摘要:

ObjectiveTo identify modifiable obstetric factors associated with the failure of zidovudine chemoprophylaxis to prevent perinatal human immunodeficiency virus type 1 (HIV-1) transmission.MethodsWe analyzed data from Pediatric AIDS Clinical Trials Group protocol 076, a randomized, double-masked, placebo-controlled trial that demonstrated that a zidovudine regimen could prevent perinatal HIV-1 transmission. We estimated the zidovudine treatment effect using the relative reduction in transmission risk among women randomized to treatment with zidovudine compared with women randomized to receive placebo. Univariate and multivariate statistical analyses were used to assess whether the treatment effect differed in magnitude according to potential antepartum or intrapartum risk factors.ResultsIn the univariate analysis, the zidovudine treatment effect was found to differ significantly in magnitude according to quartile of maternal weight at the time of study entry (interaction test,P= .03); among women in the heaviest-weight quartile (weight more than 82 kg), there was a 26% relative reduction in transmission risk, compared with a 79% relative reduction among the other three quartiles (interaction test,P= .05). In the zidovudine treatment group, women who transmitted HIV-1 were significantly more likely than nontransmitters to have had antepartum procedures or conditions associated with increased risk of fetal exposure to maternal blood or cervicovaginal secretions (43% compared with 19%,P= .04). In the multivariate analysis, adjustment for the plasma HIV-1 RNA level and CD4+cell percentage did not eliminate the differential treatment effect according to these factors.ConclusionHigh maternal weight and conditions associated with fetal exposure to maternal blood or cervicovaginal secretions may diminish the efficacy of zidovudine chemoprophylaxis.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the reliability of prenatal diagnosis of cytomegalovirus infection in women with primary or recurrent infection.MethodsAmniotic fluid (AF) samples from 117 pregnant women were evaluated for cytomegalovirus culture and cytomegalovirus-DNA detection. Neonatal and postnatal samples also were examined to confirm or exclude transmission of maternal-fetal cytomegalovirus infection.ResultsOf 25 women with primary cytomegalovirus infection, 13 (52%) had cytomegalovirus-positive AF samples by polymerase chain reaction (PCR), nine of which also were diagnosed by culture. All eight neonates born to mothers whose AF was cytomegalovirus-positive by PCR and culture were cytomegalovirus-infected, and three were symptomatic. One aborted fetus had cytomegalovirus-DNAemia. Of four women with cytomegalovirus-positive AF samples by PCR only, two delivered asymptomatic cytomegalovirus-infected neonates and two aborted (one fetus had cytomegalovirus encephalopathy).Of 45 mothers with recurrent infection, two with AF cytomegalovirus-positive by PCR and culture, and another with cytomegalovirus-positive AF samples by PCR only, aborted cytomegalovirus-DNA-positive fetuses. Of the other seven women with cytomegalovirus-positive AF samples by PCR only, two delivered asymptomatic cytomegalovirus-infected neonates, two delivered neonates cytomegalovirus-positive by PCR only (one was symptomatic), and three delivered infants cytomegalovirus-negative by PCR and culture. All 47 mothers with nonactive cytomegalovirus infection and cytomegalovirus-negative AF samples had uninfected neonates.Polymerase chain reaction was superior to viral culture in sensitivity and negative predictive value (100% compared with 57% and 94%, respectively) but was lower in specificity and positive predictive value (97% and 83%, respectively, compared with 100%).ConclusionPrenatal diagnosis of fetal cytomegalovirus infection should include PCR in addition to viral culture, particularly for congenital cytomegalovirus infections following maternal recurrence.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine how often a perinatal autopsy identified the cause of death, and how frequently this information changed recurrence risk estimates or altered parental counseling.MethodsWe reviewed all autopsies of fetal stillbirths and briefly viable neonates performed by one perinatal pathologist at the University of Alabama Hospital from 1992 to 1994.ResultsFour hundred sixteen fetal and early neonatal deaths occurred at our hospital from January 1, 1992, to June 1, 1994. Consent for an autopsy examination was granted for 139 of these (33%), and all autopsies were performed by a single perinatal pathologist. Abnormalities likely to be the cause of death were identified in 130 of 139 cases (94%). Ninety-one subjects did not have structural anomalies: In 14 cases autopsy revealed previously unsuspected pathology that altered parental counseling; in 68 cases autopsy findings were consistent with the clinical obstetrical diagnosis; and in nine cases the cause of death could not be identified. Forty-eight subjects were anomalous. Thirty-seven of these (79%) had been evaluated by antenatal ultrasonography, and autopsy identified additional abnormalities in 51% (19 of 37). In the 11 deaths evaluated neonatally, a previously unsuspected diagnosis likely to be the cause of death was identified in three. Overall, autopsy findings changed recurrence risk estimates and/or parental counseling in 36 of 139 cases (26%).ConclusionThe cause of fetal or perinatal death was determined by autopsy in 94% of cases in our series. Counseling and recurrence risk estimates were altered by autopsy findings in 26%.