Peer norms moderate the association between mental health and sexual risk behaviors among young men living in Dar es Salaam, Tanzania.

BACKGROUND: Young men living in Dar es Salaam's informal settlements face environmental stressors that may expose them to multiple determinants of HIV risk including poor mental health and risky sexual behavior norms. We aimed to understand how these co-occurring risk factors not only independently affect men's condom use and sexual partner concurrency, but also how they interact to shape these risk behaviors. METHODS: Participants in the study were male members of 59 social groups known as "camps" in Dar es Salaam, Tanzania. We assessed moderation by changes in peer norms of the association between changes in symptoms of anxiety and depression and sexual risk behaviors (condom use and sexual partner concurrency) among 1113 sexually active men. Participants nominated their three closest friends in their camp and reported their perceptions of these friends' behaviors, attitudes, and encouragement of condom use and concurrency. Anxiety and depression were measured using the HSCL-25, and condom use and sexual partner concurrency were assessed through self-report. RESULTS: Perceptions of decreasing condom use among friends (descriptive norms) and decreasing encouragement of condom use were associated with lower levels of condom use. Perceptions of increasing partner concurrency and acceptability of partner concurrency (injunctive norms) among friends were associated with higher odds of concurrency. Changes in perceived condom use norms (descriptive norms and encouragement) interacted with changes in anxiety symptoms in association with condom use such that the negative relationship was amplified by norms less favorable for condom use, and attenuated by more favorable norms for condom use. CONCLUSIONS: These results provide novel evidence of the interacting effects of poor mental health and risky sexual behavior norms among a hard to reach population of marginalized young men in Dar es Salaam. Our findings provide important information for future norms-based and mental health promotion interventions targeting HIV prevention in this key population.

An analysis of diabetic pregnancies at Mayo Clinic, 1950-79.

We reviewed the records of pregnant diabetic women attended at Mayo Clinic during the years 1950-79 and matched each nonaborted diabetic pregnancy with two control pregnancies. Abortions occurred in 49 of 277 diabetic pregnancies (17.7%). The relative risk of other adverse outcomes of pregnancy (+/- 95% confidence interval) in comparison with controls was as follows: perinatal mortality, 7.0 (3.6-13.8); major congenital birth defects, 6.3 (2.8-14.2); and respiratory distress, 9.0 (4.5-17.9). Diabetic ketoacidosis resulted in fetal death in 5 of 18 cases. Patients with mean fasting blood glucose levels of less than or equal to 140 mg/dl had a perinatal mortality of 81 per 1000 births and an incidence of respiratory distress and congenital birth defects of 18.9% and 9.9%, respectively. Patients with mean blood glucose levels greater than 140 mg/dl had corresponding rates of 306 per 1000, 20.4%, and 11.2%, respectively. Hydramnios occurred almost exclusively in diabetic women, and its presence was associated with a twofold increase in the frequency of perinatal death. Analysis of diabetic pregnancy outcome by decade showed no appreciable decrease in the occurrence of perinatal mortality, congenital birth defects, or respiratory distress over the 30-yr period.

Diagnosis and management of fetal distress.

Both biophysical and biochemical techniques may be used to diagnose fetal distress. Fetal heart rate monitoring should be thought of as a screening technique to define a population at significant risk for fetal acidosis. The addition of fetal scalp blood sampling improves the clinician's diagnostic accuracy. The hallmark of treatment is to alleviate the stress on the fetus, to restore intervillous and cord blood flow, and, hence, to improve fetal oxygenation. This improvement may be accomplished by (1) discontinuing oxytocin, (2) correcting maternal hypotension, (3) administering oxygen to the mother, and (4) attempting to alleviate cord compression by changing the relationship of the fetal presenting part to the umbilical cord and pelvis.

Metabolism of uric acid in normal and toxemic pregnancy.

The formation, measurement, and excretion of uric acid are reviewed. Since fluctuations in serum uric acid may be as high as 40% over a 24-hour period, a single value must be evaluated with caution. Alterations in the renal handling of uric acid are responsible for the pronounced decrease in serum uric acid over the first 20 weeks of gestation, its gradual increase in the latter part of pregnancy, and its further increase with pregnancy-induced hypertension. Although there is a fair degree of overlap between a normotensive control and a preeclamptic group, the level of serum uric acid generally correlates with the severity of preeclampsia. Possible intrarenal mechanisms that could produce these changes are discussed.

Effects of drugs and chemicals on the fetus and newborn (2).

Physicians have become increasingly aware of the side effects of specific drugs. Obstetricians and family physicians should especially be cognizant of the implications of the administration of any drug, not only for the pregnant mother but also for the unborn child. In this second installment of our two-part article, we conclude our review of drugs, chemicals, and environmental pollutants that may affect the fetus or newborn.

