Robert Lapinski

Delayed childbearing and the outcome of pregnancy.

Whether women who delay childbearing are at increased risk for adverse outcomes of pregnancy is of concern because of the growing proportion of first births to older women. We assessed the effect of advancing maternal age on the outcome of pregnancy in first births in a hospital-based cohort study of 3917 private patients who were 20 years of age or older with a singleton gestation. There was a slight elevation in the risk of having a low-birth-weight infant among women who were 35 years of age or older (adjusted odds ratio, 1.3; 95 percent confidence interval, 0.9 to 1.9) as compared with the risk among women 20 to 29 years of age. However, there was no evidence that women between 30 and 34 or those 35 and older had an increased risk of having a preterm delivery or of having an infant who was small for gestational age, had a low Apgar score, or died in the perinatal period. In contrast, even after controlling for sociodemographic and medical risk factors, we found that women who were 35 or older were significantly more likely to have specific antepartum and intrapartum complications and those who were 30 or older were significantly more likely to have both cesarean sections and infants who were admitted to the newborn intensive care unit. This study suggests that although older primiparous women have higher rates of complications of pregnancy and delivery, their risk of a poor neonatal outcome is not appreciably increased.

Pregnancy outcome and weight gain recommendations for the morbidly obese woman.

Objective To examine the anatomic identity of sonographically visible sphincteric structures of the female urethra. Methods The urethra, urinary bladder, and vagina were removed from 11 fresh female cadavers and placed in a water bath. Intraurethral ultrasound was performed with a 360°-rotating 7.5-MHz ultrasound probe. Afterward, the specimens were fixed and cross sections were made transverse to the urethral axis at 5-mm intervals. Corresponding ultrasonograms and histologic images were matched and depicted simultaneously side by side. The anatomic identity of sonographically visible structures was determined by histologic examination and thickness of the longitudinal smooth urethral sphincter measured. Results Structures visible sonographically were the striated and smooth urethral sphincter muscle layers, vagina, and blood vessels with diameters exceeding 0.2 mm. The longitudinal smooth muscle layer appeared as a well-defined internal hypoechoic ring. The outer circular smooth muscle layers and the striated muscle layers were a more irregular and hyperechoic zone. The circular smooth muscle layers and the striated sphincter muscle layers could not always be differentiated easily. With formalin fixation, tissue shrinkage resulted in a smaller thickness of the longitudinal smooth muscle measured on the histologic specimen. Conclusion With intraurethral ultrasound, the longitudinal smooth muscle layer appears as a well-defined and measurable hypoechoic ring. The region of the circular smooth muscle and the striated muscle emerges as a hyperechoic and less definable outer zone.Objective To compare pregnancy outcomes between morbidly obese and nonobese women and to determine the effect of gestational weight gain on pregnancy outcome in morbidly obese women. Methods A retrospective cohort study was conducted comparing 613 morbidly obese and 11,313 nonobese women who were delivered of a singleton live birth. Morbid obesity was defined as a body mass index greater than 35. The incidence of selected perinatal and neonatal outcomes was assessed for the two groups. Multiple logistic regression analysis was used to evaluate the association between morbid obesity and various measures of outcome while controlling for potential confounders. A subanalysis of the morbidly obese patients was performed to assess the effect of gestational weight gain on pregnancy outcome. Results Morbidly obese patients were more likely to experience pregnancy complications including diabetes, hypertension, preeclampsia, and arrest-of-labor disorders; however, these were not affected by gestational weight gain. Morbidly obese patients were more likely to experience fetal distress and meconium and to undergo cesarean delivery than their nonobese counterparts (P < .05). Weight gains of more than 25 lb were associated strongly with birth of a large for gestational age (LGA) neonate (P < .01); however, poor weight gain did not appear to increase the risk of delivery of a low birth weight neonate. Conclusion Gestational weight gain was not associated with adverse perinatal outcome, but it did influence neonatal outcome. To reduce the risk of delivery of an LGA newborn, the optimal gestational weight gain for morbidly obese women should not exceed 25 lb.

