An evaluation of nutritional and vasoactive stimulants as risk factors for gastroschisis: a pilot study.

OBJECTIVE: The objective of this study is to evaluate poor maternal nutrition, environmental exposures and vasoactive stimulants as potential risk factors for gastroschisis. METHODS: A case-control study was conducted among singleton pregnancies diagnosed in a tertiary teaching hospital in a 22-month period. Cases of gastroschisis were matched to controls at the time of diagnosis by race and maternal age. Demographics, periconceptual exposures, nutritional biomarkers, and illicit drug hair analysis were evaluated. Analyses were performed using conditional logistic regression. RESULTS: Thirty gastroschisis cases and 76 controls were studied with no associations observed for illicit drug use or serum levels of ferritin, iron, B6, B12, folate, or zinc. Neither prescription medication nor over the counter mediation use differed between cases and controls. Following adjustment for insurance, education, low BMI, and nulliparity, mothers of gastroschisis cases had an increased odds of alcohol use 1 month prior and/or during early pregnancy compared with controls, with adjusted odds ratio (OR) 3.19 (95% CI 1.01-11.61). CONCLUSIONS: Our findings suggest that further investigation of vasoactive stimulants such as alcohol is warranted in the search to identify risk factors for gastroschisis.

A randomized controlled trial of intramuscular versus vaginal progesterone for the prevention of recurrent preterm birth.

OBJECTIVE: To compare the efficacy of intramuscular hydroxyprogesterone caproate with that of vaginal progesterone for prevention of recurrent preterm birth. METHODS: A prospective randomized controlled trial was conducted at a US tertiary care center between June 1, 2007, and April 30, 2010. Women with singleton pregnancies (16-20 weeks) and a history of spontaneous preterm birth were randomly allocated using a computer-generated randomization sequence to receive either a weekly intramuscular injection of hydroxyprogesterone caproate (250 mg) or a daily vaginal progesterone suppository (100 mg). Participants, investigators, and assessors were not masked to group assignment. The primary outcome was birth before 37 weeks of pregnancy. Per-protocol analyses were performed: participants who completed follow-up were included. RESULTS: Analyses included 66 women given intramuscular progesterone and 79 given vaginal progesterone. Delivery before 37 weeks was recorded among 29 (43.9%) women in the intramuscular progesterone group and 30 (37.9%) in the vaginal progesterone group (P=0.50). CONCLUSION: Weekly intramuscular administration of hydroxyprogesterone caproate and daily vaginal administration of a progesterone suppository exhibited similar efficacy in reducing the rate of recurrent preterm birth. ClinicalTrials.gov: NCT00579553.

Immediate compared with delayed cord clamping in the preterm neonate: a randomized controlled trial.

OBJECTIVE: The comparative risks and benefits of early compared with delayed cord clamping in the preterm neonate remain unclear. Our objective was to evaluate the short-term effects of delayed clamping of the umbilical cord in preterm neonates. METHODS: We conducted a randomized controlled trial comparing immediate with delayed cord clamping among preterm neonates born between 24 and 34 weeks of gestation. The primary study outcome was the need for blood transfusion. To detect a 33% reduction in this outcome (from 65 to 43.5%) with a two-tailed α of 0.5 and ß of 0.8 required 178 patients equally divided into two groups. RESULTS: A total of 200 women were randomized, 99 to the delayed and 101 to the immediate clamp group. The groups were similar with respect to baseline characteristics. The mean gestational age at delivery was 30.8±3.1 weeks in the delayed compared with 30.7±2.8 weeks in the immediate clamp group (P=.64). There was no statistically significant difference between groups with regard to the need for blood transfusion: 25 of 99 (25.3%) in the delayed cord clamp group received one or more blood transfusion compared with 24 of 101 (23.7%) in the immediate clamp group (P=.8). The rates of various neonatal outcomes including respiratory distress syndrome, periventricular leukomalacia, necrotizing enterocolitis, anemia of prematurity, and neonatal morality did not differ significantly between the groups. However, the mean initial hemoglobin (17.4±2.5 compared with 16.3±2.3 g/dL, P=.001) and hematocrit (51.3±7.3 compared with 47.4±7.3, P=.001) was significantly higher in the delayed group. In the delayed clamp group, 11.1% (11/99) of neonates had intraventricular hemorrhage compared with 19.8% (20/101) in the immediate clamp group (P=.09). CONCLUSION: Delayed cord clamping for 30 seconds did not decrease the need for blood transfusion among preterm neonates. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00579839.

