Objective Fetal growth is associated with long-term health yet no appropriate standards exist for the early identification of under- or over-grown fetuses. We sought to develop contemporary fetal growth standards for four self-identified U.S. racial/ethnic groups. Study Design We recruited for prospective follow-up 2,334 healthy women with low-risk, singleton pregnancies from 12 community and perinatal centers between July 2009 and January 2013. The cohort comprised: 614 (26%) non-Hispanic Whites, 611 (26%) non-Hispanic Blacks, 649 (28%) Hispanics, and 460 (20%) Asians. Women were screened at 8w0d to 13w6d for maternal health status associated with presumably normal fetal growth (aged 18–40 years; body mass index 19.0–29.9 kg/m2; healthy lifestyles and living conditions; low-risk medical and obstetrical history); 92% of recruited women completed the protocol. Women were randomized among four ultrasonology schedules for longitudinal fetal measurement using the Voluson E8 GE Healthcare. In-person interviews and anthropometric assessments were conducted at each visit; medical records were abstracted. The fetuses of 1,737 (74%) women continued to be low-risk (uncomplicated pregnancy, absent anomalies) at birth, and their measurements were included in the standards. Racial/ethnic-specific fetal growth curves were estimated using linear mixed models with cubic splines. Estimated fetal weight and biometric parameter percentiles (5th, 50th, 95th) were determined for each gestational week and comparisons made by race/ethnicity, with and without adjustment for maternal and socio-demographic factors. Results Estimated fetal weight differed significantly by race/ethnicity after 20 weeks. Specifically at 39 weeks, the 5th, 50th, and 95th percentiles were 2790, 3505, and 4402 grams for White, 2633, 3336, and 4226 grams for Hispanic, 2621, 3270, and 4078 grams for Asian, and 2622, 3260, and 4053 grams for Black women (adjusted global p<0.001). For individual parameters, racial/ethnic differences by order of detection were: humerus and femur lengths (10 weeks), abdominal circumference (16 weeks), head circumference (21 weeks), and biparietal diameter (27 weeks). The study-derived standard based solely on the White group erroneously classifies as much as 15% of non-White fetuses as growth-restricted (estimated fetal weight < 5th percentile). Conclusions Significant differences in fetal growth were found among the four groups. Racial/ethnic-specific standards improve the precision in evaluating fetal growth.

Thyroid diseases were associated with obstetrical, labor, and delivery complications. Although we lacked information on treatment during pregnancy, these nationwide data suggest either that there is a need for better thyroid disease management during pregnancy or that there may be an intrinsic aspect of thyroid disease that causes poor pregnancy outcomes.

BACKGROUND-This study examined the association between maternal smoking and alcohol use (including binge drinking) during the periconceptional period (i.e., 2 months before through 2 months after conception) and the risk of orofacial clefts, NTDs, and conotruncal heart defects in offspring.

Background Systematic evaluation and estimation of growth trajectories in twins require ultrasound measurements across gestation, performed in controlled clinical settings. Currently there are few such data for contemporary populations. There is also controversy about whether twin fetal growth should be evaluated using the same benchmarks as singleton growth. Objectives Our objective was to empirically define the trajectory of fetal growth in dichorionic twins using longitudinal two-dimensional ultrasonography and to compare the fetal growth trajectories for dichorionic twins with those based on a growth standard developed by our group for singletons. Study Design A prospective cohort of 171 women with twin gestations was recruited from eight U.S. sites from 2012 to 2013. After an initial sonogram at 11w0d–13w6d where dichorionicity was confirmed, women were randomized to one of two serial ultrasonology schedules. Growth curves and percentiles were estimated using linear mixed models with cubic splines. Percentiles were compared statistically at each gestational week between the twins and 1,731 singletons, after adjustment for maternal age, race/ethnicity, height, weight, parity, employment, marital status, insurance, income, education and infant sex. Linear mixed models were used to test for overall differences between the twin and singleton trajectories using likelihood ratio tests of interaction terms between spline mean structure terms and twin-singleton indicator variables. Singleton standards were weighted to correspond to the distribution of maternal race in twins. For those ultrasound measurements where there were significant global tests for differences between twins and singletons, we tested for week-specific differences using Wald tests computed at each gestational age. In a separate analysis, we evaluated the degree of reclassification in small for gestational age, defined as below the 10th percentile that would be introduced if fetal growth estimation for twins was based upon an unweighted singleton standard. Results Women underwent a median of 5 ultrasounds. The 50th percentile abdominal circumference and estimated fetal weight trajectories of twin fetuses diverged significantly beginning at 32 weeks, while biparietal diameter in twins was smaller from 34 through 36 weeks. There were no differences in head circumference or femur length. The mean head circumference/abdominal circumference ratio was progressively larger for twins compared with singletons beginning at 33 weeks, indicating a comparatively asymmetric growth pattern. At 35 weeks, the average gestational age at delivery for twins, the estimated fetal weights for the 10th, 50th and 90th percentiles were 1960, 2376, and 2879 g for dichorionic twins and 2180, 2567, and 3022 g for the singletons. At 32 weeks, the initial week when the mean estimated fetal weight for twins was smaller than that of singletons, 34% of twins would be classified as small for gestational age using a singleton, non-Hispanic white standard. By 35 weeks, 38% of...

