Chorioamnionitis and uterine function.

OBJECTIVE: To clarify the relationships between intrapartum chorioamnionitis and abnormalities of uterine function, including labor abnormalities, cesarean delivery, and hemorrhage during parturition. METHODS: We did a retrospective cohort study on 16,226 deliveries between 1986 and 1996 that were identified from the University of California, San Francisco Perinatal Database. Variables included maternal age, parity, birth weight, gestational age, epidural usage, oxytocin usage, cesarean delivery, labor abnormalities, length of labor stages, estimated blood loss, and chorioamnionitis status. Analyses included chi(2), Student t test, and logistic regression. RESULTS: In the chorioamnionitis group, there was a statistically significantly higher proportion of women with labor abnormalities (relative risks [RRs] 2.6-4.1), cesarean delivery (RR 3.3; 95% confidence interval [CI] 3.0, 3.5), hemorrhage after cesarean (RR 1.2; 95% CI 1.1, 1.3), and hemorrhage after vaginal delivery (RR 2.1; 95% CI 1.9, 2.4) compared with the nonchorioamnionitis group. Those findings stayed significant after multivariate analysis for various labor abnormalities (adjusted odds ratios [ORs] ranged 1.3-2.1), cesarean delivery (adjusted OR 1.8; 95% CI 1.5, 2.1), hemorrhage after cesarean (adjusted OR 1.5; 95% CI 1.2, 1.8), and hemorrhage after vaginal delivery (adjusted OR 1.8; 95% CI 1.5, 2.1). CONCLUSION: Adverse associations between chorioamnionitis and labor abnormalities, cesarean rate, and hemorrhage during parturition appear to be significant, suggesting a deleterious effect of chorioamnionitis on uterine function.

Effect of magnesium prophylaxis and preeclampsia on the duration of labor.

OBJECTIVE: Our goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not. STUDY DESIGN: We performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The chi2 odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration. RESULTS: Our study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P <.003). Total labor duration did not differ between women with preeclampsia and normotensive women (P =.15) or between women with preeclampsia who received magnesium and those who did not (P =.09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P =.005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P =.002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2. 6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1. 1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0. 5, 95% confidence interval 0.4-0.8) were associated with faster labor. CONCLUSIONS: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration.

Research interests of physicians in two practice-based primary care research networks.

Regional practice-based network research has grown significantly in the past 15 years. Previous studies have reported on characteristics of physicians who participate in network research, but little is known about the specific a priori research interests of practicing physicians. Knowledge of such interests could be useful in planning network research studies. We conducted a mail survey to assess the research interests of primary care physicians in two contiguous research networks at the University of California at San Francisco (UCSF) and at Stanford University. Among 120 respondents from the UCSF Collaborative Research Network and 85 from the Stanford Ambulatory Research Network, the most common topics of interest were disease prevention, communication and compliance, and managed care. Among specific conditions, heart disease, hypertension, and respiratory infection were of interest to the majority of respondents. Topics not of interest to network members were obstetrics, diagnostic procedures, alcoholism, drug abuse, tuberculosis, male genito-urinary problems, occupational hazards, domestic violence, and AIDS and HIV. Identification of network physician research interests can help focus research and recruitment efforts on topics of interest and provide estimates of participation levels for planning studies and preparing funding applications for research networks.

Is there an association between water baths during labor and the development of chorioamnionitis or endometritis?

OBJECTIVE: Our purpose was to determine whether water baths during labor are associated with the development of chorioamnionitis or endometritis. STUDY DESIGN: One hundred ten cases of chorioamnionitis or endometritis and 97 controls were identified among singleton term gestations from the University of California at San Francisco perinatal database. Medical record review and patient interviews provided information on membrane rupture, history of bathing during labor, and relaxation and pain relief perceived by patients who experienced water bathing during labor. RESULTS: There was no statistically significant association between water baths during labor and the occurrence of chorioamnionitis or endometritis (odds ratio 0.93 [95% confidence interval 0.53 to 1.63]). CONCLUSIONS: Water baths during labor are not associated with chorioamnionitis or endometritis.

Head entrapment and neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation.

OBJECTIVES: We attempted to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation. STUDY DESIGN: Computerized data and charts of 321 viable consecutive singleton breech deliveries from 28 to 36 weeks' gestation were reviewed. Statistical methods used included chi2, logistic regression, and analysis of variance. RESULTS: Head entrapment occurred in 4 of 52 (7.7%) neonates delivered vaginally and 14 of 269 (5.2%) neonates delivered by cesarean section (p = 0.48). There were no statistically significant associations between head entrapment and adverse neonatal outcomes. CONCLUSIONS: There was no significant difference in the incidence of head entrapment by mode of delivery for breech infants at 28 to 36 weeks' gestation, nor was there an association with adverse neonatal outcomes after entrapment.

