Robert L. Goldenberg

The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation ☆ ☆☆ ★

OBJECTIVE Our purpose was to determine whether various measures of poor psychosocial status in pregnancy are associated with spontaneous preterm birth, fetal growth restriction, or low birth weight. STUDY DESIGN Anxiety, stress, self-esteem, mastery, and depression were assessed at 25 to 29 weeks in 2593 gravid women by use of a 28-item Likert scale. Scores for each psychosocial subscale were determined, and an overall psychosocial score was calculated. Scores were divided into quartiles, and the lowest quartile scores were used to define poor psychosocial status. The percent spontaneous preterm birth, low birth weight, and fetal growth restriction in women with low and high psychosocial scores were compared. Logistic regression analyses provided the odds ratios and 95% confidence intervals. RESULTS Analyses revealed that stress was significantly associated with spontaneous preterm birth and with low birth weight with odds ratios of 1.16, p = 0.003, and 1.08, p = 0.02, respectively, for each point on the scale. A low score on the combined scale or on any subscale other than stress did not predict spontaneous preterm birth, fetal growth restriction, or low birth weight. After multivariate adjustment was performed for psychosocial status, substance use, and demographic traits, black race was the only variable significantly associated with spontaneous preterm birth, fetal growth restriction, and low birth weight; stress and low education were associated with spontaneous preterm birth and low birth weight. CONCLUSION Stress was associated with spontaneous preterm birth and low birth weight even after adjustment for maternal demographic and behavioral characteristics. Black race continues to be a significant predictor of spontaneous preterm birth, fetal growth restriction, and low birth weight even after adjustment for stress, substance use, and other demographic factors.

Trial of calcium to prevent preeclampsia

Background Previous trials have suggested that calcium supplementation during pregnancy may reduce the risk of preeclampsia. However, differences in study design and a low dietary calcium intake in the populations studied limit acceptance of the data. Methods We randomly assigned 4589 healthy nulliparous women who were 13 to 21 weeks pregnant to receive daily treatment with either 2 g of elemental calcium or placebo for the remainder of their pregnancies. Surveillance for preeclampsia was conducted by personnel unaware of treatment-group assignments, using standardized measurements of blood pressure and urinary protein excretion at uniformly scheduled prenatal visits, protocols for monitoring these measurements during the hospitalization for delivery, and reviews of medical records of unscheduled outpatient visits and all hospitalizations. Results Calcium supplementation did not significantly reduce the incidence or severity of preeclampsia or delay its onset. Preeclampsia occurred in 158 of the 2295 wome...

Risk factors associated with preeclampsia in healthy nulliparous women

Abstract Objective: Our goal was to identify risk factors for the development of preeclampsia in nulliparous women enrolled in a multicenter trial comparing calcium supplementation to a placebo. Study Design: A total of 4589 women from five centers was studied. Analysis of risk factors for preeclampsia was performed in 4314 who carried the pregnancy to >20 weeks. Baseline systolic and diastolic blood pressure, demographic characteristics, and findings after randomization were examined for the prediction of preeclampsia. Preeclampsia was defined as hypertension (diastolic blood pressure ≥90 mm Hg on two occasions 4 hours to 1 week apart) and proteinuria (≥300 mg/24 hours, a protein/creatinine ratio ≥0.35, one dipstick measurement ≥2+ or two dipstick measurements ≥1+ at an interval as specified for diastolic blood pressure). Results: Preeclampsia developed in 326 women (7.6%). The first analysis treated each risk factor as a categoric variable in a univariate regression. Maternal age, blood group and Rh factor, alcohol use, previous abortion or miscarriage, private insurance, and calcium supplementation were not statistically significant. Risk factors initially found to be significant were body mass index, systolic blood pressure, diastolic blood pressure, non-white race (African-American and other), clinical center, and smoking. Adjusted odds ratios computed with a Iogistic regression model revealed that body mass index (odds ratio 3.22 for ≥35 kg/m 2 vs 2 ), systolic blood pressure (odds ratio 2.66 for ≥120 vs p Conclusion: These risk factors should be of value in counseling women regarding preeclampsia and should aid in understanding the pathophysiologic characteristics of this syndrome.

