Papers by Tamar Wainstock
American Journal of Obstetrics and Gynecology, 2017
Pediatric Infectious Disease Journal, Feb 1, 2019
Background: Studies have found associations between delivery mode and offspring long-term health.... more Background: Studies have found associations between delivery mode and offspring long-term health. We aimed to study the possible association between delivery mode and the risk for long-term infectious diseases of the offspring during a follow-up period of up of 18 years. Methods: A population-based cohort analysis was performed comparing different subtypes of infectious morbidity leading to hospitalization among children, based on delivery mode (vaginal vs. elective cesarean). Data on pregnancy course and outcome, delivery mode and later offspring hospitalizations were available from a single tertiary center. All singleton uncomplicated deliveries and pregnancies between the years 1991 and 2014 were included in the analysis. Kaplan-Meier and multivariable Weibull survival models were applied to adjust for differences in follow-up time between the study groups and confounders. Results: During the study period, 138,910 newborns met the inclusion criteria: 13,206 (9.5%) were delivered by elective cesarean delivery, and 125,704 (91.5%) were delivered vaginally. During the follow-up period (median: 10.22 years), 13,054 (9.4%) were hospitalized (at least once) with infectious morbidity: 12.0% and 9.1% among the cesarean and vaginally delivered children, respectively (Relative Risk: 1.36; 95% confidence interval: 1.28-1.43; incidence density rates for first hospitalization were 15.22/1000 person-years and 9.06/1000 person-years among cesarean and vaginally delivered children, respectively; Kaplan-Meier log rank P < 0.001). The association between cesarean delivery and long-term pediatric infectious morbidity remained significant in the multivariable model, controlling for confounding variables (adjusted hazard ratio: 1.18; 95% confidence interval: 1.11-1.25; P < 0.001). Conclusions: Children delivered by elective cesarean section are at an increased risk for hospitalization with pediatric infectious morbidity when compared with vaginally delivered children.
American Journal of Obstetrics and Gynecology, 2017
OBJECTIVE: Cesarean delivery (CD) has been shown to affect the newborn's microbiome. We aimed to ... more OBJECTIVE: Cesarean delivery (CD) has been shown to affect the newborn's microbiome. We aimed to study a possible association between mode of delivery and the risk for infectious diseases of the offspring, during a follow-up period of up to 18 years. STUDY DESIGN: A population based cohort analysis was performed comparing different subtypes of infectious morbidity leading to hospitalization among children (up to the age of 18 years) based on mode delivery: vaginal (VD) or CD. Data on pregnancy course and outcome, mode of delivery, and later offspring hospitalization were collected from the same database of a single tertiary center in the region. All singleton deliveries between the years 1991-2013 were included in the analysis. Exclusion criteria were congenital malformations, perinatal deaths, instrumental deliveries, pregnancy, delivery, and fetal complications (including: maternal hypertensive disorders and gestational diabetes, labor dystocia, fetal distress, labor induction, and fetal growth restriction). Kaplan-Meier survival curve was constructed to compare cumulative infectious disease hospitalization incidence based on mode of delivery, and a Cox proportional hazard model was used to control for confounders including gestational age and maternal factors. RESULTS: During the study period, 138 910 newborns met the inclusion criteria: 13 206 (9.5%) were delivered by CD, and 125 704 (91.5%) were delivered vaginally. During the follow up period (0-18 years, median 10.22), 13 054 (9.4%) were hospitalized (at least once) due to infectious morbidity: 12.0% among the CD children, and 9.1% of the VD (RR¼1.36; 95%CI 1.28-1.43; incidence density rates for first hospitalization: CD 15.22/1000 person years; VD 9.06/1000 person years; Kaplan-Meier Log rank p<0.001, figure).
