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Maternal mortality in southern Africa, 1980-1982. Part II. Causes of maternal deaths.

Of 737 maternal deaths studied in southern Africa between January 1980 and December 1982, 660 were classified as direct obstetric deaths. Hypertensive disorders of pregnancy were the most frequent cause of death (30%). Obstetric haemorrhage and infection were associated with 20% and 19% of maternal deaths respectively. Advancing age and increased parity were strongly associated with death from obstetric haemorrhage.

Adolescent↗

Factors affecting the outcome of maternal alcohol exposure: II. Maternal age.

Despite relatively comparable amounts of alcohol ingestion, not all women who drink excessively give birth to children with fetal alcohol effects. The present study evaluated how maternal age affects the outcome of pregnancy in maternal rats of different ages. All dams were nulliparous and were 66, 121 or 156 days at time of treatment. Alcohol was administered at a dose of 3.5 g/kg, twice daily on gestation days 11-21. Alcohol had a greater impact on offspring born to older- and middle-age dams than to younger dams on a number of attributes including neonatal mortality and birth weight.

Aging↗

Maternal and fetal brain and plasma levels of cocaine and benzoylecgonine after acute or chronic maternal intravenous administration of cocaine.

The effect of repeated i.v. administration of cocaine HCl (1.5, 3 or 6 mg/kg daily) from gestational day 8 through gestational day 18 was studied on maternal and litter parameters in the pregnant female Sprague-Dawley rat. These doses of cocaine had no significant effect on maternal weight gain or nutritional intake and did not significantly affect litter size. Levels of cocaine and its metabolite benzoylecgonine in the brain and plasma of the dams and their fetuses were measured on gestational day 18 at 1, 5, 20 or 60 min after a single injection or 11 daily i.v. injections of cocaine (6 mg/kg). The shape of the time courses for cocaine differed somewhat between dams and fetuses, with fetal plasma concentrations of cocaine initially being lower than those of their dams and then by 5 min becoming equivalent to those of their dams. Although plasma concentrations of cocaine soon equilibrated between dams and fetuses, plasma concentrations of benzoylecgonine did not. Interestingly, brain concentrations of cocaine did not differ between dams and fetuses. The most remarkable finding was that the relative distribution of cocaine between brain and plasma differed after chronic vs. acute treatment, with a relative shift in the distribution of cocaine from plasma to the brain in the fetuses, and with the exception of the earliest time point measured, in the dams after repeated dosing.

Animals↗

Identification of levels of maternal HIV-1 RNA associated with risk of perinatal transmission. Effect of maternal zidovudine treatment on viral load.

OBJECTIVE: To determine if there are levels of human immunodeficiency virus type 1 (HIV-1) associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which zidovudine treatment reduces perinatal transmission. DESIGN: A nonrandomized prospective cohort study. SETTING: University medical center and two general hospital affiliates from May 1989 to September 1994. PATIENTS: Ninety-two HIV-1-seropositive women (95 pregnancies) and their 97 infants. INTERVENTION: Forty-two mothers (43 pregnancies) received zidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic zidovudine for the first 6 weeks after delivery. MAIN OUTCOME MEASURE: HIV-1 infection status of the infant. RESULTS: Twenty of the 97 infants were perinatally infected with HIV-1. Transmitting mothers were more likely to have plasma HIV-1 RNA levels higher than 50000 copies per milliliter at delivery than nontransmitting mothers (15 [75.0%] of 20 transmitters vs four [5.3%] of 75 nontransmitters; P < .001). None of the 63 women with less than 20000 HIV-1 RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral zidovudine during gestation showed an eightfold median decrease in plasma RNA levels (median [25th and 75th percentile], 43043 [5699 and 63053] copies per milliliter before zidovudine vs 4238 [603 and 5116] HIV-1 RNA copies per milliliter at delivery; P < .001) and none transmitted. Four zidovudine-treated women with high HIV-1 levels transmitted despite the presence of zidovudine-sensitive virus in vitro in both the mothers and their infants. CONCLUSIONS: Maternal HIV-1 RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associated with both a high risk and a low risk of transmission. Our results also suggest that zidovudine exerts a major protective effect by reducing maternal HIV-1 RNA levels prior to delivery and that further strategies are needed to prevent perinatal transmission in women with high or increasing virus levels and/or zidovudine-resistant virus.