The management of preterm labor

Preterm birth is the leading cause of neonatal mortality and a substantial portion of all birth-related short- and long-term morbidity. Spontaneous preterm labor is responsible for more than half of preterm births. Its management is the topic of this review. Although there are many maternal characteristics associated with preterm birth, the etiology in most cases is not clear, although, for the earliest cases, the role of intrauterine infection is assuming greater importance. Most efforts to prevent preterm labor have not proven to be effective, and equally frustrating, most efforts at arresting preterm labor once started have failed. The most important components of management, therefore, are aimed at preventing neonatal complications through the use of corticosteroids and antibiotics to prevent group B streptococcal neonatal sepsis, and avoiding traumatic deliveries. Delivery in a medical center with an experienced resuscitation team and the availability of a newborn intensive care unit will ensure the best possible neonatal outcomes. Obstetric practices for which there is little evidence of effectiveness in preventing or treating preterm labor include the following: bed rest, hydration, sedation, home uterine activity monitoring, oral terbutaline after successful intravenous tocolysis, and tocolysis without the concomitant use of corticosteroids.

Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.

The preterm prediction study: Fetal fibronectin testing and spontaneous preterm birth*

Objective To evaluate the presence of fetal fibronectin in the cervix and vagina as a screening test for spontaneous preterm birth. Methods Two thousand nine hundred twenty-nine women at ten centers were routinely screened every 2 weeks from 22–24 to 30 weeks for cervical and vaginal fetal fibronectin. A positive test was defined as a value equal to or greater than 50 ng/mL. The relation between a positive test at four gestational ages and spotaneous pretern birth at various intervals after the test was determined. Results In each testing period 3–4% of the fetal fibronectin tests were positive. The correlation between cervical and vaginal fetal firbonectin at the same visit was always approximately 0.7 (P < .001), and that between cervical or vaginal fetal fibronectin in consecutive visits was between 0.17 and 0.25 (P < .001). The sensitivity of fetal fibronectin at 22–24 weeks to predict spontaneous preterm birth at less than 28 weeks was 0.63, and the relative risk for a positive versus negative test was 59. The specificity was always 96–98%, whereas the positive predictive value rose from 13% to 36% as the upper limit of the definition of preterm birth was increased from less than 28 to less than 37 weeks. The relative risk for spontaneous preterm birth after a positive fetal fibronectin test compared with a negative fetal fibronectin test varied substantially by testing period and by the definition of spontaneous preterm birth, but always remained greater than 4 and statistically significant. Conclusion A positive cervical or vaginal fetal fibronectin test at 22–24 weeks predicted more than half of the spontaneous preterm births at less than 28 weeks (sensitivity 0.63). As the definition of spontaneous preterm birth was extended to include later gestational ages or when the fetal fibronectin test was performed later in pregnancy, the level of association between a positive fetal fibronectin test and spontaneous preterm birth, while remaining highly significant, tended to decrease. Although fetal fibronectin is an excellent test for predicting spontaneous preterm birth, we present no evidence that the use of this test will result in a reduction in spontaneous preterm birth.

The infectious origins of stillbirth

OBJECTIVE Our objective was to determine the relationship between various types of perinatal infections and stillbirths. STUDY DESIGN By use of various textbooks on perinatal infections, multiple MEDLINE searches, and the reference list of all appropriate manuscripts, the appropriate English language literature was reviewed to define the relationship between various perinatal infections and stillbirths. RESULTS Infection may cause stillbirth by a number of mechanisms, including direct infection, placental damage, and severe maternal illness. A large variety of organisms have been associated with stillbirth, including many bacteria, viruses, and protozoa. In developed countries, between 10% and 25% of stillbirths may be caused by an infection, whereas in developing countries, which often have much higher stillbirth rates, the contribution of infection is much greater. Ascending bacterial infection, both before and after membrane rupture, with organisms such as Escherichia coli, group B streptococci, and Ureaplasma urealyticum is usually the most common infectious cause of stillbirth. However, in areas where syphilis is very prevalent, up to half of all stillbirths may be caused by this infection alone. Malaria may be an important cause of stillbirth in women infected for the first time in pregnancy. The two most important viral causes of stillbirth are parvovirus and Coxsackie virus, although a number of other viral infections appear to be causal. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, and the organisms that cause leptospirosis, Q fever, and Lyme disease have all been implicated as etiologic for stillbirth. CONCLUSION Because infection-related stillbirth is relatively rare in developed countries, and those that do occur are caused by a wide variety of organisms, reducing this etiologic component of stillbirth much further will be difficult. However, in certain developing countries, the stillbirth rate is so high and the infection-related component so great that achieving a substantial reduction in stillbirth should be possible simply by reducing maternal infections.

