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International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx

Contents lists available at SciVerse ScienceDirect

International Journal of Hygiene and

Environmental Health
journal homepage: www.elsevier.com/locate/ijheh

Birth outcome measures and maternal exposure to heavy metals

(lead, cadmium and mercury) in Saudi Arabian population
Iman Al-Saleh a,∗ , Neptune Shinwari a , Abdullah Mashhour a , Abdullah Rabah b
a
Environmental Health Section, Biological & Medical Research Department, King Faisal Specialist Hospital & Research Centre, PO Box 3354, Riyadh, Saudi Arabia
b
Department of Pediatrics, King Khalid Hospital-Al-Kharj, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: This cross-sectional study was conducted to assess the association between exposure to heavy metals
Received 3 September 2012 (lead, cadmium and mercury) during pregnancy and birth outcomes in 1578 women aged 16–50 years
Received in revised form 30 March 2013 who delivered in Al-Kharj hospital, Saudi Arabia, in 2005 and 2006. The levels of lead, cadmium and mer-
Accepted 22 April 2013
cury were measured in umbilical cord blood, maternal blood and the placenta. Outcome variables were
anthropometric measures taken at birth, along with the risk of being small-for-gestational age (SGA). We
Keywords:
selected the 10th percentile as the cutoff for dichotomizing measures of birth outcome. Cadmium, despite
Lead
its partial passage through the placenta had the most prominent effect on several measures of birth out-
Mercury
Cadmium
come. After adjustment for potential confounders, logistic regression models revealed that crown-heel
Birth outcome length (p = 0.034), the Apgar 5-minute score (p = 0.004), birth weight (p = 0.015) and SGA (p = 0.049) were
Anthropometric measures influenced by cadmium in the umbilical cord blood. Significant decreases in crown-heel length (p = 0.007)
Small-for-gestational age and placental thickness (p = 0.022) were seen with higher levels of cadmium in maternal blood. As placen-
Umbilical cord blood tal cadmium increased, cord length increased (p = 0.012) and placental thickness decreased (p = 0.032).
Maternal blood Only lead levels in maternal blood influenced placental thickness (p = 0.011). Mercury in both umbilical
Placenta cord and maternal blood was marginally associated with placental thickness and placental weight, respec-
Saudi Arabia
tively. Conversely, placental mercury levels significantly influenced head circumference (p = 0.017), the
Apgar 5-minute score (p = 0.01) and cord length (p = 0.026). The predictions of these models were further
assessed with the area under the curve (AUC) of the receiver operating curves (ROCs), which were mod-
est (larger than 0.5 and smaller than 0.7). The independence of gestational age or preterm births on the
observed effect of metals on some measures of birth outcome, suggested detrimental effects of exposure
on fetal development. The magnitude of the estimated effects might not necessarily be of clinical sig-
nificance for infants but may have a considerable public-health relevance given the high prevalence of
exposure to heavy metals. Further research should be conducted to confirm these findings and to evaluate
their long-term risks, if any.
© 2013 Elsevier GmbH. All rights reserved.

Introduction
Even though in utero exposure to heavy metals has been well
investigated over the last few decades (Yoshida, 2002; Bellinger,
2005; Thompson and Bannigan, 2008), our knowledge of the threats
to the fetus at low levels of exposure remains either limited or
inconsistent (Rahman and Hakeem, 2003; Jelliffe-Pawlowski et al.,
2006; Tian et al., 2009; Gundacker et al., 2010; Shirai et al., 2010).
Umbilical cord blood, as a noninvasive sample, has been frequently
tested for assessing prenatal exposure to a variety of metals;
other biological tissues such as maternal blood, human milk, urine,
∗ Corresponding author at: Environmental Health Section, Biological & Medical
Research Department, King Faisal Specialist Hospital & Research Centre, PO Box
3354, Riyadh 11211, Saudi Arabia. Tel.: +966 11442 4772; fax: +966 11442 4971.
E-mail address: iman@kfshrc.edu.sa (I. Al-Saleh).
meconium and amniotic fluid can also be used (Gundacker et al.,
2010; Shirai et al., 2010; Caserta et al., 2011). The placenta
has recently been used as a tool for investigating and predict-
ing some aspects of fetal developmental toxicity. It acts as a
selective fetal–maternal barrier allowing nutrients and oxygen to
pass to the fetus and is supposed to prevent potentially harm-
ful compounds from crossing (Iyengar and Rapp, 2001). Heavy
metals, however, do cross the placenta. Lead and mercury can
easily cross placenta and accumulate in fetal tissues, while cad-
mium can partially cross (Iyengar and Rapp, 2001). Studies have
suggested that placental metallothionein might play a protec-
tive role against cadmium toxicity by its binding to the metal
(Kippler et al., 2010). The detection of cadmium in umbilical cord
blood as reported in some studies (Tian et al., 2009; Lin et al.,
2011), however, indicates that the role of placental metalloth-
ionein as a barrier to cadmium is inconclusive (Nakamura et al.,
2012).

1438-4639/$ – see front matter © 2013 Elsevier GmbH. All rights reserved.
http://dx.doi.org/10.1016/j.ijheh.2013.04.009

Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
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Associations have been reported between cadmium in umbili-
cal cord blood and detrimental effects on the head circumference
of newborns (Lin et al., 2011), thyroid hormone status at birth
(Iijima et al., 2007) or child growth later in life (Tian et al., 2009).
Different studies, though report conflicting results. Gundacker et al.
(2010) found that placental and meconium lead were predictors of
birth height, while birth weight was affected by lead in the placenta
and maternal blood. Zhang et al. (2004) revealed that cadmium in
umbilical cord blood, but not in maternal blood or the placenta,
was negatively associated with neonatal birth height. On the other
hand, Salpietro et al. (2002) reported that a decrease in birth weight
was associated with cadmium in samples of maternal and umbilical
cord blood. Gundacker et al. (2010) found that mercury in hair, but
not in umbilical cord blood, maternal blood or the placenta, was
associated with birth height.
Our previous study on the same population provided evidence
that both the mothers and their newborns were substantially
exposed to heavy metals, even though 88.7% of the participants
were housewives at the time of the study, and all were non-smokers
(Al-Saleh et al., 2011). Lead, cadmium and mercury were detected
in the majority of the three compartments studied (placenta and
umbilical cord and maternal blood), confirming their transplacental
transfer. In the present study, we have expanded our data analyses
by examining the influence of lead, cadmium and mercury mea-
sured in the placenta and in umbilical cord and maternal blood on
measures of birth outcome.
Materials and methods
The data evaluated in this study originated from samples and
questionnaires collected for the project “Exposure to environ-
mental pollutants and its effect on pregnancy outcome” (Al-Saleh
et al., 2011). The source population included 1578 women who
delivered between June 2005 and 2006 in a main public hos-
pital in the Al-Kharj area located about 80 km southeast of the
capital city of Riyadh. None of the women smoked, but 26% had
either a husband or at least one household member who smoked
(cigarettes, sheesha and/or muaasal). Each woman was asked to
join the study and completed a consent form. The women answered
a detailed questionnaire and were interviewed after delivery by
trained health-care personnel. The response rate was 99%. Umbil-
ical cord blood and the placenta were obtained at the time of
delivery, while maternal blood was collected within next hours of
delivery. The details of sample collection and analytical procedures
have been previously described elsewhere (Al-Saleh et al., 2011).
The study protocol was approved by the Research Ethics Committee
of King Faisal Specialist Hospital and Research Centre.
Birth anthropometric measurements. These data were obtained by
the obstetrician at birth included birth weight (g), birth height (cm),
head circumference (cm), crown-heel length (cm), Apgar 1-min
score, Apgar 5-minute score, placental weight, placental thickness,
and cord length. Ponderal index was calculated as birth weight
(kilograms) divided by birth height3 (m) cubed. The cephalization
index was calculated as the ratio of head circumference (cm) to
birth weight (g × 102 ). Gestational age was calculated from the last
menstrual period to the termination of pregnancy. The obstetrician
examined each placenta and umbilical cord in the delivery room
and recorded the placental weight, placental thickness and cord
length.
Laboratory methods
Samples of umbilical cords and maternal venous blood were
collected in Vacutainer tubes containing 10.5 mg of K3 -EDTA
(tripotassium-ethylene diaminetetraacetic acid) as anticoagulant
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
and stored at 4 ◦ C until analysis. These tubes were tested for
metal contamination before use. All blood and placental samples
were analyzed for lead and cadmium using a Varian AA-280 Zee-
man Atomic Absorption Spectrophotometer coupled to a GTA-120
graphite furnace (Varian Techtron Pty. Ltd., Australia). Mercury
was analyzed by a Varian AA-880 Zeeman atomic absorption spec-
trophotometer coupled to a Vapor Generation Accessory VGA-77
(Varian Techtron Pty. Ltd., Australia). Details of the analytical pro-
cedure have been reported previously (Al-Saleh et al., 2011). The
accuracy of the methods were verified by the analysis of two lev-
els of certified reference materials for lead and cadmium (CONTOX
Heavy Metal Blood Control A, Kaulson Laboratories, NJ, USA). The
experimental values agreed well with the certified recommended
values for both controls. The experimental values for levels I and
III lead were 19.67 ± 2.72 ␮g/l N = 88 and 45.76 ± 6.98 ␮g/l N = 87
respectively, while the recommended values were 14.0–22.0 and
39.0–51.0 ␮g/l respectively. The measured values for cadmium for
level I (10.34 ± 1.89 ␮g/l, N = 79) and level II (15.79 ± 3.31 ␮g/l,
N = 77) were within the recommended ranges of 4–12 ␮g/l and
11–19 ␮g/l, respectively. Unfortunately, we were unable to use the
reference materials for mercury analysis due to limited sample vol-
umes. The bovine muscle powder (SRM 8414) reference material
from the National Institute of Standards and Technology (NIST)
was used for placental metal analysis. The results of our determina-
tions were (0.47 ± 0.132 ␮g/g, N = 44) for lead, (0.014 ± 0.0058 ␮g/g,
N = 38) for cadmium and (0.0054 ± 0.002 ␮g/g, N = 23) for mercury.
The results are in good agreement with the recommended cer-
tified values for lead (0.38 ± 0.24 ␮g/g), (0.013 ± 0.011) ␮g/g for
cadmium and (0.005 ± 0.003 ␮g/g) for mercury. The mean recov-
eries for spiked blood samples ranged from 102% to 104% for lead,
99% to 102% for cadmium and 102% to 107% for mercury with rela-
tive standard deviation (%RSD) ranging from 5.6% to 9.1%. The mean
recoveries for placental samples were 99% to 103% for lead, 99% to
102% for cadmium and 100% to 109% for mercury, with %RSDs in
the range of 6–11%. The method’s detection limits (MDLs) in blood
were 0.397 ␮g/dl, 0.42 ␮g/l, and 0.25 ␮g/l for lead, cadmium and
mercury, respectively. The MDLs in placental tissues were 0.25 ␮g/g
dry wt., 0.025 ␮g/g dry wt. and 0.033 ␮g/g dry wt. for lead, cadmium
and mercury, respectively.
Due to the inaccuracy of self-reported smoking, urinary cotinine
was measured as an index of smoking using the commercial Cotin-
ine Direct ELISA Kit (Bio-Quant, Inc., USA). Values were corrected
for creatinine which was measured by colorimetric assays (Oxford
Biomedical Research, MI, USA).
Statistical analyses. Data were analyzed using SPSS for Windows
(version 17; SPSS Inc., Chicago, IL, USA). A p-value of <0.05 was set
as the level of statistical significance.
Data are given as arithmetic means, standard deviations (SDs)
or proportions (%) unless otherwise stated. When required, skewed
data were natural log-transformed to approximate normality
before statistical analyses.
We selected the 10th percentiles as cutoffs for dichotomizing
birth anthropometric measures (head circumference, heel-crown
length, Apgar 1-min score, Apgar 5-minute score, birth weight,
birth height, placenta weight, placenta thickness, cord length, pon-
deral index and cephalization index) to easily interpret the risk to
fetal growth. A further binary outcome for small-for-gestational age
(SGA) was created according to the method of Khanjani and Sim
(2006) by comparing the birth weight below the 10th percentile of
each newborn for that gestational age and gender.
Information on potential confounding variables related to
demographic, socioeconomic, environmental and maternal and
newborn health conditions were obtained from a detailed ques-
tionnaire. We also calculated total maternal weight gain by
summing the average weight gains for the second and third
trimesters. Among the socioeconomic indicators, only the highest
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level of mothers’ education and the total family income were used.
To assess potential confounders, we evaluated their associations
with birth outcome measures or with the metals, using Pear-
son correlation analyses for continuous variables and standards,
2 -tests, Student-t tests or one way analyses of variance (ANOVA)
for categorical variables followed by a Scheffe post hoc analysis
when necessary. Univariate logistic regression analysis was first
performed to determine the odds of low birth anthropometric
measures (<10th percentile) per log unit change in metal levels
compared to those above the 10th percentile. A multivariate logistic
regression analysis was subsequently constructed after including
only the variables in the bivariate logistic regression model if the
p value was less than or equal to 0.05. Odds ratios (ORs) and 95%
confidence intervals (CIs) are reported. We also repeated all anal-
yses after adjusting for gestational age and or excluding preterm
births (delivered before 37 completed weeks of gestation). Finally,
the receiver-operating characteristics (ROCs) analysis was applied
to estimate the discriminative value of only those metals that were
statistically significant in predicting the measures of birth outcome.
Estimates of predictive accuracy were obtained from the area under
the curve (AUC) and its 95% confidence intervals derived from the
logistic regression analyses. The practical lower limit for the AUC
of a diagnostic test is 0.5. Park et al. (2004) considered an AUC
value larger than 0.5 as having at least some ability to discriminate
between two groups with and without a particular disease.
In this study, undetectable measurements were reported as
zeros, and we also used quantifiable values below the MDL to
optimize statistical power and to avoid biased estimates as recom-
mended by Kim et al. (1995). Furthermore, Helsel (2005) suggested
that substituting results below the MDL with one-half the detection
limit is recommended only if the proportion of values falls below
10%. In our study, 10.7%, 24.5%, 29.8% and 52.2% of participants
had levels of maternal blood mercury, placental lead, placental
cadmium and placental mercury, respectively, below their MDLs.
Results
General characteristics of the study population
Selected demographic, socioeconomic and maternal and neona-
tal clinical characteristics of the studied population are presented
in Table 1. The mean age of the mothers at the interviews was
28.5 ± 6.0 years, mean gestational age was 37.96 ± 1.768 weeks,
and mean birth weight was 3.14 ± 0.54 kg. The mean pregnant body
mass index (BMI) was 27.0, 28.4 and 29.1 kg/m2 during the first,
second and third trimesters, respectively. The average increase in
maternal weight during the second trimester was 2.38 ± 3.9 kg and
peaked during the third trimester at 5.97 ± 5.6 kg. The proportions
of female and male babies in the population were relatively sim-
ilar (49.1% to 50.9%, respectively). The percentages of newborns
born prematurely (<37 weeks) or with SGA (<10th percentile) were
6.9% and 10%, respectively. The average birth height and head cir-
cumference were 50.15 ± 2.97 cm (24–59 cm) and 34.11 ± 2.05 cm
(18–55 cm), respectively. Of the newborns, 85.6% were delivered
by normal vaginal birth, and 14.4% were delivered by cesarean sec-
tion (C.S.). Labor had been induced in 5.2% of the mothers. Fetal
distress during the first 24 hours after birth was observed in 7% of
the newborns, 6.2% needed resuscitation, 6.7% needed medication,
mainly antibiotics, 3.5% had an abnormal color, 3.7% had abnormal
cry, 2.6% had abnormal movement, 1.7% had congenital malforma-
tions, 10.2% were admitted to either the neonatal intensive care
unit or the special care baby unit, 0.38% had an injury and 13.2%
had various other clinical problems.
Of the 1578 mothers, 23.4% were either illiterate or attended lit-
eracy classes, 33.4% had completed either primary or intermediate
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
3
school, 23.4% had completed high school and 19.9% had completed
either a college diploma or a university degree. The majority of
the women (88.7%) either never worked or had worked previously.
Only 11.3% were working during the period of the study. Of the
women who worked, most were teachers (8.1%). Income levels
of the participant’s families were: 30.5% ≤5000 Saudi riyals (SR),
20.5% in the range of SR5001-7500, 15.4% above SR7501, 22.9% with
either unknown or irregular income and 10.7% refused to answer
the question. The geographical distribution of the current dwelling
was represented by dividing Al-Kharj into five regions: the West-
ern Region reported the highest rate, with 37.3% of the participating
women, followed by the Southern Region with 20.7%, the Eastern
Region with 16.9%, the Northern Region with 15.7%, and the Central
Region with 9.4%. None of the mothers in the study smoked. How-
ever, 26% had either a husband or at least one household member
who smoked (cigarettes, sheesha or/and muaasal).
Exposure profile and potential confounding variables
Descriptive statistics of the levels of lead, cadmium and mer-
cury in maternal and umbilical cord bloods and in placental
tissues are summarized in Table 2. The median levels of these
metals in maternal blood had the following descending order:
lead (2.540 ␮g/dl) > mercury (1.949 ␮g/l) > cadmium (0.983 ␮g/l).
The median levels of metals in umbilical cord blood were:
mercury (2.876 ␮g/l) > lead (2.057 ␮g/dl) > cadmium (0.704 ␮g/l).
The median concentrations of the three metals in placental tis-
sue had the following descending series: lead (0.450 ␮g/g dry
wt.) > cadmium (0.035 ␮g/g dry wt.) > mercury (0.031 ␮g/g dry wt.).
The status of exposure for each metal has been reported previously
in detail (Al-Saleh et al., 2011). However, we will briefly present in
this section the possible confounding variables and the profile of
each metal.
Lead. The mean lead levels in maternal and umbilical cord
blood at delivery were 2.897 ± 1.851 ␮g/dl, with a range of
0.073–25.955 ␮g/dl, and 2.551 ± 2.592 ␮g/dl, with a range of
0.154–56.511 ␮g/dl, respectively. Mean lead levels in maternal
blood were significantly higher than the levels in umbilical cord
blood (t = −9.52, p < 0.001). Maternal blood lead levels were signif-
icantly correlated with umbilical cord blood lead levels (r = 0.456,
p < 0.001). Lead was detected in all samples of maternal and umbil-
ical cord blood, with only seven mothers and six newborns having
lead levels below the MDL (0.42 ␮g/dl). The mean concentration of
lead in placenta was 0.579 ± 2.176 ␮g/g dry wt. (range, 0–78.0 ␮g/g
dry wt). Lead was detected in 96% of the placental tissues, and more
than 75.4% (N = 1189) of the women had a level higher than the MDL
for lead (0.25 ␮g/g dry wt.). As shown in Table 3, lead in samples
of umbilical cord and maternal blood was significantly and posi-
tively correlated with maternal age, parity and urinary cotinine. The
first and second maternal trimester BMIs were only correlated with
umbilical cord blood lead levels. ANOVA analyses revealed that lead
levels in both umbilical cord and maternal blood were higher in
mothers who were either illiterate or attending literacy class than
the levels in mothers who attended primary, intermediate, or sec-
ondary or college/university, with p < 0.01 for all. The levels of lead
in umbilical cord and maternal blood were significantly lower in
mothers with total family incomes >SR7500 than in those earn-
ing < SR5000, with p-values of 0.003 and 0.015 respectively. The
levels of lead in umbilical cord blood from mothers with family
incomes >SR7500 were lower than those reported from mothers
with an irregular income (p = 0.026). The analyses also indicated
that mothers living in the Western Region of Al-Kharj had signif-
icantly lower levels of blood lead than those living in the Central
(p = 0.02) or Northern Regions (p < 0.001). Placental lead levels were
significantly higher in mothers living in areas of heavy traffic com-
pared to those living in residential areas (p < 0.001) but not to those
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Table 1
General characteristics of the studied population.

Continuous variables N Mean ± SD Median Min–Max

Maternal age (yr) 1574 28.47 ± 6.029 28 16–50

Maternal height (cm) 1576 158.97 ± 5.787 159 132.0–189.0
First maternal trimester body weight (kg) 1291 68.24 ± 14.636 67 31.50–160.0
Second maternal trimester body weight (kg) 1406 71.820 ± 14.544 70 39.0–162.0
Third maternal trimester body weight (kg) 1573 73.705 ± 14.677 72 36.0–168.0
Total maternal weight gain (kg/week) for the 1283 0.461 ± 0.427 0.423 −1.62–5.37
second and third trimester
First maternal trimester BMI (kg/m2 ) 1289 26.984 ± 5.588 26.271 13.28–67.47
Second maternal trimester BMI (kg/m2 ) 1404 28.405 ± 5.482 27.620 14.50–68.31
Third maternal trimester BMI (kg/m2 ) 1571 29.133 ± 5.452 28.399 15.24–70.84
Parity 1198 3.64 ± 2.464 3 1–15
Duration of living in the district (years) 1575 24.07 ± 10.108 25 1–50
Gestational age (weeks) 1578 37.96 ± 1.768 38 22–43
Birth weight (kg) 1572 3.135 ± 0.541 3.16 0.43–5.07
Birth height (cm) 1576 50.145 ± 2.966 50 24–59
Ponderal index (kg/m3 ) 1570 24.795 ± 3.911 24.48 6.742–82.127
Head circumference (cm) 1576 34.107 ± 2.049 34 18–55
Crown heel length (cm) 1575 12.185 ± 2.148 12 5–53
Apgar 1-min scores 1573 7.39 ± 1.266 8 0–9
Apgar 5-minute scores 1573 8.70 ± 0.979 9 0–9
Placenta thickness (cm) 1575 1.812 ± 0.725 2 1–25
Placenta weight (gm) 1577 566.371 ± 123.073 550 100–1110
Cord length (cm) 1576 51.968 ± 9.295 51 13–104
Cephalization index (cm/g) 1569 112.460 ± 25.539 1087.824 71.146–465.116

Categorical variables Category Count Percentage (%)

SGA birth (N = 1571) <10th percentile/≥10th 157/1414 10.0%/90.0%

percentile
Preterm birth <37 weeks/>37 weeks 109/1469 6.9%/93.1%
(N = 1578)
Mode of delivery Normal/C.S. 1345/226 85.6%/14.4%
(N = 1571)
Induced labor Yes/No 82/1495 5.2%/94.8%
(N = 1572)
Fetal distress (N = 1565) Yes/No 109/1456 7%/93%
Illness during Yes/No 90/1487 5.7%/94.3%
pregnancy (N = 1577)
Use of medication Yes/No 73/1504 4.6%/95.4%
during pregnancy
(N = 1577)
Newborn’s gender Male/Female 801/772 50.9%/49.1%
(N = 1573)
Mothers’ highest Illiterate or attending literacy 362/517/363/308 23.4%/33.4%/23.4%/19.9%
education (N = 1550) class/Primary/Intermediate
Secondary/College or University
Total monthly family <5000/5001–7500/>7501 481/323/242/360/ 30.5%/20.5%/15.4%/22.9%
income in SR
(N = 1575)
Irregular or unknown/Refused 169
10.7% North/South/East/West/Central 246/325/265/584/147 15.7%/20.7%/16.9%/37.3%/9.4%
Location of current Residential/Close to heavy 1167/371/40 74.0%/23.5%/2.5%
dwelling (N = 1578) traffic or industry/Others such
as farm, desert
Smoking status at Yes/No 409/1167 26%/74%
dwelling (N = 1576)
Coffee (N = 1578) Yes/No 1141/167 89.4%/10.6%
Tea (N = 1578) Yes/No 1359/219 86.1%/13.9%

Table 2
Distribution of lead, cadmium and mercury levels in cord and maternal blood as well as placenta samples.

Statistics Lead (␮g/dl) Cadmium (␮g/l) Mercury (␮g/l) Placental (␮g/g dry wt.)