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare electronic fetal heart rate (FHR) monitoring characteristics between appropriate for gestational age (AGA) fetuses and small for gestational age (SGA) fetuses and to determine whether SGA fetuses have specific abnormalities at second-trimester electronic fetal monitoring (EFM), using nonstress test.MethodsAmong 953 children born from 1993–1996, we identified 500 singleton infants born after 36 weeks' gestation of uncomplicated pregnancies in whom second-trimester (24–27 weeks' gestation) EFM records were obtained. Individual components of FHR patterns (baseline rate, baseline FHR variability, presence of acceleration [at least 10 beats per minute for at least 10 seconds], and periodic or episodic deceleration [at least 25 beats per minute for at least 15 seconds]) and birth characteristics were compared between AGA and SGA infants, or between pregnancies with or without second-trimester decelerations.ResultsAmong 500 infants, 443 were AGA and 57 SGA; 105 had and 395 did not have second-trimester decelerations. Baseline FHR variability (12.9 ± 3.2 beats per minute) in SGA fetuses was significantly higher than variability (10.3 ± 3.4 beats per minute) in AGA fetuses (P< .001). Small for gestational age fetuses were significantly more likely to have second-trimester decelerations than AGA fetuses (33.3% vs 19.4%,P< .05). There were no significant differences in baseline rate and accelerations between AGA and SGA infants. Small for gestational age infants were more frequent in pregnancies with second-trimester decelerations, compared with those without second-trimester decelerations (18.1% vs 9.6%,P< .05). Baseline FHR variability in pregnancies with second-trimester decelerations was significantly higher than in pregnancies without second-trimester decelerations (12.2 ± 3.7 vs 10.0 ± 3.1 beats per minute,P< .001).ConclusionPeriodic or episodic decelerations and increased FHR variability during late second-trimester EFM were associated with an increased risk of SGA birth weight.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the frequency of atypical aneuploidy resulting from prenatal testing and assess the implications of these diagnoses on prenatal decision making.MethodsWe reviewed all amniotic fluid and chorionic villus samples obtained between January 1994 and September 1997 and grouped the abnormal cases into typical or atypical subcategories. This distinction was based upon whether the diagnosis provided a straightforward range of prognoses or an ambiguous clinical implication. Results were stratified by sample source to determine whether atypical aneuploidy was more commonly seen in cultures of chorionic villi or amniocytes. We also evaluated the influence of ultrasound findings on prenatal decision making in atypical aneuploid cases.ResultsOf 2960 samples, 134 were abnormal (4.4%), with 27 of 134 abnormalities (20%) representing atypical aneuploidies. The percentages of chorionic villus and amniocentesis cases complicated by atypical aneuploidy (22% and 78%, respectively) were consistent with the distribution of procedures in the entire study. Ultrasound abnormalities did not invariably prompt a decision to terminate pregnancy (only two terminations of six fetuses with congenital malformation), whereas atypical karyotypes led to termination even in the presence of normal-appearing fetal anatomy (five terminations of 21 without malformations;P=.63).ConclusionThe frequency of atypical aneuploidy resulting from prenatal diagnosis was approximately 1.0%, and these cases represented 20% of all abnormal karyotypes observed. The ambiguity conferred by atypical aneuploidy can influence a family's decision making, even in the presence of normal ultrasound findings.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine whether the relationship between adverse pregnancy outcome and elevated maternal serum alpha-fetoprotein (MSAFP) and/or maternal serum hCG levels in women whose fetuses have no chromosomal abnormalities or neural tube defects is restricted to pregnancies with a priori elevated risk for pathology or also present in low-risk pregnancies.MethodsThe outcomes of pregnancy in two groups of patients with elevated MSAFP and/or maternal serum hCG values were compared with the outcomes of a reference group with normal serum values. The first study group consisted of 83 women without pre-existing risk for poor outcome as defined by the guidelines of the Dutch Society of Obstetrics and Gynecology. The second study group consisted of 62 women with a priori elevated risk according to these guidelines.ResultsFetal or neonatal death, pregnancy-induced hypertension, placental abruption, placenta previa, preterm delivery, delivery of infants with birth weights in the 2.3rd percentile, and complications during the third stage of labor occurred significantly more often in patients with elevated values and low a priori risk than in women with normal values and without pre-existing risk factors. There was no significant increase in adverse pregnancy outcome in women with elevated values and high a priori risk compared with women with normal values and elevated a priori risk.ConclusionIn women at low risk, elevated MSAFP and/or maternal serum hCG values are predictive of adverse pregnancy outcome. In women with a priori elevated risk, abnormal serum values do not increase this risk.