Mary S. Croughan-Minihane

Attitudes of Beginning Medical Students Toward Older Persons: A Five-Campus Study

OBJECTIVE: To examine the attitudes of beginning medical students toward older persons and their medical care.

Perinatal mortality in twins and singletons matched for gestational age at delivery at ≥30 weeks

OBJECTIVEnOur purpose was to compare perinatal mortality between twins and singletons matched for gestational age at delivery with the hypothesis that perinatal mortality would be similar.nnnSTUDY DESIGNnA retrospective cohort study compared perinatal mortality in twins (790 babies) matched for gestational age at delivery at > or = 30 weeks with the next singleton. Perinatal mortality was also compared by expected growth (small and average for gestational age) and by the cause of the preterm delivery (medical indication, spontaneous preterm delivery, or preterm premature rupture of membranes with preterm delivery.nnnRESULTSnUncorrected perinatal mortality was significantly greater in singletons (56/1000) than in twins (26/1000) (p = 0.004). After major congenital anomalies were excluded, perinatal mortality remained significantly higher in singletons (25/1000) than in twins (11/1000) (p = 0.04). In preterm deliveries perinatal mortality was significantly greater in singletons (72/1000) than in twins (19/1000) (p = 0.0002). Perinatal mortality was significantly greater in small- compared with average-for-gestational-age neonates, whether singletons or twins (p = 0.005), and singleton small-for-gestational-age neonates had a significantly greater perinatal mortality (105/1000) than did twin small-for-gestational-age neonates (36/1000) (p = 0.02). Perinatal mortality was not significantly different between preterm singletons and twins delivered by spontaneous preterm labor. However, perinatal mortality in preterm singletons delivered for a medical indication (156/1000) was significantly greater than for twins (20/1000) (p = 0.0006).nnnCONCLUSIONSnAt > or = 30 weeks at delivery, twins either had a perinatal mortality similar to, or less than singletons matched for gestational age at delivery. This suggests that when preterm delivery is controlled for perinatal mortality is not greater in twins. In twins, without risk factors for perinatal death, routine antepartum testing may not be indicated.

Chorioamnionitis and uterine function

Objective To clarify the relationships between intrapartum chorioamnionitis and abnormalities of uterine function, including labor abnormalities, cesarean delivery, and hemorrhage during parturition. Methods We did a retrospective cohort study on 16,226 deliveries between 1986 and 1996 that were identified from the University of California, San Francisco Perinatal Database. Variables included maternal age, parity, birth weight, gestational age, epidural usage, oxytocin usage, cesarean delivery, labor abnormalities, length of labor stages, estimated blood loss, and chorioamnionitis status. Analyses included χ2, Student t test, and logistic regression. Results In the chorioamnionitis group, there was a statistically significantly higher proportion of women with labor abnormalities (relative risks [RRs] 2.6–4.1), cesarean delivery (RR 3.3; 95% confidence interval [CI] 3.0, 3.5), hemorrhage after cesarean (RR 1.2; 95% CI 1.1, 1.3), and hemorrhage after vaginal delivery (RR 2.1; 95% CI 1.9, 2.4) compared with the nonchorioamnionitis group. Those findings stayed significant after multivariate analysis for various labor abnormalities (adjusted odds ratios [ORs] ranged 1.3–2.1), cesarean delivery (adjusted OR 1.8; 95% CI 1.5, 2.1), hemorrhage after cesarean (adjusted OR 1.5; 95% CI 1.2, 1.8), and hemorrhage after vaginal delivery (adjusted OR 1.8; 95% CI 1.5, 2.1). Conclusion Adverse associations between chorioamnionitis and labor abnormalities, cesarean rate, and hemorrhage during parturition appear to be significant, suggesting a deleterious effect of chorioamnionitis on uterine function.