A multicenter study of preterm birth weight and gestational age-specific neonatal mortality

OBJECTIVE This analysis was performed to present updated neonatal mortality data by age and birth weight for preterm newborns and to demonstrate the influence of plurality, ethnicity, and infant sex on mortality. STUDY DESIGN Preterm birth weight and gestational age-specific mortality rates were compiled from the five centers that participated in the March of Dimes Multicenter Preterm Birth Prevention Project. In each center gestational age was assessed by standardized methods. A birth weight and gestational age-specific mortality chart for preterm births was created with live-birth data. RESULTS In each birth weight group mortality decreased as the gestational age advanced; for each gestational age group heavier infants had less mortality. Female infants < 29 weeks survived better than male infants, and singletons < 29 weeks survived better than twins. Survival for black preterm newborns was better than that of whites but differences were not significant. Mortality for black term infants was significantly higher. The largest improvement in survival occurred between 25 and 26 weeks. At 30 weeks survival was > 90% and improved < 1% per week thereafter. CONCLUSIONS When compared with rates in previous reports, mortality rates appear to have improved, especially at gestational ages < 29 weeks. These data may be useful in decision-making and in counseling patients at risk for preterm delivery.

Neonatal morbidity according to gestational age and birth weight from five tertiary care centers in the United States, 1983 through 1986.

OBJECTIVES This study details the incidence, by gestational age and birth weight, of specific neonatal morbidities in singleton neonates without major congenital anomalies. STUDY DESIGN Data were prospectively collected on all deliveries at five tertiary centers in the United States during the years 1983 through 1986. Pregnancies were meticulously dated and the gestational ages of the neonates at delivery were confirmed by Dubowitz score. RESULTS The incidence of respiratory distress syndrome gradually decreases with increasing gestational age until 36 weeks. A marked decrease in the incidence of necrotizing enterocolitis, patent ductus arteriosus, intraventricular hemorrhage, and sepsis occurs after 32 completed weeks. The number of days of mechanical ventilation for respiratory distress syndrome and newborn stay in the tertiary care facility also were significantly reduced after 32 weeks. CONCLUSIONS The incidence of both respiratory distress syndrome and patent ductus arteriosus is markedly decreased by both increasing gestational age and birth weight. The incidence of grade III and IV intraventricular hemorrhage, necrotizing enterocolitis, and sepsis virtually vanishes after 34 weeks. These data relating neonatal morbidities to gestational age are important to the obstetrician in the critical decision regarding the timing of delivery and to the parents, who can benefit from a realistic prediction of the neonatal course.

Medical, psychosocial, and behavioral risk factors do not explain the increased risk for low birth weight among black women☆☆☆★★★

OBJECTIVE Our purpose was to determine whether various demographic, behavioral, housing, psychosocial, or medical characteristics explain the difference in pregnancy outcome between black and white women. STUDY DESIGN A sample of 1491 multiparous women with singleton pregnancies, 69% of whom were black and 31% of whom were white and who enrolled for care between Oct. 1, 1985, and March 30, 1988, participated in the study. The frequencies of various demographic, medical environmental, and psychosocial risk factors among black and white women were determined. The outcome measures were birth weight, gestational age, fetal growth restriction, preterm delivery and low birth weight. RESULTS White infants were heavier and born later than black infants. The white women in this sample smoked more cigarettes, moved more frequently, and had worse psychosocial scores. The black women had lower incomes, were less likely to be married, and had more hypertension, anemia, and diabetes. Besides race, only maternal height, weight, blood pressure, diabetes, and smoking had a consistent impact on outcome and did not explain the difference in outcome between the two groups. CONCLUSION In this low-income population, many of the risk factors for low birth weight were more common among white women than black women. Nevertheless, black women had more infants born preterm, with growth restriction, and with low birth weight than did white women. The various maternal characteristics studied did not explain these differences.