Abstract Purpose Severe hypercalcemia resulting from hyperparathyroidism may result in adverse perinatal outcomes. The objective of this study was to evaluate maternal and neonatal outcomes among pregnant women with hyperparathyroidism using a population database. Methods A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999–2015. ICD-9 codes were used to identify women diagnosed with hyperparathyroidism during pregnancy. Perinatal outcomes between pregnant women with and without hyperparathyroidism were compared. Multivariate logistic regression, controlling for age, race, income, insurance type, hospital location, and comorbidities, evaluated the effect of hyperparathyroidism on perinatal outcomes. Results Of 13,792,544 deliveries included over the study period, 368 were to women with hyperparathyroidism. The overall incidence of hyperparathyroidism was 2.7/100,000 births, increasing from 1.6 to 5.2/100,000 births over the study period (p < 0.0001). Women with hyperparathyroidism were older and had more comorbidities, such as obesity, and pre-gestational hypertension and diabetes. Relative to the comparison group, women with hyperparathyroidism were more likely to deliver preterm, OR 1.69 (95% CI 1.24–2.29), to develop preeclampsia, 3.14 (2.30–4.28), and to deliver by cesarean, 1.69 (1.36–2.09). Infants born to mothers with hyperparathyroidism were more likely to be growth restricted, 1.83 (1.08–3.07), and to be diagnosed with a congenital anomaly, 4.21 (2.09–8.48). Conclusion Hyperparathyroidism during pregnancy is associated with a significant increase in adverse perinatal outcomes, including preeclampsia, preterm delivery, fetal growth restriction, and congenital anomalies. As such, pregnancies among women with hyperparathyroidism should be considered high-risk, and specialized care is recommended in order to minimize maternal and neonatal morbidity.

Labor induction at 39 weeks has been associated with a decreased risk of cesarean delivery. The objective of this study is to evaluate the effect of labor induction at 39 weeks on perinatal death in low risk pregnancies. We used the National Center for Health Statistics Linked Birth and Infant Deaths data from 2013 to 2017 to carry out a matched cohort study using propensity score matching to test the influence of induction of labor at 39 weeks on risk of stillbirth and infant death. Low risk singleton pregnancies with a live fetus at 39 weeks with no known congenital malformations who underwent an induction of labor were matched with comparable pregnancies that were not induced at 39 weeks that delivered no later than 42 weeks. From a total of over 20 million births, 825,323 (4%) low risk pregnancies were induced at 39 weeks and propensity score matched at a 5:1 ratio to a comparable group of pregnancies. As compared to pregnancies that were not induced at 39 weeks, induction of labor at 39 weeks was associated with an overall increased risk of perinatal death, 10.8 vs 5.8 per 10,000, 3.8 (3.5-4.2), p< 0.0001, which consisted of a decreased risk of stillbirth, 0 vs 0.7 per 10,000, and an increased risk of infant death, 10.8 vs 5.1 per 10,000, OR 4.2 (3.8-4.6), p< 0.0001. Among live birth infants, the risk of sudden infant death syndrome was more common among pregnancies induced at 39 weeks, 4.3 (3.6-5.2), p< 0.0001. Induction of labor at 39 weeks in low-risk singleton pregnancies is associated with an increased risk of perinatal death. While this may not have a material effect on risk to an individual patient, adoption of widespread practices of inducing low-risk pregnancies at 39 weeks may lead to increases in perinatal deaths on a population level.