Pregnancy outcome at age 40 and older

Objective To examine pregnancy outcome among women age 40 years and older. Methods A retrospective cohort study, including 1404 pregnant women at least 40 years of age and 6978 controls age 20–29 years, was conducted. The two groups were stratified, according to parity, to facilitate separate analysis. Associations between maternal age and pregnancy outcomes were assessed with the contingency χ2 or two-tailed Fisher exact test. Multiple logistic regression was used to evaluate these associations and allowed for calculation of adjusted odds ratios (OR). Results Older gravidas were more likely to develop gestational diabetes (nulliparas: OR 2.7,95% confidence interval [CI] 1.9–3.7; multiparas: OR 3.8, 95% CI 2.7–5.4), preeclampsia (nulliparas: OR 1.8, 95% CI 1.3–2.6; multiparas: OR 1.9, 95% CI 1.2–2.9), and placenta previa (nulliparas: OR 13.0, 95% CI 4.8–35.0; multiparas: OR 6.4, 95% CI 2.6–15.6). Older women were also at increased risk for cesarean delivery (nulliparas: OR 3.1, 95% CI 2.6–3.7; multiparas: OR 3.3, 95% CI 2.6–4.1), operative vaginal delivery (nulliparas: OR 2.4, 95% CI 1.9–2.9; multiparas: OR 1.5, 95% CI 1.2–1.9), and induction of labor (nulliparas: OR 1.5, 95% CI 1.2–1.8; multiparas: OR 1.4, 95% CI 1.1–1.7). Older nulliparas had an increased incidence of abnormal labor patterns (OR 1.4, 95% CI 1.2–1.7), neonatal intensive care unit admissions (OR 1.6, 95% CI 1.2–2.2), and low l-minute Apgar scores (OR 2.3, 95% CI 1.1–4.9). Older multiparas were more likely to experience fetal distress (OR 2.0, 95% CI 1.4–2.8), antepartum vaginal bleeding (OR 1.8, 95% CI 1.1–3.1), and preterm premature rupture of membranes (OR 1.7, 95% CI 1.1–2.9). Conclusion Although maternal morbidity was increased in the older gravidas, the overall neonatal outcome did not appear to be affected.

Risk factors for preterm birth subtypes.

To assess epidemiologic risk factors for preterm birth subcategories in an urban population, we undertook a study of 31,107 singleton livebirths that took place at Mount Sinai Hospital in New York City between 1986 and 1994. We subdivided the preterm births into preterm premature rupture of the membranes, preterm labor, and medically induced births. We obtained information regarding the preterm subtypes and their epidemiologic risk factors from a computerized perinatal database. Adjusted odds ratios showed an increased risk for all three preterm birth subtypes in women who were black (1.9 for preterm premature rupture of membranes, 2.1 for preterm labor, and 1.7 for medically induced births) or Hispanic (1.7 for preterm premature rupture of membranes, 1.9 for preterm labor, and 1.6 for medically induced births), those who had had a previous preterm birth (3.2 for preterm premature rupture of membranes, 4.5 for preterm labor, and 3.3 for medically induced births), those who began prenatal care after the first trimester (1.4 for preterm premature rupture of membranes, 1.3 for preterm labor, and 1.3 for medically induced births), women who had been exposed to diethylstilbestrol in utero (3.1 for preterm premature rupture of membranes, 4.1 for preterm labor, and 3.7 for medically induced births), patients with preexisting diabetes mellitus (2.2 for preterm premature rupture of membranes, 2.4 for preterm labor, and 9.5 for medically induced births), and those with antepartum bleeding (2.8 for preterm premature rupture of membranes, 3.6 for preterm labor, and 3.7 for medically induced births). Other sociodemographic, constitutional, life-style, and obstetrical characteristics differed across the groups. Variation in some of the risk factors among the preterm subtypes implies that epidemiologic assessment of the more specific outcomes would be advisable. (Epidemiology 1998;9:279–285)

