Early discharge revisited: problems encountered with the home visit follow-up after the liberalization of eligibility criteria.

OBJECTIVE: To determine how changes in eligibility criteria for early discharge affected quality and costs of home nursing follow-up care for Medicaid patients. METHODS: A nurse screened women delivering vaginally to determine eligibility for discharge at 24-47 h. Maternal criteria were a vaginal delivery, no serious medical problems, > or = 8 h after bilateral tubal ligation and, if 24 h postpartum, by 21.00 on day of discharge. Newborn criteria were 36 weeks' gestation or more, 2000 g or greater and a normal examination at 24 h of age. By 48 h after discharge, a nursing visit was ordered for each mother and newborn. Nursing consultations were tracked and later entered into a database linked to hospital financial data. RESULTS: Of 3133 vaginal deliveries occurring from 1 August 1997 to 31 January 1999, eligibility criteria allowed 1799 mothers (58%) and 1587 newborns (51%) to be discharged early. Medical problems were rarely detected at follow-up (1% mothers, 2% newborns). To perform the increased number of visits, more personnel were hired and home nursing costs rose 150%. Despite the increased staff and costs, 19 mothers (1%) and ten newborns (0.6%) were lost to follow-up and 25 mothers (1%) and 20 newborns (1%) were visited beyond 72 h after discharge. CONCLUSIONS: Liberal changes in maternal and newborn eligibility criteria did not adversely affect the quality of home nursing follow-up care following early discharge. For hospitals performing a large number of early discharges, follow-up care using only a home nursing visit may be too expensive and difficult to organize. Alternative follow-up plans, such as clinic visits or phone calls, may also need to be utilized.

Periodontal infection and preterm birth: results of a prospective study.

BACKGROUND: Previous studies have suggested that chronic periodontal infection may be associated with preterm births. The authors conducted a prospective study to test for this association. METHODS: A total of 1,313 pregnant women were recruited from the Perinatal Emphasis Research Center at the University of Alabama at Birmingham. Complete periodontal, medical and behavioral assessments were made between 21 and 24 weeks gestation. After delivery, medical records were consulted to determine each infant's gestational age at birth. From these data, the authors calculated relationships between periodontal disease and preterm birth, while adjusting for smoking, parity (the state or fact of having born offspring), race and maternal age. Results were expressed as odds ratios and 95 percent confidence intervals, or CIs. RESULTS: Patients with severe or generalized periodontal disease had adjusted odds ratios (95 percent CI) of 4.45 (2.16-9.18) for preterm delivery (that is, before 37 weeks gestational age). The adjusted odds ratio increased with increasing prematurity to 5.28 (2.05-13.60) before 35 weeks' gestational age and to 7.07 (1.70-27.4) before 32 weeks' gestational age. CONCLUSIONS: The authors' data show an association between the presence of periodontitis at 21 to 24 weeks' gestation and subsequent preterm birth. Further studies are needed to determine whether periodontitis is the cause. CLINICAL IMPLICATIONS: While this large prospective study has shown a significant association between preterm birth and periodontitis at 21 to 24 weeks' gestation, neither it nor other studies to date were designed to determine whether treatment of periodontitis will reduce the risk of preterm birth. Pending an answer to this important question, it remains appropriate to advise expectant mothers about the importance of good oral health.

Effect of smoking on serum concentrations of total homocysteine and B vitamins in mid-pregnancy.

There are conflicting findings in the literature on the effect of smoking on total homocysteine (tHcy) concentrations in non-pregnant subjects. We evaluated the effect of smoking on serum concentrations of tHcy, folate, vitamin B-12 pyridoxal 5'-phosphate (PLP, a coenzyme form of vitamin B-6) in 196 women at 18 and 30 weeks' gestation. The smokers were defined as those who self-reported cigarette smoking and had serum concentrations of thiocyanate, a biomaker of smoking, in the highest quartiles of the population. Mid-pregnancy serum tHcy concentrations were not significantly different between smokers and non-smokers. Folate, vitamin B-12 and PLP concentrations were generally lower in smokers than non-smokers. In smokers, tHcy concentrations had significant negative correlations with folate at both time points. The multiple regression analyses indicated that serum folate concentration was the most significant factor associated with tHcy concentrations among smokers, whereas thiocyanate concentrations showed no such effect. We conclude that serum tHcy concentrations were most strongly associated with the nutritional status of folate among the B vitamins tested during mid-pregnancy in our subjects. We suggest that it is essential to consider the nutritional status of folate, vitamin B-12 and vitamin B-6 in evaluating the effect of smoking on homocysteine metabolism.

Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: would they do it again?

OBJECTIVE: This study was undertaken to assess the cure rate of stress urinary incontinence, long-term effects on other lower urinary tract symptoms, and quality of life in a cohort of patients who underwent pubovaginal sling procedures for treatment of incontinence related to intrinsic sphincteric deficiency and urethral hypermobility. STUDY DESIGN: This was a retrospective analysis of 57 patients with 90% follow-up who underwent pubovaginal autologous fascial sling procedures for stress urinary incontinence related to urethral hypermobility and intrinsic sphincteric deficiency. Objective postoperative urodynamic evaluation was performed in 34 (60%) of the cases. Telephone interviews to assess quality-of-life parameters were performed in all cases. RESULTS: The mean follow-up period was 42 months and the median follow-up period was 34 months, with a range of 0.5 to 134 months. The age at the time of the sling procedure ranged from 18 to 84 years, with a median parity of 3.0 (range, 0-6). Preoperative body mass index ranged from 19.5 to 39.1 kg/m(2). Five percent of patients had detrusor instability before the operation. Forty-one percent (41%) of the patients who underwent postoperative urodynamic evaluation had voiding dysfunction. The postoperative objective cure rate for stress urinary incontinence was 97%. Of all patients 88% indicated that the sling had improved the quality of life, 84% indicated that the sling relieved the incontinence in the long-term, and 82% would choose to undergo the procedure again. CONCLUSION: Construction of a pubovaginal sling is an effective technique for relief of severe stress urinary incontinence. Voiding dysfunction is a common side effect. Despite this problem, a significant number of patients would elect to undergo the procedure again.

A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women.

OBJECTIVES: This project investigated whether augmented prenatal care for high-risk African American women would improve pregnancy outcomes and patients' knowledge of risks, satisfaction with care, and behavior. METHODS: The women enrolled were African American, were eligible for Medicaid, had scored 10 or higher on a risk assessment scale, were 16 years or older, and had no major medical complications. They were randomly assigned to augmented care (n = 318) or usual care (n = 301). Augmented care included educationally oriented peer groups, additional appointments, extended time with clinicians, and other supports. RESULTS: Women in augmented care rated their care as more helpful, knew more about their risk conditions, and spent more time with their nurse-providers than did women in usual care. More smokers in augmented care quit smoking. Pregnancy outcomes did not differ significantly between the groups; however, among patients in augmented care, rates of preterm births were lower and cesarean deliveries and stays in neonatal intensive care units occurred in smaller proportions. Both groups had lower-than-predicted rates of low birthweight. CONCLUSIONS: High-quality prenatal care, emphasizing education, health promotion, and social support, significantly increased women's satisfaction, knowledge of risk conditions, and perceived mastery in their lives, but it did not reduce low birthweight.

Vaginal fetal fibronectin levels and spontaneous preterm birth in symptomatic women.

OBJECTIVE: To relate vaginal fetal fibronectin levels in women with symptoms of preterm labor to subsequent spontaneous preterm birth. METHODS: Quantitative fetal fibronectin values were calculated from women who participated in two prospective multicenter trials relating fetal fibronectin to subsequent spontaneous preterm birth. The study populations consisted of women who presented with symptoms of preterm labor between 24(0)/(7) and 34(6)/(7) weeks, a singleton pregnancy, intact membranes, no prior tocolysis, and cervical dilation less than 3 cm. RESULTS: The characteristics of the two study populations were similar. In both populations, the rates of delivery within 7, 14, and 21 days after sampling were clustered into three distinct fetal fibronectin groups (less than 40, 40-100, and 100 ng/mL or more). As fetal fibronectin values increased, the risk of subsequent spontaneous preterm birth also increased. Delivery within 7 days of sampling was 0.4%, 3.3%, and 18.2% (trial A) and 1.4%, 8.0%, 30.0% (trial B) as the fetal fibronectin levels increased from less than 40 ng/mL, to 40-100 ng/mL, and to at least 100 ng/mL, respectively. CONCLUSION: In women with symptoms of preterm labor, an increase in fetal fibronectin from under 40 ng/mL, to 40-100 ng/mL, to at least 100 ng/mL was associated with a progressive increase in the risk of subsequent spontaneous preterm birth. The use of a single fetal fibronectin cutoff of 50 ng/mL for defining a positive test in women with symptoms of preterm labor should be reevaluated.