Local anesthesia and pain perception during amniocentesis: a randomized double blind placebo-controlled trial.

OBJECTIVE: To determine the effect of local anesthesia on the maternal pain perception from amniocentesis. METHODS: We conducted a randomized double blind placebo controlled trial comparing use of local anesthesia (1% lidocaine) with placebo with regards to maternal perception of pain among women undergoing genetic amniocentesis. The primary outcome was the intensity of perceived maternal pain as measured by the Visual Analogue Scale (VAS) as well a 101 point Numerical Rating Scale. RESULTS: Seventy six women participated in the trial. 36 (47.4%) women were randomized to lidocaine, whereas 40 (52.6%) were randomized to placebo. There were no statistically significant differences between the groups in terms of baseline sociodemographic and clinical characteristics. However, pain perception as characterized by the median 9.5 (2.1-21.0) VSA scores was significantly lower among women in the lidocaine group compared with among women in the placebo group [18.4 (12.9-31.3), P = 0.005]. Similarly the mean VSA scores was significantly lower in the lidocaine group (P = 0.02). A trend toward lower scores was also observed when maternal pain perception was measured by the Numerical Rating Scale. CONCLUSION: Local anesthetic lidocaine significantly lowers maternal perceived pain during genetic amniocentesis.

Unsuccessful trial of labor in women with and without previous cesarean delivery.

OBJECTIVE: To compare maternal and neonatal outcomes after unsuccessful labor in women with and those without prior cesarean delivery. METHODS: This was a retrospective cohort study of all women in labor delivered by cesarean section (CS) from November 2004 through December 2006. The study population was dichotomized by previous CS and compared for various maternal and neonatal outcomes. Student t-test, χ² and Fisher exact tests were used for analysis. RESULTS: There was a significantly higher rate of symptomatic uterine rupture [3/100 (3%) vs. 0/449 (0%), p = 0.006], asymptomatic uterine scar dehiscence [6/100 (6%) vs. 0/449 (0%), p = 0.0001], and bladder injury [2/100 (2%) vs. 0/100 (0%), p = 0.001], among women with prior cesarean delivery compared to those without. The rate of respiratory distress syndrome [(6/100) (6%) vs. 10/449 (2.2%), p = 0.05] and meconium aspiration [4/100 (4%) vs. 2/449 (0.4%), p = 0.01] was also significantly higher among neonates of women with prior cesarean delivery. However, the rate of endomyometritis [3/100 (3%) vs. 50/449 (11.1%), p = 0.009] and febrile morbidity [17/100 (17%) vs. 144/449 (32.1%), p  = 0.003] was significantly lower among women with prior cesarean delivery compared to those without prior cesarean birth. CONCLUSIONS: Compared to laboring women without previous cesarean delivery, women with previous cesarean delivery have increased maternal and neonatal morbidity. Febrile morbidity was, however, lower among women with previous cesarean delivery. These differential findings should further inform our perinatal counseling of women contemplating trial of labor after a previous cesarean delivery.

A comparison of meningococcal carriage by pregnancy status.

Neisseria meningitidis is the second leading cause of invasive meningitis. A prerequisite for infection is colonization of the nasopharynx, and asymptomatic carrier rates are widely reported in the range of 10-15%. Recent reports have indicated an increased likelihood that a pediatric admission for Neisseria meningitidis will have a mother who is pregnant in the home. We hypothesized that this association may relate to immunologic changes in pregnancy leading to higher carrier rates.We compared the carrier status by performing nasopharyngeal swabs for Neisseria meningitidis in 100 pregnant and 99 non-pregnant women.Average age of the participants was 28.9 +/- 6.7 years. The average gestational age at specimen collection was 27.5 +/- 9.4 weeks. Non pregnant women were significantly more likely to use tobacco (38% vs 24%, p < 0.0001). In the entire 199 patients, only one pregnant patient tested positive for Neisseria meningitidis (0.5%; 95% CI: 0.01%-2.8%).The meningococcal carrier rate in our population is well below what is widely reported in the literature. Assuming a 1% carrier rate in the pregnant group and a 0.5% carrier rate in the non pregnant group, 4,763 patients would be required to detect a difference of this magnitude, given 80% power and an alpha of 0.05.

