Development of a Postpartum Stressor Measure.

To develop a brief self-report assessment of the type and magnitude of stressors during the postpartum period. A cross-sectional study of a convenience sample of 138 women at Massachusetts General Hospital in Boston, MA completed a measure of postpartum stressors at their 6-week postpartum visit. Item analyses were conducted; items were eliminated based on low relevance, low endorsement, and cross-loadings, resulting in a 9-item measure. Items were summed to create a total postpartum stressors score. To establish concurrent validity with perceived stress, the total postpartum stressors score was correlated with the 4-item Perceived Stress Scale (PSS-4). The stressors score was tested for bivariate associations with depression (Patient Health Questionnaire-2) and with social support (three items adapted from the MOS Social Support Scale). The 9-item measure, which was comprised of three factors (baby care, well-being, and work) demonstrated good reliability (Cronbach's α = .74) and concurrent validity with the PSS-4 (r = .53; p < .001) in the current sample. The stressors total score was negatively associated with social support (p < .001) and was positively associated with depression symptoms (p < .001). The early psychometric results on this measure are promising and associated with postpartum social support and depressive symptoms. With additional research to enhance external validity, this measure could be used and tested in an intervention study at the 6-week postpartum visit to identify women at risk for distress.

Outpatient calcium-channel blockers and the risk of postpartum haemorrhage: a cohort study.

OBJECTIVE: To determine whether outpatient exposure to calcium-channel blockers (CCBs) at the time of delivery is associated with an increased risk for postpartum haemorrhage (PPH). DESIGN: Cohort study. SETTING: United States of America. POPULATION OR SAMPLE: Medicaid beneficiaries. METHODS: We identified a cohort of 9750 patients with outpatient prescriptions for CCBs, methyldopa, or labetalol for pre-existing or gestational hypertension whose days of supply overlapped with delivery; 1226 were exposed to CCBs. The risk of PPH was compared in those exposed to CCBs to those exposed to methyldopa or labetalol. Propensity score matching and stratification were used to address potential confounding. MAIN OUTCOME MEASURES: The occurrence of PPH during the delivery hospitalisation. RESULTS: There were 27 patients exposed to CCBs (2.2%) and 232 patients exposed to methyldopa or labetalol (2.7%) who experienced PPH. After accounting for confounders, there was no meaningful association between CCB exposure and PPH in the propensity score matched (odds ratio 0.77, 95% CI 0.50-1.18) or stratified (odds ratio 0.79, 95% CI 0.53-1.19) analyses. Similar results were obtained across multiple sensitivity analyses. CONCLUSIONS: The outpatient use of CCBs in late pregnancy for the treatment of hypertension does not increase the risk of PPH.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample.

OBJECTIVE: We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women. STUDY DESIGN: This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery. RESULTS: The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188). CONCLUSION: Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

A decline in myometrial nitric oxide synthase expression is associated with labor and delivery.

The mechanisms that maintain relative uterine quiescence during pregnancy remain largely unknown. A possible role for nitric oxide has recently emerged, however, the expression of nitric oxide synthase within human myometrium at midgestation, a time when the uterus is normally quiescent, has not been investigated. The purpose of this study was to identify cell types in human myometrium that contain inducible nitric oxide synthase (iNOS), and to examine changes in its expression during pregnancy and labor. We found that iNOS is expressed in smooth muscle cells of pregnant myometrium. Expression of iNOS was highest in myometrium of preterm not-in-labor patients. At term, iNOS expression fell by 75%, and was barely detectable in preterm in-labor or term in-labor specimens. There was no staining in the myocytes of nonpregnant myometrium. Western blotting also revealed a similar pattern of changes in iNOS expression. In summary, iNOS expression in the myocytes of human myometrium is increased greatly during pregnancy, and declines towards term or with labor. Significantly, preterm inlabor patients also had a large decline in iNOS expression. These data suggest that changes in myometrial iNOS expression may participate in the regulation of uterine activity during human pregnancy.

Routine ultrasound screening in low-risk pregnancies: imperatives for further study.

The benefits of screening ultrasonography in low-risk pregnancies are uncertain and require further investigation. As researchers organize future trials, however, they will need to define clearly the structure and content of the screening ultrasound examination and explicitly detail those outcomes considered important. Such studies must examine the effectiveness of screening sonography in comparison with and in the context of other available prenatal tests and screens. Until studies showing efficacy are available, screening ultrasound in low-risk pregnancies should be considered only when patients, guided by clinicians, consider the potential benefits to be of value.