Evaluation of a new testing policy for human immunodeficiency virus to improve screening rates.

OBJECTIVE: To assess the effect of a change in human immunodeficiency virus (HIV) testing policy on HIV testing rates in an urban maternity clinic population. METHODS: Since 1995, our institution has provided pretest counseling and voluntary HIV testing to all pregnant women. After the 1999 Institute of Medicine recommendation of HIV testing with patient notification as a routine component of prenatal care, we conducted a prospective study to determine whether this policy would increase our HIV screening rates. The intervention incorporated HIV testing into the routine battery of tests drawn at antenatal care. Not to be tested required active refusal. The intervention group was comprised of all women receiving an initial antenatal visit in one of our eight maternity clinics between August 1, 1999, and July 30, 2000. The control group was comprised of all women presenting for prenatal care in the same clinics during the year before the intervention. RESULTS: The 3415 women in the intervention group and 3778 controls were similar with respect to most demographic and risk factors. After the intervention, HIV testing increased from 75% to 88% (P <.001). Among all women in both years of the study, women who were in the intervention group, less than 20 years of age, or who had a history of substance abuse, were more likely not to refuse testing. CONCLUSION: After implementation of a policy of routine HIV testing with active patient refusal, HIV testing rates increased among pregnant women in our large, urban obstetric clinic population.

Changes in intendedness during pregnancy in a high-risk multiparous population.

OBJECTIVES: Our objectives were to determine whether pregnancy intendedness changes as the pregnancy progresses and, if so, in what direction. METHODS: Intendedness questions similar to those used in the 1988 National Survey of Family Growth were administered in the second trimester of pregnancy (16-18 weeks) and again in the third trimester (30-32 weeks) to a population of 1223 low-income women who were medically at high risk. Information was also collected on characteristics identified in previous studies as being associated with intendedness. Changes in reported intendedness status were categorized as positive if the woman switched from unwanted to mistimed or intended or from mistimed to intended. Changes were categorized as negative if the woman switched from intended to mistimed or unwanted or from mistimed to unwanted. RESULTS: Among the 436 women who reported an intended pregnancy at midpregnancy, 79.1% still reported the pregnancy as intended in late pregnancy, while 15.9% moved to mistimed and 6.4% to unwanted. Of the 601 women who reported a mistimed pregnancy in midpregnancy, 80.9% still reported it as mistimed in late pregnancy, with 13.9% switching to intended and 5.2% switching to unwanted. Of the 186 women who reported an unwanted pregnancy at midpregnancy, 62.9% remained unwanted, 30.7% switched to mistimed, and 6.4% switched to intended. CONCLUSIONS: This study indicates that intendedness is not fixed during pregnancy. Between the first and the second administration of the intendedness questions, 275 (22.5%) of the women changed their responses and the larger percentage (12.5%) changed them in a positive direction. These findings have both policy and clinical implications.

Increased risk of preterm delivery with elevated maternal alpha-fetoprotein and plasma zinc levels in African-American women.

BACKGROUND: This study evaluated the relationship of maternal serum alpha-fetoprotein (MSAFP) and plasma zinc levels (PZn) to pregnancy outcome. METHODS: The subjects for this investigation consisted of 917 African-American women, who on registration for prenatal care between 7-22 weeks gestational age (GA), had PZn levels determined and also had MSAFP recorded in their charts. RESULTS: MSAFP levels greater than the 90th percentile significantly increased the risk of PTD (adjusted odds ratio or AOR=2.5, 95% C.I.=1.5-4.2) but not of IUGR. There was no significant relationship between maternal PZn level and PTD or IUGR. When subjects were stratified by MSAFP levels, in women with MSAFP greater than the 90th percentile, the AOR for PTD was 4.0 (95% C.I.=1.2-13.5) for women with PZn levels greater than the median vs. those with PZn equal to or less than the median. In women with MSAFP equal to or less than the 90th percentile, there was no such difference. Multiple regression analyses, using GA at birth as the dependent variable, indicated an interaction between MSAFP and PZn levels. CONCLUSION: In this population, the adverse pregnancy outcome associated with elevated MSAFP was seen only in women with PZn levels greater than the median. The reason for this association is not currently apparent.

