Wendy Hansen

Factors associated with substance use during pregnancy: results from a national sample.

OBJECTIVEnTo examine the prevalence and correlates of substance use during pregnancy among women in the United States.nnnMETHODSnWe analyzed data from pregnant (n=1800) and non-pregnant women (n=37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design.nnnRESULTSnThe overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9% and 10%, respectively. Compared to the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income.nnnCONCLUSIONSnAlthough the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

Violence Against Women and Postpartum Depression

BACKGROUNDnViolence against women (VAW), including intimate partner violence (IPV) in its various forms (sexual, physical, or stalking), and childhood violence (sexual or physical) are common and are associated with depressive symptoms. We examined the association between these violence exposures and self-reported history of postpartum depression (PPD).nnnMETHODSnWomen from the Kentucky Womens Health Registry (KWHR) who reported at least one live birth were included in this study. Individual IPV and child abuse histories were examined for association with self-reported history of PPD. Multivariate regression analysis estimated adjusted risk ratios (aRR) and 95% confidence intervals (95% CI), controlling for age, obstetrical history, and substance abuse history.nnnRESULTSnThe 5380 women in the KWHR reporting at least one live birth were included in this study. Of these women, 2508 (46.6%) reported a history of any VAW. A history of adult VAW was associated with a history of PPD (aRR 1.48, 95% CI 1.12-1.95). Physical IPV (aRR 1.48, 95% CI 1.12-1.95) and stalking IPV (aRR 1.39, 95% CI1.03-1.87) were individually associated with PPD. Other types of violence were not individually associated with a history of PPD. The strength of association increased with each additional type of violence experienced (aRR1.17, 95% CI 1.06-1.30).nnnCONCLUSIONSnAdult VAW is associated with self-reported history of PPD. With an increase in the number of types of abuse experienced, this association became stronger. Our findings highlight the need for thorough VAW screening in obstetrical populations.

Sonographic Findings of Trisomy 18 in the Second Trimester of Pregnancy

Objective. The purpose of this study was to examine the sonographic findings in fetuses with trisomy 18 in the second trimester of pregnancy. Methods. A retrospective review of the cytogenetic laboratory databases at 6 tertiary referral centers identified all cases of trisomy 18. The prenatal sonographic studies in fetuses at 15 to 21 weeks gestation, done before invasive testing for the karyotype, were reviewed for anatomic and biometric findings. We defined abnormal fetal biometric findings as a biometric measurement (biparietal diameter, abdominal circumference, or femur length) below the fifth percentile in the second trimester. Results. Of 98 fetuses with trisomy 18, 95 (97%) were detected sonographically; an anomaly was found in 92 (94%). A biometric measurement below the fifth percentile was noted in 50 (51%). Cardiac (63%) and central nervous system (34%) anomalies were most frequently detected. Although choroid plexus cysts were commonly seen, no fetuses with trisomy 18 and isolated choroid plexus cysts were found. Conclusions. Targeted sonography identified abnormal fetal anatomy or abnormal biometric findings in 97% of fetuses with trisomy 18 in the second trimester. A biometric measurement below the fifth percentile was noted in half of the cases in the second trimester.

Should we treat periodontal disease during gestation to improve pregnancy outcomes

Until recently many physicians in the United States including obstetrician gynecologists have been relatively unconcerned with oral health. During most physical examinations, the oral cavity is given only a rudimentary examination. With the recognition of the oral-systemic health care link, physicians have been keenly interested in the findings from their dental colleagues in periodontal medicine which have convincingly linked periodontal disease with such diverse systemic health complications as aging, Alzheimer disease, cardiovascular disease, diabetes, and also pregnancy complications including low birth weight, preterm delivery, preeclampsia, and early pregnancy loss. Intervention trials designed to improve oral health during pregnancy have proven to be safe; however, the outcomes have been inconsistent. Further studies will be required to determine the nature of the association and the optimal timing and efficacy of intervention.

Sonographic detection of trisomy 13 in the first and second trimesters of pregnancy

The purpose of this study was to examine sonographic findings in fetuses with trisomy 13.

Up-regulation of oxytocin receptor expression at term is related to maternal body mass index.

