The prevalence of significant left-right hip bone mineral density differences among black and white women.

SUMMARY: In a cross-sectional retrospective study, we examined the prevalence of significant opposite hip bone mineral density difference among white and black women. Left-right hip bone mineral density difference was a common finding in both races, raising the possibility that osteoporosis can be missed if only one hip is imaged. INTRODUCTION: We examined the prevalence of significant left-right hip bone mineral density (BMD) difference among black and white female subjects and its implications on the diagnosis of osteoporosis. METHODS: This was a retrospective review of dual energy X-ray absorptiometry (DXA) data in black and white subjects age 50 years and older. One thousand four hundred seventy-seven scans obtained using a GE Lunar Prodigy scanner in dual hip mode were analyzed (24% black, 76% white). Significant left-right hip BMD difference was considered present when the subregion least significant change (LSC) was exceeded. Its prevalence was determined, along with consequences on the diagnosis of osteoporosis. RESULTS: Significant differences in BMD were common in both races; the LSC was exceeded in 47% of the patients at the total hip, 37% at the femoral neck, and 53% at the trochanter. Diagnostic agreement was lower when the LSC was exceeded than when it was not. The LSC was exceeded in a statistically significant number of black and white patients with normal or osteopenic spines and unilateral hip osteoporosis. CONCLUSIONS: Significant left-right hip BMD difference is a common finding among black and white women and can result in osteoporosis being missed if only one hip is imaged.

[Current debates on immunology of preeclampsia. Report of the sixth international workshop of Reunion Island (Indian Ocean, December 2008)]. / Débats actuels sur l'immunologie de la prééclampsie. Comptes rendus du sixième colloque international de La Réunion (décembre 2008).

Hypertensive disorders of pregnancy (HDP) represent globally 10% of human births and their major complication, preeclampsia, 3 to 5%. The etiology of these HDP remains still uncertain, however major advances have been made these last 25 years. The Sixth International Workshop on Reproductive Immunology, Immunological Tolerance and Immunology of Preeclampsia 2008 celebrated its 10th Anniversary in Reunion-island (French overseas Department in the Indian Ocean). Over this decade, these six workshops have contributed extensively to immunological, epidemiological, anthropological and even vascular debates. The defect of trophoblastic invasion encountered in preeclampsia, intra-uterine growth retardation and to some extend also preterm labour has been understood only at the end of the 1970's. On the other hand, clinical and epidemiological findings at the end of the 20th century permitted to apprehend that "preeclampsia disease of primiparae" may in fact well be the disease of first pregnancies at the level of human couples. Among the important advances, immunology of reproduction is certainly the topic where knowledge has literally exploded in the last decade. This paper relates some major steps in comprehension of this disease and focuses on the interest to follow these immunological works and their new concepts. It seems, at the beginning of the 21st century, that we are possibly closer than ever to understand the etiology of this obstetrical enigma. In this quest, the immunology of reproduction will certainly come out as one of the main players.

[Obstetrical and neonatal outcomes of gestational diabetes mellitus at Reunion Island (France)]. / Conséquences obstétricales et néonatales du diabète gestationnel dans la population du sud de l'île de la Réunion.

OBJECTIVE: To assess maternal and fetal outcomes in patients with gestational diabetes mellitus. PATIENTS AND METHODS: A retrospective study was conducted at the Sud-Reunion Hospital's maternity (French overseas department located in the Indian Ocean), during the period from January 1, 2001, through December 31, 2004. During this period, 1172 pregnant women presenting gestational diabetes mellitus were compared with 1172 non-diabetic controls matched on the basis of age, parity. Student t test, Pearson chi-square test and logistic regression model were used for statistical analysis. RESULTS: Gestational diabetes mellitus complicates about 7.5% of pregnancies in Reunion Island. Its occurrence was associated with a significantly increased prevalence of pre-pregnancy obesity (27 versus 9.4%) and chronic hypertension (5.3 versus 3.3%). The prevalence of preeclampsia and obstetrical vascular disorders were not different between the two groups, respectively 2.2 versus 2.7% (P=0.43) and 6.2 versus 4.4% (P=0.06). The rate of caesarean sections and inductions of labour was increased in the study group. The term of delivery was inferior in the study group, consecutive to increased rate of labour induction at 38 week-gestation. Macrosomia and large for gestational age (LGA) newborns rate were significantly higher in the study group, respectively 8.9 versus 4.2% and 22.5 versus 10.1% (P<0.001) but the rate of admission into neonatal unit was not significantly different. DISCUSSION AND CONCLUSION: Active management of gestational diabetes mellitus is associated with low maternal and perinatal morbidity. While age and parity are controlled by the study design, the prevalence of preeclampsia and gestational hypertension are not increased in women presenting gestational diabetes mellitus.