Maternal serum ferritin and fetal growth.

OBJECTIVE: To determine the relationship between maternal serum ferritin and concentrations and specific types of fetal growth restriction (FGR). METHODS: Serum ferritin concentrations were measured at approximately 25 and 36 weeks' gestation in 480 multiparas with singleton fetuses who participated in a study of risk factors for repeated FGR. Asymmetric FGR was defined by low birth weight for gestational age criteria and a ponderal index less than 2.32, and symmetric FGR was defined by the same birth weight for gestational age criteria and a ponderal index of at least 2.32. RESULTS: Among 480 infants, 370 were appropriate for gestational age (AGA), 58 had asymmetric FGR, and 52 had symmetric FGR. Higher ferritin concentrations were associated with black race, maternal age 25 years or older, and smoking. Mothers of asymmetric-FGR infants had higher mean ferritin levels than mothers of AGA infants at 25 weeks' (38.0 versus 20.2 microg/L, P < .01) and 36 weeks' gestation (21.0 versus 13.3 microg/L, P < .01), whereas mothers of symmetric-FGR infants had significantly lower ferritin levels at 36 weeks (8.3 microg/L). For mothers with serum ferritin levels of at least 26 microg/L (highest quartile at 25 weeks), the adjusted odds ratio (OR) for asymmetric-FGR infants was 3.4, 95% confidence interval (CI) 1.6, 7.2. There was a similar association between the highest quartile of serum ferritin at 36 weeks (at least 20 microg/L) and asymmetric FGR (adjusted OR 2.7, 95% CI 1.3, 5.8). Women with serum ferritin levels less than 3 microg/L (lowest quartile at 36 weeks) had an adjusted OR for symmetric-FGR infants of 2.2, 95% CI 1.01, 4.6. CONCLUSION: High maternal serum ferritin levels are associated with asymmetric FGR, whereas low serum ferritin levels are associated with symmetric FGR.

Cost of neonatal care according to gestational age at birth and survival status.

OBJECTIVE: This study was undertaken to determine the cost of initial hospital care for newborn infants according to gestational age at birth and survival status. STUDY DESIGN: This was a retrospective review of prospectively collected data on hospital and physician costs for all infants born in the study institutions at < or = 32 weeks' gestation for 1989 through 1992. A cohort of term and near-term infants was selected at random. Variables were examined by multiple logistic regression for their independent effects on cost. RESULTS: Length of stay and gestational age were related to cost among survivors born at < or = 32 weeks' gestation but not among nonsurvivors. Total cost of initial care for the US population of neonates is estimated at $10.2 billion annually, with 11.9% spent on infants born between 24 and 26 weeks' gestation and 42.7% spent on those born at > or = 37 weeks' gestation. CONCLUSIONS: Although costs for an individual surviving extremely premature baby may be high, the costs for extremely low gestational age infants is a small component of total neonatal care costs because so few infants are born at these gestational ages. The mathematic model developed from these data allows cost savings to be predicted for management strategies designed to alter gestational age at birth or survival.

Hydramnios prediction of adverse perinatal outcome.

OBJECTIVE: To determine whether hydramnios is associated with an increased risk of adverse perinatal outcomes. METHODS: Computerized records of all ultrasound examinations done at the University of Alabama at Birmingham from 1986 to 1996 (n = 40,065) were reviewed to identify 370 women with singleton pregnancies beyond 20 weeks' gestation and hydramnios diagnosed sonographically by amniotic fluid index of 25 cm or more, largest vertical pocket of 8 cm or more, or subjective impression. Controls were all women with singleton gestations with normal amniotic fluid volumes (n = 36,426). Obstetric outcomes were determined by cross-reference to our database. Cases with hydramnios were compared with controls for perinatal death, anomaly rate, fetal growth restriction (FGR), cesarean delivery, fetal aneuploidy, and maternal diabetes. Cases were sorted according to diabetes status, after which perinatal death, anomaly rate, FGR, cesarean delivery, and fetal aneuploidy were compared again. RESULTS: The incidence of hydramnios was 1%. The perinatal mortality rate in all women with hydramnios was 49 per 1000 births, compared with 14 per 1000 births in the control group (P < .001). Women with hydramnios had 25 times more anomalies than controls (8.4% versus 0.3%; P < .001), although the prevalence of fetal aneuploidy was not significantly different (one in 370 versus one in 3643; P = .10). The cesarean rate was three times higher in women with hydramnios compared with controls (47.0% versus 16.4%; P < .001). When hydramnios cases were divided according to diabetes status, all of the increased risk was in nondiabetic women: Perinatal mortality was 60 per 1000 in nondiabetic women versus 0 per 1000 in diabetic women (P = .03); the anomaly rate was 10.4% versus 0%, respectively (P = .005). CONCLUSION: Hydramnios indicated an increased risk of adverse perinatal outcomes, especially if not associated with diabetes. A comprehensive fetal evaluation, a workup to rule out maternal factors, and fetal surveillance are warranted; amniocentesis for fetal karyotype analysis might not be necessary.