Cord Maternal Cord Maternal Cord Maternal Lead Cadmium Mercury

N 1572 1577 1566 1565 1561 1574 1576 1578 1568

MDL 0.397 0.42 0.25 0.25 0.025 0.033
N (%) above MDL 1566 (99.6%) 1570 (99.6%) 1485 (94.8%) 1532 (97.9%) 1463 (93.7%) 1405 (89.3%) 1189 (75.4%) 1107 (70.2%) 750 (47.8%)
Mean 2.551 2.897 0.780 0.986 3.354 3.005 0.579 0.045 0.064
Std. Deviation 2.592 1.851 0.623 0.313 2.673 6.319 2.176 0.116 0.403
Minimum 0.154 0.073 0.245 0.233 0.000 0.000 0.000 0.000 0.000
Maximum 56.511 25.955 15.325 3.157 26.532 206.410 78.000 4.363 13.003
Percentiles
25th 1.594 1.934 0.586 0.766 1.497 0.940 0.263 0.022 0.015
50th (median) 2.057 2.540 0.704 0.983 2.876 1.949 0.450 0.035 0.031
75th 2.689 3.314 0.853 1.207 4.600 3.507 0.630 0.048 0.060

Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
 IJHEH-12693; No. of Pages 14
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in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)

Table 3
The bivariate relationships between exposure to heavy metals (lead, cadmium and mercury) in cord and maternal blood as well as placental tissues of mothers and a number of confounding variables (demographic, socioeconomic
and lifestyle).

Confounding variables Cord Maternal Placental tissues

Lead Cadmium Mercury Lead Cadmium Mercury Lead Cadmium Mercury

Maternal age (years) 0.098 (<0.001) 0.074 (0.003)a 0.012 (0.644)a 0.102 (<0.001)a 0.049 (0.053)a −0.009 (0.738)a −0.021 (0.416)a 0.088 (<0.001)a −0.005 (0.862)a
Parity 0.11 (<0.001)a 0.064 (0.028)a −0.015 (0.611)a 0.164 (<0.001)a 0.033 (0.261)a 0.014 (0.629)a 0.015 (0.605)a 0.064 (0.028)a −0.028 (0.348)a

I. Al-Saleh et al. / International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx
First maternal 0.062 (0.026) a 0.026 (0.345)a 0.05 (0.078)a 0.038 (0.171)a −0.017 (0.536)a 0.1 (<0.001)a −0.009 (0.739)a 0.009 (0.744)a 0.095 (0.001)a
trimester BMI

ARTICLE IN PRESS
(kg/m2 )
Second maternal 0.073 (0.006)a 0.007 (0.794)a 0.078 (0.004)a 0.035 (0.190)a −0.019 (0.485)a 0.104 (<0.001)a −0.016 (0.551)a 0.004 (0.872)a 0.095 (0.001)a
trimester BMI
(kg/m2 )
Third maternal 0.023 (0.360)a −0.013 (0.604)a 0.067 (0.009)a −0.016 (0.535)a −0.024 (0.335)a 0.098 (<0.001)a −0.019 (0.467)a 0.009 (0.723)a 0.093 (<0.001)a
trimester BMI
(kg/m2 )
Total maternal weight −0.021 (0.465)a −0.054 (0.064)a −0.003 (0.915)a −0.047 (0.111)a 0.051 (0.081)a −0.043 (0.160)a −0.009 (0.759)a 0.008 (0.774)a −0.055 (0.071)a
gain for the second
and third trimester
(kg)
Duration of living in −0.008 (0.746)a 0.027 (0.288)a −0.044 (0.092)a 0.028 (0.273)a 0.128 (<0.001)a −0.036 (0.168)a 0.027 (0.301)a 0.070 (0.006)a −0.043 (0.102)a
the district (years)
Urinary cotinine (␮g/g 0.127 (<0.001)a −0.007 (0.782)a 0.064 (0.013)a 0.176 (<0.001)a 0.03 (0.236)a 0.05 (0.056)a −0.016 (0.526)a 0.039 (0.121)a 0.046 (0.082)a
Cr)
Geographical 1.538 (0.189)b 1.465 (0.211)b 2.276 (0.059)b 6.263 (<0.001)b 1.429 (0.222)b 2.846 (0.023)b 1.964 (0.098)b 0.784 (0.536)b 2.291 (0.058)b
distribution of the
current dwelling
Cen-
tral/Northern/Southern/Eastern/Western
Location of current 2.652 (0.071)b 2.085 (0.125)b 0.878 (0.416)b 0.287 (0.751)b 4.795 (0.008)b 1.989 (0.137)b 9.591 (<0.001)b 0.220 (0.802)b 3.978 (0.019)b
dwelling Residential
area/Heavy traffic or
industry/Farm or
desert
Mother’s educational 20.103 (<0.001)b 0.952 (0.414)b 3.504 (0.015)b 34.775 (<0.001)b 1.784 (0.148)b 3.1 (0.026)b 1.185 (0.314)b 1.387 (0.245)b 2.218 (0.084)b
level:
Illiterate/literacy
class/Primary/intermediate/Secondary/College
or University
Total monthly family 4.899 (0.001)b 1.071 (0.369)b 1.78 (0.13)b 3.47 (0.008)b 6.495 (<0.001)b 1.221 (0.3)b 1.795 (0.127)b 2.934 (0.02)b 1.033 (0.389)b
income in SR
5001−7500/>7500/Irregular/Refused
Newborn’s gender −1.787 (0.074)c 1.687 (0.092)c −1.464 (0.143)c −2.183 (0.029)c 0.27 (0.787)c 1.401 (0.161)c −1.061 (0.289)c 1.195 (0.232)c −0.998 (0.318)c
a
Result was tested by Pearson’s correlation analysis.
b
Result was tested by ANOVA.
c
Result was tested by Student-t test. Values between parentheses are the level of significance (p).

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6 I. Al-Saleh et al. / International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx
living in other areas such as farms or deserts (p = 0.908). Student’s
t-tests showed that the blood lead levels were higher in mothers of
male than of female newborns.
Cadmium. The mean cadmium levels in maternal and umbil-
ical cord blood were 0.986 ± 0.313 ␮g/l (0.233–3.157 ␮g/l) and
0.780 ± 0.623 ␮g/l (0.245–15.325 ␮g/l), respectively. Cadmium was
detected in all samples, with approximately 94.8% and 97.9% of the
samples of umbilical cord and maternal blood respectively, above
the MDL of cadmium (0.42 ␮g/l). Even though cadmium levels
were significantly higher in samples of maternal than in umbil-
ical cord blood (t = −21.42, p < 0.001), no relationship was found
between them (r = 0.042, p = 0.1). The overall mean + SD for placen-
tal cadmium levels was 0.045 ± 0.116 ␮g/g dry wt., with a range
of 0–4.363 ␮g/g dry wt. Cadmium was detected in 99% of placen-
tal samples. About 70.2% (N = 1107) of all cadmium measurements
were above the MDL of 0.025 ␮g/g dry wt. Cadmium in umbili-
cal cord blood and placental tissues was associated with maternal
age and parity (Table 3). Cadmium levels in maternal blood and
placental tissues were positively correlated with the duration of
living in the district. Mothers living in areas of heavy traffic had
higher blood cadmium levels compare to those living in other areas
such as residential areas, farms or deserts (p = 0.026). Mothers who
refused to report their total family income had the highest blood
cadmium levels, which were significantly different than the lev-
els in mothers from other classes: <SR5000 (p = 0.001), >SR7500
(p = 0.023) or irregular (p < 0.001) but not from mothers with a total
family income of SR5001-7500 (p = 0.373). Even though placental
cadmium levels were highest in mothers with a total family income
>SR7500, they were not significantly different from the levels in
mothers from other classes (SR < 5000, SR5001–7500, irregular or
refused). Mothers who refused to report family income, though,
had higher placental cadmium levels than those with a total family
income of SR5001–7500 (p = 0.036).
Mercury. The maternal mercury blood levels ranged from 0 to
206.41 ␮g/l, with a mean of 3.005 ± 6.319 ␮g/l. The correspond-
ing levels in their newborns ranged from 0 to 26.532 ␮g/l with a
mean of 3.354 ± 2.673 ␮g/l. In 96 newborns (6.1%) and 196 moth-
ers (12.5%), mercury levels were below the MDL of 0.25 ␮g/l.
Unlike lead and cadmium, mercury was significantly higher in
umbilical cord blood than in maternal blood, with a t-value of
8.036 (p < 0.001). These two parameters were significantly corre-
lated (r = 0.202, p < 0.001). The average placental mercury level was
0.064 ± 0.403 ␮g/g dry wt. (range, 0–13.003 ␮g/g dry wt). Approxi-
mately 93% of tested placental tissues contained mercury. Placental
mercury levels in 47.8% (N = 750) of the women were above the MDL
of 0.033 ␮g/g dry wt. Mercury in cord blood was correlated with
both the second and third maternal trimester BMIs and with urinary
cotinine. On the other hand, mercury in maternal blood and placen-
tal tissues was associated with the third maternal trimester BMI.
Mothers living in the Central Region of Al-Kharj had the highest
levels of mercury in their blood, but these levels were significantly
different only from those in mothers living in the Northern Region
(p = 0.041). The levels of mercury in placental tissues were higher
in mothers living in areas of heavy traffic compared to those living
in residential areas (p = 0.025). The levels of mercury in umbilical
cord and maternal blood were significantly higher in mothers with
a college diploma and/or university degree than in those who were
either illiterate or attended literacy classes with p-values of 0.032
and 0.04 respectively. Results are shown in Table 3.
Risk factors associated with the measures of birth outcome
Uni- and multivariate logistic regression analyses determined
the crude (unadjusted) and adjusted ORs for the associations
between the various measures of birth outcome and each metal
in umbilical cord blood, maternal blood and placental tissues.
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
The observed trends in the prevalence of participants with the
measures of birth outcome below the 10th percentile were:
placental weight (17.3%) > Apgar 5-minute score (17%) > Apgar
1-min score (14.4%) > crown-heel length (13.9%) > placenta thick-
ness (12.6%) > birth height (11.2%) > cord length (10.4%) > birth
weight (10.3% > head circumference (10.2%) > ponderal index
(10%) > SGA (10%) > cephalization index (9.9%).
Univaiate logistic regression analysis. As shown in Table 4, cad-
mium levels in umbilical cord blood were significantly higher in
newborns with <10th percentile head circumferences (p = 0.005),
while placental mercury levels were significantly higher in new-
borns with ≥10th percentile head circumferences (p = 0.047). The
cadmium levels in umbilical cord and maternal blood were sig-
nificantly higher in newborns with <10th percentile crown-heel
lengths with p-values of 0.001 and 0.027, respectively. Newborns
with <10th percentile Apgar 5-minute scores had significantly
higher cord blood cadmium (p = 0.011). The same pattern was
seen with mercury levels in maternal blood (p = 0.044). In contrast,
newborns with <10th percentile Apgar 5-minute scores had signifi-
cantly lower placental mercury levels (p = 0.018) compared to those
with ≥10th percentile scores. Newborns with <10th percentile
birth weights had higher cord blood cadmium levels (p = 0.002).
Maternal blood mercury levels were significantly higher in moth-
ers with <10th percentile placental weights (p = 0.024). The levels of
maternal blood lead, maternal blood cadmium and placental cad-
mium were significantly higher in mothers with <10th percentile
placental thicknesses with p-values of 0.022, 0.029 and 0.024,
respectively. Mercury levels in umbilical cord blood and cadmium
levels in placental tissues were respectively lower in mothers with
<10th percentile placenta thicknesses (p = 0.029) and in newborns
with <10th percentile cord lengths (p = 0.005). Lead levels in umbil-
ical cord blood were significantly higher in newborns with a ≥10th
percentile ponderal index (p = 0.022). The risk of SGA births (<10th
percentile) was significantly increased with higher cadmium levels
in umbilical cord blood (p = 0.009).
Birth anthropometric measures below <10th percentile sig-
nificantly increased with maternal age such as head cir-
cumference (OR = 0.949, 95% CI: 0.922–0.977, p < 0.001), birth
weight (OR = 0.966, 95% CI: 0.939–0.994, p = 0.017), birth height
(OR = 0.962, 95% CI: 0.936–0.989, p = 0.006), and placental weight
(OR = 0.969, 95% CI: 0.948–0.991, p = 0.006). On the other hand,
older mothers had a higher risk of giving birth to newborns
with a <10th percentile cephalization index (OR = 1.071, 95%
CI: 1.043–1.10, p < 0.001). Parity was only associated with the
risk of <10th percentile cephalization index (OR = 1.129, 95% CI:
1.057–1.207, p < 0.001). Maternal BMIs during the third trimester
were significantly lower for newborns with <10th percentiles of
head circumference (OR = 0.066, 95% CI: 0.025–0.174, p < 0.001),
crown-heel length (OR = 0.303, 95% CI: 0.135–0.683, p = 0.004),
birth weight (OR = 0.057, 95% CI: 0.022–0.15, p < 0.001), birth
height (OR = 0.063, 95% CI: 0.025–0.16, p < 0.001), placental weight
(OR = 0.085, 95% CI: 0.039–0.183, p < 0.001), placental thickness
(OR = 0.327, 95% CI: 0.141–0.758, p = 0.009), cord length (OR = 0.197,
95% CI: 0.078–0.499, p = 0.001), ponderal index (OR = 0.302, 95%
CI: 0.119–0.767, p = 0.012) and SGA (OR = 0.084, 95% CI: 0.032–0.22,
p < 0.001). In contrast, maternal BMIs during the third trimester
were significantly higher for newborns with a <10th percentile
cephalization index (OR = 24.024, 95% CI: 9.481–60.872, p < 0.001).
Male newborns had an increased risk of <10th percentile cephal-
ization index (2 = 8.392, p = 0.004) and SGA birth (2 = 7.925,
p = 0.007), while female newborns had a higher risk of <10th per-
centile head circumferences (2 = 6.627, p = 0.01). Newborns in
the Western Region had a higher risk of <10th percentile head
circumferences (2 = 19.46, p = 0.001), birth weights (2 = 13.559,
p = 0.009), birth heights (2 = 10.572, p = 0.032) and placental thick-
nesses (2 = 15.149, p = 0.004). Mothers who were either illiterate
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Table 4
Arthmatic mean, n, unadjusted ORs, 95% CI, and p-value for the association between birth outcome measures falling < or ≥10th percentile and heavy metals in cord blood,
maternal blood and placental tissues.