Perinatal outcomes in inflammatory bowel disease

Objective: To determine whether inflammatory bowel disease (IBD) is associated with increased risk for adverse perinatal outcome. Methods: A case–control study of 116 singleton pregnancies with IBD compared to 56 398 singleton controls delivered between 1986 and 2001. Results: Patients with IBD were slightly older (32.8 vs. 30.6 years, p < 0.001), more likely to be Caucasian or Asian than Black or Latino (92% vs. 57%, p < 0.001) and have private health insurance (33% vs. 3%, p < 0.001). IBD was associated with an increased risk for labor induction (32% vs. 24%, p = 0.002), chorioamnionitis (7% vs. 3%, p = 0.04) and Cesarean section (32% vs. 22%, p = 0.007), but there were no differences in neonatal outcomes. Subgroup analysis demonstrated an increased risk for low birth weight (LBW) in the ulcerative colitis group vs. the Crohns disease group (19% vs. 0%, p = 0.002). Patients with prior surgery for IBD had a lower incidence of LBW (0% vs. 12%, p = 0.03). Flares during pregnancy were associated with an increased risk for preterm delivery (27% vs. 8%, p = 0.02) and LBW (32% vs. 3%, p = 0.003). Conclusion: IBD was an independent risk factor for Cesarean section but there was no increase in adverse perinatal outcome. Crohns disease, prior IBD surgery and quiescent disease were associated with a lower risk for LBW.

Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy

OBJECTIVE To evaluate the long-term clinical significance of intrauterine hematomas detected in the first trimester of pregnancy in a general obstetric population. METHODS A prospective study was designed to compare perinatal outcomes in 187 pregnant women with intrauterine hematomas and 6488 controls in whom hematomas were not detected at first-trimester ultrasonographic examination. RESULTS The incidence of intrauterine hematoma in the first trimester in a general obstetric population was 3.1%. A retroplacental position of the hematoma was significantly correlated with an increased risk for adverse maternal and neonatal complications. The presence or absence of symptoms of threatened abortion did not affect these outcomes. The rates of operative vaginal delivery (relative risk [RR] 1.9; confidence interval [CI] 1.1, 3.2) and cesarean delivery (RR 1.4; CI 1.1, 1.8), as well as the rates of pregnancy-induced hypertension (RR 2.1; CI 1.5, 2.9) and preeclampsia (RR 4.0; CI 2.4, 6.7), were significantly greater in the hematoma group. Placental abruption (RR 5.6; CI 2.8, 11.1) and placental separation abnormalities (RR 3.2; CI 2.2, 4.7) were also significantly more frequent in the hematoma group. Perinatal complications, including the rate of preterm delivery (RR 2.3; CI 1.6, 3.2), fetal growth restriction (RR 2.4; CI 1.4, 4.1), fetal distress (RR 2.6; CI 1.9, 3.5), meconium-stained amniotic fluid (RR 2.2; CI 1.7, 2.9), and neonatal intensive care unit admission (RR 5.6; CI 4.1, 7.6), were also significantly increased in this group. Furthermore, the frequency of intrauterine demise and perinatal mortality was increased in the hematoma group, but this difference did not reach statistical significance (Ps = .6 and .2). CONCLUSION Our study suggests that the presence of an intrauterine hematoma during the first trimester may identify a population of patients at increased risk for adverse pregnancy outcome.

Twin pregnancies conceived by assisted reproductive techniques: maternal and neonatal outcomes.

Objective To determine whether twin pregnancies conceived by assisted reproductive techniques are at increased risk for obstetric complications or perinatal morbidity. Methods A computerized perinatal data base was reviewed for all twin pregnancies managed by private obstetricians and delivered between 1990 and 1995. The obstetric and neonatal outcomes of those conceived following in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) were compared to the outcomes of those conceived spontaneously. Results There were 105 twin deliveries following IVF or GIFT and 279 following natural fertilization. Discordant birth weight and low birth weight occurred more frequently in pregnancies conceived by IVF or GIFT (adjusted odds ratio [OR] 2.11, 95% confidence interval [CI] 1.14, 3.91; OR 1.65, 95% CI 0.98, 2.79, respectively). Elective cesarean delivery was more frequent in twin pregnancies conceived after IVF GIFT (relative risk [RR] 4.02, 95% CI 1.28, 12.6). There were no statistically significant differences in the frequency of antepartum or intrapartum complications, preterm delivery, or mean gestational age at delivery. There was no statistically significant increase in the frequency of neonatal complications among infants born after IVF GIFT. Conclusion Although twin pregnancies following IVF or GIFT are more likely to result in discordant birth weight infants, the perinatal outcome is comparable to that of spontaneously conceived twin pregnancies.

Maternal and neonatal risk factors for cryptorchidism.

