Gestational weight gain, pregnancy outcome, and postpartum weight retention.

OBJECTIVE: To determine whether the risk of maternal overweight associated with an excessive rate of gestational gain needs to be balanced against the risks of impaired fetal growth associated with a low rate of gain. METHODS: Rate of gestational weight gain was measured prospectively in a sample of 274 young, low-income, and primarily minority women (12-29 years old) with pregravid body mass indices (BMI) in the normal range (19.8-26.0). We defined an excessive rate of gain between 20-36 weeks' gestation as one greater than 0.68 kg/week, and a low rate of gain as one less than 0.34 kg/week. Women were followed-up at 4-6 weeks and 6 months postpartum. RESULTS: Rate of measured gestational gain between 20-36 weeks' gestation was associated with total weight gain based on pregravid weight, with infant birth weight and gestation duration, and with maternal overweight (BMI greater than 26) and weight retention postpartum. Infant birth weight and gestation duration were significantly reduced for women with low rates of gain, and there was no significant difference between women with excessive and moderate gains. Despite little difference in pregravid BMI, women with excessive rates of gain retained more weight overall, attained a greater postpartum BMI, and had higher levels of subcutaneous fat and overweight. Maternal anthropometric status showed little change between 4-6 weeks and 6 months postpartum. CONCLUSION: Weight gained at an excessive rate by women with a pregravid BMI in the normal range does not greatly enhance fetal growth and gestation duration, contributing instead to postpartum maternal overweight.

Young maternal age and parity. Influences on pregnancy outcome.

The influence of very young maternal age and parity on pregnancy outcome was examined in a cohort of nearly 900 adolescents and mature women from Camden, New Jersey. Young primigravid primiparas (aged 12 to 15 years) were compared with mature primigravid primiparas (18 to 29 years). Young multiparas (19 years or younger, with a first pregnancy at the age of 12 to 15 years) were compared with mature, multiparas (19 to 29 years old, with a first pregnancy at 18 years or older). After controlling for confounding factors, young primiparas were found to have a modest increase in preterm delivery, which was not statistically significant. However, low gynecologic age contributed disproportionately to the risk of preterm delivery in this group, with risk decreasing with each year from menarche (Cox's proportional hazard, 0.80; 95% confidence interval [CI], 0.68 to 0.94). Among multiparas, there were several statistical interactions associated with increased risk of small-for-gestational-age infants, including interactions between young age and low pre-pregnancy body mass (adjusted odds ratio [AOR], 5.74; 95% CI, 2.18 to 15.08), young age and a prior low-birth-weight infant (AOR, 10.58; 95% CI, 3.89 to 28.77), and young age and a prior preterm delivery (AOR, 5.52; 95% CI, 2.04 to 14.98). Thus, while chronologic age per se may not be a good predictor of pregnancy outcome, adolescents remain a high-risk group because of factors that are more common among them (e.g., biologic immaturity, inadequate prenatal care, poverty, minority status, low prepregnancy weight) and because factors associated with an early adolescent pregnancy, such as low gynecologic age, may continue to influence the outcome of subsequent pregnancies.

PIP: The authors explored the influence of young maternal age and parity upon pregnancy outcome in a cohort of almost 887 adolescents and mature women from Camden, New Jersey. Primigravid primiparas aged 12-15 years were compared with mature primigravid primiparas aged 18-29 years. Multiparas aged 19 years and younger were compared with multiparas aged 19-29. The young multiparas had their first pregnancy at age 12-15 years, while the older multiparas had their first pregnancy at age 18 years or older. After controlling for confounding factors, the younger primiparas were found to have a modest, statistically insignificant increase in preterm delivery. Low gynecologic age, however, contributed disproportionately to the risk of preterm delivery in the group, with risk decreasing with each year from menarche. Statistical interactions associated with increased risk among multiparas of small-for-gestational-age infants included interactions between young age and low pre-pregnancy body mass, young age and a prior low-birth-weight infant, and young age and a prior preterm delivery. Although chronologic age may not be a good predictor of pregnancy outcome, adolescents remain a high-risk group due to factors which are more common among them such as biologic immaturity, inadequate prenatal care, poverty, minority status, and low prepregnancy weight, and because factors associated with an early adolescent pregnancy, such as low gynecologic age, may continue to influence the outcome of subsequent pregnancies.

