Publications by authors named "Nathalie Auger"

227 Publications

Increased risk of allergy hospitalization after cesarean delivery: a longitudinal study of 950,000 children.

Ann Allergy Asthma Immunol 2021 Apr 10. Epub 2021 Apr 10.

University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.anai.2021.04.009DOI Listing
April 2021

Maternal mental disorders and risk of pathological abdominal conditions in children.

Arch Womens Ment Health 2021 Apr 8. Epub 2021 Apr 8.

University of Montreal Hospital Research Centre, Montreal, Canada.

The etiology of pediatric abdominal disorders is poorly understood, and the relationship with maternal mental health is understudied. We sought to determine the association between maternal psychiatric disorders and abdominal conditions in childhood. We performed a retrospective cohort study of 1,080,518 newborns in Quebec, Canada, between 2006 and 2020. We identified maternal mental disorders before or during pregnancy and computed the incidence of abdominal disorders in offspring before 1 year of age. Outcomes included Hirschsprung disease; hypertrophic pyloric stenosis; and esophageal, intestinal, and biliary atresia. We calculated adjusted risk ratios (RR) with 95% confidence intervals (CI) for the association of maternal mental disorders with these pediatric abdominal disorders. Among 51,371 children exposed to maternal mental disorders, 200 children had an abdominal condition, for a rate of 38.9 cases per 10,000 children (95% CI 33.6-44.3) compared with 27.7 per 10,000 for children who were unexposed to maternal mental disorders (95% CI 26.7-28.7). Compared with no mental disorder, maternal mental disorders were associated with hypertrophic pyloric stenosis (RR 1.39, 95% CI 1.16-1.68). Associations were stronger for severe mental disorders and were more marked for depression and stress and anxiety disorders. Maternal mental disorders are associated with the risk of hypertrophic pyloric stenosis in offspring. The origin of hypertrophic pyloric stenosis may relate to maternal mental disorders that were present during pregnancy.
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http://dx.doi.org/10.1007/s00737-021-01126-3DOI Listing
April 2021

Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study.

Arch Gynecol Obstet 2021 Apr 4. Epub 2021 Apr 4.

University of Montreal Hospital Research Centre, 900 Saint Denis St., Montreal, QC, H2X 0A9, Canada.

Purpose: The association between placental detachment disorders and risk of chronic disease is unclear. We determined the association of placenta accreta and retained placenta with risk of future maternal cardiovascular disease and cancer.

Methods: We tracked a longitudinal cohort of 541,051 pregnant women over a period of 13 years (2006-2019) in Quebec, Canada. The main exposure measures were placenta accreta and retained placenta in any pregnancy. Outcomes included future hospitalizations for cardiovascular disease and cancer. Using Cox regression models adjusted for maternal characteristics, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of accreta and retained placenta with cardiovascular disease and cancer at 13 years.

Results: The incidence of cardiovascular hospitalization was 21.2 per 10,000 person-years for accreta and 23.4 per 10,000 for retained placenta with postpartum hemorrhage, compared with 20.3 per 10,000 for neither placental disorder. Cancer incidence followed a similar pattern, with rates highest for retained placenta with hemorrhage. Retained placenta with hemorrhage was associated with 1.19 times the risk of cardiovascular disease (95% CI 1.03-1.38) and 1.27 times the risk of cancer (95% CI 1.06-1.53). Retained placenta with hemorrhage was associated with heart failure (HR 1.84, 95% CI 1.04-3.27), cardiomyopathy (HR 1.88, 95% CI 1.03-3.43), and cervical cancer (HR 2.03, 95% CI 1.17-3.52). Accreta and retained placenta without hemorrhage were not associated with these outcomes.

Conclusion: Retained placenta with hemorrhage may be a risk marker for cardiovascular disease and certain cancers later in life.
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http://dx.doi.org/10.1007/s00404-021-06044-4DOI Listing
April 2021

Original article: Is the protective association between hyperemesis gravidarum and birth defects biased by pregnancy termination?

Ann Epidemiol 2021 Mar 30. Epub 2021 Mar 30.

Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Quebec, Canada. Electronic address:

Purpose: We assessed whether the protective association between hyperemesis gravidarum and birth defects could be due to selection bias from exclusion of pregnancy terminations.

Methods: We designed a cohort study of 2,115,581 live births in Canada, 1990-2016. The main exposure measure was hyperemesis gravidarum. The main outcome measure included any birth defect at delivery. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association of hyperemesis gravidarum with birth defects in log-binomial regression models, and assessed the extent of selection bias through correction factors.

Results: Hyperemesis gravidarum was associated with 0.88 times the risk of birth defects in models not corrected for bias (95% CI 0.82-0.94). Correction for selection bias suggested that if screening for birth defects was associated with 1.33 times the chance of detecting birth defects and having a pregnancy termination, there would be no association with hyperemesis gravidarum. If ultrasound was associated with 2.00 times the chance of detecting birth defects and 1.50 times the risk of pregnancy termination, hyperemesis gravidarum would be associated with 1.27 times the risk of birth defects (95% CI 1.18-1.35).

