Felix A. Okah

An Infant With Trisomy 18 and a Ventricular Septal Defect

Decisions for critically ill infants with trisomy 18 raise thorny issues about values, futility, the burdens of treatment, cost-effectiveness, and justice. We presented the case of an infant with trisomy 18 to 2 neonatologists with experience in clinical ethics, Annie Janvier and Felix Okah, and to a parent, Barbara Farlow. They do not agree about the right thing to do.

Effect of prenatal steroids on skin surface hydrophobicity in the premature rat.

ABSTRACT: The skin surface of the newborn rat at term is highly hydrophobic. This surface hydrophobicity plays a putative role in the transition from an aqueous to a gaseous environment at birth and is dependent on the presence of an intact periderm. Glucocorticoids given to pregnant dams, during late gestation, will accelerate formation of the stratum corneum and reduce transepidermal water loss in prematurely delivered pups. We tested the related hypotheses that surface hydrophobicity and maturation of the periderm are developmentally accelerated by prenatal exposure to steroids. Thirty pregnant Sprague-Dawley rats received either normal saline or 0.5 mg/kg betamethasone on d 17 of gestation. After cesarean delivery on d 18, 19, and 20, dorsal skin surface hydrophobicity was quantified by direct surface electrical capacitance (SEC) measurement. Initial skin surface hydration at birth was significantly lower in steroid-treated pups than in control pups at gestational ages 19 and 20 d (3060 pm 1379 versus 4441 ± 153 pF and 646 ± 295 versus 1493 ± 1019 pF, respectively, p < 0.001, mean ± SD). Likewise, after desorption of amniotic fluid, baseline skin hydration was significantly lower in steroid-treated pups than in control pups at gestational ages 19 and 20 d (1862 ± 1560 pF versus 4278 ± 97 pF and 60 ± 56 pF versus 128 ± 264 pF, p< 0.001). Scanning and transmission electron microscopy showed morphologic maturation of the periderm after steroid treatment. These results demonstrate accelerated development of both functional and structural correlates of skin surface hydrophobicity in the premature rat after prenatal exposure to steroids.

Pre-Pregnancy Overweight Status between Successive Pregnancies and Pregnancy Outcomes

OBJECTIVE The two objectives of this study were to (1) examine factors associated with changes in pre-pregnancy overweight to pre-pregnancy normal/underweight or obese Body Mass Index (BMI) in the subsequent pregnancy, and (2) assess select pregnancy and newborn outcomes associated with changes in pre-pregnancy BMI. METHODS Birth certificates from 1995-2004 for residents of Kansas City, Missouri, were used to identify overweight nulliparous women who had a singleton birth and subsequently a second singleton birth. Maternal factors associated with changes in BMI between pregnancies were determined. Hypertension in pregnancy, preterm birth, emergency cesarean section, small-for-gestational age, and large-for-gestational age outcomes were examined. RESULTS At second pregnancy, 55% of the women remained overweight, 33% were obese, and 12% had normal/underweight BMIs. The upward shift in BMI was associated with being unmarried and having a birth interval of 18 or more months, while the downward shift was associated with gestational weight gain. Of the five outcomes variables, only emergency cesarean section was significantly associated with an upward shift in BMI. CONCLUSIONS Clinical interventions for pre-pregnancy overweight women should focus on appropriate weight gain during pregnancy and motivators for loss of pregnancy-related weight during the postpartum period.

Risk factors for recurrent small-for-gestational-age birth.

The factors associated with recurrent small-for-gestational-age birth (R-SGA) have not been previously studied in a multiracial population. This is a retrospective cohort study of 5932 black and white women who had consecutive singleton first and second births in a Midwestern metropolis, from 1995 through 2004, to measure the risk and determine the factors associated with R-SGA. The rates for second-born small-for-gestational-age birth and R-SGA were 10.3% and 4.0%, respectively. Compared with mothers of firstborns who were appropriate for gestational age, mothers of firstborns who were small for gestation age had a higher risk of second-born small-for-gestational-age infants (relative risk [RR] = 3.93; 95% confidence interval [95% CI] = 3.36 to 4.59). Among those with firstborns who were small for gestational age, the odds ratio (OR) and 95% CI of R-SGA were higher for lean body mass index + poor gain (2.83; 1.20 to 6.69), blacks (1.58; 1.09 to 2.29), and smokers (1.61; 1.05 to 2.47). R-SGA occurs in 4% of second births and is responsible for 40% of second-born small-for-gestational-age infants. R-SGA is potentially preventable because of its association with potentially modifiable factors such as smoking and weight gain in pregnancy.

Community violence and pregnancy health behaviors and outcomes.

