[show abstract][hide abstract] ABSTRACT: The objective of this study was to determine the association between maternal 25-hydroxyvitamin D (25(OH)D) and the risk of spontaneous preterm birth (sPTB) before 35 weeks' gestation. A random subcohort from the US Collaborative Perinatal Project (1959-1965) was sampled (n = 2,629) and augmented with all remaining cases of sPTB before 35 weeks' gestation for a total of 767 cases. Banked serum samples collected at 26 weeks' gestation or earlier were assayed for 25(OH)D. Constructs for vascular histology and inflammatory histology were developed from placental pathology examinations. There was no relationship between 25(OH)D and sPTB among white women. Among nonwhite mothers, serum 25(OH)D levels of 30-<50, 50-<75, and ≥75 nmol/L were associated with reductions of 1.0-1.6 cases of sPTB per 100 live births and 20%-30% reductions in risk of sPTB compared with 25(OH)D levels less than 30 nmol/L after adjustment for prepregnancy body mass index (weight (kg)/height (m)(2)), season, and other confounders. This association was driven by inflammation-mediated cases of sPTB and sPTB cases without placental lesions. A sensitivity analysis for unmeasured confounding by exercise, fish intake, and skin color suggested some bias away from the null in the conventional results, but conclusions were generally supported. The vitamin D-sPTB relationship should be examined in modern cohorts with detailed data on skin pigmentation and other covariates.
American journal of epidemiology 10/2013; · 5.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: 17-alpha hydroxyprogesterone caproate (17-OHPC) 250 mg weekly reduces recurrent spontaneous preterm birth (SPTB) in women with a prior SPTB by 33%. The dose is not based on pharmacological considerations. A therapeutic concentration has not been determined hampering any attempt to optimize treatment. This study evaluated the relationship between 17-OHPC plasma concentrations and the rate of SPTB in women with singleton gestation.
A single blood sample was obtained between 25 and 28 weeks gestation from 315 women with a SPTB who participated in a placebo-controlled, prospective, randomized clinical trial evaluating the benefit of omega-3 supplementation in reducing preterm birth. All women in the parent study received 17-OHPC and 434 received omega-3 supplementation and 418 received a placebo. Plasma from 315 consenting women was analyzed for 17-OHPC concentration.
There were no differences between placebo and omega-3 supplemented groups in demographic variables, outcomes or in mean 17-OHPC concentration. Plasma concentrations of 17-OHPC ranged from 3.7- 56 ng/ml. Women with plasma concentrations of 17-OHPC in the lowest quartile had a significantly higher risk of spontaneous preterm birth (p= 0.03) and delivered at significantly earlier gestational ages (p = 0.002) than did women in the 2(nd) to 4(th) quartiles. The lowest preterm birth rates were seen when median 17-OHPC concentrations exceeded 6.4 ng/ml.
Low plasma 17-OHPC concentration is associated with an increased risk of SPTB. This finding validates efficacy of this treatment but suggests that additional studies are needed to determine the optimal dosage.
American journal of obstetrics and gynecology 10/2013; · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objective: To determine the practice variance, prevalence, and economic burden of clinically diagnosed gastroesophageal reflux disease (GERD) in preterm infants.
Methods: Applying a retrospective cohort study design, we analyzed data from 18 567 preterm infants of 22 to 36 weeks’ gestation and >400 g birth weight from the NICUs of 33 freestanding children’s hospitals in the United States. GERD prevalence, comorbidities, and demographic factors were examined for their association with average length of stay (LOS) and hospitalization cost.
Results: Overall, 10.3% of infants received a diagnosis of GERD (95% confidence interval [CI]: 9.8–10.7). There was a 13-fold variation in GERD rates across hospitals (P < .001). GERD diagnosis was significantly (P < .05) associated with bronchopulmonary dysplasia and necrotizing enterocolitis, as well as congenital anomalies and decreased birth weight. GERD diagnosis was associated with $70 489 (95% CI: 62 184–78 794) additional costs per discharge and 29.9 additional days in LOS (95% CI: 27.3–32.5).
Conclusions: One in 10 of these premature NICU infants were diagnosed with GERD, which is associated with substantially increased LOS and elevated costs. Better diagnostic and management strategies are needed to evaluate reflux-type symptoms in this vulnerable NICU population.