Evaluation of outcomes after transabdominal cervicoisthmic cerclage.

PURPOSE: To evaluate maternal and neonatal outcomes after transabdominal cerclage. METHODS: Retrospective analysis of 15 patients receiving transabdominal cerclage. Using the patient's prior pregnancy as her own control, we assessed the effect of this procedure on gestational age and neonatal survival. RESULTS: All patients had experienced a prior pregnancy loss. Twelve out of the 15 patients (80%) had at least one prior failed vaginal cerclage. The median gestational age at surgery was 14 (range 12-16) weeks. There was one case of surgical site infection. After cerclage, the proportion of women delivered beyond 32 weeks was significantly higher [11/15 (73.3%) vs. 1/15 (6.7%), P=0.0016], as was neonatal survival [12/15 (80%) vs. 1/15 (6.7%), P=0.0009]. CONCLUSIONS: While transabdominal cerclage is a major surgical procedure, subsequent pregnancy outcomes were improved.

The effect of digital cervical examination on group B streptococcal culture.

OBJECTIVE: We sought to evaluate whether group B streptococcus (GBS) detection is altered by the digital cervical examination. STUDY DESIGN: A total of 302 women undergoing the clinical GBS culture had a digital cervical examination and a repeated GBS culture. Statistical comparison of pre-post culture results were performed with kappa and McNemar tests. RESULTS: The clinical prevalence of GBS was 19.5%. Discordant results were seen in 30/302 (9.9%) paired cultures (kappa = 0.68; 95% confidence interval, 0.568-0.783). An initially negative GBS culture result was positive on repeated testing in 13/243 (5.3%) pairs. Initially positive cultures were negative on repeated testing in 17/59 (28.8%) pairs. Patients with discordant results had similar characteristics as the remainder of the study group. Given the observed proportion of discordant results (9.9%), the study had 80% power to detect a 5% difference between discordant pairs. CONCLUSION: Paired GBS cultures showed a good level of agreement. The 28.8% rate of positive cultures becoming negative is clinically concerning and warrants further study.

Antenatal betamethasone compared with dexamethasone (betacode trial): a randomized controlled trial.

OBJECTIVE: To compare betamethasone with dexamethasone in terms of effectiveness in reducing perinatal morbidities and mortality among preterm infants. METHODS: We enrolled 299 women at risk for preterm delivery in a double-blind, placebo-controlled, randomized trial of antenatal betamethasone compared with dexamethasone at Stony Brook University Hospital from August 2002 through July 2004. We excluded women with clinical chorioamnionitis, fetal structural and chromosomal abnormalities, prior antenatal steroid exposure, and steroid use for other indications. Statistical analysis was performed in accordance of the intention-to-treat principle. RESULTS: There were no significant differences between the groups with regard to baseline characteristics. The rate of respiratory distress syndrome, need for vasopressor therapy, necrotizing enterocolitis, retinopathy of prematurity, patent ductus arteriosus, neonatal sepsis, and neonatal mortality were not significant different between the groups. However, the rates of intraventricular hemorrhage (6 of 105 [5.7%] compared with 17 of 100 [17.0%], relative risk [RR] 2.97, 95% confidence interval [CI] 1.22-7.24, P=.02) and any brain lesion (7 of 105 [6.7%] compared with 18 of 100 [18.0%], RR 2.7, 95% CI 1.18-6.19, P=.02) were significantly lower in neonates exposed to dexamethasone compared with betamethasone. The absolute risk reduction in the rate of intraventricular hemorrhage was 11.3 % ( 95% CI 2.7-11.9%), and the number needed to treat was 9 (95% CI 5-37) in favor of dexamethasone. CONCLUSION: Betamethasone and dexamethasone are comparable in reducing the rate of most major neonatal morbidities and mortality in preterm neonates. However, dexamethasone seems to be more effective in reducing the rate of intraventricular hemorrhage compared with betamethasone.

