Martha A. Wojtowycz

Association between pre-pregnancy obesity and the risk of cesarean delivery

Objective To explore the relationship between prepregnancy obesity and the risk for cesarean delivery. Methods The population studied included 20,130 women with live births after 20 weeks gestation in central New York state between June 1, 1994, and May 31, 1995. Women who were obese before pregnancy were compare with nonobese women with regard to mode of delivery. Obesity was defined as body mass index (BMI) greater than 29. Separate analyses were conducted on the entire sample and on a subset of women with singleton pregnancies and no prior cesarean deliveries, as an estimate of the risk of primary cesarean delivery in obese women. Statistical analyses included χ2 test, crude odds ratio (OR) with 95% confidence interval (CI), and adjusted OR with 95% CI, using logistic regression to control for confounding variables. Results The adjusted OR was 1.64 (95% CI 1.46, 1.83) for obese women with singleton pregnancies and no prior cesarean deliveries to undergo cesarean delivery. The adjusted OR was 1.66 (95% CI 1.51, 1.82) for obese women in the entire sample to undergo cesarean delivery. In addition, increasing BMI was associated with increased risk for cesarean delivery. conclusion Compared with nonobese women, women who are obese before pregnancy are at increased risk for cesarean delivery. Preconceptional counseling regarding dietary and life-style nmodifications may alter this pattern.

Female alloimmunization with antibodies known to cause hemolytic disease

Objective To determine the current frequency of red blood cell antigen alloimmunizations that are capable of causing hymolytic disease and would be suitable for prenatal DNA studies. Methods We reviewed blood-bank records at a single large tertiary center to identify patients with a positive antibody screen between January 1993 and June 1995. Data were analyzed based on age, gender, and specific blood-group alloimmunizations. The incidence of antibodies as published in the literature was reviewed and compared with our data. Results We identified 452 women who had a positive antibody screen. The frequencies of specific alloimmunization relevant to the development of fetal hemolytic disease were: anti-D, 18.4%, anti-E, 14%; anti-c, 5.8%, anti-C, 4.7%; Kell group, 22%; anti-MNS, 4.7%; anti-Fya (Duffy), 5.4%; and anti-Jka, 1.5%. Compared with other populations, in our group the frequency of antibodies to RhD decreased and Kell alloimmunization increased between 1967 and 1996. Conclusions Despite the use of rhesus immune globulin, anti-D is still a common antibody identified in women presenting to a tertiary care center. The frequency of Kell-group alloimmunization is higher among the central New York female populatin that in other populations. Rhesus and Kell antigen status can be determined by DNA studies. Research in prenatal determination of fetal antigen status should continue, as alloimmunization to these antigen is common.

Unintended pregnancy and breast-feeding behavior.

OBJECTIVES This study assessed the effect of unintended pregnancy on breast-feeding behavior. METHODS All women delivering a live birth between January 1, 1995, and July 31, 1996 (n = 33,735), in the 15-county central New York region were asked whether they had intended to become pregnant and their breast-feeding plans. RESULTS Women with mistimed pregnancies, and pregnancies that were not wanted were significantly less likely to breast-feed than were women whose pregnancies were planned. After adjustment for confounding variables and contraindications for breast-feeding, the odds ratios of not breast-feeding remained significant. CONCLUSIONS Promoting breast-feeding among women with unintended pregnancies is important to improve health status.

Early Language Development in Children Exposed to or Infected With Human Immunodeficiency Virus