American Journal of Obstetrics and Gynecology, 2017
American Journal of Obstetrics and Gynecology, 2017
Obstetric Anesthesia Digest, Mar 1, 2015
To evaluate the association between exposure to life-threatening rocket attacks and the risks of ... more To evaluate the association between exposure to life-threatening rocket attacks and the risks of preterm birth (PTB) and low birth weight (LBW). Methods: The present retrospective cohort study compared the outcomes of 1851 births by women exposed to rocket attacks and 2979 births by unexposed women. The timing, frequency, and intensity of exposure were calculated for each trimester and for the entire pregnancy period. Demographic and medical data were abstracted from the patients' records. Results: The rates of PTB and LBW were higher among exposed than unexposed women (PTB: 9.1% versus 6.8%, P = 0.004; LBW: 7.6% versus 5.8%, P = 0.02). The rate of infants who were small for gestational age did not differ between the groups. After controlling for potential confounders, the risks for PTB and LBW remained significantly higher in the exposed group (PTB: adjusted odds ratio 1.3 [95% confidence interval, 1.1-1.7]; LBW: adjusted odds ratio 1.3 [95% confidence interval, 1.03-1.7]). There was no linear association between the intensity of exposure and the risk of PTB or LBW. Conclusion: Maternal exposure to intermittent but repeated life-threatening rocket attacks for a prolonged period might be associated with increased risks of PTB and LBW.
Archives of Women's Mental Health, 2020
The aim of the current study was to assess the risk for post-partum depression among women delive... more The aim of the current study was to assess the risk for post-partum depression among women delivering during the COVID-19 pandemic as compared to the risk among women delivering before the COVID-19 pandemic. A cohort study was performed among women delivering singletons at term which were recruited in the maternity wards of the Soroka University Medical Center. Recruitment was done during the COVID-19 strict isolation period (March 18 and April 29, 2020). Women delivering during the COVID-19 pandemic completed the Edinburgh Postnatal Depression Scale (EPDS), and the results were compared to women delivering at the same medical center before the COVID-19 pandemic. Multivariable logistic regression models were constructed to control for potential confounders. A total of 223 women who delivered during the COVID-19 strict isolation period were recruited. Women delivering during the COVID-19 pandemic had lower risk of having a high (> 10) or very high (≥ 13) EPDS score as compared with women delivering before the COVID-19 pandemic (16.7% vs 31.3%, p = 0.002, and 6.8% vs 15.2%, p = 0.014, for EPDS ≥ 10 and EPDS ≥ 13, respectively). These results remained similar in the multivariable logistic regression models, for both EPDS score ≥ 10 and EPDS score ≥ 13, while controlling for maternal age, ethnicity, marital status, and adverse pregnancy outcomes (adjusted OR 0.4, 95% CI 0.23-0.70, p = 0.001 and adjusted OR 0.3, 95% CI 0.15-0.74, p = 0.007 for EPDS score > 10 and > 13, respectively). In our population, delivering during the COVID-19 pandemic was independently associated with lower risk of post-partum depression.
Journal of Maternal and Child Health, 2020
Background: Inter-pregnancy interval (IPI), defined as the time interval between a live birth and... more Background: Inter-pregnancy interval (IPI), defined as the time interval between a live birth and estimated conception time of a subsequent pregnancy, has an established effect on perinatal outcome. The long-term impact of IPI on offspring is unknown. This study aimed to examine the effect of short and long IPIs on longterm endo-metabolic health of offspring. Subjects and Method: This populationbased cohort study included singleton live births in parturient with at least one previous birth. Singleton deliveries between the years 1991-2014 in a regional tertiary medical center were included. Offspring were followed until 18 years of age for endo-metabolic related hospitalizations. Survival curves were used to compare cumulative incidence of endo-metabolic morbidity, and Cox proportional hazards models to control for confounders. Results: During the study period 144,397 deliveries met the inclusion criteria. Offspring following long IPIs exhibited higher rates of endometabolic related hospitalizations. Survival curve demonstrated a significantly higher cumulative incidence of endo-metabolic morbidity in the long IPI group (p<0.001). The Cox model demonstrated long IPI to significantly increase the risk for endo-metabolic related hospitalizations during childhood (aHR= 1.34, 95%CI= 1.06 to 1.70; p=0.015). Conclusion: Long IPI appears to have an independent impact on long-term endo-metabolic health of the offspring.