Conclusions: The protective association between hyperemesis gravidarum and birth defects in previous studies may be due to selection bias.
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http://dx.doi.org/10.1016/j.annepidem.2021.03.007DOI Listing
March 2021

Stillbirth in Canada: anachronistic definition and registration processes impede public health surveillance and clinical care.

Can J Public Health 2021 Mar 19. Epub 2021 Mar 19.

McGill University, Montreal, Quebec, Canada.

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks' gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.
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http://dx.doi.org/10.17269/s41997-021-00483-xDOI Listing
March 2021

The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis.

CMAJ 2021 Mar 19. Epub 2021 Mar 19.

Department of Obstetrics and Gynecology (Wei), Centre hospitalier universitaire Sainte-Justine; Centre de recherche du Centre hospitalier de l'Université de Montréal, Department of Social and Preventive Medicine (Auger), School of Public Health, Université de Montréal; Bureau d'information et d'études en santé des populations (Wei, Bilodeau-Bertrand, Auger), Institut national de santé publique du Québec, Montréal, Que.; Centre for Surveillance and Applied Research (Liu), Public Health Agency of Canada, Ottawa, Ont.

Background: The impact of coronavirus disease 2019 (COVID-19) on maternal and newborn health is unclear. We aimed to evaluate the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and adverse pregnancy outcomes.

Methods: We conducted a systematic review and meta-analysis of observational studies with comparison data on SARS-CoV-2 infection and severity of COVID-19 during pregnancy. We searched for eligible studies in MEDLINE, Embase, ClinicalTrials.gov, medRxiv and Cochrane databases up to Jan. 29, 2021, using Medical Subject Headings terms and keywords for "severe acute respiratory syndrome coronavirus 2 OR SARS-CoV-2 OR coronavirus disease 2019 OR COVID-19" AND "pregnancy." We evaluated the methodologic quality of all included studies using the Newcastle-Ottawa Scale. Our primary outcomes were preeclampsia and preterm birth. Secondary outcomes included stillbirth, gestational diabetes and other pregnancy outcomes. We calculated summary odds ratios (ORs) or weighted mean differences with 95% confidence intervals (CI) using random-effects meta-analysis.

Results: We included 42 studies involving 438 548 people who were pregnant. Compared with no SARS-CoV-2 infection in pregnancy, COVID-19 was associated with preeclampsia (OR 1.33, 95% CI 1.03 to 1.73), preterm birth (OR 1.82, 95% CI 1.38 to 2.39) and stillbirth (OR 2.11, 95% CI 1.14 to 3.90). Compared with mild COVID-19, severe COVID-19 was strongly associated with preeclampsia (OR 4.16, 95% CI 1.55 to 11.15), preterm birth (OR 4.29, 95% CI 2.41 to 7.63), gestational diabetes (OR 1.99, 95% CI 1.09 to 3.64) and low birth weight (OR 1.89, 95% CI 1.14 to 3.12).

Interpretation: COVID-19 may be associated with increased risks of preeclampsia, preterm birth and other adverse pregnancy outcomes.
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http://dx.doi.org/10.1503/cmaj.202604DOI Listing
March 2021

Maternal Mental Disorders and Pediatric Infectious Diseases: A Retrospective Cohort Study.

Pediatr Infect Dis J 2021 Mar 2. Epub 2021 Mar 2.

From the University of Montreal Hospital Research Centre Institut national de santé publique du Québec Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada Institute of Public Health, Epidemiology and Development, University of Bordeaux, Bordeaux, New-Aquitaine, France Department of Psychiatry, McGill University Department of Pediatrics, Sainte-Justine Hospital Research Centre, University of Montreal, Montreal, QC, Canada.

Background: Maternal stress and depression are associated with infections in offspring, but there is a paucity of data for other mental disorders.

Methods: We conducted a retrospective cohort study of 832,290 children born between 2006 and 2016 in hospitals of Quebec, Canada. We identified maternal mental disorders before and during pregnancy, and admissions for otitis media, pneumonia, infectious enteritis and other infections in children before 13 years of age. We used Cox proportional hazards regression to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for the association between maternal mental disorders and the risk of pediatric infectious diseases, adjusted for maternal age, comorbidity, socioeconomic disadvantage, and other confounders.

Results: The incidence of pediatric infection hospitalization was higher for maternal mental disorders compared with no disorder (66.1 vs. 41.1 cases per 1000 person-years). Maternal mental disorders were associated with 1.38 times the risk of otitis media (95% CI: 1.35-1.42), 1.89 times the risk of bronchitis (95% CI: 1.68-2.12), and 1.65 times the risk of infectious enteritis in offspring (95% CI: 1.57-1.74). Stress and anxiety disorders (HR 1.49, 95% CI: 1.46-1.53) and personality disorders (HR 1.55, 95% CI: 1.49-1.61) were more strongly associated with the risk of pediatric infection hospitalization than other maternal mental disorders. Associations were prominent in the first year of life and weakened with age.

