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Biomedical subjects

R L Goldenberg

Publications and source records attributed to R L Goldenberg.

At least 145 records · Page 8Linked to original sources
PubMed1995

Determinants of the optimal time in gestation to initiate antenatal fetal testing: a decision-analytic approach.

To identify the most important determinants of the optimal timing for the initiation of antenatal fetal testing in a high-risk pregnancy (such as insulin-dependent diabetes mellitus), we performed a decision analysis based on a Markov model. The model incorporated several components: test sensitivity and specificity and week-specific probability estimates for fetal death, delivery, and neonatal morbidity and mortality. The analysis demonstrated that the optimal time in gestation to begin testing (from the combined standpoint of both maximizing neonatal survival and minimizing fetal death) was highly dependent on test specificity, the cumulative risk of fetal death (and its distribution throughout gestation), and the week-specific probabilities of neonatal death. For example, even with the increased risk of fetal death associated with insulin-dependent diabetes, very high test specificity (> 99%) is required to recommend testing before 30 weeks. If tests of lower specificity (higher false-positive rates) are used, neonatal deaths will increase and will not be offset by a corresponding decrease in fetal deaths. By performing sensitivity analyses, we demonstrated the effect and relative importance of the model components for determining the optimal gestational age to initiate fetal testing.

Decision Support Techniques↗
PubMed1995

The preterm prediction study: significance of vaginal infections. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

OBJECTIVE: Our purpose was to evaluate the association of bacterial vaginosis, trichomonas vaginitis, and monilial vaginitis with spontaneous preterm birth at < 35 weeks 0 days. STUDY DESIGN: A total of 2929 women at 10 centers were studied at 24 and 28 weeks' gestation by Gram stain of vaginal smear, wet mount, and 10% potassium hydroxide preparations to detect vaginal infections. RESULTS: The rates of detected infection at 24 and 28 weeks, respectively, were bacterial vaginosis 23.4% and 19.4%, trichomonas 3.3% and 2.7%, and monilia 21.1% and 19.5%. The occurrence of bacterial vaginosis at 28 weeks was associated with an increased risk of spontaneous preterm birth, odds ratio 1.84 (95% confidence interval 1.15 to 2.95, p < 0.01). Detection of Trichomonas vaginalis (by wet mount) or monilia (by potassium hydroxide preparation) had no significant associations with preterm birth. CONCLUSION: The presence of bacterial vaginosis at 28 weeks' gestation is associated with an increased risk of spontaneous preterm birth.

Adult↗
PubMed1995

The effect of low-dose aspirin on pregnancies complicated by elevated human chorionic gonadotropin levels.

OBJECTIVE: Our purpose was to determine whether elevated second-trimester human chorionic gonadotropin levels identify women likely to benefit from low-dose aspirin therapy. STUDY DESIGN: We evaluated second-trimester human chorionic gonadotropin levels obtained from healthy nulliparous women before screening for participation in a double-blind randomized trial of aspirin therapy: 262 women took 60 mg of aspirin daily and 420 did not. RESULTS: Among women who did not take aspirin, those with human chorionic gonadotropin levels > or = 2.0 multiples of the median had a significantly lower mean birth weight (2859 vs 3159 gm, p = 0.04) than did those with normal human chorionic gonadotropin levels. All women who took aspirin had a higher mean birth weight than women who did not, but women with human chorionic gonadotropin levels > or = 2.0 multiples of the median had the greatest increase (416.2 gm higher in those with human chorionic gonadotropin levels > or = 2.0 multiples of the median, p = 0.02; 96 gm higher in those with human chorionic gonadotropin levels > or 2.0 multiples of the median, p = 0.04). Regression analysis suggested that the higher birth weight was partly explained by a higher gestational age at delivery and partly by increased weight independent of gestational age. CONCLUSIONS: Aspirin therapy increased birth weight in all women, especially in women with high human chorionic gonadotropin levels, partly by increasing gestational age at delivery. This observation needs to be confirmed by further studies.

Adolescent↗
PubMed1995

Risk factors for the development of preterm premature rupture of the membranes after arrest of preterm labor.