Measurement of embryotoxic factors is predictive of pregnancy outcome in women with a history of recurrent abortion.

OBJECTIVE: To determine whether the production of embryotoxic factors in early pregnancy is predictive of pregnancy outcome in women with a history of two or more unexplained recurrent abortions. METHODS: Between July 1987 and June 1991, 450 nonpregnant women were evaluated for recurrent abortion. Embryotoxic factors were found in 328 of 346 women with an otherwise unexplained etiology. These women were given progesterone immunosuppressive therapy in a subsequent conception cycle, and embryotoxic factors were measured at 5 weeks' gestation. RESULTS: Data on embryotoxic factors and pregnancy outcome were available for 141 of 208 reported subsequent pregnancies. Of women still positive for embryotoxic factors, 40 had a repeat first-trimester spontaneous abortion whereas 16 delivered a viable infant; of women who no longer produced embryotoxic factors, only 11 had a repeat first-trimester abortion and 74 delivered a viable infant. CONCLUSIONS: The embryotoxic factor assay may be useful in predicting pregnancy outcome in women with a history of unexplained recurrent abortion. Further work is needed to evaluate the effectiveness of immunosuppression for this condition.

Birth weight as a predictor of brachial plexus injury.

OBJECTIVE: To examine the relationship between birth weight and brachial plexus injury and estimate the number of cesareans needed to reduce such injuries. METHODS: All 80 neonatal records coded for brachial plexus injury from October 1985 to September 1993 at the Brigham and Women's Hospital in Boston, Massachusetts, were studied along with linked maternal files. Birth weight, method of delivery, presence or absence of shoulder dystocia, and any diagnosis of maternal gestational or nongestational diabetes were abstracted. Data for the group with brachial plexus injury were compared with data for live-born infants without this injury during the same period. The sensitivity and specificity of birth weight as a predictor of brachial plexus injury were calculated. Further, the number of cesarean deliveries necessary to prevent a single brachial plexus injury was estimated using various weight cutoffs (4000, 4500, and 5000 g) for elective cesarean delivery. RESULTS: Among 77,616 consecutive deliveries, there were 80 brachial plexus injuries identified, for an incidence of 1.03 per 1000 live births. The incidence of brachial plexus injury increased with increasing birth weight, operative vaginal delivery, and the presence of glucose intolerance. In the group of women without diabetes, between 19 and 162 cesarean deliveries would have been necessary to prevent a single immediate brachial plexus injury. Among women with diabetes, between five and 48 additional cesareans would have been required. CONCLUSION: Although birth weight is a predictor of brachial plexus injury, the number of cesarean deliveries necessary to prevent a single injury is high at most birth weights. Because of the large number of cesarean deliveries needed to prevent a single brachial plexus injury in infants born to women without diabetes, it is difficult to recommend routine cesarean delivery for suspected macrosomia in these women.

Neonatal outcome of infants born at 23 weeks' gestation.

OBJECTIVE: To determine the neonatal outcome in accurately dated 23-week deliveries. METHODS: We reviewed the records of consecutive births between 23 0/7 and 23 6/7 weeks at Brigham & Women's Hospital, Boston, Massachusetts, from January 1995 to December 1999. Women were excluded if they presented for elective termination or had known fetal death or poor dating criteria. Neonatal records were abstracted for mortality and short-term morbidity, including the respiratory distress syndrome (RDS), intraventricular hemorrhage, chronic lung disease, necrotizing enterocolitis, periventricular leukomalacia, and retinopathy of prematurity. Survival was defined as discharge from neonatal intensive care. RESULTS: Thirty-three singleton pregnancies met criteria for inclusion, 11 of whom survived to discharge (survival rate 0.33; 95% CI 0.18, 0.52). More advanced gestational age was associated with increased likelihood of survival: 0 of 12 at 23 0/7 to 23 2/7 weeks, 4 of 10 at 23 3/7 to 23 4/7 weeks, and 7 of 11 at 23 5/7 to 23 6/7 weeks (P =.02). All 11 survivors developed RDS and chronic lung disease. One of 11 survivors had necrotizing enterocolitis, and 2 of 11 had severe retinopathy of prematurity. One survivor had periventricular leukomalacia on head ultrasonography, compared with 7 of the nonsurvivors who had head ultrasonography (P =.03). One survivor developed severe intraventricular hemorrhage (grade 3 or 4) compared with 8 of the 12 at-risk nonsurvivors who had head ultrasonography (P =.01). CONCLUSION: About one third of infants delivered at 23 weeks' gestation survived to be discharged from neonatal intensive care. More advanced gestational age was associated with increased likelihood of survival. No neonates survived free of substantial morbidity.

