Preventing abuse during pregnancy: a clinical protocol

Routine screening for abuse with appropriate intervention during pregnancy is essential to interrupt the cycle of violence and prevent future trauma. Over a decade ago, the Surgeon General called for routine abuse assessment of pregnant women (10). If women are not assessed for abuse, violence will remain undetected and untreated, placing women at risk for escalating abuse and further trauma. Additionally, if follow-up interventions are not implemented once abuse has been confirmed, the cycle of violence will continue. Routine assessment and expanded intervention strategies that includes case management and multi-agency collaboration must become standard care for all pregnant women.     

Laboratory work and pregnancy outcome

Spontaneous abortions among women working in laboratories, and congenital malformations and birth weights of the children were examined in a retrospective case-referent study. In the spontaneous abortion study there were 535 women (206 cases and 329 referents), and in the malformation study 141 women (36 cases and 105 referents). The analysis of the birth weights concerned 500 women (referents). Significant associations with spontaneous abortion were found for exposure to toluene (odds ratio [OR], 4.7, 95% confidence interval [CI], 1.4 to 15.9), xylene (OR 3.1, CI 1.3 to 7.5) and formalin (OR 3.5, CI 1.1 to 11.2) > or = 3 days a week, adjusted for the covariates. Most of the women exposed to formalin and xylene were working in pathology or histology laboratories. No association with congenital malformation was found.     

Triplet and quadruplet pregnancy: management and perinatal outcome

The frequency of multiple pregnancies with more than two fetuses has increased considerably since the introduction of methods of ovulation induction, in vitro fertilization, and embryo transfer. We have analyzed the evolution, complications, delivery and perinatal outcome of 23 triplet and 3 quadruplet pregnancies occurred during a four-year period in one medical center. The most frequent complication was preterm labor (62%). The mean gestational age at delivery was 32.5 weeks for the quadruplets and 31.5 weeks for the triplets and the mean birth weight was 1461 and 1526 for quadruplets and triplets, respectively. Perinatal mortality for the whole group was 148/1000.     

Acute myocardial infarction during pregnancy and puerperium: a review

The purpose of this review is to analyze the possible parameters that lead to the development of what is a rare event--acute myocardial infarction (AMI) during pregnancy and puerperium. Through the Index Médicus, 109 publications on the subject were obtained. Since the first well-documented case by Katz in 1922, 136 patients have been reported, and from these reports the following data have been gathered: the average age was 32.1 years. This event is more frequent during the third trimester and puerperium of the first and second pregnancies. In 42.6% of the patients no coronary risk factors were observed, but when present, hypertension and cigarette smoking were the most common. The anterior wall along or in combination with any other anatomic area was affected in 73% of cases. Coronary angiograms, when taken, appeared normal in 47%. The maternal mortality rate was 26/136 (19.1%) and was higher during the third trimester, labor, and puerperium. Eight patients (8/26) (30.7%) had sudden death. In 5 of these, (62.5%) coronary thrombosis was found. In 18/26 deaths, an autopsy was performed; 9/18 (50%) had coronary thrombus formation and in 7/18 (39%) variable degrees of atherosclerosis were detected. On the other hand, the fetal mortality rate was 16.9%; however, in only 52% was death coincidental with that of the mother. Coronary artery spasm associated with a probable hypercoagulability state was the most likely mechanism in the majority of these patients, followed by atherosclerotic heart disease and coronary dissection-the last being secondary most likely to hormonal changes. During the AMI these patients should be studied by a medical team composed of a cardiologist, gynecologist, and anesthesiologist. A complete cardiologic work-up should be made to decide individually about further pregnancies.     

Hypertensive disorders of pregnancy and maternal and foetal outcome: a case controlled study

A case controlled prospective study of 250 cases of hypertension complicating pregnancy (study group) and 400 normal pregnant women (control group) was carried out to determine the effect of hypertension on maternal and foetal outcome. Pregnancy induced hypertension was present in 96% cases and chronic hypertension in 4% cases. Preterm delivery (28.8% versus 3%), labour induction rate (52.8% versus 3.25%), caesarean section rate (14.8% versus 3.5%), stillbirth rate (4.8% versus 0.25%) and overall perinatal mortality rate (14.8% versus 1%) were higher in study group compared to controls. In study group (40%) babies required special nursery care compared to controls (6.75%). From these results it can be concluded that maternal hypertension is associated with adverse pregnancy outcome.     

