Maternal shunt dependency: implications for obstetric care, neurosurgical management, and pregnancy outcomes and a review of selected literature

OBJECTIVE: Because more women with cerebrospinal fluid shunts are surviving to child-bearing age, neurosurgeons, obstetricians, and other health care professionals require information about the care of these patients, especially during pregnancy and delivery. The purpose of this study was to gather comprehensive data from women with shunts regarding their clinical histories during and immediately after pregnancy. The following questions were addressed. 1) How does maternal shunt dependency influence the course of pregnancies and pregnancy outcomes? 2) What neurosurgical complications characterize this population of patients? 3) What complications of shunt dependency influence obstetric management, including prenatal testing and delivery? METHODS: A total of 37 respondents (age, 18-41 yr), accounting for 77 pregnancies, completed a questionnaire providing information on maternal background and medical history, shunt performance during pregnancy, management of delivery, pregnancy outcomes, and unusual complications. RESULTS: Fifty-six pregnancies resulted in live births; of these, 47 occurred in women with ventriculoperitoneal shunts. Three women underwent therapeutic abortions, 1 experienced preterm delivery, and 8 experienced 17 miscarriages. Four women experienced seizures during pregnancy, five reported third-trimester headaches, and eight described abdominal pains during the first and third trimesters. Four babies were diagnosed as having congenital defects. Shunt malfunctions and revisions occurred 10 times in 7 women, either during pregnancy or within 6 months after delivery. No acute malfunctions occurred during delivery. Forty-seven cases, representing 84% of all pregnancies, exhibited no shunt malfunctions or revisions. CONCLUSION: This study extends previous observations to a larger population of shunt-dependent mothers. The results suggest that maternal shunt dependency entails a relatively high incidence of complications but that proper care of these patients can lead to normal pregnancies and deliveries.     

Measles and pregnancy. Apropos of 16 cases in Burkina Faso

We report an epidemic of 16 cases of measles during pregnancy. The risk factors for such an association and the materno-fetal outcomes are presented. The mean age of the patients was 20.6 years, with a mean gravidity and parity of 2.1 and 1.1 respectively. The mean clinical features were: conjunctivitis, hyperthermia and cutaneous rash. Nine maternal complications occurred: 6 laryngitis and 3 pneumopathies. All patients were HIV negative. The outcomes of the pregnancy were the following: 2 abortions, 3 stillbirths, 1 preterm delivery and 2 full term births. Eight patients with ongoing pregnancies were lost to follow-up after their discharge from the hospital. We conclude on the need for a systematic prevention in exposed pregnant women by immunotherapy and in children by immunization.     

Prospective assessment of pregnancy outcomes after first-trimester exposure to fluconazole

OBJECTIVE: Our purpose was to study prospectively the pregnancy outcome after first-trimester exposure to fluconazole, an effective antifungal agent teratogenic in animals. STUDY DESIGN: We conducted a prospective cohort study of women who contacted three Italian teratogen information services. We compared the pregnancy outcomes of 226 women exposed to fluconazole with that of 452 women exposed to nonteratogenic agents, with use of logistic regression to control for potential confounders. RESULTS: Among the 226 pregnancies exposed to fluconazole there were 22 miscarriages, 1 stillbirth, and 7 infants with congenital anomalies. The prevalence of these outcomes and of neonatal growth parameters and the rate of neonatal complications were similar to those in the reference group. Women in the fluconazole group had a fivefold increased occurrence of induced abortions. CONCLUSIONS: First-trimester exposure to fluconazole does not appear to increase the prevalence of miscarriages, congenital anomalies, and low birth weight.     

