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PURPOSE - To determine if women with leiomyomata detected using uniform ultrasound methods are at increased risk of cesarean birth, without regard to indication.
METHODS - Women were enrolled in Right from the Start (2000-2010), a prospective pregnancy cohort. Leiomyomata were counted, categorized, and measured during first trimester ultrasounds. Women provided information about demographics and reproductive history during first trimester interviews. Route of delivery was extracted from medical records or vital records, if the former were unavailable. Generalized estimating equations were used to calculate risk ratios (RR) and 95% confidence intervals (CIs) for the risk of cesarean birth by leiomyoma presence and characteristics.
RESULTS - Among 2635 women, the prevalences of leiomyomata and cesarean birth were 11.2% and 29.8%, respectively. Women with leiomyomata, compared with those without, had a 27% increase in cesarean risk (RR, 1.27; CI, 1.17-1.37). The association was weaker following adjustment for maternal body mass index and age (adjusted risk ratio [ARR], 1.11; CI, 1.02-1.20). The adjusted risk was elevated for women with a single leiomyoma 3 cm or more in diameter (ARR, 1.22; CI, 1.14-1.32) and women with the largest total leiomyoma volumes (ARR, 1.59; CI, 1.44-1.76).
CONCLUSIONS - Women with leiomyomata were at increased risk for cesarean birth particularly, those with larger tumor volumes.
Copyright © 2014 Elsevier Inc. All rights reserved.
No current instrument assesses women's health locus of control beliefs in relation to childbirth. Form C of the Multidimensional Health Locus of Control Scales was used to develop items for a new instrument specific to labor and delivery (MHLC-LD). Psychometric analyses conducted with two independent samples of pregnant women supported a three-factor model of the new instrument, consisting of Internal, Powerful Others, and Chance subscales. Results revealed modest coefficient alphas (>.70) for the subscales and demonstrated construct validity in known group analyses. Future validation research will focus on improving the internal consistency reliability of the MHLC-LD, testing factorial invariance across demographic groups, and examining the relationships between obstetric risk, previous birth experiences, and beliefs about control over childbirth outcomes.
Copyright © 2011 Wiley Periodicals, Inc.
OBJECTIVE - We determined interobserver variability in the classification of fetal heart rate (FHR) tracing with periodic deceleration as being reassuring or nonreassuring and in the ability to predict emergency cesarean delivery (ECD) or umbilical arterial pH < 7.00.
STUDY DESIGN - Five clinicians reviewed 100 FHR tracings 1 hour before abnormalities and, if applicable, the hour before delivery. We calculated weighted Kappa coefficients (WKC) to assess interobserver variability and likelihood ratio of FHR tracing to identify ECD and low pH.
RESULTS - Among 100 parturients, 46% of the women had ECD, and 2% of the women had low pH. The WKC for the classification of the FHR tracing as reassuring or nonreassuring in early labor was -0.12 and before delivery was 0.15. The WKC for ECD was 0.26 and for low pH was 0.21. The likelihood ratio for these 2 outcomes was < 2.0.
CONCLUSION - There was poor agreement among the clinicians who classified FHR as reassuring vs nonreassuring; they could not identify which parturient would have ECD or a newborn infant with low pH.
In a community hospital, the rate of cesarean delivery varied significantly for uncomplicated nulliparous patients managed by four practice groups, although the rate of shoulder dystocia did not. Among four practice groups in a single center, our objective was to discern the rate of cesarean delivery (CD) among uncomplicated, term nulliparous parturients, and the likelihood of shoulder dystocia and admission to the neonatal intensive care unit (NICU). The inclusion criteria for this retrospective study were uncomplicated nullipara > or = 37 weeks. Multivariable models were used for analysis. Over 2 years, 1217 women met the inclusion criteria. The overall rate of primary CD was 21%, with rates of 15%, 24%, 17%, and 32% for the four groups. After controlling for confounding variables, the rate of primary CD was significantly higher for group 2 (odd ratio [OR] 1.68; 95% confidence interval [CI] 1.17, 2.42) and 4 (OR 1.83; 95% CI, 1.25, 2.68) versus groups 1 and 3 combined. Shoulder dystocia and admission to NICU did not vary between groups. Among uncomplicated term nulliparous patients, the rate of primary CD varied significantly by practice groups, without an effect on rate of shoulder dystocia or NICU admission.
