Richard H. Aubry

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.

High-risk obstetrics: II. Value of semiobjective grading system in identifying the vulnerable group

An arbitrary system of levying penalties against all presumed adverse obstetric factors was devised. Abnormal conditions were grouped into eight categories and degrees of anticipated perinatal vulnerability were expressed as a numerical value resulting from the sum of all such penalties subtracted from a perfect score of 100. Index scores assigned to 1,001 consecutive ward service patients at the time of their initial prenatal visit permitted three general groupings: a high-risk group with scores of less than 70, 299 patients; a moderate-risk group with scores of 70 to 84, 390 patients; and a low-risk group with scores of 85 or over, 312 patients. There was a consistent trend for patients with the lowest scores to yield the poorest obstetric results. In general, the risk of antenatal and intrapartum complications as well as of poor perinatal outcome among the low scoring patients (29 per cent of the total) was twice as great as that observed in the remaining 71 per cent. This obstetric approach which includes aggressive laboratory investigation can be expected to identify in a broad sample of pregnant women a group of approximately 30 per cent who will give rise to 60 per cent or more of all pathologic outcomes. Gradations of risk occur even within socially deprived groups and the use of a simple, relatively sensitive screening device of the type presented permits a sharper focus of attention and intensification of effort upon the most vulnerable minority.

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.

High-risk obstetrics

A control series of 20 normal obstetric patients and 133 high-risk patients, exhibiting diabetes, chronic hypertension, and/or a history of repeated premature births were evaluated with serial determinations of estriol, pregnanediol, and quantitative chorionic gonadotropin excretion as well as vaginal hormonocytology as measured by the karyopyknotic index. The cytohormonal profile of these vulnerable patients who experienced normal outcome of pregnancy, in addition to those who experienced fetal death, premature labor, or gave birth to an underweight infant, was presented and the predictive reliability for each assessment singly and in combination was determined. Estriol was the most sensitive reflector of fetal status in states of both chronic and acute stress and the predictive reliability of tests in combination was not significantly greater than that of estriol alone. The finding of depressed estriol excretion among complicated pregnancies eventuating in apparently normal perinatal outcome suggests that subtle degrees of fetal jeopardy may occur which escape notice in the usual clinical evaluations. Our experience indicates that it is unlikely that fetal mortality can be dramatically reduced by the use of cytohormonal tests; however, by detecting patients who can be safely allowed to continue in pregnancy without early obstetric interference, some of the well-known hazards associated with prematurity may be avoided.

Investigation of Metronidazole Use during Pregnancy and Adverse Birth Outcomes

ABSTRACT To assess whether treatment with metronidazole during pregnancy is associated with preterm birth, low birth weight, or major congenital anomalies, we conducted chart reviews and an analysis of electronic data from a cohort of women delivering at an urban New York State hospital. Of 2,829 singleton/mother pairs, 922 (32.6%) mothers were treated with metronidazole for clinical indications, 348 (12.3%) during the first trimester of pregnancy and 553 (19.5%) in the second or third trimester. There were 333 (11.8%) preterm births, 262 (9.3%) infants of low birth weight, and 52 infants (1.8%) with congenital anomalies. In multivariable analysis, no association was found between metronidazole treatment and preterm birth (odds ratio [OR], 1.02 [95% confidence interval [CI], 0.80 to 1.32]), low birth weight (OR, 1.05 [95% CI, 0.77 to 1.43]), or treatment in the first trimester and congenital anomalies (OR, 0.86 [0.30 to 2.45]). We found no association between metronidazole treatment during the first or later trimesters of pregnancy and preterm birth, low birth weight, or congenital anomalies.

Amnioinfusion and the intrauterine prevention of meconium aspiration.

