Massive fetomaternal hemorrhage and fetal death: are they predictable?

OBJECTIVE: To report the incidence of massive fetomaternal hemorrhage (FMH) associated with fetal death and to test the hypothesis that FMH is more likely to occur in those with risk factors for FMH. STUDY DESIGN: All cases of fetal death of infants weighing > 500 gm between January 1, 1990 and December 31, 1994 were reviewed for evidence of massive FMH (> or = 2% fetal cells in the maternal circulation as measured by the Betke-Kleihauer test). Women with risk factors were compared with those without risk factors with respect to the occurrence of massive FMH. RESULTS: The prevalence of massive FMH was 14 of 319 (4.4%) cases, occurring in 4 of 102 (3.9%) of those with risk factors and 10 of 217 (4.6%) of patients without risk factors (p = 0.78). Otherwise unexplained fetal death was associated with massive FMH in 5 of 141 (3.5%). Major fetal anomalies were present in 5 of 14 (35.7%) cases of massive FMH. CONCLUSION: Clinical risk factors do not predict an increased likelihood of massive FMH. Massive FMH is associated with fetal anomalies. Betke-Kleihauer testing should be performed in all cases of fetal death, including those with anomalies regardless of the presence or absence of risk factors for FMH.

Stillbirth evaluation: what tests are needed?

OBJECTIVE: We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated. STUDY DESIGN: A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions. RESULTS: We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases. CONCLUSION: The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial.

Human immunodeficiency virus-1 seroprevalence among parturients in Los Angeles County public hospitals.

To estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) among parturients in an area with a high cumulative incidence of AIDS, an HIV seroprevalence study was conducted in 1988 in Los Angeles County. Test results were available from 8485 (86.1%) of the 9860 women delivering at four public hospitals. The test results were linked to demographic and medical information available from routinely collected delivery records. Three specimens were HIV-positive, for a seroprevalence of 3.5 per 10,000. The seropositive women were all Latina. The prevalence of HIV among women delivering at all hospitals in Los Angeles County has been shown to be relatively low compared with that of other metropolitan areas with a high number of AIDS cases, such as New York city, but appears to be even lower among women delivering at public hospitals during this time period. This low prevalence is attributed to the predominance of Latinas, who may have lower levels of infection, among public hospital parturients. The relatively low prevalence of HIV among injection drug users in Los Angeles County may contribute to the overall lower prevalence among women in Los Angeles County compared with those in New York city. This study supplements county-specific data obtained from statewide blinded neonatal testing by providing details on HIV seroprevalence among the catchment populations of public hospitals in Los Angeles County.

Mother-child HIV disease: a model for collaborative care.

Women Connected and the Maternal Child Clinic are two unique dyad-centered programs for providing quality care to HIV-infected women and their children. Each is a collaborative effort to maintain standard of care for these patients within a large county facility. Women Connected facilitates their inpatient treatment and care, while the Maternal Child HIV Clinic provides follow-up outpatient health and social services.

Vitamin B-6 nutriture and plasma diamine oxidase activity in pregnant Hispanic teenagers.

Vitamin B-6 status was assessed by measuring erythrocyte glutamic-pyruvic transaminase (EGPT) indices in 122 pregnant Hispanic teenagers. Seventeen percent were vitamin B-6 deficient (EGPT indices greater than 1.25) at the initial interview (first or second trimester). A daily supplement of 5 mg vitamin B-6, beginning at initial interview, did not reduce prevalence of vitamin B-6 deficiency at final interview (third trimester). No association was found between EGPT indices greater than 1.25 and the outcome of pregnancy. The activity of diamine oxidase (DAO), a vitamin B-6-dependent enzyme produced by the placental decidua, was measured in maternal plasma. At initial and final interviews, plasma-DAO activity was increased by in vitro addition of pyridoxal-5'-phosphate. The activity in early pregnancy was positively associated with dietary vitamin B-6 intake and was lower in teenagers with EGPT indices greater than 1.25 at the final interview. Findings suggest that plasma-DAO activity is influenced by vitamin B-6 status.

Zinc supplementation during pregnancy in low-income teenagers of Mexican descent: effects on selected blood constituents and on progress and outcome of pregnancy.

As a follow-up of our study of pregnant women, we report effects of zinc supplementation during pregnancy in another population of 138 Hispanic teenagers in Los Angeles. Teenagers were randomized (double-blind) to a control or zinc-supplemented group and received similar daily vitamin and mineral supplements except for 20 mg zinc added to the zinc-supplemented group's capsules. Initially, mean dietary zinc intakes of both groups were about 50% of the Recommended Dietary Allowance and their mean serum zinc levels did not differ significantly (69.8 +/- 11.2 micrograms/dl in control and 69.0 +/- 11.4 micrograms/dl in zinc-supplemented group). Zinc supplementation did not maintain mean serum zinc levels during pregnancy but, as in our earlier study, it reduced (p = 0.018) the number of low serum zinc values (less than or equal to 53 micrograms/dl) in late pregnancy. Zinc supplementation did not affect outcome of pregnancy but serum zinc levels were lower (p = 0.038) in teenagers with pregnancy-induced hypertension than in normotensives.

Birth control and the private physician: The view from Los Angeles.

PIP: In an effort to elucidate how physicians in the Los Angeles area regard family planning services and how they actually make them available to their patients, a mail survey of a sample of physicians was undertaken in the summer of 1972. Of the 992 questionnaires sent out, 628 usable questionnaires were returned. 70% of the physicians indicated that they believe birth control provision should be a standard service. The highest level of support came from ob-gyns, 85% of whom said they believe it should be standard. This shows a rise since 1957 when 1 study reported that only 29% of nonCatholic physicians and 4% of Catholic physicians believed that birth control provision should be a standard medical service. A study by Silver in 1971 found that 62% of those sampled said it should be standard. The Los Angeles physicians showed some reluctance in initiating discussion of birth control. If requested, 80% would provide help to female minors with parental consent, compared with 54% who would initiate advice to unwed sexually active minors. More than 80% of the internists and more than 90% of the other specialists indicated that they have assisted patients by referral or otherwise in receiving sterilization. About 90% of the ob-gyns and GPs and about 2/3 of the internists and urologists believed that they were adequately qualified to provide birth control services. 5 questions probing the physicians' knowledge of the relative safety, effectiveness, and legality of various birth control methods raised some question as to whether the doctors did not overestimate their qualifications. 1 example of this was that when asked to rank the theoretical effectiveness of oral contraceptives, diaphragm with jelly, vaginal foam, and postcoital douche, almost 1/4 of the specialists failed to give the correct response.^ieng