John T. Harrigan

Maternal age and risk of fetal death in singleton gestations: USA, 1995–2000

Objective: To determine the magnitude of risk for fetal death among singleton pregnancies in relation to maternal age, and to compare the risks with other common indications for fetal testing.Study design: We performed a retrospective cohort analysis of singleton births delivered between 1995 and 2000 using the US linked birth/infant death data. Gestational age at <24 weeks and fetuses with anomalies were excluded. Fetal death rates at ≥24 and ≥32 weeks were calculated among women aged 15–19, 20–24, 25–29, 30–34, 35–39, 40–44 and 45–49 years, as well as for other common indications for testing: chronic and pregnancy-induced hypertension, diabetes and smallfor-gestational age (SGA). The association between maternal age and fetal deaths was derived after adjusting for potential confounders through multivariable logistic regression models. Relative risks (RR) and 95% confidence intervals (CI) were derived from these models after adjusting for the effects of gravidity, race, marital status, prenatal care, education, smoking and placental abruption.Results: Among the 21 610 873 singleton births delivered at ≥24 weeks, fetal deaths occurred in 58 580 (2.7 per 1000). Births to young (15–19 years) and older (≥35 years) women comprised 12.6% and 11.4%, respectively. Compared with women aged 20–24 years, young women did not experience an increased risk of fetal death. However, increasing rates of fetal death at ≥24 and at ≥32 weeks were seen with increasing maternal age. The RR for fetal death at ≥24 and at ≥32 weeks among women 35–39 years were 1.21 and 1.31, respectively, while the RRs were 1.62 and 1.67 among women aged 40–44 years. Women 45–49 years were 2.40-fold (95% CI 1.77, 3.27) and 2.38-fold (95% CI 1.64, 3.46) as likely to deliver a stillborn fetus at ≥24 weeks and ≥32 weeks, respectively. RRs for fetal death at ≥24 and ≥32 weeks for hypertensive disease, diabetes, and SGA ranged between 1.46 and 4.95.Conclusion: Fetal deaths are increased among older women (≥35 years). Fetal testing in women of advanced maternal age may be beneficial.

Domestic abuse in pregnancy: A comparison of a self-completed domestic abuse questionnaire with a directed interview☆☆☆

OBJECTIVE The purpose of this study was to compare the results of a standardized self-completed domestic abuse questionnaire with those of a directed interview in the identification of domestic abuse in pregnant patients. STUDY DESIGN All patients with a first prenatal visit between March 1 and September 30, 1997, were assessed for self-reported domestic abuse with a standardized domestic abuse questionnaire. This was followed by a directed interview that involved verbal review of the standardized domestic abuse questionnaire. Self-reported domestic abuse was defined as any positive response to the domestic abuse questionnaire or the directed interview. The number of patients with a positive response to either the standardized questionnaire or the directed interview, or both, were recorded. The 2 techniques were compared by the McNemar chi(2) test. The group demographics and characteristics were evaluated. RESULTS Among the 224 patients evaluated, a total of 36% (n = 80) of the patients reported domestic abuse by either method. The standardized domestic abuse questionnaire identified 85% (n = 68) compared with 59% (n = 47) by a directed interview (P =.03). The use of the standardized domestic abuse questionnaire and the directed interview in parallel identified an additional 15% (n = 12) of patients with domestic abuse. CONCLUSION A standardized domestic abuse questionnaire is superior to a directed interview in identifying self-reported domestic abuse in pregnancy. Utilizing both methods in parallel further increases the number of patients identified.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: does a directed interview improve detection rates compared with the standard self-completed questionnaire?

Background. The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression. It was postulated that screening utilizing the EPDS in a directed interview would increase the detection rate compared with a self-completed EPDS in an indigent population. Objective. To compare the results of a self-completed EPDS with those of a directed interview utilizing the EPDS in the identification of patients at increased risk for postpartum depression. Methods. All patients undergoing a 6-week postpartum evaluation in the obstetric clinic at a community teaching hospital between November 1, 2003 and March 31, 2004 were screened for postpartum depression using the self-completed EPDS. This was followed by a directed interview, which consisted of a verbally administered EPDS by a social worker blinded to the results of the self-completed EPDS. A positive screen was defined as an EPDS score of ≥12 by either method. The number of patients with a positive screen to either the self-completed EPDS, the directed interview EPDS, or both were recorded. The two techniques were compared by the McNemar Chi-square test. The self-completed and directed interview EPDS scores were compared by Pearsons correlation coefficient to examine differences in screening techniques. Demographic data and characteristics in each group were examined. Results. Among the 134 patients evaluated, 24 (17.9%) screened positively for being at an increased risk of having postpartum depression. The self-completed EPDS and the directed interview EPDS screening detection rates were not different, identifying 23 (17.2%) and 22 (16.4%) patients, respectively (p = 1.0). The use of the self-completed EPDS and the directed interview EPDS in parallel detected one additional subject (0.7%; p = 0.99). The self-completed EPDS and directed interview EPDS scores correlated significantly (r = 0.94; p = 0.01). The demographics and characteristics of patients with a positive screen were not different from those with a negative screen. Conclusions. The self-completed EPDS and directed interview EPDS are equivalent screening techniques for postpartum depression. There is no evidence to suggest that parallel screening improves detection. Either technique should be incorporated into the postpartum visit to screen for postpartum depression.

Health Promoting Habits of People Who Pray for Their Health

To determine the health habits of people who pray for their health, data from the National Health Interview Survey was analyzed for health habits of people who prayed or did not pray for their health. Of the 22,314 respondents, 13,179 (59%) prayed for their health. These individuals saw a physician more frequently, participated more frequently in vigorous exercise and used more relaxation techniques, support groups, meditation and complimentary and alternative medicine therapies. People who pray for their health participate in more health promoting behaviors than people who do not pray for their health.

Fetal cardiac arrhythmia during labor

did not have squamous carcinoma of the cervix were removed, most of these being primary endometrial carcinomas. At the same time, any squamous carcinomas appearing to be endometrial lesions were, of course, added. In this table it can be seen that there is a satisfactory drop in the mortality rates from 11 per 100,000 to 4.8 per 100,000 for the refined rate. Again, this is in women over 20 years of age. The converted ratio for the whole female population is 3.2 per 100,000 women. Fig. 1 was prepared by Dr. Gerald Hill4 of the Division of Vital #Statistics of the Government of Canada. The drop in deaths from cervical cancer in the provinces of Canada is shown in women between the ages of 20 and 54. This group was selected because they would have been most exposed to screening. Two three-year averages were used for comparison, and the period chosen was a time when there was at least some screening in all provinces. The screening rates are averages for 1963 and 1967. ‘This figure indicates that the more screening done, the greater the fall in deaths. We believe that the worth of screening for cervical cancer by means of Papanicolaou smears has been established.

Outcome predictors for patients delivered by cesarean section for fetal distress.

Objective: To determine predictive variables identifying infants admitted to neonatal intensive care (NIC) following cesarean section for fetal distress in labor at term.Methods: Two hundred eight patients were studied. Sixty-six patients delivered by cesarean section at term for fetal distress were compared to 142 term patients not diagnosed as fetal distress. The outcome indicator was admission to NIC. Patients diagnosed as fetal distress were studied to determine variables that increased prediction of adverse outcome. Variables studied were patient age, induction of labor, augmentation of labor, epidural anesthesia, birth weight, antepartum complications, and intrapartum complications. Comparisons were by Fishers Exact text and logistic regression.Results: Twenty-six infants were admitted to NIC. Eleven had a diagnosis of fetal distress and 21 had a diagnosis of antepartum complications. Fetal distress was not associated with admission to NIC (P =.26) and had a low sensitivity (42%) and positive predictive value (17%). Antepartum complications, intrapartum complications, and birth weight were associated with admission to NIC (P =.00001) (P =.04) (P =.05). Antepartum complications had a sensitivity of 81% and a positive predictive value of 33% for admission to NIC. The presence of both fetal distress and antepartum complications increased the positive predictive value to 91%. Only one infant was admitted to NIC with a diagnosis of fetal distress without antepartum complications. Positive predictive value 2.4%, negative predictive value 96%. Birth weight when dichotomized at the 5th percentile (2,606 g) had a sensitivity of 20% and a positive predictive value of 50% for admission to NIC. Five of 10 infants with a birth weight below the 5% percentile were admitted to NIC.Conclusion: Antepartum complications coupled with fetal distress in labor are a strong predictor of adverse outcome, which is not altered by cesarean section. There are two groups of patients with fetal distress in labor at term, and the group with antepartum complications or subtle reduction in birth weight are at extreme risk for adverse outcome. It appears that cesarean section for fetal distress may rescue infants without antepartum problems but may not rescue those with a challenging antepartum course, lending credence to the feeling that fetal distress in labor may be an indicator of prior stress in many patients.