Identifying twin gestations at low risk for preterm birth with a transvaginal ultrasonographic cervical measurement at 24 to 26 weeks' gestation

OBJECTIVE: Because twins are a high-risk group for preterm birth, many clinicians routinely use prophylactic interventions such as home bed rest, hospital bed rest, oral tocolytics, or home uterine activity monitoring to prevent preterm delivery. We sought to identify twin gestations at low risk for spontaneous preterm birth with transvaginal ultrasonography of the cervix to avoid the unnecessary use of prophylactic interventions in these pregnancies. STUDY DESIGN: We measured cervical length at 24 to 26 weeks' gestation by transvaginal ultrasonography in women with twin gestations referred to our prematurity prevention clinic. Each delivery was classified as (1) spontaneous preterm birth < 34 weeks' gestation, (2) delivery at > or = 34 weeks' gestation with intervention, or (3) delivery at > or = 34 weeks' gestation without intervention. Intervention included strict bed rest at home or in the hospital, either parenteral or oral tocolysis, or both, or home uterine activity monitoring. Indicated preterm deliveries and patients with cerclage were excluded from this analysis. The ability of transvaginal cervical length to predict women who would deliver at > or = 34 weeks without intervention was evaluated. A cervical length of 35 mm was chosen by scatter diagram as the best cutoff to discriminate between the group delivered at term without intervention and the other two groups. RESULTS: Of 85 women with twin gestations who underwent ultrasonographic cervical length measurements at 24 to 26 weeks' gestation, 17 had spontaneous preterm birth at < 34 weeks, 23 were delivered at > or = 34 weeks but required intervention, and 45 were delivered at > or = 34 weeks without intervention. The mean cervical length for those delivered at > or = 34 weeks' gestation without intervention (36.4 +/- 5.8 mm) was significantly greater (p < 0.0001) than the mean for those delivered preterm (27.4 +/- 8.5) and those delivered at > or = 34 weeks' gestation who required intervention (27.7 +/- 10.5 mm). The sensitivity, specificity, and positive and negative predictive values of a cervical length > 35 mm for predicting delivery at > or = 34 weeks' gestation are 49%, 94%, 97%, and 31%, respectively. CONCLUSION: A transvaginal ultrasonographic measurement of the cervix of > 35 mm at 24 to 26 weeks in twin gestations can identify patients who are at low risk for delivery before 34 weeks' gestation.     

Prognostic significance of prior preterm twin delivery on subsequent singleton pregnancy

OBJECTIVE: Our purpose was to determine whether preterm birth of twins is associated with an increased risk of preterm birth in a subsequent singleton pregnancy. STUDY DESIGN: The Medical University of South Carolina perinatal database was accessed to identify a cohort of patients who were delivered of twins followed by a singleton gestation (1981 to 1993). Maternal transports were excluded to minimize referral bias. Preterm birth was defined as < 37 weeks' gestation. Relative risks with 95% confidence intervals were calculated. RESULTS: One hundred forty-four patients were identified who were delivered of twins followed by a singleton gestation. Preterm delivery occurred in 86 (59.7%) of the twins and 21 (14.6%) of the subsequent singletons. Preterm birth of twins was associated with a significantly increased risk of preterm delivery in a subsequent singleton pregnancy (relative risk 2.87, 95% confidence interval 1.02 to 8.09). In the subset of women who were delivered of twins at < 30 weeks' gestation, 42% of the subsequent singletons were delivered preterm (relative risk 6.11, 95% confidence interval 2.07 to 18.02). The relative risk of preterm birth of a singleton after delivery of twins between 30 and 34 weeks' gestation was 3.63 (95% confidence interval 1.02 to 12.92). However, if the preceding twins delivered between 34 and 37 weeks' gestation, the relative risk of preterm birth of the subsequent singleton was not significantly increased (relative risk 1.42, 95% confidence interval 0.40 to 5.01). CONCLUSIONS: Preterm birth of twins before 34 weeks' gestation is associated with a significant risk for preterm delivery in a subsequent singleton pregnancy. The magnitude of risk increases with decreasing gestational age of the preceding twin delivery.     

