Maternal age and risk of fetal death in singleton gestations: USA, 1995-2000.

OBJECTIVE: To determine the magnitude of risk for fetal death among singleton pregnancies in relation to maternal age, and to compare the risks with other common indications for fetal testing. STUDY DESIGN: We performed a retrospective cohort analysis of singleton births delivered between 1995 and 2000 using the US linked birth/infant death data. Gestational age at < 24 weeks and fetuses with anomalies were excluded. Fetal death rates at > or = 24 and > or = 32 weeks were calculated among women aged 15-19, 20-24, 25-29, 30-34, 35-39, 40-44 and 45-49 years, as well as for other common indications for testing: chronic and pregnancy-induced hypertension, diabetes and small-for-gestational age (SGA). The association between maternal age and fetal deaths was derived after adjusting for potential confounders through multivariable logistic regression models. Relative risks (RR) and 95% confidence intervals (CI) were derived from these models after adjusting for the effects of gravidity, race, marital status, prenatal care, education, smoking and placental abruption. RESULTS: Among the 21,610,873 singleton births delivered at > or = 24 weeks, fetal deaths occurred in 58,580 (2.7 per 1000). Births to young (15-19 years) and older (> or = 35 years) women comprised 12.6% and 11.4%, respectively. Compared with women aged 20-24 years, young women did not experience an increased risk of fetal death. However, increasing rates of fetal death at > or = 24 and at > or = 32 weeks were seen with increasing maternal age. The RR for fetal death at > or = 24 and at > or = 32 weeks among women 35-39 years were 1.21 and 1.31, respectively, while the RRs were 1.62 and 1.67 among women aged 40-44 years. Women 45-49 years were 2.40-fold (95% CI 1.77, 3.27) and 2.38-fold (95% CI 1.64, 3.46) as likely to deliver a stillborn fetus at > or = 24 weeks and > or = 32 weeks, respectively. RRs for fetal death at > or = 24 and > or = 32 weeks for hypertensive disease, diabetes, and SGA ranged between 1.46 and 4.95. CONCLUSION: Fetal deaths are increased among older women (> or = 35 years). Fetal testing in women of advanced maternal age may be beneficial.

Assessing genetic risk: comparison between the referring obstetrician and genetic counselor.

OBJECTIVE: To compare the genetic risk assessment of the referring obstetrician to the risk assessment of the genetic counselor. STUDY DESIGN: All patients evaluated between January 1, 1999, and March 31, 1999, and who required genetic counseling were retrospectively reviewed. The genetic risk assessment of the referring obstetrician was compared to the genetic risk assessment following counseling by a genetic counselor who used a questionnaire and a three-generation pedigree. The number of patients with additional genetic risk factors identified by the genetic counselor were recorded and compared by using the McNemar chi-square test. Group demographics and characteristics were evaluated. RESULTS: Among the 145 patients evaluated, 38% (n = 55) had additional genetic risk factors detected by the genetic counselor (P =.01). The maternal demographics and characteristics did not differ between the two groups. CONCLUSION: The practice of referring high-risk obstetric patients for genetic counseling improves the detection of identifiable genetic risk factors.

Antenatal steroids and neonatal periventricular leukomalacia.

OBJECTIVE: To evaluate the effect of antenatal steroid treatment on the development of neonatal periventricular leukomalacia. METHODS: This retrospective cohort study included 1161 neonates with gestational ages of 24-34 weeks and birth weights of 500-1750 g, divided into two groups on the basis of antenatal steroid treatment. Neonatal neurosonograms were done on days 3 and 7 of life and labeled normal or abnormal. The abnormal outcomes evaluated were periventricular leukomalacia or intraventricular hemorrhage, periventricular leukomalacia with intraventricular hemorrhage, and isolated periventricular leukomalacia. The group treated with antenatal steroids was compared with the untreated group for these outcomes. RESULTS: Antenatal steroids were associated with significantly less periventricular leukomalacia or intraventricular hemorrhage (23% versus 31%, P =.005), periventricular leukomalacia with intraventricular hemorrhage (5% versus 11%, P =.001), and isolated periventricular leukomalacia (3% versus 7%, P =.009). Logistic regression analysis of antenatal steroid treatment, controlling for confounding maternal and neonatal characteristics, indicated that neonates treated with antenatal steroids had a 56% lower likelihood of periventricular leukomalacia with intraventricular hemorrhage (adjusted odds ratio [OR] 0.44, 95% confidence interval [CI] 0.25, 0.77) and a 58% lower likelihood of isolated periventricular leukomalacia (adjusted OR 0.42, 95% CI 0.20, 0.88). CONCLUSION: Antenatal steroid treatment was associated with over 50% reduction in the incidence of periventricular leukomalacia in preterm neonates. Increased use of antenatal steroid therapy might improve long-term neonatal neurologic outcomes.

Changing trends in patient decisions concerning genetic amniocentesis.