Stress, social support and pregnancy outcome: a reassessment based on recent research

We present an assessment of studies published in the last decade that consider the relationship of stress and social support to preterm delivery or fetal growth retardation. Included in the review are all reports on the direct effects of stressors or psychological distress; the indirect effects of stressors or distress through health behaviours such as smoking; and the direct and buffering effects of social support. Although an important stimulus for recent stress research has been the attempt to explain racial and social class differences in birth outcome, the recent data show that stressful life events during pregnancy, though more common in disadvantaged groups, do not increase the risk of preterm birth. In contrast, intimate social support from a partner or family member appears to improve fetal growth, even for women with little life stress. Questions unanswered by the research to date are whether elevated levels of depressive symptoms affect pregnancy outcome, either directly or by encouraging negative health behaviours, and whether chronic (vs. acute) stressors are harmful. Additional research is also needed to determine whether psychosocial factors interact with specific clinical conditions to promote adverse pregnancy outcomes. Focusing on intimate support and how it benefits pregnancy outcome could lead to the design of more effective interventions.     

Successful pregnancy outcome following Tompkins metroplasty done early in pregnancy

A hysterosalpingogram revealed a septate uterus in a 29 year old nulliparous woman with a history of recurrent pregnancy loss. The patient underwent Tompkins metroplasty in the proliferative phase of the menstrual cycle. One month after the operation she presented with a delay in her menses and a positive pregnancy test. Ultrasound revealed a viable fetus commensurate with 10 weeks gestation, making the gestation period 5 weeks at the time of surgery. After reviewing the patient's menstrual history it was found that the period the patient had before surgery was on time but with unusually minimal bleeding. A repeat ultrasound scan for anomaly done 7 weeks later was commensurate with 17 weeks gestation. The patient carried her pregnancy for the first time until approximately 37 weeks when she delivered by Caesarean section a healthy female baby weighing 3700 g.     

Male pesticide exposure and pregnancy outcome

Potential health effects of agricultural pesticide use include reproductive outcomes. For the Ontario Farm Family Health Study, the authors sampled Ontario farms from the 1986 Canadian Census of Agriculture, identified farm couples, and obtained questionnaire data concerning farm activities, reproductive health experience, and chemical applications. Male farm activities in the period from 3 months before conception through the month of conception were evaluated in relation to miscarriage, preterm delivery, and small-for-gestational-age births. Among the 1,898 couples with complete data (64% response), 3,984 eligible pregnancies were identified. Miscarriage was not associated with chemical activities overall but was increased in combination with reported use of thiocarbamates, carbaryl, and unclassified pesticides on the farm. Preterm delivery was also not strongly associated with farm chemical activities overall, except for mixing or applying yard herbicides (odds ratio = 2.1, 95% confidence interval 1.0-4.4). Combinations of activities with a variety of chemicals (atrazine, glyphosate, organophosphates, 4-[2,4-dichlorophenoxy] butyric acid, and insecticides) generated odds ratios of two or greater. No associations were found between farm chemicals and small-for-gestational-age births or altered sex ratio. Based on these data, despite limitations in exposure assessment, the authors encourage continued evaluation of male exposures, particularly in relation to miscarriage and preterm delivery.     

Plasma alkaline phosphatase and pregnancy outcome

To investigate the change in adult T-cell leukemia incidence between 1983 and 1992 and to evaluate the sensitivity of the nationwide adult T-cell leukemia survey, we estimated adult T-cell leukemia incidence in the Kyushu district, southern Japan, where adult T-cell leukemia is endemic. The incidence of adult T-cell leukemia was calculated from the difference between Kyushu and the rest of Japan in mortality from malignant lymphoid neoplasms, i.e., Kyushu's excess rate was assumed to be due to adult T-cell leukemia. In Kyushu, average annual adult T-cell leukemia cases aged > or = 20 years were estimated for men as 252 during the period 1983-87 and 341 during 1988-92, and for women as 201 and 246 respectively. The age-adjusted mortality rate tended to be higher in the latter period [6.29 per 100000 (95% confidence interval 5.59-7.00) vs. 5.25 (4.60-5.90) in men, and 3.33 (2.85-3.80) vs. 3.18 (2.71-3.66) in women]. By contrast, the registered number of adult T-cell leukemia cases nationwide during 1988-93 was only 35% (203/587) of the estimated number, and the number of registered versus estimated cases decreased with age, especially when cases were > 60 years old. In conclusion, the estimated adult T-cell leukemia incidence for 1983-92 increased in the latter half of the period. The estimation suggests that 65% of adult T-cell leukemia cases might be missed by a nationwide survey, and older cases were more likely than younger ones to be missed.     

Physical work load and pregnancy outcome

Pronounced physical exertion may influence intraabdominal pressure and uterine blood flow, hormonal balance, and nutritional status, all of which are important determinants of embryonic and fetal development and survival. Most of the epidemiologic evidence of reproductive effects from occupational physical activity concerns gestational age/premature birth, birth weight/intrauterine growth retardation, and spontaneous abortion. Strenuous work, especially when involving long hours of standing and walking, seems to increase the risk of preterm delivery. The effect on intrauterine growth and spontaneous abortion risk is less clear. As a single factor, heavy lifting has in most circumstances not been associated with a significantly increased risk of these outcomes. In general, heavy work duties should be avoided, and enough rest periods assured, especially in late pregnancy.     