AIDS Serodiagnosis↗

Maternity care and maternal serum screening. Do male and female family physicians care for women differently?

OBJECTIVE: To examine whether male and female family physicians practise maternity care differently, particularly regarding the maternal serum screening (MSS) program. DESIGN: Mailed survey fielded between October 1994 and March 1995. SETTING: Ontario family practices. PARTICIPANTS: Random sample of 2000 members of the College of Family Physicians of Canada who care for pregnant women. More than 90% of eligible physicians responded. MAIN OUTCOME MEASURES: Attitudes toward, knowledge about, and behaviour toward MSS. RESULTS: Women physicians were more likely than men to practise part time, in groups, and in larger communities. Men physicians were more likely to perform deliveries; women were more likely to do shared care. Despite a shorter work week, on average, female physicians cared for more pregnant women than male physicians did. Among those providing intrapartum care, women performed more deliveries, on average, than men. Women physicians were more likely than men to offer MSS to all pregnant patients. Although average time spent discussing MSS before the test was similar, women physicians had better knowledge of when best to do the test and its true-positive rate. All differences reported were statistically significant (P < or = 0.001). CONCLUSIONS: Among family physicians caring for pregnant women, women physicians cared for more pregnant women than men did. Both spent similar time discussing MSS with their patients before offering screening, but more women physicians offered MSS to all their patients and were more knowledgeable about MSS than men physicians.

Delivery, Obstetric↗

[The role of maternal parathyroids and vitamin D3 metabolites in fetal growth and the deposition of glycogen reserves in the maternal and fetal liver in rats].

Thyro-parathyroidectomy of pregnant Rats at 12.5 days of gestation decreased maternal liver glycogen on 21.5 days of gestation and fetal weight as well as fetal liver glycogen stores. The graft of one parathyroid gland or the injection of 1 alpha-hydroxycholecalciferol in these thyro-parathyroidectomized mothers increased their liver glycogen stores at 21.5 days of gestation. These treatments also markedly increased both fetal weight and fetal liver glycogen stores. It was concluded that maternal 1,25-dihydorxycholecalciferol, which is synthesized under the control of parathyroid hormone secretion, controls fetal growth and liver glycogen stores. The mechanism of these effects (direct or indirect) requires further investigations.

Animals↗

Maternal separation alters maternal care, but has minor effects on behavior and brain opioid peptides in adult offspring.

The aim of the study was to investigate the effect of repeated maternal separation (MS; 4 hr per day) during postnatal Days 1 to 15 on emotionality and voluntary ethanol intake in adult male and female Wistar rat offspring relative to controls exposed to a brief (5-min) daily handling procedure. Brain immunoreactive opioid peptide levels and plasma levels of corticosterone also were measured. There were mainly no alterations in any of the tested behaviors (i.e., fleeing and freezing responses, exploratory behavior, spontaneous and amphetamine-induced locomotor activity and competitive behavior), ethanol intake, or immunoreactive opioid peptide levels in MS offspring, either in males or females, compared to their respective controls nor were there any differences in plasma corticosterone between groups. In addition, the dams' retrieval behavior of the pups also was studied, showing that MS dams spent more time in the nest with the pups after the 4-hr separation period compared to control dams. With respect to the used protocol of the MS procedure in the present study, our results do not provide support for the suggestion that this procedure is a relevant model for studying development of psychopathology and vulnerability to drug abuse.

Animals↗

[Importance of maternity routines in the success of maternal breast feeding].