OBJECTIVE: Our purpose was to determine risk factors predictive of preterm premature rupture of the membranes in women treated for preterm labor with intact membranes. STUDY DESIGN: Women with intact membranes participating in a National Institute of Child Health and Human Development multicenter randomized trial of adjunctive antibiotic therapy for preterm labor (24 to 34 weeks) were studied (n = 275). After randomization, 22 women continued to have contractions and were delivered of their infants. The remaining 253 women whose contractions had ceased composed our study population. Preterm premature rupture of the membranes was diagnosed if ruptured membranes occurred > or = 1 hour before the onset of recurrent preterm labor. As part of the study protocol, most women underwent amniocentesis on admission. RESULTS: Preterm premature rupture of the membranes developed in 44% women (17.4%). Women who had preterm premature rupture of the membranes were more likely to be black (p = 0.004), to be multiparous (p = 0.014), to have a history of abortion(s) (p = 0.001), to have had a preterm birth(s) (p = 0.036), to have early onset preterm labor (p = 0.04), to have more advanced cervical dilatation (p = 0.0001), to have one or more amniotic fluid markers suggestive of infection (p = 0.01, odds ratio 4.2), and to have positive amniotic fluid cultures (p = 0.0007, odds ratio 27). Assignment to antibiotic therapy did not prevent preterm premature rupture of the membranes in the 253 women randomized or in the 16 women with a positive amniotic fluid marker(s) of infection. CONCLUSION: Black race, multiparity, a history of abortion or preterm birth, advanced dilatation, and a positive amniotic fluid marker(s) are associated with preterm premature rupture of the membranes in women with preterm labor. Antibiotic treatment did not prevent preterm premature rupture of the membranes.

Abortion, Spontaneous↗
PubMed1995

The relationship between maternal and neonatal anthropometric measurements in term newborns.

OBJECTIVE: To determine whether measures of maternal lean mass, fat reserves, or a combination of both best predict the various measures of newborn size at birth. METHODS: The population consisted of 1205 multiparous, predominantly black women at high risk for fetal growth retardation, who delivered at term at the University of Alabama at Birmingham. Maternal body mass index (BMI) was calculated using the reported pre-pregnancy weight. Maternal anthropometric measurements taken at mid-pregnancy included skinfold thicknesses, lean body mass, and mid-arm, calf, and wrist circumferences. Weight and 11 other neonatal measurements were made within 24 hours of birth and related to various maternal anthropometric measurements. RESULTS: Reported maternal pre-pregnancy weight was the best predictor of all neonatal size measures except for the neonatal skinfold thicknesses, which were better predicted by the pre-pregnancy BMI. For example, the range between the tenth and 90th percentiles of maternal pre-pregnancy weight (46.3-86.4 kg) was associated with 295 g birth weight compared to only 188 g birth weight for a measure of lean body mass. CONCLUSION: Most maternal anthropometric measurements were significantly associated with most neonatal measurements. However, for nearly every neonatal measurement considered, the maternal pre-pregnancy weight was the best predictor.

Adult↗
PubMed1995

Predicting low Apgar scores of infants weighing less than 1000 grams: the effect of corticosteroids.

