Effect of smoking on plasma ferritin concentrations in pregnant women.
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Female↗
Biomedical subjects
R L Goldenberg
Publications and source records attributed to R L Goldenberg.
Preterm labor: emerging role of genital tract infections.
Preterm birth complicates 8-10% of all pregnancies in the United States and is the leading cause of infant morbidity and mortality. Neonatal morbidity and mortality is concentrated among very low-birthweight and extremely premature infants, particularly those delivered prior to 30 weeks' gestational age. In addition to the contribution of preterm birth to neonatal morbidity and mortality, the economic costs associated with this pregnancy complication are staggering. Efforts to reduce the preterm birth rate have been largely focused on prevention and early intervention with treatment for preterm labor. Mixed results regarding the success of prematurity prevention programs have been reported, and controversy continues to surround the efficacy of tocolytic therapy in the treatment of preterm labor. Although neonatal survival for infants born at early gestational ages has steadily improved in recent years, survival of infants delivered prior to 24 weeks' gestation remains very poor. Additionally, despite this decline in neonatal mortality, the United States still lags behind most industrialized nations in infant mortality, and no change in the rate of low birthweight has occurred in recent decades. Multiple lines of evidence support a role for infection as an etiologic factor in preterm labor. Although this association has been well known for many years, a wealth of new data is emerging, linking subclinical genital tract infection with spontaneous preterm birth, particularly among pregnancies that result in birth prior to 30 weeks' gestational age as a result of spontaneous preterm labor or preterm, premature rupture of membranes. Conversely, preterm birth that occurs closer to term is less likely to be associated with genital tract infection. Improved understanding of the link between genital tract infection and preterm birth now provides an exciting potential for the development of sensitive new markers to identify women at risk and effective interventions to prevent preterm birth. A review and comment on this growing literature is provided.
Biomarkers↗
The prevention of low birthweight and its sequelae.
BACKGROUND: Low birthweight and its components preterm birth and fetal growth retardation account for the vast majority of perinatal mortality and more than 50% of the long term neurologic morbidity. METHODS: Historical trends and the effectiveness of various interventions designed to improve pregnancy outcomes associated with low birthweight were evaluated in an attempt to define which future research efforts might be useful. RESULTS: Practices aimed at achieving a reduction in the low birthweight rate (the use of tocolytics, enhanced prenatal care, nutritional interventions) have not generally been successful or have not been widely utilized (smoking cessation programs). Practices aimed at improving low birthweight survival and reducing morbidity (group B streptococcus prophylaxis, maternal corticosteroids, surfactant use, newborn ventilation) have been responsible for most of the improvements in outcome. CONCLUSION: Continued effort into discovering effective practices for reducing low birthweight, for understanding the most appropriate methods of implementing practices known to be effective in reducing low birthweight, and refinement of practices known to reduce mortality and long term handicap in low birthweight babies should be major foci of prevention research.
Female↗
Glucokinase gene in gestational diabetes mellitus: population association study and molecular scanning.
Mutations of the glucokinase gene result in early-onset familial Type 2 (non-insulin-dependent) diabetes mellitus, and several members of the mutant glucokinase kindreds were originally diagnosed as having gestational diabetes. This study examined the glucokinase gene in 270 American Black women, including 94 with gestational diabetes whose diabetes resolved after pregnancy (gestational diabetes only), 77 with gestational diabetes who developed Type 2 diabetes after pregnancy (overt diabetes), and 99 normal control subjects who were recruited during the peripartum period. Two simple sequence repeat polymorphisms flanking either end of the glucokinase gene were evaluated. No association was found between glucokinase alleles and gestational diabetes only or overt diabetes, after adjustment for multiple comparisons. To detect single base changes, all 11 exons and proximal islet and liver promoter regions were examined by polymerase chain reaction plus single-stranded conformational polymorphism analysis in 45 gestational diabetes only patients who had not yet developed Type 2 diabetes. Nine coding region variants were identified: Ala11 (GCC) to Thr11 (ACC) in islet exon 1, and 8 variants either in untranslated regions or in the third base of a codon. Four variant sites were found in introns, but none in splicing consensus sequences. Analysis of the promoter regions revealed two common variants, G-->A at islet -30 (24%), and G-->A at liver -258 (42%). The frequencies of the promoter variants, determined by allele specific polymerase chain reaction analysis, but did not differ among the three groups. Thus, no significant coding sequence glucokinase mutations were found in 90 alleles from 45 patients with gestational diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Comparison of perceived and actual rates of survival and freedom from handicap in premature infants.