OBJECTIVE - Our objective was to determine the potential for chlorhexidine used as a vaginal and neonatal wash to reduce adverse outcomes of pregnancy, especially in developing countries.
DATA SOURCES - We searched the English literature from January 1950 through October 2005 for all articles related to the use of chlorhexidine.
METHODS OF STUDY SELECTION - Every article on chlorhexidine use in pregnancy and in the newborn period was reviewed in detail. The results of every study in which chlorhexidine was used as a vaginal treatment, with or without a neonatal wash, for all pregnancy outcomes except mother-to-child transmission of human immunodeficiency virus, are summarized in this review.
TABULATION, INTEGRATION AND RESULTS - Chlorhexidine is a highly effective killer of most bacteria, has an excellent safety profile, rarely is associated with bacterial resistance, is easy to administer, and costs a few cents per application. When used as a vaginal or newborn disinfectant, it clearly reduces bacterial load, including transmission of Group B Streptococcus from the mother to the fetus. Nevertheless, in developed countries, chlorhexidine generally has not been shown to significantly reduce life-threatening maternal or neonatal infections. However, 2 large but not randomized studies, one in Malawi and the other in Egypt, suggest that important reductions in maternal and neonatal sepsis and neonatal mortality may be achievable with vaginal or neonatal chlorhexidine treatment.
CONCLUSION - With 4 million neonates and about 700,000 pregnant or recently pregnant women-mostly in developing countries-dying each year, many from infections originating in the vagina, further study of this highly promising treatment is indicated.
CONTEXT - Single-dose intrapartum and neonatal nevirapine (NVP) reduces perinatal HIV transmission and is in increasingly common use throughout the developing world.
OBJECTIVE - We studied risk factors for perinatal transmission in the setting of NVP.
DESIGN AND SETTING - A prospective cohort study at two public obstetrical clinics in Lusaka, Zambia.
PATIENTS AND METHODS - In a volunteer sample of HIV-infected pregnant women and their newborns, the women received a 200 mg oral dose of NVP at the onset of labor; their infants received 2 mg/kg of NVP syrup within 24 h of birth. The main outcome measure was the infant HIV infection status at 6 weeks of life, determined by DNA polymerase chain reaction.
RESULTS - Only 31 of 278 (11.2%) infants were infected at 6 weeks. In logistic regression, viral load exceeding the median [adjusted odds ratio (AOR), 3.1; 95% confidence interval (CI), 1.1-8.7] and 1 h or less elapsing between NVP ingestion and delivery (AOR, 5.0; 95% CI, 1.8-14) were associated with transmission. Women delivering within 1 h of NVP ingestion had a lower mean drug concentration (351 versus 942 ng/ml; P<0.001) and were more likely to have a 'sub-therapeutic' NVP level of less than 100 ng/ml (56 versus 20%; P<0.001) than those who delivered more than 1 h post-ingestion. However, concentrations <100 ng/ml were not more likely to be associated with transmission than concentrations > or = 100 ng/ml (12.9 versus 11.7%; P=0.8). We did not identify a threshold concentration below which risk of transmission increased.
CONCLUSIONS - We confirmed low perinatal transmission rates with single-dose NVP. At least 1 h of pre-delivery NVP prophylaxis was a critical threshold for efficacy.
OBJECTIVE - The purpose of this study was to evaluate the evidence regarding antibiotics for the treatment of preterm labor.
STUDY DESIGN - Through dual review, we abstracted study design and masking, definitions of preterm labor and pregnancy outcome, patient inclusion/exclusion characteristics, patient demographic characteristics, drug and cointerventions, and numerous birth, maternal, and neonatal outcome measures. We graded the quality of the individual articles and the strength of the evidence for antibiotic benefit.