Objectives. To compare language development in infants and young children with human immunodeficiency virus (HIV) infection to language development in children who had been exposed to HIV but were uninfected, and (among subjects with HIV infection) to compare language development with cognitive and neurologic status. Design. Prospective evaluation of language development in infected and in exposed but uninfected infants and young children. Setting. Pediatric Infectious Disease Clinic, State University of New York–Health Science Center at Syracuse. Subjects. Nine infants and young children infected with HIV and 69 seropositive but uninfected infants and children, age 6 weeks to 45 months. Results. Mean Early Language Milestone Scale, 2nd edition (ELM-2) Global Language scores were significantly lower for subjects with HIV infection, compared with uninfected subjects (89.3 vs 96.2, Mann–Whitney U test). The proportion of subjects scoring >2 SD below the mean on the ELM-2 on at least one occasion also was significantly greater for subjects with HIV infection, compared with uninfected subjects (4 of 9 infected subjects, but only 5 of 69 uninfected subjects; Fishers exact test). Seven of the 9 subjects with HIV infection manifested deterioration of language function. Four manifested unremitting deterioration; only 1 of these 4 demonstrated unequivocal abnormality on neurologic examination. Three subjects with HIV infection and language deterioration showed improvement in language almost immediately after the initiation of antiretroviral drug treatment. Magnetic resonance imaging or computed tomography of the brain were performed in 6 of 7 infected subjects with language deterioration, and findings were normal in all 6. ELM-2 Global Language scaled scores showed good agreement with the Bayley Mental Developmental Index or the McCarthy Global Cognitive Index (r = 0.70). Language deterioration, or improvement in language after initiation of drug therapy, coincided with or preceded changes in global cognitive function, at times by intervals of up to 12 months. Conclusions. Language deterioration occurs commonly in infants and young children with HIV infection, is seen frequently in the absence of abnormalities on neurologic examination or central nervous system imaging, and may precede evidence of deterioration in global cognitive ability. Periodic assessment of language development should be added to the developmental monitoring of infants and young children with HIV infection as a means of monitoring disease progression and the efficacy of drug treatment.

Papanicolaou Smears by the Bethesda System in Endometrial Malignancy: Utility and Prognostic Importance

Objective To evaluate the prognostic significance of the Bethesda systems cytologic categories in patients with endometrial malignancy. Methods Patients with biopsy or hysterectomy-proven endometrial malignancy and a Papanicolaou smear result reported using the Bethesda system within 1 year of diagnosis were identified through retrospective review of our computerized database. Results After introduction of the Bethesda system in our laboratory on November 1, 1992, until January 1, 1997, 112 eligible patients were identified (108 with crcinomas and four with carcinosarcomas). Patients with cytologic dianoses of malignancy (n = 17) were significantly more likely to hacve International Federation of Gynecology and Obstetrics (FIGO) grade 3 tumors and high-risk histology (serous, clear cell, and adenosquamous carcinoma and carcinosarcoma) than those with atypical glandular cells of uncertain significance (n = 33) or those with cytology not suspicious for malignancy (n = 63). Patients with malignant smears were also significantly more likely to have cervical extension, malignant peritoneal cytology, and FIGO stage II, III, or IV than those with atypical glandular cells of uncertain significance or those with cytology not suspicious for malignancy. Conclusion Papanicolaou smears obtained within 1 year of histologic diagnosis of endometrial malignancy and interpreted using the Bethesda system were suspicious for (atypical glandular cells of uncertain significance) or diagnostic of malignancy in nearly half of all cases (29 and 15%, respectively). Patients having malignant glandular cells were more likely to have poor prognostic pathologic finings.

A cost evaluation of implementing a quality-oriented, regional perinatal data system.

We evaluated the cost impact of implementing a perinatal data system (PDS) on birth certificate (BC) processing and perinatal quality improvement (QI) reporting. Relevant staff in all birthing hospitals in the 15-county Central New York region (N = 23) were interviewed at baseline prior to implementation of the PDS and one year after implementation of the PDS to ascertain the time and costs of BC processing and of QI report generation. The average time and cost to collect and complete BCs did not change significantly from baseline to year 1. The time and costs to complete QI reports decreased significantly by 70 percent during this same period. Hospitals fully using the PDS for QI reporting purposes took, on average, six percent of the time it took other hospitals to generate comparable QI reports. The PDS significantly reduced the time and cost of generating perinatal reports from a consolidated database over what hospitals had done previously. Given the richness of the reports and the efficiency with which they are produced, hospitals are encouraged to adopt electronic means of BC processing and accessing these data for QI reporting purposes.