Obstetrical and neonatal outcomes in obese women.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among pre-pregnant obese women. METHODS: At the Sud-Reunion Hospital's maternity, Reunion Islands, France, over a 54-month period, each obese pregnant woman (BMI > or = 30 kg/m2) delivering a singleton after 22-weeks gestation was compared to the next age and parity-matched woman of normal pre-pregnancy weight (BMI 18.5-25 kg/m2), who delivered after the index case. The Students t test, Mann and Whitney test, Chi-square test and logistic regression model were used for statistical analysis. RESULTS: The study enrolled 2081 obese women and 2081 controls. The incidences of pre-eclampsia, chronic and pregnancy-induced hypertension, chronic and gestational diabetes mellitus were increased in the obese women group. Prenatal care in obese women required a high rate of hospitalizations as well as a high rate of insulin treatment. Obese women were more likely to be delivered by Caesarean section. The rate of in utero fetal death, neonatal and perinatal death was significantly higher in the obese women group. The high BMI in relation with both pre-eclampsia and in utero fetal death remained unchanged after adjustment of other risk factors. CONCLUSION: Obese women were more likely to present several obstetric complications and to be delivered by Caesarean section. Obstetricians who decide on a first Caesarean section in an obese woman should be aware of the cumulated obesity and uterine scar risks that could threaten any subsequent Caesarean section.

Clinical diagnosis and management of respiratory distress in preterm neonates: effect of participation in a controlled trial.

The ability to generalize the results of a clinical trial depends on the ability to compare a population of patients with the population described in the trial, emphasizing the importance of objective diagnostic criteria in study design and clinical medicine. However, clinical decisions are often based on subjective interpretations of data. There is concern that bias that an experimental therapy is beneficial might lead to alterations in clinical diagnosis and management. To evaluate this concern, the authors reviewed a preexisting database comprising information obtained by trained personnel by chart review to investigate prospectively the frequency of the diagnosis of hyaline membrane disease and the use of mechanical ventilation before and during participation in a clinical trial of surfactant therapy during which such therapy was available exclusively through clinical trials. Major eligibility criteria for a randomized trial at the Medical University of South Carolina included mechanical ventilation and the diagnosis of hyaline membrane disease. Both the diagnosis of hyaline membrane disease and the use of mechanical ventilation increased between pre-surfactant and randomized trial periods (hyaline: 47.2% to 55.9%, P less than .05; ventilation: 55.6% to 66.3%, P less than .01). The possibility that enthusiasm for surfactant influenced clinical diagnosis and management of respiratory distress during this period cannot be dismissed.

Paternity patterns and risk of preeclampsia in the last pregnancy in multiparae.

Few authors have published investigations regarding a possible association between preeclampsia and changing paternity. This study employs an epidemiological approach to explore the relationship between severe preeclampsia and changes in paternity patterns among multigravidae in a Caribbean community (Guadeloupe, French West Indies). Multiparae who were diagnosed with preeclampsia or eclampsia with fetal complications (transfer of their infants in the Neonatal Department) and controls were examined (134 mothers' interviews). Information concerning paternity for the index and previous pregnancies was collected from three groups: women with pregnancy-induced hypertension (PIH); women with chronic hypertension (CH); and a control group consisting of women without hypertension during pregnancy. In 21/34 (61.7%) of PIH mothers, the father of the current pregnancy was different than that of the former, compared to 4/40 (10%) among CH and 10/60 (16.6%) in the controls (P < 0.0001). Moreover, considering three and four consecutive pregnancies, there was a significant trend (P < 0.005 and P < 0.02) for an increase in PIH with having a different father in each successive pregnancy. Patterns of changing paternity were significantly correlated with pregnancy-induced hypertension in multiparae but not with chronic hypertension and controls.

Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies.

OBJECTIVE: To determine whether the risk of cesarean section following uncomplicated pregnancies has been reduced by current obstetric practices by comparing the neonatal risk of vaginal deliveries with the risk incurred following abdominal delivery in otherwise uncomplicated pregnancies. DESIGN: Observational, cohort study. A subpopulation of 11,702 women without complications of pregnancy was identified from a perinatal database, classified by subsequent mode of delivery, and compared for neonatal morbidity. This analysis was repeated after the cesarean section group was further narrowed to include only "repeated elective" deliveries. SETTING: Low-risk inborn setting. Tertiary care (level III nursery) referral center and a community (level II nursery) hospital. INTERVENTION: Cesarean section performed electively, for cephalopelvic disproportion, or for failure to progress. OUTCOME VARIABLES: Chosen prior to data analysis: neonatal mortality and morbidity. RESULTS: Groups differed with regard to ethnicity and sex. Infants who were delivered by cesarean section were more likely to have 1-minute Apgar scores less than 4, require intermediate or intensive nursery care at admission (6.3% vs 1.3% [P < .001]), and require greater respiratory support (mechanical ventilation, 1.6% vs 0.3%; oxygen therapy, 4.9% vs 1.4%; or room air, 93.5% vs 98.4% [P < .001]) than infants who were delivered vaginally. Similar results were found when patients who were delivered vaginally and by repeated elective cesarean section were compared. CONCLUSION: Although reports have recently emerged suggesting otherwise, abdominal delivery following an uncomplicated pregnancy remains a risk factor for adverse neonatal outcome despite current obstetric practices.

Reduction in very low birth weight deliveries and perinatal mortality in a specialized, multidisciplinary twin clinic.

OBJECTIVE: To determine whether a specialized, multidisciplinary twin clinic could reduce rates of very low birth weight (VLBW) and perinatal mortality. Multifetal gestations account for only 1% of all pregnancies, yet are responsible for nearly 10% of all perinatal mortality. Very low birth weight (less than 1500 g) infants are the major contributors to this increased perinatal mortality rate. METHODS: Eighty-nine twin pairs followed in the Twin Clinic since 1988 were compared with 51 contemporary twin pairs who did not attend the Twin Clinic. Patients not attending the Twin Clinic were attended in the high-risk clinic by the obstetric residents and faculty. All maternal transports were excluded. Aspects of prenatal care emphasized in the Twin Clinic that differed from the high-risk clinic included consistent evaluation of maternal symptoms and cervical status by a single certified nurse-midwife, intensive preterm birth prevention education, individualized modification of maternal activity, increased attention to nutrition, and tracking of clinic non-attenders. RESULTS: There were no differences between the groups in demographic characteristics, adequacy of prenatal care, or antepartum complications. However, Twin Clinic attenders had lower rates of VLBW infants, neonatal intensive care unit admission, and perinatal mortality. CONCLUSIONS: These improvements in perinatal outcome for twin gestations are attributed to intensive preterm birth prevention education, individualization of prenatal care, and frequent maternal assessment by a consistent care provider. This approach reduced the rate of very early preterm delivery and its neonatal sequelae.

Determinants of prenatal care use in Hawaii: implications for health promotion.

