Occupational fatigue and preterm premature rupture of membranes. National Institute of Child Health and Human Development Maternal-Fetal Medicine, Units Network.

OBJECTIVE: The aim of this study was to prospectively determine the relationship between occupational fatigue and spontaneous preterm delivery segregated into the etiologically distinct categories of spontaneous preterm labor, preterm premature rupture of membranes, and indicated preterm delivery. STUDY DESIGN: A total of 2929 women with singleton pregnancies at 22 to 24 weeks' gestation were enrolled in a multicenter (10 sites) Preterm Prediction Study. Patients reported the number of hours worked per week and answered specific questions designed to determine the following 5 sources of occupational fatigue described by Mamelle et al: posture, work with industrial machines, physical exertion, mental stress, and environmental stress. Fatigue was quantified (0-5 index) according to the number of these sources positively reported. Simple and Mantel-Haenszel chi2 tests were used to test the univariate association and hypothesis of a linear trend between sources of occupational fatigue and spontaneous preterm delivery. Covariables were considered by multivariate logistic regression analysis. Women who did not work outside the home were considered separately from those who worked but did not report any sources of occupational fatigue. RESULTS: Each source of occupational fatigue was independently associated with a significantly increased risk of preterm premature rupture of membranes among nulliparous women but not among multiparous women. The risk of preterm premature rupture of membranes increased (P = .002) with an increasing number of sources of occupational fatigue-not working outside the home, 2.1%; working but not reporting fatigue, 3.7%; working with 1 source of fatigue, 3.2%; working with 2 sources of fatigue, 5.2%; working with 3 sources of fatigue, 5.1%; and working with 4 or 5 sources of fatigue, 7.4%. There was also a significant relationship (P = .01) between preterm premature rupture of membranes and an increasing number of hours worked per week among nulliparous women. Neither spontaneous preterm labor nor indicated preterm delivery was significantly associated with occupational fatigue among either nulliparous or multiparous women. CONCLUSION: The occupational fatigue index of Mamelle et al discriminated a group of nulliparous women at increased risk for preterm premature rupture of membranes. The relationship between preterm premature rupture of membranes and occupational fatigue or hours worked may provide guidelines according to which nulliparous women and their employers can be advised.

Preterm prediction study: is socioeconomic status a risk factor for bacterial vaginosis in Black or in White women?

Bacterial vaginosis (BV), an important risk factor for preterm birth, is a more common infection in Black compared with White pregnant women. Because Black women in the United States are more likely to have lower measures of socioeconomic status (SES), this study examined the hypothesis that BV is associated with low SES. The project evaluated data from the Preterm Prediction Study of 2,929 women prospectively followed during their pregnancies. The women, who were screened for BV at 24 and 28 weeks of gestation, underwent a structured interview to evaluate demographic factors, SES, home and work environment, drug or alcohol use, and prior medical history. Black women in the study had many measures of lower SES compared with the White women, and reported less use of tobacco, alcohol and drugs. In neither the Black nor White women was an association found between BV and measures of SES (with the sole exception of "absence of a home telephone"). Most measures of SES do not explain the difference in rates of BV in Black and in White pregnant women.

Obstetric determinants of neonatal survival: influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units.

OBJECTIVE: Our purpose was to evaluate the relationship between the approach to obstetric management and survival of extremely low-birth-weight infants. STUDY DESIGN: In this prospective observational study we evaluated 713 singleton births of infants weighing < or = 1000 gm during 1 year at the 11 tertiary perinatal care centers of the National Institutes of Child Health and Human Development network of maternal-fetal medicine units. Major anomalies, extramural delivery, antepartum stillbirth, induced abortion, and gestational age < 21 weeks were excluded. The obstetrician's opinion of viability and willingness to perform cesarean delivery in the event of fetal distress were ascertained from the medical record or interview when documentation was unclear. Grade 3 and 4 intraventricular hemorrhage, grade 3 and 4 retinopathy of prematurity, necrotizing enterocolitis requiring surgery, oxygen dependence at discharge or 120 days, and seizures were considered serious morbidity. Survival without serious morbidity was considered intact survival. Logistic regression was used to evaluate the influence of the approach to obstetric management, adjusted for birth weight, growth, gender, presentation, and ethnicity. RESULTS: Willingness to perform cesarean delivery was associated with increased likelihood of both survival (adjusted odds ratio 3.7, 95% confidence interval 2.3 to 6.0) and intact survival (adjusted odds ratio 1.8, 95% confidence interval 1.0 to 3.3). Willingness to intervene for fetal indications appeared to virtually eliminate intrapartum stillbirth and to reduce neonatal mortality. Below 800 gm or 26 weeks, however, willingness to perform cesarean delivery was linked to an increased chance of survival with serious morbidity. Although obstetricians were willing to intervene for fetal indications in most cases by 24 weeks, willingness to perform cesarean delivery was associated with twice the risk for serious morbidity at that gestational age. CONCLUSIONS: The approach to obstetric management significantly influences the outcome of extremely low-birth-weight infants. Above 800 gm or 26 weeks the obstetrician should usually be willing to perform cesarean delivery for fetal indications. Between 22 and 25 weeks willingness to intervene results in greater likelihood of both intact survival and survival with serious morbidity. In these cases patients and physicians should be aware of the impact of the approach to obstetric management and consider the likelihood of serious morbidity and mortality when formulating plans for delivery.

