Are hypertensive disorders of pregnancy (HDP) associated with poorer neurodevelopmental outcomes in offspring independently of shared familial confounding factors?In this cohort study, offspring of HDP-complicated pregnancies had a somewhat higher incidence of autism spectrum disorders (ASDs), attention-deficit/hyperactivity disorder (ADHD), and intellectual disability (ID) and slightly lower overall cognitive performance. Analyses comparing siblings had less statistical power and indicated associations of a similar magnitude with ASDs and possibly ADHD only.This study suggests that HDP are associated with modestly increased risks of ASDs and possibly ADHD in offspring, whereas associations with ID and cognitive performance are likely the result of confounding by shared familial characteristics. Hypertensive disorders of pregnancy (HDP) have been associated with poorer neurodevelopmental outcomes in offspring, but the role of familial confounding in these associations is unclear.To investigate associations of maternal HDP with risks in offspring of autism spectrum disorders (ASDs), attention-deficit/hyperactivity disorder (ADHD), and intellectual disability (ID), as well as variation in overall cognitive performance in offspring.This Swedish register-based study used data from a birth cohort divided into 1 085 024 individuals born between 1987 and 1996 and followed up until December 31, 2014, and 285 901 men born between 1982 and 1992 who attended assessments for military conscription, including a cognitive function test. Statistical analysis was performed from April 1, 2019, to June 1, 2020.Diagnoses of HDP, which were provided by the Medical Birth Register.Diagnoses of ASDs, ADHD, and ID were extracted from the National Patient Register. Cognitive function was assessed using written tests and summarized as a single 9-point score. Whole-cohort and within-sibship analyses were performed; the latter accounted for unmeasured familial confounding factors shared by siblings.The study included 1 085 024 individuals  born between 1987 and 1996 and 285 901 men born between 1982 and 1992 who attended assessments for military conscription. The prevalence of maternal HDP was 4.0% in the 1987-1996 birth cohort (n = 42 980) and 5.1% in the military conscription cohort (n = 14 515). A total of 15 858 participants received a diagnosis of ASD, 36 852 received a diagnosis of ADHD, and 8454 received a diagnosis of ID. The mean (SD) cognitive score among the men in the conscription cohort was 5.1 (1.9). In whole-cohort analyses with multivariable adjustment, HDP were associated with offspring ASDs , ADHD , and ID . Analyses comparing siblings discordant for HDP were less statistically powered but indicated estimates of similar magnitude for ASDs  and possibly ADHD , but not for ID . Hypertensive disorders of pregnancy were associated with somewhat lower cognitive scores in whole-cohort analysis , but in within-sibship analysis, the association was null .The study results suggest that HDP are associated with small increased risks of ASDs and possibly ADHD in offspring, whereas associations with ID and cognitive performance are likely confounded by shared familial  factors. This cohort study investigates associations of maternal hypertensive disorders of pregnancy with risks in offspring of autism spectrum disorders, attention-deficit/hyperactivity disorder, and intellectual disability, as well as variation in overall cognitive performance in offspring. In addition, some,12 but not all,14 studies have found a higher incidence of intellectual disability (ID) and lower cognitive performance scores among offspring of HDP-complicated pregnancies. However, evidence as to whether reported associations represent true causal intrauterine effects has been judged as being insufficient.15Several studies have reported an increased incidence of neurodevelopmental disorders, including autism spectrum disorders (ASDs) and attention-deficit/hyperactivity disorder (ADHD),18 factors that tend to cluster within families and may determine the likelihood of offspring receiving a diagnosis of a neurodevelopmental outcome. Familial confounding by shared genetic factors may also exist because both traits are genetically determined, with recent evidence suggesting an association between maternal risk alleles for neurodevelopmental disorders (primarily ADHD) and pregnancy-related exposures.19 Because it would be impossible to randomize women with HDP, observational studies investigating the causal role of maternal HDP in offspring’s neurodevelopmental outcomes need to consider potential residual confounding by these shared familial factors.20Studies examining associations of prenatal exposures with offspring health outcomes are prone to residual confounding by environmental and genetic factors that are shared within families. Hypertensive disorders of pregnancy have been associated with sociodemographic and lifestyle characteristics,In this study, we examined the association of HDP with offspring ASDs, ADHD, and ID in a Swedish register-based birth cohort. In addition, we assessed the association with overall cognitive performance in male adolescents who were conscripted for military service in Sweden. To strengthen causal inference, we compared results from whole-cohort and within-sibship analyses, with the latter accounting for unmeasured familial confounding factors.21 which enables identification of first-degree relatives of each index individual. Permission for the study was granted by the Swedish Ethical Review Agency. Because this is a register-based study, informed consent was waived.We analyzed data from a birth cohort divided into 1 085 024 individuals born between 1987 and 1996 and followed up until December 31, 2014 (hereafter referred to as the “1987-1996 birth cohort”), and 285 901 men born between 1982 and 1992 who attended assessments for conscription into the Swedish military service at around 18 years of age (referred to as the “military conscription cohort”). These 2 subcohorts were assembled by merging data from various Swedish registers  codes 401 and 637 and International Classification of Diseases, Ninth Revision (ICD-9) code 642.10 These codes do not differentiate between specific HDP diagnoses but combine chronic hypertension (predating pregnancy or diagnosed before 20 weeks of gestation), gestational hypertension, and preeclampsia.23 Diagnostic criteria for gestational hypertension and preeclampsia specify that there is elevated blood pressure (in those without chronic hypertension) after 20 weeks of gestation. Because chronic hypertension is relatively rare in women of reproductive age, most HDP diagnoses will identify gestational hypertension or preeclampsia.Maternal HDP diagnoses were identified in the Medical Birth Register24 based on relevant International Classification of Diseases codes  database27 provided details on parental marital status, highest completed educational level, and occupational classification using an approximation of the European Socio-economic Classification28 around the time of birth of each offspring.Information on calendar year of birth, sex, gestational age, and birth weight was obtained from the Medical Birth Register. Maternal characteristics  and diagnoses of pregestational diabetes , whichever came first. The proportional hazards assumption was assessed graphically using scaled Schoenfeld residuals plots, showing no evidence of nonproportional hazards. Linear regression was used for examining associations with cognitive function scores, but we also evaluated the existence of a potential nonlinear association using multinomial logistic regression, including the scores as an ordinal outcome .P < .05 was considered statistically significant.Within-sibship analyses were conducted in a multilevel framework (siblings within families) by conditioning the analysis on the family identifier. The fixed-effects regression coefficients from these models provide estimates of the within-sibship association. We fitted 2 models for the whole-cohort and within-sibship analyses: (1) a model adjusted for year of birth only and (2) a multivariable-adjusted model including year of birth, maternal age, parity, height, and BMI; pregestational diabetes; parental educational level, occupation, and marital status; and offspring sex. The generalizability of the within-sibship results was assessed by repeating whole-cohort analyses for offspring with or without siblings. To investigate whether associations were mediated by timing of delivery and fetal growth, we performed model 2 with additional adjustment for gestational age at birth and birth weight for gestational age. All effect estimates are presented with 95% CIs. A 2-sided In total, 507 479 offspring (46.8%) in the 1987-1996 birth cohort and 131 861 offspring (46.1%) in the military conscription cohort had missing data for 1 or more covariates. The level of missing data was highest for maternal BMI and height because these variables were not routinely recorded in the Medical Birth Register until 1992. Because missing values were likely to be missing at random and to avoid loss in statistical efficiency, missing values were imputed using multiple imputation  analyses with more refined definitions of ASDs, ADHD, and ID requiring at least 2 diagnoses more than 6 months apart; (2) analyses with additional adjustment for conditions other than HDP complicating pregnancy, birth, or the puerperium in offspring with this diagnostic information  and 5.1% in the military conscription cohort (n = 14 515). The In the 1987-1996 birth cohort, offspring were followed up until a median age of 22.8 years ; 15 858 individuals were identified as having ASDs, 36 852 as having ADHD, and 8454 as having ID. In whole-cohort analysis with adjustment for calendar year of birth, HDP were associated with a 1.3-fold increased incidence of ASDs  and a 1.1-fold increased incidence of ADHD  . AdjustmAdditional adjustment for gestational age and birth weight for gestational age did not change the HRs for ASDs and ADHD (eTable 4 in the The mean (SD) cognitive function score in the military conscription cohort was 5.1 (1.9). Offspring exposed to HDP had a slightly lower score compared with those unexposed after adjustment for all measured confounders in whole-cohort analysis . In the within-sibship analysis, the point estimate indicated a null association  . ResultsOverall, effect estimates for all neurodevelopmental outcomes were not altered notably by varying conditions in sensitivity analyses  factors.In conventional analyses adjusted for measured confounding factors, we found that offspring who experienced HDP in utero had a small increased incidence of ASDs, ADHD, and ID and somewhat lower mean cognitive scores at 18 years of age compared with offspring who did not experience HDP in utero. In within-sibship analyses, which account for confounding by unmeasured shared familial characteristics, associations of similar magnitude were observed for ASDs and ADHD, although effect estimates (for ADHD in particular) did not reach conventional 4 showing an approximately 30% increased incidence of ASDs and ADHD associated with HDP. However, studies included in this meta-analysis had limited control for confounding factors, including socioeconomic, lifestyle, and genetic characteristics. More recent studies with better confounder control evaluating associations with preeclampsia only31 have reported effect estimates similar to those found in our study for HDP, including evidence of lower-magnitude associations for ADHD than ASDs. Our within-sibship results are also consistent with findings from a study by Leppert et al19 showing that maternal risk alleles for ASDs and ADHD are not associated with HDP. However, in that same study, maternal genetic predisposition to ADHD was associated with a range of other prenatal exposures, including maternal BMI. Because maternal BMI was not routinely measured for all individuals in our study, this might have biased the within-sibship association with ADHD observed in complete case analyses. Adjustment for gestational age and birth weight for gestational age did not materially change the association, indicating that impaired fetal growth is not implicated in the putative associations. Other mechanisms may include reduced fetal oxygenation resulting in structural brain alterations32 or inflammatory conditions that have been associated with both HDP33 and neurodevelopmental outcomes in offspring.34The magnitude of the associations observed