This study examines the association between maternal sociodemographic characteristics and the receipt of different levels of prenatal care use (no care, inadequate, intermediate, adequate) in order to determine different patterns in the relationships between maternal characteristics and these distinct categories of prenatal care use. Using the 1979-1992 Hawaii live birth vital record file, single live births to Hawaii resident mothers of white, Hawaiian/part-Hawaiian, Filipino, or Japanese ethnicity, who did not indicate on the birth certificate that either parent was active duty military, were selected. Over one quarter of this study population did not initiate prenatal care in the first trimester. Given the high level of insurance coverage found in Hawaii, this finding is disconcerting, particularly in relation to the U.S. Year 2000 Objective of 90% initiation in the first trimester. Overall, the factors that predicted receipt of any prenatal care predicted more adequate use of prenatal care as well. Noteworthy exceptions were maternal age and ethnicity. Identifying these exceptions is important for the development of a more detailed understanding of risk factors related to use of prenatal care to better target program responses aimed at improving prenatal care use. In addition, these data suggest that removing financial barriers to access to care does not guarantee universal use of disease prevention and health promotion services.

Immune maladaptation in the etiology of preeclampsia: a review of corroborative epidemiologic studies.

Genuine preeclampsia is a disease of first pregnancies. The protective effect of multiparity, however, is lost with change of partner. Also, exposure to semen provides protection against developing preeclampsia. Analogous to altered paternity, artificial donor insemination and oocyte donation are reported to result in a substantial increase of preeclampsia. Thus, epidemiologic studies strongly suggest that immune maladaptation is involved in the etiology of preeclampsia. Although the exact etiology of preeclampsia remains unknown, the conclusions derived from epidemiologic studies may have consequences for practicing physicians: 1) according to the primipaternity concept, a multiparous women with a new partner should be approached as being a primigravid women; 2) artificial donor insemination and oocyte donation are associated with an increased risk of developing pregnancy-induced hypertensive disorders; 3) a more or less prolonged period of sperm exposure provides a partial protection against pregnancy-induced hypertensive disorders. In the 1990s, all women with changing partners are strongly advised to use condoms to prevent sexually transmitted diseases. However, a certain period of sperm exposure within a stable relation, when pregnancy is aimed for, is associated with a partial protection against preeclampsia.

Discordance between LMP-based and clinically estimated gestational age: implications for research, programs, and policy.

This study examines the comparability between the last menstrual period-based and clinically estimated gestational age as collected on certificates of live birth. It explores whether sociodemographic or delivery characteristics influence their agreement and contrasts health status and health care utilization indicators, such as preterm, small for gestational age, and adequacy of prenatal care percentages, produced by each gestational age measure. The 1989-91 South Carolina public use live birth files were used for this analysis. A total of 169,082 single births to resident mothers were selected for investigation. The clinically estimated gestational age distribution exhibited a higher mean and a tendency toward even number digit preference. The last menstrual period-based measure produced higher preterm and postterm percentages. More than 60 percent of the last menstrual period-based preterm births were classified as preterm by the clinical estimate. The sensitivity of the clinical estimate was 27 percent for postterm births. The overall concordance (the percentage of cases with the same value for both measures) was 47 percent, but it varied considerably by gestational age. Between 30 and 35 weeks, the clinical estimate exceeded the last menstrual period-based value by 2 weeks or more for more than 40 percent of the cases. Concordance also varied by race of mother, hospital delivery size, trimester prenatal care began, and birth weight. The last menstrual period-based and the clinically estimated gestational age distributions exhibited notable dissimilarities, produced marked differences in health status indicators, and varied in concordance by gestational age and by sociodemographic, prenatal care, and hospital characteristics. These systematic differences suggest that a transition from the traditionally used last menstrual period-based measure to the clinical estimate or a composite measure will not produce uniform results across geo-political areas and at-risk groups but will be appreciably influenced by population and health care characteristics.

Predictors of hospital postdischarge infant mortality: implications for high-risk infant follow-up efforts.