OBJECTIVE: This study was undertaken to determine whether there was a change in patient decisions concerning genetic amniocentesis during the period 1995-1998. STUDY DESIGN: All patients referred for genetic counseling because of advanced maternal age, abnormal serum triple-screen results, or ultrasonographic abnormalities between January and March 1995 and between January and March 1998 were evaluated through a retrospective chart review. Patient characteristics included age, race, and gestational age. Group 1 consisted of patients from 1995. Group 2 consisted of patients from 1998. Data on patient decisions concerning amniocentesis before and after genetic counseling and ultrasonographic examination were compared in each group. Groups 1 and 2 were then compared with respect to decisions before and after genetic counseling and ultrasonographic evaluation. RESULTS: A total of 112 patients were studied. Group 1 consisted of 53 patients and group 2 consisted of 59 patients. When the groups were compared, no differences in age, race, or gestational age were noted. In group 1, before counseling, 18 of 53 patients desired genetic testing, compared with 44 of 53 after counseling (P =.02). In group 2, before counseling, 4 of 59 patients desired genetic testing, compared with 15 of 59 after counseling (P =.01). A significantly greater number of patients in group 1 than in group 2 desired genetic testing both before counseling (n = 18/53 vs n = 4/59; P =.01) and after counseling (n = 44/53 vs n = 15/59; P =.01). CONCLUSION: Fewer patients at risk for Down syndrome in 1998 than in 1995 desired amniocentesis both before and after genetic counseling and ultrasonographic examination.

Domestic abuse in pregnancy: A comparison of a self-completed domestic abuse questionnaire with a directed interview.

OBJECTIVE: The purpose of this study was to compare the results of a standardized self-completed domestic abuse questionnaire with those of a directed interview in the identification of domestic abuse in pregnant patients. STUDY DESIGN: All patients with a first prenatal visit between March 1 and September 30, 1997, were assessed for self-reported domestic abuse with a standardized domestic abuse questionnaire. This was followed by a directed interview that involved verbal review of the standardized domestic abuse questionnaire. Self-reported domestic abuse was defined as any positive response to the domestic abuse questionnaire or the directed interview. The number of patients with a positive response to either the standardized questionnaire or the directed interview, or both, were recorded. The 2 techniques were compared by the McNemar chi(2) test. The group demographics and characteristics were evaluated. RESULTS: Among the 224 patients evaluated, a total of 36% (n = 80) of the patients reported domestic abuse by either method. The standardized domestic abuse questionnaire identified 85% (n = 68) compared with 59% (n = 47) by a directed interview (P =.03). The use of the standardized domestic abuse questionnaire and the directed interview in parallel identified an additional 15% (n = 12) of patients with domestic abuse. CONCLUSION: A standardized domestic abuse questionnaire is superior to a directed interview in identifying self-reported domestic abuse in pregnancy. Utilizing both methods in parallel further increases the number of patients identified.

Maternal magnesium sulfate and the development of neonatal periventricular leucomalacia and intraventricular hemorrhage.

OBJECTIVE: Neonatal periventricular leucomalacia and intraventricular hemorrhage are strong correlates of cerebral palsy. Our objective was to evaluate the effect of maternal magnesium sulfate exposure on the incidence and severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. METHODS: Nine hundred eighteen consecutive inborn neonates with birth weights from 500 to 1750 g were divided primarily into two groups on the basis of maternal exposure to magnesium sulfate. The groups were divided secondarily into two clinical groups, a physician-initiated group, which consisted of neonates delivered for maternal or fetal indications, and a preterm delivery group, which included neonates delivered as a result of preterm labor or preterm premature rupture of membranes. These clinical groups were stratified further into magnesium sulfate-exposed and -unexposed subgroups. Neonatal neurosonograms were performed on days 3 and 7 of life and described as normal or abnormal. Abnormal sonograms included any periventricular leucomalacia or intraventricular hemorrhage. Severe lesions included periventricular leucomalacia, periventricular leucomalacia with intraventricular hemorrhage, or grades 3 or 4 intraventricular hemorrhage. The magnesium sulfate groups and the clinical groups with their magnesium sulfate strata were compared for the incidence and severity of abnormal sonograms. They also were compared for maternal and neonatal characteristics. RESULTS: Maternal magnesium sulfate exposure was not associated with reduction in the incidence of abnormal sonograms when compared with the unexposed group (27% compared with 33%, P = .06). However, fewer severe lesions were observed in the exposed group (14% compared with 21%, P = .004). When clinical groups were examined, magnesium sulfate was not associated with a decrease in abnormal sonograms (adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.78, 1.52, P = .40) or severe lesions (adjusted OR 1.11, 95% CI 0.73, 1.68, P = .42). Logistic regression analyses of magnesium sulfate exposure within clinical groups controlling for the confounding effects of maternal and neonatal characteristics revealed no protective effect of magnesium sulfate exposure on the incidence of abnormal sonograms (adjusted OR 1.01, 95% CI 0.70, 1.44, P = .97) or severe lesions (adjusted OR 1.01, 95% CI 0.70, 1.74, P = .69). Within clinical groups, the preterm delivery group exhibited an increased risk for abnormal sonograms (adjusted OR 1.63, 95% CI 1.01, 2.67, P = .05) and severe lesions (adjusted OR 9.79, 95% CI 3.27, 29.29, P = .001) when compared with the physician-initiated delivery group, independent of maternal magnesium sulfate exposure. CONCLUSION: Maternal magnesium sulfate exposure had no protective effect on the incidence or severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. The prevalence of these lesions was correlated better with the clinical group of origin and indication for its use.