[show abstract][hide abstract] ABSTRACT: The relationship between Chlamydia trachomatis (CT) and preeclampsia was examined longitudinally among 205 cases and 423 normotensive controls nested within the Collaborative Perinatal Project. Antibodies were analyzed at a first prenatal visit (mean 14.2 weeks) and at delivery. Prenatal infections were identified as IgG/IgM seroconversion or a four-fold rise in IgG antibody titers. Although serological evidence of incident prenatal CT infection was uncommon (n=9, 1.4%) in this general pregnant population, infected women were more likely to develop preeclampsia, after adjustment for maternal age, body mass index, smoking status, race and time between blood draws (ORadj 7.2, 95% CI 1.3 - 39.7).
[show abstract][hide abstract] ABSTRACT: Maternal vitamin D deficiency has been linked to fetal growth restriction, but the underlying mechanisms are unclear.
We tested the hypothesis that poor maternal 25-hydroxyvitamin D [25(OH)D] was associated with increased risk of placental vascular pathology.
Maternal serum 25(OH)D was measured at ≤26 wk of gestation in a random subcohort of term, singleton infants in the Collaborative Perinatal Project (1959-1966; n = 2048). A dichotomous vascular construct was created from the presence of any of 12 pathologies identified on placental examinations, including evidence of placental abruption, infarction, hypoxia, decidual vasculopathy, or thrombosis of fetal vessels (n = 240 cases).
The relation between 25(OH)D and vascular pathology was modified by infant sex (P = 0.003). A maternal 25(OH)D concentration ≥80 compared with <50 nmol/L was associated with 49% lower risk of pathology in boys [adjusted OR (95% CI): 0.27, 0.95] after conditioning on study site. No associations were observed between maternal 25(OH)D and pathology in mothers with female offspring. Subsequent analyses showed that, in pregnancies with a female fetus, vascular pathology was associated with a reduced birth-weight z score when the mother's 25(OH)D concentration was <30 nmol/L (β: -0.73; 95% CI: -1.17, -0.30). No association was observed between pathology and birth weight in mothers of female offspring with 25(OH)D concentrations ≥30 nmol/L or in boys, regardless of maternal 25(OH)D status.
Our findings suggest complex relations between vitamin D, placental vascular pathology, and birth weight that differ by infant sex. Maternal vitamin D status may be beneficial for male and female offspring through different mechanisms.
American Journal of Clinical Nutrition 06/2013; · 6.50 Impact Factor
[show abstract][hide abstract] ABSTRACT: In some previous studies, prenatal exposure to persistent organochlorines such as 1,1,-dichloro-2,2-bis(p-chlorophenyl)ethylene (p,p'-DDE), polychlorinated biphenyls (PCBs), and hexachlorobenzene (HCB) has been associated with higher body mass index (BMI, kg/m(2)) in children.
To evaluate the association of maternal serum levels of β-hexachlorocyclohexane (β-HCH), p,p'-DDE, p,p'-DDT, dieldrin, heptachlor epoxide, HCB, trans-nonachlor, oxychlordane, and PCBs with offspring obesity during childhood.
The analysis was based on a subsample of 1,915 children followed until the age of 7 years as part of the U.S. Collaborative Perinatal Project (CPP). The CPP enrolled pregnant women in 1959-1965; exposure levels were measured in third trimester maternal serum that was collected before these organochlorines were banned in the U.S. Childhood overweight and obesity were defined using age-and-sex specific cut points for BMI as recommended by the International Obesity Task Force.
Adjusted results did not show clear evidence for an association between organochlorine exposure and obesity; however, a suggestive finding emerged for dieldrin. Compared with those in the lowest quintile (dieldrin, <0.57 µg/L), odds of obesity were 3.6 (95% confidence interval [CI]: 1.3, 10.5) for the fourth and 2.3 (95% CI: 0.8, 7.1) for the highest quintile. Overweight and BMI were unrelated to organochlorine exposure.
In this population with relatively high levels of exposure to organochlorines, no clear associations with obesity or BMI emerged.