OBJECTIVE We evaluated the published literature on the effectiveness of amnioinfusion in reducing meconium below the vocal cords and meconium aspiration syndrome among infants born to women presenting with more than trace meconium-stained fluid. STUDY DESIGN A literature search was conducted to evaluate clinical trials of amnioinfusion and meconium aspiration. Trials meeting certain basic design criteria (n = 5), which included a prospective study design and blinded assessment of newborn outcome, were selected for statistical analyses estimating the average effects size and direction. In total, 247 women with meconium-stained fluid receiving amnioinfusion and 260 women with meconium-stained fluid not receiving amnioinfusion were represented by these trials. RESULTS Infants born to women with meconium-stained fluid receiving amnioinfusion were less likely to have meconium below the vocal cords (odds ratio 0.13, 95% confidence interval 0.08 to 0.20) and were less likely to have meconium aspiration syndrome (odds ratio 0.20, 95% confidence interval 0.08 to 0.48) than were infants born to women with meconium-stained fluid not receiving amnioinfusion. DISCUSSION Amnioinfusion appears to be an effective intrauterine intervention for the prevention of meconium aspiration. Clinicians should consider implementing amnioinfusion in women presenting with thick meconium to prevent intrapartal meconium aspiration in newborns.

Effects of intimate partner violence on pregnancy trauma and placental abruption.

AIMS Intimate partner violence (IPV) during pregnancy increases womens risk of pregnancy complications and adverse birth outcomes. The goal of this study was to examine the association between IPV and prenatal trauma and placental abruption during pregnancy. METHODS Prenatal and hospital obstetrical charts were reviewed for 2873 women who gave birth between January 2000 and March 2002 in a Northeastern city. We examined associations among sociodemographic characteristics, health-related variables, IPV, and pregnancy trauma and placental abruption using univariate and multivariate logistic regression. RESULTS Of the 2873 women in the analyses, 105 (3.7%) reported IPV during prenatal care. After controlling for sociodemographic variables; tobacco, alcohol, and drug use; preeclampsia; and gestational diabetes during pregnancy, women who reported IPV also had higher odds of pregnancy trauma and placental abruption (adjusted odds ratio [OR] 32.08, 95% confidence interval [CI] 14.33-71.80, p < 0.01, and OR 5.17, 95% CI 1.37-19.51, p < 0.05, respectively). CONCLUSIONS This study found that IPV is a significant and independent risk factor for pregnancy trauma and placental abruption after controlling for factors typically associated with these outcomes. This study has implications for partner violence screening and intervention policies among pregnant women and highlights the importance of making distinctions about the type of IPV that women experience.

Fetal pulmonary maturity as determined by fluorescent polarization of amniotic fluid

Abstract A special technique, fluorescent polarization (F.P.) has been used to measure the microviscosity of amniotic fluid. A total of 151 samples of amniotic fluid from 118 patients, both normal and high-risk, were included in this study. The results were compared to L/S ratios and to the neonatal outcomes. The F.P. value was found to decrease as pregnancy progressed, and a value of 0.345 or less was found to be associated with apparent fetal lung maturity. The correlation between the F.P. value and the L/S ratio was good when mature results were compared (L/S >2 and F.P.≤0.345). When the L/S ratio was immature ( 345) developed RDS and three of these died with hyaline membrane disease. In 83 patients delivered within 48 hours of the amniotic fluid sampling, the predictive value of the F.P. increased to 100 per cent but that of the L/S ratio remained 14 per cent.

Racial and ethnic disparities in infant mortality: risk in social context.

This article presents the multifaceted efforts of Syracuse Healthy Start, a federally funded initiative of the Onondaga County Health Department and over 20 partnering agencies to reduce racial and ethnic disparities in infant mortality. The analyses presented in this article demonstrate that many women--Caucasian, African American, and Hispanic--have serious risks for low birth weight and infant death. In many cases, multiple, simultaneous risks complicate a pregnant womans situation and in other cases the longitudinal cumulative risks impact health across generations. Infant mortality decreased overall, and for both Caucasian and African American infants during the first 3 years of the project.

High-risk obstetrics: I. Perinatal outcome in relation to a broadened approach to obstetric care for patients at special risk☆

Abstract A special clinical facility was set up to provide exemplary, individualized care to high-risk obstetric patients and to serve as a model to test the effects of broadening the scope and intensity of obstetric supervision. A method of identifying patients at risk was devised and an intensified screening and diagnostic program was instituted. Even among the disadvantaged groups, gradations of risk and variable demands for intensified and expanded care were demonstrated. Previously undetected, underlying ills were encountered in almost one third of the patients. More than one-quarter required antepartal hospitalization for diagnostic work-up and treatment. The finding of improved perinatal salvage rates based on a comparison with this vulnerable groups past obstetric record would seem to justify extending prenatal investigations and concentrating greater effort on those patients at risk.