The association between maternal/infant characteristics and postdischarge mortality was determined for 19,573 infants from a single regional perinatal center. Postdischarge mortality was not associated with infant sex or ethnicity, mother's marital status, education, method of delivery, or income status. Mortality risk was statistically increased for infants who were neonatal intensive care unit graduates, of low birth weight, preterm, or small for gestational age. Infants who were either of low birth weight, neonatal intensive care unit graduates, or preterm represented 38% of hospital discharges and 64% of postdischarge deaths. Mortality odds for low-birth-weight infants exceeded that of neonatal intensive care unit graduates or preterm infants. Within these high-risk groups, mortality was further increased for infants with pulmonary interstitial emphysema, patent ductus arteriosus, bronchopulmonary dysplasia, hyaline membrane disease, apnea, or intraventricular hemorrhage III/IV. There were no postdischarge deaths among infants with meconium aspiration, persistent fetal circulation, or necrotizing enterocolitis. Partitioning infant mortality attributable to a single tertiary center suggested that 73.5% of the deaths occurred in infants who were continuously hospitalized from birth; 1.7% of the deaths occurred after discharge in infants who had lethal anomalies and were not expected to survive; 9.0% of the deaths occurred after discharge in infants without a selected risk factor; and 15.8% of the deaths occurred after discharge in infants with at least one high-risk characteristic.

Determinants of meconium-stained amniotic fluid in term pregnancies.

This study examines ethnic variations in meconium-stained amniotic fluid in term pregnancies, taking into account the role of gestational age, maternal sociodemographic characteristics, and medical risk factors. The study population included black and white singleton live births (N = 14,419) between 37 and 42 weeks' gestation, delivered vaginally at the Medical University of South Carolina from 1982 through 1990. Chi-square and logistic regression analysis were used to examine the association between the independent variables and meconium-stained amniotic fluid (MSAF). An increased risk of MSAF was found for advancing gestational age, indicators of fetal stress, fewer than five prenatal care visits, and > 15 hours labor. After controlling for demographic and clinical characteristics, the risk of MSAF in black patients was approximately 1.5 times that of white patients. The higher proportion of MSAF in blacks could not be explained with obvious risk factors.

The effect of anemia on retinopathy of prematurity in extremely low birth weight infants.

OBJECTIVE: Numerous risk factors for development of retinopathy of prematurity (ROP) in very low birth weight infants have been identified in the literature. However, the role of anemia in the development of ROP has not been adequately addressed. STUDY DESIGN: We retrospectively examined the medical records of all infants weighing < or = 800 g who were admitted to a university hospital between July 1, 1992 and December 30, 1997. Highest and lowest hemoglobin and hematocrit values and the number of blood transfusions were recorded at each week of life during hospitalization. Gestational age at birth, birth weight, race, sex, oxygen status, history of bronchopulmonary dysplasia, length of hospital stay, and sepsis were also identified as potential risk factors. Data were analyzed using logistic regression to adjust for these confounding variables. RESULTS: Infants were grouped according to ROP status in the following manner: stage 0 to 1 ROP, stage 2 ROP, and stage 3 to threshold ROP. Sex, gestational age at birth, bronchopulmonary dysplasia, ventilator days, length of hospital stay, and number of blood transfusions were significantly associated with severity of ROP by univariate analysis. Using a logistic regression model, only gestational age (p = 0.007) and number of blood transfusions (p = 0.04) remained statistically significant. CONCLUSIONS: Anemia did not affect severity of ROP as an independent risk factor. However, the number of blood transfusions did affect the highest stage of ROP in this group of premature infants. Infants who remained severely anemic (Hgb < or = 8 g/dl or Hct < or = 25%) for longer periods of time developed milder ROP than less anemic infants.

Revisiting the epidemiological standard of preeclampsia: primigravidity or primipaternity?

Pregnancy-induced hypertensive disorders, and especially preeclampsia, are documented to occur primarily in first pregnancies and rarely in subsequent pregnancies. Therefore, the concept of primigravidity is the epidemiological cornerstone of this disease. The authors propose a concept in which preeclampsia is a disease of new couples, especially after a short period of sexual cohabitation, and explore if this alternative primipaternity model, as compared with the primigravidity concept, provides a better fit with well-known epidemiologic descriptions. First, the primipaternity model provides a mathematical modelling which may explain the prevalence of approximately 10% in long-term monogamic populations. Further, it proposes explanations for many epidemiological descriptions which were previously difficult to understand and assemble in a single concept.

Hyaline membrane disease in black newborns: does fetal lung maturation occur earlier?