Environmental Health Perspectives 06/2013; · 7.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: Lipoproteins are associated with atherogenic and inflammatory processes, and these processes may be related to adverse pregnancy outcomes. We therefore examined whether variations in lipoprotein particle size and concentration are associated with preterm birth (PTB) < 35 weeks' gestation. METHODS: This is a case-control ancillary study to a randomized trial of omega-3 fatty acid supplementation to prevent recurrent PTB. We measured standard lipids and used nuclear magnetic resonance (NMR) spectroscopy to characterize 17 lipoprotein particles from plasma collected at the baseline randomization visit (16-21 weeks gestation) in 128 cases (PTB < 35 weeks' gestation) and 132 term controls. Logistic regression models controlled for study center, race/ethnicity, number of prior PTB, smoking and treatment group, as well as total LDL, HDL and triglyceride concentrations when examining LDLNMR lipoproteins, HDLNMR lipoproteins and VLDLNMR lipoproteins, respectively. RESULTS: Only one of the 17 NMR lipoproteins was associated with recurrent PTB. We observed an increased odds of recurrent PTB of 1.04 (95% CI= 1.01-1.08; p=0.02) per nanometer increase in VLDLNMR particle size and an odds ratio of 3.00 (CI= 1.40-6.43; p=0.005) for the 3(rd) tertile of VLDLNMR particle size compared with the 1(st) tertile. CONCLUSION: In women with prior PTB, variations in mid-pregnancy lipoproteins were not associated with recurrent PTB overall, however the trend observed with VLDLNMR particle size is suggestive that PTB may be amenable to lifestyle, nutritional or pharmacologic interventions.
American journal of obstetrics and gynecology 06/2013; · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE:
To estimate the associations of change in immune response with preterm delivery, omega-3 supplementation, and fish diet.
This was an ancillary study to a randomized trial of omega-3 fatty acid supplementation for the prevention of recurrent preterm birth. In vitro maternal peripheral blood mononuclear leukocyte production of the anti-inflammatory cytokine, interleukin-10, and the proinflammatory cytokine, tumor necrosis factor-α, in response to stimulation with lipopolysaccharide, was measured at 16-22 weeks of gestation (baseline) and again at 25-28 weeks of gestation (follow-up) among women with prior spontaneous preterm birth. Changes in concentrations from baseline to follow-up ([INCREMENT]) were compared separately among groups defined by gestational age category at delivery, fish diet history, and omega-3 compared with placebo treatment assignment with Kruskal-Wallis tests.
Interleukin-10 [INCREMENT] differed by gestational age category among 292 women with paired assays. Concentrations increased less in women delivering between 35 and 36 6/7 weeks of gestation (48.9 pg/mL) compared with women delivering at term (159.3 pg/mL) and decreased by 65.2 pg/mL in women delivering before 35 weeks of gestation (P=.01). Tumor necrosis factor-α Δ also differed by gestational age category among 319 women, but the pattern was inconsistent. Those delivering between 35 and 36 6/7 weeks of gestation exhibited decreased concentrations of tumor necrosis factor-α at follow-up compared with baseline (-356.0 pg/mL); concentrations increased among women delivering before 35 weeks of gestation and those delivering at term, 132.1 and 86.9 pg/mL (P=.03). Interleukin-10 Δ and tumor necrosis factor-α Δ were unaffected by either omega-3 supplementation or fish diet.
Recurrent preterm birth was associated with decreased peripheral blood mononuclear leukocyte production of interleukin-10 in response to a stimulus during the second trimester.