Change in pulse pressure during the preclinical phase of preeclampsia.

OBJECTIVE: To measure and compare pulse pressure in early pregnancy between parturients who subsequently did or did not develop preeclampsia. STUDY DESIGN: Retrospective chart review of 44 parturients with preeclampsia and 187 controls without. The groups were compared for blood pressure indices before 15 weeks' gestation and other maternal variables. RESULTS: The preeclampsia group had a higher proportion of African Americans (23% vs. 9.6%, p = 0.005) and higher body mass index (26.2 +/- 7.1 SD vs. 24.0 +/- 4.9 kg/m2, p = 0.03). Before 15 weeks' gestation, women who later developed preeclampsia had higher systolic (114.3 +/- 11.6 vs. 107 +/- 12 mm Hg, p = 0.001), mean arterial (83.7 +/- 8.8 vs. 79.6 +/- 7.6 mm Hg, p = 0.002) and pulse (45.8 +/- 7.7 vs. 42.4 +/- 8.3 mm Hg, p = 0.001) pressure. On multivariable logistic regression analysis, only African American race (OR 3.1; 95% CI 1.13, 8.40; p = 0.028), and pulse pressure (OR 1.05; 95% CI 1.01, 1.1; p = 0.014) were independently associated with the development of preeclampsia. CONCLUSION: Primiparous women who later develop preeclampsia have an elevation in pulse, systolic and mean arterial pressure before 15 weeks.

Evaluation of amniotic fluid cytokines in preterm labor and intact membranes.

OBJECTIVE: To compare the amniotic fluid (AF) concentration of pro-inflammatory cytokines between women with preterm labor and intact membranes that delivered within 7 days, with those that delivered after 7 days of the amniocentesis according to the result of the AF culture. METHODS: Fifty-two women with preterm labor and intact membranes between 21 and 35 weeks of gestation were included in the study. Transabdominal amniocentesis was performed to rule out intra-amniotic infection, and AF concentrations of interleukin-1alpha (IL-1alpha), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF) were determined with sensitive and specific enzyme-linked immunosorbent assays. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Ureaplasma urealyticum, and Mycoplasma hominis. Exclusion criteria included preterm premature rupture of membranes, vaginal bleeding, multiple gestations, uterine anomalies, fetal congenital anomalies, ominous fetal heart rate tracings and fetal deaths. Proportions were compared using chi2 or Fisher's exact test. Receiver operator characteristic (ROC) curve analysis was performed for each cytokine for the prediction of delivery within 7 days. RESULTS: Sixty-two percent (32/52) of women delivered within 7 days and 38% (20/52) delivered after 7 days of amniocentesis. All women that delivered after 7 days of the procedure had negative AF cultures. In contrast, 28% (9/32) of women that delivered within 7 days had positive AF cultures and 72% (23/32) had negative AF cultures. Women that delivered within 7 days regardless of AF cultures had a lower birth weight and a shorter amniocentesis-to-delivery interval than those that delivered after 7 days of amniocentesis. Among women that delivered within 7 days, those with positive AF cultures had a lower gestational age at delivery and a higher frequency of histologic chorioamnionitis than those with negative AF cultures. The AF concentrations of all cytokines were significantly higher in women that delivered within 7 days with positive AF cultures than in those with negative AF cultures. Similarly, the AF concentrations of IL-1alpha, IL-6, and IL-8 were significantly higher in women that delivered within 7 days than those that delivered after 7 days of the amniocentesis, regardless of the AF culture results. Diagnostic indexes were calculated for all cytokines using critical values derived from ROC curve analysis for the prediction of delivery within 7 days. CONCLUSIONS: Women with preterm labor and intact membranes that delivered within 7 days had higher AF concentrations of pro-inflammatory cytokines than those who delivered after 7 days of the amniocentesis regardless of the AF culture results.

The influence of genetic counselors on the acceptance of mid-trimester amniocentesis.