Effects of drugs and chemicals on the fetus and newborn (1).

Drug teratogenicity has been demonstrated experimentally for more than 30 years. After the discovery of the thalidomide-induced embryopathies, the fetal dangers of maternal drug ingestion were overemphasized. Accumulation of additional information during the past 15 years has led to a more balanced viewpoint concerning drug teratogenicity. A complex set of circumstances must prevail for a specific teratogenic effect to result. Not only the drug or environmental pollutant in question but also its dose, timing, and frequency of administration as well as the genetic and individual susceptibility of the embryo are important factors. Herein we review the currently available information on drug and environmental effects on the fetus and neonate.

The prenatal detection of congenital malformations by ultrasonography.

Approximately 150,000 children with congenital anomalies are born annually in the United States. Antenatal detection of these disorders would help to improve not only postpartum management but also the management of labor and delivery in the early neonatal period. With the current widespread availability of real-time ultrasound equipment, 40% of obstetric practices have all of their patients undergo scanning at least once during the antepartum period, and 75% of such practices have 50% of their patients undergo ultrasonography. Ultrasound standards for normal fetal growth and development at various gestational ages have been or are being developed. Hence, as the experience of the sonographer continues to grow, the potential for diagnosing the ever-increasing number of congenital anomalies will likewise increase. If the obstetrician suspects or is looking for a specific congenital anomaly, an initial sonogram should be obtained by 16 to 18 weeks' gestation. Serial scanning may be necessary before a definitive diagnosis can be made or a particular anomaly can be excluded.

Management of maternal vegetative state during pregnancy.

A pregnant patient with irreversible anoxic brain damage was maintained by life-support measures from 14 weeks' gestation until delivery of a healthy male infant at 34 weeks. Because two patients (the mother and the fetus), as well as the surviving family members, will be affected by decisions about life support, each case should be assessed individually.

Deletion of terminal portion of 6q: report of a case with unusual malformations.

We present the necropsy findings of a 21-week-gestation male fetus with deletion of the terminal portion of long arm of chromosome 6 [46,XY,del(6)(q23----qter)]. Major anomalies include intrauterine growth retardation, facial anomalies, nuchal cyst, scoliosis, bilateral diaphragmatic hernias, persistent common atrioventricular canal, absent olfactory bulbs and agenesis of corpus callosum. In aberrations of chromosome 6q, patients usually have psychomotor retardation, somatic growth failure, and facial anomalies; nuchal cyst and bilateral diaphragmatic hernias have not yet been described.

An unusual constellation of sonographic findings associated with congenital syphilis.

Sonography of a fetus, later proved to have congenital syphilis, revealed hepatosplenomegaly, noncontinuous gastrointestinal tract obstruction, and placentomegaly. This unusual constellation of sonographic findings should raise suspicion of syphilis infection of the fetus.

The use of quinidine sulfate throughout pregnancy.

A gravid patient was given quinidine sulfate for idiopathic ventricular tachycardia. The serum levels of quinidine remained stable throughout pregnancy. At delivery, maternal and neonatal quinidine levels were equivalent, while the level in the amniotic fluid was significantly elevated. Explanations for the latter include 1) a concentration of quinidine in amniotic fluid due to spontaneous fetal voiding and 2) the use of a nonspecific protein precipitate method to measure quinidine that is unable to differentiate quinidine from its nonfunctioning metabolites. The diffusion of quinidine into breast milk was related to the serum quinidine concentration.

Small bowel obstruction in pregnancy. A review and report of four cases.

Four gravid patients with small bowel obstruction secondary to adhesions were seen during a 17-year span (1955 through 1971) at the Mayo Clinic. Three of these patients had been referred to us for definitive diagnosis and treatment. During the time span under investigation, there were 25,189 deliveries at our institution. As the incidence of surgical procedures increases, small bowel obstruction is likely to be seen more frequently. One must consider this diagnosis in any pregnant patient with an abdominal scar and the characteristic signs and symptoms of obstruction. When mechanical intestinal obstruction has been diagnosed, the recommended treatment is surgery regardless of the gestational age or status of the fetus.

A spring-loaded needle for amniocentesis.

The spring-loaded needle for amniocentesis that is described has theoretic advantages over a spinal needle. These include increased safety for the fetus and better recognition of when the needle enters the uterine cavity.

Transvaginal sonographic detection of the pseudogestational sac associated with ectopic pregnancy.