Rate and amount of weight gain during adolescent pregnancy: associations with maternal weight-for-height and birth weight.

This study presents information on the course and rates of weight gain and the associations among weight gain, prepregnancy weight-for-height, and infant birth weight, based on a total sample of 1419 uncomplicated term deliveries to adolescents. The distribution of cumulative weight gain indicates that for adolescents not only is the median gain at term (14.2-15.5 kg) significantly in excess of that reported for adults, but also weight-gain velocity is greater from the beginning of pregnancy. Although the contributions of prepregnancy weight-for-height and weight gain to birth weight may be independent, they are not necessarily additive. Birth weight does not appear improved for the infants of overweight adolescents except when weight gain is low (less than 11.1-12.3 kg at term), and, for Puerto Rican and black adolescents, birth weight is not further improved at any maternal prepregnancy body mass index (weight-for-height) with excessive weight gains (greater than 17.9-19.3 kg at term).

Weight gain during pregnancy in adolescence: predictive ability of early weight gain.

Pregnancy weight gains were examined at 4-week intervals from 12-36 weeks' gestation and total gain assessed at delivery in a cohort of 2008 pregnant women aged 18 or less at entry to prenatal care. As early as 12 weeks' gestation, there was a significant association between the amount of weight gained and infant birth weight measured at the time of delivery. At 16 weeks' gestation, gains below the 25th percentile were associated with an increased risk of low birth weight (LBW) (adjusted odds ratio 1.56; 95% confidence interval 1.01-2.43), and by 20 weeks' gestation, the risk of LBW was doubled (adjusted odds ratio 2.00; 95% confidence interval 1.34-2.99). Also at 16 weeks, there was a doubling in the risk of excessive fetal size or macrosomia (adjusted odds ratio 2.31; 95% confidence interval 1.31-4.10) associated with maternal weight gain above the 75th percentile. These results suggest that an increased risk of certain poor pregnancy outcomes is detectable late in the first or early in the second trimester. Consequently, weight gain monitoring may be important early in pregnancy.

Maternal growth during pregnancy and decreased infant birth weight.

We used stature and measurement of knee height to measure continued maternal growth during adolescent pregnancy in a sample of young gravidas (primigravidas and multiparas) and mature pregnant control subjects. Growth during pregnancy has been masked by a tendency of all gravidas to shrink while pregnant (approximately 0.5 cm over 6 mo of observation). Consequently, growth of many adolescent gravidas has not been clinically apparent. There was no effect on maternal growth during a first pregnancy in adolescence but this may be a result of the relatively good prepregnant nutrition status of the young gravidas in developed countries. Maternal growth during pregnancy, however, is associated with significantly decreased (-282 g, p less than 0.05) birth weight for infants when maternal growth continues during a subsequent adolescent pregnancy. This observation is consistent with the hypothesized competition between the metabolic demands of the growing adolescent mother and the nutrient needs of her developing fetus.

Association between low gynaecological age and preterm birth.

Low gynaecological age, defined as conception within 2 completed years of menarche, was examined for its association with preterm birth, using data from a geographically based cohort of over 1700 young primigravidae aged 18 or younger at start of prenatal care. After stratifying by chronological age and controlling for confounding variables, low gynaecological age was associated with almost double the risk of preterm delivery whether estimated from the mother's last menstrual period (adjusted odds ratio (AOR) = 1.77, 95% CI 1.19-2.64) or using the obstetric estimate of gestation (AOR = 2.10, 95% CI 1.36-3.25). Low gynaecological age was also associated with an increase in risk of low birthweight (LBW) (AOR = 1.70, 95% CI 1.01-2.88), but not of small-for-gestational-age babies (AOR = 0.94, 95% CI 0.49-1.81). Thus low gynaecological age may be an important addition to assessment systems to detect women at risk of preterm labour and delivery.

Effects of early maturation on fetal growth.

