Smoking in Preg-nancy

2016.7.12전임의 부혜연

Smoking in Pregnancy

•여성의 흡연율• 2011 년 6.8%, 2012 년 7.9%, 2013 년 6.2%, 2014 년 5.7% ( 국민건강영양조사 )

• In the US : about 16 % of pregnant women smoke• In Korea : 8-10%

• Cigarette smoke contains over 4,000 chemicals and toxins including NicotineTarArsenicLeadCarbon monoxideAt least 40 known cancer-causing agents

Smoking in Pregnancy

Carbon Monoxide

• Carbon monoxide(CO) + Hemoglobin (Hb)Carboxyhemoglobin(COHb)

• Fetal concentrations are generally higherd/t higher affinity

Decrease the amount of oxygen car-ried to cells

Impair cytochrome enzymes->Affects intracellular process

Nicotine

• Lipid-soluble• Large distribution volume(2-3L/kg)• Permeates cell membranes

• Absorbed by lung, skin, GI tract, nasal mucosa• Actively secreted by renal tubules

• Elimination half life 1-3Hrs• Major metabolite level(eg. Cotinine)->Most accurate es-

timation

Adverse Effects in Pregnancy

• Increased miscarriage risk• Reduced fetal growth• Congenital malforma-tion: Some, Small

• Abnormal placenta-tion

• Sudden infant death syndrome•Neurobehavioral de-velopment

Reprotox

Fetal Growth and Prematurity

• Intrauterine growth restriction: most consis-tent effect200gm lighterDose-response relationshipStopped during the first half of gestation -> virtually normal birth weight

• Possible mechanisms)Premature placental maturationChronic reduction in placental blood flow Increase in Cadmium burdenFetal hypoxia(d/t CO)

Long-term Effects

• Long-term growth and developmental studies

• Smoking in pregnancy might affect Physical growth, mental development, and behavioral problem

•Mean 8-point decrement in IQ test in heavy smokers

Malformations

• Some reports suggested..

• Club foot ?

• Craniosynostosis : Premature closure of sagit-tal suture(OR 1.48)

• Facial clefts(1/500->1/183)

Malformations

•Hydrocephaly, microcephaly•Omphalocele, gastroschisis• Limb reduction defects• Congenital heart defect

•Paternal Smoking

• Increase in facial clefts• Congenital heart defect

Other Pregnancy Outcomes

• Ectopic pregnancy• Spontaneous abortion• Fetal death• Sudden infant death syndrome (SIDS)

• Placenta previa, placenta abruption and bleed-ing early or late in pregnancy.

• Childhood cancer (leukemia)• Paternal smoking around conception -> child-hood cancer prior to age 5 (leukemias, lym-phomas, and brain tumors)

• Pulmonary function

• ADHD?• Later schizophrenia

•Higher food allergen sensitization (OR : 2.2)•Obesity, hyprtension

Lactation

• Breastfeeding within 1 hour->nicotine concentration in milk

• Impeded iodine transport into milk in smoking mother

• To access maternal and fetal exposure

•Umbilical carboxyhemoglobin (COHb)Elimination t½ of CO is around 5 hours.

Only if the mother had continued smoking When elimination t½ is long enough

• Level of CotinineMeconium(first day of life)Hair(3-4 months)

Biological Markers

• Cheil General Hospital • Between January 2000 and December 2014

Maternal smokingPregnancy outcome

Paternal smoking

Control (n=1487)

Smoking (n=540)

Smoking (n=268) Control (n=807)

AA 21Transfer

638F/u loss 21

AA 8Transfer

257F/u loss 7

Smoking (n=238) Control (n=739)

SA 68SA 30

  Cases(n=268) Controls(n=807)

     

  n (%) n (%) OR 95% CI P valueAge(mean±SD) 31.9±4.1 31.9±3.8   -0.5-0.6 0.82

Gravidity(mean±SD)

2.5±1.5 2.2±1.3   -0.5 to -0.1

<0.01

Parity(mean±SD) 0.4±0.6 0.6±0.6   0.2-0.4 <0.01

Body Mass Index(mean±SD)

21.2±3.8 22.1±24.7   -0.9-2.7 0.31

Exposure to X-rays 48 17.9 153 18.9 0.9 0.7-1.3 0.71

Total dose(mSv) 2.9±6.8 2.3±6.7   -2.8-1.6 0.58

Gestational age at Exposure

3.5±3.3 3.7±2.5   -0.9-1.2 0.75

Exposure to Alco-hol

182 67.9 292 36.1 3.7 2.8-5.0 <0.01

Total dose(oz) 2.4±4.5 1.6±1.3   -1.6 to -1.3

0.01

Gestational age at Exposure

4.4±2.7 4.3±3.0   -0.6-0.4 0.74

Paternal smoking 166 61.9 307 38.0 2.7 2.0-3.5 <0.01

Cigarettes/day 11.1±15.9 5.7±9.0   -7.0 to -3.9

<0.01

  Cases(n=268)