with ASDs and ADHD is somewhat lower than those reported in a meta-analysis summarizing results of conventional whole-cohort analyses,15 A moderately large population-based study of children born in the 1950s in Scotland that adjusted for a wide range of potential confounders  found no association with offspring’s intelligence score measured in childhood.35 Between-study heterogeneous results may also be the consequence of the different methods used to assess these outcomes across studies. A cohort study of male conscripts in Finland found a lower cognitive score for those born to mothers with HDP.11 However, in our study, the magnitude of association was much smaller in whole-cohort analyses, and we failed to replicate this association in within-sibship analyses.Previous systematic reviews point to a possible positive association of HDP with ID and an inverse association with overall cognitive performance, but they highlight that this evidence comes mostly from studies involving selected  populations, such as those with low birth weight or born preterm, and studies that often fail to adjust for maternal characteristics that are likely to confound the association.37 Therefore, further research is warranted in this area, ideally with more specific definitions of HDP and ASDs. The lack of within-sibship associations for maternal HDP with offspring ID and overall cognitive performance suggests that the intrauterine milieu of HDP-complicated pregnancies does not play a critical role in the development of these outcomes.The consistent finding of an association of maternal HDP with ASDs, and possibly ADHD, in offspring suggests that HDP may represent an early-life risk factor for these outcomes. However, the magnitude of these associations might be too weak (for ADHD in particular) to be considered an important risk factor at the level of the general population, although it is anticipated that an increasing number of women will enter their pregnancy with high blood pressure.Our study has some strengths, including a population-based design with diagnoses obtained using individual record linkage from national registers, minimizing selection and information bias. We further examined associations across a broad spectrum of cognitive performance, including the extreme end of receiving a diagnosis of ID.38 but no external validation data exist for other outcomes. Register-based diagnoses are likely to be more conservative, and differential ascertainment due to socioeconomic factors and family history  may exist. However, because these factors tend to cluster within families, within-sibship analysis, at least to some extent, addresses this potential bias. Second, cognitive score data were available for men who were assessed for conscription into military service; most of these men were in good health, so those with an intellectual impairment may not have been included. Hence, results for this outcome may not be generalizable to the total Swedish population. Third, we had no data that allowed us to study associations with specific HDP diagnoses. Currently, there is insufficient evidence as to whether associations with neurodevelopmental outcomes are different for gestational hypertension and preeclampsia,15 partly because of the variable criteria used by studies to distinguish these diagnoses. The Medical Birth Register also does not hold information on gestational blood pressure and antihypertensive medications. Further studies investigating the influence of blood pressure control and treatment on the observed associations are therefore warranted. Fourth, within-sibship analyses are more susceptible to confounding by individual-level factors (as opposed to family-level confounders).39 We aimed to reduce potential bias by adjusting the within-sibship analyses for measured confounders used in the whole cohort that can differ between siblings of the same family.41 The actual familial discordance in HDP may also be less than modeled, but the impact of this is anticipated to be the same for the different outcomes studied. Fifth, within-sibship analyses are less statistically powered, and we carefully interpreted these results, focusing on the magnitude of associations as compared with those observed in whole-cohort analyses. Also, considering the relatively low incidence of ID and the smaller cohort for cognitive performance analysis, we cannot completely rule out associations for these 2 outcomes, but these would be very small given the effect estimates observed, and the clinical relevance of any such associations is likely to be limited.Several limitations are also noteworthy. First, we did not have diagnostic data from outpatient specialist records or psychometric measures not covered by the National Patient Register. A high positive predictive value has been reported for ASD diagnoses in this register (94%),Maternal HDP appear to be associated with small increased risks of ASDs and possibly ADHD in offspring. Associations with ID and overall cognitive performance are likely due to confounding by shared familial factors.


Are racial/ethnic disparities in care practices and major outcomes increasing or decreasing among extremely preterm infants in the US?In this cohort study of 20 092 extremely preterm infants, racial/ethnic disparities in rates of antenatal corticosteroids and cesarean delivery decreased over time. Changes in rates of mortality and most major morbidities did not differ among white, black, and Hispanic infants, and while mortality decreased over time from 2002 to 2016, rates of moderate-severe neurodevelopmental impairment increased over time in all groups.Racial/ethnic disparities in rates of potentially life-saving care practices decreased over time in the US, with reductions in mortality but increases in neurodevelopmental impairment in all racial/ethnic groups. Racial/ethnic disparities in quality of care among extremely preterm infants are associated with adverse outcomes.To assess whether racial/ethnic disparities in major outcomes and key care practices were changing over time among extremely preterm infants.This observational cohort study used prospectively collected data from 25 US academic medical centers. Participants included 20 092 infants of 22 to 27 weeks’ gestation with a birth weight of 401 to 1500 g born at centers participating in the National Institute of Child Health and Human Development Neonatal Research Network from 2002 to 2016. Of these infants, 9316 born from 2006 to 2014 were eligible for follow-up at 18 to 26 months’ postmenstrual age , of whom 745 (8.0%) did not have known follow-up outcomes at 18 to 26 months.Rates of mortality, major morbidities, and care practice use over time were evaluated using models adjusted for baseline characteristics, center, and birth year. Data analyses were conducted from 2018 to 2019.P = .59 for race × year interaction). The rates of late-onset sepsis among black infants (went from 37% to 24%) and Hispanic infants (went from 45% to 23%) were initially higher than for white infants (went from 36% to 25%) but decreased more rapidly and converged during the most recent years (P = .02 for race × year interaction). Changes in rates of other major morbidities did not differ by race/ethnicity. Death before follow-up decreased over time , but moderate-severe neurodevelopmental impairment increased over time in all racial/ethnic groups . Rates of antenatal corticosteroid exposure  and of cesarean delivery  were initially lower among black and Hispanic infants compared with white infants, but these differences decreased over time.In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Hospital mortality decreased over time in all groups. The rate of improvement in hospital mortality over time did not differ among black and Hispanic infants compared with white infants (black infants went from 35% to 24%, Hispanic infants went from 32% to 27%, and white infants went from 30% to 22%; Among extremely preterm infants, improvements in adjusted rates of mortality and most major morbidities did not differ by race/ethnicity, but rates of neurodevelopmental impairment increased in all groups. There were narrowing racial/ethnic disparities in important care practices, including the use of antenatal corticosteroids and cesarean delivery. This cohort study evaluates whether racial/ethnic disparities in key care practices and major outcomes changed among extremely preterm infants from 2002 to 2016 at centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Published reports document higher infant mortality rates among black infants in the United States,2 largely driven by a higher rate of preterm delivery.4 Although black mothers are more likely to deliver preterm and low-birth-weight infants,7 a survival advantage among black preterm infants and low-birth-weight infants has been reported.8 However, data from national population-based data sets have shown that the mortality rate among very preterm black infants is higher than that among very preterm white infants or among Hispanic infants,4 while the infant mortality rate may be decreasing faster among white infants and Hispanic infants relative to black infants.9Mortality and morbidity rates among extremely preterm infants are decreasing,12 but vital statistics databases do not collect this information.14 In addition to mortality and major morbidities, including neurodevelopmental impairment, data on selected prenatal and postnatal care practices are included in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network database. The primary goal of the present study was to assess whether racial/ethnic differences in hospital mortality rates were changing over time among infants born at one of the centers in this network. We also assessed whether racial/ethnic differences in rates of major morbidities and in utilization rates of major prenatal and postnatal care practices were changing over time.Racial disparities in health outcomes between white perterm infants and black preterm infants may be due to differences in care practices,15 were included. Gestational age was determined by best obstetrical estimate when available; otherwise, the best neonatal estimate was used.15 We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Data collection was approved by each center’s institutional review board. Most centers approved a waiver of informed consent (45 CFR part 46). Otherwise, written informed consent was obtained in a manner consistent with the US Common Rule requirements. No one received compensation or was offered any incentive for participating in this study.This cohort study evaluated maternal and neonatal data collected prospectively by trained research personnel. We included infants from 22 0/7 through 27 6/7 weeks’ gestation and with a birth weight 401 g to 1500 g born at one of the centers in the National Institute of Child Health and Human Development Neonatal Research Network between January 1, 2002, and December 31, 2016. Infants with congenital anomalies who were not resuscitated and infants who were stillborn were excluded. Infants without anomalies who died during the first 12 hours after birth with or without resuscitation1 Bronchopulmonary dysplasia was defined as the use of supplemental oxygen at 36 weeks’ postmenstrual age. Severe intracranial hemorrhage was defined as ventricular enlargement with concurrent or prior blood in the ventricles, or parenchymal blood or echodensity or both. Proven necrotizing enterocolitis was defined as stage 2 or greater by the modified Bell criteria.16 Severe retinopathy of prematurity was defined as stage 3 or greater or receiving surgery or both. Moderate-severe neurodevelopmental impairment at 18 to 26 months corrected age was defined as moderate or severe cerebral palsy based on an abnormal neuromotor examination and a score higher than 2 on the Gross Motor Function Classification System scale17; bilateral blindness; bilateral hearing loss receiving amplification; or cognitive composite score less than 70 on Bayley Scales of Infant Development, Third Edition (Bayley-III). Infants were eligible for follow-up if they weighed 401 to 1000 g from 2006 to 2007 regardless of gestational age, if they had a gestational age from 22 0/7 to 26 6/7 weeks from 2008 to 2014 regardless of weight, or if they were in a clinical trial that assessed neurodevelopmental outcomes. For uniformity, neurodevelopmental outcomes were not analyzed for infants born before 2006 because the Bayley-III was introduced in that year.18 Antenatal care practices examined