Pulse pressure and risk of preeclampsia: a prospective study.

OBJECTIVE: To find whether pulse pressure, a measure of arterial compliance, is associated early in pregnancy with increased risk of developing preeclampsia. METHODS: In a prospective cohort of 576 nulliparas, we examined blood pressures throughout pregnancy and at 6-8 weeks postpartum. Measurements during weeks 7-15, 16-24, and 25-38 of gestation were pooled to find averages for each period. Outcomes assessed were gestational hypertension and preeclampsia. Logistic regression analysis was used to develop relative risks and 95% confidence intervals. RESULTS: We confirmed 34 (5.9%) cases of preeclampsia, 32 (5.6%) cases of gestational hypertension, and 510 normotensive women. Mean systolic and diastolic blood pressures and mean arterial pressures were elevated throughout pregnancy in women who developed hypertensive disorders of pregnancy compared with normotensive women. Pulse pressure at 7-15 weeks was significantly higher in women who developed preeclampsia (45 +/- 6 mmHg) than in those who developed gestational hypertension (41 +/- 7 mmHg, P =.03) and normotensive women (41 +/- 8 mmHg, P =.01). Examined in tertiles, increasing pulse pressure was associated with increasing risk of developing preeclampsia (P for trend =.01) but not gestational hypertension (P for trend =.95). After adjustment for potential confounders, a 1-mmHg rise in early pregnancy pulse pressure was associated with a 6% (95% confidence interval: 1, 10) increase in risk for developing preeclampsia but not gestational hypertension (relative risk: 1%; 95% confidence interval: -1, 6). Beyond 15 weeks' gestation, differences between groups diminished, but women with any hypertensive disorder had higher pulse pressures than women with uncomplicated pregnancies. CONCLUSION: Elevated pulse pressure, indicating poor arterial compliance, was evident early in pregnancies of women who subsequently developed preeclampsia.

Obesity and preeclampsia: the potential role of inflammation.

OBJECTIVE: Systemic inflammation might contribute to the pathogenesis of preeclampsia. In addition, the association between obesity and inflammation in preeclampsia has not been examined in detail. We determined whether first-trimester elevation of serum C-reactive protein, an index of systemic inflammation, was associated with preeclampsia. METHODS: We conducted a prospective, nested case-control study among women enrolled in the Massachusetts General Hospital Obstetrical Maternal Study cohort. High-resolution C-reactive protein assays were performed on first-trimester (11 +/- 2 weeks' gestation) serum samples in 40 women in whom preeclampsia developed (blood pressure [BP] greater than 140/90 mmHg, and proteinuria, either 2+ or more by dipstick or greater than 300 mg per 24 hours), and in 80 matched controls. This sample size had greater than 80% power to detect a difference in C-reactive protein levels between cases and controls. We used nonparametric tests to compare C-reactive protein levels and conditional logistic regression to control for confounding variables. RESULTS: First-trimester C-reactive protein levels were significantly higher among women in whom preeclampsia subsequently developed compared with controls (4.6 compared with 2.3 mg/L, P =.04). When women were subdivided into C-reactive protein quartiles, the odds ratio (OR) of being in the highest quartile of C-reactive protein was 3.2 (95% confidence interval [CI] 1.1, 9.3, P =.02) among cases of preeclampsia compared with controls. When body mass index (BMI) was added to the multivariable model, the highest quartile of C-reactive protein was no longer associated with increased risk of preeclampsia (OR 1.1, 95% CI.3, 4.3, P =.94). In the same model without BMI, the highest quartile of C-reactive protein was associated with increased risk of preeclampsia (OR 3.5, 95% CI 1.3, 9.5, P =.01). CONCLUSION: In women with preeclampsia, there was evidence of increased systemic inflammation in the first trimester. Inflammation might be part of a causal pathway through which obesity predisposes to preeclampsia.