Secular trends in preterm birth: a hospital-based cohort study

CONTEXT: Canada and the United States have reported a recent increase in the incidence of preterm birth, but the reasons for this increase are unknown. OBJECTIVE: To assess secular trends in preterm birth and its potential determinants. DESIGN: Hospital-based cohort study. SETTING: Canadian tertiary care university teaching hospital, 1978-1996. PARTICIPANTS: A total of 65574 nonreferred live births and stillbirths. MAIN OUTCOME MEASURES: Changes in occurrence of preterm birth, before and after adjustment for changes in method of gestational age assessment, obstetric intervention, registration of births weighing less than 500 g, and sociodemographic, behavioral, and clinical determinants. RESULTS: A crude secular increase in preterm births was seen for births less than 37, 34, and 32 completed weeks using 3 alternative gestational age estimation methods. Based on an algorithm incorporating both menstrual and early ultrasound gestational age estimates, rates increased from 6.6% to 9.8% for births at less than 37 weeks' gestation, 1.7% to 2.3% at less than 34 weeks, and 1.0% to 1.2% at less than 32 weeks. Exclusion of births weighing less than 500 g and those with induction or preterm cesarean delivery without labor before each of the corresponding gestational age cutoffs eliminated the secular trends for births before 34 and 32 weeks and attenuated the trend for births before 37 weeks. Nearly half of the remaining trend for births before 37 weeks was accounted for by the increasing use of early ultrasound dating. The residual trend was eliminated after controlling for secular increases in unmarried status and the proportion of women aged 35 years or older. These factors, combined with a decrease in alcohol consumption and increases in histological chorioamnionitis and cocaine use, appear to have counteracted a reduction in preterm birth since the mid-1980s that otherwise would have been observed. CONCLUSIONS: This hospital's increase in preterm births since 1978 parallels increases reported in population-based national studies from the United States and Canada. This trend appears largely attributable to the increasing use of early ultrasound dating, preterm induction and preterm cesarean delivery without labor, and changes in sociodemographic and behavioral factors.     

Prognosis and long-term follow-up of a twin after antenatal death of the co-twin

It is generally believed that among twin pregnancies with one fetal loss prior to delivery, the surviving twin has an increased rate of perinatal mortality and childhood morbidity (cerebral palsy and mental retardation). By using data from the National Medical Birth Registry of Sweden between 1973 and 1983, we identified 206 gestations with the death of at least one twin (in 36 pregnancies both twins died) prior to delivery. The original medical records were retrieved for study. The presence of childhood morbidity for 65 of 129 surviving (8 years of age or older) twins born between 1973 and 1980 was evaluated by a questionnaire sent to rehabilitation centers for disabled children, as well as to offices for the Provision of Care for the Mentally Retarded. Perinatal mortality for a twin after the antenatal death of the co-twin was considerable. Fifty percent of survivors died before 34 weeks' gestation, and 18.7% thereafter. At follow-up, 8 years or more after birth, three twins (4.6%) were handicapped. Our results indicate the need for careful monitoring of the surviving twin fetus after one twin has succumbed prenatally.     

Neonatal morbidity and mortality associated with triplet pregnancy

OBJECTIVE: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time. METHODS: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period. RESULTS: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [CI] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins. CONCLUSION: When stratified by gestational age, triplet neonates delivered at 24-34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.     

Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique

OBJECTIVE: This study's objective was to determine whether the concentrations of beta-human chorionic gonadotropin in the secretions of the cervix and vagina could be used to predict preterm delivery in a group of women at high risk for this complication. STUDY DESIGN: Women attending a prematurity prevention clinic at an inner-city hospital July 1, 1996-October 1, 1997, were invited to participate. From those who consented, secretions from the cervix and posterior vaginal fornix were sampled every 2 weeks until delivery, beginning at 24 weeks' gestation. Concentrations of beta-human chorionic gonadotropin were measured with a commercially available enzyme-linked immunosorbent assay. Providers of obstetric care were blinded to the results. Levels of beta-human chorionic gonadotropin in those who were delivered before 34 weeks' gestation and those who were delivered at term were compared. A value >50 mIU/mL was considered elevated. This cutoff value was determined according to beta-human chorionic gonadotropin values obtained during pregnancies that were delivered at term. RESULTS: Of the 146 women asked to participate, 77 consented. There was no difference between participants and nonparticipants with respect to age, race, indication for enrollment in the clinic, gestational age at delivery, or parity. Of the 77 participants, 24 (31%) were delivered before 37 weeks' gestation and 12 (16%) were delivered before 34 weeks' gestation. A single beta-human chorionic gonadotropin value >50 mIU/mL obtained between 24 and 28 weeks' gestation was associated with a significant increase in the incidence of delivery before 34 weeks' gestation (P = .03). This cutoff value had sensitivity, specificity, and positive and negative predictive values for predicting delivery before 34 weeks' gestation of 50%, 87%, 33%, and 93%, respectively. CONCLUSION: These data suggest that the concentration of beta-human chorionic gonadotropin in cervicovaginal secretions may be a useful predictor of preterm delivery.     

Treatment of severe forms of sickle cell anemia with bone marrow allograft: French experience (15 cases). SFGM

OBJECTIVE: To determine whether home uterine activity monitoring reduces the likelihood of preterm birth in women successfully treated for preterm labor in their current pregnancies. METHODS: Women between 20-34 weeks' gestation who had been treated successfully for preterm labor were solicited to participate in a randomized clinical trial of home uterine activity monitoring versus routine high-risk care. The sample size of 56 was based on power calculations using the results of earlier investigators. Twenty-eight women were randomized to home uterine activity monitoring and 29 were assigned to the type of care appropriate for women discharged after hospitalization for parenteral treatment of preterm labor. One of the routine-care subjects was lost to follow-up. The two groups were comparable in distribution for race, insurance status, multiple gestation, marital status, gestational age at beginning of the study, and incidence of prior preterm birth. RESULTS: The 28 women receiving routine care had a 54% incidence of preterm birth, whereas the incidence was 57% in monitored women (relative risk 1.08, 95% confidence interval 0.6-1.9; P = .79). The incidences of delivery before 32 weeks and 34 weeks also were unaffected by the intervention. CONCLUSION: Home uterine activity monitoring is not effective in reducing the likelihood of preterm delivery in patients successfully treated for preterm labor in their current pregnancies.     

Risk factors for aboriginal low birthweight, intrauterine growth retardation and preterm birth in the Darwin Health Region

Risk factors for Aboriginal low birthweight (< 2500 g), preterm birth (< 37 weeks' gestation) and intrauterine growth retardation (under the tenth percentile of Australian birthweights for gestational age) were examined in 503 live-born singletons recorded as born to an Aboriginal mother and routinely delivered at the Royal Darwin Hospital between January 1987 and March 1990. Infants born to mothers with body mass index less than 18.5 kg/m2 had five times the risk of having low birthweight and 2.5 times the risk of intrauterine growth retardation. Population-attributable risk percentages suggest that 28 per cent of low birthweight and 15 per cent of growth retardation could be attributed to maternal malnutrition. Risk percentages for maternal smoking of more than half a packet of cigarettes a day were 18 per cent for low birthweight and 10 per cent for growth retardation. For growth retardation, 18 per cent could be attributed to a maternal age under 20 years. Risk factors for preterm birth were predominantly obstetric: the population-attributable risk percentage for pregnancy-induced hypertension was 26 per cent and for other obstetric conditions was 16 per cent. For Aboriginal births in the Darwin Health Region, maternal malnutrition and smoking are key elements in the prevention of low birthweight and intrauterine growth retardation. Teenage pregnancy is an important risk for intrauterine growth retardation, and pregnancy-induced hypertension is a risk for preterm birth.     