INTRODUCTION: Induction of labor (IOL) at 39 weeks has been associated with decreased risk of cesarean delivery. The study objective was to evaluate the effect of IOL at 39 weeks on perinatal death in low-risk pregnancies. METHODS: We used the National Center for Health Statistics Linked Birth/Infant Deaths data from 2013 to 2017 to carry out a propensity score matched cohort study to test the influence of IOL at 39 weeks on risk of stillbirth and infant death. Low-risk singleton pregnancies with a live fetus at 39 weeks with no known congenital malformations who underwent an IOL were matched with comparable pregnancies that were not induced at 39 weeks and that delivered no later than 42 weeks. RESULTS: From >20 million births, 825,323 (4%) low-risk pregnancies that were induced at 39 weeks were propensity score matched (5:1 ratio) to a comparable group of pregnancies that were not induced at 39 weeks. Compared to pregnancies that were not induced at 39 weeks, IOL at 39 weeks was associated with increased risk of perinatal death (10.8 versus 5.8/10,000; OR, 3.83.5–4.2; P <.0001), which consisted of a decreased risk of stillbirth (0 versus 0.7/10,000) and an increased risk of infant death (10.8 versus 5.1/10,000; OR, 4.2; 95% CI, 3.8–4.6; P <.0001). Among live-born infants, the risk of sudden infant death syndrome was more common among pregnancies induced at 39 weeks (OR, 4.3; 95% CI, 3.6–5.2; P <.0001). CONCLUSION: IOL at 39 weeks in low-risk singleton pregnancies is associated with an increased risk of perinatal death. While this may not have a material effect on risk to an individual patient, adoption of widespread practices of inducing low-risk pregnancies at 39 weeks may lead to increases in perinatal deaths on a population level.

CONTEXTE:L'hématome du grand droit (HGD) est une cause rare mais importante de douleur abdominale pendant la grossesse. CAS: Une femme de 32 ans a consulté à 316 semaines de grossesse en raison de douleurs abdominales du côté droit. L'échographie a révélé une structure hétérogène compatible avec un HGD. Une prise en charge s'est composée d'un traitement symptomatique au moyen d'analgésiques et d'un suivi obstétrical et échographique. L'échographie a révélé la résorption de l'HGD après 6 semaines. À 38 semaines de grossesse, la patiente a subi un déclenchement artificiel du travail pour cause de pré-éclampsie et a donné naissance à une fille en bonne santé. CONCLUSION:Notre étude de cas présente un HGD spontané survenu à 32 semaines de grossesse, lequel a été pris en charge par traitement symptomatique. La grossesse s'est soldée par un accouchement à terme.

Objective Spontaneous coronary artery dissection (SCAD) is a rare and potentially lethal cause of myocardial infarction (MI). The purpose of our study was to estimate the prevalence and maternal outcomes of pregnancies complicated by SCAD. Materials and methods A population-based cohort study on all births identified in the Healthcare Cost and Utilization Project from 2008 to 2012. Disease prevalence was calculated and logistic regression was used to estimate the adjusted odds ratio (aOR) for risk factors and different maternal complications. Results A total of 4 363 343 pregnancy-related discharges were evaluated. 79 cases of SCAD were identified resulting in a prevalence of 1.81 per 100 000 pregnancies. The mean maternal age at the time of diagnosis was 33.4 years (±5.2). Chronic hypertension (aOR, 2.67; 95% CI 1.18 to 6.03), lipid profile abnormalities (aOR, 48.22; 95% CI 24.25 to 95.90), chronic depression (aOR, 3.56; 95% CI 1.43 to 8.83) and history of migraine (aOR, 3.93; 95% CI 1.52 to 10.17) were associated with an elevated risk for SCAD. MI was diagnosed in 66 (85.5%) cases of SCAD with anterior and subendocardial territories being the most common locations. Thirty one patients (40%) with SCAD underwent angioplasty with the majority receiving stents, which was associated with a longer hospital stay than those treated conservatively or with bypass. Conclusions SCAD is a rare aetiology of MI; risk factors and outcomes are illustrated in the current study. The puerperium is an important period for the development of pregnancy-related SCAD. Careful evaluation of pregnant and postpartum women with chest pain is warranted, especially if these risk factors are identified.