BACKGROUNDnThe likelihood of cesarean is in part related to maternal body mass index (BMI). Myometrial changes may be responsible.nnnMETHODSnMyometrial biopsies were collected from the upper edge of the hysterotomy from women undergoing scheduled cesarean with term, singleton gestations. Oxytocin receptor and connexin-43 mRNA protein expression was quantified with real-time polymerase chain reaction and Western blot.nnnRESULTSnTwenty subjects were recruited: 13 repeat and 7 primary cesareans. Oxytocin receptor mRNA was associated with BMI among women undergoing primary (r = 0.75; p = 0.05) but not repeat cesarean (p > 0.05). Controlling for gestational age, this association strengthened (p = 0.004). Receptor protein expression showed a linear correlation with BMI in the primary cesarean group (p = 0.002). Connexin-43 mRNA expression was not related to BMI in women undergoing primary (r = -0.14, p = 0.76) or repeat (r = -0.01, p = 0.86) cesarean.nnnCONCLUSIONSnOxytocin receptor, but not connexin-43, expression is related to BMI, suggesting an alteration in oxytocin receptor expression or function related to obesity.

Prenatal diagnosis of partial trisomy 16p and its association with congenital diaphragmatic hernia.

A 30y/oG2P1001 presented at 6 6/7weeks gestation for a routine ultrasound. The gestational sac, the fetus, and the cardiac activity were normal, but the yolk sac appeared enlarged. It was round and regular, measuring 7.4mm in diameter. She denied any signs or symptoms of early pregnancy loss. Her medical history was significant for mitral valve stenosis and tobacco use (15 cigarettes per day) in the first week of pregnancy. Medications included cetirizine for seasonal allergies and prenatal vitamins. Her obstetric history revealed a full term, normal infant delivered by cesarean secondary to failure to descend. Maternal family history was significant for a sister with monosomy X. Paternal family history was significant for several male relatives with cardiac deaths prior to 40 years of age. Given the association of an enlarged yolk sac with both spontaneous abortion and aneuploidy, she returned 2weeks later for a second ultrasound. At 9weeks gestation, the gestational sac again appeared normal; interval fetal growth was normal as well as cardiac activity. The yolk sac had maintained a normal shape but continued to be very enlarged. She again denied any signs or symptoms of early pregnancy loss. Genetic counseling was completed out of concern for an increased risk for aneuploidy. The patient declined chorionic villous sampling (CVS) and opted to wait for first trimester screening or possible amniocentesis. At 12 5/7weeks gestation, she presented for first trimester screening. Fetal growth, as measured by crown rump length, and cardiac activity were normal. Nuchal translucency (NT) was thickened, measuring 3.3mm (Figure 1). She again declined CVS and elected to return for an early anatomic survey and possible amniocentesis. First trimester screening was not completed. Ultrasound at 16 6/7weeks gestation revealed a left-sided congenital diaphragmatic hernia (CDH) along with left renal pelviectasis. Fetal biometry and amniotic fluid volume were normal. She elected to have amniocentesis. Chromosome analysis identified an unbalanced translocation between one chromosome 16 and one chromosome 17 resulting in trisomy for most of the short (p) arm of chromosome 16 (p11.2!pter): (46,XX,der(17)t(16;17)(p11.2;q25.3) (Figure 2). Fluorescence in situ hybridization with the 17q subtelomere probe D17S928 identified a signal on the derivative 17 suggesting no or very minimal loss of chromosome 17 material from the derivative. There were three 16p subtelomere signals with probe 16pTEL05 confirming that the additional chromatin on 17q was derived from 16p. The cytogenetic findings were consistent with pure partial trisomy 16p. The patient elected to terminate the pregnancy given the poor prognosis of a diaphragmatic hernia due to a chromosome imbalance. Maternal and paternal chromosome analyses were normal indicating the translocation was de novo. Trisomy 16 is one of the most common chromosomal causes of spontaneous abortion in the first trimester, but its occurrence among live births is exceedingly rare. In fact, nonmosaic trisomy 16 is considered a lethal genetic imbalance. There are reports, however, of infants born with partial or complete trisomy of the short arm (p) of chromosome 16. These cases have been summarized in an effort to define the phenotype of trisomy 16p. Recurring anomalies for trisomy 16p include craniofacial abnormalities (prominent glabella, hypertelorism, anteverted nares, short philtrum, cleft palate, and micrognathia), congenital heart defects, renal anomalies, single umbilical artery, and skeletal abnormalities. The mortality rate in infancy is approximately 50%. There are rare long-term survivors. In these individuals, growth delays, severe intellectual disability, and seizures are very common. Our finding of a CDH has not been considered as part of the phenotype for trisomy 16p. However, there is a recent report of a 15 year old with a repaired CDH, dysmorphism and autism, and a microduplication of 16p11.2 detected by chromosomal microarray analysis (CMA). The molecular breakpoints were