included exposure to antibiotics in the 72 hours before delivery, any antenatal corticosteroids, or magnesium sulfate, and mode of delivery. Postnatal care practices included treatment with surfactant, mechanical ventilation, or postnatal steroids for bronchopulmonary dysplasia, and whether any human milk was received in the first 28 days after birth.Self-reported maternal race/ethnicity was abstracted from the medical record and used to define infant race/ethnicity. Mothers with more than 1 race, unknown race/ethnicity, or race/ethnicity other than black non-Hispanic (referred to as black in the present study), white non-Hispanic (referred to as white in the present study), or Hispanic (including black or white) were not included. Paternal race/ethnicity was not recorded. Hospital outcomes until death, hospital discharge, or 120 days were collected using standardized definitions.19 An a priori power calculation showed that the sample of all infants delivered between 2002 and 2016 would provide more than 90% power to detect a statistically significant odds ratio of 0.9 or lower or 1.1 or higher , assuming a 2-sided statistical significance level of 5%.The primary outcome was the difference between black infants, Hispanic infants, and white infants (the reference group) in the rate of change of the in-hospital mortality rate over time. Prespecified exploratory outcomes included changes in rates of major morbidities and receipt of care practices over time. Because mortality is a competing outcome for major morbidities in extremely preterm infants, composite rates of mortality or individual major morbidities were also evaluated.2 test. The Kruskal-Wallis test was used for continuous skewed variables. Logistic regression was performed adjusting for infant and maternal factors present at birth associated with adverse infant outcomes, including infant gestational age, birth weight, sex, antenatal corticosteroid exposure, mode of delivery, multiple gestation, small for gestational age (<10th centile),20 birth center, and prenatal care, and maternal age, educational level, insurance status, marital status, diabetes , hypertension (chronic and pregnancy-induced), and antepartum hemorrhage. Missing data were not imputed. All models were adjusted for birth year  and tested for the presence of statistical interaction between birth year and race/ethnicity. A type 3 P value for the interaction term between race/ethnicity and time was used to evaluate whether adjusted rates of change over time for a given outcome differed by race/ethnicity. Smoothed lines were fit to the unadjusted data using a spline routine. Smoothing splines provide a flexible means for smoothing noisy data using piecewise polynomial regression modeling to uncover patterns in the data.Unadjusted differences in categorical variables were analyzed with the χ21 We used SAS software, version 9.4 (SAS Institute Inc), for statistical analyses, with a 2-sided P < .05 indicating statistical significance. Analyses were conducted from 2018 to 2019.Post hoc logistic regression models adjusting for biological variables alone , care practice variables alone , and socioeconomic factors alone  were undertaken to understand the relative association of these factors with the complete model. We conducted additional sensitivity analyses excluding maternal educational level owing to a high rate of missing data (15.9%). Sensitivity analyses were also undertaken excluding infants who died within 12 hours after birth without resuscitation to ensure that results were not affected by postnatal restriction of care and also excluding centers that were not part of the Neonatal Research Network for the entire period to examine for confounding by center participation. Differential associations of race/ethnicity by center were also explored by adding an interaction term between race/ethnicity and center.In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Baseline maternal characteristics, including rates of documented chorioamnionitis, hypertension, antepartum hemorrhage, prenatal care, high school graduation, private health insurance, and marriage differed by race/ethnicity . Black iP = .59 for race × year interaction)  . From 20raction) . After araction) . Black iraction) . There wP < .001). After exclusion of these infants, there remained no difference in the rate of improvement in hospital mortality among black infants (went from 27% to 21%) and Hispanic infants (went from 25% to 20%) compared with white infants (went from 27% to 18%) over time  (P = .02) due to a faster decrease among Hispanic infants (went from 47% to 28%) compared with white infants (went from 39% to 33%) during this shortened period , 340 of 3701 Hispanic infants (9.2%), and 452 of 8060 white infants (5.6%) (raction) . Among td period .P = .04; For composite outcomes, there was a significant race × year interaction in the rate of late-onset sepsis or death because the rates among black infants (went from 59% to 40%) and Hispanic infants (went from 62% to 42%) were initially higher but decreased faster compared with white infants (went from 54% to 40%) and converged during the most recent years P = .04; . Race × P = .02)  and Hispanic infants (went from 45% to 23%) were initially higher but decreased faster compared with white infants (went from 36% to 25%) and converged during the most recent years (P = .02) . Race × P = .01 for race × year interaction) . Increasing rates of antibiotic exposure within 72 hours before delivery were observed in all groups but increased faster among Hispanic infants (P = .01 for race × year interaction). There was no difference in the rate of treatment with magnesium sulfate before delivery by race/ethnicity. The rate of treatment with mechanical ventilation decreased across all groups over time, and there was a significant race × year interaction because rates of treatment decreased faster among Hispanic infants   and Hispanic infants (went from 73% to 83%), but this difference with white infants (went from 86% to 90%) decreased over time (P = .79 for race × year interaction). To better understand center differences by race/ethnicity, we then dropped the race × year interaction term and added a term for race × center interaction to allow for race/ethnicity associations to differ by center. This interaction was statistically significant (P < .001). However, further analyses showed that this race × center interaction was mostly due to differences in magnitude rather than to the direction of the association because the trend toward lower adjusted mortality rates among minority infants was generally consistent (eFigure 4 in the Center participation was examined as a potential confounder in an analysis restricted to 11 centers that participated for the entire study period, and the results for mortality over time did not differ (This large multicenter cohort study showed no racial/ethnic disparities in changes over time in mortality or most major neonatal morbidities among extremely preterm infants. While hospital mortality decreased over time, rates of moderate-severe neurodevelopmental impairment increased across all racial/ethnic groups. Racial/ethnic disparities in late-onset sepsis narrowed over time, decreasing faster among black infants and Hispanic infants compared with white infants before converging. Racial/ethnic disparities in the rates of important care practices, including receipt of antenatal corticosteroids and cesarean delivery, also decreased over time among black infants and Hispanic infants compared with white infants.24 and 1 study found that mortality increased among very low-birth-weight black infants and was associated with a survival disadvantage.25 Recent data from the Vermont Oxford Network noted a narrowing survival disadvantage among black and among Hispanic very preterm infants.12 The aforementioned studies did not adjust for many known risk factors for adverse outcomes, including biological, care practice, and socioeconomic variables.26 In the present study, in contrast to the unadjusted mortality rates, adjusted mortality rates favored black infants and Hispanic infants compared with white infants.Population-based data sets comparing survival trends have noted a narrowing survival advantage among extremely preterm and extremely low-birth-weight black infants compared with white infants,21 Socioeconomic factors are associated with lower rates of survival within 1 hour after birth among periviable infants, likely owing to differences in providing resuscitation.27 We found multiple socioeconomic differences by race/ethnicity, but it is unknown whether these influenced clinical decision-making.Exclusion of infants who died without resuscitation did not alter our results, suggesting that mortality rates by race/ethnicity were not significantly associated with postnatal restriction of care. However, a larger proportion of Hispanic infants died without resuscitation. Differences in hospital rates of active treatment account for a large proportion of variation in survival among periviable infants, and these rates vary by race/ethnicity.28 Racial/ethnic disparities in the quality of care and infant outcomes among preterm infants vary between centers.28 Our data represented a nonrandom sample of extremely preterm infants from a geographically diverse set of academic centers of excellence. Although the center was a significant confounder for overall mortality by race/ethnicity in the present study, the direction of this association indicated a trend toward lower adjusted mortality rates among minority infants across most centers.A significant proportion of racial/ethnic disparities in infant outcomes may be attributed to birth center.14 the Vermont Oxford Network found narrowing disparities in late-onset sepsis, receipt of antenatal corticosteroids, and cesarean delivery.12 Disproportionate improvements in rates of late-onset sepsis and antenatal corticosteroid receipt29 among black infants and Hispanic infants were also identified in our study, suggesting that minority infants benefitted most from quality improvement initiatives. Willingness to perform cesarean delivery is associated with improved survival,30 and narrowing disparities in cesarean delivery may reflect improved fetal monitoring. Moderate-severe neurodevelopmental impairment increased over time across all groups in our study, emphasizing the importance of long-term follow-up data. It is possible that this increase was associated with improvements in mortality because there was no significant change in the rate of death or moderate-severe neurodevelopmental impairment.Using a database that overcomes the limitations of vital statistics data sets,31 Furthermore, genetic ancestry markers show much heterogeneity,32 indicating that race/ethnicity may be largely a social construct.33 It is unlikely that our results are due solely to confounding, but there was likely residual bias in our models.33 For example, data were unavailable on the adequacy of prenatal care, fetal monitoring, perinatal decision-making and counseling, the length of prenatal maternal admission,35 and parental employment. The multiple testing with a 5% significance level may have resulted in outcomes being significant by chance. Our detailed data set includes a subset of infants born in academic centers in the United States that may not be representative of the broader population.This study analyzed major outcomes, including neurodevelopmental impairment, using a large prospective database with adjustment for multiple biological, care practice, and socioeconomic variables. However, there were a number of limitations that must be noted. Race/ethnicity was recorded as reported by the mother alone, although self-reported maternal race/ethnicity and infant genetic ancestry are closely correlated.This cohort study found no racial/ethnic differences in changes in mortality rates or most major morbidities among extremely preterm infants, with mortality decreasing over time across all groups. Racial/ethnic disparities in the rate of late-onset sepsis decreased over time. There were narrowing racial/ethnic disparities in key interventions, including receipt of antenatal corticosteroids and cesarean delivery. However, there were increasing rates of moderate-severe neurodevelopmental impairment that did not differ by race/ethnicity. Adherence to evidence-based medicine and continued quality improvement efforts should further improve outcomes of extremely preterm infants among all racial and ethnic groups.


Retinopathy of prematurity (ROP) is a disease that causes vision loss, vision impairment, and blindness, most frequently manifesting among preterm infants. ROPScore and CHOP ROP  are similar scoring models to predict ROP using risk factors such as postnatal weight gain, birth weight (BW), and gestation age (GA). The purpose of this study was to compare the accuracy and difference between using ROPScore and CHOP ROP for the early prediction of ROP.A retrospective study was conducted from January 2009 to December 2019 in China. Patients eligible for enrollment included infants admitted to NICU at ≤32 weeks GA or those with ≤1500 g BW. The sensitivity and specificity of ROPScore and CHOP ROP were analyzed, as well as its suitability as an independent predictor of ROP.Severe ROP was found in 5.0% of preterm infants. The sensitivity and specificity of the ROPScore test at any stage of ROP was 55.8 and 77.8%, respectively. For severe ROP, the sensitivity and specificity was 50 and 87.0%, respectively. The area under the receiver operating characteristic curve for the ROPScore for predicting severe ROP was 0.76. This value was significantly higher than the values for birth weight (0.60), gestational age (0.73), and duration of ventilation (0.63), when each was category measured separately. For the CHOP ROP, it correctly predicted infants who developed type 1 ROP .The CHOP ROP model predicted infants who developed type 1 ROP at a sensitivity of 100% whereas ROPScore had a sensitivity of 55.8%. Therefore, the CHOP ROP model is more suitable for Chinese populations than the ROPScore test.This article was a retrospective cohort study and reported the results of the ROPScore and CHOP ROP algorithms. No results pertaining to interventions on human participants were reported. Thus, registration was not required and this study followed STROBE guidelines. Retinopathy of prematurity (ROP) is a disease that causes vision loss, vision impairment, and blindness, most frequently manifesting among infants with low birth weight (BW) and poor health status. The survival of preterm infants has increased in the last few decades due to the rapid improvement in neonatal intensive care. Consequently, the incidence of ROP has increased, particularly in newly industrialized countries, comprising of a “third epidemic.”  The repoThe development of ROP is associated with multiple risk factors. Early gestation age (GA) and low BW are two of the most important risk factors. Other factors include blood transfusion, mechanical ventilation, anemia, respiratory distress, dyspnea, and poor health. Several screening guidelines of ROP based on GA and BW have been introduced for neonatologists to use in identification of preterm neonates who are at ≤32 weeks GA, or BW ≤1500 g. Risk criteria for preterm neonates include neonates at ≤32 weeks GA or with a BW ≤1500 g. An infant with a very unstable clinical course can also be identified to be of high risk for developing ROP, indicating a need for ophthalmology screening . ChallenThe ROPScore proposed by Eckert et al. is a scoring system that can be used to predict the severity of ROP . This alAs far as known to the authors, only a few studies have validated this screening tool –11. ThesA retrospective cohort study was conducted from January 2009 to December 2019 in NICUs in Henan Province, China. The Life Science Ethics Committee of Children’s Hospital Affiliated to Zhengzhou University approved the study (IRB number 20081227).Patients eligible for enrollment included infants admitted to the NICU at GA ≤32 weeks or BW ≤1500 g. Infants with any of the following were excluded from this study: genetic metabolic diseases, congenital major abnormalities, and infants who died before the sixth week after birth.Follow standard clinical procedures for all infants and weight measurements were conducted weekly from birth to discharge. These measurements were repeated again at a GA of 40 weeks .ROPScore Screening was conducted in the sixth week of life with a Microsoft Excel spreadsheet , as suggested by Eckert et al.  This algBinenbaum et al. developed a simpler logistic regression based model named PINT ROP . The PINROP screening was performed for all extremely preterm infants by qualified ophthalmologists with expertise in ROP in accordance with the Chinese guidelines for the examination and treatment of ROP . The choThe following clinical data was collected: age, sex, gestational age, birth weight, number of blood transfusion, weekly weight measurements, days of mechanical ventilation and oxygen administration, ROP examination results, and the incidences of necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and sepsis. Diagnosis of ROP was conducted by pediatric ophthalmologists. Evaluations of ROP were judged as follows: none, immature, or mature vascularization. Staging of disease was performed in accordance with the International Classification of ROP , 19.p < 0.05.SPSS software version 19.0  was used for statistical analysis and data management. Maternal and infant characteristics were analyzed using descriptive methods and compared using t-test or one-way ANOVA (> 2 levels) for continuous variables and the chi-squared test for categorical variables. Receiver operating characteristic (ROC) curves were used to assess the accuracy of the continuous values of the ROPScore and CHOP ROP model to predict severe ROP. ROPScore was used as a dependent variable in conducting multiple linear regressions. The independent variables used in multiple logistic regression analysis were based on significant correlations and significant non-parametric univariate analyses. For severe ROP, these variables were: BW, GA, duration of ventilation, sepsis, and weight gain at the sixth week of life. The statistical significance level was set at p < 0.001 respectively).In this study, 3624 children were screened for ROP and underwent weekly weight measurements. The ROPScore and CHOP ROP model was developed for infants with GA ≤32 weeks at birth or BW ≤1500 g. 37 infants were excluded due to incomplete weight data or because they had pathological conditions. Thus, 3587 infants born at GA ≤32 weeks or with BW ≤1500 g were included in this study. The prevalence at any stage of ROP was 372/3587 infants (10.4%). 192 preterm infants developed type 2 ROP (5.4%) and 180/3587 developed type 1 ROP that required treatment (5.0%). The baseline demographics and clinical characteristics for this cohort are shown in , GA (0.73), and duration of ventilation (0.63), when measured separately Table .Table 2Multivariate logistic regression analysis showed that BW, GA, duration of ventilation, number of blood transfusions, and weight gain at the sixth week of life were risk factors for ROP. ROPScore had less tendency of predicting ROP. The unadjusted coefficient was 0.064, with an odds ratio of 1.07 at a 95% confidence interval CI, 1.03 to 1.11). The adjusted coefficient was 1.088 with an odds ratio of 2.97 at 95% CI (0.84 to 10.45) , but with a low specificities of 21.4% from birth to six weeks of life, 41.2% in the third week, 36.9% in the fourth week, 32.6% in the fifth week, and 38.0% in the sixth week. These results are summarized in  has already increased, such that low IGF-1 may play a smaller role in the pathogenesis of severe ROP . In contWe validated the CHOP ROP model in a large cohort of Chinese infants. The size of the cohort, including 180 infants who developed severe ROP, allowed us to estimate the sensitivity of the model with a high degree of precision. In this study, it was showed that the CHOP ROP model can be applied clinically to reduce the number of infants requiring examinations by one-third. No infants with type 1 ROP were excluded  using this model, which showed higher sensitivity compared to the evaluation of North American infants  . TherefoIn China, the prevalence of ROP varies according to the region, level of neonatal care, and access to ophthalmologic screening programs. Importantly, blindness caused by ROP can be prevented with timely screening . The CHORegardless of the positive aspects of these predictive algorithm, there are also limitations in clinical application. First, ROPScore calculation uses preterm weight only at the sixth week of life. Hence, this test may be unable to detect high-risk preterm infants in which aggressive posterior ROP begins prior to weight measurement, then evolves rapidly . MoreoveWe demonstrated that the ROPScore and CHOP ROP models were an effective, promising, and noninvasive screening tool for the prediction of ROP in a Chinese population of preterm infants. The results obtained by Eckert et al.  were com


Porphyromonas gingivalis, as well as urogenital microorganisms (UGM) could translocate to the placenta and activate immune mechanisms in decidual tissue that is associated with adverse pregnancy outcomes (APO). This study establishes the associations between the presence of microbes in the placenta and placental cytokine patterns in women who presented APO, e.g., low birth weight (LBW), preterm premature rupture of membranes (PPROM), preterm birth (PTB) and other clinical signs related to Chorioamnionitis (CA). A total of 40 pregnant women were included in the study and divided into five groups according to placental infection (PI) and APO, as follows: (1) women without PI and without APO (n = 17), (2) women with P. gingivalis-related PI and APO (n = 5), (3) women with P. gingivalis-related PI and without APO (n = 4), (4) women with PI related to UGM and APO (n = 5) and (5) women without PI with APO (n = 9). Obstetric, clinical periodontal status evaluation, and subgingival plaque sampling were performed at the time of delivery. Placental levels of interleukin IL-1β, IL-6, IL-10, IL-15, IL-17A, IL-17F, IL-21, IL-12p70, tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein-1 α (MCP-1α), granzyme B, and interferon-γ (IFN-γ) were determined using a multiplex flow cytometry assay. All patients showed a predominant Th-1 cytokine profile related to labor, characterized by IFN-γ overexpression. The analysis by groups suggests that Th-1 profile was trending to maintain cytotoxic cell activity by the expression of IL-15 and granzyme B, except for the group with P. gingivalis-related PI and APO, which exhibited a reduction of IL-10 and IL-17F cytokines (p < 0.05) and a Th-1 profile favoring macrophage activation by MCP-1 production (p < 0.05). This study confirms a pro-inflammatory pattern associated with labor, characterized by a Th-1 profile and the activity of cytotoxic cells, which is enhanced by PI with UGM. However, PI associated with P. gingivalis suggests a switch where the Th-1 profile favors an inflammatory response mediated by MCP-1 and macrophage activity as a mechanistic explanation of its possible relationship with adverse outcomes in pregnancy.The microbiome modulates inflammation at the fetal maternal interface on both term and preterm labor. Inflammophilic oral bacteria, such as  Given the concept that the uterus is a sterile microenvironment, the description of the presence of a healthy microbiome, typical of the placenta, has been widely debated since 2014 by different studies, both in favor  and agaiNowadays, there is a lack of consensus regarding the definition of the terms chorioamnionitis (CA) or intra-amniotic infection, and a of specific clinical signs and symptoms of intra-amniotic infection even if diagnosed with the gold standard of culture/PCR in amniotic fluid . NeverthThe abundance of certain species with clinical relevance differs between placentas after spontaneous PTB, non-spontaneous PTB, and term birth and supports the fact that a significant percentage of placentas prone to spontaneous PTB has a component of intrauterine infection . The frevia the fallopian tubes; (4) from the intestine or from the blood; or (5) from leukocytes and dendritic cells carrying bacteria and spreading them to other locations such as the uterus (The intrauterine microbiome can come from different sites and get there by different routes: it may arrive (1) ascending from the vagina through small channels in the cervical mucus; (2) by the hematogenous route; (3) by transmembrane filtration from the intestine to the peritoneal cavity with retrograde ascension e uterus . The heme uterus .Periodontitis is an inflammatory non-communicable disease that develops in susceptible subjects from the actions of dysbiotic microbial communities and pathobionts that exhibit synergistic virulence that potentiates the host response, while promoting their own survival by cross feeding from the products of inflammation related to tissue destruction. Periodontitis may eventually lead to tooth loss and systemic complications , includiP. gingivalis is considered a keystone pathogen in the pathogenesis of periodontitis. This type of pathogens supports and stabilizes microbiota associated with disease states and has the capacity to cause inflammation even if present in insignificant quantities  cells and macrophages and they decrease the production of proinflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor-α (TNF-α). Progesterone may inhibit lymphocyte activation and reduce Th-1 profile cytokines , so an increase in the levels of these hormones may be involved in maternal-fetal nonrejection . HoweverThe presence of several cytokines in the amniotic fluid has been reported as an inflammatory marker to predict the risk of preterm delivery . Th-1-tyA complex interaction between infection and inflammation on both the systemic and intrauterine environments and various biological processes between pathogen and host seem to be crucially involved in the pregnancy outcomes. However, the mechanisms of the immune activation pathways and the triggers of the immune response at the molecular level, associated with induction of preterm labor are not clear. Causal infectious agents, the role of polymicrobial infections, critical sites of infection, as well as the participation of cells and activation pathways of the immune response have barely been identified .P. gingivalis to the amniotic fluid and placenta of women with APO; however, the molecular mechanisms by which P. gingivalis relates to the occurrence of complications during pregnancy and in the newborn are not clear in the literature  Direct invasion, translocation, and injury to the foetal-placental unit/interface and maternal tissues, (2) Persistence and survival within the foetal and maternal tissues and immune response evasion, (3) Increased production of proinflammatory cytokines and shift in maternal-foetal immune response from Th2 to Th1 with the onset of Th17/T regulatory cell imbalance, (4) Activation of the acute-phase response, (5) Onset of Polymicrobial dysbiosis and development of pathobiont species, (6) Increased oxidative stress in the foetal and maternal tissue, and (7) Increased foetal adrenal cortisone production and the onset of foetal stress  and the pattern of cytokine expression in the placenta  which may be related to the occurrence of APOs  and other clinical signs related to CA.Based on the occurrence of APO and the presence or absence of placental infection (PI), this study seeks to establish a possible relationship between the presence of PI by This study involved a group of subjects from a larger previously published case control study  whose obA total of 224 pregnant women aged ≥18 years that were admitted for delivery at the Service of Gynecology and Obstetrics of Hospital Simon Bolivar in Bogotá, Colombia from August 2014 to August 2016 were initially enrolled in the case control study of oral and urogenital intra-amniotic infection in women with preterm delivery , in whicFor cytokine analysis, a second phase was carried out and the patients were selected based on the results of first phase specially the presence of infection and perinatal condition. In order to control the influence of age and other reasons of inflammation, all women older than 40 years and patients with pre-eclampsia were excluded.P. gingivalis infection. The groups were distributed as follows:n = 17.Group 1 – Control group for APO and PI. All women without APO, with a suitable pregnancy control  and periodontal health with very low rates of inflammation evidence  P. gingivalis-related PI with APO. All women with PI associated with P. gingivalis with APO (one aged >40 years was excluded) n = 5.Group 2 – P. gingivalis-related PI without APO. All women with PI associated with P. gingivalis without APO  n = 4.Group 3 – n = 5.Group 4 – UGM-related PI with APO. All women with PI associated with UGM with APO (three participants were excluded due to preeclampsia or >40 years old) P. gingivalis and by UGM only. n = 9 .Group 5 – No PI with APO. nine women with APO without PI paired by age with nine women with APO/PI including infection by PTB was established for those births that occurred before 37 weeks of gestation, and LBW was established for infants weighing <2,500 g. PPROM was established for those patients who had >12 h from rupture to delivery. Clinical signs of PI were identified as fever, maternal tachycardia, fetal tachycardia, and fetid fluid .Two calibrated periodontists (properly trained before the beginning of the study), who were blinded regarding the group category at the time of the evaluation, performed the periodontal assessment of all patients before or up to 8 h after delivery. A full-mouth examination was performed at six sites on each permanent tooth using a North Carolina® probe . The indices employed for the diagnosis were: probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), plaque index, and gingival index (GI). The presence of periodontitis was determined according to the criteria established by the Centers for Disease Control and Prevention/American Academy of Periodontology  detection of 2) were taken: one at the umbilical cord insertion base and the second at the free edge of the contralateral cotyledon of the first sample, which were transferred to an empty sterile microcentrifuge tube and refrigerated at −20°C until processing. One sample was used for extraction and amplification of bacterial DNA in the placenta and the other one for tissue cytokine profile detection in patients with PI.After delivery, two samples of amniotic membrane  was added to homogenize in vortex. All tubes with the samples were submerged in liquid nitrogen for 5 min to achieve a complete lysis of the tissue. After thawing, 100 μl buffer ATL, 3 μl proteinase K, and 16 μl lysozyme were added and mixed in vortex until complete homogenization was achieved. The samples were incubated with shaking at a temperature of 56°C for 24 h until complete lysis was achieved and vortexed again.P. gingivalis, T. forsythia, T. denticola, A. actinomycetemcomitans, Campylobacter rectus, and Prevotella intermedia  was used. Before DNA amplification, the purity and amount of DNA were obtained using NanoDrop 2000 . Bacterial DNA amplification was performed by nested PCR using a universal primer for Eubacteria for the first amplification EUB27F: 5'-GAG TTT GAT CCT GGC TCA G-3' and EUB1544R: 5'-AGA AAG GAG GTG ATC CAG CC-3', directed to the amplification of a fragment of the 16S rRNA gene, common among the bacteria. The amplification was evidenced by the presence of the amplification product (1407 bp) in agarose gel (2%) with 0.5 μg/ml ethidium bromide. The amplification of the specified DNA for each microorganism was done using the PCR product obtained from the amplification as the template for the universal primer of oral bacteria such as termedia , Parvimoucleatum , and theaginalis , Ureaplaalyticum , Mycopla hominis , and Canalbicans . Those iThe placental samples were homogenized by mechanical disaggregation of tissues using the Medimachine System . The samples were cut in small pieces, which were inserted into a Medicon of 35 μm  by adding 10 μl protease-free PBS  for 3 cycles at 80 rpm. The homogenized samples were passed through Filcons of 20 μm , a washing cycle at 1800 rpm for 5 min was done, and the supernatants were recovered to measure the soluble cytokine levels using a multiplex bead-based LEGENDplex™ assay by flow cytometry. A Human Th Cytokine mix and match 13 plex Panel  was customized, in which 13 capture beads of two different sizes were used, each one conjugated with antibodies against IFN-γ, IL-12p70, IL-17A, IL-17F, IL-23, IL-21, IL-10, IL-15, granzyme B, MCP-1, TNF-α, IL-1ß, or IL-6. The samples were processed according to manufacture instructions in a sandwich immunoassay. The flow cytometry acquisition was carried out in a BD FACS Accuri™ C6 Plus using the BD Accuri™ C6 Plus software; the analysis was performed based on a standard curve into a logistic regression model . The results were expressed in pg/ml units.post-hoc test was performed to compare the relationship between cytokine/IFN-γ among