OBJECTIVE: To evaluate maternal and neonatal factors that predict low Apgar scores in newborns weighing less than 1000 g. METHODS: From a data set of all live-born infants who were delivered between 1979-1991 and who weighed 1000 g or less, we reviewed the records of 837 neonates born at 24-28 weeks' gestation. Potential risk factors were evaluated for associations with a 1-minute Apgar score of 3 or less and a 5-minute Apgar score of 6 or less. Analyses used chi 2 test and multiple logistic regression. RESULTS: The prevalence of 1-minute Apgar scores of 3 or less decreased from 65.9% at 24 weeks to 38.2% at 28 weeks, and the prevalence of 5-minute Apgar scores of 6 or less decreased from 83.3% at 24 weeks to 51.2% at 28 weeks. As the birth weight increased from 500-599 g to 900-1000 g, 1-minute Apgar scores of 3 or less decreased from 77.0% to 39.6%, and 5-minute Apgar scores of 6 or less decreased from 89.2% to 56.4%. Aside from gestational age and birth weight, corticosteroid use was the strongest predictor of Apgar scores above 3 at 1 minute and above 6 at 5 minutes. Male and nonvertex-presenting infants had an increased likelihood of low Apgar scores, as did infants with cord blood pH less than 7.05 or bicarbonate value less than 17 mEq/L. CONCLUSION: Neonates at very low gestational ages and birth weights are more likely than larger or more mature infants to have low Apgar scores. Males, nonvertex-presenting infants, and those who are acidotic at birth also have an increased prevalence of low scores. Infants born to mothers treated with antenatal corticosteroids are less likely to have low Apgar scores. This finding indicates that antenatal corticosteroids may benefit the newborn at birth, before respiratory distress syndrome becomes apparent.

Adrenal Cortex Hormones↗
PubMed1995

Association of post-cesarean delivery endometritis with colonization of the chorioamnion by Ureaplasma urealyticum.

OBJECTIVE: To determine if asymptomatic antenatal colonization of the chorioamnion with Ureaplasma urealyticum is a risk factor for the development of post-cesarean delivery endometritis. METHODS: The chorioamnion was cultured at cesarean delivery for aerobic and anaerobic bacteria, mycoplasmas, Chlamydia trachomatis, and Trichomonas vaginalis in 575 singleton gestations with intact membranes. Culture results were compared with the clinical outcome. Postoperative endometritis was defined as a temperature of 38C with uterine tenderness and without other nonpelvic sources of fever. RESULTS: Fifty-eight (10%) of the 575 women developed endometritis. Women with spontaneous labor developed endometritis twice as often as those delivered for medical or obstetric indications (17 versus 8%, P = .002). Endometritis occurred in 28% of women with U urealyticum present in the chorioamnion at cesarean delivery, compared with only 8.4% if the culture was negative and 8.8% if only bacteria other than U urealyticum were isolated (P < .001). Gestational age less than 34 weeks, spontaneous labor, and a vertical uterine incision were all associated with endometritis (P < or = .002). Regression analysis controlling for gestational age and incision type revealed a threefold increased risk of endometritis if the chorioamnion was colonized with U urealyticum at cesarean (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.1-8.3) and an eightfold risk (OR 7.7, 95% CI 1.9-31.5) in women in whom the onset of labor was spontaneous. CONCLUSION: Colonization of the chorioamnion with U urealyticum in women with intact membranes being delivered by cesarean is a significant, independent predictor of subsequent endometritis.

Amnion↗
PubMed1995

The effect of cigarette smoking on neonatal anthropometric measurements.

OBJECTIVE: To estimate the effect of maternal cigarette smoking on birth weight, crown-heel length, and ten other neonatal anthropometric measurements. METHODS: Data are from a cohort study on risk factors for fetal growth retardation (FGR) in multiparous women conducted from December 1985 through October 1988. Information on smoking status was collected four times during pregnancy. Data analysis included 1205 singleton infants of women delivering at term. Neonatal anthropometric measurements were obtained within 48 hours of birth, including birth weight, crown-heel length, ponderal index, head and abdominal circumferences, arm length and circumference, femur length and thigh circumference, and triceps, thigh, and subscapular skinfold measurements. Analysis of covariance models were used to assess the independent effect of smoking on each neonatal measurement. RESULTS: Neonates born to women who reported smoking during the first trimester had a 0.6-1.9% reduction in most neonatal anthropometric measurements, resulting in an overall reduction of birth weight of 130 g (4%). Neonates born to women who continued to smoke throughout pregnancy had an average adjusted reduction in birth weight of 189 g (5.9%), compared with a 55 g (1.7%) reduction for neonates born to women who stopped smoking after the first trimester. For women who continued to smoke throughout pregnancy, an increased number of cigarettes smoked was associated with increased reductions in birth weight and neonatal chest and abdominal circumferences. For women who stopped smoking after the first trimester, stopping was a better predictor of neonatal anthropometric measurements than the number of cigarettes smoked early in pregnancy. CONCLUSIONS: Except for the ponderal index, all neonatal anthropometric measurements studied showed some negative effect of maternal cigarette smoking. Head circumference is the measurement least reduced. Smoking cessation is a better predictor of infant size than the number of cigarettes smoked in the first trimester.