What use are fibromyalgia control points?

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.     

DNA amplification polymorphisms of Mucor piriformis

OBJECTIVE: The aim was to determine the chorionic and amniotic types in multifetal pregnancies with transvaginal ultrasonography at very early stage of gestation. STUDY DESIGN: Twenty-one spontaneous multifetal pregnancies were scanned transvaginally before 8 weeks' gestation (four of them from 4th week). The chorionic and amniotic type was determined ultrasonographically. All twin gestations had postpartum pathologic evaluation of the placenta and histologic determination of the chorionic and amniotic type. RESULTS: Ultrasonographic evaluation of the 21 pregnancies demonstrated 20 twin and 1 triplet gestation. Four of the twin pregnancies were monochorionic-diamniotic. Triplet was monochorionic-triamniotic (spontaneously aborted in 8th week of gestation). In all 20 twin pregnancies, transvaginal ultrasonography correctly predicted the chorionic and amniotic type before 8 weeks of gestation. CONCLUSION: Transvaginal ultrasonography allows a reliable, simple and rapid determination; the dichorionic twin pregnancy in 4 weeks, monochorionic in 5 weeks, and differentiation of mono- or diamniotic in 7 weeks of gestation.     

Examination of wear in Duraloc acetabular components: two- to five-year evaluation of Hylamer and Enduron liners

BACKGROUND: The purpose was to determine the prognostic value of interleukin (IL) 1-alpha, IL-6 and IL-8 in cervico/vaginal secretion for preterm birth (<37 weeks of gestation) in twin pregnancies. METHODS: The study included screening of 121 women with twin pregnancies with sampling at 24, 26, 28, 30, 32 and 34 weeks of gestation. IL-1alpha, IL-6 and IL-8 was analyzed with ELISA immunoassays. The detection limit was 30 pg/mL for IL-1 and IL-8 and 40 pg/mL for IL-6. Vaginal fluid was smeared and dried for later evaluation of bacterial vaginosis (presence of clue cells). RESULTS: Spontaneous preterm birth occurred in 36 women and 65 women were delivered at term. IL-8 was significantly higher (p=0.03) in samples from women delivered preterm (median 3.72 ng/g mucus, range <0.07-220.00) compared with samples from women delivered at term (median 3.03 ng/g mucus, range <0.08-378.60). At 28 weeks of gestation, IL-8 (cut off 1.75 ng/g mucus) was associated with preterm delivery (relative risk 2.2, CI 95% 1.1-4.5) with a sensitivity, specificity, positive and negative predictive value of 78.8, 45.8, 44.8 and 79.4%, respectively. The levels of IL-1alpha and IL-6 were not significantly associated with preterm birth. Bacterial vaginosis was found in 47/541 (8.7%) samples analyzed. The levels of IL-1alpha and IL-8 were significantly higher in samples positive for bacterial vaginosis than in negative samples (p<0.0001 and p<0.01, respectively). There was no significant association between the level of IL-6 and bacterial vaginosis. CONCLUSIONS: IL-8, but not IL-1alpha and IL-6, was associated with preterm delivery but the relationship was too weak to be of predictive value for preterm birth in twin pregnancies. IL-1alpha and IL-8, but not IL-6, were associated with bacterial vaginosis.     