BACKGROUND Placental weight is an independent predictor of adverse perinatal outcome. However, risk factors for high and low placental weight are poorly understood. The objective of this study was to identify maternal, placental, and umbilical cord determinants of placental weight, before and after accounting for birthweight. METHODS This cohort study of 87,600 singleton births at the Royal Victoria Hospital in Montreal, Canada assessed the relationship between maternal, placental, and umbilical cord characteristics and placental weight (standardised for sex and gestational age). We separately examined risk factors for high (z-score >+1) and low (z-score <-1) placental weight. Multivariable logistic regression was used to study associations after adjusting for confounders and further adjusting for birthweight. RESULTS Chronic hypertension was associated with low placental weight {relative risk (RR) 2.1 [95% confidence interval (CI) 1.8, 2.4] and 1.8 [95% CI 1.5, 2.1] before and after accounting for birthweight}, while pre-eclampsia was associated with low placenta weight before, but not after adjustment for birthweight. Anaemia and gestational diabetes were linked with high placental weight (RRs 1.2-1.4, respectively) before and after adjustment for birthweight, while smoking was linked with high placental weight only after adjustment for birthweight (RR 1.4 [95% CI 1.3, 1.5]). Placental and cord determinants of high placental weight included chorioamnionitis, chorangioma/chorangiosis, circumvallate placenta, marginal cord insertion, and other cord abnormalities. CONCLUSIONS The broad range of risk factors for high placental weight suggests multiple aetiologic pathways. Future work should seek to understand the pathways by which the placenta adapts to unfavourable intrauterine conditions, which may provide insights into potential therapies.

OBJECTIVE:To examine the effect of cigarette smoking during pregnancy on the development of preterm premature rupture of membranes (PPROM) categorized by gestational age. METHODS:We conducted a retrospective cohort study of 17,961 births using data from the McGill Obstetric and Neonatal Database between years 2001 and 2006. Our exposure was defined according to self-reported maternal cigarette smoking status categorized as nonsmoker, smoker of 1 to 10 cigarettes per day, and smoker of > 10 cigarettes per day. The outcome was measured as incidence of premature rupture of membranes (PROM) among gestational age categories of < 28, < 32, < 37, and > 37 weeks. Unconditional logistic regression analysis and Wald test for trend were used to estimate the adjusted risk of PPROM according to smoking status. RESULTS:Among the study population, 640 cases of PPROM (<37 weeks) and 40 cases of PROM (>37 weeks). After adjusting for confounding variables, smoking > 10 cigarettes per day was associated with an increased risk of PPROM at < 28 weeks (odds ratio [OR] 5.28; 95% confidence interval [CI] 2.20 to 12.7); < 32 weeks (OR 2.36; 95% CI 1.09 to 5.11; < 37 weeks (OR 1.97; 95% CI 1.32 to 2.94); and > 37 weeks (OR 3.19; 95% CI 0.92 to 11.0). Smoking 1 to 10 cigarettes per day was not associated with a significant risk of PPROM at any gestational age. CONCLUSION:Heavy cigarette smoking increases the risk of PPROM more so at early gestational age than at term.

OBJECTIVES:To examine the association between prior induced abortions and prematurity and to explore potential mechanisms for a relationship, including second trimester pregnancy losses and infections.METHODS:We conducted a retrospective review of the records of all women who delivered between April 2001 and March 2006 using data from the McGill Obstetric and Neonatal Database. Exposure was categorized as having had no prior induced abortions, one prior induced abortion, or two or more prior induced abortions. Our primary outcome was gestational age at delivery, categorized as < 24 weeks, < 26 weeks, < 28 weeks, < 32 weeks and < 37 weeks. Secondary outcomes were intrapartum fever, NICU admission, and use of tocolysis.RESULTS:A total of 17 916 women were included in the study. Of these 2276 (13%) had undergone one prior induced abortion, and 862 (5%) had undergone two or more prior induced abortions. Women with a prior induced abortion were more likely to be smokers and to consume alcohol, and were less likely to be married. Women who reported one prior induced abortion were more likely to have premature births by 32, 28, and 26 weeks; adjusted odds ratios were 1.45 (95% CI 1.11 to 1.90), 1.71 (95% CI 1.21 to 2.42), and 2.17 (95% CI 1.41 to 3.35), respectively. This association was stronger for women with two or more previous induced abortions. Prior induced abortion was associated with an increased requirement for tocolysis in subsequent pregnancies, but there was no association between prior induced abortions and NICU admission, intrapartum fever, and preterm premature rupture of membranes.CONCLUSION:Our study showed a significant increase in the risk of preterm delivery in women with a history of previous induced abortion. This association was stronger with decreasing gestational age.