Controls(n=807)

     

  n (%) n (%) OR 95% CI P valueComorbidities   Hypertension 1 0.4 2 0.2 1.5 0.1-16.7 0.74 Thyroid disease 2 0.7 8 1 0.8 0.2-3.6 0.72 Type II Diabetes 0 0 3 0.4   0.7-0.8 0.32

Education level  Post-secondary education

92 34.3 362 44.8 0.6 0.5-0.9 <0.01

High school 46 17.2 71 8.8 2.2 1.4-3.2 <0.01Not answered 130 48.5 375 46.4 1.1 0.8-1.4 0.55

Occupation              Professional, technical and related occupa-

tions

29 10.8 108 13.4 0.8 0.5-1.2 0.28

Excutive, administra-tive, managerial and sales occupations

123 45.9 353 43.7 1.1 0.8-1.4 0.53

Constructive workers 102 38.1 326 40.3 0.9 0.7-1.2 0.51Unemployed 8 3 16 2 1.5 0.6-3.6 0.33No answer 6 2.2 5 0.6 3.7 1.1-12.2 0.02

Case(n=268)Mean

Cigarette/Day

(mean±SD)

8.0±6.3 1.0-40.0

Gestational age at expo-

sure(weeks)

(mean±SD)

5.3±3.9 0-31.0

Table 2. Characteristics of Smoking group.

Table 3. Fetal and neonatal outcomes.  Cases(n=238) Controls(n=7

39)     

  n (%) n (%) OR 95% CI P valueGestational age at

birth(weeks)(mean±SD)

39.1±2.2 39.2±1.4 -0.1-0.3 0.37

Birth weight(g) (mean±SD)

3274.8±503.5 3309.7±428.0 -30-100 0.30

Birth length(cm)(mean±SD)

49.2±5.0 49.4±3.7 -0.5-0.9 0.51

Head circumfer-ence(cm)

(mean±SD)

34.2±3.5 34.5±2.5 -0.2-0.7 0.31

Apgar score, 1 min(mean±SD)

8.2±1.1 8.3±0.9 0-0.3 0.05

Apgar score, 5min(mean±SD)

9.0±1.0 9.1±1.0 -0.1-0.2 0.21

Stillbirth 2/236 0.8 1/738 0.1 6.3 0.6-69.3 0.09Major malforma-

tions6 18.2 6 6.3 3.3 1.0-11.1 0.04

NICU admission 15 6.3 33 4.5 1.4 0.8-2.7 0.26Length of stay at

NICU (days) (mean±SD)

0.7±2.6 0.6±2.7 -0.5-0.3 0.58

Major MalformationsControl(n=6) Case(n=6)

VSD 2Microtia 2Cleft palate 1Necrotizing enterocoli-tis 1

Inguinal hernia 2Both Hydrocele 1Cryptorchidism 1Polydactly 1Hirchsprung Dz 1

Table 5. Details of major malformations.

Table 4. Fetal and neonatal outcomes by Paternal smoking.  Smoking(n=4

24)Controls(n=5

53)     

  n (%) n (%) OR 95% CI P valueGestational age at

birth(weeks)(mean±SD)

39.2±1.6 39.2±1.7 -0.2-0.2 0.91

Birth weight(g) (mean±SD)

3301.0±426.2 3301.4±463.5 -55.8-56.5 0.99

Birth length(cm)(mean±SD)

49.2±3.2 49.4±2.5 -0.3-0.7 0.40

Head circumfer-ence(cm)

(mean±SD)

34.4±3.5 34.4±2.5 -0.3-0.4 0.78

Apgar score, 1 min(mean±SD)

8.2±0.9 8.3±0.9 0-0.3 0.03

Apgar score, 5min(mean±SD)

9.0±1.0 9.1±0.9 0-0.2 0.10

Stillbirth 1/423 0.2 2/551 0.4 0.6 0.1-7.2 0.73Major malforma-

tions8 12.3 4 6.3 2.1 0.6-7.3 0.25

NICU admission 19 4.5 29 5.3 0.9 0.5-1.6 0.61Length of stay at

NICU (days) (mean±SD)

0.6±2.6 0.6±2.8 -0.3-0.3 0.95

Mater-nal

smok-ing

Alcohol Ex-posure

Educa-tion

Major mal-formation

Paternal smoking

Thank you for your at-tention