Automobile accidents in patients with sleep apnea syndrome. An epidemiological and mechanistic study

AIM: To compare the pregnancy outcome, in particular gestational age and birth weight in women with systemic lupus erythematosus (SLE) diagnosed before and after pregnancy, and to review data on presence or absence of the antiphospholipid (aPL) antibody and flares of disease activity. METHOD: Case histories were reviewed of women with a diagnosis of SLE and an obstetric event attending Monash Medical Centre (MMC) over an eight year period (1988-96). Fifty-four pregnancies in 28 women were studied, with 44 occurring after the diagnosis of SLE (Group 1) and ten prior to the diagnosis of SLE (Group 2). RESULTS: In Group 1 there were 25 live births (63%) with 16 full term and nine premature deliveries, 12 spontaneous abortions, three foetal deaths in utero and four elective terminations. In Group 2 there were seven live births (70%), two spontaneous abortions and one foetal death in utero. The mean gestational age of live births was 35.8 weeks and 39.2 weeks respectively (p < 0.001). The mean birth weight of live births was 2448 g and 3030 g respectively (p < 0.023). a PL antibodies were positive in eight of 26 women tested with three live births and were negative in 18 of 26 women with 12 live births. Flares of disease activity occurred in 17 of 28 pregnancies. CONCLUSION: Pregnancy in women with a predisposition to SLE have a high risk of an adverse outcome. Clinical disease confers an additional risk. The mean gestational age and birth weight were significantly less in women with established disease. Mild flares in disease activity resulted in a favourable outcome while renal flares had a worse outcome.     

Midpalmar approach to the carpal tunnel: an alternative to endoscopic release

OBJECTIVE: To determine whether hysteroscopic adhesiolysis improves reproductive outcome in women with Asherman's syndrome and pregnancy failure. SUBJECTS: Ninety consecutive women who had undergone hysteroscopic adhesiolysis of intrauterine adhesions during a 5-year period. Only women in whom at least two previous pregnancies had ended with either a spontaneous abortion or a premature delivery accompanied by fetal or neonatal mortality and a hysteroscopic diagnosis of intrauterine adhesions were enrolled. RESULTS: Whereas pregnancy outcome prior to the operation was 18.3% term deliveries, 3.3% premature deliveries, 62.4% first-trimester abortions, and 16.0% late abortions, after hysteroscopic adhesiolysis pregnancy outcome was 68.6% term deliveries, 9.3% premature deliveries, 17.4% first-trimester abortions, and 4.7% late abortions. In women with two previous unsuccessful pregnancies, the operative success rate measured by delivering a healthy newborn improved from 18.3% preoperatively to 64% postoperatively. In women with three or more unsuccessful pregnancies the success rate improved from 18.3% to 75%. Successful outcome of adhesiolysis was observed in 61.9% of mild (stage I) and in 70.6% of moderate to severe cases (stages II and III) of intrauterine adhesions. CONCLUSION: Hysteroscopic adhesiolysis in women with Asherman's syndrome and poor reproductive performance contributes significantly to a successful reproductive outcome.     

Thrombophilia, anticoagulant therapy and pregnancy

Thromboembolic complications during pregnancy are the most common causes of maternal death. Here we report on thromboembolic prophylaxis of 60 pregnancies of 32 pregnant women with familial thrombophilia. Long-term Fraxiparine (Sanofi-Chinoin) as thromboprophylaxis was applied in 26 cases throughout pregnancy. UFH (Heparin-Ca inj.) was used in 11 cases, and there were 23 pregnancies without thromboembolic prophylaxis in our patient's case histories. Artificial abortions were not included in this paper. The ratio of successful pregnancies were: with Fraxiparine: 24/26 (92.3%), with UFH (Heparin-Ca): 8/11 (72.7%), without prophylaxis: 4/23 (17.4%). In the patient group treated with Fraxiparine there were no foetopathy, thrombocytopenia or bleeding complication. LMWH is recommended for pregnant women with familial thrombophilia. According to literature data and our own experiences the doses of LMWH in patients with familial thrombophilia, and -antiphospholipid syndrome, and -artificial heart value are suggested.     