groups. Spearman rank based pairwise correlation analysis was performed to analyze cytokine abundances in all the groups. R statistical software and IBM-SPSS version 23 were used for all analyses. Heatmaps were made using Morpheus, https://software.broadinstitute.org/morpheus.In order to find correlations among cytokine profile groups and APO, a Factorial analysis of mixed data (FAMD) was performed that combined Principal Component Analysis (PCA) for continuous variables and Multiple Correspondence Analysis (MCA) for categorical variables . KruskalP. gingivalis to placental tissue (p > 0.05).In total 40 patients were included to assess the cytokine response and the association with atopobiosis of l tissue . The socl tissue . There wP. gingivalis-related PI with APO), group 3  and group 4  which presented a higher frequency of periodontitis (p < 0.05). No significant differences were observed for plaque index, PD, or CAL among groups (p > 0.05). Distribution of microorganisms in subgingival plaque is presented in Oral clinical assessment showed periodontitis presence in group 2 , which was the group with the greatest contribution to the model representing a differential pattern associated to an activation of inflammatory response . Meanwhile, macrophage activation cytokines (MCP-1 and IL6) in Th-1 profiling were maintained in both groups , suggesting an important role for these cells in APO related to P. gingivalis placental infection. UGM infections did not show significant differences with the control group for any cytokine profile , P. gingivalis-related PI without APO (Pg-APO+), UGM-related PI with APO (UGM + APO+), and No PI with APO (PI-APO+) groups by Spearman’s rank-based correlations  and the maintenance of those which are associated to macrophage activation when it was compared with the control group. In contrast, the other groups evaluated in this study presented a very similar pattern of cytokine expression characterized by high levels of IFN-γ and NK-related cytokines.These results for It is well known that during pregnancy there are multiple factors  that impact and influence the oral microflora; nevertheless, the role of oral atopobiosis in modulating inflammation in conditions like pregnancy is not yet clear since the oral microflora during gestation is still poorly characterized. This is even more relevant if the similarities of the placenta microbiome and that of the oral cavity are considered, which highlights the importance of atopobiosis of oral microorganisms in APOs .The amniotic cavity of women with PTB has a much higher DNA content (more than previously believed) with a great diversity of microorganisms, including many that have not yet been characterized; The strength of these findings, due to the amount and timing in which they occur, could be useful in formulating a hypothesis to establish a causal association with APOs ; In the P. gingivalis was the most prevalent identified oral microorganism in PI ; however, in most cases it was not associated with the presence of clinical signs of intrauterine infection, although its frequency was higher in cases with APO  and independent of the presence of APO. In group 4, where there was no PI due to P. gingivalis, the prevalence of periodontitis was lower and in the group with aseptic APOs, there was no periodontitis. Thus, not only the presence of the bacteria determines the occurrence of conditions or diseases linked to it. This would explain why not all the subjects with subgingival P. gingivalis have periodontitis or why not all the patients with PI with P. gingivalis show signs of clinical intrauterine infection or APO. Other factors, such as the amount of inoculum, virulence of the isolated microorganism, and individual immune response to the microorganism, could be associated with perinatal complications , which alters the development of the entire biofilm; then P. gingivalis exerts its role of “keystone pathogen” modulating the host response in susceptible individuals  showed clinical signs of intrauterine infection, which could indicate alterations in the mechanisms of inflammation in subjects susceptible to both infection and inflammation. There are multiple mechanisms described by which P. gingivalis could be related to the above. In the murine model, changes in gestational tissues have been observed after translocation of P. gingivalis, including areas of focused necrosis and increased inflammatory infiltrate. An increase in the expression of Fas, Fas-L and TLR2 at the placental level related to PTB is also observed in rats  is related to a dysregulation of the system by activation of the previously described proinflammatory mechanisms, which could trigger labor prematurely.The role of macrophages in childbirth is well documented; Their participation occurs in multiple ways that include: Participation in the remodeling of the cervix at delivery due to MMP secretion (such as MMP9) both in PPT and at term birth, related to an increase in macrophages residing in the decidua at the moment of delivery ; It coulP. gingivalis induced a significant increase in the expression of COX-2, IL-8, and TNF-α in the trophoblast HTR-8 through the TLR-2/TLR-4-NF-κB signaling pathway, supporting the potential of P. gingivalis to induce proinflammatory effects in the placenta , which could indicate that the cytokines of the Th-17 profile do not seem to be increased or related to the adverse event with PI associated with P. gingivalis. In contrast, it was observed that IL-17F regulating IL-17A in this same group presented a significant reduction, which may indicate that the problem is not the overproduction of proinflammatory cytokines but an alteration in the regulation of this cytokine profile.Another immunological mechanism that has been proposed to explain preterm delivery corresponds to detectable levels of cytokines associated with the Th-17 profile that has been reported to be related to the degradation of the decidua and that increase in cases of PTB with CA . HoweverP. gingivalis can induce atopobiosis (translocation) to the placenta and trigger inflammation, although a direct relationship with the occurrence of APO cannot be proven.Periodontitis could be associated with clinical signs of placental infection and APO. Periodontal infection by P. gingivalis suggests a switch where the balance of Th-1 profile favors an inflammatory response mediated by MCP-1 and macrophage activity as a mechanistic explanation of its possible relationship with adverse outcomes during pregnancy.There is a pro-inflammatory pattern associated with labor, characterized by Th-1 profile and the activity of cytotoxic cells, which is enhanced by placental infection with UGM. However, PI associated with P. gingivalis associated with APO or CA.One of the major limitations of this study was the size of the groups. Despite the number of patients included in the initial phase, the prevalence of PI was low and low concentrations of bacterial DNA were obtained. Although 12 species of microorganisms associated with PI were evaluated in this study, more could be accomplished using nested PCR-species-specific, sequencing and metagenomic techniques which could provide more information on the placental microbiome; the use of these techniques is suggested for future studies that evaluate immune response in the placenta in the presence of infection. Although the size of the groups was small, the results of this study are the first to be published on a differential pattern associated with human placental infection by The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Ethics Committee of Universidad El Bosque (PCI-2014-18). The patients/participants provided their written informed consent to participate in this study.The authors certify that they have participated sufficiently in the work to take public responsibility for the appropriateness of the design and method of review, as well as, the reviewing of the manuscript and approve it for publication. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Our study suggests that infants with DD who present dysmorphism or brain anomaly may benefit from early CMA analysis, for adequate diagnosis and timely treatment. Further studies are warranted to confirm the relationship between DD clinical parameters and CMA results.Chromosomal microarray (CMA) is considered a first-tier test for genetic analysis as it can be used to examine gene copy number variations (CNVs) throughout the entire genome, with enhanced sensitivity for detecting submicroscopic deletions and duplications. However, its cost can represent a heavy burden. Moreover, the diagnostic yield of CMA in infants with developmental delay (DD) was reported to be less than 10%. Therefore, we aimed to investigate the relationship between CMA results and clinical features and risk factors of DD. The study included 59 infants with DD who were recruited between August 2019 and February 2020 during a visit to the outpatient clinic of a rehabilitation department. We reviewed the clinical records of the infants regarding gender, age, body weight at birth, delivery method, brain imaging data, perinatal history, and parent-related clinical parameters, such as mother and father age at birth. The infants were categorized according to CMA results, and differences in clinical parameters were evaluated. Except for brain anomalies, there was no statistically significant differences between infants who had pathogenic and variants of unknown significance (VOUS)-likely pathogenic CNVs groups compared with those within the VOUS-likely no sub-classification, VOUS-likely benign, benign, and normal CNVs groups. The incidence of brain anomalies was significantly higher within infants with pathogenic and VOUS-likely pathogenic CNVs groups ( A developmental delay (DD) is characterized by noticeable shortage of developmental milestones achieved by a child throughout development . AlthougSeveral cytogenetic and molecular biology techniques are used to identify the underlying genetic cause of DD, from conventional approaches (such as molecular karyotyping) to state-of-the-art chromosomal microarray (CMA) and next-generation sequencing (NGS) . RecentlThe study included 59 infants who visited the outpatient department of rehabilitation medicine at our hospital from August 2019 to February 2020 for suspected DD. Most of the infants showed delayed gross motor function or impaired language