Debate has developed among several authors about possible accelerated maturation of black fetuses in comparison with whites. In Guadeloupe, French West Indies, where 85% of the population is of black African-American origin, it has been noted that the incidence of hyaline membrane disease (HMD) represents a significant drop beginning after the 32nd week of gestation. Over a 3-year period, 419 black low-birthweight singleton newborns were admitted in the University Hospital's Neonatal Department covering 70% of all births of the island. The incidence of HMD was 50% among very low birthweight (< 1500 g) and 8.3% among moderate low birthweight (> or = 1500 g; P < 0.001). The incidence of HMD was 48.8% among the very preterm (< 32 weeks) and 7.8% (26/331) among the moderate preterm (> or = 32 weeks; P < 0.001). These differences were similar for appropriate for gestational age and small for gestational age infants. Significant differences remained after controlling for several maternal risk factors. These results suggest that the 32nd week of gestation represents a significant drop in the risk for respiratory distress syndrome in black premature compared with that reported in literature on European infants (34th week) and therefore may implicate different obstetrical decisions in the management of critical pregnancies in this population.

Family characteristics and measures of behavior in foster and nonfoster children.

Behavior scores of maltreated children in foster care were compared with those of a homogeneous group of children who had never been in care. Mean scores for foster children were significantly higher than those for controls. After controlling for group differences in family structure and stability, differences in behavior scores between groups were not significant.

Evaluation of neonatal sepsis screening in a tropical area. Part I: Major risk factors for bacterial carriage at birth in Guadeloupe.

This prospective study reports on screening for neonatal sepsis among 3,372 live births out of 6,060 consecutive deliveries at the University Hospital of Pointe-à-Pitre, Guadeloupe, during a 30-month period. Group B Streptococcus (GBS) was the most common pathogen, representing 46% (89/194) of positive blood cultures and 52% (335/637) of positive gastric aspirates. Although only 3,372 (55%) of all live births were screened, 637 (10%) had gastric bacterial carriage at birth; of those, 335 (5.5%) involved GBS. Similarly, there were 194 (3.2%) positive blood cultures, of which 89 (1.5%) involved GBS. In this report, all newborns who presented with a positive GBS blood culture had at least one of the external tests positive for GBS (gastric, ear canal, rectum and placenta). Thirty-seven per cent (14/38) of positive neonatal blood cultures occurred in newborns with foetid liquor while in deliveries with intrapartum fever 16.5% (32/195) of blood cultures were positive. In our clinical practice, characteristics that were evident in the delivery room (without knowledge of prenatal follow-up) such as foetid liquor, intrapartum fever, prolonged rupture of membranes, foetal tachycardia and meconium staining were associated with the great majority of neonatal sepsis.

Evaluation of neonatal sepsis screening in a tropical area Part III: Neonatal sepsis in meconium stained deliveries.

Of the 6,060 consecutive live births delivered at the University Maternity Unit of Guadeloupe (French West Indies) during a 30-month period, 635 newborns (10.4%) presented with meconium stained (MS) amniotic fluid, of which 595 (94%) received bacteriological screening at birth (light MS, n = 543; thick MS, n = 52). Thirty (5%) of MS newborns had a bacteraemia (n = 13, group B streptococcus, GBS), and 128 (21.5%) a bacterial positive gastric aspirate (n = 54, GBS). Sixty-six newborns among MS babies needed tracheal suctioning (11%) in the delivery room for meconium inhalation. Among these 595 screened MS newborns, 286 (48%) presented clinical signs of postmaturity at birth, having therefore an explanation for their MS condition. For the other MS newborns without the postmaturity explanation, we experienced twofold increased risk of neonatal sepsis (OR 1.88 for bacteraemia and 2.61 for external carriage p < 0.02, Chi square) as compared with their MS postmature counterparts. We conclude that when meconium stained deliveries are associated with postmaturity signs, one may not need to initiate prophylactic antibiotic treatment at birth unless they present with other traditional risk factors for neonatal sepsis such as intrapartum fever and prolonged rupture of membranes.

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol.

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90% of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75% of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.