American Journal of Obstetrics and Gynecology, 2020
American Journal of Obstetrics and Gynecology, 2020
Of a total of 210,984 pregnancies, there were 64,804 within the 15 zip codes correlating with his... more Of a total of 210,984 pregnancies, there were 64,804 within the 15 zip codes correlating with historic "Redlined" regions. PTB varied directly across the historic regions and reached significance for periviable birth (F¼5.301, p¼0.0152). Comparing the most to least "favorable" regions, secondary outcomes also worsened significantly (Figure 2). These effects on PTB remained significant on multi-variant regression correcting for income levels, poverty levels, educational attainment, and race however zip code distributions themselves remained significantly correlated with community income (p¼0.0475) and maternal white race (p¼0.0442). CONCLUSION: These data demonstrate the modern obstetric impacts of historic policies driving inter-generational inequity. Fusion of historic and modern community datasets into obstetric datasets offers the opportunity to analyze the current health impacts of historic inequity. These data should inspire socioeconomic policies supporting economic vibrancy for all to ensure the best obstetric outcomes for our patients and their families.
American Journal of Obstetrics and Gynecology, 2020
OBJECTIVE: To determine whether conception prior to the first menstrual period after a first trim... more OBJECTIVE: To determine whether conception prior to the first menstrual period after a first trimester pregnancy loss is associated with a risk of repeat miscarriage or adverse fetal outcomes. STUDY DESIGN: A retrospective cohort study (n¼ 107 women) who had a spontaneous first-trimester miscarriage followed by a subsequent pregnancy with an IPI (interpregnancy interval) < 12 weeks. All pregnancies ended either in spontaneous, medical or surgical abortion. Pregnancy outcome was compared between women who conceived after their next menstrual period (n¼57) to women who conceived prior to their next menstrual period (n¼50). The primary outcome was miscarriage, and secondary outcomes were gestational age at delivery and birth weight. RESULTS: 1. The rate of recurrent first trimester pregnancy loss among women who conceived prior to their next menstruation was 10.4% in comparison 15.8% for women conceived after their next menstruation (p¼0.604). 2. There was no difference in gestational age at delivery and birth weight between the study groups (Table). Other outcomes were also similar for both groups (Table 1). 3. Multiple logistic regression analysis confirmed that conception prior to the next menstrual period was not associated with a higher incidence of miscarriage (OR 1.74, 95% CI: 0.7-4.0, p¼0.46) (Table 2). CONCLUSION: Conception shortly after a spontaneous miscarriage without waiting for the next menstrual period is not associated with adverse maternal or perinatal outcomes
American Journal of Obstetrics and Gynecology, 2020
During the study period, 242,342 newborns met the inclusion criteria, 2558 (1.1%) of which were b... more During the study period, 242,342 newborns met the inclusion criteria, 2558 (1.1%) of which were born with a diagnosis of true knot of cord. During the follow up period, total neurological hospitalizations were comparable between the groups (3.7% of the exposed group and 3.1% in the comparison group, p¼0.078; Table) as were the cumulative incidences of neurological morbidities over time (log rank p¼0.12; Figure). The Cox regression confirmed lack of association between true knot of cord and total neurological related morbidity (adjusted HR¼1.153, 95% CI 0.942-1.412, P¼0.168) while controlling for diabetes, hypertensive disorders, preterm delivery and maternal age. CONCLUSION: Children born following a confirmed diagnosis of true knot of umbilical cord are not at an increased risk for long-term neurological morbidity.