Variables ORs (95% CI), p

Head circumference Crown-heel length Apgar 1-minute scores

≥10th <10th ≥10th <10th ≥10th <10th

Cord blood lead (␮g/dl) 2.579 (N = 1410) 2.316 (N = 159) 2.578 (N = 1351) 2.398 (N = 218) 2.543 (N = 1343) 2.609 (N = 225)
0.747 (0.541–1.032) p = 0.077 0.992 (0.756–1.302), p = 0.954 1.01 (0.773–1.32), p = 0.942
Maternal blood lead (␮g/dl) 2.902 (N = 1414) 2.845 (N = 160) 2.896 (N = 1355) 2.901 (N = 219) 2.902 (N = 1345) 2.853 (N = 227)
1.007 (0.724–1.400) p = 0.968 1.061 (0.795–1.415), p = 0.689 0.968 (0.729–1.286), p = 0.823
Placental tissue lead (␮g/g dry wt.) 0.580 (N = 1413) 0.574 (N = 160) 0.551 (N = 1354) 0.751 (N = 219) 0.540 (N = 1344) 0.808 (N = 227)
1.150 (0.947–1.397) p = 0.158 1.107 (0.936–1.31), p = 0.235 0.989 (0.842–1.162), p = 0.895
Cord blood cadmium (␮g/l) 0.766 (N = 1405) 0.901 (N = 158) 0.774 (N = 1348) 0.815 (N = 215) 0.775 (N = 1339) 0.816 (N = 223)
1.791 (1.191–2.695) p = 0.005 1.85 (1.28–2.674), p = 0.001 1.411 (0.972–2.047), p = 0.07
Maternal blood cadmium (␮g/l) 0.986 (N = 1403) 0.983 (N = 159) 0.979 (N = 1344) 1.024 (N = 218) 0.988 (N = 1335) 0.978 (N = 225)
0.865 (0.535–1.398) p = 0.554 1.644 (1.058–2.555), p = 0.027 0.884 (0.584–1.339), p = 0.561
Placental tissue cadmium (␮g/g dry wt.) 0.046 (N = 1415) 0.036 (N = 160) 0.045 (N = 1356) 0.040 (N = 219) 0.045 (N = 1346) 0.040 (N = 227)
0.831 (0.675–1.022) p = 0.079 0.886 (0.738–1.064), p = 0.196 0.978 (0.814–1.175), p = 0.813
Cord blood mercury (␮g/l) 3.330 (N = 1400) 3.576 (N = 158) 3.363 (N = 1342) 3.320 (N = 216) 3.331 (N = 1334) 3.534 (N = 223)
1.109 (0.909–1.353) p = 0.308 0.934 90.8–1.091), p = 0.391 1.054 (0.896–1.239), p = 0.526
Maternal blood mercury (␮g/l) 3.004 (N = 1411) 3.024 (N = 160) 3.054 (N = 1352) 2.710 (N = 219) 3.026 (N = 1343) 2.919 (N = 226)
1.097 (0.932–1.291) p = 0.264 1.013 (0.883–1.163), p = 0.85 1.082 (0.943–1.242), p = 0.26
Placental tissue mercury (␮g/g dry wt.) 0.065 (N = 1405) 0.060 (N = 160) 0.060 (N = 1347) 0.091 (N = 218) 0.066 (N = 1337) 0.053 (N = 226)
1.172 (1.002–1.372) p = 0.047 0.99 (0.866–1.131), p = 0.877 1.127 (0.985–1.289), p = 0.082

Variables ORs (95% CI), p

Apgar 5-minute scores Birth weight Birth height

≥10th <10th ≥10th <10th ≥10th <10th

Cord blood lead (␮g/dl) 2.507 (N = 1303) 2.778 (N = 265) 2.577 (N = 1405) 2.336 (N = 161) 2.563 (N = 1395) 2.468 (N = 175)
1.171 (0.916–1.497), p = 0.207 0.794 (0.577–1.092), p = 0.156 1.019 (0.757–1.371), p = 0.903
Maternal blood lead (␮g/dl) 2.890 (N = 1305) 2.916 (N = 267) 2.895 (N = 1409) 2.907 (N = 162) 2.883 (N = 1399) 3.001 (N = 176)
1.027 (0.787–1.341), p = 0.842 1.107 (0.797–1.538), p = 0.545 1.299 (0.945–1.786), p = 0.107
Placental tissue lead (␮g/g dry wt.) 0.538 (N = 1304) 0.780 (N = 267) 0.580 (N = 1408) 0.576 (N = 162) 0.582 (N = 1398) 0.555 (N = 176)
0.975 (0.839–1.133), p = 0.741 1.153 (0.95–1.4), p = 0.151 1.079 (0.898–1.296), p = 0.417
Cord blood cadmium (␮g/l) 0.773 (N = 1300) 0.819 (N = 262) 0.773 (N = 1399) 0.845 (N = 161) 0.777 (N = 1389) 0.802 (N = 175)
1.568 (1.106–2.221), p = 0.011 1.894 (1.266–2.834), p = 0.002 1.431 (0.952–2.151), p = 0.085
Maternal blood cadmium (␮g/l) 0.989 (N = 1295) 0.970 (N = 265) 0.983 (N = 1398) 1.011 (N = 161) 0.983 (N = 1388) 1.009 (N = 175)
0.814 (0.553–1.199), p = 0.298 1.287 (0.787–2.107), p = 0.315 1.239 (0.772–1.989), p = 0.374
Placental tissue cadmium (␮g/g dry wt.) 0.046 (N = 1306) 0.040 (N = 267) 0.045 (N = 1410) 0.039 (N = 162) 0.046 (N = 1400) 0.036 (N = 176)
0.972 (0.819–1.154), p = 0.748 0.91 (0.738–1.122), p = 0.375 0.86 (0.704–1.05), p = 0.138
Cord blood mercury (␮g/l) 3.339 (N = 1294) 3.465 (N = 263) 3.354 (N = 1398) 3.412 (N = 157) 3.378 (N = 1385) 3.174 (N = 174)
1.004 (1.163), p = 0.963 0.966 (0.803–1.161), p = 0.711 0.907 (0.766–1.074), p = 0.259
Maternal blood mercury (␮g/l) 2.986 (N = 1302) 3.129 (N = 267) 3.011 (N = 1406) 2.985 (N = 162) 3.037 (N = 1396) 2.749 (N = 176)
1.144 (1.004–1.304), p = 0.044 1.072 (0.913–1.259), p = 0.395 0.995 (0.856–1.157), p = 0.951
Placental tissue mercury (␮g/g dry wt.) 0.066 (N = 1297) 0.057 (N = 266) 0.065 (N = 1401) 0.059 (N = 161) 0.066 (N = 1391) 0.053 (N = 175)
1.165 (1.027–1.32), p = 0.018 1.111 (0.951–1.298), p = 0.185 1.081 (0.93–1.257), p = 0.31

Variables ORs (95% CI), p

Placental weight Placental thickness Cord length

≥10th <10th ≥10th <10th ≥10th <10th

Cord blood lead (␮g/dl) 2.546 (N = 1299) 2.575 (N = 273) 2.541 (N = 1372) 2.589 (N = 198) 2.520 (N = 1407) 2.821 (N = 164)
1.036 (0.81–1.326), p = 0.776 1.025 (0.773–1.36), p = 0.862 1.222 (0.908–1.645), p = 0.185
Maternal blood lead (␮g/dl) 2.898 (N = 1303) 2.891 (N = 273) 2.884 (N = 1376) 2.980 (N = 198) 2.896 (N = 1411) 2.908 (N = 164)
1.018 (0.782–1.324), p = 0.896 1.423 (1.051–1.926), p = 0.022 1.043 (0.752–1.445), p = 0.801
Placental tissue lead (␮g/g dry wt.) 0.592 (N = 1302) 0.511 (N = 273) 0.559 (N = 1375) 0.712 (N = 198) 0.567 (N = 1410) 0.675 (N = 164)
0.973 (0.838–1.128), p = 0.714 1.1 (0.923–1.312), p = 0.287 0.997 (0.829–1.2), p = 0.977
Cord blood cadmium (␮g/l) 0.779 (N = 1294) 0.786 (N = 272) 0.783 (N = 1366) 0.763 (N = 198) 0.779 (N = 1401) 0.791 (N = 164)
1.15 (0.805–1.642), p = 0.442 1.056 (0.701–1.593), p = 0.794 1.399 (0.919–2.13), p = 0.117
Maternal blood cadmium (␮g/l) 0.991 (N = 1292) 0.964 (N = 272) 0.980 (N = 1364) 1.029 (N = 198) 0.985 (N = 1401) 0.998 (N = 162)
0.801 (0.547–1.174), p = 0.256 1.671 (1.055–2.646), p = 0.029 1.084 (0.668–1.759), p = 0.744
Placental tissue cadmium (␮g/g dry wt.) 0.045 (N = 1304) 0.044 (N = 273) 0.044 (N = 1376) 0.046 (N = 199) 0.046 (N = 1412) 0.035 (N = 164)
1.063 (0.895–1.262), p = 0.487 1.256 (1.03–1.533), p = 0.024 0.751 (0.615–0.919), p = 0.005
Cord blood mercury (␮g/l) 3.372 (N = 1289) 3.256 (N = 271) 3.390 (N = 1365) 3.087 (N = 193) 3.356 (N = 1399) 3.328 (N = 160)
0.929 (0.806–1.07), p = 0.307 0.843 (0.722–0.983), p = 0.029 0.96 (0.803–1.149), p = 0.659
Maternal blood mercury (␮g/l) 2.946 (N = 1300) 3.281 (N = 273) 3.067 (N = 1374) 2.592 (N = 197) 3.000 (N = 1408) 3.058 (N = 164)
0.87 (0.771–0.982), p = 0.024 0.977 (0.846–1.129), p = 0.751 1.059 (0.904–1.24), p = 0.48
Placental tissue mercury (␮g/g dry wt.) 0.068 (N = 1296) 0.047 (N = 271) 0.067 (N = 1367) 0.043 (N = 198) 0.065 (N = 1402) 0.056 (N = 164)
0.965 (0.853–1.092), p = 0.574 0.918 (0.798–1.055), p = 0.227 1.158 (0.991–1.354), p = 0.065

Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
 ARTICLE IN PRESS
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8 I. Al-Saleh et al. / International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx

Table 4 (continued ).