Obstetrics and Gynecology 04/2013; 121(4):805-811. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: Context:Inconsistent associations between maternal vitamin D status and fetal size have been published in small studies.Objective:Our objective was to examine the association between maternal 25-hydroxyvitamin D [25(OH)D] levels and measures of newborn and placental weight.Design and Setting:We measured maternal 25(OH)D in mothers from the Collaborative Perinatal Project, an observational cohort conducted in 12 U.S. medical centers from 1959 to 1965.Participants:Women delivering singleton, term, live births with 25(OH)D measured at a gestation of 26 wk or less (n = 2146).Main Outcome Measures:Birth weight, ponderal index, placental weight, the placental to fetal weight ratio, and small for gestational age were measured. Hypotheses were formulated after data collection.Results:After confounder adjustment, mothers with 25(OH)D of 37.5 nmol/liter or greater gave birth to newborns with 46 g [95% confidence interval (CI), 9-82 g] higher birth weights and 0.13 cm (0.01-0.25 cm) larger head circumferences compared with mothers with less than 37.5 nmol/liter. Birth weight and head circumference rose with increasing 25(OH)D up to 37.5 nmol/liter and then leveled off (P < 0.05). No association was observed between 25(OH)D and ponderal index, placental weight, or the placental to fetal weight ratio. Maternal 25(OH)D of 37.5 nmol/liter or greater vs. less than 37.5 nmol/liter in the first trimester was associated with half the risk of small for gestational age (adjusted odds ratio 0.5; 95% CI 0.3-0.9), but no second-trimester association was observed.Conclusions:Maternal vitamin D status is independently associated with markers of physiological and pathological growth in term infants. Adequately powered randomized controlled trials are needed to test whether maternal vitamin D supplementation may improve fetal growth.
The Journal of clinical endocrinology and metabolism 11/2012; · 6.50 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objective To determine if tobacco use increases the incidence of preterm premature rupture of the membranes (pPROM) or alters perinatal outcomes after pPROM.Study Design This is a secondary analysis of the databases of three completed Eunice Kennedy Shriver National Institute of Child Health and Human Development-supported Maternal Fetal Medicine Units Network studies. Self-reported tobacco exposure data was obtained. Its relationship with the incidence of pPROM and associated neonatal outcome measures were assessed.Results There was no difference in the incidence of pPROM when comparing nonsmokers to those using tobacco. Although a trend was seen between the incidence of pPROM and the amount smoked, this did not reach statistical significance. Among the patients with pPROM, the use of tobacco was not associated with an increase in perinatal morbidity.Conclusion Our data do not support a significant relationship between tobacco use and pPROM.
American Journal of Perinatology 08/2012; · 1.57 Impact Factor
[show abstract][hide abstract] ABSTRACT: Dichlorodiphenyltrichloroethane (DDT) continues to be used for control of infectious diseases in several countries. In-utero exposure to DDT and dichlorodiphenyldichloroethylene (DDE) has been associated with developmental and cognitive impairment among children. We examined this association in an historical cohort in which the level of exposure was greater than in previous studies.
The association of in-utero DDT and DDE exposure with infant and child neurodevelopment was examined in 1100 subjects in the Collaborative Perinatal Project, a prospective birth cohort enrolling pregnant women from 12 study centers in the United States from 1959 to 1965. Maternal DDT and DDE concentrations were measured in archived serum specimens. Infant mental and motor development was assessed at age 8 months using the Bayley Scales of Infant Development, and child cognitive development was assessed at age 7 years, using the Wechsler Intelligence Scale for Children.
Although levels of DDT and DDE were relatively high in this population (median DDT concentration, 8.9 μg/L; DDE, 24.5 μg/L), neither were related to Mental or Psychomotor Development scores on the Bayley Scales nor to Full-Scale Intelligence Quotient at 7 years of age. Categorical analyses showed no evidence of dose- response for either maternal DDT or DDE, and estimates of the association between continuous measures of exposure and neurodevelopment were indistinguishable from 0.
Adverse associations were not observed between maternal serum DDT and DDE concentrations and offspring neurodevelopment at 8 months or 7 years in this cohort.
[show abstract][hide abstract] ABSTRACT: To describe inter-center hospital variation in inhaled nitric oxide (iNO) administration to infants born prior to 34 weeks' gestation at US children's hospitals.
This was a retrospective cohort study using the Pediatric Health Information System to determine the frequency, age at first administration, and length of iNO use among 22 699 consecutive first admissions of unique <34 weeks' gestation infants admitted to 37 children's hospitals from January 1, 2007, through December 31, 2010.