A five-year experience with fragile X screening of high-risk gravid women.

OBJECTIVE: We sought to compare our 5-year program of fragile X screening of high-risk gravid women with our program of fragile X testing of affected individuals (probands). STUDY DESIGN: All women referred to the prenatal genetics clinic from 1994 to 1998 who had a family history of unspecified mental retardation or learning or behavioral disorders (known fragile X families excluded) were offered fragile X screening. Results were compared with those of probands with the same diagnoses who underwent fragile X testing during the same time period. RESULTS: We counseled 12,349 prenatal patients from 1994-1998, of whom 263 (2.1%) had a positive family history and underwent fragile X screening. No mutations or premutations were identified. In contrast, 31 (1.9%) of 1637 affected probands who underwent fragile X testing during the same time period had positive results, which was a significant difference (0/263 vs 31/1637; P <.05). CONCLUSIONS: Testing the affected proband is superior to screening the pregnant relative of the proband for identification of families at risk for fragile X syndrome.

Relationship of gestational age and cervical dilation to the timing of delivery.

OBJECTIVE: To determine the effect of gestational age and cervical dilation on pregnancy continuation in women with idiopathic preterm labor who were treated with parenteral tocolysis. METHOD: A total of 950 women with singleton gestations, intact membranes and preterm labor treated with tocolysis prior to 34 weeks' gestation were retrospectively studied. These women were identified from the March of Dimes prematurity prevention program database. For analysis, women were categorized into five gestational age groups and three cervical dilation groups. The primary outcomes measured were the percentage of women who remained undelivered at 48 h and at 14 days post-initiation of therapy. RESULT: Overall, 82% of women remained undelivered after 48 h and 65% remained undelivered at 14 days. As cervical dilation advanced, the number of women remaining undelivered at 48 h and 14 days significantly decreased. However, even at > or = 4 cm, 52% of women remained undelivered at 48 h. If the cervix was dilated < 2 cm, gestational age did not influence the number of days gained prior to delivery. However, if the cervix was dilated > or = 2 cm, women at < 25 weeks' gestation were more likely to deliver compared to women at the same dilation but with more advanced gestational ages. CONCLUSION: Overall, 82% of women in preterm labor and 52% of those presenting with > or = 4-cm cervical dilation, delivered after 48 h. Therefore there appears to be ample opportunity for most women in preterm labor with intact membranes, even those at advanced dilations, to receive a complete course of corticosteroid therapy.

Gender difference in cord serum ferritin concentrations.

We measured cord serum ferritin concentrations in a total of 255 infants (116 females and 139 males), and evaluated the association between these values and various neonatal as well as maternal characteristics. The mean ferritin concentration in females (166 +/- 110 microg/l) was significantly higher than that in male infants (123 +/- 77 microg/l). The gender differences in ferritin were significant within groups of infants with fetal growth restriction, those who weighed <3,000 g, those whose mothers were African Americans or <25 years old. Maternal serum ferritin concentrations at 36 weeks of gestation significantly correlated with cord serum ferritin of male infants (r = 0.32, p < 0.001), whereas the association was not significant for females (r = 0.09, p > 0.41). Although the mechanism of the gender difference is unknown, it may be important to consider the sex of neonates when evaluating their iron nutriture immediately after birth.

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial.

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Determinants of zinc intake in low-income black and white pregnant women.