Development of attention in preterm infants

The quality of the awake state and attention in preterm infants has been evaluated by rating indices of attention such as widening of the eye, type of fixation, brightening, scanning, and cessation of sucking measured during visual fixation of patterns. Twenty-six infants ranging from 28 to 32 weeks' gestation at birth (mean, 31 weeks) were tested from one to four weeks postnatally until 36 weeks' gestation. Indices of attention were rated on a scale of 4 with an optimal mean index of 4. A progressive increase in behaviors associated with fixation of visual stimuli has been shown from 32 to 36 weeks of conceptual age. Mean scores ranged from 0.7 at 31 weeks' gestation to 1.8 at 34 weeks' and 2.7 at 36 weeks' gestation. The possibility therefore exists that by as early as 31 to 32 weeks from conception the human brain may be capable of waking states and thus able to process some sensory stimulation.rease in behaviors associated with fixation of visual stimuli has been shown from 32 to 36 weeks of conceptual age. Mean scores ranged from 0.7 at 31 weeks' gestation to 1.8 at 34 weeks' and 2.7 at 36 weeks' gestation. The possibility therefore exists that by as early as 31 to 32 weeks from conception the human brain may be capable of waking states and thus able to process some sensory stimulation.     

Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol, and caffeine

OBJECTIVE: To examine the relation between preterm birth and socioeconomic and psychological factors, smoking, and alcohol, and caffeine consumption. DESIGN: Prospective study of outcome of pregnancy. SETTING: District general hospital in inner London. PARTICIPANTS: 1860 consecutive white women booking for delivery; 1513 women studied after exclusion because of multiple pregnancy and diabetes, refusals, and loss to follow up. MEASUREMENTS: Gestational age was determined from ultrasound and maternal dates; preterm birth was defined as less than 37 completed weeks. Independent variables included smoking, alcohol and caffeine consumption, and a range of indicators of socioeconomic status and psychological stress. MAIN RESULTS: Unifactorial analyses showed that lower social class, less education, single marital status, low income, trouble with "nerves" and depression, help from professional agencies, and little contact with neighbours were all significantly associated with an increased risk of preterm birth. There were no apparent effects of smoking, alcohol, or caffeine on the length of gestation overall, although there was an association between smoking and delivery before 32 weeks. Cluster analysis indicated three subgroups of women delivering preterm: two predominantly of low social status and a third of older women with higher social status who did not smoke. Mean gestational age was highest in the third group. CONCLUSIONS: Adverse social circumstances are associated with preterm birth but smoking is not, apart from an association with very early births. This runs counter to findings for fetal growth (birth weight for gestational age) in this study, where a strong effect of smoking on fetal growth was observed but there was no evidence for any association with psychosocial factors.     

Endomyocardial biopsy--helpful in differential diagnosis between myocarditis and dilated cardiomyopathy. A case report

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.     

The risk of prematurity and small-for-gestational-age birth in Mexico City: the effects of working conditions and antenatal leave

OBJECTIVES: This study examined the effect of working conditions, occupational stress, and antenatal leave on risk of small-for-gestational age and premature births in Mexico City. METHODS: Over a 3-month period, 2663 (96.2%) of 2767 women who gave birth at three major hospitals and worked at least 3 months during pregnancy were interviewed shortly after delivery. After the exclusion of multiple gestations and birth defects, 261 (10.0%) small-for-gestational-age and 288 (11.0%) preterm births were identified. RESULTS: For small-for-gestational-age births, working more than 50 hours a week (odds ratio [OR] = 1.59), standing more than 7 hours a day (OR = 1.40), and no antenatal leave (OR = 1.55) were associated with an increased risk. Women with no antenatal leave were also much more likely to give birth prematurely (OR = 3.04). CONCLUSIONS: In this study, arduous working conditions and lack of antenatal leave benefits were found to increase the risk of poor birth outcome in Mexican women. Enforcement of existing antenatal leave laws and provision of comparable benefits for the uninsured may reduce the incidence of small-for-gestational-age births and prematurity.     

Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies)

OBJECTIVE: To determine whether treatment with low dose aspirin and heparin leads to a higher rate of live births than that achieved with low dose aspirin alone in women with a history of recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies), lupus anticoagulant, and cardiolipin antibodies (or anticardiolipin antibodies). DESIGN: Randomised controlled trial. SETTING: Specialist clinic for recurrent miscarriages. SUBJECTS: 90 women (median age 33 (range 22-43)) with a history of recurrent miscarriage (median number 4 (range 3-15)) and persistently positive results for phospholipid antibodies. INTERVENTION: Either low dose aspirin (75 mg daily) or low dose aspirin and 5000 U of unfractionated heparin subcutaneously 12 hourly. All women started treatment with low dose aspirin when they had a positive urine pregnancy test. Women were randomly allocated an intervention when fetal heart activity was seen on ultrasonography. Treatment was stopped at the time of miscarriage or at 34 weeks' gestation. MAIN OUTCOME MEASURES: Rate of live births with the two treatments. RESULTS: There was no significant difference in the two groups in age or the number and gestation of previous miscarriages. The rate of live births with low dose aspirin and heparin was 71% (32/45 pregnancies) and 42% (19/45 pregnancies) with low dose aspirin alone (odds ratio 3.37 (95% confidence interval 1.40 to 8.10)). More than 90% of miscarriages occurred in the first trimester. There was no difference in outcome between the two treatments in pregnancies that advanced beyond 13 weeks' gestation. Twelve of the 51 successful pregnancies (24%) were delivered before 37 weeks' gestation. Women randomly allocated aspirin and heparin had a median decrease in lumbar spine bone density of 5.4% (range -8.6% to 1.7%). CONCLUSION: Treatment with aspirin and heparin leads to a significantly higher rate of live births in women with a history of recurrent miscarriage associated with phospholipid antibodies than that achieved with aspirin alone.     

Cesarean delivery in the United States, 1990

Information now available on method of delivery from birth certificates confirms past findings on the groups at highest risk of cesarean delivery and greatly expands our knowledge of the demographic and health characteristics associated with cesarean delivery. Mothers who live in the South, who are in the oldest years of childbearing, having their first birth, married, or who have high educational attainment are all at increased risk of a cesarean delivery. Very short gestations, low or high birthweights, multiple delivery, the presence of certain complications of pregnancy, labor and/or delivery, abnormal conditions of the newborn, and the use of some obstetric procedures are also associated with elevated cesarean rates. Several recent studies (28,29) have concluded that advanced maternal age in and of itself may be an independent risk factor for cesarean delivery, due to physician and patient concern over pregnancy outcome for older women. Many of the characteristics examined in this study are highly related to maternal age (for example, marital status and educational attainment). Therefore, for these variables, mother's age is also taken into account to determine if age itself is the underlying reason for differences in rates of cesarean delivery. The importance of the role of maternal age in the risk of cesarean delivery is clearly demonstrated throughout this report: Older mothers are more likely to deliver by cesarean regardless of race, Hispanic origin, parity, marital status, or educational attainment. The overall rate of cesarean delivery is only slightly lower for black than for white mothers (22.1 percent compared with 23.0 percent), despite the generally lower educational attainment of black mothers and the higher percentage who are unmarried or in their teen years, all factors that tend to substantially lower the risk of cesarean delivery. However, there are many offsetting factors that tend to raise the cesarean rate for black mothers. A relatively high proportion of black births occur in the South, which has the highest cesarean rate of all regions; the incidence of low and very low birthweight is far higher for black births; and premature delivery is twice as frequent for black babies. Also, although rates of cesarean delivery for most medical risk factors, complications of labor and or delivery, and abnormal conditions of the infant are about the same for both races, the incidence of a number of these conditions is substantially higher for black mothers and babies, and that has the effect of increasing the overall cesarean rate for black mothers.(ABSTRACT TRUNCATED AT 400 WORDS)     

"Appearing twin": undercounting of multiple gestations on early first trimester sonograms