A total of 1644 (7.2%) infants received iNO during their hospitalization, with substantial variation in iNO use between hospitals (range across hospitals: 0.5%-26.2%; P < .001). The age at which iNO was started varied by hospital (mean: 20.0 days; range: 6.0-65.1 days, P < .001), as did the duration of therapy (mean: 13.1 days; range: 1.0-31.1 days; P < .001). Preterm infants who received iNO were less likely to survive (36.3% mortality vs 8.3%; odds ratio: 6.27; P < .001). The association between the use of iNO and mortality persists in propensity score-adjusted analyses controlling for demographic factors and diagnoses associated with the use of iNO (odds ratio: 3.79; P < .0001).
iNO practice patterns in preterm infants varied widely among institutions. Infants who received iNO were less likely to survive, suggesting that iNO is used in infants already at high risk of death. Adherence to National Institutes of Health consensus guidelines may decrease variation in iNO use.
[show abstract][hide abstract] ABSTRACT: The etiologies of the male urogenital anomalies--cryptorchidism and hypospadias--are poorly understood. Given positive associations between chlordane isomers and testicular germ cell tumors, it is reasonable to assume that chlordanes might also be associated with other testicular dysgenesis syndrome disorders, namely cryptorchidism and hypospadias.
To examine whether exposure to in utero chlordane is related to cryptorchidism and hypospadias, we evaluated levels of chlordane derivatives, trans-nonachlor and oxychlordane, among pregnant women enrolled in the Collaborative Perinatal Project (CPP).
From 1959 to 1965, the CPP enrolled pregnant women at 12 U.S. medical centers. We analyzed serum trans-nonachlor and oxychlordane levels measured in third-trimester serum from the mothers of 217 sons with cryptorchidism, 197 sons with hypospadias, and 557 sons with neither condition. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated using conditional logistic regression.
The quartile-specific ORs for cryptorchidism or hypospadias show no notable associations with trans-nonachlor or oxychlordane. Further, there were no significant trends with increasing quartile of maternal trans-nonachlor or oxychlordane level in either cryptorchidism or hypospadias (p-trend all > 0.45).
The results do not support an association between chlordane levels and cryptorchidism or hypospadias. It is unlikely that current chlordane exposure is related to the development of either anomaly, given that serum chlordane levels at the time of sample collection, the early 1960s, were considerably higher than levels at present.
Environmental Health Perspectives 03/2012; 120(3):478-82. · 7.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: Traditionally, obstetricians have grouped together all pregnancy losses before the mid-second trimester as spontaneous abortions. However, this nomenclature is arbitrary, outdated, and not clinically useful. Using this system, miscarriages due to genetic abnormalities, fetal deaths associated with abnormal placental growth and development, and spontaneous preterm births of liveborn fetuses at previable gestations are lumped together in a single category. In addition, the term abortion is fraught with emotional connotations for families suffering the loss of a pregnancy. Thus, whereas the existing classification for pregnancy loss has served a somewhat pragmatic role, it ignores precepts of developmental biology and the clinical realities of these adverse pregnancy outcomes. In this article, we propose a more useful nomenclature for pregnancy loss and preterm births that is informative and is based on developmental periods in gestation and shared pathophysiology.
Obstetrics and Gynecology 12/2011; 118(6):1402-8. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: Birthweight for gestational age (BW/GA) has been associated with risk of adverse health outcomes. Biological indices of pregnancy complications, maternal mid-pregnancy serum biomarkers, and placental pathology may shed light on these associations, but at present, they are most often examined as single entities and offer little insight about overlap. Additionally, these indices are typically assessed in relation to the extremes of the BW/GA distribution, leaving open the question of how they relate to the entire BW/GA distribution. Addressing issues such as these may help elucidate why postnatal health outcomes vary across the BW/GA continuum.In this study, we focused on a subset of women who participated in the Pregnancy Outcomes and Community Health (POUCH) study (N=1371). We examined BW/GA (i.e., gestational age and sex-referenced z-scores) in relation to obstetric complications, second trimester maternal serum screening results, and histologic evidence of placental pathology along with maternal demographics, anthropometrics, and substance use. In adjusted models, mean reductions in BW/GA z-scores were associated with preeclampsia (β= -.70, 95%CI -1.04, -.36), high maternal serum alpha fetoprotein (MSAFP: β= -.28, 95%CI -.43, -.13), unconjugated estriol (uE3: β= -.31 per .5 MoM decrease, 95%CI -.41, -.21), and high levels of maternal obstructive vascular pathology in the placenta (MV-O: β= -.46, 95%CI -.67, -.25). Findings were similar when preterm infants, SGA, or LGA infants were removed. Future research is needed to examine how the factors studied here might directly mediate or mark risk when evaluating associations between BW/GA and postnatal health outcomes.