OBJECTIVE: Our goal was to learn whether physicians delivering obstetric care accurately estimated rates of survival and freedom from handicap in premature infants. STUDY DESIGN: We surveyed by mail 409 obstetricians and general and family physicians reported to perform deliveries in Alabama to identify their perceptions regarding survival and handicap-free rates of infants born at gestational ages between 23 and 36 weeks, inclusive. Responses were compared with published national rates of survival and freedom from handicap by means of unpaired t tests. RESULTS: A total of 224 physicians responded (55%), and 183 were still practicing obstetrics. They significantly underestimated survival rates from 23 through 34 weeks' gestation (p < 0.05) and freedom from serious handicap from 23 through 36 weeks' gestation (p < 0.05). They advocated early treatment of preterm labor, but < 50% would perform cesarean delivery for fetal distress before 26 weeks' gestation. CONCLUSION: We conclude that physicians delivering obstetric care significantly underestimate survival and freedom from handicap in preterm infants. Perinatal care may be adversely affected by these misperceptions.
Persons with Disabilities↗
The effect of corticosteroid therapy in the very premature infant. March of Dimes Multicenter Study Group.
OBJECTIVE: Our purpose was to determine the efficacy of maternal corticosteroid therapy between 26 and 31 weeks' gestation. STUDY DESIGN: The data in this study were derived from 32,658 women who participated in the March of Dimes-sponsored multicenter prematurity prevention program. Of the 432 women who were delivered at 26 to 31 weeks, 67 received betamethasone before delivery and 365 did not. The frequency and relative risks of adverse outcomes, including respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death were compared for each of two gestational age periods by means of univariate and multivariate techniques. RESULTS: When betamethasone was administered > or = 2 days before delivery (n = 45), there was a lower incidence of respiratory distress syndrome in both the 26 to 28 week group (53.9% vs 86.5%, p = 0.008) and the 29 to 31 week group (25.0% vs 59.1%, p = 0.0003). The rate of intraventricular hemorrhage was less in the betamethasone group at 26 to 28 weeks (15.4% vs 32.3%, p = 0.17), but the difference reached statistical significance only at 29 to 31 weeks (3.1% vs 16.5%, p = 0.029). Neonatal death occurred significantly less often in infants who were delivered at 26 to 28 weeks when their mothers received betamethasone compared with infants of the same gestational age whose mothers did not receive betamethasone treatment (0% vs 34.6%, p = 0.01). In a regression analysis of infants born between 26 and 31 weeks in which birth weight, gestational age, race, infant sex, and tocolytic use were controlled, the odds ratio for respiratory distress syndrome associated with betamethasone use was 0.20 (0.10, 0.42), for intraventricular hemorrhage 0.26 (0.08, 0.90), and for neonatal death 0.14 (0.02, 1.09). Insufficient numbers of women were given betamethasone before 26 weeks for analysis. CONCLUSION: Betamethasone appears to significantly reduce neonatal death and the morbidity between 26 and 31 weeks' gestation.
Betamethasone↗
Acid-base status at birth and subsequent neurosensory impairment in surviving 500 to 1000 gm infants.
OBJECTIVE: The purpose of this study was to assess, in infants born weighing < or = 1000 gm, if umbilical cord blood acid-base measures at birth are associated with an additional increase in neurosensory impairment. STUDY DESIGN: Of 289 surviving infants with a birth weight of 500 to 1000 gm born from 1979 to 1989, 219 had umbilical cord acid-base status measured at birth and were followed prospectively for > or = 1 year. Measures of neurologic impairment used in this study included mental retardation, cerebral palsy, and major neurosensory impairment. RESULTS: Gestational age was inversely associated with all neurosensory impairments and was a better predictor of subsequent impairment in this population than was birth weight. Very low umbilical cord pH values were also significantly related to adverse outcomes. There was also an inverse relationship between cord blood bicarbonate levels and major neurosensory impairment. The highly significant relationship between cord blood bicarbonate and pH values and the development of neurosensory impairments persisted in spite of adjustment for gestational age, birth weight, plurality, use of general anesthesia, maternal race, and presence of hypertension. CONCLUSION: An adverse acid-base status at birth is additive to the effect of gestational age in predicting neurosensory impairment in infants weighing < or = 1000 gm.
Acid-Base Equilibrium↗
Strategies for the prevention of early-onset neonatal group B streptococcal sepsis: a decision analysis.