Conclusions: Maternal mental disorders are risk factors for infectious disease hospitalization in offspring. Women with mental disorders may benefit from psychosocial support to reduce the risk of serious infections in their children.
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http://dx.doi.org/10.1097/INF.0000000000003108DOI Listing
March 2021

Association of first trimester anaesthesia with risk of congenital heart defects in offspring.

Int J Epidemiol 2021 Feb 28. Epub 2021 Feb 28.

Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre, Montreal, QC, Canada.

Background: A substantial number of pregnant women require anaesthesia for non-obstetric surgery, but the risk to fetal heart development is unknown. We assessed the relationship between first trimester anaesthesia and risk of congenital heart defects in offspring.

Methods: We conducted a longitudinal cohort study of 2 095 300 pregnancies resulting in live births in hospitals of Quebec, Canada, between 1990 and 2016. We identified women who received general or local/regional anaesthesia in the first trimester, including anaesthesia between 3 and 8 weeks post-conception, the critical weeks of fetal cardiogenesis. The main outcome measures were critical and non-critical heart defects in offspring. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association of first trimester anaesthesia with congenital heart defects, using log-binomial regression models adjusted for maternal characteristics.

Results: There were 107.3 congenital heart defects per 10 000 infants exposed to anaesthesia, compared with 87.2 per 10 000 unexposed infants. Anaesthesia between 3 and 8 weeks post-conception was associated with 1.50 times the risk of congenital heart defects (95% CI 1.11-2.03), compared with no anaesthesia. Anaesthesia between 5 and 6 weeks post-conception was associated with 1.84 times the risk (95% CI 1.10-3.08). Associations were driven mostly by general anaesthesia, which was associated with 2.49 times the risk between weeks 5 and 6 post-conception (95% CI 1.40-4.44).

Conclusions: General anaesthesia during critical periods of fetal heart development may increase the risk of congenital heart defects. Further research is needed to confirm that anaesthetic agents are cardiac teratogens.
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http://dx.doi.org/10.1093/ije/dyab019DOI Listing
February 2021

Tombstone size and life expectancy: a cross-sectional analysis of cemetery data before the turn of the century.

Eur J Epidemiol 2021 Feb 6. Epub 2021 Feb 6.

University of Montreal Hospital Research Centre, Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada.

The extent to which socioeconomic status was associated with life expectancy in the 19 and early part of the twentieth century is poorly understood. We sought to determine the association between a deceased individual's tombstone size, a potential marker of socioeconomic status, and their age of death in the late modern period. We conducted a cross-sectional study of 276 deceased individuals buried between 1820 and 1992 in a large cemetery in Quebec, Canada. The main outcome measure was age of death. We used generalized linear models adjusted for sex, marital status, and year of death to determine whether tombstone height and volume were associated with a greater number of years lived. Tombstone height and volume were associated with an older age of death in adjusted regression models. Individuals with tall tombstones lived 9.6 years longer than those with short tombstones (95% confidence interval, CI 3.9 to 15.4). Individuals with large volume tombstones lived 6.2 years longer than those with small tombstones (95% CI 1.7 to 10.8). Our findings indicate that in the 1800s and early 1900s, tombstone size was strongly associated with age of death. A possible explanation for this occurrence is that wealthy individuals, capable of purchasing more sizeable tombstones, were more likely to live a longer and healthier life.
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http://dx.doi.org/10.1007/s10654-021-00724-wDOI Listing
February 2021

Pregnancy Outcomes of Women Hospitalized for Physical Assault, Sexual Assault, and Intimate Partner Violence.

J Interpers Violence 2021 Feb 3:886260520985496. Epub 2021 Feb 3.

University of Montreal, Montreal, Quebec, Canada.

Pregnancy outcomes of women with serious injuries due to violence receive limited attention. We examined the association of assault before and during pregnancy with maternal and infant outcomes at delivery. We performed a retrospective cohort study of 2,193,711 births in Quebec, Canada between 1989 and 2016. We identified women who were hospitalized for physical assault, sexual assault, and assault with documented intimate partner violence before and during pregnancy. We examined adverse outcomes at delivery, including preeclampsia, placental abruption, antepartum hemorrhage, stillbirth, preterm birth, low birthweight, and other disorders. In log-binomial regression models, we estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between violence hospitalization and adverse birth outcomes, adjusted for potential confounders. Compared with no exposure, violence before or during pregnancy was associated with the future risk of placental abruption (RR 1.49, 95% CI 1.23-1.82), antepartum hemorrhage (RR 1.43, 95% CI 1.19-1.71), stillbirth (RR 1.83, 95% CI 1.27-2.63), preterm birth (RR 1.70, 95% CI 1.54-1.87), and low birthweight (RR 1.78, 95% CI 1.58-2.00). Physical assault, sexual assault, and assault with documented intimate partner violence were all associated with adverse outcomes. The risk of adverse outcomes was elevated regardless of timing and number of violence admissions, although associations were stronger for women hospitalized twice or more. Physical assault, sexual assault, and intimate partner violence are important risk factors for adverse pregnancy outcomes. Screening for violence in women of childbearing age and closer follow-up during pregnancy may help improve birth outcomes.
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http://dx.doi.org/10.1177/0886260520985496DOI Listing
February 2021

In the arms of Morpheus: meta-analysis of sleep and fertility.