Many of the problems that are associated with breast-feeding appear to be caused by various postnatal care procedures that take place in the majority of our hospitals. In order to identify these obstacles, a survey was carried out on a sample of 400 mothers whose children were born in Móstoles in 1989. The results were as follows: 1) The average duration of breast-feeding was 2.43 months (SD = 2.19 months). 2) The lower the baby's birth weight and the longer that he was kept in the hospital, the shorter the time that he was breast-fed. Two basic procedures in the hospital "norms" appear to contribute to the failure of breast-feeding. First, the provision of glucose water or formula bottles and second, a ridged feeding schedule. If the newborn was fed on demand in the hospital it tended to be continued once at home. In both the hospital and in the home, on demand feeding was strongly associate with successful breast-feeding. Some simple modifications to the Maternity departments are recommended.

Birth Weight↗

Implications of 'low' maternal serum alpha-fetoprotein levels: are maternal age risk criteria obsolete?

An association has been reported between 'low' maternal serum alpha-fetoprotein (MSAFP) and fetal chromosome abnormalities, notably Down syndrome. We suggest the predictive value be used for genetic counselling when a 'low' MSAFP is found, and present an illustrative risk table. It can also be seen that normal MSAFP in a woman may lower her age-related risks below that previously defined as 'high risk'. However, until good estimates of sensitivity and specificity are available from prospective, population based studies, patients should be told that any risk estimates are rough approximations. When good estimates are available, use of age risks alone may become obsolete.

Adult↗

Childhood iron deficiency anemia, maternal nutritional knowledge, and maternal feeding practices in a high-risk population.

BACKGROUND: Despite the proven success of national efforts such as the Special Supplementary Food Program for Women, Infants, and Children (WIC) to curb childhood iron deficiency anemia (IDA) in the United States, aggregate programmatic data may not accurately represent the experience of particularly high risk groups, such as the children of adolescent mothers of low socio-economic status. METHODS: This study evaluated the prevalence and severity of childhood anemia and associated risk factors, at one urban teen health center serving primarily low-income adolescent mothers and their children. A total of 175 pediatric WIC charts were reviewed to abstract hemoglobin status and other data. Additionally, 81 mothers were interviewed with regard to their nutritional knowledge and feeding practices; these findings were compared with the measured hemoglobin (Hgb) of their children. RESULTS: A total of 34.9% of children in the study population were found to be anemic (Hgb </= 11. 2). Low childhood Hgb status was significantly correlated with racial identification, child age, maternal perception of feeding difficulty, and the presence of concurrent pediatric medical illness. Report of extensive nutritional discussion with a physician was correlated with normal Hgb levels. No differences in nutritional knowledge or feeding practices were detected between mothers of children with low iron status. CONCLUSIONS: We conclude that the risk of iron deficiency, even among children receiving WIC services, may be underestimated in certain "nutritionally very high risk" populations. Further study of interventions for IDA in children of young, low-income mothers is recommended.

Adolescent↗

Risk of fetal Down's syndrome based on maternal age and varying combinations of maternal serum markers.

Serum samples from 320 women with chromosomally normal fetuses and from 50 women with fetuses affected by Down's syndrome were assayed retrospectively for human chorionic gonadotropin (hCG), pregnancy-specific beta 1 glycoprotein (SP1), alpha fetoprotein (AFP), and unconjugated estriol (uE3) between 14 and 21 weeks of gestation. Nonparametric discriminant analysis was applied to calculate Down syndrome risks on the basis of various combinations of serum parameters. At a risk threshold that falsely identifies 5% of controls as being affected, 46 to 48% of Down syndrome pregnancies were detected by combinations of hCG/AFP, hCG/AFP/uE3, and hCG/AFP/uE3/SP1 respectively. HCG, AFP, and uE3 were assayed in 652 serum samples from women who underwent amniocentesis because of maternal age (> or equal to 35 years in this prospective study). 49% of women with euploid fetal karyotype, 8 of 10 pregnancies with Down's syndrome, and 3 pregnancies with sex chromosomal anomalies were identified as being at an increased risk (> 1:380).

Biomarkers↗

Alterations in maternal and fetal prostaglandin dehydrogenase as a result of maternal ethanol consumption.

Various lines of research have suggested that ethanol consumption may alter prostaglandin-related physiology. Our laboratory has reported that chronic exposure to high doses of ethanol lowers the ability of kidney and lung homogenates from rats to catabolize prostaglandin E2 and F2 alpha via 15-prostagladin dehydrogenase (PGDH). Because of the apparently unique role played by prostaglandins in conception, growth and development of the fetus and parturition, we have attempted to determine if the alterations observed in male rats also occur in females and if any alterations in fetal metabolism result from maternal ethanol exposure. Further, we have measured the influence of ethanol administration on renal clearance of the 15-keto metabolite of PGF2 alpha in an attempt to determine the in vivo significance of the enzyme inhibition observed in vitro. Initial results indicate the following. 1) Female Holtzman rats doses at 2.0, 5.0 and 7.0 mg ethanol/kg during the first, second, and third trimesters of pregnancy, respectively, showed losses in renal PGDH activity similar to those found in males (1.52 versus 1.05 picomole/min/mg, p < 0.001 by matched t-test). 2) Placental tissue (amnion) isolated from these same animals on day 21 of the pregnancies also showed a significant decrease in PGDH activity (14.79 versus 11.77 picomoles/min/mg, p < 0.01). 3) Kidney homogenates from fetuses delivered on day 21 of the pregnancies showed a significant increase in PGDH relative to pair-dosed controls (16.77 versus 12.65 picomoles/min/mg, p < 0.01). 4) In a separate experiment, urinary clearance of PGF2 alpha metabolite was inhibited in a dose related manner up to a level of 6 gm/kg.

15-Oxoprostaglandin 13-Reductase↗

Pregnancy and autoimmunity: maternal treatment and maternal disease influence on pregnancy outcome.

If a woman suffers from autoimmune disease (AD), several factors can affect pregnancy or neonatal outcome: repeated spontaneous pregnancy losses (frequently related to antiphospholipid antibodies (aPL)), neonatal lupus with complete congenital heart block (CHB) (linked to transplacental passage of IgG anti Ro/SS-A antibodies) and the disease activity itself that can affect the mother, the pregnancy and fetal outcome. If appropriately managed, the antiphospholipid syndrome (APS) is "one of the few tractable causes of pregnancy losses." A recent case control study, on babies from APS-mothers and healthy mothers, did not show any difference in the occurrence of neonatal complications. There are few data about the long-term outcome of babies born to patients with AD. We recently reported increased occurrence of learning disabilities in children born to aPL positive mothers with systemic lupus erythematosus (SLE). The modern management of pregnancy in patients with AD includes the treatment of disease flares, using drugs effective but safe for fetus. Corticosteroids and some immunosuppressive drugs can be used in pregnancy to control maternal disease. A prolonged fetal exposure to dexamethasone was reported to impair cerebral development, but we recently studied 6 children, born to patients treated with dexamathasone because of CHB, showing a normal intelligence quotient. The last 10-year experience shows that fetal exposure to antimalarial drugs should not be regarded as an important risk factor for gestational nor neonatal complications. However, information about long-term outcome of children exposed to immunosuppressive drugs "in utero" are still lacking and more efforts are needed in this research area.

Autoimmune Diseases↗

Maternal touch and maternal child-directed speech: effects of depressed mood in the postnatal period.

BACKGROUND: Postnatal depression affects the emotional state of mothers and the quality of mother-infant interaction. METHOD: Touch behaviour and content of child-directed speech were analysed for 72 mothers and their infants during pleasurable play. Infants (18) of mothers with depressed mood and 18 controls were seen when they were 6 months old; and 18 infants of mothers with depressed mood and 18 controls were seen when they were 10 months old. RESULTS: Depressed mothers in comparison with non-depressed mothers lifted their infants more, restraining their behaviours. Infants of depressed mothers in contrast to infants of non-depressed mothers spent greater periods of time in touching self rather than mother or toy, compensating for the lack of positive touch from their mothers. Mothers with depressed mood of 6-month-old infants included fewer affective and informative features in their speech than their controls. Non-depressed mothers of younger babies showed a higher use of affective features when compared with non-depressed mothers of older infants. In contrast, depressed mothers of 6- and 10-month-old babies showed similar frequencies of affect-salient speech during interactions in spite of their infants' changing developmental demands. LIMITATIONS: Mothers in this study were only mildly depressed, as assessed by the Edinburgh Postnatal Depression Scale (EPDS). Nevertheless, the findings indicate that mothers with depressive symptoms differ from non-depressed mothers in relation to touch and content of speech when interacting with their infants. CONCLUSIONS: These results suggest that postnatal depression may influence touch behaviour as well as the affective and informative content of maternal speech. The effect is that mothers with depressed mood in comparison with non-depressed mothers touch their infants more negatively and their speech is less well adjusted concerning the amount of emotional vs. information-related content thereby preventing depressed mothers from responding effectively to their infants' developmental needs.

Adolescent↗

Postpartum maternal corticosterone decreases maternal and neonatal antibody levels and increases the susceptibility of newborn mice to herpes simplex virus-associated mortality.

The effects of corticosterone on the transmammary transfer of herpes simplex virus (HSV)-specific antibody and the ability of the neonate to survive HSV-2 infection were assessed. Increased postpartum maternal corticosterone reduced the levels of total and HSV-specific IgG in the serum and milk of mothers. Neonates nursed by these mothers received increased levels of corticosterone and decreased levels of total and HSV-specific IgG. Accordingly, these neonates were more susceptible to HSV-2-associated mortality; however, survival was restored through passive immunization with HSV-specific antibody. These studies demonstrate that postpartum elevations in corticosterone compromise a mother's ability to provide protective antibody to their offspring.

Adjuvants, Immunologic↗

Trigeminal lesions and maternal behavior in Norway rats: I. Effects of cutaneous rostral snout denervation on maintenance of nurturance and maternal aggression.

Cutaneous desensitization of the upper, rostral snout by bilateral section of the infraorbital nerves in lactating Norway rat dams markedly, but transiently, disrupted retrieval and licking of pups, nursing behavior, and fighting with a strange male intruder. Removal of the mystacial vibrissae, which provide major inputs to the infraorbital nerves, or cutaneous desensitization of the chin by bilateral sectioning of the mental nerves did not disrupt these behaviors. However, cutaneous desensitization of both the upper and lower rostral snout exacerbated and prolonged the effects produced by infraorbital denervation alone. The control of maternal behavior and aggression by somatosensory reflexes and the possible bases for rapid behavioral recovery after partial trigeminal sensory denervations are discussed.

Aggression↗

The medial preoptic area, necessary for adult maternal behavior in rats, is only partially established as a component of the neural circuit that supports maternal behavior in juvenile rats.

To determine whether the neurons of the medial preoptic area (MPOA) are necessary for pup-induced maternal behavior (MB) in juvenile and adult rats, subjects received bilateral injections of the neurotoxin N-Methyl-D-Aspartic acid into the MPOA. Controls were intact or were sham treated by surgical placement of the syringe barrel. The rats were then induced into MB by constant pup exposure. Starting at 27 (juvenile) or 60 (adult) days of age, rats were tested for MB for 12 consecutive days. After histological analysis, rats were categorized as having either large or small lesions of the MPOA. In juveniles, large lesions of the MPOA blocked retrieval and impaired nest-building, but crouching behavior was unaffected; small lesions had no effect on MB. In contrast, in adults, large or small lesions severely impaired all components of MB. The results suggest that in juvenile rats, the role of the MPOA neurons in MB is only partially established, whereas by 60 days of age, the unsubstitutable role of the MPOA in the neural circuit that mediates MB is fully established.

Age Factors↗