OBJECTIVE: To determine the effect of the genetic counselor on the acceptance of genetic amniocentesis. METHODS: We studied women with singleton pregnancies who would be at least 35 years of age at the estimated date of delivery without fetal structural anomalies or family history of chromosomal abnormalities. The acceptance rate of genetic amniocentesis among women evaluated by each counselor was compared with the average acceptance rate for our population. Chi-square test, Fisher exact test and ANOVA were used for analysis. RESULTS: Of the 2,180 women met our inclusion criteria, 1,719 (78.9%) accepted genetic amniocentesis. The maternal age at estimated date of delivery, the proportion of women who conceived by in vitro fertilization, and the proportion with history of miscarriage were similar among women evaluated by each of the six genetic counselors. However, the acceptance rate of genetic amniocentesis was significantly lower in women evaluated by counselor C [115/170 (67.6%), P=0.001] and significantly higher in the group evaluated by counselor D [138/154 (89.6%), P=0.002] compared with the overall study population rate [1719/2180 (78.9%)]. The acceptance rate of 80.4% (210/261, P=0.52), 75.6 % (232/307, P=0.23), 80.9% (443/547, P=0.30] and 78.4% (581/741, P=0.83) for Counselors A, B, E and F respectively did not differ from the overall study population rate. CONCLUSIONS: Considerable variation exists in the acceptance rate of genetic amniocentesis among women based on the genetic counselor.

Commercial laboratory IgM testing for Toxoplasma gondii in pregnancy: a 20-year experience.

OBJECTIVE: This study was performed to review the clinical utility of commercial laboratory Toxoplasmosis-specific IgM testing during pregnancy and outcomes of the gestation at our institution. METHODS: A retrospective review of all women referred for suspected acute Toxoplasma gondii infection during pregnancy from 1984 through 2004 was performed. Women were diagnosed with suspected acute toxoplasmosis based on commercial laboratory serologic antibody testing. All women had blood sent to a recognized reference laboratory for antibody testing within 2 weeks of the commercial laboratory results. The study protocol was approved by the Institutional Review Board. Chi-square analysis were used with a significance of P < .05. RESULTS: A total of 130 women were evaluated during the study period with 116 IgM positive results from the commercial laboratories. The commercial laboratory antibodies were as follows: IgM positive with IgG negative (n = 20), IgM positive with IgG positive (n = 96), and IgM negative with IgG positive (n = 14). There was a significant reduction in the IgM positive results when comparing commercial laboratory (n = 116) with the reference laboratory results (n = 28; p < .001). Acute toxoplasmosis infection was diagnosed in 7 (5%) of the women. All cases of acute toxoplasmosis infection had a positive commercial laboratory IgM result. The false positive rate for the commercial laboratory IgM was 88.6% and the diagnostic indices were sensitivity 100%, specificity 11.4%, positive predictive value 6% and negative predictive value 100%. CONCLUSION: Commercial laboratory Toxoplasmosis-specific IgM is associated with a high false positive rate. The commercial and reference laboratory IgM results identified all cases of acute toxoplasmosis infection. Commercial laboratories reflexively obtaining reference laboratory confirmation of positive results could reduce costs associated with testing, referrals, retesting, and invasive procedures.

Pheochromocytoma in a pregnant woman with a history of intracerebral aneurysms.

Pheochromocytoma in pregnancy is rare; if unrecognized, potentially fatal hypertensive crises may occur. We report a case of a 35-year-old woman with a history of two intracerebral aneurysms who presented at 26 weeks' gestation with tachycardia, hypertension, and pulmonary edema. Laboratory data revealed elevated 24-hour urinary catecholamine and metanephrine levels, and abdominal sonography showed a 10-cm right adrenal mass. After stabilization with phenoxybenzamine and metoprolol, cesarean section was successfully performed at 36 weeks' gestation. Postpartum abdominal computed tomography scanning confirmed a 10-cm right adrenal mass. A benign pheochromocytoma was removed without incident. This case illustrates the importance of early diagnosis and management of pheochromocytoma in pregnancy and is also an example of the rare association of pheochromocytoma with intracerebral aneurysms.

Second-trimester sonographic comparison of the lower uterine segment in pregnant women with and without a previous cesarean delivery.