Journal of Developmental Origins of Health and Disease 10/2011; 2(5):280-290. · 1.21 Impact Factor
[show abstract][hide abstract] ABSTRACT: Bacterial vaginosis (BV) is a common condition of unknown etiology and has been linked to adverse reproductive and obstetric health outcomes. Prior dietary research on BV has focused on specific macro- and micronutrients, but not dietary indices. We assessed the relationship between BV and selected dietary indicators among a cohort of 1735 nonpregnant women ages 15-44 y from Birmingham, Alabama. Annual intake was assessed with the Block98 FFQ, and the glycemic index, glycemic load (GL), and Healthy Eating Index were calculated by the Block Dietary Data System. The Naturally Nutrient Rich (NNR) score was also calculated. Vaginal flora was evaluated using Nugent Gram-stain criteria. Crude OR and adjusted OR were determined by multinomial and logistic regression in cross-sectional and prospective analyses, respectively. Participants were predominantly African American (85.5%) aged 25.3 ± 6.8 y (mean ± SD). Per 10-unit increase, GL was positively (adjusted OR = 1.01, 95% CI = 1.00-1.03) and NNR was negatively (adjusted OR = 0.93, 95% CI = 0.88-0.99) associated with BV compared to normal vaginal flora. In prospective analyses, only GL was associated with BV progression (adjusted OR = 1.03, 95% CI = 1.00-1.05) and persistence (adjusted OR = 1.02, 95% CI = 1.01-1.04) after adjustment. Both GL and NNR were associated with greater BV prevalence and GL was associated with an increase in BV persistence and acquisition. These results suggest that diet composition may contribute to vaginal flora imbalances and be important for elucidating the etiology of BV.
Journal of Nutrition 09/2011; 141(9):1698-704. · 4.20 Impact Factor
[show abstract][hide abstract] ABSTRACT: Preterm birth, defined as a pregnancy ending at less than 37 completed weeks of gestation, is the leading cause of infant mortality in the United States. The occurrence of preterm births rose steadily from 9.4% of all pregnancies in the United States in 1981 to 12.8% in 2006, before declining to 12.7% in 2007 and 12.3% in 2008. Most of the increase was attributable to increases in multiple gestations. Recent research has sought to understand this condition by evaluating its familial occurrence and both clinical and pathologic information to derive an etiologically homogeneous categorization.
Clinics in perinatology 09/2011; 38(3):339-50. · 1.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: To estimate the association between fish consumption and erythrocyte omega-3 long-chain polyunsaturated fatty acids and preterm birth in a high-risk cohort.
This was an ancillary study to a randomized trial of omega-3 supplementation to prevent preterm birth in women with at least one previous spontaneous preterm delivery. Dietary fish intake was assessed by questionnaire and erythrocyte fatty acids were measured at enrollment (16-21 completed weeks of gestation). The association between fish consumption and preterm delivery was modeled with linear and quadratic terms.
The probability of preterm birth was 48.6% among women eating fish less than once a month and 35.9% among women eating fish more often (P<.001). The adjusted odds ratio for preterm birth among women reporting moderately frequent fish consumption (three servings per week) was 0.60 (95% confidence interval 0.38-0.95), with no further reduction in preterm birth among women who consumed more than three servings of fish per week. Erythrocyte omega-3 levels correlated weakly but significantly with frequency of fish intake (Spearman r=0.22, P<.001); women in the lowest quartile of erythrocyte omega-3 levels were more likely to report consuming less than one fish meal per month (40.3%) than were women in the highest three quartiles (26.3%, P<.001).
Moderate fish intake (up to three meals per week) before 22 weeks of gestation was associated with a reduction in repeat preterm birth. More than moderate consumption did not confer additional benefit. These results support the recommendations of the U.S. Food and Drug Administration and the American Congress of Obstetricians and Gynecologists for fish consumption during pregnancy.
ClinicalTrials.gov, www.clinicaltrials.gov, NCT00135902.
Obstetrics and Gynecology 05/2011; 117(5):1071-7. · 4.80 Impact Factor