Iron deficiency anemia in pregnancy.

Iron deficiency is seen commonly in women during their reproductive years and particularly during pregnancy. The physician who primarily cares for women should be aware of this and initiate iron supplementation when indicated. The association of poor pregnancy outcome is of concern when iron deficiency is present in the first trimester. It is unclear whether this is because of the anemia or other epidemiologic factors. It is also unknown whether correcting iron deficiency before conception improved neo-natal outcome. Until more is known concerning IDA, it is recommended that pregnant women receive nutritional assessment and prenatal care along with adequate iron supplementation to potentially decrease the risk of poor pregnancy outcome.

Efficacy of intraperitoneal sodium carboxymethylcellulose in preventing postoperative adhesion formation.

Various regimens to reduce postoperative intraperitoneal adhesion formation have been tested; however, none has been consistently successful. The purpose of this study was to compare the efficacy of three compounds instilled into the peritoneal cavity--32% dextran 70, 0.9% normal saline and sodium carboxymethylcellulose--to no therapy on their ability to prevent postoperative adhesion formation in the New Zealand white rabbit. Bilateral posterior uterine horn incisions and cecal and transverse colon abrasions were performed during a two-phased study on each of 25 rabbits that were randomly assigned in a blind fashion into one of four study groups. Two weeks postoperatively, each rabbit underwent an autopsy to assess the magnitude of intraperitoneal adhesion formation. Adhesion scores were determined by counting the number of adhesions and assigning one or two points for each thin, filmy or dense, broad adhesion. As compared to no therapy, all three substances tested significantly reduced adhesion formation. Although 32% dextran 70 and 0.9% normal saline showed similar results, the degree of adhesion formation was reduced most significantly with sodium carboxymethylcellulose (P < .002) Sodium carboxymethylcellulose is effective in preventing postoperative adhesion formation in the New Zealand white rabbit.

The fetal-pelvic index: a method of identifying fetal-pelvic disproportion in women attempting vaginal birth after previous cesarean delivery.

In 1986 the fetal-pelvic index was introduced as an accurate method of prospectively identifying the presence or absence of fetal-pelvic disproportion. The concept of the fetal-pelvic index is one in which the fetal head and abdominal circumferences (ultrasonographic mensuration) are compared with the respective maternal pelvic inlet and midpelvic circumferences (x-ray pelvimetry). The purpose of this study is to evaluate the efficacy of this index as a predictor of fetal-pelvic disproportion in gravid women attempting vaginal birth after previous cesarean delivery. Findings of the fetal-pelvic index are compared with those of two other means of identifying fetal-pelvic disproportion (Colcher-Sussman x-ray pelvimetry and ultrasonographically derived estimated fetal weight of greater than or equal to 4000 gm). Of the 65 prospective study participants, 18 (28%) failed to progress in labor, and a repeat cesarean delivery was required. Forty-seven of the 52 patients with a negative fetal-pelvic index value were delivered vaginally (negative predictability = 0.90). Of the five with false-negative fetal-pelvic index values, four fetuses persisted in an occipitoposterior position and failed to progress in labor. All 13 patients with a positive fetal-pelvic index value failed to progress in labor and required a cesarean delivery (positive predictability = 1.00). In contrast, when used alone, neither x-ray pelvimetry nor ultrasonography-determined estimated fetal weight of greater than or equal to 4000 gm provided accurate identification of fetal-pelvic disproportion.

Management and outcome of two pregnancies in a woman with craniodiaphyseal dysplasia.

Hyperostotic bone dysplasias are characterized by progressive hyperostosis and sclerosis of the cranium and facial bones. As a result of progressive bony overgrowth, intracranial pressure may increase and lead to brain and nerve compression, cranial nerve palsies, and an increased incidence of seizures. The long bones often exhibit defective modeling as well as variable degrees of metaphyseal and diaphyseal hyperostosis. In addition, the axial skeleton (including the pelvis) is often hyperostotic and sclerotic. The clinical features of these disorders may have relevance to the outcome of pregnancy; however, there are no reports on the management and pregnancy outcome of patients affected with hyperostotic bone disease. In this report, we describe the course of two pregnancies in a woman with craniodiaphyseal dysplasia (a rare craniotubular dysplasia). Prenatal assessment, method of delivery, choice of anesthesia, and neonatal management are discussed. Although this disorder is rare, the pathophysiologic considerations relevant to pregnancy outcome may be applicable to the management of pregnant women with other hyperostotic bone dysplasias.

Vaginal and bladder angiosarcoma after therapeutic irradiation.

Angiosarcoma involving the female genitourinary tract is a rare soft tissue malignancy of vascular origin. We have described probably the first reported case of postirradiation angiosarcoma involving the vagina and bladder, and have reviewed the existing literature on the subject of angiosarcoma resulting from previous therapeutic irradiation for gynecologic malignancy.