William L. Graves

Adverse perinatal outcome in parturients who use crack cocaine.

Objective To determine the risk of adverse pregnancy outcome among crack cocaine users in a large homogeneous prenatal population with objective documentation of drug use. Methods A retrospective cohort study was performed on a population of inner-city women who were offered routine voluntary urine drug screening and who delivered between January and December 1992 at a large county hospital. The study population consisted of 483 users (positive drug screens) and 3158 non-users (negative drug screens). Univariate analysis and multiple logistic regression were used to identify the relation between crack cocaine use and adverse perinatal outcome. Results Users were significantly more likely than nonusers to deliver low birth weight (LBW) infants (31.3% versus 14.9%; crude odds ratio [OR] 2.6; 95% confidence interval [CI] 2.1, 3.2), growth-restricted infants (29.0% versus 13.0%; crude OR 2.7; 95% CI 2.2, 3.4), and preterm infants (28.2% versus 17.1%; crude OR 1.9; 95% CI 1.5, 2.4). In addition, users were more likely to have abruptions (3.3% versus 1.1%; crude OR 3.0; 95% CI 1.6, 5.6) and infants with low 5-minute Apgar scores (7.9% versus 4.5%; crude OR 1.8; 95% CI 1.2, 2.7). After adjusting for confounders (including alcohol use and smoking), only the risks of LBW and fetal growth restriction (FGR) remained significant, with adjusted OR 1.6 (95% CI 1.03, 2.4) and adjusted OR 1.7 (95% CI 1.2, 2.3), respectively. Although there was no significant difference in the rate of low 5-minute Apgar scores between users and non-users after controlling for confounders, users with a positive urine drug screen within 1 week of delivery were significantly more likely than non-users to deliver infants with low 5-minute Apgar scores: crude OR 2.4; adjusted OR 2.0 (95% CI 1.1, 3.7). Conclusion In this inner-city population, crack cocaine use is associated with adverse pregnancy outcomes, as noted by increased risks of LBW and FGR.

Condom use and breakage among women in a municipal hospital family planning clinic

For those who choose to be sexually active, condoms are the best available means of protection against sexually transmitted diseases including the human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS). Condoms are also an effective method for preventing pregnancy. Unfortunately, condoms are not 100% effective at preventing pregnancy or the spread of infection, in part because condoms do break. In order to gain insight into condom breakage, a questionnaire was administered to women attending a municipal hospital family planning clinic. Thirty-six percent of the 106 subjects had experienced at least one condom breakage. Condom breakage occurred in approximately 1 out of 100 acts of intercourse using condoms, with a lifetime breakage rate of 10 per 1000 condom uses and a past year breakage rate of 8 per 1000 condom uses. Breakage rates did not differ substantially by age. Five percent of the womens unplanned pregnancies were attributed to broken condoms. The results of this study corroborate previously reported rates. Factors associated with these womens most recent breakage experiences included: vaginal intercourse, minimal foreplay, and breakage prior to ejaculation. Controlled studies will be needed to determine how the condom can be used to reduce the likelihood of breakage.

Initial and repeat screening for Chlamydia trachomatis during pregnancy.

OBJECTIVES: The objective of this study is to determine the prevalence of Chlamydia trachomatis and risk factors for positive repeat tests in a high-risk population presenting for early prenatal care. METHODS: We completed a retrospective cohort study of 2,484 women who initiated prenatal care prior to 20 weeks gestation, delivered, and received testing for cervical C. trachomatis at Grady Memorial Hospital or a Grady-affiliated clinic between July 1, 1993 and December 31, 1994. We calculated adjusted odds ratios (OR) for selected risk factors for a positive initial test and for a positive subsequent test after an initial negative test. RESULTS: The prevalence of C. trachomatis was 14.8%. At initial testing, 10.4% of the women were positive. If the initial test was negative, 5.7% had a positive subsequent test; but if the initial test was positive, 32.0% had a positive subsequent test (P < 0.001). The variables significantly and independently associated with a positive initial test were black race/ethnicity, age less than 25, unmarried, and less than a high-school education (adjusted OR of 1.66, 3.53, 2.18, and 1.81, respectively). Variables significantly and independently associated with a positive subsequent test after a negative initial test were white race/ethnicity, black race/ethnicity, age less than 25, and less than a high-school education (adjusted OR 8.69, 7.77, 4.12, and 2.27, respectively). CONCLUSIONS: In our inner-city population, most pregnant women have risk factors suggesting the need to rescreen for C. trachomatis in the second half of pregnancy.