Pregnancy outcome following ultrasound-detected fetal cardiac activity in women with a history of multiple spontaneous abortions.

OBJECTIVE: To determine whether women with two or more previous spontaneous abortions of unknown etiology, by conventional testing criteria, have a different rate of subsequent fetal loss than controls after ultrasonic documentation of fetal cardiac activity. METHODS: Medical records were reviewed from 185 women with spontaneous abortion of unknown etiology. Of these women, 91.9% were found to have evidence of cellular immunity to trophoblast and were treated with progesterone for immunosuppression. Ultrasound evaluation was obtained at 5-6 weeks' gestation to document fetal cardiac activity. A control group of 63 women was also studied. All women were followed for pregnancy outcome. RESULTS: A total of 248 pregnancies were identified from the 185 study patients with multiple spontaneous abortions. Fetal cardiac activity was visualized by ultrasound in 209 pregnancies from 171 study subjects; of these, the outcomes of 208 pregnancies were known. The rate of spontaneous abortion after ultrasound documentation of fetal cardiac activity was 22.7%. Neither maternal age nor number of previous losses was associated with an increased incidence of spontaneous abortion following documentation of fetal cardiac activity. The rate of spontaneous abortion in the control group after documentation of fetal cardiac activity was 3.3%. CONCLUSION: These data may help clinicians give couples who have experienced recurrent pregnancy loss a more realistic prognosis for pregnancy success once fetal cardiac activity has been confirmed.

Treatment of thyroid disease in pregnancy.

With appropriate therapy, complications related to thyroid disease in pregnancy can be minimized. Although the diagnosis of thyroid endocrinopathy may be difficult in pregnancy, few therapies are contra-indicated. Because medications may cross the placenta, however, clinicians need always to be mindful of potential fetal effects and should work to use the minimal dose necessary to achieve maternal euthyroidism. Thyroid function tests, in particular free T4 and TSH, remain good measures of thyroid function and therapy in pregnancy.

Hirschsprung's disease: associated abnormalities and demography.

We here examine the demographic parameters of patients with Hirschsprung's disease. The study population includes all patients with histologically confirmed disease treated at the Children's Hospital Medical Center of Boston over the 25-year period extending from 1961 through the first quarter of 1986. There were 179 cases. Overall, children with Hirschsprung's disease were found less likely to be first born (P less than .01). This relationship was seen to persist irrespective of maternal age, maternal race, or type of disease. The implications of this finding are discussed. Overall, 22% of these children had one or more associated abnormalities involving the neurological, cardiovascular, urological, and gastrointestinal systems. Many of the disorders appeared to be related to neurocrestopathies. Frequent associations included Down's syndrome, defects in cardiac septation, tetralogy of Fallot, and Dandy-Walker syndrome. These conditions occurred more frequently than would have been predicted through chance alone. This study found no association between an increased maternal age and the occurrence of Hirschsprung's disease. This study also found that approximately 7% of the affected children had been born prematurely.

Placenta increta complicating a first-trimester abortion. A case report.

Placenta increta complicating pregnancy in the first trimester is rare. A patient with risk factors for placenta increta required a hysterectomy to control a hemorrhage after a first-trimester abortion. Pathologic study confirmed the preoperative diagnosis of placenta increta.

Management of a parturient with high-grade osteosarcoma of the proximal femur: a multidisciplinary approach.

Osteosarcoma is the most common primary malignant bone tumor, yet it is exceedingly rare in pregnancy. We present a case of a 33-year-old multiparous woman diagnosed with high-grade osteosarcoma during the third trimester of pregnancy. A plan was formulated to perform cesarean delivery at 33 weeks of gestation under spinal anesthesia, and, in subsequent surgery, radical femoral neck resection with limb salvage and adjuvant chemotherapy. The outcome was a healthy newborn baby boy and a disease-free mother. This case highlights the benefits of multidisciplinary planning: balancing the needs of the developing fetus with those of the mother, mitigating the risk of pathologic fracture and ensuring timely oncologic therapy.

Multiple photoreceptors contribute to nonimage-forming visual functions predominantly through melanopsin-containing retinal ganglion cells.