We assessed risk factors for Cryptorchidism in a prospective hospital-based cohort study at Mount Sinai Hospital in New York City. We examined at birth 6,699 singleton male neonates who were delivered between October 1987 and October 1990. Follow-up examinations were undertaken at 3 months and 1 year for those diagnosed as cryptorchid at birth. We calculated prevalence ratios and adjusted odds ratios according to selected maternal and neonatal characteristics for those who remained cryptorchid at the 1-year assessment. We found elevated risks for maternal obesity [prevalence ratio = 2.42; 95% confidence interval (CI) = 1.11–5.27], for infants delivered by cesarean section (adjusted odds ratio = 2.17; 95% CI = 1.29–3.65), for low birthweight (adjusted odds ratio = 2.29; 95% CI = 1.12–4.70), for preterm birth (adjusted odds ratio = 2.25; 95% CI = 1.16–4.35), and for infants with congenital malformations (prevalence ratio = 13.97; 95% CI = 1.27–26.67). We observed a seasonal effect, with a peak in births of cryptorchid infants during September through November and a smaller peak during the months of March through May. We found no evidence that young women, white women, or primiparas were at increased risk.

Perinatal outcome in grand and great-grand multiparity: Effects of parity on obstetric risk factors

OBJECTIVE We sought to compare obstetric and neonatal complications among great-grand multiparous, grand multiparous, and multiparous women. STUDY DESIGN One hundred thirty-three great-grand multiparas, 314 grand multiparas, and 2195 multiparas who were delivered of their infants between 1988 and 1998 were selected for the study. To facilitate comparison, the patients were all >35 years old and had similar socioeconomic characteristics. RESULTS The incidence of malpresentation at the time of delivery, maternal obesity, anemia, preterm delivery, and meconium-stained amniotic fluid increased with higher parity, whereas the rate of excessive weight gain and cesarean delivery decreased. Compared with grand multiparas, great-grand multiparas had significantly elevated risks for abnormal amounts of amniotic fluid, abruptio placentae, neonatal tachypnea, and malformations but lower rates of placenta previa (P <.05). The incidence of postpartum hemorrhage, preeclampsia, placenta previa, macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand multiparas than in multiparas, whereas the proportion of induction, forceps delivery, and total labor complications was significantly lower than in the multiparous group (P <.05). Similar frequency of maternal diabetes, infection, uterine wall scar rupture, variations in fetal heart rate, fetal death, and neonatal mortality was found in the 3 groups. CONCLUSION Both high-parity groups have their own risk factors, but the rate of some complications decreases with higher parity. In addition, perinatal mortality remains low in these patients, and therefore, under satisfactory socioeconomic and health care conditions, high parity should not be considered dangerous.

An elevated day three follicle-stimulating hormone:luteinizing hormone ratio (FSH:LH) in the presence of a normal day 3 FSH predicts a poor response to controlled ovarian hyperstimulation

OBJECTIVE To determine if an elevated FSH:LH ratio predicts response in infertile patients undergoing controlled ovarian hyperstimulation (COH) for IVF-ET. DESIGN Retrospective study. SETTING The Division of Reproductive Endocrinology at the Mount Sinai Medical Center, New York, New York. PARTICIPANTS Seventy-four patients undergoing IVF-ET using similar protocols for COH with day 3 FSH, LH, and E2 testing available for analysis. All patients were < 41 years of age and had day 3 serum FSH < 15 mIU/mL (conversion to SI unit, 1.00). MAIN OUTCOME MEASURES Follicle-stimulating hormone:LH ratio, day 8 serum E2, peak serum E2, cancellation rate, pregnancy rate, and number and size of follicles. RESULTS An FSH:LH ratio > or = 3.6 (group I) predicted a poor response to COH (sensitivity 85.7% and specificity 95%). There were no significant differences regarding day 3 serum FSH and ampules of gonadotropins used for COH. Group I (ratio > or = 3.6) patients responded to COH with lower day 8 E2 (97 +/- 18 versus 319 +/- 36 pg/mL; conversion factor to SI unit, 3.671), peak E2 (422 +/- 115 versus 2,368 +/- 183 pg/mL), and fewer follicles > 15 mm (1.3 +/- 0.5 versus 17.1 +/- 1.0). In group I the cycle cancellation rate (12/14) was significantly higher than the group II cycle cancellation rate (2/60) and pregnancy rate in group II (ratio < 3.6) was 25%. CONCLUSIONS The FSH:LH ratio may increase before a dramatic increase in serum FSH is observed and appears to be a useful marker of ovarian reserve.