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The World Trade Center Disaster and Intrauterine Growth Restriction
To the Editor: Exposure to air pollution has been associated with intrauterine growth restriction (IUGR)1-2 and preterm births.3 Similarly, high levels of polycyclic aromatic hydrocarbon (PAH)-DNA adducts in umbilical cord leukocytes (which are related to prenatal exposure to air pollution) also have been associated with reduced size at birth.4
The destruction of the World Trade Center (WTC) in New York City on September 11, 2001, released a toxic atmospheric plume that contained soot, benzene, PAHs, heavy metals, pulverized glass and cement, and alkaline particulates. We evaluated whether exposure to these materials in lower Manhattan was related to impaired fetal growth or other adverse pregnancy outcomes.
Methods
We established a cohort study of 187 women who were pregnant and present in 1 of 5 exposure zones near the WTC at 9 AM on that day or within the succeeding 3 weeks. Most participants were self-referred in response to media publicity of our investigation. Additional recruitment was achieved by sending letters to nearly 3000 obstetricians in the greater New York City area, distributing fliers in lower Manhattan, and advertising in local newspapers. Because there exists no WTC registry of pregnant women, it is not possible to estimate the total number of potential participants.
As a comparison group, we evaluated a consecutive series of all pregnant patients under private care who delivered at Mount Sinai Medical Center on the Upper East Side of Manhattan during the same time period, and who were not known to have been in lower Manhattan on September 11, 2001 (n = 2367). Patients under private care constituted an appropriate comparison group, as participants in the WTC cohort were delivered either by private obstetricians (n = 174) or midwives (n = 8). Five were lost to follow-up as described below.
In both groups we measured demographic characteristics, gestational age, birth weight, and the presence of IUGR (birth weight <10th percentile for gestational age5), preterm birth (<37 weeks), and low birth weight (<2500 g). Participants also were asked to complete the PostTraumatic Stress Disorder (PTSD) checklist6; we defined probable PTSD as a score greater than 50.
Our study was approved by the institutional review board of Mount Sinai School of Medicine, and all participants provided either written or oral (n = 17) informed consent.
Results
In the WTC group, 3 had miscarriages and 2 were lost to follow-up, leaving 182 participants in the WTC cohort. The distribution of the women according to their exposure zone was as follows: south of Murray Street (39.6% of the sample, including 12 pregnant women who were in one of the towers); south of Chambers Street and north of Murray Street (32.4%); south of Canal Street and north of Chambers Street (16.5%); Brooklyn Heights (1.7%); and the easternmost part of New Jersey across the Hudson River from the WTC (0.6%). In addition, there were 17 (9.3% of the sample) pregnant women who were present in the area within the following 3 weeks.
Most women in the WTC cohort were white (72.5%), married or living with a partner (96.2%), aged 30 years or older (84.6%), and college graduates (82.4%). The demographics of the comparison cohort were similar, except for age (mean 34.6 in the WTC cohort vs 32.4 years, P<.001).
No significant differences were found between the groups for mean gestational age (39.1 weeks in the WTC cohort vs 39.0 weeks, P = .55) or mean birth weight (3203 g vs 3267 g, P = .14). There were no significant differences in the frequency of preterm births (9.9% vs 9.2%, P = .76) or low birth weight (8.2% vs 6.8%, P = .47).
The WTC cohort, however, had a 2-fold increased risk of IUGR compared with the Mount Sinai cohort (presence of IUGR in the WTC cohort, 15 [8.2%]; in the Mount Sinai cohort, 89 [3.8%]; unadjusted relative risk, 2.19; 95% confidence interval [CI], 1.30-3.71). This difference remained significant after controlling for race/ethnicity, sex of infant, maternal age, parity, and cigarette smoking (adjusted odds ratio, 1.90; 95% CI, 1.05-3.46). Other potential confounding factors such as marital status, education, prepregnancy weight, and pregnancy-induced hypertension were not statistically significant in this model.
The frequency of IUGR did not differ between women enrolled during pregnancy and those enrolled after delivery (9.2% vs 7.6%, P = .69). The adjusted odds ratios were 2.05 (95% CI, 0.90-4.71) for those recruited before delivery and 1.78 (95% CI, 0.79-3.88) for those recruited after delivery. No significant difference in the frequency of IUGR was observed according to trimester at the time of exposure to the WTC attacks. Finally, no association was found between probable PTSD and the relative risks of preterm birth (P = .88), low birth weight (P = .22), or IUGR (P = .94).
Comment
We found an apparent association between maternal exposure to the WTC disaster and IUGR, suggesting that this event had a detrimental impact on exposed pregnancies. This may have been mediated through exposure to PAH or particulate matter. A number of other birth outcomes, however, did not differ between the cohorts. Possible long-term effects on infant development are unclear and will require continuing follow-up.
Funding/Support: This research was supported by grants from the National Institute of Environmental Health Sciences (NIEHS P42 ES07384-07S1) and The September 11th Fund created by The United Way of New York City and The New York Community Trust.
Gertrud S. Berkowitz, PhD;
Mary S. Wolff, PhD;
Teresa M. Janevic, MPH
Department of Community and Preventive Medicine
Ian R. Holzman, MD
Department of Pediatrics
Mount Sinai School of Medicine
New York, NY
Rachel Yehuda, PhD
Department of Psychiatry
Bronx Veterans Affairs Medical Center
Bronx, NY
Philip J. Landrigan, MD
Department of Community and Preventive Medicine
Mount Sinai School of Medicine
New York
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6. Schlenger WE, Caddell JM, Ebert L, et al. Psyschological reactions to terrorist attacks: findings from the National Study of American' reactions to September 11. JAMA. 2002;288:581-588.
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Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.
JAMA. 2003;290:595-596.
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