An important role of first trimester sonography is to determine whether a pregnancy is a singleton, twin, or higher order multiple gestation. We assessed how frequently sonography at 5.0-5.9 weeks undercounts multiple gestations. We identified all pregnancies at our institution since 1988 in which (1) an initial sonogram obtained at 5.0-5.9 weeks demonstrated at least a singleton intrauterine pregnancy and (2) a subsequent sonogram at 6.0 weeks or beyond demonstrated a living multiple gestation. Twenty-four (11%) of 213 dichorionic twin gestations were initially undercounted as singletons, as were six (86%) of seven monochorionic twin gestations. Among 105 higher order multiples, 17 (16%) were undercounted initially. All but one of the undercounted cases were scanned transvaginally. Undercounting occurred in both natural and assisted conceptions, and it occurred more frequently on sonograms obtained at 5.0-5.4 weeks than at 5.5-5.9 weeks (P = 0.02, Fisher's exact test). Prognosis for undercounted multiple gestations was similar to that of correctly counted ones with respect to several measures of pregnancy outcome, including the likelihood that all fetuses would be delivered liveborn, gestational age at birth, and birth weight (P > 0.20, all comparisons). In conclusion, transvaginal sonography at 5.0-5.9 weeks frequently undercounts multiple gestations. Initially undercounted multiple gestations and those correctly counted have similar pregnancy outcomes.     

Multicenter randomized clinical trial of home uterine activity monitoring: pregnancy outcomes for all women randomized

OBJECTIVE: Our purpose was to evaluate the impact of home uterine activity monitoring on pregnancy outcomes among women at high risk for preterm labor and delivery. STUDY DESIGN: Women at high risk for preterm labor at three centers were randomly assigned to receive high-risk prenatal care alone (not monitored) or to receive the same care with twice-daily home uterine activity monitoring without increased nursing support (monitored). There were 339 women with singleton gestations randomized with caregivers blinded to group assignment. The two groups were medically and demographically similar at entry into the study. RESULTS: Women in the monitored group had prolonged pregnancy survival (p = 0.02) and were less likely to experience a preterm delivery (relative risk 0.59; p = 0.04). Infants born to monitored women with singleton gestations were less likely to be of low birth weight (< 2500 gm; relative risk 0.47, p = 0.003), and were less likely to be admitted to a neonatal intensive care unit (relative risk 0.5, p = 0.01). CONCLUSION: These data show, among women with singleton gestations at high risk for preterm delivery, that the use of home uterine activity monitoring alone, without additional intensive nursing care, results in improved pregnancy outcomes, including prolonged gestation, decreased risk for preterm delivery, larger-birth-weight infants, and a decreased need for neonatal intensive care.     

Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania

BACKGROUND: In HIV-1-infected women, poor micronutrient status has been associated with faster progression of HIV-1 disease and adverse birth outcomes. We assessed the effects of vitamin A and multivitamins on birth outcomes in such women. METHODS: In Tanzania, 1075 HIV-1-infected pregnant women at between 12 and 27 weeks' gestation received placebo (n=267), vitamin A (n=269), multivitamins excluding vitamin A (n=269), or multivitamins including vitamin A (n=270) in a randomised, double-blind, placebo-controlled trial with a 2x2 factorial design. We measured the effects of multivitamins and vitamin A on birth outcomes and counts of T lymphocyte subsets. We did analyses by intention to treat. RESULTS: 30 fetal deaths occurred among women assigned multivitamins compared with 49 among those not on multivitamins (relative risk 0.61 [95% CI 0.39-0.94] p=0.02). Multivitamin supplementation decreased the risk of low birthweight (<2500 g) by 44% (0.56 [0.38-0.82] p=0.003), severe preterm birth (<34 weeks of gestation) by 39% (0.61 [0.38-0.96] p=0.03), and small size for gestational age at birth by 43% (0.57 [0.39-0.82] p=0.002). Vitamin A supplementation had no significant effect on these variables. Multivitamins, but not vitamin A, resulted in a significant increase in CD4, CD8, and CD3 counts. INTERPRETATION: Multivitamin supplementation is a low-cost way of substantially decreasing adverse pregnancy outcomes and increasing T-cell counts in HIV-1-infected women. The clinical relevance of our findings for vertical transmission and clinical progression of HIV-1 disease is yet to be ascertained.