American Journal of Obstetrics and Gynecology, 2020
with increased reward-based (hedonic) eating and obesity liability in MATOB-exposed offspring, wi... more with increased reward-based (hedonic) eating and obesity liability in MATOB-exposed offspring, with Fs more vulnerable. STUDY DESIGN: C57Bl/6J dams were assigned to a 60% high-fat or 10% fat control diet (CD) for 14 weeks pre-breeding and during pregnancy/lactation. Male (M) and F offspring were weaned at 3.5 weeks to CD. 15-30 offspring/sex/diet group were evaluated for all experiments. Hedonic eating was evaluated in adolescent (8wk) MATOB and CD offspring with palatable food and liquid consumption tests (peanut butter and chocolate beverage). Usual food consumption and metabolic rate were quantified in adult offspring using metabolic cages. Weekly weight gain was quantified from weaning to adulthood, and adult body composition was determined with EchoMRI. RESULTS: F but not M MATOB adult offspring were significantly heavier with significantly increased body fat percentage compared to sex-matched controls (Fig 1A/B). Metabolic rate was not significantly different between MATOB and CD adult offspring (Fig 1C). F offspring had both significantly increased hedonic eating (Fig 2A) and usual food consumption compared to sex-matched controls and MATOB Ms, respectively (Fig 2B). Patterns of hedonic eating differed by offspring sex (Fig 2A). CONCLUSION: F offspring have increased vulnerability to obesity when exposed to MATOB in utero. Together with our prior finding of persistently reduced mesolimbic dopamine release in F MATOB offspring only, these data suggest that reduced dopamine release may program F offspring to overeat, leading to a sex-biased increase in obesity risk. Future studies will focus on mesolimbic dopamine signaling as a therapeutic target to reduce offspring obesity.
American Journal of Obstetrics and Gynecology, 2020
American Journal of Obstetrics and Gynecology, 2020
The prevalence of obesity in the US has risen exponentially, increasing pregnancy risks in women ... more The prevalence of obesity in the US has risen exponentially, increasing pregnancy risks in women of reproductive age. The influence of extremes of maternal obesity on risk of birth defects is not well established. We aim to estimate this risk in the offspring of mothers stratified by pre-pregnancy BMI category. STUDY DESIGN: Population-based retrospective cohort of live births in the US from 2012-2016 birth certificate data. Rates of newborn cardiovascular, musculoskeletal, gastrointestinal, genitourinary and central nervous system defects of normal weight women (BMI 18.5 to < 25) were compared to overweight (BMI 25 to < 30), obesity classes I (30 to < 35), II (35 to < 40), III (>/¼40), as well as strata of severe obesity (BMI 40 to < 50, 50 to < 60 and >/¼ 60). Multivariate logistic regression quantified the relationship between maternal BMI and birth defect risk after adjustment for pregestational diabetes mellitus, late prenatal care, maternal race and maternal smoking. RESULTS: Of the 19,844,580 live births in the study period, maternal obesity rates were 3.4%, 23.4%, 12.5%, 23.4%, 12.5%, 6% and 4.2%, respectively for underweight, overweight, and obesity classes I, II and III. Increasing maternal BMI and particularly morbid obesity (BMI >/¼40) was associated with increased rates of all birth defects except gastroschisis. The most robust relative risk increases were observed in defects of the musculoskeletal and central nervous systems, see figure. Increasing maternal BMIs were associated with decreased risk of gastroschisis. Maternal BMI had no significant influence on chromosomal abnormality. CONCLUSION: Risks of any major congenital malformation or multiple malformations, except for gastroschisis, progressively increase with increasing maternal BMIs and specifically with morbid obesity. For obese women who are planning pregnancy, efforts should be made to optimize BMI prior to pregnancy to decrease risk of birth defects.