Blockade of the oestrogen-induced luteinizing hormone surge in ovariectomized ewes by a highly selective opioid mu-receptor agonist: evidence for site of action

OBJECTIVE: We studied the course of pregnancy in women with epilepsy to identify possible risk factors which might complicate the epilepsies and pregnancy outcomes. MATERIAL AND METHODS: Data were collected retrospectively from the records of 151 pregnancies in 124 women with epilepsy from 1978-1992. Epilepsy variables were compared with that of non-pregnant women with epilepsy matched for age. Obstetric and neonatal variables were compared with those of all deliveries in the same unit from 1979-1992 (n=38,983). RESULTS: Pregnancy among patients with epilepsy was more likely to occur in women with relatively mild epilepsy. In 12% of the pregnancies, the women were untreated while 71% were on monotherapy. Twenty-one percent had increased seizure frequency during the pregnancy. Perinatal deaths among newborns of epileptic mothers (1.3%) was more frequent but not significantly increased compared to the background population of 0.5% (95% CI 0.2-4.7). A total of 5.3% had congenital malformations compared to 1.5% in the controls (95% CI 2.3-10.3). No neural tube defects were observed. Maternal treatment with phenytoin was significantly related to the occurrence of congenital malformations, P=0.04. CONCLUSIONS: Most women with epilepsy have an uncomplicated pregnancy and normal healthy offsprings. Maternal treatment with phenytoin might be associated with congenital malformations. No other risk factors could be identified.     

Evaluation of long-term follow-up of glomerular function in renal transplant recipients

The determinants and outcomes of unwanted pregnancies were explored in a prospective study of 1454 women who delivered in Moscow, Russia, during 1984-85. Mothers were interviewed during their postpartum hospital stay and again 3 years later. 131 women (9%) demonstrated a negative attitude toward their pregnancy. Another 72 women (5%) had a negative attitude initially, but developed positive feelings over the course of the pregnancy. The percentage of unwanted pregnancies was 2.9 times greater among unmarried women (14.9%) than married women (5.1%). Poor marital relationships, inadequate living conditions, tobacco/alcohol use, and low per capita income were found significantly more often among women with unwanted pregnancies. Significantly more infants of mothers with unwanted than wanted pregnancies had infants who were premature (28.3% vs. 9.5%) and low birth weight, but there was no significant difference in neonatal complications. Mothers of unwanted infants also were more likely to delay prenatal care and attend infrequently and, once the child was born, made fewer visits to the pediatrician. Even if unwanted pregnancy has no adverse medical sequelae, being unwanted should be considered a psychosocial risk factor with implications for a child's development.     

Comparative clinical and biochemical analyses of two methods of pancreatic cannulation in pigs

Over the last 16 years the evolution of 24 pregnancies in 17 women with biopsy-proven glomerular disease was analyzed. The underlying renal histology was IgA nephropathy in 8 cases, lupus nephritis in 7, mesangiocapillary glomerulonephritis type I in 1, and focal segmental glomerulosclerosis in 1. All but 2 had normal renal function before conception and 3 were hypertensive. Fetal survival rate was 75%. There were 6 preterm deliveries (33.3%), 3 newborns small for gestational age (17%), 1 stillbirth, and 5 therapeutic abortions. The perinatal mortality was 5.5%. De novo hypertension occurred in 8 pregnancies (33.3%). In 11 pregnancies (46%) increased proteinuria was diagnosed and in 6 (25%) a decline in maternal renal function was recorded. Permanent impairment of renal function was seen in 2 women with renal insufficiency before conception. Maternal hypertension and renal function impairment were associated more frequently with obstetric complications. In conclusion, pregnancy is safe for normotensive mothers with glomerular diseases and normal renal function. Hypertension and impaired renal function at conception seem to carry increased risk for mothers and fetuses. Low-dose immunosuppressive treatment during pregnancy is not harmful for the fetus.     

The effect of Rh-D immunoprophylaxis with hyperimmune anti-D-immunoglobulin on the occurrence of RhD immunization in pregnancy

During prenatal immunohaematological examination in the period from January 1, 1991 to December 31, 1995, in the Croatian Institute of Transfusion Medicine we tested sera of 5107 RhD negative women. All of them had pregnancies in their medical history. The frequency of Rh immunization was 4.6% in 1991; 4.1% in 1992; 2.5% in 1993; 2.5% in 1994 and 2.4% in 1995. Rh immunization during the first pregnancy was observed in 0.46% of women, in 1.8% during the second, in 9.4% during the third, in 22.4% during the fourth pregnancy, and 33.8% in women with more than five pregnancies. In women that have no abortions in their medical history, anti-D alloantibodies were found with the frequency of 0.46% at the end of the first pregnancy, 1.2% at the end of the second pregnancy, 5.9% at the end of the third pregnancy, 14.3% at the end of the fourth pregnancy, and 15.3% in women with more than five pregnancies. The frequency of anti-D alloantibodies in women who in their medical history have only abortions is 3.4% after the first abortion, 10.5% after the second, 17.8% after the third and 20.8% after the fourth or more abortions. The frequency of antibodies of anti-D specificities in women who had abortions and births is 17.1% at the end of the third pregnancy, 26.2% at the end of the fourth pregnancy, and 42.7% after more than five pregnancies. The frequency of anti-D alloantibodies in women who were protected from Rh immunization by hyperimmune anti-D globulin is 1%. The obtained results demonstrate that prevention of Rh immunization by hyperimmune anti-D globulin does not comprise all the Rh negative women, and is especially inadequate after abortions and multiple pregnancies.     

The use of dimethylsulfoxide for fixation of yeasts for electron microscopy

Increasing numbers of young women with ovarian failure and women of advanced reproductive age (> 40 yrs) utilize oocyte donation to treat their infertility. In both groups, women who become pregnant frequently experience multiple gestation, occurring in up to 30% of pregnancies. Advanced maternal age and high-order multiple gestations are associated with an increased risk for obstetric complications. We reviewed the pregnancies of patients with high-order multiple gestations (> or = 3 gestational sacs) with respect to their antepartum course and neonatal outcomes. Mothers were divided into two groups according to age at conception; Group I (> or = 40 yr, n = 20) and Group II (< 40 yr, n = 10). These 30 high-order multiple gestations were found among 127 successful oocyte donation cycles (23.6% of all pregnant patients). Data regarding pregnancy outcomes were gained by chart review and telephone interview. Results demonstrated spontaneous reductions in the number of implantation sites were similar between groups (Group I: 21.4% vs. Group II: 17.6%). Multifetal pregnancy reduction (MFPR) was more often chosen by older women (Group I: 45% vs. Group II: 10%; P < 0.05). Antenatal complications were commonly experienced by both groups (> 80%) as were operative deliveries (> 85%). However, neonatal outcomes were generally good, with only one death occurring in the 79 delivered infants (1.3%). We conclude transferring supernumerary embryos to women undergoing ovum donation places patients at great risk for high-order multiple gestations. These pregnancies are associated with increased antenatal and neonatal complications. Although advanced maternal age is normally an added risk factor, well-screened older patients carrying high-order multiple gestations experienced similar outcomes as younger mothers.     

Syphilis in pregnant women and their children in the United Kingdom: results from national clinician reporting surveys 1994-7

OBJECTIVE: To measure the incidence of syphilis detected in pregnancy and congenital syphilis in the United Kingdom. DESIGN: Surveys through consultants in genitourinary medicine and paediatricians with active surveillance. SETTING: United Kingdom, 1994-7. SUBJECTS: Women treated for syphilis in pregnancy, and children with early congenital syphilis born in the United Kingdom. RESULTS: Over 3 years 139 women were diagnosed with and treated for syphilis in pregnancy; 121 were detected through antenatal screening. Thirty one had confirmed or probable congenitally transmissible syphilis, putting their pregnancies at risk. These were minimum figures but are compatible with the 90 to 100 women newly diagnosed annually as having infectious or early latent syphilis. A universal screening policy would require 18 600 and 55 700 women (maximum numbers) to be screened, respectively, to detect one woman needing treatment and to prevent one case of congenital syphilis. Nine presumptive cases of children with congenital syphilis born in the United Kingdom were reported. Mothers requiring treatment for syphilis were found in almost every health region but were more prevalent in London and the south east. Being born abroad and belonging to an ethnic minority group were strong risk factors, but 14% (19 of 121) of cases treated and six of 31 definite or probably transmissible cases occurred in white women born in the United Kingdom. CONCLUSIONS: Congenitally transmissible syphilis continues to occur among pregnant women in the United Kingdom. Cases would be missed and stillbirths and congenitally infected babies would occur if antenatal screening was abandoned.     

National Transplantation Pregnancy Registry: analysis of pregnancy outcomes in female liver transplant recipients

Outcomes from 48 pregnancies in 34 female liver transplant recipients were analyzed. Data were collected via interviews, questionnaires, and hospital records. All recipients were treated with cyclosporine-based immunosuppression except 2 patients treated with FK506 and 2 treated with no immunosuppression. The age at conception was 26.1 +/- 5.9 years (mean +/- SD) with a transplant interval (time from transplantation to conception) of 2.9 +/- 2.5 years. There were 49 outcomes (1 set of twins): miscarriage 9 (18%), therapeutic abortion 4 (8%), and live birth 36 (74%). No stillbirths or ectopic pregnancies were reported. Of the 36 live births, the gestational age was 36.9 +/- 3.5 weeks, the birthweight was 2,604 +/- 698 grams, 39% were premature (< 37 weeks), and 31% had low birthweight (< 2,500 grams). No birth defects or neonatal deaths (< 28 days) were reported. The newborn complication rate was 17% (n = 6), 5% in premature infants. The incidence of drug-treated hypertension was 46%; pre-eclampsia 21%; infectious complications 26%; and Caesarean section 47%. Recipients with hypertension had a higher proportion of premature infants (71%) than normotensive patients (38%) (P = .04 by Fisher's exact test). Acute rejection was diagnosed in 6 pregnancies, 2 of which were ended by therapeutic abortion. Four recipients who continued their pregnancies were treated with increased immunosuppression for rejection, and all delivered livebirths. There were two grafts lost within 6 months of pregnancy. The only maternal death occurred in a patient who required retransplantation for recurrent C hepatitis 3 months afte therapeutic abortion and died 6 months later. The other recipient with graft loss was successfully retransplanted for chronic rejection 6 months after delivery. We draw the following conclusions: (1) female liver transplant recipients can safely undergo pregnancy, although there is a high rate of premature and low birthweight infants; (2) pregnancies in this population should be considered high-risk and require close monitoring of liver function; and (3) altered graft function during pregnancy should be thoroughly investigated.     

Risks of subsequent pregnancies on mother and newborn in female heart transplant recipients

BACKGROUND: Female heart transplant recipients are able to carry pregnancies successfully. This study evaluates the effect of subsequent pregnancies on newborn and maternal outcomes and graft survival. METHODS: Subjects were identified through a previously reported multicenter study, case reports from literature review, and recipients entered in the National Transplantation Pregnancy Registry. A retrospective analysis was completed of 35 heart transplant recipients with first pregnancies (FP) and 12 who had one or two additional pregnancies (P>1). Newborns were assessed for gestational age, neonatal birth weight, and complications. Maternal data included pregnancy outcome, peripartum complications, including infection and rejection, current graft function, and recipient survival. RESULTS: Forty-seven pregnancies (35 FP and 12 P>1) from 35 heart transplant recipients were studied. FP outcomes included 26 live births (one set of twins), four miscarriages, and six therapeutic abortions, whereas P>1 outcomes included 11 live births (one set of twins), and two miscarriages. There was no significant difference between mean birth weights (2353+/-986 gm vs 2588+/-521 g, P>1 vs FP; mean+/-SD; p=NS) or prematurity incidence (<37 weeks; 50% vs 40%; p=NS) for the live-born infants. Compared with the FP group, there was a trend toward increased neonatal complications in P>1 (40% vs 12%; p=NS). Complications were significantly more common in premature newborns compared with full-term newborns (33% vs 5%; p < 0.05). No structural malformations were identified in the live-born infants. Maternal complication rates were the same in both groups (40%). Of 28 recipients available for follow-up, the maternal survival rate was 75% for the FP group and 89% for the P> group. Mean rejection rate per year was slightly increased after pregnancy in the P>1 group. Surviving recipients had similar graft function by echocardiographic left ventricular ejection fraction. CONCLUSIONS: Post-heart transplantation pregnancies often have successful outcomes, but there is a high incidence of prematurity and low birth weight. Subsequent pregnancies do not seem to significantly increase the incidence of complications in either the newborn or mother or increase graft rejection or failure. Larger studies of posttransplantation pregnancies may provide more definitive information.     

Pregnancy in patients with pulmonary autograft valve replacement

AIM: The purpose of this study is to determine the outcome and complications of pregnancy in women with pulmonary autograft valve replacement for aortic valve disease. METHODS AND RESULTS: The records of all women who had undergone pulmonary autograft valve replacement at the National Heart Hospital (now Royal Brompton Hospital) since 1968 were reviewed. From 1968 to 1993, 27 hospital survivors were female and among eight of them there were 14 pregnancies. All women were in Ability Index 1 at time of pregnancy with normal ventricular function, mild aortic regurgitation (six), mild pulmonary regurgitation (three) and mild pulmonary stenosis (two). None took anticoagulants. There was no maternal death, thromboembolic or haemorrhagic event or evidence of deterioration in valve function during pregnancy. Except for one woman (Ability Index 3) who developed dilated cardiomyopathy without aortic or pulmonary valve disease 6 months after delivery, the women remained in Ability Index 1 after pregnancy. There was no significant progression of aortic regurgitation (mild after seven pregnancies), pulmonary regurgitation (mild after six) or right-sided obstruction (mild after four). Reoperation for right-sided obstruction was carried out in two patients 4 and 7 years after a second pregnancy (9 and 15 years after the pulmonary autograft). CONCLUSION: No valve-related complications occurred during pregnancy and pregnancy appeared to have no effect on the function of the pulmonary valve autograft or the right-sided homograft. The pulmonary autograft is thus an ideal procedure for a young female needing aortic valve replacement.     

Postmarketing surveillance of lovastatin and simvastatin exposure during pregnancy

Pregnancy outcomes in women with inadvertent exposure to lovastatin and simvastatin during pregnancy have been examined based on reports submitted to the manufacturer as part of worldwide postmarketing surveillance. There were 134 reports of exposure during pregnancy in which pregnancy outcome was known. Among prospectively followed pregnancies with known outcome, the proportion of normal outcomes was 85%, congenital anomalies 4.0%, spontaneous abortions 8.0%, fetal deaths/stillbirths 1.0%, and miscellaneous adverse outcomes 2.0%. While the number of prospective reports available for evaluation were only sufficient to rule out a three- to fourfold increase in the overall frequency of congenital anomalies, these proportions do not exceed what would be expected in the general population. Based on findings from this interim evaluation, there is no relationship between exposure to therapeutic doses of these agents during pregnancy and the occurrence of adverse pregnancy outcomes.     