OBJECTIVE: To perform a decision analysis to understand better the implications of 19 potential group B streptococcus screening and treatment strategies. METHODS: We searched the literature to locate appropriate articles from which to derive probability estimates. Using decision analysis, we determined the likely outcomes of 19 group B streptococcus screening and treatment strategies and focused on three main outcomes: 1) number of expected cases of early-onset neonatal group B streptococcal sepsis, 2) percentage of gravidas treated with intrapartum antibiotics, and 3) total costs. RESULTS: The strategy recently recommended by two committees of the American Academy of Pediatrics (universal 28-week maternal rectovaginal group B streptococcal culture and treatment of culture-positive, high-risk patients in labor) is among the least effective at reducing neonatal sepsis and the most costly. Strategies based on the currently available rapid streptococcus identification tests are ineffective at reducing neonatal sepsis and are costly. Three strategies outperform the rest: 1) Universal intrapartum maternal antibiotic treatment is the most effective strategy in reducing early-onset neonatal group B streptococcal sepsis (6% of expected) and is also the least costly; 2) intrapartum treatment based solely on risk factors (recently endorsed by ACOG) lowers the rate of neonatal sepsis to 31% of expected with an 18% maternal treatment rate and low total costs; and 3) universal 36-week maternal culture, and treatment of all patients experiencing preterm birth and all culture-positive patients results in 14% of expected neonatal sepsis, with a 27% maternal treatment rate and low total costs. CONCLUSION: Given the present state of knowledge, three strategies emerge from this decision analysis as most optimal for the prevention of early-onset neonatal group B streptococcal sepsis: universal treatment, treatment based on risk factors, and treatment based on preterm delivery and 36-week culture status.
Anti-Bacterial Agents↗
The predictive value of umbilical artery Doppler studies for preeclampsia or fetal growth retardation in a preeclampsia prevention trial.
OBJECTIVE: To determine the clinical utility of longitudinal Doppler umbilical artery systolic-diastolic ratios (S/D) to predict the occurrence of either preeclampsia or fetal growth retardation (FGR) in a low-risk population. METHODS: Healthy nulliparas with singleton gestations were enrolled in a double-blind trial of low-dose (60 mg) aspirin for preeclampsia prevention. Treatment was initiated at 24 weeks and continued until delivery. Continuous-wave Doppler studies were scheduled before assignment to treatment and at 27-31, 32-36, and 37-42 weeks. Preeclampsia was defined as a persistent diastolic blood pressure of at least 90 mmHg with proteinuria, and FGR was defined as birth weight below the tenth percentile. Doppler values were considered abnormal if they exceeded the 90th percentile for the gestational age range in the study population. Summary predictive values were computed for the abnormal S/D at each gestational age interval. To assess the potential effect of the administration of low-dose aspirin, logistic regression was used to model the relation between the Doppler indices, aspirin use, and these abnormal pregnancy outcomes. RESULTS: A total of 1665 Doppler examinations were performed on 565 women. Forty-four fetuses developed FGR and 21 women were diagnosed with preeclampsia. The positive predictive values of an abnormal S/D for the subsequent development of FGR were 13-17% across the gestational age ranges studied, and the positive predictive values for preeclampsia were 0-5%. Aspirin treatment did not affect the relation between the Doppler indices and these outcomes in the logistic regression model. CONCLUSION: Elevated umbilical artery S/D is not a clinically useful predictor of either FGR or preeclampsia in a low-risk population.
Adult↗
Noncompliance of high-risk pregnant women in keeping appointments at an obstetric complications clinic.
We conducted this survey to determine reasons for missed appointments and the relationship between missed appointments, knowledge of diagnosis, and perception of the impact of this diagnosis on pregnancy outcome. We attempted to interview, by telephone, 506 women within 24 hours of their missing an appointment at a high-risk obstetric clinic. Information from 118 respondents was analyzed. The study population was 71% black and 29% white, the average age was 23, and both income and educational levels were low. Seventy-three percent of the women know their medical diagnosis, yet only 30% perceived the problem as a threat. Women who could identify their diagnosis were more likely to evaluate prenatal care positively (P < .006). Women who perceived their condition as a threat seemed to blame lack of transportation less often as a reason for missing an appointment. Many women who missed appointments did not know why they were being seen, and many did not perceive that the care was useful. Effective patient education could improve compliance.
Adult↗
The relationship between maternal skinfold thickness, smoking and birthweight in black and white women.