Variables ORs (95% CI), p

Ponderal index Cephalization index SGA

≥10th <10th ≥10th <10th ≥10th <10th

Cord blood lead (␮g/dl) 2.590 (N = 1408) 2.224 (N = 156) 2.492 (N = 1410) 3.122 (N = 153) 2.576 (N = 1408) 2.343 (N = 157)
0.681 (0.491–0.947), p = 0.022 1.274 (0.941–1.725), p = 0.118 0.81 (0.587–1.117), p = 0.198
Maternal blood lead (␮g/dl) 2.904 (N = 1413) 2.814 (N = 156) 2.895 (N = 1413) 2.906 (N = 155) 2.893 (N = 1413) 2.921 (N = 157)
0.946 (0.679–1.318), p = 0.743 1.042 (0.746–1.456), p = 0.809 1.168 (0.837–1.631), p = 0.362
Placental tissue lead (␮g/g dry wt.) 0.591 (N = 1411) 0.475 (N = 157) 0.590 (N = 1412) 0.482 (N = 155) 0.592 (N = 1412) 0.459 (N = 157)
1.005 (0.831–1.217), p = 0.957 0.939 (0.804–1.097), p = 0.428 0.996 (0.823–1.206), p = 0.971
Cord blood cadmium (␮g/l) 0.776 (N = 1402) 0.820 (N = 156) 0.787 (N = 1404) 0.713 (N = 153) 0.766 (N = 1402) 0.910 (N = 157)
1.315 (0.852–2.029), p = 0.217 0.639 (0.388–1.052), p = 0.078 1.728 (1.146–2.606), p = 0.009
Maternal blood cadmium (␮g/l) 0.985 (N = 1402) 0.989 (N = 155) 0.987 (N = 1401) 0.963 (N = 155) 0.980 (N = 1402) 1.037 (N = 156)
1.052 (0.643–1.722), p = 0.839 0.827 (0.51–1.342), p = 0.442 1.623 (0.975–2.702), p = 0.063
Placental tissue cadmium (␮g/g dry wt.) 0.045 (N = 1413) 0.045 (N = 157) 0.045 (N = 1414) 0.045 (N = 155) 0.045 (N = 1414) 0.042 (N = 157)
1.129 (0.907–1.407), p = 0.277 0.994 (0.801–1.234), p = 0.956 1.042 (0.84–1.293), p = 0.709
Cord blood mercury (␮g/l) 3.343 (N = 1400) 3.530 (N = 153) 3.364 (N = 1400) 3.331 (N = 152) 3.376 (N = 1402) 3.209 (N = 152)
1.029 (0.849–1.247), p = 0.771 1.078 (0.885–1.312), p = 0.456 0.936 (0.781–1.122), p = 0.474
Maternal blood mercury (␮g/l) 3.024 (N = 1410) 2.859 (N = 156) 3.006 (N = 1411) 3.030 (N = 154) 3.070 (N = 1410) 2.464 (N = 157)
0.999 (0.853–1.171), p = 0.992 1.106 (0.937–1.305), p = 0.232 0.944 (0.808–1.102), p = 0.466
Placental tissue mercury (␮g/g dry wt.) 0.056 (N = 1403) 0.138 (N = 157) 0.066 (N = 1405) 0.049 (N = 154) 0.065 (N = 1405) 0.053 (N = 156)
1.141 (0.974–1.336), p = 0.103 0.939 (0.804–1.097), p = 0.428 1.056 (0.902–1.238), p = 0.497

or attending literacy class had a higher risk of newborns with
<10th percentile cephailzation index (2 = 11.157, p = 0.011). Fam-
ilies with low income < SR5000 had a higher risk of SGA births
(2 = 10.006, p = 0.04).
Adjusted multivariate logistic models. We further evaluated the
significant association between metals and various measures of
birth outcome in the bivariate logistic after adjusting for con-
founding variables. As shown in Table 5, – model I, only placental
mercury levels remained significantly correlated with the risk of
newborns with ≥10th percentile head circumferences (p = 0.017).
This relationship remained significant after adjusting for gesta-
tional age (p = 0.026) or excluding preterm births (p = 0.021) as
shown in Table 5, models II and III. The AUC of placental mer-
cury was 0.686 (95% CI, 0.626–0.746) which was larger than 0.5
(p < 0.001). The AUC did not change after adjusting for gestational
age or excluding preterm births. On the other hand, the association
between <10th percentile head circumferences and cadmium levels
in umbilical cord blood disappeared (p = 0.230) after adjusting for
confounders.
The risk of newborns with <10th percentile crown-heel lengths
remained significantly associated with cadmium levels in umbil-
ical cord blood (p = 0.034) in the adjusted model I (Table 5). The
same relationship was observed with maternal blood cadmium
(p = 0.007). The AUC was 0.586 (95% CI, 0.533–0.639, p = 0.003)
for cadmium levels in umbilical cord blood and 0.589 (95% CI,
0.531–0.646, p = 0.002) in maternal blood. After controlling for ges-
tational age or excluding preterm births, the association between
the risk of <10th percentile crown-heel lengths and cadmium levels
in umbilical cord blood disappeared. On the other hand, the asso-
ciation remained significant with maternal blood cadmium after
adjusting for gestational age (p = 0.01) and after excluding preterm
births (p = 0.042), with no change in the AUC. Results are presented
in Table 5, models II and III.
The increase in the risk of <10th percentile Apgar 5-minute
scores with cadmium levels in umbilical cord blood remained sig-
nificant in the adjusted model (p = 0.004). The AUC of the model
was 0.637 (95% CI, 0.581–0.693, p < 0.001). The risk of ≥10th per-
centile Apgar 5-minute scores remained significant with placental
mercury levels (p = 0.01). The model’s AUC was 0.573 (95% CI,
0.519–0.627, p = 0.012). After adjusting for gestational age (Table 5,
model II), the relationship remained significant with cadmium lev-
els in umbilical cord blood (p = 0.025) and with placental mercury
(p = 0.015). After excluding preterm births, however, a marginally
significant relationship was seen between <10th percentile Apgar
5-minute scores and cadmium levels in umbilical cord (p = 0.069).
A similar pattern was also seen between placental mercury and
the risk of ≥10th percentile Apgar 5-minute scores after excluding
preterm births (p = 0.076).
The risk of <10th percentile birth weights remained signifi-
cantly associated with cadmium levels in umbilical cord (p = 0.015)
after adjusting for confounders. The model’s AUC was 0.652 (95%
CI, 0.58–0.723, p < 0.001). The trend, however, was weaker and no
longer significant after adjusting for gestational age (p = 0.188) or
excluding preterm births (p = 0.124).
The association between <10th percentile placental weights and
mercury levels in maternal blood remained marginally significant
(p = 0.059), with an AUC of 0.639 (95% CI: 0.598–0.681 p < 0.001).
Additional adjustment for gestational age or excluding preterm
births changed the estimates little, with p-values of 0.057 and
0.053, respectively, as displayed in Table 5, models II and III.
The risk of placental thickness below the 10th percentile
remained significant with maternal blood lead (p = 0.011), mater-
nal blood cadmium (p = 0.022) and placental cadmium (p = 0.032). A
borderline significant relationship was observed between mercury
in umbilical cord blood and ≥10th percentile placental thicknesses
(p = 0.05). The model’s AUCs were 0.625 (95% CI: 0.575–0.675) for
maternal blood lead, 0.618 (95% CI: 0.573–0.662) for maternal
blood cadmium, 0.618, (95% CI: 0.57–0.667) for placental cadmium
and 0.607 (95% CI: 0.560–0.654) for mercury in umbilical cord
blood, with p < 0.001 for all. The relationships remained unchanged
after adjusting for gestational age or excluding preterm births, as
shown in Table 5, models II and III.
The risk of cord lengths above the 10th percentile remained
significant with placental cadmium (p = 0.012), with an AUC of
0.59 (95% CI: 0.532–0.648, p = 0.004). The risk of ≥10th per-
centile cord lengths remained unchanged after controlling for
gestational age (p = 0.025) but not after excluding preterm births
(p = 0.532).
The relationship between umbilical cord blood lead and the risk
of a ≥10th percentile ponderal index disappeared (p = 0.216) after
controlling for confounders, as shown in Table 5 – Model I.
After adjusting for confounding variables, cadmium in umbili-
cal cord blood remained significantly associated with SGA births
(p = 0.049). The AUC was 0.659 (95% CI: 0.6–0.718, p < 0.001). A

Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
 IJHEH-12693; No. of Pages 14
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in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)

Table 5
Adjusted ORs (and corresponding 95% CI, p-value) for predicting the association between birth outcome measures at the 10th percentile and heavy metals in cord blood, maternal blood and placental tissues after controlling for
cofounders (Model I); plus adjusting for gestational age (Model II); and excluding preterm births (Model III).

Lead (␮g/dl) Cadmium (␮g/l) Mercury (␮g/l) Placenta (␮g/g dry wt.)

Cord Maternal Cord Maternal Cord Maternal Cadmium Mercury

Model I Head 1.447 1.223

circumference (cm) (0.792–2.643) (1.036–1.444)
p = 0.230c p = 0.017o
Crown-heel length 1.698 1.875
(cm) (1.042–2.767) (1.191–2.953)

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p = 0.034d p = 0.007h
Apgar 5-minute 2.014 (1.25–3.244) 1.113 1.184

ARTICLE IN PRESS
scores p = 0.004e (0.972–1.274) (1.041–1.346)
p = 0.122k p = 0.01p
Birth weight (Kg) 2.026
(1.148–3.575)
p = 0.015f
Placental weight 0.884
(gm) (0.778–1.005)
p = 0.059l
Placental thickness 1.638 1.746 0.852 (0.726–1.0) 1.291
(cm) (1.118–2.399) (1.083–2.815) p = 0.05j (1.022–1.631)
p = 0.011b p = 0.022i p = 0.032m
Cord length (cm) 0.731
(0.571–0.934)
p = 0.012n
Ponderal index 0.772
(0.512–1.163)
p = 0.216a
SGA 1.768
(1.003–3.117)
p = 0.049g

Model II Head 1.042 1.23 (1.025–1.476)

circumference (cm) (0.524–2.073) p = 0.026o
p = 0.906c
Crown-heel length 1.49 (0.899–2.471), 1.848
(cm) p = 0.122d (1.157–2.956),
p = 0.01h
Apgar 5-minute 1.748 1.115 (0.971–1.28) 1.179
scores (1.071–2.854) p = 0.125k (1.033–1.347)
p = 0.025e p = 0.015p
Birth weight (Kg) 1.549
(0.807–2.973)
p = 0.188f
Placental weight 0.882
(gm) (0.775–1.004)
p = 0.057l
Placental thickness 1.643 (1.12–2.41), 1.746 0.852 (0.726–1.0) 1.306
(cm) p = 0.011b (1.083–2.814) p = 0.05j (1.034–1.651)
p = 0.022i p = 0.025m
Cord length (cm) 0.753
(0.588–0.965)
p = 0.025n

9
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in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)

Table 5 (Continued)

Lead (␮g/dl) Cadmium (␮g/l) Mercury (␮g/l) Placenta (␮g/g dry wt.)