OBJECTIVE:Although anti-D prophylaxis has greatly reduced the rate of Rh-immunization, there remain women who sensitize during or after pregnancy because of inadequate prophylaxis. The purpose of this study was to compare adherence to prophylaxis recommendations for antenatal and postnatal anti-D immunoglobulin administration.METHODS:We conducted a retrospective cohort study of all pregnancies recorded at the Royal Victoria Hospital between 2001 and 2006 to determine the rates of antenatal and postnatal prophylaxis in Rh(D)-negative women. We compared adherence to anti-D prophylaxis recommendations between our institution's physician-dependent antenatal approach and the protocol-based postpartum approach. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals of determinants of non-adherence to current recommendations for anti-D prophylaxis.RESULTS:Antenatal administration was analyzed in 1868 pregnancies in eligible Rh-negative women. Among these women, 85.7% received appropriate antenatal prophylaxis and 98.5% of eligible women received appropriate postnatal prophylaxis. Factors independently associated with non-adherence to antepartum prophylaxis included first visit in the third trimester (P < 0.001), transfer from an outside hospital (P = 0.03), and physician licensing before 1980 (P = 0.04).CONCLUSION:Unlike hospital-based protocol-dependent systems, physician-dependent systems for antenatal anti-D prophylaxis remain subject to errors of omission. A more standardized system is needed to ensure effective antenatal prophylaxis.

OBJECTIVE: The fetoplacental ratio has been used conventionally to study the contribution of the placenta to fetal growth restriction. However, this measure is problematic because a normal fetoplacental ratio can reflect birth weight and placental weight that are both normal, both low, or both high. The objective of this study was to examine the independent association between placental weight for gestational age and perinatal mortality or serious neonatal morbidity.METHODS: A sex-and gestational age-specific placental weight z score was calculated for a cohort of 87,600 singleton births at the Royal Victoria Hospital in Montreal, Canada, 1978-2007. The relationship between placental weight z score and adverse perinatal outcomes (stillbirth, neonatal death, 5-minute Apgar score lower than 7, seizures, or respiratory morbidity) was examined using logistic regression. Multivariable models examined whether the relationship was independent of birth weight and other pregnancy risk factors.RESULTS: After controlling for birth weight, fetuses with a low placental weight z score were at significantly increased risk of stillbirth (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4-2.6, percent population attributable risk 17.8%). In contrast, adverse neonatal outcomes were significantly more likely among those with high placental weight z scores (OR 1.4, 95% CI 1.2-1.7, percent population attributable risk 5% for any serious neonatal morbidity). Similar trends were observed after further adjusting for pregnancy risk factors.CONCLUSION: Placental weight for gestational age is an independent risk factor for adverse perinatal outcomes, above and beyond the known association with birth weight. The mechanisms behind the opposing effects of placental weight z score on risk of stillbirth compared with adverse neonatal outcomes require further elucidation. (Obstet Gynecol 2012;119:1251-8) DOI: 10.1097/AOG.0b013e318253d3df