performance compared to age-matched children with no developmental problems. According to the after Korean Developmental Screening Test (K-DST) manual, the children can be categorized into four groups based on their individual K-DST result: further evaluation (<−2 standard deviation [−2SD]), follow-up test (−2SD to −1SD), peer-level (−1SD to 1SD), and high level (>1SD) ,13. We rPeripheral venous blood was collected into an ethylenediaminetetraacetic acid (EDTA) collection tube, and DNA was extracted from peripheral blood leukocytes. CytoScanDx assay  was used for CNVs analysis and it was performed according to the instructions of the manufacturer . The asst-test, and Mann–Whitney U-test were used to evaluate the differences between pathogenic, VOUS-likely pathogenic CNVs, and other groups, and between two groups . Categorical variables included gender, brain anomalies, cardiac anomalies, dysmorphism, autism spectrum disorder, cerebral palsy, delivery method, and mode of conception. Continuous variables included age, father and mother age, body weight at birth, and gestational age. Statistical analyses were performed using SPSS 25.0 for Windows  and R software for Windows . A p-value < 0.05 was considered to be statistically significant in all tests.The Kolmogorov–Smirnov test was used to determine whether the data conformed to a normal distribution. Pearson Chi-square test, independent CMA data were collected from 59 infants, of whom 41 were males and 18 were females. All 59 infants with DD who included in this study were classified within the ‘further evaluation’ or ‘follow-up test’ groups according to K-DST . The average age of the infants was 38.7 ± 18.50 months, and the average age of their fathers and mothers at the time of birth was 35.7 ± 5.23 and 32.2 ± 4.04 years, respectively. The average birthweight of the infants was 2921.0 ± 716.48 g, their gestational age was 37.4 ± 2.72 weeks, and 61% of children were born by cesarean section .We found 41 CNVs in 35 infants, including 4 (9.8%) pathogenic CNVs, 2 (4.9%) VOUS-likely pathogenic CNVs, 16 (39.0%) VOUS with no sub-classification, 16 (39.0%) VOUS-likely benign CNVs, and 3 (7.3%) benign CNVs . CMA resp < 0.05). Moreover, the rate of infants with cardiac and/or brain anomalies, and dysmorphism was higher in the pathogenic and VOUS-likely pathogenic CNV groups than in the VOUS like no sub-classification, VOUS-likely benign, benign, and normal CNVs groups. However, this difference did not reach statistical significance (p = 0.053)  . Additio= 0.053) .Between pathogenic, VOUS-likely pathogenic, and VOUS with no sub-classification versus VOUS-likely benign, benign, and normal CNVs groups, additional analyses showed that gender, age, body weight at birth, gestational age, delivery method, mode of conception, result of brain magnetic resonance imaging, and perinatal history of the infants, as well as parent-related clinical parameters, showed no significant differences .We found four pathogenic CNVs and two VOUS-likely pathogenic CNVs in six infants, which indicated that 10.2% of the infants had genetic alterations associated with DD and comorbid conditions. This finding was in concordance with the findings of a previous CMA study conducted in infants with DD .We identified a variety of CMA results; however, most of these genetic alterations were of unknown phenotype (39% of VOUS with no sub-classification). Nevertheless, we expected to find more abnormal CNVs within our study population. Therefore, we also evaluated potential correlations between demographic and clinical parameters of the infants and their parents, including risk factors known to cause DD, and the genetic findings. This analysis failed to find significant differences between pathogenic and VOUS-likely pathogenic CNV groups versus VOUS-likely no sub-classification, VOUS-likely benign, benign, and normal CNVs group, with exception of brain anomalies. Indeed, our data showed a tendency of slightly higher rate of infants with brain and cardiac anomalies and dysmorphism within the pathogenic and VOUS-likely pathogenic CNVs groups. Nevertheless, only one and two infants included in the study had brain anomalies and dysmorphism, respectively, which may contribute to the low statistical power of the analysis. Kim et al. reported that dysmorphism was significantly higher in infants with pathogenic CNVs as compared with those with normal CMA results . MoreoveInterestingly, the average age of infants with pathogenic or VOUS likely-pathogenic CNVs was 22.1 months, which was much lower than the overall average age of the study population . This reDespite of these findings, our study has some limitations. First, we investigated CMA results within a small number of infants with DD. However, we expanded our analysis to include additional demographic and clinical parameters, such as body weight at birth, delivery method, and parent-related clinical parameters, which was not performed in the previous study . ContrarIn conclusion, our research suggests that infants with DD who present dysmorphism or brain anomaly may benefit from early CMA analysis for adequate diagnosis and timely treatment. However, further studies are needed with focus on CMA data in infants with DD.


We also found that the risk of being born small for gestational age increased with the level of exhaust particles in all three exposure windows, but these associations were not statistically significant.We have studied the associations between exhaust particles and birth weight. Adjustments were made for ozone and potential confounding factors at the individual level. The study included all singletons conceived between August 2003 and February 2013 with mothers living in Greater Stockholm. We obtained record-based register data from the Swedish Medical Birth Register. Data concerning the parents were provided by Statistics Sweden. Exposure levels for nearly 187,000 pregnancies were calculated using a validated air quality dispersion model with input from a detailed emission database. A higher socioeconomic status was associated with higher levels of exhaust particles at the home address. In this region, with rather low air pollution levels, the associations between levels of exhaust particles and birth weight were negative for all three of the studied exposure windows . For the entire pregnancy, the linear decrease in birth weight was 7.5 grams  for an increase in exposure, corresponding to the inter quartile range (IQR = 209 ng/m Restricted fetal growth, often studied as small for gestational age (SGA) or term low birth weight, is not only an important predictor of neonatal mortality and morbidity, but also a risk factor for adult mortality and morbidity. For mortality and morbidities related to cardiovascular disease, stroke, and type 2 diabetes, the risk increases continuously as birth weight decreases, even for those infants born within the normal (>2500 g) birth-weight range .In addition to individual level maternal and social factors associated with restricted fetal growth, many studies have found adverse effects of air pollution on birth outcome. A recent systematic review, based on published cohort studies on prenatal exposure to fine particulate matter and adverse birth outcomes, included 43 studies from 2008 through 2017 [3 PM2.5 was observed for exposure during the entire pregnancy, however, the summary OR = 1.05  was based on only four studies and was, therefore, not fully significant [In another systematic review, the biggest pooled increase in risk for term low birth weight associated with 10 µg/mnificant . Seven s3 [The effects of ozone on fetal growth are much less studied than the effects of particle exposure. However, all six studies of ozone and birth weight included in a recent review reported statistically significant decrements; e.g., per 10 ppb over the entire pregnancy, the reduction ranged between −4.6 and −27.3 (n = 3) grams [2) is formed [The mixture of pollutants in ambient air is varying and complex, but vehicle exhaust particles and ozone typically show a negative correlation due to nitrogen oxide (NO) emissions reducing ozone levels when nitrogen dioxide , conceived between August 2003 and February 2013. Only singletons were included in the study.The information extracted from the Medical Birth Register includes information on the mother , collected by maternal care nurses during the pregnancy, the pregnancy and delivery , and the child , reported from the delivery hospital. The national Medical Birth Register is nearly complete and the quality is good . Registehttp://airviro.com). The dispersion calculations of road traffic emissions were performed on a fixed grid with a grid size of 100 × 100 m. Individual buildings and street canyons were not resolved but were treated using a roughness parameter. In an open area, the calculation height was 2 m above ground level. Over a city, the simulation reflected the concentrations at roof-top level height. The system, including the wind model, air quality dispersion models, emission database, and a database with monitoring data, is part of the Eastern Sweden Air Quality Management Association (www.slb.nu) and has been used in Stockholm for more than 20 years. It has provided exposure estimates for several epidemiological studies and health impact assessments [For all births we used the geocodes of the maternal home addresses to estimate the mean air pollution exposures during the first and second trimester, and over the entire pregnancy. The concentrations at the home address, due to local emissions of combustion particles and NOx, were calculated using a wind model and a Gaussian air quality dispersion model, both part of the Airviro Air Quality Management System . For PM-exhaust, only road traffic contributions are included. Vehicle fleet emissions data are obtained from information on the distribution of vehicle types  and euro classes in the national vehicle registry. This provides the total mass of particles emitted from the exhausts of road traffic vehicles in the area but excludes secondary PM2.5 formed from exhaust emissions further away.The emission database, used as input data for the dispersion model calculations, is updated annually and contains detailed information about emissions from road and ferry traffic, petrol stations, industrial areas, and households . The datOzone concentrations are indirectly calculated based on the