A prospective study was conducted to evaluate and compare the determinants of dietary zinc intake in black and white low-income pregnant women. The study population consisted of 1298 low-income women (70% Black, 30% White) who received prenatal care at University Hospital at the University of Alabama in Birmingham from 1985 to 1989. Various maternal characteristics were evaluated at the first prenatal visit. Two 24 h recalls were obtained at 18 and 30 wk of gestation to calculate the intakes of dietary zinc and other nutrients. Student's t test, chi2, Pearson correlation coefficients, and multiple regression analyses were used to compare and evaluate the determinants of zinc and other nutrient intakes in Black and White subjects. The mean prepregnancy body mass index and the mean intake of zinc, energy, and all the other nutrients except calcium were significantly higher in Black than in White subjects. There was a significant correlation between zinc and energy intake (r = 0.69, p = 0.001). Age, marital status, parity, socioeconomic status, smoking, and alcohol intake were not significant predictors of zinc or other nutrient intakes. After adjusting for energy intake, race was the only significant predictor of dietary zinc intake. Race and energy intake explained 24% of the variation in zinc intake. Results of this study indicate that after adjusting for other covariates, race and energy intakes are the only predictors of zinc intake in low-income pregnant women.

The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population.

OBJECTIVES: The objective of this study was to determine whether the length of the interval between pregnancies was associated with either preterm birth or intrauterine growth retardation in a low-income, largely Black population. METHODS: The study population consisted of 4400 women who had received prenatal care in county clinics and had two consecutive singleton births between 1980 and 1990. RESULTS: Interpregnancy intervals were positively associated with age and negatively associated with the trimester in which care was initiated in the second pregnancy. Whites had shorter intervals than non-Whites. The percentage of preterm births increased as the length of the interpregnancy interval decreased, but only for women who had not had a previous preterm birth. The association between interval and preterm birth was maintained when other factors associated with preterm birth were controlled. There was no significant relationship between intrauterine growth retardation and interpregnancy interval. CONCLUSIONS: Women, particularly those who are poor and young, should be advised of the potential harm to their infants of short interpregnancy intervals.

Perinatal mortality and its relationship to the reporting of low-birthweight infants.

OBJECTIVES: This study examined changes in the reporting of very low-birthweight infants in Alabama from 1974 to 1994 and the impact on perinatal mortality rates. METHODS: Linked live birth, neonatal death, and stillbirth records of infants born weighing less than 1500 g were compared. RESULTS: The changes in mortality over time ranged from a drop from 100% to 92% in the under-500-g group to a drop from 39% to 4% in the 1000-to 1499-g group. The percentage of total births weighing less than 500 g increased by 155%; the percentage of 1000- to 1499-g births increased by only 7%. As a result, the percentage of neonatal mortality attributable to live births below 500 g increased from 3% to 32%. CONCLUSIONS: Increased reporting of births below 500 g has masked improvements in neonatal mortality.

Elevated second-trimester amniotic fluid interleukin-6 levels predict preterm delivery.

OBJECTIVE: Our purpose was to determine whether early second-trimester amniotic fluid interleukin-6 levels predict delivery before 34 weeks' gestation. STUDY DESIGN: We used stored second-trimester amniotic fluid samples obtained from women undergoing genetic amniocentesis from 1988 to 1996. Interleukin-6 levels were measured by enzyme-linked immunosorbent assay in samples from every case known to result in delivery from 20 to 34 weeks' gestation (n = 290), and 290 matched controls delivering at > or =37 weeks. Fetal aneuploidies, anomalies, and all cases delivering within 30 days of the amniocentesis (which were thought to be possibly procedure related) were excluded. RESULTS: Interleukin-6 levels were higher in cases than controls (1.9 +/- 5.2 vs 1.0 +/- 2.4 ng/ml, p = 0.004). Cases were grouped according to whether the preterm delivery was indicated or spontaneous: The mean interleukin-6 levels were significantly higher than controls in the spontaneous group (1.6 +/- 3.2 vs 0.8 +/- 1.2 ng/ml, p = 0.01) but not in the indicated group (1.4 +/- 4.0 vs 0.8 +/- 1.2 ng/ml, p = 0.12). In all samples the interleukin-6 level was negatively correlated with the gestational age at delivery (R = -0.11633, p = 0.007). CONCLUSION: Elevated early second-trimester amniotic fluid interleukin-6 levels are associated with preterm delivery, confirming that in some women this indicator of very early intrauterine inflammation predicts birth before 34 weeks' gestation.