Breast cancer in pregnancy is a rare condition. The objective of our study was to describe the incidence, risk factors, and obstetrical outcomes of breast cancer in pregnancy. We conducted a population-based cohort study on 8.8 million births using data from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample from 1999-2008. The incidence of breast cancer was calculated and logistic regression analysis was used to evaluate the independent effects of demographic determinants on the diagnosis of breast cancer and to estimate the adjusted effect of breast cancer on obstetrical outcomes. There were 8,826,137 births in our cohort of which 573 cases of breast cancer were identified for an overall 10-year incidence of 6.5 cases per 100,000 births with the incidence slightly increasing over the 10-year period. Breast cancer appeared to be more common among women >35 years of age, odds ratio (OR)=3.36 (2.84-3.97); women with private insurance plans, OR=1.39 (1.10-1.76); and women who delivered in an urban teaching hospital, OR=2.10 (1.44-3.06). After adjusting for baseline characteristics, women with pregnancy-associated breast cancer were more likely to have an induction of labor, OR=2.25 (1.88, 2.70), but similar rates of gestational diabetes, preeclampsia, instrumental deliveries, and placental abruption. The incidence of breast cancer in pregnancy appears higher than previously reported with women over 35 being at greatest risk. Aside from an increased risk for induction of labor, women with breast cancer in pregnancy have similar obstetrical outcomes.

AIMS:To examine the effect of a prior cesarean delivery on neonatal outcomes.METHODS:We conducted a retrospective cohort study on all women with a prior livebirth who delivered at the Royal Victoria Hospital between 2001 and 2006. We defined our exposure as a positive history for cesarean delivery and used unconditional logistic regression analysis to estimate the adjusted effect of a previous cesarean delivery on adverse neonatal outcomes.RESULTS:A total of 18,673 births took place of which 9708 were in women with a prior livebirth (77.0% with no previous cesarean delivery and 23.0% with a previous cesarean delivery). As compared to newborns delivered by mothers with no prior cesarean delivery, increasing number of prior cesarean deliveries was associated with an increasing risk of preterm birth [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.09-1.39]; respiratory distress syndrome (OR 3.54, 95% CI 2.02-5.91); and admission to the neonatal intensive care unit (OR 1.41, 95% CI 1.25-1.60). These findings were predominantly due to differences in gestational age and mode of delivery.CONCLUSION:Having a prior cesarean delivery is associated with an increased risk of adverse neonatal outcomes. Adverse neonatal outcomes in subsequent pregnancies is additional evidence to suggest that unless specifically indicated, cesarean delivery should be avoided.

OBJECTIVE: To compare maternal and neonatal complications in natural twins to those of in vitro fertilization (1VF) conceived twins.STUDY DESIGN: Twin gestations delivered from 1995 to 2000 were reviewed.Cases (N = 56) consisted of IVF twins and controls (N = 165) comprised spontaneous twins.They were compared regarding various maternal and neonatal complications.RESULTS: Maternal age was significantly higher and frequency of multiparity lower in cases compared to controls (31 _+ 5 vs 29 _+ 5 years; P= .010and 21.4% vs 62.4%; P = .000),respectively.The cesarean delivery rate was significantly higher in cases (76.8 vs 56.4%; P .011)despite similar indications and incidence of non-vertex presenting twin A in both groups.Maternal hospir, d stay was significantly longer in cases (11 _+ 15 vs 6 + 9 days; P = .003).Preterm labor (51.8 vs 21.1%; P -.000) and preterm delivery rates (67.9 vs 41.8%; P-.002) were significantly higher in cases with a significantly lower gestational age at delivery (35 _+ 3 vs 36 _+ 3 weeks; P .032).The incidence of preeelan-tpsia was 1t).7% in cases compared to 4.2% in controls (P= .147).The incidence of placental abruption, previa and diabetes were similar in both group.Both twins were on the average ~200 grains lighter in cases compared to controls and this was statistically significant.However, intrauterine growth restriction was more fi'equent in controls (36.4 vs 25.0%: P = .037).There was a significantly higher incidence of neonatal intensive care unit admission, respiratoly distress syndrome, need for nmchanical ventilation, and pneumothorax in cases vs controls; however, mean Apgar scores at 1 and 5 minntes and incidence of intraventricular heinon'hage, necrotizing enterocolitis, anomalies, sepsis and perinatal mortality rates were similar in the 2 groups.CONCLUSION: IVF twins are more likely to have a cesarean delivery, longer maternal hospital stay, higher incidence of preterm delivery and neonatal prematurity-related respiratory complications, and a longer nurser), stay.