The outcome of pregnancy and labor after a period of sterility

In a retrospective study is examine the effect of a previous state of sterility on the outcome of pregnancy and labor. For two years (1993-1994) there were 203 (2.6%) women who gave birth after 6.7% +/- 3.5 years of sterility. From the study are excluded 9 women (4.4%) with multifetal pregnancies and 13 cases (6.4%) with different diseases, which may adversely affect the pregnancy of the foetus. In the study group of 181 primiparous women the rate of premature labor is 2.2% which is significantly lower than the hospital incidence (11%) for the same period. The cesarean section (CS) rate after period of sterility is unreasonably high--69%. In the subgroup scheduled for vaginal labor CS are performed in 34% of cases. The indications for the elective CS are complex, less justifiable and partially due to non medical reasons. The past period of sterility has not adverse effect on the course of the vaginal labor or the state of the newborn at delivery.     

Effects of a behavioural rhythm on conception probability and pregnancy outcome

This paper concerns a behaviour-driven weekday rhythm in conception rates in a large natural human population. From 1978 to 1991, North Carolina normal live single births arose from menstrual cycles which began on Monday in clear excess over other weekdays. Cycles beginning on Friday were also in excess. Cycles starting on Saturday and Sunday, or Wednesday and Thursday, each represented significantly less than one in seven of weekly totals. The source of the observed synchrony was a Sunday morning peak of coital frequency. Average cycles which began on Monday had their most fertile day on the most likely day for intercourse, translating a weekly insemination rhythm into a weekly conception rate rhythm. The secondary conception peak in Friday-onset cycles increased with age, to become the major peak for mothers aged > 30 years. We interpret this to represent a previously unreported second type of cycle with a modal follicular phase length of 10 days, the frequency of which increases with age. Several large groups of anomalous human births depart significantly from the weekday rhythm of normal conceptions. These outcomes parallel results of experimental interference with fertilization timing in estruative mammals. We believe that this implicates anomalous fertilization timing in several of the most numerous anomalies of human prenatal development.     

Foetal outcome in women with inflammatory bowel disease treated during pregnancy with oral mesalazine microgranules

BACKGROUND: Little information is available about the safety of high doses of mesalazine during pregnancy. AIM: To study the fate of pregnancy and foetal outcome in women taking 1-4 g/day of mesalazine microgranules for inflammatory bowel disease. PATIENTS AND METHODS: Case reports were collected from the Pharmacovigilance Department of Ferring SA, France, from a survey conducted in three gastroenterology units, and from a teratology information service. The evolution of pregnancy and foetal outcome were assessed by questionnaire. RESULTS: The study covered a total of 123 pregnancies (126 foetuses). Ninety-six women took mesalazine during the first trimester, 85 during the second and 83 during the third. The mean daily dose was 2.1+/-0.8 g; 86 women received <3 g/day (low-dose group), 37 women received > or =3 g/day (high-dose group). The following abnormalities were observed in the low-dose and high-dose groups, respectively: ectopic pregnancy (1/0), spontaneous abortions (1/1), foetal death (0/1), premature deliveries (3/5, P < 0.05), congenital malformations (3/1) and one case of lethal oxalosis. Abnormalities were not considered to be related to mesalazine. CONCLUSIONS: The use of oral mesalazine microgranules during pregnancy is safe at doses < or =2 g/day, and probably also at a dose of 3 g/day.     

A cohort study of pregnancy outcome after amniocentesis in twin pregnancy

We conducted a retrospective cohort study to assess the risk of amniocentesis in twin pregnancy for adverse outcomes. The study base consisted of women who had an amniocentesis performed during twin pregnancy and a comparison representative sample of women who carried a twin pregnancy, but did not have invasive prenatal diagnosis. The 227 women in each of the exposed and non-exposed groups were residents of the state of New South Wales, Australia, over the period 1980-92, and were matched on maternal age and period of the infant's birth. Nearly 10% of twin pregnancies among the women having an amniocentesis were affected by a stillbirth, and the stillbirth rate among exposed fetuses (5.3%) was nearly twice as high as among non-exposed fetuses (3.1%). After adjustment for confounding and excluding abnormalities, there was a non-significant elevated relative risk of stillbirth after exposure to amniocentesis. The analysis by type of amniocentesis (with and without methylene blue dye) was limited by small numbers, but the burden of risk was primarily among women who had dye exposure during amniocentesis (relative risk = 3.64, 95% confidence interval = 1.15, 11.48). This increase remained after adjusting for confounding, although the confidence interval was wide. In conclusion, we were unable to establish with certainty whether an increased risk of stillbirth could be ruled out among women who had any type of amniocentesis in twin pregnancy.