Recent cocaine use is not associated with fetal acidemia or other manifestations of intrapartum fetal distress.

The objective of this paper is to evaluate the impact of recent cocaine use on umbilical cord blood gas values in cocaine-dependent pregnant women who received formal prenatal care. Ninety-two cocaine-dependent pregnant women receiving comprehensive prenatal care were divided into two groups, with patients in Group A (n = 35) testing positive for cocaine metabolites at the time of delivery and Group B (n = 57) testing negative. One hundred and three patients with no history of drug or alcohol dependence served as the control group (Group C). Umbilical cord blood gases were obtained at all deliveries. Additional variables included 1 and 5-min Apgar scores, meconium staining of the amniotic fluid, route of delivery, premature rupture of the membranes, and length of nursery stay. There were no statistically significant differences between groups in either umbilical artery pH, pO2, pCO2, bicarbonate, or base excess. Similarly, there was no difference in meconium staining of the amniotic fluid, depressed Apgar scores, cesarean delivery, or neonatal length of stay. Our data do not support an association between recent cocaine use and fetal hypoxemia or acidemia, depressed 5-min Apgar scores, meconium staining of the amniotic fluid, or cesarean delivery in cocaine-dependent pregnant women enrolled in prenatal care.

Fetal acidemia in the absence of fluid observed at amniotomy.

The objective of this study was to determine the rate of pathological fetal acidemia in the absence of fluid observed at amniotomy. Thirty-nine consecutive patients with no fluid observed at the time of amniotomy were prospectively enrolled in this study. Ultrasound measurement of amniotic fluid index was performed. Umbilical cord gases were performed on arterial and venous samples at the time of delivery. Patient name and medical record number were noted and delivery data were extracted from review of the medical record. The median gestational age at admission was 41 weeks (range 38 to 42 weeks). Sixteen patients (41%) were subsequently noted to have meconium at the time of delivery. The median amniotic fluid index was 2.0 cm with a range of 0 to 9.0 cm. Thirty patients (76.9%) had an amniotic fluid index of less than 5.0 cm. The median umbilical artery pH in this patient population was 7.21 with a range of 6.75 to 7.42. Only one infant had an umbilical artery pH less than 7.00. The rate of cesarean section for documented fetal distress was 2.6%. The absence of observed fluid at amniotomy, while commonly associated with subsequent meconium at delivery, is not predictive of fetal acidemia or operative delivery for fetal distress.

Women with sickle cell trait are at increased risk for preeclampsia.

OBJECTIVE: Our purpose was to determine the rate of preeclampsia in women who are positive for sickle cell trait. STUDY DESIGN: All African-American women were tested for sickle cell trait with the "sickledex" screen at the fist prenatal visit and prospectively enrolled in this study from March 1994 to June 1995. "Sickledex" screens were confirmed with hemoglobin electrophoresis. Demographic data were collected at the time of enrollment. Outcome data, including preeclampsia (as defined by The American College of Obstetricians and Gynecologists criteria), gestational age at delivery, birth weight, and postpartum endometritis were collected immediately post partum. Assuming a 10% rate of positive sickle cell trait, 1100 patients were required to demonstrate a doubling in the rate of preeclampsia with 80% power and p < 0.05. The Student t test, the Mann-Whitney U test, chi 2 analysis, and Fisher's exact tests were used for statistical analysis. RESULTS: Of 1584 women enrolled in the study, 162 were positive for sickle cell trait. Sickle cell trait-positive women were older than the sickle cell trait-negative women (24.4 +/- 4.6 vs 23.0 +/- 4.4 years, p < 0.001), but there was no significant difference in parity. The rate of preeclampsia was significantly increased in sickle cell-positive women (24.7% vs 10.3%, p < 0.0001). There was no significant difference in the rate of chronic hypertension, diabetes, or smoking. Parous sickle cell-positive women more frequently gave a history of preeclampsia in a previous pregnancy (21.4% vs 9.3%, p < 0.0001). There was a statistically significant decrease in gestational age at delivery and birth weight in sickle cell trait-positive women (36.7 +/- 2.7 vs 37.7 +/- 3.0 weeks, p < 0.0001; and 3082 +/- 591 vs 3369 +/- 573 gm, p < 0.0001). The rate of postpartum endometritis was significantly increased in the women positive for sickle cell trait (12.3% vs 5.1%, p < 0.001), although both groups had a similar cesarean section rate (14.8% vs 12.6%, not significant). CONCLUSION: This is the first prospective study to demonstrate that sickle cell trait-positive women are at significantly higher risk for development of perinatal complications that have traditionally been associated with sickle disease.

