic control.&lt;/p&gt;
&lt;p&gt;A weakness of the study was the fact that detailed data on glycemic control was not available in the perinatal database, &quot;and therefore we cannot comment on the association between glycemic control and anomaly rates,&quot; the investigators wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported in part by the National Institute of Child Health and Human Development.&lt;/p&gt;&lt;p&gt;The authors did not report any potential conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_369"
                     title="Working Night Shift, but Not Heavy Lifting, Is Risk Factor for Preterm Birth"
                     score="-0.005"
                     href="