OBJECTIVE: To compare measurements of the lower uterine segment during a second-trimester sonographic examination in women with and without a previous cesarean delivery. METHODS: Women undergoing second-trimester sonographic examination, 24 with a history of cesarean delivery and 30 control subjects with no history of cesarean delivery, were recruited for transvaginal sonographic evaluation of the lower uterine segment with a high-frequency probe. The uterine niche or previous cesarean scar site was defined as a small triangular anechoic defect in the anterior wall of the uterus. The uterine wall thickness was measured successively at the level where the bladder dome meets the lower uterine segment. Measurements were obtained with cursors at the interface of the urine-bladder and the amniotic fluid-decidua. The study was approved by the Institutional Review Board, and P < .05 was considered significant. RESULTS: The uterine niche was identified in 14 (58%) of 24 women with a previous cesarean delivery. The lower uterine segment was significantly thinner in women with a previous cesarean delivery compared with control subjects (mean +/- SD, 4.7 +/- 1.1 versus 6.6 +/- 2.0 mm; P < .001). In the previous cesarean group, the mean lower uterine segment thickness was similar in the 5 women with 2 cesarean deliveries when compared with those with 1 cesarean delivery (4.6 +/- 1.0 versus 4.7 +/- 1.4 mm; P = .91). In a linear regression model, the only variable retaining significance in the prediction of uterine wall thickness was previous cesarean delivery (P= .002). Maternal age, parity, number of previous cesarean deliveries, and gestational age did not attain significance in the model. CONCLUSIONS: The lower uterine segment during a second-trimester sonographic examination is significantly thinner in women with a previous cesarean delivery. Identification of the scar niche is possible in most of these women.

Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries.

OBJECTIVE: To estimate the differences in immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. METHODS: We conducted a medical record review of all forceps and vacuum-assisted deliveries that occurred from January 1, 1998, to August 30, 1999, at Winthrop-University Hospital. Maternal demographics and delivery characteristics were recorded. Maternal outcomes, such as use of episiotomy and presence of lacerations, were studied. Neonatal outcomes evaluated were Apgar scores, neonatal intensive care unit admissions, cephalohematomas, instrument marks and bruising, and caput and molding. RESULTS: Of 508 operative vaginal deliveries, 200 were forceps and 308 were vacuum assisted. Forceps were used more often than vacuum for prolonged second stage of labor (P =.001). There was a higher rate of epidural (P =.02) and pudendal (P <.001) anesthesia, episiotomies (P =.01), maternal third- and fourth-degree perineal (P <.001) and vaginal lacerations (P =.004) with the use of forceps, whereas periurethral lacerations were more common in vacuum-assisted (P =.026) deliveries. More instrument marks and bruising (P <.001) were found in the neonates delivered by forceps, whereas there was a greater incidence of cephalohematomas (P =.03) and caput and molding (P <.001) in the neonates delivered with vacuum. Multivariable logistic regression analysis showed that forceps use was associated with an increase in major perineal and vaginal tears (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.27, 2.69; P =.001), an increase in instrument marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P <.001) and a decrease in cephalohematomas (OR 0.49; 95% CI 0.29, 0.83; P =.007) compared with the vacuum. CONCLUSIONS: Maternal injuries are more common with the use of forceps. Neonates delivered with forceps have more facial injuries, whereas neonates delivered with vacuum have more cephalohematomas. LEVEL OF EVIDENCE: II-3

Antenatal corticosteroids: are incomplete courses beneficial?

OBJECTIVE: To assess the effectiveness of an incomplete course of antenatal corticosteroids on perinatal morbidity and mortality. METHOSD: We studied consecutive neonates born at 23-34 weeks' gestation between January 1, 1998, and July 31, 2002. The study population was divided into a group exposed to one 12-mg dose of betamethasone before delivery and a non-corticosteroid-exposed group, which were compared for various perinatal outcome variables. The Student t test, chi(2), Fisher exact tests, and logistic regression were used for analysis. RESULTS: One hundred twenty-five neonates (55.6%) were exposed to one 12-mg dose of betamethasone before delivery, whereas 104 neonates (45.4%) did not receive antenatal corticosteroids. Mean gestational age at delivery (28.4 +/- 3.1 weeks versus 29.7 +/- 3.5 weeks, P =.002) and birth weight (1189 +/- 409 g versus 1289 +/- 441 g, P =.07) were lower among the steroid-exposed group. Adjusting for gestational age, one dose of betamethasone was associated with significant reduction in the need for vasopressors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.14, 0.85; P =.02), the rate of intraventricular hemorrhage (OR 0.42; 95%CI 0.19, 0.92; P =.03), and neonatal death (OR 0.31; 95% CI 0.11, 0.86; P =.02). There were no differences between groups in the rate of clinical and histological chorioamnionitis, low Apgar scores, postnatal surfactant exposure, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, and neonatal sepsis. CONCLUSION: An incomplete course of antenatal corticosteroids is associated with reduction in the need for vasopressors, the rate of intraventricular hemorrhage, and neonatal death in preterm neonates.