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo identify normative changes in psychological and physiologic health status associated with pregnancy and the puerperium.MethodsSelf-administered surveys containing Ware's Short Form-36 and Derogatis's Brief Symptom Inventory were completed by 393 pregnant women during their third trimester. Of those, 253 completed the same survey during the puerperium. Results were compared between periods and with those of samples of women from standardized community samples.ResultsOn the Short Form-36, pregnant women in the third trimester had significantly poorer levels of functioning (P< .01) than community controls with regard to bodily pain (51.86 versus 79.61), physical functioning (62.91 versus 89.12), social functioning (74.0 versus 84.06), vitality (47.24 versus 58.04), and functional limitations resulting from physical health problems (45.0 versus 86.73) subscales. Those differences persisted into the puerperium. Compared with pregnancy, scores on social functioning and functional limitations caused by emotional problems decreased during the puerperium. Women reported improved perceptions of their general health in the puerperium compared with community controls (80.22 versus 74.80). On the Brief Symptom Inventory, pregnant women reported significantly higher levels of emotional distress on the three global measures and on the somatization (0.75 versus 0.35), obsessive-compulsive (0.70 versus 0.48), and hostility (0.59 versus 0.36) subscales than controls; those changes normalized in the puerperium.ConclusionPregnancy and the puerperium are associated with significant changes in psychological and physiologic health status. Documentation of those changes is important if the Short Form-36 and Brief Symptom Inventory are to be used in health outcomes research with this population.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991.MethodsThis retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery.ResultsAmong 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1–3 prior births.ConclusionPredictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo examine whether induced abortion influences subsequent pregnancy duration.MethodsWomen who had their first pregnancies during 1980, 1981, and 1982 were identified in three Danish national registries. A total of 15,727 women whose pregnancies were terminated by first-trimester induced abortions were compared with 46,026 whose pregnancies were not terminated by induced abortions. All subsequent pregnancies until 1994 were identified by register linkage.ResultsPreterm and post-term singleton live births were more frequent in women with one, two, or more previous induced abortions. After adjusting for potential confounders and stratifying by gravidity, the odds ratios of preterm singleton live births in women with one, two, or more previous induced abortions were 1.89 (95% confidence interval [CI] 1.70, 2.11), 2.66 (95% CI 2.09, 3.37), and 2.03 (95% CI 1.29, 3.19), respectively. Odds ratios of post-term singleton live births in women with one, two, or more previous induced abortions were 1.34 (95% CI 1.24, 1.44), 1.50 (95% CI 1.26, 1.78), and 1.58 (95% CI 1.09, 2.28), respectively.ConclusionThe study showed an increase in preterm and post-term pregnancies after induced abortions. The risk of post-term delivery was high regardless of the interpregnancy interval, whereas increased risk of preterm delivery was seen mainly when interpregnancy intervals were longer than 12 months.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare the efficacy and toxicity of topical vaginal 5-fluorouracil (5-FU) maintenance therapy against the effects of observation after standard treatment for high-grade cervical dysplasia in human immunodeficiency virus (HIV)-infected women and to evaluate the association between baseline CD4 count and time to recurrence.MethodsIn a phase III unmasked, randomized, multi-center, outpatient clinical trial, 101 HIV-positive women either received 6 months of biweekly treatment with vaginal 5-FU cream (2 g) or underwent 6 months of observation after standard excisional or ablative cervical treatment for cervical intraepithelial neoplasia (CIN). Papanicolaou smears and colposcopy were scheduled at regular intervals during the ensuing 18 months, with the primary end point being the time at which CIN of any grade recurred.ResultsThirty-eight percent of women developed recurrence: 14 (28%) of 50 in the 5-FU therapy group and 24 (47%) of 51 in the observation group. Treatment with 5-FU was significantly associated with prolonged time to CIN development (P= .04). Observation subjects were more likely to have high-grade recurrences, with 31% developing CIN 2–3 compared with 8% in the 5-FU treatment arm (P= .014), and disease recurred more quickly in observation subjects as well. Baseline CD4 count was related significantly to time to recurrence (P= .04), with 46% of subjects with CD4 counts less than 200 cells/mm3developing recurrence compared with 33% of subjects with CD4 counts at least 200 cells/mm3. Disease recurred more slowly in subjects who had received antiretroviral therapy than in antiretroviral therapy–naive subjects. There were no instances of grade 3 or 4 toxicity, and compliance with 5-FU treatment was generally good.ConclusionAdjunctive maintenance intravaginal 5-FU therapy after standard surgery for high-grade lesions safely and effectively reduced recurrence of cervical intraepithelial neoplasia in HIV-infected women.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID