Maternal Circulating Lipid Profile during Early Pregnancy: Racial/Ethnic Differences and Association with Spontaneous Preterm Delivery.

Prior reports on the association between altered maternal serum lipid levels with preterm delivery are inconsistent. Ethnic differences in serum lipids during pregnancy and their relation to preterm delivery have not been studied. We examined the relationships of six maternal lipids during early pregnancy with the risk of spontaneous preterm delivery (SPTD). The design represents a case-control study nested within a large prospective, multiethnic cohort of young, generally healthy pregnant women. SPTD cases (n = 183) and controls who delivered at term (n = 376) were included. SPTD is defined as delivery at <37 completed weeks of gestation without indicated conditions. We found that African-American women had significantly increased levels of high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 (apoA1), and lower triglyceride (TG) and apolipoprotein B (apoB) levels compared to Hispanic and non-Hispanic Caucasians combined. Elevated HDL-C and apoA1 concentrations were significantly associated with an increased odds of SPTD after controlling for potential confounding factors. The adjusted odds ratio (AOR) was 1.91 (95% confidence interval (CI) 1.15, 3.20) for the highest quartile of HDL-C relative to the lowest quartile, and for apoA1 the AOR was 1.94 (95% CI 1.16, 3.24). When controlling for ethnicity, the results remained comparable. These data suggest that pregnant African-American women had a more favorable lipid profile suggestive of a reduction in cardiovascular risk. Despite this, increased HDL-C and apoA1 were both found to be associated with SPTD.

Transfer function analysis of dynamic cerebral autoregulation in preeclampsia.

OBJECTIVE: The cerebral circulatory effects of preeclampsia on the latency (phase) and the efficiency (gain) of the cerebral autoregulatory response is unknown. Preeclampsia causes a progressive impairment of the cerebral autoregulatory response. We sought to identify these dynamic cerebral autoregulation changes in preeclampsia. STUDY DESIGN: We simultaneously measured continuously beat to beat outputs of mean arterial pressure (MAP) (Pilot 9200) and beat to beat, systolic, diastolic, and mean cerebral blood flow (MCBFV) (Nicolet Vascular TCD) for 2min with the patient during supine rest. Five preeclamptic and 5 matched normotensive controls were studied. R-R intervals, MAP, and MCBFV were analyzed in the frequency domain. Data sets were fast Fourier transformed and power spectral densities were calculated. We calculated the phase angle (which represents the temporal relationship between the MAP and mean MCBFV) and the transfer function (amplitude or gain between changes in the MCBFV signal and the MAP signal). All continuous data was compared between the two groups using T tests. RESULTS: We identified a significant difference between (1) the gain between the normotensive and preeclamptic groups (.29±.07 vs .10±.04) (p<.01, and (2) the phase angle (59±12 vs 129±31), p<.01. The preeclamptic group showed significant decrease in gain but an increase in phase angle). CONCLUSION: Preeclampsia paradoxically results in a significant improvement in dynamic cerebral autoregulation as demonstrated by an increase in phase and a decrease in gain. Clinical studies that can systematically assess the progression of these dynamic autoregulation changes are needed.

A comparison of Doppler waveform parameters versus flow-mediated vascular dilation of the brachial artery in pregnant women.

OBJECTIVE: Flow mediated dilation of the brachial artery is impaired with endothelial dysfunction. We previously identified that brachial artery waveforms were changed in preeclamptic women. We therefore sought to compare Doppler waveform analysis with flow mediated vascular dilation (FMVD) measurements in pregnant women. STUDY DESIGN: A cross sectional study of 71 pregnant women at >20weeks gestation comparing FMVD measurements with Doppler waveform parameters was performed. Research was conducted at three hospitals and two geographic settings; (1) Yale-New Haven Hospital in New Haven, CT, (2) Mount Hope Maternity and (3) Port of Spain General Hospital in Trinidad. Brachial artery Doppler waveform measurements were done at baseline and 90s post cuff-release. From the Doppler waveforms we assessed percent change in Peak Systolic Velocity (% ΔPSV), systolic acceleration, acceleration time and pulsatility index and compared them with the percent change in FMVD. Statistical analysis using Student's t tests and correlation coefficient was done as necessary. RESULTS: Correlation analysis between the % change in the Doppler waveform parameters and the % change in mean FMVD identified only the waveform parameter of % ΔPSV as significantly correlated (p=0.040). CONCLUSION: FMVD remains the gold standard for assessment of endothelial dysfunction. A correlation was observed between the Doppler measured % ΔPSV and FMVD, which may allow it to be used to assess endothelial dysfunction changes under different conditions was identified.

Characteristics of preeclampsia- and eclampsia-related maternal death in rural Haiti.

OBJECTIVE: The maternal mortality ratio in Haiti remains one of the highest in the world at 600/100 000 live births. Preeclampsia- and eclampsia-related complications are one of the leading causes of maternal death. In this resource-limited setting, effective, efficient hospital-based interventions are necessary to reduce this risk. Our objective was to assess the utility of common laboratory and clinical admission data for the determination of preeclampsia- and eclampsia-related maternal death. STUDY DESIGN: We performed an analysis of women presenting to the Hôpital Albert Schweitzer with preeclampsia and eclampsia during a 3-year period. Factors analyzed were: maternal age, parity, gestational age, hematocrit, serum creatinine, urine protein, systolic and diastolic blood pressure, intrauterine fetal death (IUFD), coma on arrival, and address (residence within or outside hospital catchment area). Stepwise logistic regression identified factors predictive of maternal mortality. RESULTS: Preeclampsia/eclampsia affected 423 of 2295 deliveries (18%) and resulted in 19 deaths. Multivariate analysis identified the following predictors of maternal mortality: IUFD (RR 7.57; 95% CI 2.76-12.69), eclampsia (RR 6.91; 95% CI 2.08-12.64), and oliguria (RR 5.39; 95% CI 1.80-10.69). CONCLUSION: In this setting, traditional admission laboratory and clinical tests were not useful in maternal mortality prediction. The analysis highlights clinical characteristics of women at highest risk for maternal death.

Comparison of intrapartum fetal heart rate tracings in patients with neonatal seizures vs. no seizures: what are the differences?

OBJECTIVE: To determine which intrapartum fetal heart rate parameters in the presence of severe neonatal acidosis (pH < 7.0) appropriately predicts the development of neonatal seizures in the context of hypoxic ischemic encephalopathy (HIE). METHODS: The intrapartum fetal heart rate tracings of 25 neonates who developed neonatal seizures secondary to HIE were compared with 25 matched neonates with similar pH and gestational age who did not develop seizures. All patients had at least 2 hours of intrapartum fetal heart rate patterns available for review. We compared the fetal heart rate parameters of prolonged deceleration, variable and late decelerations, variability, accelerations, fetal heart rate baseline and duration of the fetal heart rate abnormality. Comparison between the groups was done using chi-square for nominal data and student t-tests for continuous data. RESULTS: Neonates with seizures 2 degrees HIE had a significantly longer duration of abnormal fetal heart rate patterns (72 +/- 12 minutes vs 48 +/- 12 minutes, p < 0.001). DISCUSSION: This study demonstrated that in the setting of neonatal acidosis the development of seizures is related to the period of stress (duration of the abnormal fetal heart rate pattern).

Umbilical artery blood gas parameters in neonates with early onset seizures who die.

OBJECTIVE: To relate umbilical artery blood gas parameters to mortality among neonates with hypoxic-ischaemic encephalopathy related to early onset seizures. DESIGN: Population cohort study. SETTING: British Columbia Women's Hospital. POPULATION: Forty-seven infants at >or=32 weeks of gestation admitted to NICU with early onset seizures secondary to hypoxic-ischaemic encephalopathy with umbilical artery blood gases done at delivery. METHODS: Patients were divided into two groups: (1) Infants with neonatal seizures who survived, and (2) infants with neonatal seizures who died related to hypoxic-ischaemic encephalopathy complications. Comparison of umbilical artery pH, PO(2), PCO(2), base deficit was done between the two groups with Student's t tests. MAIN OUTCOME MEASURES: Umbilical artery pH, PO(2), PCO(2) and base deficit. RESULTS: The PO(2) was significantly higher in the group that expired (18.36 +/- 9.15 vs 12.33 +/- 7.51). There were no significant differences in any other blood gas parameters between the groups. CONCLUSION: Neither the umbilical artery pH nor base deficit is predictive of neonatal death in infants with hypoxic-ischaemic encephalopathy with seizures. The finding of a high PO(2) in neonates who died may indicate an inability of those infants to efficiently extract oxygen from blood.

An in depth study of the effects of socio-economic conditions on household waste recycling practices.

Waste is never consistent. Different areas use different materials, which give rise to waste streams that can vary widely in composition. With the increasing pressure on landfill operators and local governments over the amount and type of waste going to landfill, moves have to be taken to reduce, divert and recover materials. To undertake this function it is necessary to identify the composition of the waste stream. This paper contains the results of a household waste analysis conducted in a typical unitary authority of South Wales, a traditional industrial community. The waste analysis was conducted to determine whether there was a connection between an area's socio-economic standing and the quantities of waste produced. A selection of three different household categories were chosen, as described by the UK's ACORN geodemographical system. The three areas chosen were terracedd, council and semi-detached properties and were selected as they were the most dominant and easily recognised types of dwellings found in the study area. The results of the full waste analysis have been compared against a number of previous household waste characterisation studies.

Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial.