While the association of young maternal age with low birthweight (LBW) is well known, the contribution of early menarche to this association has never been studied. We examined the effects of early menarche (less than or equal to 11 years) on LBW and its two major underlying causes: pre-term delivery and smallness-for-gestational-age (SGA). Results represent a narrow chronological age range, 17-18 years, of a larger geographically based cohort of 2789 pregnant adolescents. Adjusted odds ratios (AOR) indicated that early menarche was significantly associated with an increased risk of LBW which was specific to SGA. The attributable risk of SGA with early menarche exceeded 20%. Early age at menarche is also correlated with an earlier onset of sexual activity, pregnancy, and childbearing. Consequently, adolescents with early menarche are over-represented in a sample limited to young gravidae or a sample that contains a stratum of young gravidae. This may have previously obscured the effects or early menarche on foetal growth and attributed them to a more frequently measured characteristic, young maternal age. Thus, effects of secular change in age at menarche may not be wholly benign. Improvements in maternal fertility and nutritional status appear to be offset by intrauterine growth retardation in the offspring.

Patterns of weight gain in adolescent pregnancy: effects on birth weight and preterm delivery.

Early weight gain adequacy may be a particular problem among adolescent gravidas because of their tendency to poor prepregnant nutritional status, nutritionally poor diets during pregnancy, and body image concerns, but it is not known whether irregular patterns of weight gain during adolescent pregnancy are associated with birth weight and length of gestation. We studied weight gain during pregnancy and pregnancy outcome in a cohort of 1790 teenage gravidas from Camden, New Jersey. We found that early inadequate weight gain (less than 4.3 kg by 24 weeks' gestation) was associated with a significantly increased risk of having a small for gestational age infant (adjusted odds ratio 1.88; 95% confidence interval 1.08-3.27), even when later gains brought the cumulative total weight gain to within adult standards. Late inadequate gains (less than 400 g/week) were associated significantly with preterm delivery (before 37 completed weeks' gestation), whether or not the total gain was adequate for gestation (adjusted odds ratio 1.69; 95% confidence interval 1.12-2.55). These results suggest that supplementation, intervention, or prenatal care protocols for adolescents that do not focus on balanced weight gain during adolescent pregnancy may reduce preterm delivery but may not significantly affect the incidence of intrauterine growth retardation.

Neurotransmitters and sex-hormone profiles in the human serum and ovarian follicular fluid of in vitro fertilization participants.

From the data presented, it can be assumed that the increase in catecholamines and decrease in melatonin in the ovarian follicular fluid of IVF participants has physiological significance, particularly in the process of steroidogenesis. Furthermore, it is worthy of note that low SHBG levels in follicular fluid were associated with atretic oocytes. Therefore, NE, EP, ME, and SHBG titer, as well as E2 and LH measurements might usefully index prognoses for IVF.

Ectopic twin gestation discordant for anencephaly. A case report.

A 30-year-old white woman thought to have a 12-week intrauterine pregnancy developed a large cul-de-sac mass, which proved to be an ectopic, monoamnionic twin pregnancy (males) discordant for anencephaly. While twin pregnancies discordant for neural tube defects are well known, the extrauterine location made this case remarkable.

Gynecologic injury in the nongravid female during blunt abdominal trauma.

Fifteen cases of uterine and adnexal findings in the nongravid female were identified among 220 exploratory laparotomies performed for blunt abdominal trauma. These include: 13 cases of ovarian cyst hemorrhage, one case of ovarian laceration, and one case of uterine and vaginal lacerations. All patients had positive peritoneal lavage. In 13 of the patients in this series, the bleeding was associated with and in proximity to an existing corpus luteum.

A specific cytosolic estrogen receptor in human term placenta.

Administration of the antiestrogen ethamoxytriphetol (MER-25) during baboon gestation results in a marked decline in placental progesterone production. Since this effect in primates may be modulated via an estrogen receptor, the present study investigated the possible existence of an estrogen receptor in human placenta. Villous tissue of human, term placentas was homogenized in 0.01M Tris-HCl, ethylenediaminetetraacetic acid, dithiothreitol, glycerol buffer. Cytosol was incubated with 10(-8)M [3H] 17 beta-estradiol (E2) in the presence or absence of 10(-6)M diethylstilbestrol (DES). A single peak of [3H]E2 binding occurred in the 5.2 S region after glycerol density gradient centrifugation, which was competed for by DES, E2, and enclomiphene. Scatchard analysis demonstrated E2 binding, which was saturable, of high affinity (Kd = 1.90 X 10(11)M) and of low capacity (N = 0.13 X 10(-14) moles/mg cytosolic protein). Competition for [3H]E2 binding was DES greater than E2 greater than estrone greater than MER-25 greater than enclomiphene, whereas androgens, progestins, and corticosteroids were ineffective. The results fulfill the criteria for a specific estrogen receptor. The influence of antiestrogen and, possibly, estrogen upon placental function in baboons may be modulated by an estrogen receptor.

