Control of overt maternal diabetes during pregnancy in a county hospital.

Tight metabolic control of manifest diabetes during pregnancy was attempted in 51 clinic referrals to a county hospital. Starting before the 28th week of gestation, a good control of diabetes was achieved with the help of initial hospitalization, regular home blood glucose monitoring, and frequent clinic visits. Mean preprandial plasma glucose level was 96.4 +/- 22.6 mg/dL. A mean preprandial plasma glucose level of less than 110 mg/dL was achieved in 42 (82%) of the 51 patients. Total perinatal mortality was 7.7% (4/52). When we excluded major maternal morbidity unrelated to diabetes that accounted for fetal loss, the corrected perinatal loss was 3.8%. Significant maternal hypoglycemia was uncommon. Major congenital malformations in the fetus, neonatal hyperbilirubinemia, and neonatal hypoglycemia each occurred in fewer than 5%. These results suggest that good metabolic control of diabetes is achievable in patients in a general hospital and it may lower fetal loss and morbidity associated with overt maternal diabetes.

Applying the sisterhood method for estimating maternal mortality to a health facility-based sample: a comparison with results from a household-based sample.

BACKGROUND: The sisterhood method is an indirect technique used to estimate maternal mortality in developing countries, where maternal deaths are often poorly registered in official statistics. It has been used successfully in many community-based household surveys. Because such surveys can be costly, this study investigated the suitability of using data collected in outpatient health facilities. METHODS: Adults visiting any one of 91 health centres or posts in a rural region of Nicaragua were randomly sampled and interviewed by health personnel. A sample size, proportional to the population served, was assigned to each facility and 9232 adults were interviewed. Characteristics of health facility users were compared with the general population to identify factors that would allow generalization of results to other settings. RESULTS: Based on these data, the lifetime risk of maternal death was 0.0144 (1 in 69). This estimate is essentially identical to that from a household-based survey in the same region 8 months earlier, which obtained a lifetime risk of 0.0145 (1 in 69). These findings correspond to a maternal mortality ratio of 241 and 243/100000 livebirths, respectively. CONCLUSIONS: This is the first report comparing results of the sisterhood method from household and health facility-based samples. The sisterhood method provided a robust estimate of the magnitude of maternal mortality. Results from the opportunistic health facility-based sample were virtually identical to results from the household-based study. Guidelines need to be developed for applying this low-cost and efficient aproach to estimating maternal mortality in suitable opportunistic settings at subnational levels.

PIP: Researchers compared maternal mortality estimates using the sisterhood method in a household survey conducted in November 1991 and in an outpatient health facility survey conducted in July 1992. Both surveys were conducted in Region I, a predominantly rural, mountainous area in northern Nicaragua. They analyzed data from 9232 interviews with adults younger than 49. The estimated lifetime risk of maternal death and the corresponding maternal mortality ratio were essentially identical for both the household and health facility surveys (0.145 and 0.144 [i.e., 1 in 69 of reproductive age died due to pregnancy-related events] and 243 and 241/100,000 live births, respectively). The estimates were similar for both surveys, even when the results were standardized for age, residence, and socioeconomic characteristics. An important limitation to the sisterhood method of estimating maternal mortality is that it estimates maternal mortality for a period about 10-12 years before the study and therefore cannot be used to assess the immediate effect of interventions to reduce maternal mortality. Nevertheless, in areas with poor maternal mortality surveillance or where no alternative exists to collecting population-based data, the sisterhood method can reliably estimate maternal mortality. These findings suggest that health facilities-based studies using the sisterhood method is a feasible, low-cost, and efficient method to estimate maternal mortality in certain settings at subnational levels.

Deferoxamine treatment of acute iron intoxication in pregnancy.

Acute iron intoxication in pregnancy presents a dilemma to the clinician. Toxic levels of iron are associated with severe complications and can be fatal, but the effective iron chelator, deferoxamine, has possible teratogenic potential. The present report discusses the clinical indications that can support the administration of deferoxamine for iron intoxication in pregnancy and discusses the benefits and risks of its usage.

Surveillance of assisted reproductive technology in the United States. An update.

The Centers for Disease Control and Prevention published the first Assisted Reproductive Technology (ART) Pregnancy Success Rate Report in 1997. This article presents a description of the law that initiated the public report, a description of the surveillance system used to accumulate data for the report, and some of the results from ART cycles initiated in 1995.

Maternal mortality, United States and Canada, 1982-1997.