The Solution Method: 2-year trends in Weight, Blood Pressure, Exercise, Depression, and Functioning of Adults trained in Development Skills

This study describes changes observed during a 2-year period in participants enrolled in The Solution Method, a developmental skills training program for adult weight management. This intervention is the adult application of a model of treatment previously used only in the management of pediatric obesity (The Shapedown Program). Developmental skills training integrates understandings and methods from developmental, family systems, biomedical, genetic, and behavioral theories of the etiology of obesity. Twenty-two subjects (mean age = 43.4 +/- 8.5 years and mean body mass index = 33.1 +/- 5.3) completed a group intervention based on this method, which was conducted by a registered dietitian and a mental health professional. Questionnaire responses indicated the extent to which their weight was a medical and/ or psychosocial risk. Subjects attended 2-hour weekly sessions for an average of 18 weeks during which they were trained in six developmental skills: strong nurturing, effective limits, body pride, good health, balanced eating, and mastery living. Data, which were collected at the beginning of treatment and at 3, 6, 12, and 24 months, included weight, blood pressure, 7-day exercise recalls, and responses to depression and functioning (psychosocial, vocational, and economic) questionnaires. Participants weights decreased throughout the 2-year period of the study: mean weight change was -4.2 kg (3 months), -6.0 kg (6 months), -7.0 kg (12 months), and -7.9 kg (24 months). In addition, compared with baseline values, systolic and diastolic blood pressure, exercise, and depression improved throughout the study period. These improvements were statistically significant at 24 months for weight (P < .01), systolic blood pressure (P < .02), diastolic blood pressure (P < .001), and exercise (P < .001); the results were not statistically significant for depression. Most participants reported improvement in a broad range of aspects of functioning. We conclude that this application of developmental skills training for adult weight management may produce significant long-term beneficial effects.

Hospitalization rates in nursing home residents with dementia. A pilot study of the impact of a special care unit.

Although Special Care Units (SCUs) have recently gained attention as appropriate places for caring for institutionalized patients with dementia, few studies have evaluated their effectiveness. This pilot study focused primarily on one aspect of patient care, the possible prevention of acute hospitalization. Because transfer from nursing home to the acute hospital can be a traumatic experience for patients with dementia, important services that SCUs might provide include those preventive strategies aimed at reducing the need for transfer to the acute hospital. Medical record abstraction revealed that over one year, the rate of acute hospitalization was 21% among 47 patients with dementia in SCUs, compared with 14% among 36 patients with dementia and 14% among 22 patients with no listed diagnosis of dementia residing in non‐SCU settings within the same facility. Thus, no statistically significant difference in hospitalization rates was found, although the trend was for increased hospitalization for SCU patients. There was a trend toward deterioration in functional status among SCU patients following first hospitalization (P < .10). Since the majority of these patients were hospitalized for hip fractures, this finding was not unexpected. There was a trend toward cognitive decline after hospitalization among patients with dementia who were not residing in an SCU (P < .10). In order to investigate whether acute hospitalizations among SCU patients were preventable, an expert panel was convened to review each episode of illness leading to acute hospitalization. Of the 15 hospitalizations, none were judged “preventable,” four were believed to be “possibly preventable,” and 11 were considered to have been “not preventable.” While SCUs may be an attractive alternative to traditional nursing home placement for patients with dementia, this pilot study suggests that they are probably not effective in reducing the need for acute hospitalization.

Lack of value of routine postpartum hematocrit determination after vaginal delivery

Objective To identify risk factors associated with low postpartum hematocrits after vaginal delivery and to define lower risk categories of patients for whom routine determination of hematocrit may not be necessary. Methods This case-control study was designed to identify risk factors for discharge hematocrit below 27% in nonanemic patients after a vaginal delivery using the University of California, San Francisco, Perinatal Database. Multivariate statistics were used to determine the most significant risk factors. Lower risk subpopulations were analyzed to determine their rate of low discharge hematocrits. Results Risk factors associated with odds ratios greater than 1.5 for discharge hematocrit less than 27% included estimated blood loss greater than 500 mL, placenta previa, abruption, prolonged third stage, preeclampsia, prior post-partum hemorrhage, and prior cesarean delivery. Estimated blood loss > 500 mL was the most significant risk factor for discharge hematocrit less than 27% (odds ratio 4.5, 95% confidence interval 3.8, 5.4). A population without statistically significant risk factors was identified; this group had a 1.4% risk of discharge hematocrit less than 27%. Conclusion Routine postpartum hematocrits are unnecessary in clinically stable patients with an estimated blood loss of less than 500 mL.