Adult↗
PubMed1995

The origin and outcome of preterm twin pregnancies.

OBJECTIVE: To define the etiology of preterm twin births and determine the contribution of twin births to preterm birth and related morbidity and mortality. METHODS: The March of Dimes Multicenter Prematurity and Prevention Study included a total of 33,873 women who delivered between 1982-1986, 432 (1.3%) of which delivered twins. Women were classified by reason for preterm birth and ethnicity. Neonates were classified as to stillbirth, neonatal death, and various short-term morbidities. A second data set from one center consisted of infants who weighed 1000 g or less, were born between 1979-1991, and survived to 1 year of age (n = 386, 15% twins); this was used to determine if twins and singletons born at comparable gestational ages have a similar risk for major developmental handicaps. RESULTS: Of the deliveries in the data set, 54% of twins were preterm compared with 9.6% among singletons. Of those born preterm, twins were born at a significantly earlier gestational age than were singletons. Only 2.6% of all neonates born were twins, but they represented 12.2% of all preterm infants, 15.4% of all neonatal deaths, and 9.5% of all fetal deaths. Spontaneous labor accounted for 54% of twin births, premature rupture of membranes accounted for 22%, and indicated deliveries accounted for 23%. Of the indicated preterm births in twins, 44% were due to maternal hypertension, 33% to fetal distress or fetal growth restriction, 9% to placental abruption, and 7% to fetal death. Comparing infants of similar gestational age, twins weighed less, but had a mortality equivalent to that of singletons after 29 weeks. Between 26-28 weeks' gestation, the risk of mortality for twins versus singletons was 1.6 (95% confidence interval 1.1-2.5). Preterm twins did not have significantly more respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, or other short-term morbidity than did preterm singletons. Twins who weighed 500-1000 g and survived to 1 year had a 25% rate of major developmental handicaps. However, when gestational age was controlled, the rate of major handicaps was not higher in twins than in singletons. CONCLUSIONS: Twins accounted for a disproportional amount of preterm birth and associated morbidity and mortality. Also, when preterm twins were compared with preterm singletons and corrected for their gestational ages, the rates of morbidity were similar. Preterm twins weighing less than 1000 g did not have an increased prevalence of major handicaps at 1 year of age compared with preterm singletons.

Birth Weight↗
PubMed1995

The relationship of maternal attitude toward weight gain to weight gain during pregnancy and low birth weight.

OBJECTIVE: To evaluate the relationships between maternal attitude toward weight gain, actual weight gain, and infant birth weight. METHODS: Maternal attitude toward weight gain during pregnancy was assessed in 1000 women, using an 18-item questionnaire administered at a mean of 20 weeks' gestation. Composite scores were compared with pregnancy weight gain, maternal body mass index (BMI), and infant birth weight. RESULTS: In the total population, the attitude score was not significantly related to pregnancy weight gain (r = -0.05, P = .08) and was negatively associated with birth weight (r = -0.09, P < .004). Maternal body size as measured by BMI was strongly associated with both weight gain and birth weight. Obese women (BMI greater than 26.6) tended to have negative attitudes and had the lowest mean weight gain (10.2 kg), but had the heaviest babies (3400 g). Thin women (BMI less than 19.6) had significantly higher attitude scores and a higher mean weight gain (14.1 kg) than did obese women. A significantly larger proportion of thin women achieved recommended gains when compared with larger women, but had the lightest babies (3114 g). Within the group of thin women, after adjustment for smoking, race, and gestational age at delivery, attitude scores were not significantly associated with either weight gain or birth weight. CONCLUSION: Maternal attitude regarding weight gain is strongly influenced by pre-pregnancy body size; thin women tend to have positive attitudes and obese women tend to have negative attitudes about weight gain. Within BMI groups, a positive attitude does not predict appropriate weight gain or birth weight. These findings may explain in part why nutritional counseling programs tend to be associated with only minimal increases in birth weight.