BACKGROUND: The 1998 public awareness campaign on Safe Motherhood called attention to the issue of maternal mortality worldwide. This paper focuses upon maternal mortality trends in the United States and Canada, and examines differentials in maternal mortality in the United States by maternal characteristics. METHODS: Data from the vital statistics systems of the United States and Canada were used in the analysis. Both systems identify maternal deaths using the definition of the World Health Organization's International Classification of Diseases. Numbers of deaths, maternal mortality rates, and confidence intervals for the rates are shown in the paper. RESULTS: Maternal mortality declined for much of the century in both countries, but the rates have not changed substantially between 1982 and 1997. In this period the maternal mortality levels were lower in Canada than in the United States. Maternal mortality rates vary by maternal characteristics, especially maternal age and race. CONCLUSIONS: Maternal mortality continues to be an issue in developed countries, such as the United States and Canada. Maternal mortality rates have been stable recently, despite evidence that many maternal deaths continue to be preventable. Additional investment is needed to realize further improvements in maternal mortality.

1995 assisted reproductive technology success rates: national summary and fertility clinic report.

Although ART offers important options for the treatment of infertility, the decision to use ART involves many factors in addition to success rates. Going through repeated ART cycles requires substantial commitments of time, effort, money, and emotional energy. Couples and individuals considering ART should carefully examine all related financial, psychologic, ethical, and medical issues before beginning treatment. They should also contact ART clinics to discuss their specific medical situation and potential for success using ART. The next published report will feature 1996 data and provide a listing of clinics that did not submit data. Eventually, the annual report will include information from all U.S. fertility clinics, not just those that are SART members.

Length of maternal hospital stay for uncomplicated deliveries, 1988-1995: the impact of maternal and hospital characteristics.

OBJECTIVES: To determine the independent association of selected maternal and hospital characteristics with length of maternal hospital stay for uncomplicated vaginal deliveries. METHOD: Linear regression analysis using National Hospital Discharge Survey data from 1988 to 1995. Independent variables were year, maternal age and race, method of payment, and hospital ownership, size, and geographic location. The outcome measure was length of maternal hospital stay for uncomplicated vaginal deliveries. RESULTS: Length of stay was independently associated with year, geographic region, payment method, and hospital size. From 1988 to 1995, the mean length of stay fell from 2.1 to 1.5 days. The rate of decrease was similar for all regions, methods of payment, and hospital size. Women in the West had a shorter mean length of stay (1.5 days) than women in the Northeast (2.2 days). The difference by method of payment was smaller. Length of stay was shortest for women without insurance (1.8 days) and longest for women covered by Blue Cross (2.1 days). Maternal age and race and type of hospital ownership were not independently associated with the length of stay. CONCLUSIONS: Significant variations existed in the length of time women are hospitalized for normal childbirth. These variations are primarily associated with where a woman lives and whether she is insured. Given the current public debate on the impact of shortened hospital stays, these variations need to be explored and their effects on maternal and infant well-being clarified.

Live-birth rates and multiple-birth risk using in vitro fertilization.

CONTEXT: To maximize birth rates, physicians who perform in vitro fertilization (IVF) often transfer multiple embryos, but this increases the multiple-birth risk. Live-birth and multiple-birth rates may vary by patient age and embryo quality. One marker for embryo quality is cryopreservation of extra embryos (if embryos are set aside for cryopreservation, higher quality embryos may have been available for transfer). OBJECTIVE: To examine associations between the number of embryos transferred during IVF and live-birth and multiple-birth rates stratified by maternal age and whether extra embryos were available (ie, extra embryos cryopreserved). DESIGN AND SETTING: Retrospective cohort of 300 US clinics reporting IVF transfer procedures to the Centers for Disease Control and Prevention in 1996. SUBJECTS: A total of 35554 IVF transfer procedures. MAIN OUTCOME MEASURES: Live-birth and multiple-birth rates (percentage of live births that were multiple). RESULTS: A total number of 9873 live births were reported (multiple births from 1 pregnancy were counted as 1 live birth). The number of embryos needed to achieve maximum live- birth rates varied by age and whether extra embryos were cryopreserved. Among women 20 to 29 years and 30 to 34 years of age, maximum live-birth rates (43 % and 36%, respectively) were achieved when 2 embryos were transferred and extra embryos were cryopreserved. Among women 35 years of age and older, live-birth rates were lower overall and regardless of whether embryos were cryopreserved, live-birth rates increased if more than 2 embryos were transferred. Multiple-birth rates varied by age and the number of embryos transferred, but not by whether embryos were cryopreserved. With 2 embryos transferred, multiple-birth rates were 22.7%, 19.7%, 11.6%, and 10.8% for women aged 20 to 29, 30 to 34, 35 to 39, and 40 to 44 years, respectively. Multiple-birth rates increased as high as 45.7% for women aged 20 to 29 years and 39.8% for women aged 30 to 34 years if 3 embryos were transferred. Among women aged 35 to 39 years, the multiple-birth rate was 29.4% if 3 embryos were transferred. Among women 40 to 44 years of age, the multiple-birth rate was less than 25% even if 5 embryos were transferred. CONCLUSIONS: Based on these data, the risk of multiple births from IVF varies by maternal age and number of embryos transferred. Embryo quality was not related to multiple birth risk but was associated with increased live-birth rates when fewer embryos were transferred.