Fertil Steril 2021 Mar 29;115(3):596-598. Epub 2021 Jan 29.

Institut national de santé publique du Québec, and Department of Obstetrics and Gynecology, Sainte-Justine Hospital Research Center, University of Montreal, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.fertnstert.2020.12.030DOI Listing
March 2021

Severe Maternal Morbidity and Risk of Mortality Beyond the Postpartum Period.

Obstet Gynecol 2021 02;137(2):277-284

Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, the Institut national de santé publique du Québec, the Departments of Medicine and Obstetrics and Gynecology, McGill University Health Centre, the Cardiology Service, University of Montreal Hospital Center, the University of Montreal Hospital Research Centre, and the Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada.

Objective: To examine long-term risks of mortality after a pregnancy complicated by severe maternal morbidity.

Methods: We analyzed a longitudinal cohort of 1,229,306 women who delivered in the province of Quebec, Canada from 1989 through 2016. Severe maternal morbidity included conditions such as cerebrovascular accidents, acute renal failure, severe preeclampsia, and other life-threatening complications. The outcome was in-hospital mortality after the last pregnancy, categorized as postpartum (42 days or fewer after delivery) and long-term (43 days to 29 years after delivery). We estimated hazard ratios (HRs) ofr mortality with 95% CI for severe maternal morbidity compared with no severe morbidity, using Cox regression models adjusted for maternal characteristics.

Results: Severe maternal morbidity occurred in 2.9% of women. The mortality rate associated with severe maternal morbidity was 0.86 per 1,000 person-years compared with 0.41 per 1,000 person-years for no morbidity. Compared with no morbidity, severe maternal morbidity was associated with two times the rate of death any time after delivery (95% CI 1.81-2.20). Severe cardiac complications (HR 7.00, 85% CI 4.94-9.91), acute renal failure (HR 4.35, 95% CI 2.66-7.10), and cerebrovascular accidents (HR 4.03, 95% CI 2.17-7.48) were the leading morbidities associated with mortality after 42 days.

Conclusion: Women who experience severe maternal morbidity have an accelerated risk of mortality beyond the postpartum period compared with women who do not experience severe morbidity. More intensive clinical follow-up may be merited for women with serious pregnancy complications.
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http://dx.doi.org/10.1097/AOG.0000000000004223DOI Listing
February 2021

Association of Cesarean Delivery with Childhood Hospitalization for Infections Before 13 Years of Age.

J Pediatr 2021 Apr 6;231:178-184.e2. Epub 2021 Jan 6.

Department of Microbiology, Infectious Diseases, and Immunology, University of Montreal, Montreal, Quebec, Canada; Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada.

Objectives: To determine the association between cesarean delivery and childhood infections up to 13 years of age.

Study Design: We conducted a longitudinal cohort study of 731 803 children born between 2006 and 2016 at all hospitals in the province of Quebec, Canada. We followed children born by cesarean, operative vaginal, and nonoperative vaginal delivery up to 13 years of age. Outcomes included hospitalization for otitis media, respiratory, infectious enteritis, and other infections. We estimated hazard ratios with 95% CIs for the association between mode of delivery and childhood infections, adjusted for patient characteristics.

Results: At age 3-4 years, cesarean delivery was associated with a 1.07-fold greater risk of otitis media (95% CI, 1.03-1.11), a 1.15-fold greater risk of respiratory infection (95% CI, 1.09-1.22), and a 1.13-fold greater risk of infectious enteritis (95% CI, 1.03-1.25) compared with nonoperative vaginal delivery. However, operative vaginal delivery was associated with these same outcomes. Both cesarean and operative vaginal delivery were more strongly associated with infection hospitalization before age 1 year, but associations disappeared after 5 years.

Conclusions: Cesarean delivery is associated with infection hospitalization before but not after age 5 years. However, associations were also present for operative vaginal delivery, which suggests that mechanisms other than exposure to maternal vaginal flora explain the relationship.
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http://dx.doi.org/10.1016/j.jpeds.2020.12.036DOI Listing
April 2021

Effect of publicly funded assisted reproductive technology on maternal and infant outcomes: a pre- and post-comparison study.

Hum Reprod 2021 Jan;36(1):219-228

Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Canada.

Study Question: Does publicly funded assisted reproductive technology result in improved maternal and infant outcomes?