In the absence of functional rod and cone photoreceptors, mammals retain the ability to detect light for a variety of physiological functions such as circadian photoentrainment and pupillary light reflex. This is attributed to a third class of photoreceptors, the intrinsically photosensitive retinal ganglion cells that express the photopigment melanopsin. Even though in the absence of rods and cones, mammals retain the ability to detect light for various nonimage-forming visual functions, rods and cones can compensate for the absence of the melanopsin protein in nonvisual light-dependent physiological behaviors. Several studies have addressed the relative contribution of each photoreceptor type to nonimage-forming visual functions; however, a comprehensive model for these interactions is far from complete. Under conditions where melanopsin-containing retinal ganglion cells were genetically ablated, image formation is maintained, whereas circadian photoentrainment and pupillary light reflex are severely impaired. The findings indicate that multiple photoreceptors contribute to nonimage-forming visual functions through signaling via melanopsin-containing retinal ganglion cells. Future studies will aim to determine more quantitatively the relative contributions of each retinal photoreceptor in signaling light for nonimage-forming visual functions.

The cost-effectiveness of human immunodeficiency virus screening in pregnancy.

OBJECTIVE: My purpose was to evaluate the cost-effectiveness of screening for human immunodeficiency virus during pregnancy as part of a protocol in which zidovudine was used to reduce the risk of vertical transmission. STUDY DESIGN: This mathematic model used decision analysis to calculate the marginal cost-effectiveness of screening for human immunodeficiency virus in pregnancy and treating human immunodeficiency virus-positive women with zidovudine. Cost and probability assumptions were drawn from a literature review. Sensitivity analyses were performed for important costs and probabilities. RESULTS: When baseline cost and probability assumptions were used, the marginal cost-effectiveness of human immunodeficiency virus screening was $436,927 when the prevalence of human immunodeficiency virus in the population was low (0.00075) and $198,510 when the prevalence was average (0.0015). Above a prevalence of human immunodeficiency virus of 0.009, testing is both cheaper and more effective than not testing. Of the cost variables examined, the charge for a negative testing sequence had the greatest impact on cost-effectiveness. CONCLUSION: Human immunodeficiency virus testing in pregnancy is cost-effective in populations in which the prevalence of human immunodeficiency virus exceeds 9 per 1000 population. Depending on how individual lives saved are valued, screening may also be warranted in populations with lower prevalences of infection.

Obstetric evaluation of fetal acid-base balance.

Several techniques may be used to evaluate fetal acid-base status during the ante- and intrapartum periods. Percutaneous blood sampling (cordocentesis) may be used to measure standard blood-gas parameters while the fetus is still in utero, but because of the risks associated with such procedures and the limited clinical utility of the results, this procedure is recommended for blood gas analysis only as part of a research protocol. Intrapartum blood specimens may be safely obtained via fetal scalp sampling, but the need for such sampling has been dramatically reduced by the use of other noninvasive tests such as fetal scalp stimulation or vibroacoustic stimulation. Finally, assay of blood obtained from a segment of umbilical cord collected at delivery indicates acid-base status at birth, but the range of normal values is wide, and only the most abnormal results have any prognostic significance.

The sonographic diagnosis of Dandy-Walker and Dandy-Walker variant: associated findings and outcomes.

Outcomes of pregnancies with sonographically diagnosed Dandy-Walker (DW) or Dandy-Walker variant (DWV) syndromes vary widely. We examined our own experience with these diagnoses in an effort to identify those sonographic features that best predicted neonatal outcome. We identified 50 fetuses with DW and 49 with DWV diagnosed sonographically. Eighty-six per cent of fetuses with DW and 85% of fetuses with DWV had other sonographically identifiable anomalies, the most common being ventriculomegaly (DW: 32%; DWV: 27%) and cardiac defects (DW:38%; DWV: 41%). Forty-six per cent and 36% of available karyotypes in cases of DW and DWV, respectively, were abnormal. 50 out of 99 women in our series elected pregnancy termination. Only three pregnancies with DW resulted in a living infant, and only one of these had a normal paediatric examination at six-week follow-up. Thirteen out of 49 infants with DWV survived the neonatal period and 7 of 13 were reported initially as normal infants, including six with an isolated finding of DWV. We conclude that overall, the prognosis for these posterior fossa defects is grim but not uniformly fatal. The presence of other anomalies is associated with the worst prognosis. Isolated Dandy-Walker variant has the highest chance of leading to a normal neonate.