The objective of our study was to evaluate the incidence and effect of maternal age on the risk of stillbirth. We conducted a population-based cohort study using the Centers for Disease Control and Prevention's "Linked Birth-Infant Death" and "Fetal Death" data files. We excluded all births of gestational age under 24 weeks and those with reported congenital malformations. We estimated the adjusted effect of maternal age on the risk of stillbirth using logistic regression analysis. There were 37,504,230 births that met study criteria, of which 130,353 (3.5/1,000) were stillbirths. Rates of stillbirth remained constant throughout the 10 years. As compared with women between the ages of 25 and 30, decreasing maternal age was associated with the following risk of stillbirth: odds ratio (OR) 0.95 (95% confidence interval [CI] 0.93 to 0.97) for ages 20 to 25; OR 0.97 (95% CI 0.94 to 0.99) for ages 15 to 20; and OR 1.32 (95% CI 1.18 to 1.47) for ages <15. Increasing maternal age was associated with an increasing risk of stillbirth: OR 1.02 (95% CI 0.99 to 1.04) for ages 30 to 35, OR 1.25 (95% CI 1.21 to 1.28) for ages 35 to 40, OR 1.60 (95% CI 1.53 to 1.67) for ages 40 to 45, and OR 2.22 (95% CI 1.91 to 2.53) for ages >45. Although the overall risk is low, the risk of stillbirth increases considerably in women at the extremes of the reproductive age spectrum. Antenatal surveillance may be justified in these women.

BACKGROUND:Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS:We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models. RESULTS:Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P < 0.001). CONCLUSION:Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.

Breast cancer is uncommon in pregnancy, but obstetrical care providers should nevertheless be familiar with the presenting signs and symptoms. The incidence of breast cancer in pregnancy and the postpartum period ranges from 2.3 to 40 cases per 100 000 women. Over 90% of patients with breast cancer in pregnancy or during lactation present with a palpable mass, and most often (84%) these are self-reported by patients. Less frequently, breast cancer will present as breast erythema, breast swelling, bloody nipple discharge, or local or distant metastasis. The histology of tumours appears to be similar in women who are pregnant or recently delivered and in age-matched women who are not pregnant. However, the stage of disease at diagnosis is more advanced in women who are pregnant or recently delivered and consequently incurs a worst prognosis, likely due to a delay in diagnosis. Although the majority of palpable breast masses are benign, breast examinations should routinely be performed in pregnant women, and identified masses should be promptly evaluated.

OBJECTIVE:Patient education level has been shown to affect health care outcomes in a variety of clinical contexts. The aim of this study was to evaluate whether maternal education level influences women to plan elective repeat Caesarean section rather than attempt a vaginal birth after Caesarean. METHODS:We conducted a retrospective cohort study of women with a previous Caesarean section who delivered at the Royal Victoria Hospital between 2001 and 2006. Education level was stratified as follows: = 11 years (up to and including a high school diploma), 12 to 15 years (some college or university education), and >/= 16 years (university degree). We used unconditional logistic regression to calculate age-adjusted estimates of the risk of having a planned Caesarean section. RESULTS:Among 18 673 deliveries in our cohort, 1915 were in women with a previous Caesarean section. Of these, 12.6% had a high school degree or less, 38.3% had some college or university education, and 49.1% had a university degree. Compared with women whose maximum education was a high school diploma, there was a higher rate of planned Caesarean section in women with some college or university education (OR 1.38; 95% CI 1.00 to 1.89, P = 0.047) and in women with a university degree (OR 1.42; 95% CI 1.04 to 1.94, P = 0.03). CONCLUSION:Higher education appears to be associated with an increased rate of elective repeat Caesarean section. Whether this is due to patient differences or physician bias, physicians should be aware of this disparity and should attempt to provide unbiased informed consent for all women regardless of their level of education.

OBJECTIVE:We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN:In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS:Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION:Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.