Racial patterns in the effects of tobacco use on fetal growth.

OBJECTIVE The aim of this study was to characterize the interaction between the effects on fetal growth of maternal smoking and race by means of race-specific growth normograms. STUDY DESIGN A case-control study was performed on white and African American mothers who were delivered at 2 hospitals in metropolitan Atlanta between February 1993 and December 1994. The study population consisted of 621 small for gestational age infants and their mothers and 324 appropriate for gestational age infants and their mothers. Face-to-face interviews with mothers and detailed anthropometric measurements of neonates were performed. Relationships among tobacco use, race, and fetal growth were evaluated by means of multiple logistic regression. The chi(2) test of trend was performed to assess a dose-response relationship between smoking and fetal growth. RESULTS Mothers of small for gestational age neonates were significantly more likely than control mothers to be single (52% versus 40%), to be primiparous (47% versus 37%), to have a low body mass index (26% versus 17%), to have hypertension (22% versus 15%), and to use alcohol (15% versus 9%). Mothers of small for gestational age infants were significantly more likely than control mothers to smoke (26% versus 12%) and to smoke more cigarettes (P <.05). After controlling for potential confounders cigarette smoking in the second trimester was significantly associated with small for gestational age infants in both races (whites <1 pack/d adjusted odds ratio 3.82, 1-2 packs/d adjusted odds ratio 4.86, >2 packs/d crude odds ratio; African Americans <1 pack/d adjusted odds ratio 2. 35, 1-2 packs/d adjusted odds ratio 2.52). The chi(2) test of trend results were consistent with a dose-response relationship between smoking and small for gestational age infants (whites chi(2) = 14.06, P <.0001, African Americans chi(2) = 7.99). Comparison between the 2 races of the adverse effects of smoking on fetal growth showed no significant difference. CONCLUSION Self-reported maternal smoking during the second trimester is associated with fetal growth restriction in a dose-response manner. According to race-specific growth normograms no significant difference in the effects of tobacco use on fetal growth was found between white and African American women.

Maternal death at an inner-city hospital, 1949-2000.

OBJECTIVE The purpose of this study was to determine the rates and causes of maternal deaths at an inner-city hospital from 1949 through 2000. STUDY DEATH: Death summaries, autopsy reports, and previously collected data were reviewed for maternal deaths from January 1949 through December 2000. The chi(2) and Fisher exact tests were used to test the relationship between time and classification of death. RESULTS There were 290 maternal deaths and 314,436 live births, for a hospital-specific maternal mortality rate of 92.2 per 100,000. The percentage of deaths that were related directly to pregnancy decreased, and the percentage of deaths that were unrelated to pregnancy increased (P <.001). This is attributable to a decrease in deaths from obstetric infections and hemorrhage and an increase in deaths from nonobstetric infections and homicide. CONCLUSION The major causes of maternal death in our hospital have changed. A better understanding of these causes may lead to more effective prevention efforts.

Hysterectomy for carcinoma in situ and sexual function

Forty-four multiparous women treated for carcinoma in situ of the uterine cervix were interviewed more than 1 year later to establish the effects of vaginal hysterectomy on sexual function. Thirty-eight women received a total vaginal hysterectomy and partial vaginectomy and six women received a total vaginal hysterectomy only. The patients were further subdivided into an age 30 to 49 subgroup to control for age. The study patients experienced no statistically significant decrease in sexual enjoyment, ability to attain orgasm, coital opportunity, frequency of intercourse, or coital desire. Similar results were found in the age-controlled subgroup. Vaginal alterations were not present whether or not partial vaginectomy was performed. The authors conclude that vaginal hysterectomy, with or without partial vaginectomy, does not significantly alter the sexual lives of multiparous women treated for carcinoma in situ .