Preterm premature rupture of the membranes associated with recent cocaine use.

The objective of this study was to determine the rate of recent cocaine use among a metropolitan population of predominantly Hispanic and African-American women with preterm premature rupture of the membranes (PROM) and to ascertain the impact of cocaine on the latency period between rupture of membranes and delivery. Urine toxicology screens were prospectively obtained on 147 women with preterm PROM. The urine screen did not influence management decisions. All women were expectantly managed without tocolytics until 37 weeks' gestation unless they developed clinical chorioamnionitis, or nonreassuring fetal heart rate tracing or biophysical profile. Demographic information, hours from rupture of membranes to delivery, gestational age, and birth weight at delivery were compared using Fisher's exact, Mann-Whitney U, and randomization tests where appropriate. The rate of positive urine drug screens for cocaine was 8.2%. Women in the cocaine positive group were of higher parity (3, [0-7]vs. 1, [0-6], p = 0.001) and tended to be older (27, [23-42]vs. 25, [14-40]). There was a higher rate of recent cocaine use among African-American women (20.4%) as compared to non-African-Americans (1.2%, p = 0.0001). Cocaine-positive women presented at an earlier gestational age (32 weeks', [24-34]vs. 33 weeks', [23-36], p = 0.02) and had a significantly longer membrane rupture to delivery interval than women with a negative urine drug screen (174 hr, [6-475]vs. 33 hours [1-833], p = 0.01). There was no significant difference in the reason for delivery between the two groups of patients. Recent cocaine use among women with preterm PROM is common in only some segments of an urban population. Women with recent cocaine use present with ruptured membranes at an earlier gestational age and may actually have a longer latency period than women who do not use cocaine.

Correlation of urine and serum benzoylecgonine levels in pregnant women.

The objective of this study was to evaluate the correlation between urine and serum benzoylecgonine (BE) levels in pregnant women who use crack cocaine. Ten women who had recently smoked crack cocaine were recruited from a prenatal substance abuse clinic to participate in this study. Urine and serum were obtained concurrently for quantitative determination of BE, (the major metabolite of cocaine), using gas chromatography/mass spectrometry. Pearson correlation was used for statistical analysis. The median reported interval since most recent crack use was 35 hours (range 9.5 to 63 hr). The median gestational age of the subjects was 31 weeks (range 22 to 38 weeks). Urine benzoylecgonine levels ranged from 1038 ng/mL to 1,950,563 ng/mL and serum BE levels ranged from 2.5 to 3074.3 ng/mL. Pearson correlation for urine and serum BE levels was 0.92, p < 0.001. This is the first study to report the correlation between urine and serum BE levels in pregnant women who use crack cocaine.

Quality of life assessment in pregnant women with the human immunodeficiency virus.

