Katherine M Johnson1,2,3, Aaron J Specht4, Jessica M Hart5,6, Saira Salahuddin6,7, Adrienne L Erlinger5, Michele R Hacker5,6,4, Alan D Woolf8,9,10, Marissa Hauptman8,9,10, S Ananth Karumanchi7,11, Karen O'Brien5,6, Blair J Wylie5,6,9. 1. Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA. katherine.johnson@umassmemorial.org. 2. Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA. katherine.johnson@umassmemorial.org. 3. Department of Obstetrics and Gynecology, University of Massachusetts Medical School/University of Massachusetts Memorial Medical Center, 119 Belmont Street, Worcester, MA, 01605, USA. katherine.johnson@umassmemorial.org. 4. Harvard T. H. Chan School of Public Health, Boston, MA, 02215, USA. 5. Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA. 6. Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA. 7. Center for Vascular Biology Research, Beth Israel Deaconess Medical Center/Harvard Medical School, 99 Brookline Avenue, RN 359, Boston, MA, 02215, USA. 8. Pediatric Environmental Health Center, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA. 9. Region 1 Pediatric Environmental Health Specialty Unit, Boston, MA, USA. 10. Department of Pediatrics, Harvard Medical School, Boston, MA, USA. 11. Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
Abstract
OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 μg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.
OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 μg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.
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