Summary Answer: Publicly funded ART in Quebec was associated with reduced risks of preeclampsia, cesarean delivery, preterm birth, low birth weight and other adverse outcomes.

What Is Known Already: Publicly funded ART programs that provide free access to single embryo transfer are known to decrease the rate of multiple pregnancy, but the impact on other pregnancy outcomes is unknown.

Study Design, Size, Duration: We conducted a pre- and post-comparison study of 597 416 pregnancies conceived between July 2008 and September 2015 in Quebec, Canada, a region where public funding of ART began in August 2010.

Participants/materials, Setting, Methods: We included all pregnant women who conceived by ART (n = 14 309) or spontaneously (n = 583 107) and delivered a live or stillborn infant in hospitals of Quebec. The main exposure measure was conception before versus during the publicly funded ART program. Outcomes included measures of maternal and infant morbidity and mortality. We estimated risk ratios (RR) and 95% confidence intervals for the association of publicly funded ART with maternal and infant outcomes using log-binomial regression models adjusted for maternal characteristics.

Main Results And The Role Of Chance: In this study, 2638 pregnancies were conceived by ART before, and 11 671 were conceived by ART, during public funding. Compared with no public funding, ART funding was associated with reduced risks of severe maternal morbidity (RR 0.64, 95% CI 0.50-0.83), preeclampsia (RR 0.55, 95% CI 0.44-0.68), cesarean delivery (RR 0.83, 95% CI 0.77-0.89), preterm birth (RR 0.67, 95% CI 0.60-0.75), low birth weight (RR 0.63, 95% CI 0.55-0.72), severe neonatal morbidity (RR 0.75, 95% CI 0.57-0.99) and neonatal intensive care unit admission (RR 0.65, 95% CI 0.53-0.78). When multiple pregnancies were excluded, ART funding continued to be associated with a lower risk of preeclampsia (RR 0.61, 95% CI 0.48-0.79) and preterm birth (RR 0.85, 95% CI 0.73-0.99). However, ART funding was associated with increased risk of gestational diabetes.

Limitations, Reasons For Caution: We had no information on the type of ART, number of in-vitro fertilization cycles or number of embryos transferred. We lacked data on body mass index, ethnicity and smoking and cannot rule out residual confounding.

Wider Implication Of The Findings: Our findings suggest that publicly funded ART programs that encourage single embryo transfer may have substantial benefits for a range of maternal and infant outcomes, beyond prevention of multiple births.

Study Funding/competing Interest(s): This study was supported by grant 6D02363004 from the Public Health Agency of Canada. N.A. acknowledges a career award from the Fonds de recherche du Québec-Santé (34695). The authors declare no competing interests.

Trial Registration Number: N/A.
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http://dx.doi.org/10.1093/humrep/deaa270DOI Listing
January 2021

Cannabis use disorder and the future risk of cardiovascular disease in parous women: a longitudinal cohort study.

BMC Med 2020 11 19;18(1):328. Epub 2020 Nov 19.

University of Montreal Hospital Research Centre, Montreal, Quebec, Canada.

Background: Cannabis use is increasing in women of reproductive age, but whether cannabis use disorders increase the long-term risk of cardiovascular disease in this population is not known. Cannabis may cause tachycardia, hypertension, cerebral vasoconstriction, and other adverse cardiovascular effects and has been associated with acute myocardial infarction and stroke. Data on the long-term effects of cannabis on the cardiovascular system are more limited. We assessed the relationship between cannabis use disorders early in life and the future risk of cardiovascular disease in women.

Methods: We analyzed a longitudinal cohort of 1,247,035 pregnant women in Quebec, Canada, between 1989 and 2019. The main exposure was current or past history of cannabis use disorders at cohort entry. The main outcome measure included future hospital admission for any cardiovascular disorder during 18,998,986 person years of follow-up. We used Cox proportional hazards regression models adjusted for patient characteristics to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association of cannabis use disorder with the later risk of cardiovascular hospitalization.

Results: Women with cannabis use disorders had a higher incidence of cardiovascular hospitalization than unexposed women (58.4 vs. 33.6 per 10,000 person years). Cannabis use disorder was associated with 1.48 times the risk of cardiovascular hospitalization (95% CI 1.27-1.72), compared with no cannabis use disorder. The association was greater for cannabis with concomitant use of other substances (HR 1.84, 95% CI 1.53-2.21) than for cannabis alone (HR 1.30, 95% CI 0.99-1.72). Cannabis use disorder was strongly associated with hemorrhagic stroke, even with adjustment for other substance use (HR 2.08, CI 1.07-4.05).

Conclusions: Cannabis use disorders may increase the long-term risk of cardiovascular disease in women, particularly hemorrhagic stroke. However, some of the excess risk may be due to concomitant use of other substances.
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http://dx.doi.org/10.1186/s12916-020-01804-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677785PMC
November 2020

Maternal Substance Abuse and the Later Risk of Fractures in Offspring: L'abus maternel de substances et le risque ultérieur de fractures chez les enfants.