A prospective study was conducted in a sample of 1491 multiparous women to ascertain whether the relationship between maternal tricep skinfold thickness and infant birthweight is modified by smoking status and whether the relationship is different in white and black infants. Maternal tricep skinfold thickness measured at midpregnancy was a significant predictor of infant birthweight in both white and black infants after adjusting for gestational age at birth, maternal height, maternal age, parity, alcohol consumption and sex of the infant. However, maternal tricep skinfold thickness was a better predictor of birthweight in smokers compared with nonsmokers. Both white and black women with tricep skinfold thickness below the sample mean had lower infant birthweight than women with tricep skinfold at or above the mean, after adjusting for gestational age at birth, but the difference was greater in smokers (198 g for white and 221 g for black infants) than in nonsmokers (124 g for white and 221 g for black infants) than in nonsmokers maternal subcutaneous fat measured by tricep skinfold thickness has a greater effect on infant birthweight in smokers compared with nonsmokers, with similar effects in white and black infants.
Black or African American↗
Genes within the major histocompatibility complex predict NIDDM in African-American women in Alabama.
OBJECTIVE: To test the hypothesis that genes within the major histocompatibility complex (MHC) are associated with gestational diabetes mellitus (GDM) and, subsequently, non-insulin-dependent diabetes mellitus (NIDDM) in African-American women. RESEARCH DESIGN AND METHODS: African-American women who presented with GDM were compared with pregnant African-American control subjects. Following pregnancy, GDM patients were assessed at various intervals of time (median = 6 years) to determine whether they had developed diabetes. RESULTS: GDM patients who required insulin during pregnancy possessed a significantly higher frequency of A33, DR2, DR9, and BF-S phenotypes than control subjects. GDM patients who subsequently developed NIDDM had a significantly higher frequency of B41, DR2, and BF-S and a lower frequency of DR1 and DR6 phenotypes than control subjects. Even after controlling for age and body mass index, B41 and DR2 were independent predictors of developing insulin-requiring GDM and NIDDM in GDM subjects. CONCLUSIONS: These results suggest that either one or more genes within the MHC are involved in the etiology of NIDDM.
Alabama↗
Unexplained elevation in maternal serum alpha-fetoprotein and subsequent fetal loss.
OBJECTIVE: To examine the frequency and timing of fetal death and its association with maternal serum alpha-fetoprotein (MSAFP) levels. METHODS: Pregnancy outcomes were evaluated in 6927 predominantly middle-class women (83% white, 17% black) who had second-trimester MSAFP determinations performed in our laboratory. All cases of multiple gestation, preexisting fetal death, and fetal malformation were excluded. RESULTS: The overall fetal death rate was 13 per 1000 (n = 90). Black women had a higher fetal death rate than white women (35.6 per 1000 versus 8.4 per 1000; P < .001). One hundred forty-eight women (2.1%) had an adjusted MSAFP multiples of the median (MoM) value of at least 2.5, which was not explained by multiple gestation, congenital anomaly, or preexisting fetal death. As the MSAFP increased, the fetal death rate increased (MoM less than 2.0, 11 per 1000; MoM 2-2.49, 29 per 1000; MoM 2.5 or greater, 95 per 1000; P < .001). Despite the increased risk of fetal death in the elevated MSAFP group, most fetal deaths (84%) occurred in women with levels below 2.5 MoM. Furthermore, the timing of fetal loss was significantly different between the group less than 2.5 MoM and the group at or above 2.5 MoM. Fetal death occurred at or after 26 weeks in 45% of the women with normal MSAFP, compared with only 14% of women with high MSAFP (at least 2.5 MoM) (P = .023). CONCLUSIONS: Women with unexplained elevations in MSAFP are at increased risk for fetal loss, with most of the losses occurring in the second trimester. Because many of these fetal deaths occur at gestational ages when the neonatal survival is very low, it is unlikely that antepartum fetal surveillance aimed at early delivery would substantially increase fetal salvage.
Chi-Square Distribution↗
Bed rest in pregnancy.
OBJECTIVE: To summarize existing data about the effectiveness of bed rest when used to improve various pregnancy outcomes and to determine how often bed rest is used and the cost associated with its use. DATA SOURCES: We used the MEDLINE data base to search for all English language papers evaluating the effectiveness of bed rest in pregnancy. We also reviewed a number of textbooks and the 1988 National Infant Mortality Survey. METHODS OF STUDY SELECTION: We reviewed these sources for recommendations about using bed rest in various obstetric conditions. We used the 1988 National Infant Mortality Survey to determine how often bed rest was used either to prevent or to treat various obstetric conditions and estimated the costs associated with its use. DATA EXTRACTION AND SYNTHESIS: Bed rest is used in nearly 20% of all pregnancies to prevent or treat a wide variety of conditions, including spontaneous abortion, preterm labor, fetal growth retardation, edema, chronic hypertension, and preeclampsia. There is little evidence of effectiveness. The estimated costs associated with bed rest, including hospitalization, lost wages, and lost domestic productivity, range from more than $250 million to billions of dollars per year. CONCLUSIONS: Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness. We recommend that because this intervention has failed the test of effectiveness, its use during pregnancy should be curtailed unless randomized trials demonstrate improvement in a specific outcome.
Bed Rest↗
Risk factors for fetal death in white, black, and Hispanic women. Collaborative Group on Preterm Birth Prevention.
OBJECTIVE: To document the relation between stillbirth and various demographic, obstetric, and medical risk factors. METHODS: We analyzed the risk factors and medical origins of 403 stillbirths. The population studied included 34,350 births occurring during the March of Dimes Preterm Birth Prevention Trial. All births occurring in five perinatal centers from 1982-1986 were included in the analysis. Stillbirth was defined as those infants born at 20 weeks' gestation or later whose Apgar score was 0 at 1 and 5 minutes. RESULTS: Stillbirth occurred in 1.2% of all births. Fifty-one percent occurred before 28 weeks and only 18% were at term. Blacks had a greater risk of stillbirth when compared to other women. Prior preterm delivery yielded nearly a two-fold increase in the risk of stillbirth. Preeclampsia, chronic hypertension, and class A or class B-R diabetes were not associated with an increased risk of stillbirth. Other medical factors (hemoglobinopathies, Rh sensitization) resulted in a greater than sixfold increase in the rate of stillbirth, and congenital anomalies resulted in a fivefold increase. Abruption was associated with a 12-fold increase in the risk of stillbirth; nearly 14% of all stillbirths were associated with abruption. CONCLUSION: Eighty-two percent of all stillbirths occurred before term, and more than 50% occurred before 28 weeks. The majority of stillbirths were not explained by medical complications, but instead were often associated with other risk factors related to preterm birth. Further investigations are needed to understand the complex etiology of stillbirth.
Adolescent↗
Health behavior and outcomes in sequential pregnancies of black and white adolescents.
OBJECTIVE: To examine the relationships among parity, preterm delivery, fetal growth retardation, and prenatal care utilization in first and second adolescent pregnancies. DESIGN: A longitudinal, retrospective study in which obstetric, behavioral, and sociodemographic data were used to examine birth outcomes of 737 low-income black (80%) and white (20%) teenagers delivering first and second singleton infants at 20 or more weeks' gestation. SETTING: Public health clinics in Jefferson County, Alabama, between January 1983 and February 1990. MAIN OUTCOME MEASURES: Mean birth weight, preterm delivery, fetal growth retardation, Apgar scores, and perinatal mortality. MAIN RESULTS: In their second pregnancies, adolescents presented 2.8 weeks later for care (P = .0001) and made fewer total clinic visits. Mean infant birth weight increased by 91 g (P = .0005). This increase was significantly associated with an increase in maternal prepregnancy body mass index. The rate of fetal growth retardation decreased (P = .0001) and the rate of preterm delivery increased (P < .02) in the second pregnancy. The rate of recurrence of fetal growth retardation was 13% and the rate of preterm delivery was 46%. CONCLUSIONS: Poorer utilization of prenatal care and high risk for recurrence of adverse outcomes are characteristic of adolescents' second pregnancies and should be considered in teenage pregnancy intervention programs.
Adolescent↗
The effect of low-dose aspirin on umbilical artery Doppler measurements.
OBJECTIVE: Our purpose was to determine if the maternal administration of low-dose (60 mg) aspirin from 24 weeks' gestation until delivery is associated with significant changes in longitudinal umbilical artery Doppler index values. STUDY DESIGN: Healthy, young nulliparous women with singleton gestations who were enrolled in a double-blind trial of low-dose aspirin for preeclampsia prevention underwent prerandomization and monthly postrandomization continuous-wave umbilical artery Doppler evaluations. The systolic-to-diastolic ratio and the resistance index were determined at each examination. Compliance with the medical regimen was assessed by pill counts and measurement of maternal serum thromboxane B2 levels. RESULTS: The prerandomization Doppler index values were similar between the two randomization groups in the 538 (aspirin 266, placebo 272) patients studied. We found no significant differences with univariate comparisons and multiple linear regression modeling in the postrandomization Doppler index values (p = 0.21 to 0.96). No differences were found when patients were assessed by randomization assignment group (intent to treat) or by biochemical evidence for compliance and absence of crossover with maternal serum thromboxane B2 levels. CONCLUSION: The use of low-dose aspirin from 24 weeks' gestation until delivery does not significantly affect umbilical artery Doppler index values.
Aspirin↗
Midpregnancy serum thromboxane B2 determinations do not predict subsequent adverse pregnancy outcomes.
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Female↗