Fifty-seven of 261 patients (21.8%) referred with a presumptive diagnosis of an ectopic gestation had an extrauterine pregnancy. Five of the 57 ectopic pregnancies (8.8%) had a pseudogestational sac on transvaginal sonography. In four of these five cases, a single beta-hCG level had been obtained and did not help in differentiating an ectopic gestation from an early intrauterine pregnancy. A thorough assessment of the adnexa and cul-de-sac should be performed if a patient suspected of having an ectopic pregnancy has an apparent intrauterine gestational sac without a normal yolk sac or without detectable fetal cardiac activity.

Intraluminal bladder calcifications: an antenatal sign of an enterovesical fistula.

Anorectal agenesis is usually associated with a fistula to the bladder, urethra, or vagina. The sonographic detection of a meconium concretion in the fetal bladder strongly suggests the presence of an enterovesical fistula.

Rh sensitization after genetic amniocentesis.

A retrospective evaluation was undertaken of 78 Rh-negative women who underwent genetic amniocentesis without Rh-immune globulin prophylaxis. Of the 56 patients at risk for sensitization, 3 (5.4%) became sensitized during the pregnancy in which amniocentesis was performed. This number is not statistically different from the 2.1% incidence of spontaneous Rh immunization during pregnancy. However, a trend toward increasing sensitization after second-trimester amniocentesis was noted. As the fetoplacental blood volume at 16 weeks' gestation is approximately 12 to 13 ml, a 150-micrograms dose of Rh-immune globulin is recommended for the Rh-negative patient who is undergoing genetic amniocentesis.

Rapid assessment of fetal hemoglobin concentration with the HemoCue system.

Successful treatment of severe fetal hemolytic disease depends on rapid and accurate measurement of fetal hemoglobin or hematocrit. The HemoCue is a portable hemoglobinometer that rapidly measures hemoglobin concentration. To evaluate the potential role of this instrument in fetal transfusion therapy, we measured hemoglobin concentration with the HemoCue and compared it with Coulter counter determination of hemoglobin in 39 fetuses. The HemoCue accurately measured fetal hemoglobin concentration (y = -0.3986 + 1.0276x; r = 0.97, P less than .001). This instrument is valuable for use with intravascular fetal transfusions.

Cholecystectomy in pregnancy.

During the 17 years 1955 through 1971, 20 gravid patients underwent cholecystectomy. This represented 1 case for every 1259 deliveries (0.079% of 25,189 deliveries). The primary indication for surgery was repeated attacks of gallbladder colic. Generally, surgery was performed between the 10th and the 20th week of gestation. There was one spontaneous abortion; this occurred at 10 weeks of gestation, 42 days after surgery.

Prophylactic use of hydroxyprogesterone caproate in abdominal surgery during pregnancy. A retrospective evaluation.

Abdominal surgery (unrelated to delivery) during pregnancy is not common. Review of a recent 17-year experience at our institution revealed 112 surgical procedures among 25,189 deliveries--an incidence of 0.44% (1 case for every 225 deliveries). Progestational agents have been used prophylactically in such procedures, but few studies have adequately assessed the effectiveness of these drugs to prevent onset of premature labor. The present study involved 35 gravid patients who had been treated with various doses of hydroxyprogesterone caproate before and after operations unrelated to delivery. These 35 patients were matched with 35 gravid control patients who had undergone similar operations but who had not received progestational compounds. Analysis revealed no significant difference in the abortion rate between these two groups.

Validity of transabdominal sonography in the detection of a two-vessel umbilical cord.

OBJECTIVE: To determine the validity of transabdominal ultrasound in the detection of a two-vessel and a three-vessel umbilical cord. METHODS: The ultrasound and pathology databases were collated between January 1, 1999, and December 31, 2000. Only those cases with ultrasound and pathology information concerning the number of vessels in the umbilical cord were included for analysis (group 1). In addition, 27 cases with a two-vessel umbilical cord were included from the ultrasound database before January 1, 1999, for which pathologic information was also obtained (group 2). RESULTS: A total of 1295 ultrasound/pathology reports were entered from January 1, 1999, through December 31, 2000; 268 cases did not have complete information, leaving 1027 for analysis (group 1). The visualization rate of the number of vessels in the umbilical cord increased from 15 to 17 weeks' gestation (74.1-97.6%; P <.001). The visualization rate remained stable from 17.0 to 35.9 weeks' gestation, and then declined to 83.3% (P <.01). The sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of a two-vessel umbilical cord were 85%, 99.7%, 85%, and 99.7%, respectively. CONCLUSION: The detection rate of either a two-vessel or three-vessel umbilical cord is best achieved between 17 and 36 weeks' gestation. In the majority of two-vessel umbilical cords that were called three-vessel, an appropriate transverse image of the umbilical cord was not obtained.