Can J Psychiatry 2020 Nov 3:706743720970826. Epub 2020 Nov 3.

Department of Pediatrics, Sainte-Justine University Hospital Research Centre, University of Montreal, Quebec, Canada.

Objective: To assess the association of maternal illicit drug abuse before or during pregnancy with future fractures in offspring.

Methods: We performed a longitudinal cohort study of 792,022 infants born in hospitals of Quebec, Canada, between 2006 and 2016, with 5,457,634 person-years of follow-up. The main exposure was maternal substance abuse before or during pregnancy, including cocaine, opioid, cannabis, and other illicit drugs. The main outcome measure was hospitalization for traumatic fracture in offspring up to 12 years of age. We used adjusted Cox regression models to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association of maternal drug abuse with the subsequent risk of fracture in children.

Results: The incidence of child fractures was higher for maternal illicit drug abuse than no drug abuse (21.2 vs. 15.4 per 10,000 person-years). Maternal drug abuse before or during pregnancy was associated with 2.35 times the risk of assault-related fractures (95% CI, 1.29 to 4.27) and 2.21 times the risk of transport accident-related fractures (95% CI, 1.34 to 3.66), compared with no drug abuse. Associations were strongest before 6 months of age for assault-related fractures (HR = 2.14; 95% CI, 0.97 to 4.72) and after 6 years for transport-related fractures (HR = 2.86; 95% CI, 1.35 to 6.05). Compared with no drug abuse, associations with assault and transport-related fractures were elevated for all drugs including cocaine, opioids, and cannabis.

Conclusions: Maternal illicit drug abuse is associated with future child fractures due to assault and transport accidents.
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http://dx.doi.org/10.1177/0706743720970826DOI Listing
November 2020

Infant mortality among Arabic-speakers in Quebec, Canada, 1989-2017.

J Immigr Minor Health 2021 Apr 24;23(2):215-221. Epub 2020 Oct 24.

Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.

Background: We assessed trends in infant mortality for Arabic-speakers in Quebec, Canada between 1981 and 2017.

Methods: We computed infant mortality rates for Arabic versus French and English-speakers in Quebec over time. We used adjusted risk ratios (aRR) and 95% confidence intervals (CI) to investigate trends among Arabic-speakers according to socioeconomic status, age, and cause of death.

Results: Infant mortality rates were 3.0 for Arabic-speakers and 5.1 for French and English-speakers per 1,000 live births. Infant mortality increased for Arabic-speakers between 1989-1995 and 2010-2017 (aRR 2.07; 95% CI, 1.04-4.12), but decreased for French and English-speakers (aRR 0.77; 95% CI, 0.73-0.81). The increase in infant mortality was greater for socioeconomically advantaged Arabic-speakers (aRR 2.52; 95% CI, 1.20-5.28) and early neonatal mortality (aRR 1.64; 95% CI, 0.98-2.76).

Discussion: Arabic-speakers in Quebec have a lower risk of infant mortality than French and English-speakers, but increasing infant mortality among Arabic-speakers is narrowing the gap.
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http://dx.doi.org/10.1007/s10903-020-01115-1DOI Listing
April 2021

Association between Kawasaki Disease and Prenatal Exposure to Ambient and Industrial Air Pollution: A Population-Based Cohort Study.

Environ Health Perspect 2020 10 19;128(10):107006. Epub 2020 Oct 19.

Institut national de santé publique du Québec, Montreal, Quebec, Canada.

Background: Environmental factors may contribute to the development of Kawasaki disease in children, but prenatal environmental exposures are understudied.

Objective: We used a population-based cohort to investigate whether prenatal exposure to outdoor air pollution is associated with the incidence of Kawasaki disease in childhood.

Methods: We performed a longitudinal cohort study of all children born in Quebec, Canada, between 2006 and 2012. Children were followed for Kawasaki disease from birth until 31 March 2018. We assigned prenatal air pollutant exposure according to the residential postal code at birth. The main exposure was annual average concentration of ambient fine particulate matter [PM in aerodynamic diameter () and nitrogen dioxide () from satellite-based estimates and land-use regression models. As secondary exposures, we considered industrial , , and sulfur dioxide () emissions estimated from dispersion models. We estimated hazard ratios (HRs) using Cox proportional hazards models, adjusted for maternal age, parity, sex, multiple birth, maternal smoking during pregnancy, socioeconomic status, birth year, and rural residence. We considered single and multipollutant models. We performed several sensitivity analyses, including assessing modifying effects of maternal comorbidities (e.g., diabetes, preeclampsia).