Cord Maternal Cord Maternal Cord Maternal Cadmium Mercury

Ponderal index 0.766

(0.502–1.167)
p = 0.214a
SGA 1.806
(1.026–3.179)
p = 0.04g

I. Al-Saleh et al. / International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx
Model III Head 0.808 1.266
circumference (cm) (0.365–1.788) (1.035–1.549)

ARTICLE IN PRESS
p = 0.6c p = 0.021o
Crown-heel length 1.271 (0.73–2.214), 1.69 (1.019–2.805)
(cm) p = 0.397d p = 0.042h
Apgar 5-minute 1.63 (0.964–2.758) 1.072 1.135
scores (0.926–1.241) (0.987–1.304)
p = 0.069e p = 0.252k p = 0.076p
Birth weight (Kg) 1.769
(0.855–3.662)
p = 0.124f
Placental weight 0.874
(gm) (0.763–1.002)
p = 0.053l
Placental thickness 1.634 (1.098–2.43) 1.699 0.859 1.28 (1.002–1.635)
(cm) p = 0.015b (1.034–2.792) (0.725–1.017) p = 0.048m
p = 0.036i p = 0.078j
Cord length (cm) 0.915
(0.692–1.209)
p = 0.532n
Ponderal index 0.666
(0.422–1.051)
p = 0.081a
SGA 1.548 (0.844–2.84)
p = 0.158g

Models are adjusted for the following confounders:

a
Maternal age, parity, mother’s third trimester BMI, urinary cotinine, geographical distribution of current dwelling, newborm mother’s highest education, total family income.
b
Maternal age, parity, mother’s third trimester BMI, urinary cotinine, mother’s highest education, total family income.
c
Maternal age, parity, mother’s third trimester BMI, geographical distribution of current dwelling, newborn’s gender.
d
Maternal age, parity, mother’s third trimester BMI, illness during pregnancy, newborn’s gender.
e
Maternal age, parity.
f
Maternal age, parity, mother’s third trimester BMI, geographical distribution of current dwelling.
g
Maternal age, parity, mother’s third trimester BMI, total family income, newborn’s gender.
h
Maternal third trimester BMI, illness during pregnancy, duration of living in the district, area of current dwelling, total family income.
i
Maternal third trimester BMI, urinary cotinine, mother’s highest education, geographical distribution of current dwelling.
k
Maternal third trimester BMI, mother’s highest education, geographical distribution of current dwelling.
l
Maternal third trimester BMI, maternal age, illness during pregnancy, mother’s highest education, geographical distribution of current dwelling.
m
Maternal third trimester BMI, maternal age, parity, duration of living in the district, total family income.
n
Maternal third trimester BMI, maternal age, parity, duration of living in the district, total family income.
o
Maternal age, maternal third trimester BMI, newborn’s gender, location of current dwelling.
p
Maternal third trimester BMI, location of current dwelling.
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similar pattern was observed after adjusting for gestational age
(p = 0.04) but not after excluding preterm births (p = 0.158).
Discussion
The present study expands upon our previous paper that
revealed Saudi mothers and their newborns were substantially
exposed to toxic metals that might jeopardize the health of both
(Al-Saleh et al., 2011) by examining their influence on several
birth anthropometric measures. We will start first briefly recap-
ping on the prevalence of heavy metals in our population. Both
lead and cadmium were detected in all samples of umbilical cord
and maternal blood and in 96% and 99.2%, respectively of placental
samples. Mercury was detected in 96%, 93.5% and 92.6% of sam-
ples of umbilical cord blood, maternal blood and placental tissue,
respectively. Only few participants had metal levels outside the
acceptable threshold limits. Only 6.4% and 7.1% of cord and mater-
nal blood samples, respectively, had lead levels above the newly
revised threshold limit of the United States Centers for Disease
Control and Prevention (CDC) of 5 ␮g/dl (CDC, 2012).
The American Occupational Safety and Health Administration
(OSHA, 2003) established an occupational threshold limit for cad-
mium in blood of 5 ␮g/l. Five newborns in this study had cadmium
blood levels above this limit. This occupational threshold limit,
however, is not applicable to the general population. Mijal and
Holzman (2010) reported a geometric mean of 0.29 ␮g/l (95%
CI: 0.28–0.3), and the 75th percentile blood concentration was
0.35 ␮g/l (0.33–0.36), based on a survey of 1594 nonsmoking
women of childbearing age conducted between 1999 and 2006. Our
study found a substantially higher geometric mean of 0.935 ␮g/l
(95% CI: 0.971–1.002), and 25% of the mothers had blood cadmium
levels above the 75th percentile of 1.207 ␮g/l. Such large discrep-
ancies between our results and the US levels indicate a potential
source of exposure to cadmium in Saudi Arabia that requires inves-
tigation, particularly because none of our participants smoked.
Similarly, the overall geometric mean for umbilical cord blood
cadmium was 0.716 ␮g/l (95% CI: 0.971–1.002), and 24.8% of the
measurements were above the 75th percentile of 0.853 ␮g/l. These
levels, which are higher than those reported by other researchers,
can be a risk factor for subsequent developmental impairment in
infants. Tian et al. (2009) found that the concentration of cadmium
in umbilical cord blood ≥0.6 ␮g/l influenced fetal growth and the
development of IQ.
Mercury levels in 11.2% and 13% of samples of maternal and
umbilical cord blood, respectively, were ≥5.8 ␮g/l, which is the
EPA reference dose (US EPA, 2012). Some believe, however, that
this concentration should be lowered to 3.5 ␮g/l during pregnancy,
based on the fact that mercury is usually 70% higher in umbili-
cal cord blood than in maternal blood. Furthermore, an association
between delays in neurological development and prenatal mercury
exposures below this lower threshold has been reported (Mahaffey,
2005). In our study, 39.9% newborns and 25.1% of mothers had
blood mercury levels ≥3.5 ␮g/l. This maternal percentage is quite
high compared to the 2% of pregnant with these levels found by
Miranda et al. (2011). Furthermore, the 75th percentile of mercury
in umbilical cord and maternal blood in this study were 4.6 ␮g/l
and 3.507 ␮g/l, respectively. These values are much higher than the
75th percentile of blood mercury reported by the CDC (2004) in US
women of childbearing-age (1.81 ␮g/l) and in children (0.6 ␮g/l).
Lead, cadmium and mercury were detected in 96%, 99% and
93%, respectively, of placental tissue samples, confirming their
transplacental passage. Because no threshold levels have yet been
established for these metals in the placenta, the 75th percentiles of
lead (0.63 ␮g/g dry wt.), cadmium (0.048 ␮g/g dry wt.) and mercury
(0.06 ␮g/g dry wt) were used for comparison with other studies.
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
11
Of the tested placental tissues, 26.1%, 25.2% and 24.8% had ≥ their
75th percentile levels of lead, cadmium and mercury, respectively.
These values are generally higher than those reported in other stud-
ies (Amaya et al., 2013) and are likely to affect fetal growth and
development.
Among the three tested heavy metals, cadmium in the various
compartments appeared to affect metal measures of birth outcome.
Newborns with Apgar 5-minute scores below the 10th percentile
(0–8) had higher levels of cadmium in umbilical cord blood. It is
not clear whether exposure to cadmium in utero could be deemed
as an influential factor on these scores. Low Apgar 5-minute scores
might contribute to poor prognoses. Ehrenstein et al. (2009) found
that Apgar 5-minute scores under 7 were consistently associated
with the prevalence of neurologic disability and with low cog-
nitive function in early adulthood. A recent study indicated that
low Apgar 5-minute scores lower than 5 were associated with
a higher risk of childhood cancer (Li et al., 2012). Among new-
borns reported in our study, 24 (1.5%) and 91 (5.8%) had Apgar
5-minute scores ≤5 and 7, respectively. Even though the accuracy of
the Apgar 5-minute scores has been questioned (O’Donnell et al.,
2006), it remains a widely used tool for assessing the vitality of
newborns at birth around the world (Casey et al., 2001). Despite
adjusting for gestational age or excluding preterm births, our study
suggests that a true association between cadmium exposure in
utero and lower Apgar 5-minute scores might lead to a series of
adverse developments in childhood. Only one study has reported a
potential association between cadmium in cord blood (0.66 ␮g/l,
range: 0.2–1.5 ␮g/l) and Apgar 5-minute scores (Mokhtar et al.,
2002). The levels of umbilical cord blood cadmium in our study
(0.78 ␮g/l, range: 0.245–15.325 ␮g/l) were higher than those of
Mokhtar et al.‘s study. The relevance of our findings requires fur-
ther evaluation, because low Apgar 5-minute scores have important
implications for adverse consequences in the short and long term.
We have also shown that umbilical cord blood cadmium lev-
els were associated with an increased risk of <10th percentile birth
weights. This association disappeared, though, when including only
preterm births or adjusting for gestational age. Similar findings
were reported by Lin et al. (2011) who found that prenatal cad-
mium exposure was associated with lower birth weights. Their
median value of umbilical cord blood cadmium (0.31 ␮g/l) was
lower than ours (0.704 ␮g/l). These authors also observed smaller
head circumferences, which may have a detrimental effect on child
growth in the first three years of life. An association between umbil-
ical cord blood cadmium and the risk of <10th percentile head
circumferences was seen in our study (p = 0.005) but the associa-
tion disappeared when the analysis was adjusted for confounders.
The developmental effects of cadmium exposure during early life
requires further exploration. A recent study by Kim et al. (2012)
suggested that a dose-dependent interaction between prenatal
exposures to lead and cadmium might affect cognitive develop-
ment at the age of six months.
We found an association between higher levels of cadmium
in maternal blood and lower crown-heel lengths. This associa-
tion remained significant after controlling for gestational duration
or excluding preterm births. Previous studies have found associa-
tions between lower crown-heel lengths and exposure to smoking
(Lindley et al., 2000) and organoclorinated pesticides (Dewan et al.,
2013). The mean cadmium level in maternal blood in our study was
0.986 ␮g/l, which was higher than the average levels observed in
some other countries, as previously reported (Al-Saleh et al., 2011).
Although all the women were nonsmokers, 48.6% had cadmium
levels >1 ␮g/l higher than the international standards for male and
female non-smokers set by the Commission of the German Federal
Environment Agency (Wilhelm et al., 2004). Cadmium in maternal
blood and placental tissues was associated with reduction in the
placenta thickness, which remained significant even after adjusting
 ARTICLE IN PRESS
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for gestational age or excluding preterm births, suggesting possible
independent and opposing effects of cadmium on these measures.
It has been shown that placenta thickness <2.5 cm has been associ-
ated with retarded intrauterine fetal growth (Nagi, 2011). Placental
accumulation of cadmium can have an indirect effect on fetal
growth by altering placental function (Menai et al., 2012). A recent
experimental study observed a decreased incidence of pregnancy,
delayed maternal weight gain, altered placental weight, decreased
fetal length, and delayed neonatal growth (Blum et al., 2012).
Newborns with ≥10th percentile cord lengths had significantly
higher placental cadmium levels. This relationship disappeared
only after excluding preterm births. We cannot account for this
increase. Cord length is usually an index of fetal activity (Ente and
Penzer, 1991), and abnormally short or long cords are usually com-
pared to an average cord length of 50–60 cm The mean length of the
umbilical cord in our study was 51.97 ± 9.3 cm (13–104 cm) and 56
newborns (3.6%) had umbilical cords longer than 70 cm. Baergen
et al. (2001) observed an increased risk of brain-imaging abnor-
malities and/or abnormal neurological follow-ups with higher cord
lengths. We cannot rule out the possibility, however, that our find-
ings may be biased by unmeasured confounders or by residual
confounding.
The above results indicate a partial retention of cadmium in
the placenta, which confirms other findings (Esteban-Vasallo et al.,
2012). Placental concentrations of metallothionein increased with
the accumulation of cadmium, but at a slower rate that does not
completely prevent its passage (Nakamura et al., 2012). The reten-
tion of cadmium in the placenta or a transfer to the fetus can
both have adverse effects on fetal development and/or pregnancy
outcome. For example, a recent experimental study by Ji et al.
(2011) found that exposure to cadmium during late pregnancy
impaired testicular steroidogenesis in male offspring. Maternal
blood, though, only had traces of cadmium compared to the
higher levels in the placenta, suggesting an indirect effect on fetal
testes. Cadmium can disrupt endocrine function, causing various
reproductive problems (Takiguchi and Yoshihara, 2006). Cadmium
may interfere with the production of placental progesterone that
can impair steroidogenesis and consequently affect fetal growth
and development (Stasenko et al., 2010). Few studies, though,
have reported inverse relationships between cadmium exposure
in non-smoking mothers and various birth outcomes such as head
circumference (Kippler et al., 2012), birth height (Zhang et al., 2004)
and birth weight (Salpietro et al., 2002; Kippler et al., 2012).
Both our crude and adjusted logistic regression models provided
evidence of increasing odds of SGA birth associated with higher cad-
mium levels in umbilical cord blood (p = 0.049) but not with higher
cadmium in maternal blood. This association was marginally sig-
nificant after adjusting for confounders and gestational age but not
after excluding preterm births with p-values of 0.084, 0.068 and
0.102 respectively (data not shown). Controlling for gestational
age gave the same results, but the effect disappeared when we
excluded preterm births. Murphy et al. (2010) observed that the
most sensitive window for human development affected by antie-
strogenic polychlorinated biphenyls occurred before conception
and during early pregnancy. The authors suggested that a reliance
on maternal blood samples could underscore fetal exposure during
embryogenesis. Furthermore, with only 10% SGA births, low power
likely decreased the precision of our estimates. To our knowledge,
such associations between cadmium and SGA risk have not been
reported previously.
Most of the relationships between prenatal cadmium exposure
and several birth outcomes were independent of gestational age or
preterm birth. Also, some birth measures appeared to be more sen-
sitive than other possibly indicating different effects of cadmium
at different developmental periods. The relevance of our findings,
however, requires evaluation.
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
We found no associations between lead in maternal blood,
umbilical cord blood and placental tissues with birth outcomes,
other than with placental thickness. Similarly, no associations
have been reported in other studies (Rahman and Hakeem, 2003;
Rahman et al., 2012). In contrast, relationships between lead lev-
els in maternal or umbilical cord blood and various fetal growth
parameters have been found (Bellinger, 2005; Gundacker et al.,
2010). The timing and dose of lead exposure can play an important
role in fetal growth (Cantonwine et al., 2010). Jelliffe-Pawlowski
et al. (2006) found that lead levels in maternal blood ≥10 ␮g/dl to be
associated with significant decreases in total duration of gestation
and an increased risk of preterm and SGA birth. The lower mean lev-
els of blood lead in our study population may explain this apparent
lack of an inverse association of lead levels in umbilical cord and/or
maternal blood with fetal growth. Likewise to maternal cadmium,
the multiple logistic regression analysis showed that an increase
in maternal blood lead levels caused reduced placental thickness.
Controlling for gestational age or excluding preterm births did not
affect this relationship, which again suggests that lead exposure
is likely to influence birth outcome, but via an indirect route of
a altering placental thickness. Abnormalities in placental growth
may precede fetal complications (Meèëjus, 2005). Mital et al. (2002)
suggested that placental thickness can be a useful indicator of the
gestational age of the fetus.
In contrast, mercury in cord blood was marginally higher in
mothers with ≥10th percentile placenta thicknesses. This finding
also confirmed that the presence of independent effects of ges-
tational age or preterm births. Few studies have linked placenta
thickness >4 cm with various poor birth outcome (Pinette et al.,
1998; Lee et al., 2012). We do not know if these associations are due
to chance or to unadjusted confounders such as the amniotic fluid
measurements; excess fluid may have a compressive effect on pla-
cental thickness and may distort the results (Lee et al., 2012). After
an adjustment for confounding variables, maternal blood mercury
was marginally higher in mothers with <10th percentile placenta
weights, which persisted after controlling for gestational age or
excluding preterm births. Husslein et al. (2012) found a high risk of
emergency delivery (C.S. or vacuum-assisted delivery) when pla-
cental weight was higher than the 10th percentile. An association
with mercury exposure has not been reported. Ma et al. (2006),
however, observed a reduction in placenta weight in rats exposed
to lead during different gestational periods, due to its effect on
the trophoblast that led to interference in nutrition and oxygen
transfer.
Even though 48% of placentas had levels of mercury above the
MDL, mercury levels were significantly higher in newborns with
≥10th percentile head circumferences. This association remained
similar even after adjusting for gestational age or excluding
preterm births. Normal head circumference is usually in the range
of 33–35 cm (25th to 75th percentile). Head circumferences <33
and >35 cm were found in 14.6% and 23.9% of the newborns
respectively. Head circumferences above the 75th percentile were
associated more with impaired adaptive behaviors and less with
impairment of IQ and motor and verbal-language development
(Sacco et al., 2007). Some researchers have found evidence that
autistic infants at the age of four months had higher head circum-
ferences, weights and lengths than normal (Torrey et al., 2004) and
have related these observations to abnormalities in metabolism,
growth factors, hormone levels or general development. McKean-
Cowdin (2006) suggested that higher in head circumference at birth
could be a risk factor for brain cancer during childhood and rec-
ommended further study. On the other hand, another study found
no such association (Hobbs et al., 2007). Apgar 5-minute scores
above the 10th percentile in newborns were also unexpectedly