modelling of NOx concentrations, as shown in Furthermore, the calculated NOx concentrations are scaled so that the calculated concentrations at the central site are set to the measured value. The dispersion model calculates hourly mean values that are scaled every hour based on the measurements. This means that the dispersion modelling of NOx is used to obtain the spatial contrasts in the ozone concentrations. The combined use of dispersion modelling and measured concentrations of ozone and NOx makes the amount of uncertainty in the estimated ozone concentrations very small.We studied birth weight as a continuous variable, adjusted also for sex and gestational age in the model and small for gestational age (SGA) among singletons. SGA was defined as having a birth weight lower than the 10th percentile for the duration of gestation (in days), stratified by sex.Potential confounders in the study of air pollution effects were maternal and paternal level of education, family income, family situation, parity, maternal smoking habits and body mass index (BMI) at the first antenatal visit, maternal region of origin, maternal age at delivery, and conception date. Maternal and paternal education were seven-level factor variables: pre-upper secondary school (<9 years), pre-upper secondary school (9 years), upper secondary school (<3 years), upper secondary school (3 years) post-upper secondary school (<3 years), post-secondary school (3 years), and postgraduate education. Family income was treated as a 10-level factor, based on deciles. Family situation was a three-level factor: cohabiting, single mother, and other. Parity was treated as a four-level factor: para one, para two, para three, and para four or higher. Maternal smoking habits at the first antenatal visit was a three-level factor: non-smoker, less than 10 cigarettes/day, and 10 or more cigarettes/day. Maternal BMI at first antenatal visit was a four-level factor, following the guidelines of the World Health Organization , normal weight (18.5 < BMI < 25), overweight (25 < BMI < 30), and obese (BMI > 30). Maternal region of origin was treated as an 11-level factor: Northern Africa, Central and Southern Africa, Middle East, Southeast Asia, Oceania, North America, South and Central America, Western Europe, Eastern Europe, the Nordic Countries, and Sweden. Maternal age and conception date were treated as smooth functions. The annual proportion of households with a disposable income in the highest decile and the annual proportion of parents with a university education per municipality were used as linear predictors.Linear regression and log-binomial regression using the general additive model-function in the mgcv package in R was used to estimate the potential associations between the exposure variables and the outcomes of interest . Unadjusted single and multi-pollutant models were fitted, as well as a model including all available potential confounding variables. In the analyses of birth weight, all models were adjusted for the duration of gestation. Initially potential non-linear associations were estimated with natural cubic splines, if the associations appeared to be linear; i.e., if the estimated degrees of freedom were less than 1.3, linear estimates were computed, and if the association appeared to be non-linear, estimates for a five-level factor, based on quintiles, were computed. To test statistical significance, 95% Confidence Intervals (95% CI) excluding the null were used.Ethical approval was provided by the Regional Ethical Review Board at Umeå University (2014/393-31Ö).There was a significant reduction in the calculated exposure levels for both ozone and PM-exhaust during the period 2003–2013, as shown in 3 with an average of 202 ng/m3, and ozone ranged from 28.8 to 66.7 µg/m3 with an average of 54.6 µg/m3, as shown in Full pregnancy exhaust particles levels ranged from 6.9 to 854 ng/mThe highest levels of exhaust particles were observed near busy streets in the central parts of the city, where flats are often expensive. Mothers with low particle exposure most often live in suburbs at a distance from the city center. A high level of education and high family income was associated with higher levels of exhaust particles, as shown in In total 186,912 births were included in the study. The average birth weight was 3531 g (standard deviation (SD) 541 g). The duration of gestation was, on average, 279 days (SD 12 days), and 4.4% of the births were preterm. The average maternal age was 31.4 years (SD 5 years), and 51.4% of the births were boys. 3), and 1.02  for the entire pregnancy (209 ng/m3), as shown in Higher levels of first and second trimester and full pregnancy exhaust particles were associated with an increased risk of SGA in the unadjusted models without adjustments for potential confounders, as shown in 3) and the 95% CI was . There was no association between ozone exposure during the second trimester or entire pregnancy and SGA. The PRR for an IQR increase in exposure was 0.99  for the second trimester (IQR = 20.2 µg/m3), and 1.01  for the entire pregnancy (IQR = 8.0 µg/m3).First trimester ozone was negatively associated with SGA both in the unadjusted model, as shown in 3) increase . A higher level of exhaust particles during the entire pregnancy was associated with a non-linear decrease in birth weight in the unadjusted model, and a linear decrease in birth weight in the adjusted model, −7.5 g per IQR increase .Higher levels of exhaust particles were associated with a non-linear decrease in birth weight in the unadjusted model, as shown in 3) with the third quintile (>49.7 µg/m3 and ≤57.9 µg/m3), the difference was 11.2 g , and when comparing the lowest quintile (≤39.2 µg/m3) with the third quintile, the difference was 9.4 g , as shown in In the unadjusted models, higher levels of ozone were associated with an increased birth weight, regardless of the exposure window, as shown in In this large cohort study of air pollution and birth weight, vehicle exhaust emissions and the resulting exposure was studied with a much finer spatial resolution than is typical in similar studies. Streets and addresses in the same residential area as our study have different concentrations, reflecting the local situation. Many studies have used concentrations from monitoring stations that, for some study participants, were 25–30 kilometers away from their home, or modeled concentrations in grids that could be 12 × 12 km or larger, which meant that those associations were reflecting the effects of the regional and urban background concentrations.3). For the first trimester, the decrease was −6.5 g per IQR increase . For the second trimester, a 7.5 g  lower birth weight per IQR increase was observed. These results are comparable with the effect on birth weight per IQR increase in elemental carbon (200 ng/m3), found in Massachusetts, −9 g , adjusted for the remaining PM2.5 but not ozone [3) in metropolitan Atlanta [3 PM2.5.The associations between levels of exhaust particles and birth weight were negative for all three exposure windows . For the entire pregnancy, the linear decrease in birth weight was −7.5 g  per IQR increase  for an IQR increase for the entire pregnancy exposure, which is in line with the presented combined estimate for term low birth weight from seven studies  where an3) was associated with an OR = 1.02 .A study from London found PM2.5 exhaust to adversely affect fetal growth when controlling for traffic-related noise . For terThough less investigated, ozone is also reported to reduce fetal growth . For ozoAdverse effects on birth weight and SGA were, as expected, observed for smoking during pregnancy and low socioeconomic status, such as short education, low income, and single mothers. Most socioeconomic factors were negatively correlated with the level of exhaust particles at the home address, which means that protective socioeconomic conditions are associated with higher exposure to PM-exhaust during pregnancy. Without adjustment for socioeconomic factors, these confounders tend to mask the adverse effects of vehicle exhaust.One strength of our study design is that we used state register data, allowing us to include all mothers and births as opposed to birth cohort studies, which include a selection process where the included samples may not fully represent the study population. Moreover, this method excludes potential reporting bias, since no data on risk factors during the pregnancy were reported after the child was born.2, and road dust, are highly correlated with PM-exhaust at this scale. This means that these components may partly have contributed to the observed associations between PM-exhaust and birth weight. Another limitation is that we were not able to take into account the changes in residential addresses during pregnancy. This would lead to exposure misclassification, which may lead to bias in both directions; however, it has been shown, in a Swedish population, that the study population tended to move to areas with similar levels of air pollution [Another strength of our study is the exposure assessment, using a high spatial resolution, with the combination of geocoded home addresses, fine-scale emission data, and the dispersion calculations of vehicle exhaust emissions, performed with a grid size of 100 × 100 m. One limitation is, of course, that other traffic related pollutants not included, as CO, NOollution . Howeverollution .We also understand that, in our residential areas with higher average ozone levels, there is more greenness, which we did not study, but which has been associated with higher birthweight and lower odds and SGA .We found local levels of vehicle exhaust particles at the residential address during pregnancy to be associated with a lower birth weight in Greater Stockholm, Sweden, an area with relatively low levels of air pollution. We were able to adjust for many potential confounding factors at the individual level, but most socioeconomic risk indicators were negatively correlated with the level of exhaust particles at the home address, since residences in the city center are expensive. The associations between the levels of exhaust particles and birth weight were negative for all three studied exposure windows. We also found the risk of being born small for gestational age to increase with the level of exhaust particles, but these associations were not fully statistically significant.