Perinatal mortality in twins and singletons matched for gestational age at delivery at > or = 30 weeks.

OBJECTIVE: Our purpose was to compare perinatal mortality between twins and singletons matched for gestational age at delivery with the hypothesis that perinatal mortality would be similar. STUDY DESIGN: A retrospective cohort study compared perinatal mortality in twins (790 babies) matched for gestational age at delivery at > or = 30 weeks with the next singleton. Perinatal mortality was also compared by expected growth (small and average for gestational age) and by the cause of the preterm delivery (medical indication, spontaneous preterm delivery, or preterm premature rupture of membranes with preterm delivery. RESULTS: Uncorrected perinatal mortality was significantly greater in singletons (56/1000) than in twins (26/1000) (p = 0.004). After major congenital anomalies were excluded, perinatal mortality remained significantly higher in singletons (25/1000) than in twins (11/1000) (p = 0.04). In preterm deliveries perinatal mortality was significantly greater in singletons (72/1000) than in twins (19/1000) (p = 0.0002). Perinatal mortality was significantly greater in small- compared with average-for-gestational-age neonates, whether singletons or twins (p = 0.005), and singleton small-for-gestational-age neonates had a significantly greater perinatal mortality (105/1000) than did twin small-for-gestational-age neonates (36/1000) (p = 0.02). Perinatal mortality was not significantly different between preterm singletons and twins delivered by spontaneous preterm labor. However, perinatal mortality in preterm singletons delivered for a medical indication (156/1000) was significantly greater than for twins (20/1000) (p = 0.0006). CONCLUSIONS: At > or = 30 weeks at delivery, twins either had a perinatal mortality similar to, or less than singletons matched for gestational age at delivery. This suggests that when preterm delivery is controlled for perinatal mortality is not greater in twins. In twins, without risk factors for perinatal death, routine antepartum testing may not be indicated.

Head entrapment and neonatal outcome by mode of delivery in breech deliveries from twenty-four to twenty-seven weeks of gestation.

OBJECTIVES: Our purpose was to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 24 to 27 weeks of gestation. STUDY DESIGN: Charts of 132 viable consecutive singleton breech deliveries from 24 to 27 weeks' gestation were reviewed. Statistical methods used included chi 2, logistic regression, and analysis of variance. RESULTS: Head entrapment occurred in four of 43 (9.3%) vaginally delivered neonates and five of 89 (5.6%) neonates delivered by cesarean section (p = 0.17). The only identifiable risk factor for head entrapment was the birth weight category 1000 to 1249 gm (odds ratio 6.4, 95% confidence interval 1.6 to 26.1). There were no statistically significant associations between head entrapment and adverse neonatal outcomes. CONCLUSIONS: There did not appear to be a difference in the incidence of head entrapment by mode of delivery for breech infants at 24 to 27 weeks' gestation, nor did there appear to be a difference in adverse neonatal outcomes after entrapment. However, this latter conclusion has limited power because of the small number of head entrapment cases.

Clinical trial examining effectiveness of three cough syrups.

BACKGROUND: Cough is one of the most common symptoms of respiratory infections for which patients seek relief. This study was done to assess the effectiveness of three commonly prescribed cough syrups. METHODS: In this multipractice, office-based, randomized clinical trial, guaifenesin was compared with guaifenesin plus codeine or guaifenesin plus dextromethorphan in patients with uncomplicated respiratory tract infections. Family physicians enrolled 97 patients between February 1988 and April 1990. Patients were randomly assigned to treatment and were interviewed by telephone at 2, 4, and 10 days to assess cough relief, treatment adherence, and side effects. There were no statistically significant differences among treatment groups at base line. RESULTS: At day 2 there were no statistically significant differences among treatment groups for any of the outcome measures. At day 4 five of the outcome measures of cough quality, frequency, sleep disturbances, and absenteeism were not statistically significantly different among groups. The only statistically significant difference was the ability to keep up with usual activities, which improved least in patients assigned to dextromethorphan than in patients in other groups. There were no statistically significant differences among the three groups at day 10 for any of the outcomes. CONCLUSION: It appears that codeine, dextromethorphan, and guaifenesin are equally effective in relieving cough symptoms.

Estimation of the break-even point for smoking cessation programs in pregnancy.