OBJECTIVE: To describe the perceived quality of life and functional status of women with human immunodeficiency virus (HIV) during the antenatal, perinatal, and postpartum periods. METHODS: Medical Outcome Survey-Short Form questionnaires were completed during antenatal visits, 24 hours after delivery, and 6 months postpartum by 21 HIV-positive women and 21 HIV-negative controls matched for age, race, parity, and education. The Medical Outcome Survey-Short Form measures subject perceptions of overall health, pain, physical role, social and cognitive function, mental health, energy/fatigue, health distress, quality of life, and health transition. Median scores between 0 and 100 (with 0 indicating poorest health) were compared using the Wilcoxon signed-rank and Kruskal Wallis/Dunn tests. RESULTS: All HIV-positive patients were asymptomatic; the median CD4 count was 386 on entry into the study. Seropositive patients reported increased health distress (50.0 versus 87.5; P < .001) and worse health transition (60.0 versus 80.0; P = .01) during antenatal visits. During the perinatal period, HIV-negative patients had a decreased sense of overall health (40 versus 80; P < .001) and worse health transition (40.0 versus 60.0; P = .04). Six months postpartum, the HIV-positive women reported decreased cognitive function (41.7 versus 62.5; P < .005) and worse social function (33.3 versus 66.7; P = .02). In general, HIV-negative women reported better quality of life in the antepartum as compared with the perinatal or postpartum period. This overall trend was also seen in the HIV-positive population. CONCLUSIONS: This is the first longitudinal evaluation of perceived quality of life in HIV-positive pregnant subjects. We conclude that perceived quality of life differs between HIV-positive and HIV-negative pregnant women. These differences may not be manifest during initial antenatal visits but may develop as pregnancy, the disease process, and other life events specific to delivery and the postpartum period interact and affect overall perceived quality of life. Longitudinal evaluation of quality-of-life issues may be important in the comprehensive care of HIV-positive women during pregnancy.

Cocaine is associated with intrauterine fetal death in women with suspected preterm labor.

The objectives of this study were to determine the rate of recent cocaine use in a metropolitan population of predominantly Hispanic and African-American women with suspected preterm labor and to evaluate the impact of recent cocaine use on intrapartum complications in this population. Urine toxicology screens were prospectively obtained on 102 women with suspected preterm labor. The urine screen did not influence management decisions. Gestational age at delivery, birthweight, and intrapartum complications were compared using Student's t-test, chi-square analysis, or Fisher's exact test. The rate of positive urine drug screens for cocaine was 12.7%. Women with positive toxicology were older (27.8 +/- 5.7 versus 22.1 +/- 4.8 years, p = 0.002) and of higher parity (2 [1 to 7] versus 1 [0 to 7], p = 0.0). Women with positive toxicology were more likely to be black (92.3%) than Hispanic (7.7% [p = 0.0004]). They had more advanced cervical dilation at presentation (3 cm [0 to 6] versus 1 cm [0 to 8], p = 0.008), were more likely to be admitted (85% versus 32%, p < 0.0001), but less likely to receive tocolysis due to advanced dilation or pregnancy complication (36% versus 79%, p = 0.0002). There was no difference in gestational age or birthweight at delivery. There was a significantly higher intrauterine fetal death rate in the cocaine positive group (18.2% versus 0%, p = 0.02). These data suggest that recent cocaine use among women with suspected preterm labor is common in only some segments of an urban population and significantly impacts pregnancy outcome.

Clinical nursing management of sickle cell disease and trait during pregnancy.

Sickle cell-related hemoglobinopathies present challenges for clinical management during pregnancy, labor, delivery, and the postpartum course because perinatal morbidity remains a significant practice concern. Nursing strategies that strive for synthesis of knowledge pertaining to pathophysiology, genetic counseling, life events that have affected the patient's health history, treatment modalities, and psychosocial needs may improve obstetric and neonatal outcomes. Clinical management strategies for the prenatal, intrapartum, and postpartum courses are provided. Nursing intervention strategies such as follow-up teaching, involvement of the partner and support network in aspects of care, and patient advocates, in conjunction with independent nursing practice activities involving emotional support and measures to alleviate symptoms associated with disease manifestations, are cornerstones in the contribution of nursing to the multidisciplinary care of the pregnant woman with sickle cell disease and trait.