Results: The cohort comprised 505,336 children, including 539 with Kawasaki disease. HRs for each interquartile range increase in ambient air pollution were 1.16 (95% CI: 0.96, 1.39) for and 1.12 (95% CI: 0.96, 1.31) for . For industrial air pollution, HRs were 1.07 (95% CI: 1.01, 1.13) for , 1.09 (95% CI: 0.99, 1.20) for , and 1.01 (95% CI: 0.97, 1.05) for . In multipollutant models, associations for ambient and (i.e., from all sources) were robust to adjustment for industrial pollution, and vice versa.

Discussion: In this population-based cohort study, both prenatal exposure to ambient and industrial air pollution were associated with the incidence of Kawasaki disease in childhood. Further studies are needed to consolidate the observed associations. https://doi.org/10.1289/EHP6920.
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http://dx.doi.org/10.1289/EHP6920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571626PMC
October 2020

Cannabis-related Hospitalizations Among Youth in Canada Before and After Cannabis Legalization.

J Addict Med 2020 Oct 14. Epub 2020 Oct 14.

University of Montreal Hospital Research Centre, Montreal, Quebec, Canada (NA, AA); Institut national de santé publique du Québec, Montreal, Quebec, Canada (NA, AA, MB-B, EL); Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada (NA, EL); School of Public Health, University of Montreal, Montreal, Quebec, Canada (NA); Department of Pediatrics, Sainte-Justine University Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada (TML); Department of Psychiatry, McGill University, Montreal, Quebec, Canada (NL).

Objectives: We investigated trends in cannabis-related hospitalizations among youth before and after legalization of recreational cannabis in Canada on October 17, 2018.

Methods: We computed rates of cannabis-related hospitalizations and the proportion of substance-related hospitalizations involving cannabis by age and sex in the months before and after legalization in Quebec, Canada.

Results: In boys aged 10 to 14 years, cannabis-related hospitalization rates increased from 5.2 per 100,000 one year before legalization [95% confidence interval (CI) 2.9-9.3] to 9.5 per 100,000 after legalization (95% CI 6.2-14.6), although the increase was not statistically significant. Cannabis was reported in 39.3% of substance-related hospitalizations in boys aged 10 to 14 years before legalization, compared with 70.0% after legalization, representing a difference of 30.7% (95% CI 2.8-58.6). There was no increase in cannabis-related hospitalizations among girls or boys aged 15 to 19 years.

Conclusions: This study suggests that cannabis legalization in Canada did not increase the risk of short-term cannabis-related hospitalization among girls and older boys. However, legalization may have contributed to an increase in the risk in boys under 15 years. Further data are needed to clarify trends after legalization for younger adolescents.
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http://dx.doi.org/10.1097/ADM.0000000000000747DOI Listing
October 2020

Development and Internal Validation of a Model Predicting Premature Cardiovascular Disease Among Women With Hypertensive Disorders of Pregnancy: A Population-Based Study in Quebec, Canada.

J Am Heart Assoc 2020 10 15;9(20):e017328. Epub 2020 Oct 15.

Department of Epidemiology, Biostatistics, and Occupational Health McGill University Montreal Quebec Canada.

Background Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of premature cardiovascular disease (CVD), but existing cardiovascular prediction models do not adequately capture risks in young women. We developed a model to predict the 10-year risk of premature CVD and mortality among women who have HDP. Methods and Results Using a population-based cohort of women with HDP who delivered between April 1989 and March 2017 in Quebec, Canada, we developed a 10-year CVD risk model using Cox proportional hazards regression. Women aged 18 to 45 years were followed from their first HDP-complicated delivery until March 2018. We assessed performance of the model based on discrimination, calibration, and risk stratification ability. Internal validity was assessed using the bootstrap method. The cohort included 95 537 women who contributed 1 401 084 person-years follow-up. In total, 4024 (4.2%) of women were hospitalized for CVD, of which 1585 events (1.6%) occurred within 10 years of follow-up. The final model had modest discriminatory performance (area under the receiver operating characteristic curve, 0.66; 95% CI, 0.65-0.67) and good calibration with slope of 0.95 and intercept of -0.19. There was moderate classification accuracy (likelihood ratio+: 5.90; 95% CI, 5.01-6.95) in the highest-risk group upon risk stratification. Conclusions Overall, our model had modest performance in predicting the 10-year risk of premature CVD for women with HDP. We recommend the addition of clinical variables, and external validation, before consideration for clinical use.
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http://dx.doi.org/10.1161/JAHA.120.017328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763374PMC
October 2020

Do magnetic fields affect reproductive outcomes? Evidence against a link.

Fertil Steril 2020 Nov 15;114(5):969-970. Epub 2020 Sep 15.

Institut national de santé publique du Québec, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.fertnstert.2020.07.046DOI Listing
November 2020

Maternal Mental Disorders before Delivery and the Risk of Dental Caries in Children.

Caries Res 2020 31;54(3):242-249. Epub 2020 Aug 31.

Faculty of Dentistry, McGill University, Montreal, Québec, Canada.