Care of the Critically Ill Pregnant Patient

Care for the injured or critically ill pregnant woman requires a multidisciplinary approach. Over the past decades, care for the pregnant woman and fetus has changed tremendously. The fetus is now viewed as a patient, which can be intervened upon. Maternal care has progressed to preventing morbidity and mortality through anticipation of complications. In this chapter, we focus on the most common clinical challenges in caring for the critically ill obstetric patient.

Epidemiology of Trauma in Pregnancy

Purpose of the ReviewPregnant trauma patients are especially challenging given the necessity for evaluation and management of consequential maternal and fetal injuries. We have reviewed the literature and highlight the most common mechanisms of maternal trauma and fetal injury.Recent FindingsTrauma is the leading cause of non-obstetric maternal death. However, the fetus is disproportionately harmed in comparison to the mother in all reports of trauma in pregnancy: ranging from 3:1 to 9:1 fetal mortality: maternal mortality. Front airbags in pregnancy and three-point restraint systems reduce the injury to both the mother and the fetus. Injury from domestic violence has an increased prevalence in the pregnancy and also increased risk of low birth weight, preterm birth, and perinatal death. Opioid use in pregnancy has mirrored the general population, increasing each year. Up to 30% of maternal death is attributed to self-harm, with the highest rates of suicide occurring in the 1st trimester. Abruption accounts for 50–70% of fetal death following trauma and is more common among women with higher injury severity.SummaryTrauma is a significant contributor to maternal mortality as well as fetal mortality and requires a high degree of clinical suspicion. In this paper, we propose an ABCD simultaneous assessment of the fetus emphasizing a multidisciplinary approach to optimize survivability of both the mother and the fetus.

The Use of Digital Peripheral Artery Tonometry to Detect Endothelial Dysfunction in Pregnant Women Who Smoke

OBJECTIVEnWe hypothesized that, as has been shown outside of pregnancy, endothelial dysfunction would be seen in a dose-dependent fashion among women who smoke in the midtrimester of pregnancy.nnnSTUDY DESIGNnEndothelial function in women with singleton pregnancies between 16 and 23 weeks was analyzed utilizing the Endo-PAT2000 device (Itamar Medical Ltd., Caesarea, Israel) and expressed as a reactive hyperemia ratio (RHI). Serum was drawn to check cotinine and high-sensitivity C-reactive protein (CRP) levels. SAS 9.2 (SAS Institute, Cary, NC) was used to perform statistical tests including Student t test, analysis of variance, Fisher exact test, and Pearson coefficient.nnnRESULTSnEndothelial function was noninvasively examined in 29 smokers and 31 nonsmokers. Demographics including age, race, and parity were similar between groups. Mean RHI was not significantly different between smokers and nonsmokers (1.43 ± 0.32 versus 1.53 ± 0.39, p = 0.27). No correlation was noted when cotinine values were plotted against RHI or CRP values in smokers (rho = 0.24, p = 0.21 and rho = 0.26, p = 0.18, respectively). RHI did correlate with diastolic blood pressure (rho = -0.40, p = 0.002), systolic blood pressure (rho = -0.35, p = 0.006), and heart rate (rho = -0.37, p = 0.004).nnnCONCLUSIONnWe did not find an association between smoking status and endothelial dysfunction in the midtrimester utilizing a noninvasive methodology.