American Journal of Obstetrics and Gynecology, 2020
OBJECTIVE: To evaluate maternal and neonatal morbidity and mortality in patients undergoing trial... more OBJECTIVE: To evaluate maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean (TOLAC) using a more contemporary data set. STUDY DESIGN: This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study from 2002 to 2008. Women met inclusion criteria for our study if they had a history of any prior cesarean delivery (CD). Perinatal outcomes such as uterine rupture, uterine dehiscence, blood transfusion, hemorrhage, hysterectomy, endometritis, maternal death, neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome, neonatal seizure, and neonatal death were evaluated based on desired delivery mode (planned elective CD or TOLAC). Multivariate logistic regression was used to describe the association between TOLAC and markers of maternal and neonatal morbidity and mortality. RESULTS: Of 9,858 patients who had a prior CD, our study population had 4,400 patients (44.6%) who desired TOLAC and 5,458 patients (55.4%) who underwent elective repeat CD. Of 4,400 patients who desired trial of labor, 3,162 (72%) achieved a vaginal birth. Women who attempted TOLAC compared to those who had an elective CD were more likely to have uterine rupture (OR 3.11; 95% CI 1.21 e 8.02), hemorrhage (OR 2.24; 95% CI 1.86 e 2.70), and blood transfusion (OR 2.33; 95% CI 1.70 e 3.19) (Table 1). Rate of uterine rupture was higher in patients undergoing TOLAC (0.34%), however it was still described in patients undergoing elective CD (0.11%). Rate of NICU admission was higher in patients undergoing TOLAC compared to elective CD, 12.9% and 11.3% respectively (OR 1.17; 95% CI 1.03 e 1.32). CONCLUSION: Patients undergoing TOLAC are two-times more likely to have a hemorrhage or require blood transfusion compared to women with elective repeat cesarean delivery. Compared to the Cesarean Registry data, women have half the rate of uterine rupture and a 30% higher risk for blood transfusion.
American Journal of Obstetrics and Gynecology, 2020
neonatal morbidity (oxygen use at discharge, IVH grade III/IV, necrotizing enterocolitis). Matern... more neonatal morbidity (oxygen use at discharge, IVH grade III/IV, necrotizing enterocolitis). Maternal characteristics, antenatal corticosteroid and magnesium use were compared across groups. Chi-squared and student T tests were conducted. Multiple logistic regression models were constructed to assess factors associated with PTB type. RESULTS: Of 255 live births from 22-28 wks, 200 deliveries met inclusion criteria. One third (33%, n¼67) were indicated PTB and 67% (n¼133) were spontaneous. Maternal hypertensive disorders were significantly more common in the indicated PTB group (76% vs 3%, p< 0.01), as was any corticosteroid use (84% vs 73%, p¼0.01), magnesium use (69% vs 46%, p< 0.01) and cesarean births (88% vs 48%, p< 0.01) (Table 1). Gestational age (GA) at delivery (27wk vs 25wk, p< 0.01) and 5 min APGARs (7 vs 6, p< 0.01) were higher in the indicated group. All other characteristics were similar (Table 1). Neonatal death occurred in 30% (n¼60) and significant morbidity in 49% (N¼69) of survivors. Neither mortality (p¼0.11) nor morbidity (p¼0.55) varied significantly by PTB type. GA at delivery was the only significant predictor of neonatal mortality and morbidity in multivariate models (p< 0.01). CONCLUSION: We found no difference in major neonatal outcomes by indicated vs spontaneous periviable or extremely premature delivery. GA was the only significant predictor of both death and severe morbidity in our cohort suggesting counseling regarding neonatal outcomes should be consistent regardless of indication for delivery.
American Journal of Obstetrics and Gynecology, 2020
American Journal of Obstetrics and Gynecology, 2020
During the study period, 243,682 deliveries met the inclusion criteria, of which 9756 (4.00%) occ... more During the study period, 243,682 deliveries met the inclusion criteria, of which 9756 (4.00%) occurred in women with drug allergy. Using GEE models, controlling for maternal age, maternal drug allergy was noted as an independent risk factor for hypertensive disorders, diabetes mellitus, IUGR, and preterm delivery. CONCLUSION: Pregnancy of women with documented drug allergy is independently associated with adverse perinatal outcomes such as hypertensive disorders, diabetes mellitus IUGR, and preterm delivery. Prenatal exposure to the maternal altered immune system may play a role in pregnancy outcomes of the affected fetuses.
American Journal of Obstetrics and Gynecology, 2020
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Papers by Tamar Wainstock