The influence of IVF, multiple gestation and miscarriage on the acceptance of genetic amniocentesis.

OBJECTIVES: To determine the effect of in vitro fertilization (IVF), multiple gestation, and history of unkaryotyped miscarriage on the acceptance of genetic amniocentesis. METHODS: We studied women expected to be at least 35 years of age at the estimated date of delivery without family history of chromosomal abnormalities or fetal structural anomalies. The influence of IVF, multiple gestation, and history of miscarriage on the acceptance rate of genetic amniocentesis was evaluated. Chi-square test and logistic regression were used for analysis. RESULTS: In singleton pregnancies, the acceptance rate of genetic amniocentesis was 70.7% (58/82) in the IVF group compared to 77.9% (1837/2356) (P = 0.14) in the women who conceived spontaneously. The corresponding values in multiple gestation pregnancies were 71.1% (37/52) and 62.9% (34/54) respectively (P = 0.41). There was no difference in the acceptance rate of amniocentesis between singletons (70.7%) and multiple gestations (71.1%) after IVF (P = 0.96), while in women who conceived spontaneously, the acceptance rate of 78% in singletons was significantly higher than the acceptance rate of 63% in multiple gestations (P = 0.008). Adjusting for confounding variables, women with multiple gestations were about 40% less likely to accept genetic amniocentesis (OR = 0.63, 95% CI = 0.39-1.00, P = 0.05), while women with a history of miscarriage were about 17% less likely to accept genetic amniocentesis (OR = 0.83, 95% CI = 0.68-1.00, P = 0.05). Adjusting for multiple gestation and previous miscarriage, IVF was not independently associated with acceptance of genetic amniocentesis (OR = 0.84, 95% CI = 0.54-1.29, P = 0.42). CONCLUSIONS: There is no difference in the acceptance rate of genetic amniocentesis among women with IVF pregnancies compared with those who conceive spontaneously, after adjusting for multiple gestation and previous miscarriage. Unlike women who conceive spontaneously, the decision to accept amniocentesis appears not to be influenced by the presence of multiple gestation in women with IVF pregnancies.

Antecedents of newborn hearing loss.

OBJECTIVE: To determine what factors are associated with newborn hearing loss. METHODS: We retrospectively reviewed hospital records of all neonates found on screening to have hearing loss as well as a cohort with normal audiometric findings from January 1998 through December 2000. The two groups were compared for various maternal, obstetric, and perinatal variables. RESULTS: Sixty-four neonates had hearing loss. The controls consisted of 270 neonates with normal findings. There were no differences between groups when compared for various maternal and perinatal variables. The mean gestational age (35.9 +/- 5.9 weeks versus 37.8 +/- 3.1 weeks, P =.01) and birth weight (2698 +/- 1173 g versus 3195 +/- 816 g, P =.002) were significantly lower in the hearing-loss group. Only 32 of the 64 neonates (50%) had one or more of the ten clinical neonatal high-risk factors for newborn hearing loss. On multivariable analysis, very low birth weight of 1500 g or less (odds ratio [OR] 7; 95% confidence interval [CI] 3, 18; P =.001), 5-minute Apgar scores less than 7 (OR 5; 95% CI 2, 18; P =.009), positive family history of congenital deafness (OR 7; 95% CI 2, 197; P =.02), and structural and chromosomal anomalies (OR 64; 95% CI 14, 292; P =.001) were independently associated with the development of newborn hearing loss. CONCLUSION: Congenital structural and chromosomal anomalies appear to be the most significantly associated risk factors for the development of newborn hearing loss. Very low birth weight, low Apgar scores, and family history are also independently associated with newborn hearing loss. However, most infants with hearing loss have no clinical risk factors.