RESULTS - We abstracted data from 14 randomized trials and 1 observational study. Of these studies, 13 trials met the requirements for a meta-analysis. The meta-analysis demonstrated a mixed outcome pattern with small improvements in pregnancy prolongation, estimated gestational age at birth, and birth weight. Data were insufficient to show a beneficial effect on neonatal morbidity or mortality rates.
CONCLUSION - Treatment of preterm labor with antibiotic therapy can prolong gestation. The benefits of antibiotics are small, and there is considerable uncertainty about the optimal agent, route, dosage, and duration of therapy.
Cyclooxygenase (COX)-derived prostaglandins (PGs) regulate numerous maternal-fetal interactions during pregnancy. PGs stimulate uterine contractions and prepare the cervix for parturition, whereas in the fetus, PGs maintain patency of the ductus arteriosus (DA), a vascular shunt that transmits oxygenated placental blood to the fetal systemic circulation. However, the origin and site of action of these PGs remain undefined. To address this, we analyzed mice lacking COX-1 (null mutation) or COX-2 (pharmacologic inhibition) or pups with a double null mutation. Our results show that COX-1 in the uterine epithelium is the major source of PGs during labor and that COX-1(-/-) females experience parturition failure that is reversible by exogenous PGs. Using embryo transfer experiments, we also show that successful delivery occurs in COX-1(-/-) recipient mothers carrying wild-type pups, establishing the sufficiency of fetal PGs for parturition. Although patency of the DA is PG dependent, neither COX-1 nor COX-2 expression was detected in the fetal or postnatal DA, and offspring with a double null mutation died shortly after birth with open DAs. These results suggest that DA patency depends on circulating PGs acting on specific PG receptors within the DA. Collectively, these findings demonstrate the coordinated regulation of fetal and maternal PGs at the time of birth but raise concern regarding the use of selective COX inhibitors for the management of preterm labor.
Epidemiologic studies frequently obtain exposure information through subjects' self-report (personal interview or mailed questionnaire). The authors used data from a case-control study of infant leukemia, to assess the validity and reliability of maternally reported information on birth characteristics such as birth weight, reproductive history, and medical procedures. Cases were gathered from the Children's Cancer Group, a United States and Canadian cooperative clinical trails group with approximately 100 member and affiliate institutions, during 1983-1988. Telephone interviews were completed for 302 cases and 558 matched controls. Medical records of the index pregnancy were obtained for 287 cases and 467 controls. Correlations between medical charts and maternal interview were high for birth weight (r = 0.98, kappa = 0.9) and gestational age (r = 0.86, kappa = 0.6). Mean differences between the two sources were small, -10.5 g for birth weight and -0.36 weeks for gestational age. Reproductive history and medical procedures had high to moderate reliability. Problems after delivery and pregnancy complications generally had low validity and reliability. Little evidence of differential misclassification was found. Time between delivery and interview ranged from zero to 8 years and did not greatly affect reliability. This study suggests that validity and reliability of maternally reported pregnancy and delivery information may differ with the nature of the factor of interest, but is affected little by time from birth or case-control status.
We conducted three known-groups studies to obtain discriminant validity information among potential self-report measures of the construct desire for control over health care processes. In the first study we looked at types of preparation for childbirth; in Studies 2 and 3 we investigated choice of a place in which to die and signing a Living Will. With none of the measures could we adequately distinguish those who had signed a Living Will (or intended to) from those who did not intend to sign one. The best discriminator of a choice of a place to die (hospital vs. home or hospice) and type of preparation for childbirth (Lamaze vs. other types of classes vs. no classes) was the Information subscale of Krantz's Health Opinion Survey (KHOS; Krantz, Baum, & Wideman, 1980). With the Behavioral Involvement subscale of the KHOS and our newly designed situation-specific measure of desire for control, we could only inconsistently discriminate among the groups. The generalized measure, Burger and Cooper's (1979) Desire for Control Scale, did not help us to discriminate among these groups. Correlations of these measures with demographic variables are provided and discussed.