BACKGROUND: Successful programs to help pregnant women quit smoking have been developed and evaluated, but formal smoking cessation programs are not a part of care at most prenatal sites. The cost of such programs may be an issue. Considering the costs of adverse maternal and infant outcomes resulting from smoking, we estimated there would be an amount of money a prenatal program could invest in smoking cessation and still "break even" economically. METHODS: A model was developed and published data, along with 1989 hospital charge data, were used to arrive at a break-even point for smoking cessation programs in pregnancy. RESULTS: Using overall United States data, we arrived at a break-even cost of $32 per pregnant woman. When these data were varied to fit specific US populations, the break-even costs varied from $10 to $237, with the incidence of preterm low birth weight having the most impact on the cost. CONCLUSIONS: It may be advisable to invest greater amounts of money in a prenatal smoking cessation program for some populations. However, for every population there is an amount that can be invested while still breaking even.

Weight gain by gestational age in both black and white women delivered of normal-birth-weight and low-birth-weight infants.

Although adequate maternal weight gain during pregnancy is widely acknowledged as a desirable goal, a contemporary standard for weight gain over the entire period of gestation based on a low-risk U.S. population has not been available. Information about usual weight gain in early pregnancy was particularly lacking. In a study monitoring various aspects of prenatal care in women in a population-based case-control study of low birth weight, we collected information on weight gain at various gestational ages in the 281 women who had prenatal care and were delivered of infants at a prepaid health plan facility where standardized records were kept. In white women who were delivered of infants who weighed greater than or equal to 3000 gm, average weight gain was 5.3 pounds at 9 to 10 weeks' gestation, 10.5 pounds at 11 to 20 weeks, 24.2 pounds at 21 to 30 weeks, and 35.1 pounds at 31 to 40 weeks. Weight gain among black women delivered of infants who weighed greater than or equal to 3000 gm was 4.2 pounds at 9 to 10 weeks' gestation, 14.8 pounds at 11 to 20 weeks, 24.5 pounds at 21 to 30 weeks, and 33.9 pounds at 31 to 40 weeks. Weight gain was highly variable at all gestational ages in both black and white women. Weight gain in both black and white women delivered of infants with weights greater than or equal to 3000 gm was linear at a rate of about 0.66 pounds per week from 8 through 20 weeks' gestation and linear at a rate of 1.06 pounds per week after week 20.

Morbidity among breech infants according to method of delivery.

To determine whether vaginally born breech infants are at increased risk for morbid events as compared with breech infants delivered by cesarean, we studied 1240 singleton breech infants without congenital anomalies delivered in Northern California Kaiser Permanente Medical Care Program hospitals during 1976-1977. Medical record review provided information on indications for method of delivery, delivery complications and injuries, neonatal complications, and neurologic sequelae up to 4 years of age. The relative risk estimates for asphyxia (1.0; 95% confidence interval 0.7, 1.4), head trauma (1.6; 95% confidence interval 0.2, 17.0), neonatal seizures (0.8; 95% confidence interval 0.1, 7.1), cerebral palsy (1.6; 95% confidence interval 0.2, 17.4), and developmental delay (2.0; 95% confidence interval 0.9, 4.4) for vaginally born compared with cesarean-delivered infants indicated that vaginally born infants were not at increased risk for these outcomes. We used multiple logistic regression to control for confounding variables. The adjusted relative risk estimate for the combined-outcome category of head trauma, neonatal seizures, cerebral palsy, mental retardation, or spasticity was 0.5 in vaginally delivered infants (95% confidence interval 0.1, 3.2). When all morbid outcomes were considered in combination, the adjusted relative risk estimate was 0.9 for vaginally delivered infants (95% confidence interval 0.6, 1.4).

Hospitalization rates in nursing home residents with dementia. A pilot study of the impact of a special care unit.

Although Special Care Units (SCUs) have recently gained attention as appropriate places for caring for institutionalized patients with dementia, few studies have evaluated their effectiveness. This pilot study focused primarily on one aspect of patient care, the possible prevention of acute hospitalization. Because transfer from nursing home to the acute hospital can be a traumatic experience for patients with dementia, important services that SCUs might provide include those preventive strategies aimed at reducing the need for transfer to the acute hospital. Medical record abstraction revealed that over one year, the rate of acute hospitalization was 21% among 47 patients with dementia in SCUs, compared with 14% among 36 patients with dementia and 14% among 22 patients with no listed diagnosis of dementia residing in non-SCU settings within the same facility. Thus, no statistically significant difference in hospitalization rates was found, although the trend was for increased hospitalization for SCU patients. There was a trend toward deterioration in functional status among SCU patients following first hospitalization (P less than .10). Since the majority of these patients were hospitalized for hip fractures, this finding was not unexpected. There was a trend toward cognitive decline after hospitalization among patients with dementia who were not residing in an SCU (P less than .10). In order to investigate whether acute hospitalizations among SCU patients were preventable, an expert panel was convened to review each episode of illness leading to acute hospitalization. Of the 15 hospitalizations, none were judged "preventable," four were believed to be "possibly preventable," and 11 were considered to have been "not preventable."(ABSTRACT TRUNCATED AT 250 WORDS)