The young pregnant teenager. Impact of comprehensive prenatal care.

Pregnant teenagers under the age of 15 years are known to be at highest risk for delivering low-birth-weight infants, particularly poor black girls. Sixty-seven inner-city pregnant adolescent girls 15 years or less at the time of delivery were followed in a special Teen Obstetric Clinic staffed by an interdisciplinary team trained in adolescent and prenatal health care. Ninety-three percent of the clinic population was black. The fetal outcomes of these girls were compared with the fetal outcomes of 67 girls who attended the regular obstetric clinic. Girls were matched for age at delivery, race, socioeconomic status, and parity. Only 9.0% of the infants of the teenagers in the Teen Obstetric Clinic group weighed less than 2500 g, compared with 20.9% of the infants of the girls in the regular Obstetric Clinic group. This finding has implications for the type of prenatal care provided to young adolescents.

46, XY gonadal dysgenesis with secondary amenorrhea, virilization, and bilateral gonadoblastomas.

A phenotypic girl with secondary amenorrhea, enlargement of the clitoris, XY gonadal dysgenesis, and bilateral gonadoblastomas is described. The presence of secondary amenorrhea does not obviate the existence of a Y chromosome. The presence of the Y chromosome should be a warning that a gonadal tumor may be present and, therefore, gonadectomy must be done as soon as possible and preferably before puberty.

Serum ferritin as an early determinant of decreased iron stores in pregnant women.

Serum ferritin has been shown to be an excellent determinant of iron stores. In a consecutive group of women registering at the regular prenatal clinic, we measured serum ferritin, iron, iron-binding capacity, and hemoglobin to determine their hematologic status as to anemia. It was found that serum ferritin is the most sensitive determinant of depleted iron stores, with serum iron being next in sensitivity. This assay is a rapid, economic, sensitive measure of iron stores, and results are not altered significantly by other types of anemia or oral iron therapy.

Serum progesterone and estradiol in pregnant women selected for progestagen treatment.

Patients with two or more previous spontaneous second trimester abortions and vaginal cytology indicating a poor progestational response in current pregnancies were selected for treatment with Provera (medroxyprogesterone acetate) and/or Delalutin (17 alpha-hydroxyprogesterone caproate). Serum was examined serially for progesterone (P) and estradiol (E) by radioimmunoassay. Serum from 174 untreated patients with no known complications ranging from 6--40 weeks gestation provided normal distribution data. Of 14 progestagen-treated patients, four aborted during the second trimester. These all had chronically low (greater than 50% of observations were less than 1 standard deviation of the normal population) or falling P/E ratios. The rest delivered normal full-term infants although five of the 10 had chronically low P, seven had chronically low P/E ratios, and in one other P/E was falling. Chronically high E contributed to the low P/E ratio in three cases. Thus, these selected cases with poor obstetrical histories demonstrated steroid patterns outside the +/- 1 standard deviation range, although the steroid levels were still within the normal range. Serum progesterone and estradiol analysis may eventually be useful in identifying patients who will best respond to progestagen treatment.

Stromomyoma of the uterus.

We present a solitary uterine tumor that occurred in a 28-year-old woman who complained of vaginal bleeding. Grossly, the tumor was well circumscribed and composed of lobulated tissue that varied from yellow, tan and soft, to white and rubbery. At the light microscopic level, areas identical to those described and interpreted as sex-cord differentiation in a group of closely similar uterine tumors were found and obtained for electron microscopic study. Ultrastructurally, there were two basic types of cells, neither of which can be interpreted as sex-cord derivatives. Cells that closely resembled the predominant components of Clement and Scully's group I tumors were similar to the normal endometrial stromal cells. Cells that formed plexiform cords demonstrated features diagnostic of smooth muscle cells. Cellular contents in cells comprising the tubular structures resembling that interpreted as indistinguishable from that of a Sertoli-cell tumor (tubular androblastoma) were probably smooth muscle cells. We propose the term "Stromomyoma" to designate this peculiar uterine tumor. The similarity between our tumor and those reported in the literature raises the possibility that "uterine tumor resembling" ovarian sex-cord tumors" are actually stromomyomas.