Objectives Community violence is associated with health-compromising behaviors (HCBs) and adverse general health and pregnancy outcomes. It is unknown whether these effects persist after adjusting for health behaviors. Methods Retrospective cohort study of 36,637 pregnancies, 2005–2009, using birth certificate/hospital discharge databases. Community violence rate = (nonaccidental injuries/total injuries) × 100%. ZIP codes were categorized into levels (CVL) by quartiles (lowest, 1, to highest, 4). Outcomes included HCBs (tobacco, alcohol, or drugs), fetal death, preterm birth, and infant small-for-gestational-age (SGA). Covariates included HCBs and maternal characteristics. Results The CVL median (interquartile range) was 5.5% (3.8%–8.8%). As CVL increased, rates of HCBs (8% vs 13% vs 14% vs 16%), fetal death (4 vs 5 vs 6 vs 8/1000 pregnancies), preterm birth (8% vs 9% vs 11% vs 13%), and infant SGA (8% vs 10% vs 13% vs 16%) increased. The odds of preterm birth (CVL1 = 1.00 [reference] vs CVL2 = 1.00 [0.88–1.14] vs CVL3 = 1.10 [0.96–1.26] vs CVL4 = 1.25 [1.09–1.42]) and infant SGA (CVL2 = 1.03 [0.93–1.17] vs CVL3 = 1.15 [1.01–1.30] vs CVL4 = 1.21 [1.07–1.38]) increased, after controlling for HCB. Conclusions CVL is associated with fetal death, preterm birth, and infant SGA, independent of HCB. These findings may support the role of violence-reduction programs in improving pregnancy health behaviors and outcomes.

Smoking during pregnancy rates trends in a high smoking prevalence state, 1990-2009.

Objective To assess the trends for smoking during pregnancy for whites and blacks in Missouri, a state with a high prevalence of smoking, for the period 1990–2009. Methods Retrospective cohort study of annual pregnancy smoking rates recorded on birth certificates. Trends were assessed by regression analyses for all births, births to whites and blacks, births to whites and blacks in aggregate, and by zip codes within the combined jurisdictions of Kansas City, St Louis City, and St Louis County. Zip code smoking during pregnancy rates matched with the respective zip code race-specific population compositions were analyzed by chi-square tests. Results Smoking during pregnancy rates trends for whites and blacks differed significantly during the 2 decades. Although rates for whites declined over time, they were relatively stable from 1999 through 2007. Rates for blacks exhibited a steep decline in the early 1990s, remaining stable after 1995. Within the combined jurisdictions, rates for blacks who smoked during pregnancy surpassed those of whites beginning in 2001. The lack of prenatal care for either race was the only maternal characteristic consistently associated with lack of reduction in smoking during pregnancy. There also were no declines among young birth mothers of either race who had 12 or fewer years of education. Rates of smoking during pregnancy for blacks and whites were highest in zip codes with a ≥50% black population. Conclusions Rates for smoking during pregnancy for whites and blacks in Missouri overall have not changed appreciably from 2000 to 2009. Beneficial antismoking during pregnancy effects that could reverse this trend may be achievable via improved access to prenatal care, especially for young, uneducated women.

Excess Hispanic fetal-infant mortality in a midwestern community.

Objective. We assessed excess fetal-infant mortality for Hispanic, non-Hispanic white, and non-Hispanic black populations in five contiguous counties of Missouri and Kansas. Methods. We conducted a perinatal periods of risk (PPOR) assessment of fetal-infant mortality using electronic linked birth-death record files from 2001 through 2005. We generated an internal reference group in accordance with established PPOR protocol. We used Kitagawa analysis to determine whether excess deaths were due to birthweight distribution (a higher frequency of prematurity or growth retardation) or to higher mortality rates once born at that birthweight (birthweight-specific mortality). Results. We found the excess fetal-infant death rates for Hispanic and non-Hispanic white populations to be similar and considerably lower than that for non-Hispanic black populations. Among Hispanic children, we judged 21.6% of fetal-infant mortality to be excess in relation to the reference population. Within the PPOR matrix, Hispanic excess mortality rates were distributed differently from those of non-Hispanic white and non-Hispanic black populations. Among Hispanic children, 93.6% of the excess mortality could be explained by low birthweight and birthweight-specific mortality, with the greatest contribution attributable to low birthweight. Conclusion. The excess fetal-infant mortality experience of Hispanic people in the five-county region was similar to that of the non-Hispanic white population, but was distributed differently in the PPOR model, which has significance regarding interventions targeting reductions in fetal-infant mortality.

Primiparous outcomes and future pregnancy health behaviors.

OBJECTIVE To examine the impact of repeat, G2, and outcomes of first, G1, (previous livebirth, PLB, or stillbirth, PSB) pregnancies on health-compromising behaviors (HCB). METHODS Retrospective cohort study of 137,374 pregnancies in Kansas City, MO, 1990 through 2009, using birth certificate database. RESULTS Overall HCB rate was 17% and increased with G2 and PSB (G1=12% v G2-PLB=21% v G2-PSB=29%, p < .001). Compared to G2-PLB, the odds of HCB increased for G2-PSB (OR=1.42; 95%CI 1.10, 1.82) and decreased for G1 (0.54; 0.52, 0.56). CONCLUSION Women are more likely to engage in HCB during their second pregnancy, especially those who lose their first pregnancy. This finding is evidence for promoting effective inter-conception health care at post-partum and primary care visits.