Black or African American↗
PubMed1995

Low-dose aspirin: lack of association with an increase in abruptio placentae or perinatal mortality.

OBJECTIVE: To perform a meta-analysis determining the association of low-dose aspirin treatment with subsequent abruptio placentae or perinatal mortality. DATA SOURCES: Studies were identified and selected using the MEDLINE bibliographic data base of entries from January 1985 through April 1994. In addition, a manual search was performed using the references from all retrieved reports, review articles, and chapters from textbooks. METHODS OF STUDY SELECTION: Three criteria were used to select studies for inclusion: 1) Studies were designed as randomized or double-blind clinical trials; 2) aspirin was administered in doses of less than 200 mg/day; and 3) outcome data included the incidence of abruptio placentae and perinatal mortality. Three studies did not report the occurrence of abruptio placentae, but the authors of those papers answered written requests for such data. A total of 11 studies met our inclusion criteria. DATA EXTRACTION AND SYNTHESIS: We independently evaluated the study methods for each trial and abstracted quantitative outcome data. For each outcome, relative risk, risk differences, and 95% confidence intervals were calculated. The diagnosis of abruptio placentae was taken as self-reported in each trial. No trial of low-dose aspirin in pregnancy had predefined criteria for the diagnosis of abruptio placentae, and abruption was not a primary outcome in any of the 11 trials. We combined data from all studies and compared the data from the randomized trials to those from the double-blind studies. CONCLUSION: We found no increased risk for abruptio placentae or increased perinatal mortality in women taking low-dose aspirin.

Abruptio Placentae↗
PubMed1995

Prenatal weight gain patterns and spontaneous preterm birth among nonobese black and white women.

OBJECTIVE: To examine the relationship between prenatal weight gain and spontaneous preterm delivery, using the Institute of Medicine (IOM) guidelines. METHODS: Nonobese low-income black (677 subjects) and white (338) women were grouped by ethnicity and prepregnancy body mass index (BMI) as low (less than 19.8) or normal (19.8-26.0). The relationship of total gain (first trimester) and weekly rate of gain (second and third trimester) to spontaneous preterm delivery was determined while controlling for sociodemographic and reproductive variables as well as for time between last weight observation and delivery. RESULTS: For all women combined, the mean (+/- standard deviation) weight gain during the first trimester was 2.48 +/- 3.36 kg, and the mean rate of gain during the second and third trimesters was 0.49 +/- 0.21 and 0.45 +/- 0.28 kg/week, respectively. Low first- or second-trimester weight gain was not associated with increased adjusted odds ratios (OR) for spontaneous preterm delivery. Third-trimester rates of gain below the lower limit of the IOM-recommended range (less than 0.38 kg/week with low BMI, less than 0.37 kg/week with normal BMI) were associated with increased preterm delivery among all women (OR 2.46, 95% confidence interval [CI] 1.53-3.92), all black women (OR 1.98, 95% CI 1.16-3.41), and all white women (OR 4.05, 95% CI 1.41-11.66). CONCLUSION: These observations suggest that a low third-trimester rate of weight gain, defined using IOM guidelines, is associated with an increased risk of spontaneous preterm delivery among nonobese black and white women.

Adult↗
PubMed1995

Screening and treatment of asymptomatic bacteriuria of pregnancy to prevent pyelonephritis: a cost-effectiveness and cost-benefit analysis.