Head entrapment and neonatal otucome by mode of delivery in breech deliveries from twenty-four to twenty-seven weeks of gestation

OBJECTIVESnOur purpose was to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 24 to 27 weeks of gestation.nnnSTUDY DESIGNnCharts of 132 viable consecutive singleton breech deliveries from 24 to 27 weeks gestation were reviewed. Statistical methods used included chi 2, logistic regression, and analysis of variance.nnnRESULTSnHead entrapment occurred in four of 43 (9.3%) vaginally delivered neonates and five of 89 (5.6%) neonates delivered by cesarean section (p = 0.17). The only identifiable risk factor for head entrapment was the birth weight category 1000 to 1249 gm (odds ratio 6.4, 95% confidence interval 1.6 to 26.1). There were no statistically significant associations between head entrapment and adverse neonatal outcomes.nnnCONCLUSIONSnThere did not appear to be a difference in the incidence of head entrapment by mode of delivery for breech infants at 24 to 27 weeks gestation, nor did there appear to be a difference in adverse neonatal outcomes after entrapment. However, this latter conclusion has limited power because of the small number of head entrapment cases.

Effect of magnesium prophylaxis and preeclampsia on the duration of labor

OBJECTIVEnOur goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not.nnnSTUDY DESIGNnWe performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The chi2 odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration.nnnRESULTSnOur study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P <.003). Total labor duration did not differ between women with preeclampsia and normotensive women (P =.15) or between women with preeclampsia who received magnesium and those who did not (P =.09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P =.005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P =.002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2. 6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1. 1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0. 5, 95% confidence interval 0.4-0.8) were associated with faster labor.nnnCONCLUSIONSnIn term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration.

Is there an association between water baths during labor and the development of chorioamnionitis or endometritis

OBJECTIVEnOur purpose was to determine whether water baths during labor are associated with the development of chorioamnionitis or endometritis.nnnSTUDY DESIGNnOne hundred ten cases of chorioamnionitis or endometritis and 97 controls were identified among singleton term gestations from the University of California at San Francisco perinatal database. Medical record review and patient interviews provided information on membrane rupture, history of bathing during labor, and relaxation and pain relief perceived by patients who experienced water bathing during labor.nnnRESULTSnThere was no statistically significant association between water baths during labor and the occurrence of chorioamnionitis or endometritis (odds ratio 0.93 [95% confidence interval 0.53 to 1.63]).nnnCONCLUSIONSnWater baths during labor are not associated with chorioamnionitis or endometritis.

WEIGHT GAIN BY GESTATIONAL AGE IN BOTH BLACK AND WHITE WOMEN DELIVERED OF NORMAL-BIRTH-WEIGHT AND LOW-BIRTH-WEIGHT INFANTS

Although adequate maternal weight gain during pregnancy is widely acknowledged as a desirable goal, a contemporary standard for weight gain over the entire period of gestation based on a low-risk U.S. population has not been available. Information about usual weight gain in early pregnancy was particularly lacking. In a study monitoring various aspects of prenatal care in women in a population-based case-control study of low birth weight, we collected information on weight gain at various gestational ages in the 281 women who had prenatal care and were delivered of infants at a prepaid health plan facility where standardized records were kept. In white women who were delivered of infants who weighed greater than or equal to 3000 gm, average weight gain was 5.3 pounds at 9 to 10 weeks gestation, 10.5 pounds at 11 to 20 weeks, 24.2 pounds at 21 to 30 weeks, and 35.1 pounds at 31 to 40 weeks. Weight gain among black women delivered of infants who weighed greater than or equal to 3000 gm was 4.2 pounds at 9 to 10 weeks gestation, 14.8 pounds at 11 to 20 weeks, 24.5 pounds at 21 to 30 weeks, and 33.9 pounds at 31 to 40 weeks. Weight gain was highly variable at all gestational ages in both black and white women. Weight gain in both black and white women delivered of infants with weights greater than or equal to 3000 gm was linear at a rate of about 0.66 pounds per week from 8 through 20 weeks gestation and linear at a rate of 1.06 pounds per week after week 20.