Prevention of childhood caries is an ongoing public health challenge, but the possibility of an association with maternal mental disorders has received limited attention. We estimated the extent to which maternal mental disorders are associated with an increased risk of hospitalization due to dental caries. We conducted a longitudinal cohort study of 790,758 infants born in Quebec, Canada between 2006 and 2016, with follow-up extending to 2018. We identified women with mental disorders before or during pregnancy and computed the incidence of dental caries in their children. We estimated HR and 95% CI for the association of maternal mental disorders with the risk of dental caries, adjusted for personal characteristics. Infants of women with mental disorders before or during pregnancy had a higher incidence of dental caries compared to children of women with no mental disorder (56.1 vs. 27.2 per 10,000 person-years). Maternal stress and anxiety disorders (HR = 1.73; 95% CI 1.60-1.86), depression (HR = 1.81; 95% CI 1.60-2.03), schizophrenia and delusional disorders (HR = 1.69; 95% CI 1.29-2.22), and personality disorders (HR = 1.89; 95% CI 1.70-2.11) were associated with the risk of dental caries. The associations were present throughout childhood, including after 7 years (HR = 1.65; 95% CI 1.38-1.96). Maternal mental disorders were associated with caries of the enamel, dentin, and cementum and caries that reached the dental pulp. Maternal mental disorders before or during pregnancy, especially stress and anxiety, depression, schizophrenia, and personality disorders, are associated with the risk of childhood caries. Women with a history of mental disorders may benefit from enhanced strategies for prevention of dental caries in their children.
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http://dx.doi.org/10.1159/000505906DOI Listing
January 2021

Coeliac disease and risk of birth defects in pregnancy.

Gut 2020 Aug 19. Epub 2020 Aug 19.

Department of Medical Genetics, The University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1136/gutjnl-2020-322425DOI Listing
August 2020

Preeclampsia and the longitudinal risk of hospitalization for depression at 28 years.

Soc Psychiatry Psychiatr Epidemiol 2021 Mar 11;56(3):429-436. Epub 2020 Jul 11.

Department of Obstetrics and Gynecology, Sherbrooke University Hospital Research Centre, Sherbrooke, Canada.

Purpose: The association between pregnancy characteristics and risk of depression in women is poorly understood. We investigated the relationship between preeclampsia and risk of hospitalization for depression over three decades.

Methods: We carried out a longitudinal cohort study of 1,210,963 women who delivered an infant in any hospital in Quebec, Canada, between 1989 and 2016. The exposure was preeclampsia at the first or in subsequent pregnancies, including preeclampsia onset time (early < 34 weeks vs. late ≥ 34 weeks of gestation) and severity (mild, severe, superimposed). The outcome was hospitalization for depression any time after pregnancy. We used Cox proportional hazards regression models adjusted for maternal characteristics to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of preeclampsia with depression hospitalization.

Results: Women with preeclampsia had a higher incidence of hospitalization for depression compared with no preeclampsia (1.43 vs. 1.14 per 1000 person-years). Preeclampsia was associated with 1.16 times the risk of depression hospitalization after 28 years of follow-up (95% CI 1.09-1.23). Associations were present for mild (HR 1.15, 95% CI 1.07-1.24), severe (HR 1.16, 95% CI 1.04-1.29) and late onset preeclampsia (HR 1.17, 95% CI 1.10-1.25). Risks were more pronounced after the first year postpartum.

Conclusion: Preeclampsia appears to be associated with the risk of depression hospitalization several decades after pregnancy. Clinicians who care for women with mental health disorders should be aware that a history of preeclampsia increases the risk of severe depression.
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http://dx.doi.org/10.1007/s00127-020-01920-xDOI Listing
March 2021

Letrozole: future alternative to methotrexate for treatment of ectopic pregnancy?

Fertil Steril 2020 08 1;114(2):273-274. Epub 2020 Jul 1.

Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, Sainte-Justine Hospital Research Center, University of Montreal, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.fertnstert.2020.04.063DOI Listing
August 2020

The Reply.

Am J Med 2020 06;133(6):e319-e320

University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Division of Cardiology, Department of Medicine, University of Montreal Hospital Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.amjmed.2019.12.042DOI Listing
June 2020

Reply to A Seiermann and S Gabrysch.

J Nutr 2020 04;150(4):969

School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.

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http://dx.doi.org/10.1093/jn/nxaa034DOI Listing
April 2020

Maternal Autoimmune Disorders and Risk of Kawasaki Disease in Offspring.

J Pediatr 2020 07 11;222:240-243.e1. Epub 2020 Mar 11.

Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Quebec, Canada; Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada. Electronic address:

We assessed the association between maternal autoimmune disorders and offspring risk of Kawasaki disease in a longitudinal cohort of 792 108 newborns. We found that maternal autoimmune disorders, especially autoimmune thyroiditis, may be risk factors for Kawasaki disease in children, particularly young children.
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http://dx.doi.org/10.1016/j.jpeds.2020.02.016DOI Listing
July 2020