OBJECTIVE: To compare the effectiveness, benefits, and costs of two asymptomatic bacteriuria screening and treatment strategies to prevent pyelonephritis in pregnancy. METHODS: A decision analytic model was created to compare strategies based on either 1) a leukocyte esterase-nitrite dipstick, or 2) on urine culture, with a policy of no screening or treatment. A literature search was conducted to generate probability estimates. Cost estimates were based on a local pharmacy and laboratory survey and supplemented by recent literature estimates. Sensitivity analyses were performed over wide ranges of probability and cost estimates. RESULTS: Under baseline assumptions, no screening resulted in 23.2 cases of pyelonephritis per 1000 pregnancies, versus 16.2 cases with the dipstick strategy and 11.2 with the culture strategy. The cost of screening and treatment of asymptomatic bacteriuria per 1000 pregnancies was $1968 with dipstick and $19,264 with culture. The cost of treating pyelonephritis with no screening was $57,562, versus $40,257 with dipstick and $27,832 with culture. Therefore, both the dipstick strategy and the culture strategy were cost-beneficial (based on a pyelonephritis cost of $2485) when compared with no screening. However, because it cost $3492 to prevent each additional case of pyelonephritis with culture that was not prevented by dipstick, the culture strategy was not cost-beneficial compared with the dipstick strategy. These results were sensitive to varying estimates for the prevalence of asymptomatic bacteriuria, the rate of progression of asymptomatic bacteriuria to pyelonephritis, the sensitivity of the dipstick, culture costs, and the cost of a case of pyelonephritis. CONCLUSION: When compared with a policy of no screening, screening for and treatment of asymptomatic bacteriuria to prevent pyelonephritis in pregnancy is cost-beneficial whether based on the leukocyte esterase-nitrite dipstick or on urine culture. However, the culture strategy is not cost-beneficial when compared with the dipstick strategy.

Bacteriological Techniques↗
PubMed1995

Relationship of psychosocial status to low prenatal weight gain among nonobese black and white women delivering at term.

OBJECTIVE: To examine the association of six indices of psychosocial well-being with low prenatal weight gain. METHODS: Scales assessing depression, trait anxiety, stress, mastery, self-esteem, and social support were self-administered at mid-pregnancy to 536 black and 270 white low-income, nonobese, multiparous women who subsequently delivered at term. All women had one or more risk factors for fetal growth restriction. The association of individual scale scores with prenatal weight gain values below current Institute of Medicine guidelines was examined while controlling for sociodemographic and reproductive variables, and for time between last weight observation and delivery. RESULTS: None of the scales were associated with low gain among black women. Among white women, poor scores (worst quartile) on four of the scales were associated with increased adjusted odds ratios for low gain, including 2.5 for high trait anxiety, 3.0 for increased levels of depression, 3.9 for low mastery, and 7.2 for low self-esteem. When scale scores and weight gain were examined as continuous variables, poor scores on five of the six scales were associated with lower weight gain values among white women (scores on the stress scale were the exception). CONCLUSION: These data suggest an important role for psychosocial factors in the etiology of low prenatal weight gain among white women but show no such role for black women. Along with reports of wide inter-individual variability in the energy costs of pregnancy, these data also suggest that attempts to manipulate pregnancy weight gain through dietary means will meet with variable success until psychosocial and other factors affecting prenatal energy intake and/or utilization are further delineated.

Adult↗
PubMed1995

Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics.

OBJECTIVES: This study assessed the impact of mother's race, insurance status, and use of prenatal care on very low birthweight infant delivery in or transfer to hospitals with neonatal intensive care units (ICUs). METHODS: Multivariate analysis of Alabama vital statistics records between 1988 and 1990 for infants weighing 500 to 1499 g was conducted, comparing hospital of birth and maternal and infant transfer status, and controlling for infant birthweight and for maternal pregnancy history and demographic characteristics. RESULTS: With other factors adjusted for, non-White mothers with early prenatal care were more likely than White mothers to deliver their very low birthweight infants in hospitals with neonatal ICUs without transfer. Among the mothers who presented first at hospitals without such facilities, those who had late prenatal care were less likely than those with early care to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for White women. Likelihood of infant transfer was not associated with these maternal characteristics. CONCLUSIONS: Maternal race, prenatal care use, and insurance status may influence the likelihood that very low birthweight infants will have access to neonatal intensive care. Interventions to improve perinatal regionalization should address individual and system barriers to the timely referral of high-risk mothers.

Adolescent↗