Objective To describe details of labor induction, including precursors and methods, and associated vaginal delivery rates. Study Design A retrospective cohort study of 208,695 electronic medical records from 19 hospitals across the United States, 2002–2008. Results Induction occurred in 42.9% of nulliparas and 31.8% of multiparas and elective or no recorded indication for induction at term occurred in 35.5% and 44.1%, respectively. Elective induction at term in multiparas was highly successful (vaginal delivery 97%) compared to nulliparas (76.2%). For all precursors, cesarean delivery was more common in nulliparas in the latent compared to active phase of labor. Regardless of method, vaginal delivery rates were higher with a ripe versus unripe cervix, particularly for multiparas (86.6 – 100%). Conclusions Induction of labor was a common obstetric intervention. Selecting appropriate candidates and waiting longer for labor to progress into the active phase would make an impact on decreasing the national cesarean delivery rate.

Why was the cohort set up? Optimal fetal growth is a foundation for long-term health, whereas abnormal growth affects disease risk across the lifespan. Both fetal growth restriction and overgrowth are associated with increased fetal, infant and child mortality and morbidity, 1,2 as well as being factors in reproductive disorders and later-onset diseases. Population-level data suggest a relationship between diminished birth size and chronic disorders, including hypertension, 3,4 supporting the early origins of health and disease research paradigm. 5 Despite the importance of adequate fetal growth, no US standards for ultrasound-measured fetal growth exist. Existing natality references describe the gestational age distribution of birthweight for all fetuses, including growth-restricted preterm infants and infants of diabetic mothers. 6-8 Existing ultrasound references have generally been constructed from local convenience samples which are not representative of the US population. In contrast, ultrasonographic standards can be purposefully developed to reflect optimal growth by restricting study populations

Aims/hypothesis The aim of this study was to prospectively and longitudinally investigate maternal iron status during early to mid-pregnancy, and subsequent risk of gestational diabetes mellitus (GDM), using a comprehensive panel of conventional and novel iron biomarkers. Methods A case-control study of 107 women with GDM and 214 controls (matched on age, race/ethnicity and gestational week during blood collection) was conducted within the the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singleton Cohort (2009)(2010)(2011)(2012)(2013), a prospective and multiracial pregnancy cohort. Plasma hepcidin, ferritin and soluble transferrin receptor (sTfR) were measured and sTfR:ferritin ratio was derived, twice before GDM diagnosis (gestational weeks 10-14 and 15-26) and at weeks 23-31 and 33-39. GDM diagnosis was ascertained from medical records. Adjusted ORs (aORs) for GDM were estimated using conditional logistic regression analysis, adjusting for demographics, prepregnancy BMI and other major risk factors. Results Hepcidin concentrations during weeks 15-26 were 16% higher among women with GDM vs controls (median 6.4 vs 5.5 ng/ml; p = 0.02 ), and were positively associated with GDM risk; the aOR (95% CI) for highest vs lowest quartile was 2.61 (1.07, 6.36). Ferritin levels were also positively associated with GDM risk; the aOR (95% CI) for highest vs lowest quartile was 2.43 (1.12, 5.28) at weeks 10-14 and 3.95 (1.38, 11.30) at weeks 15-26. The sTfR:ferritin ratio was inversely related to GDM risk; the aOR (95% CI) for highest vs lowest quartile was 0.33 (0.14, 0.80) at weeks 10-14 and 0.15 (0.05, 0.48) at weeks 15-26. Conclusions/interpretation Our findings suggest that elevated iron stores may be involved in the development of GDM from as early as the first trimester. This raises potential concerns for the recommendation of routine iron supplementation among iron-replete pregnant women.

Summary Several studies have reported that neural tube defects (NTD) occur more frequently among children born to women of lower socio-economic status (SES). This study investigated the relationship between individual- and neighbourhood-level SES and the risk of an NTD-affected pregnancy. Data were drawn from a population-based case-control study of fetuses and infants among a cohort of California births between July 1999 and June 2003. Information on individual SES was obtained via telephone interviews with mothers of 337 (76% of eligible) cases and 626 (79% of eligible) non-malformed liveborn controls. Respondents’ addresses were linked to the 2000 US Census to characterise six measures of neighbourhood SES (education, poverty, unemployment, occupation, crowding and rental occupancy). The analyses indicated that relative to women with a high school education, those with less than a high school education had a 1.7-fold increased risk of delivering infants with NTDs [95% CI 1.2, 2.6]. Twofold elevated risks for NTDs were observed for women with less than a high school education who lived in neighbourhoods where a majority of residents had not graduated from high school [95% CI 1.3, 3.1]. No consistent risk gradients were observed between NTD-affected pregnancies and indicators of lower neighbourhood SES. Results for phenotype subgroups were similar to those for all cases. Low maternal education was associated with an elevated risk of NTD in offspring. This risk varied by the education profile of the neighbourhood: women who did not graduate from high school and lived in less educated neighbourhoods exhibited a higher risk.