associated with placental mercury, which persisted after adjus-
ting for gestational age. The possibility of residual confounding
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that was either not measured or was difficult to measure is again
plausible in the case of head circumferences and Apgar 5-minute
scores.
In the present study, the AUC for the prediction of the above
models was larger than 0.5 and smaller than 0.7, which represents a
modest predictive capability for the measures of birth outcome. We
believe that prediction could be improved by including additional
risk factors. Lindell et al. (2013) recently found that predictions
for large-gestational-age neonates at term using fetal weights esti-
mated during routine third-trimester ultrasounds improved the
AUC after including maternal characteristics.
Our study has many strengths: (1) the large sample size
strengthened the analysis of the effects of heavy metal exposure on
health after adjusting for several confounders, (2) the population
was homogeneous for socioeconomic and prenatal-care profiles,
reducing the potential for uncontrolled confounding, and (3) heavy
metals were measured in umbilical cord and maternal blood and
particularly in the placenta, providing a more accurate picture of
the redistribution of metals between the mother and the fetus. This
study, however, does have limitations: (1) the heavy metals were
measured only at a single time point (at delivery), and extent to
which these single measurements can reflect exposures at criti-
cal times during pregnancy is still debated (Murphy et al., 2010),
(2) the low numbers of newborns of low birth weight and SGA
risk reduced the precision of our statistical estimates due to low
power, mainly related to the cross-sectional design of the study that
enrolled any eligible mother without considering the characteris-
tics of newborns, (3) genetic information that could be associated
with birth outcome was not included (Rossner et al., 2011), and
(4) the measures of birth outcome were recorded according to
hospital protocol, and our findings may have been subject to non-
differential measurement error.
Conclusion
Despite its partial passage through the placenta, cadmium had
the most prominent effect on several measures of birth outcome.
Crown-heel lengths, Apgar 5-minute scores, birth weights and SGAs
below the 10th percentile were influenced by cadmium levels in the
umbilical cord. On the other hand, crown-heel length and placen-
tal thickness were affected by cadmium levels in maternal blood.
As placental cadmium levels increased, placental thickness signif-
icantly decreased and an cord length significantly increased. Only
lead levels in maternal blood influenced placental thickness. The
absence of some effects in our study may be due to either low
maternal lead exposure or exposure measurements taken out-
side the window of fetal vulnerability. Even though mercury was
efficiently transferred transplacentally to the fetus, mercury in
both umbilical cord and maternal blood was marginally associ-
ated with placental thickness and placental weight, respectively.
Conversely, placental mercury significantly influenced head cir-
cumference, Apgar 5-minute scores and cord length. The prediction
of these measures of birth outcome by the AUCs of metals were
generally modest (larger than 0.5 and smaller than 0.7). The study
showed that the retention of metals in the placenta or the trans-
fer of metals to the fetus can both have adverse effects on fetal
development and/or pregnancy outcome. The independence of ges-
tational age or preterm births on the observed effect of metals on
some measures of birth outcome, suggested detrimental effects of
exposure on fetal development. The magnitude of the estimated
effects might not necessarily be of clinical significance for infants
but may have a considerable public-health relevance given the high
prevalence of exposure to heavy metals. Further research should be
conducted to confirm these findings and to evaluate their long-term
risks, if any. In addition, the sources of exposure to these metals
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
13
remain to be determined in this population. Finally and impotantly,
the findings of this study are likely to pertain only to nonsmoking
women living in the Al-Kharj area that has history of occupational
exposure. The results thus cannot be generalized to women living
in other areas but may reflect typical exposure in rural settings.
The intensity of exposure is obviously expected to be far greater
in urban settings due mainly to the emissions of motor vehicles
and/or industrial activities, which may have larger adverse effects
on pregnancy outcome.
Conflict of interest
The authors do declare that there is no conflict of interest.
Acknowledgments
The investigators would like to thank King Abdulaziz City for
Science and Technology for funding this study ARP-23-7. We would
like to thank all the women who participated in this study and the
staff of King Khalid Hospital in Al-Kharj.
References
Al-Saleh, I., Shinwari, N., Mashhour, A., Mohamed Gel, D., Rabah, A., 2011. Heavy
metals (lead, cadmium and mercury) in maternal, cord blood and placenta of
healthy women. Int. J. Hyg. Environ. Health 214, 79–101.
Amaya, E., Gil, F., Freire, C., Olmedo, P., Fernández-Rodríguez, M., Fernández, M.F.,
Olea, N., 2013. Placental concentrations of heavy metals in a mother–child
cohort. Environ. Res. 120, 63–70.
Baergen, R.N., Malicki, D., Behling, C., Benirschke, K., 2001. Morbidity, mortality,
and placental pathology in excessively long umbilical cords: retrospective study.
Pediatr. Dev. Pathol. 4, 144–153.
Bellinger, D.C., 2005. Teratogen update: lead and pregnancy. Birth Defects Res. A:
Clin. Mol. Teratol. 73, 409–420.
Blum, J.L., Xiong, J.Q., Hoffman, C., Zelikoff, J.T., 2012. Cadmium associated with
inhaled cadmium oxide nanoparticles impacts fetal and neonatal development
and growth. Toxicol. Sci. 126, 478–486.
Cantonwine, D., Hu, H., Sanchez, B.N., Lamadrid-Figueroa, H., Smith, D., Ettinger, A.S.,
Mercado-Garcia, A., Hernandez-Avila, M., Wright, R.O., Tellez-Rojo, M.M., 2010.
Critical windows of fetal lead exposure: adverse impacts on length of gestation
and risk of premature delivery. J. Occup. Environ. Med. 52, 1106–1111.
Caserta, D., Mantovani, A., Ciardo, F., Fazi, A., Baldi, M., Sessa, M.T., la Rocca, C., Ronchi,
A., Moscarini, M., Minoia, C., 2011. Heavy metals in human amniotic fluid: a pilot
study. Prenat. Diagn. 31, 792–796.
Casey, B.M., McIntire, D.D., Leveno, K.J., 2001. The continuing value of the Apgar
score for the assessment of newborn infants. N. Engl. J. Med. 344, 467–471.
Centers for Disease Control and Prevention (CDC), 2004. Blood mercury levels
in young children and childbearing-aged women—United States, 1999-2002.
MMWR Morb. Mortal. Wkly Rep. 53, 1018–1020.
CDC Centers for Disease Control and Prevention. Low level lead exposure harms
children: a renewed call for primary prevention. Atlanta, GA: US Department
of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/
nceh/lead/acclpp/final document 030712.pdf (accessed 09.02.13).
Dewan, P., Jain, V., Gupta, P., Banerjee, B.D., 2013. Organochlorine pesticide residues
in maternal blood, cord blood, placenta, and breastmilk and their relation to birth
size. Chemosphere 90, 1704–1710.
Ehrenstein, V., Pedersen, L., Grijota, M., Nielsen, G.L., Rothman, K.J., Sørensen, H.T.,
2009. Association of Apgar score at five minutes with long-term neurologic
disability and cognitive function in a prevalence study of Danish conscripts.
BMC Pregnancy Childbirth 9, 14.
Ente, G., Penzer, P.H., 1991. The umbilical cord: normal parameters. J. R. Soc. Health
111, 138–140.
US EPA Environmental Protection Agency, 2012. US Environmental Protec-
tion Agency. Mercury. Human exposure. Available http://www.epa.gov/
mercury/exposure.htm (accessed 03.03.13).
Esteban-Vasallo, M.D., Aragonés, N., Pollan, M., López-Abente, G., Perez-Gomez, B.,
2012. Mercury, cadmium and lead levels in human placenta: a systematic
review. Environ. Health Perspect. 120, 1369–1377.
Gundacker, C., Frohlich, S., Graf-Rohrmeister, K., Eibenberger, B., Jessenig, V., Gicic,
D., Prinz, S., Wittmann, K.J., Zeisler, H., Vallant, B., Pollak, A., Husslein, P.,
2010. Perinatal lead and mercury exposure in Austria. Sci. Total Environ. 408,
5744–5749.
Helsel, D.R., 2005. Nondetections and Data Analysis: Statistics for Censored Envi-
ronmental Data. John Wiley and Sons, Hoboken, NJ.
Hobbs, K., Kennedy, A., Dubray, M., Bigler, E.D., Petersen, P.B., McMahon, W., Lainhart,
J.E., 2007. A retrospective fetal ultrasound study of brain size in autism. Biol.
Psychiatry 62, 1048–1055.
Husslein, H., Moswitzer, B., Leipold, H., Moertl, M., Worda, C., 2012. Low placental
weight and risk for fetal distress at birth. J. Perinat. Med. 40, 693–695.
 ARTICLE IN PRESS
G Model
IJHEH-12693; No. of Pages 14
14 I. Al-Saleh et al. / International Journal of Hygiene and Environmental Health xxx (2013) xxx–xxx
Iijima, K., Otake, T., Yoshinaga, J., Ikegami, M., Suzuki, E., Naruse, H., Yamanaka,
T., Shibuya, N., Yasumizu, T., Kato, N., 2007. Cadmium, lead, and selenium in
cord blood and thyroid hormone status of newborns. Biol. Trace Elem. Res. 119,
10–18.
Iyengar, G.V., Rapp, A., 2001. Human placenta as a ‘dual’ biomarker for monitoring
fetal and maternal environment with special reference to potentially toxic trace
elements, Part 3: toxic trace elements in placenta and placenta as a biomarker
for these elements. Sci. Total Environ. 280, 221–238.
Jelliffe-Pawlowski, L.L., Miles, S.Q., Courtney, J.G., Materna, B., Charlton, V., 2006.
Effect of magnitude and timing of maternal pregnancy blood lead (Pb) levels on
birth outcomes. J. Perinatol. 26, 154–162.
Ji, Y.L., Wang, H., Liu, P., Zhao, X.F., Zhang, Y., Wang, Q., Zhang, H., Zhang, C., Duan,
Z.H., Meng, C., Xu, D.X., 2011. Effects of maternal cadmium exposure during late
pregnant period on testicular steroidogenesis in male offspring. Toxicol. Lett.
205, 69–78.
Khanjani, N., Sim, M.R., 2006. Maternal contamination with dichlorodiphenyl-
trichloroethane and reproductive outcomes in an Australian population.
Environ. Res. 101, 373–379.
Kim, R., Aro, A., Rotnitzky, A., Amarasiriwardena, C., Hu, H.K., 1995. X-ray fluores-
cence measurements of bone lead concentration: the analysis of low-level data.
Phys. Med. Biol. 40, 1475–1485.
Kim, Y., Ha, E.H., Park, H., Ha, M., Kim, Y., Hong, Y.C., Kim, E.J., Kim, B.N., 2012. Prena-
tal lead and cadmium co-exposure and infant neurodevelopment at 6 months
of age: The Mothers and Children’s Environmental Health (MOCEH) study. Neu-
rotoxicology 35C, 15–22.
Kippler, M., Hoque, A.M., Raqib, R., Ohrvik, H., Ekstrom, E.C., Vahter, M., 2010.
Accumulation of cadmium in human placenta interacts with the transport of
micronutrients to the fetus. Toxicol. Lett. 192, 162–168.
Kippler, M., Tofail, F., Gardner, R., Rahman, A., Hamadani, J.D., Bottai, M., Vahter,
M., 2012. Maternal cadmium exposure during pregnancy and size at birth: a
prospective cohort study. Environ. Health Perspect. 120, 284–289.
Lee, A.J., Bethune, M., Hiscock, R.J., 2012. Placental thickness in the second trimester:
a pilot study to determine the normal range. J. Ultrasound Med. 31, 213–
218.
Li, J., Cnattingus, S., Gissler, M., Vestergaard, M., Obel, C., Ahrensberg, J., Olsen,
J., 2012. The 5-minute Apgar score as a predictor of childhood cancer: a
population-based cohort study in five million children. BMJ Open. 2 (August
(4)), doi:pii:e001095.10.1136/bmjopen-2012-001095.
Lin, C.M., Doyle, P., Wang, D., Hwang, Y.H., Chen, P.C., 2011. Does prenatal cadmium
exposure affect fetal and child growth? Occup. Environ. Med. 68, 641–646.
Lindell, G., Maršál, K., Källén, K., 2013. Predicting risk for large-for-gestational
age neonates at term: a population-based Bayesian theorem study. Ultrasound
Obstet. Gynecol. (March), doi:10.1002/uog.11218 [Epub ahead of print] PubMed
PMID: 23505150.
Lindley, A.A., Becker, S., Gray, R.H., Herman, A.A., 2000. Effect of continuing or stop-
ping smoking during pregnancy on infant birth weight, crown-heel length, head
circumference, ponderal index, and brain:body weight ratio. Am. J. Epidemiol.
152, 219–225.
Ma, H.Y., Li, H., Wang, J.C., Liu, X.Q., Xu, F.S., Tan, J.S., 2006. Effects of lead exposure
to rat placenta and pubs during different gestation periods. Zhonghua Yu Fang
Xue Za Zhi 40, 101–104.
Mahaffey, K.R., 2005. Mercury exposure: medical and public health issues. Trans.
Am. Clin. Climatol. Assoc. 116, 127–153.
McKean-Cowdin, R., 2006. Head circumference at birth linked to cancer in child-
hood. Lancet Oncol. 7, 4–5.
Meèëjus, G., 2005. Influence of placental size and gross abnormalities on intrauterine
growth retardation in high-risk pregnancies. Acta Med. Lituanica 12, 14–19.
Menai, M., Heude, B., Slama, R., Forhan, A., Sahuquillo, J., Charles, M.A., Yazbeck,
C., 2012. Association between maternal blood cadmium during pregnancy and
birth weight and the risk of fetal growth restriction: the EDEN mother–child
cohort study. Reprod. Toxicol. 34, 622–627.
Mijal, R.S., Holzman, C.B., 2010. Blood cadmium levels in women of childbearing
age vary by race/ethnicity. Environ. Res. 110, 505–512.
Miranda, M.L., Edwards, S., Maxson, P.J., 2011. Mercury levels in an urban pregnant
population in Durham County, North Carolina. Int. J. Environ. Res. Public Health
8, 698–712.
Please cite this article in press as: Al-Saleh, I., et al., Birth outcome measures and maternal exposure to heavy metals (lead, cadmium and mercury)
in Saudi Arabian population. Int. J. Hyg. Environ. Health (2013), http://dx.doi.org/10.1016/j.ijheh.2013.04.009
Mital, P., Hooja, N., Mehndiratta, K., 2002. Placental thickness: a sonographic param-
eter for estimating gestational age of the fetus. Ind. J. Radiol. Imag. 12, 553–554.
Mokhtar, G., Hossny, E., el-Awady, M., Zekry, M., 2002. In utero exposure to cadmium
pollution in Cairo and Giza governorates of Egypt. East Mediterr. Health J. 8,
254–260.
Murphy, L.E., Gollenberg, A.L., Buck Louis, G.M., Kostyniak, P.J., Sundaram, R., 2010.
Maternal serum preconception polychlorinated biphenyl concentrations and
infant birth weight. Environ. Health Perspect. 118, 297–302.
Nagi, A.H., 2011. A monograph-placenta. Examination and pathology. Biomedica
27, 81–99.
Nakamura, Y., Ohba, K., Suzuki, K., Ohta, H., 2012. Health effects of low-level cad-
mium intake and the role of metallothionein on cadmium transport from mother
rats to fetus. J. Toxicol. Sci. 37, 149–156.
O’Donnell, C.P., Kamlin, C.O., Davis, P.G., Carlin, J.B., Morley, C.J., 2006. Interobserver
variability of the 5-min Apgar score. J. Pediatr. 149, 486–489.
OSHA Occupational Safety and Health Administration DoL., 2003. Occupational
safety and health standards: toxic and hazardous substances: cadmium. Code
Fed. Regul. 29, 135–229, CFR 1910.1027.
Park, S.H., Goo, J.M., Jo, C.H., 2004. Receiver operating characteristic (ROC) curve:
practical review for radiologists. Korean J. Radiol. 5, 11–18.
Pinette, M.G., Pan, T., Blackstone, J., Pinette, S.G., 1998. Ultrasound placental thick-
ness measurements and pregnancy outcomes [abstract]. Am. J. Obstet. Gynecol.
178, S167.
Rahman, A., Hakeem, A., 2003. Blood lead levels during pregnancy and pregnancy
outcome in Karachi women. J. Pak. Med. Assoc. 53, 529–533.
Rahman, A., Al-Rashidi, H.A., Khan, A.R., 2012. Association of maternal blood lead
level during pregnancy with child blood lead level and pregnancy outcome in
Kuwait. Ecol. Food Nutr. 51, 40–57.
Rossner Jr., P., Tabashidze, N., Dostal, M., Novakova, Z., Chvatalova, I., Spatova, M.,
Sram, R.J., 2011. Genetic, biochemical, and environmental factors associated
with pregnancy outcomes in newborns from the Czech Republic. Environ. Health
Perspect. 119, 265–271.
Sacco, R., Militerni, R., Frolli, A., Bravaccio, C., Gritti, A., Elia, M., Curatolo, P., Manzi,
B., Trillo, S., Lenti, C., Saccani, M., Schneider, C., Melmed, R., Reichelt, K.L., Pas-
cucci, T., Puglisi-Allegra, S., Persico, A.M., 2007. Clinical, morphological, and
biochemical correlates of head circumference in autism. Biol. Psychiatry 62,
1038–1047.
Salpietro, C.D., Gangemi, S., Minciullo, P.L., Briuglia, S., Merlino, M.V., Stelitano, A.,
Cristani, M., Trombetta, D., Saija, A., 2002. Cadmium concentration in maternal
and cord blood and infant birth weight: a study on healthy non-smoking women.
J. Perinat. Med. 30, 395–399.
Shirai, S., Suzuki, Y., Yoshinaga, J., Mizumoto, Y., 2010. Maternal exposure to low-
level heavy metals during pregnancy and birth size. J. Environ. Sci. Health A:
Tox. Hazard. Subst. Environ. Eng. 45, 1468–1474.
Stasenko, S., Bradford, E.M., Piasek, M., Henson, M.C., Varnai, V.M., Jurasovic, J., Kusec,
V., 2010. Metals in human placenta: focus on the effects of cadmium on steroid
hormones and leptin. J. Appl. Toxicol. 30, 242–253.
Takiguchi, M., Yoshihara, S., 2006. New aspects of cadmium as endocrine disruptor.
Environ. Sci. 13, 107–116.
Thompson, J., Bannigan, J., 2008. Cadmium: toxic effects on the reproductive system
and the embryo. Reprod. Toxicol. 25, 304–315.
Tian, L.L., Zhao, Y.C., Wang, X.C., Gu, J.L., Sun, Z.J., Zhang, Y.L., Wang, J.X., 2009. Effects
of gestational cadmium exposure on pregnancy outcome and development in
the offspring at age 4.5 years. Biol. Trace Elem. Res. 132, 51–59.
Torrey, E.F., Dhavale, D., Lawlor, J.P., Yolken, R.H., 2004. Autism and head circum-
ference in the first year of life. Biol. Psychiatry 56, 892–894.
Wilhelm, M., Ewers, U., Schulz, C., 2004. Revised and new reference values for some
trace elements in blood and urine for human biomonitoring in environmental
medicine. Int. J. Hyg. Environ. Health 207, 69–73.
Yoshida, M., 2002. Placental to fetal transfer of mercury and fetotoxicity. Tohoku J.
Exp. Med. 196, 79–88.
Zhang, Y.L., Zhao, Y.C., Wang, J.X., Zhu, H.D., Liu, Q.F., Fan, Y.G., Wang, N.F., Zhao, J.H.,
Liu, H.S., Ou-Yang, L., Liu, A.P., Fan, T.Q., 2004. Effect of environmental expo-
sure to cadmium on pregnancy outcome and fetal growth: a study on healthy
pregnant women in China. J. Environ. Sci. Health A: Tox. Hazard. Subst. Environ.
Eng. 39, 2507–2515.