Hormone therapy of spontaneous abortion. Our experience with treatment with Gravibinan

The results of the treatment of 151 pregnancies with threatened and/or habitual abortions by using high hormonal dosages (Gravibinan "Alkaloid") are presented. Eight pregnancies were in primigravidas, the remaining 143 patients having previously had 47 interruptions of pregnancy, 66 deliveries, and 313 spontaneous abortions. Disregarding artificial abortions in 379 previous pregnancies there were 313 or 82.5 per cent spontaneous abortions. The treatment was performed by i. m. applications of Gravibinan, during the first week every two days, during the following two weeks every three days, and until the accomplished 16 weeks of pregnancy every five days. Besides hormonal therapy, all patients were on bed rest; in the following course of pregnancy tocolysis and in the case of opened cervix the cerclage cervicis were performed. The vitality of the ovum and the fetus, as well as the efficacy of the treatment were evaluated by clinical findings, HCG and estriol urinary eliminations, and by ultrasonography. Out of 151 treated pregnancies, 21 (13.91%) resulted in early abotion, 17 (11.26%) in mid-trimester abortion, 6 (3.97%) in pre-term, and 107 (70.86%) in term deliveries. There were two (1.77%) perinatally dead premature infants. HCG urinary eliminations were significantly lower in pregnancies resulting is missed abortion or first-trimenon miscarriage, whereas no difference was established between pregnancies resulting in delivery or mid-trimester abortion. The authors recommend hormonal treatment in early threatening and/or habitual abortions by administering high dosages of estrogens and gestagens. Such a treatment stimulates secretory transformation of the endometrium at the beginning of pregnancy, and this allows early placentation and the uterine growth with a simultaneous quiescence of the myometrium, which, in turn, makes the growth of the ovum possible. The authors stress the importance of a complex procedure in the establishment of the etiology and in the treatment of spontaneous and/or habiutal abortion.     

Urinary tract infections and pregnancy in women who underwent antireflux surgery in childhood

PURPOSE: For several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy. MATERIALS AND METHODS: We identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions. RESULTS: Patients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections through the intervening years. Despite a higher than expected incidence of pyelonephritis, they had relatively little hypertension and renal insufficiency. During pregnancy the incidence of pyelonephritis was only slightly higher than that of the general population. However, severe complications of pregnancy, such as preeclampsia, premature birth and acute renal failure, occurred more frequently in women with a history of renal scarring or hypertension (7 of 12) than in those with a history of recurrent infection alone (3 of 10). CONCLUSIONS: When renal scarring is present, reflux should be corrected before pregnancy to minimize maternal and fetal morbidity. When scarring is not present, the literature suggests that women with a history of reflux are at increased risk for pyelonephritis during pregnancy whether or not ureterocystostomy was performed. Pregnant women with a history of reflux may benefit from prophylactic antibiotics and women with reflux nephropathy should be followed throughout life.     

Racial disparity in pregnancy outcomes: analysis of black and white teenage pregnancies

The pregnancies of black women are complicated by adverse outcomes such as prematurity and low birth weight at twice the rate of complications in pregnancies of white women. Although the cause of this racial disparity is unknown, it is most likely multifactorial. The disparity in outcomes has been found in many studies despite implementation of controls for the factors of age, socioeconomic status, and access to health care. We hypothesized that the increased incidence of adverse outcomes may be strongly affected by adequacy of prenatal care. We investigated the effects of comprehensive prenatal care delivered at the University of North Carolina-Chapel Hill Teenage Obstetric Clinic. The gestational age at the onset of prenatal care and the mean number of prenatal visits were the same for black and white teenagers. Among 183 teenagers we found no significant difference between black and white pregnancies for the outcomes of premature labor, premature delivery, fetal death, neonatal mortality, or hypertensive diseases. The mean gestational age at delivery was 38.3 weeks and 39.1 weeks for black and white women, respectively. The mean birth weight was 3126 gm and 3272 gm for black and white women, respectively. There was a trend (p < 0.09) toward more low birth weight infants in white women: 7% for black infants and 12% for white infants. We believe that comprehensive prenatal care significantly lessens the racial disparity in pregnancy outcomes between black and white adolescent women.