OBJECTIVE: The purpose of this study was to evaluate the ability of two different modes of antepartum fetal testing to screen for the presence of peripartum morbidity, as measured by the cesarean delivery rate for fetal distress in labor. STUDY DESIGN: Over a 36-month period, all patients who were referred to the Fetal Assessment Unit at BC Women's Hospital because of a perceived increased fetal antepartum risk at a gestational age of > or =32 weeks of gestation were approached to participate in this study. Fetal surveillance of these women was allocated randomly to either umbilical artery Doppler ultrasound testing or nonstress testing as a screening test for fetal well-being. If either the umbilical artery Doppler testing or the nonstress testing was normal, patients were screened subsequently with the same technique, according to study protocol. When the Doppler study showed a systolic/diastolic ratio of >90th percentile or the nonstress testing was equivocal (ie, variable decelerations), an amniotic fluid index was performed, as an additional screening test. When the amniotic fluid index was abnormal (<5th percentile), induction and delivery were recommended. When the Doppler study showed absent or reversed diastolic blood flow or when the nonstress test result was abnormal, induction and delivery were recommended to the attending physician. Statistical comparisons between groups were performed with an unpaired t test for normally distributed continuous variables and chi(2) test for categoric variables. RESULTS: One thousand three hundred sixty patients were assigned randomly to groups in the study; 16 patients were lost to follow up. Six hundred forty-nine patients received Doppler testing and 691 received nonstress testing. The mean number of visits for the Doppler test and nonstress test groups was two versus two, respectively. The major indications for fetal assessment included postdates (43%), decreased fetal movement (22%), diabetes mellitus (11%), hypertension (10%), and intrauterine growth restriction (7%). The incidence of cesarean delivery for fetal distress was significantly lower in the Doppler group compared with the nonstress testing group (30 [4.6%] vs 60 [8.7%], respectively; P <.006). The greatest impact on the reduction in cesarean deliveries for fetal distress was seen in the subgroups in which the indication for testing was hypertension and suspected intrauterine growth restriction. CONCLUSION: Umbilical artery Doppler as a screening test for fetal well-being in a high-risk population was associated with a decreased incidence of cesarean delivery for fetal distress compared to the nonstress testing, with no increase in neonatal morbidity.

Intrapartum influences on cesarean delivery in multiple gestation.

OBJECTIVE: To evaluate which intrapartum factors influence the method of delivery in a group of twin pregnancies eligible for vaginal delivery. STUDY DESIGN: Over a 10-year period, 967 consecutive twin pregnancies at gestational age >/=32 weeks with twin A presenting as a vertex and eligible for vaginal delivery were reviewed. Excluded were 40 (4.1%) patients who underwent a repeat and elective cesarean section. All patients who underwent a cesarean section were placed into one of two groups according to the method of delivery of both twins: group 1, cesarean section/cesarean section delivery; and group 2, vaginal/cesarean section delivery. The impact of the following intrapartum factors on the type of delivery were assessed: (1) presentation of the 2nd twin: vertex vs. breech vs. other; (2) experience of the obstetrician: 10 years in practice; (3) multiparity: nulliparous vs. multiparous; (4) incidence of epidural usage; (5) induction vs. spontaneous labor; and (6) difference in fetal weight between twin B and twin A: /= 25% difference. The chi-square statistic was used to compare differences in the incidence of cesarean section between the groups. RESULTS: Total incidence of cesarean section was 266/927 (28.7%). Risk of delivering by a combined vaginal delivery and cesarean section was reduced if the presentation of twin B was vertex or breech (RR: 0.114; 95% confidence interval: 0.049-0.266) or if an epidural was used (RR: 0.380; 95% confidence interval: 0.163-0.883). In twin gestations eligible for vaginal delivery the risk of requiring delivery by cesarean section for both twins is reduced if the presentation of twin B was vertex (RR: 0.782; 95% confidence interval; 0.631-0.968), if an epidural was used (RR: 0.461; 95% confidence interval: 0.375-0.566), or if the birthweight discrepancy was

Correlation of platelet count changes with liver cell destruction in HELLP syndrome.

OBJECTIVE: HELLP syndrome is defined as a subset of preeclampsia involving a combination of hemolysis, low platelets affecting the circulatory system, and elevated liver enzymes, reflecting liver cell destruction. Our objective was to assess the correlation between the platelet count changes and liver cell destruction as indicated by aspartate aminotransferase (AST) levels. METHOD: We reviewed the records of 15 preeclamptic patients who developed HELLP syndrome as defined by 1) hemolysis, 2) elevated liver enzymes with an AST greater than 70 U/L (>2 SD above mean), and 3) low platelets (<100x10(9)/L). In these patients, both platelet counts and AST were assessed every 4-6 hr before and after delivery until recovery. At least eight laboratory assessments were done on each patient and were available for review. In each patient, the correlation between platelet count and AST levels was done using the Spearman rank order correlation coefficient. RESULTS: A negative correlation was found between platelet count and AST levels. A correlation coefficient of greater than 0.8 occurred in 53% of cases. The correlation coefficient ranged from 0.1 to 0.93. In all cases, improvement of liver cell dysfunction occurred within 4 hr of recovery of platelet count. At 72 hr postpartum, 73% of the platelet counts had not recovered to >150x10(9)/L, and 66% of patients with abnormally elevated AST levels had not returned to <35 U/L. CONCLUSIONS: Liver dysfunction and platelet count are poorly correlated in individual cases. This lack of correlation is evident both during decline and recovery of the platelet counts. Changes in platelet count cannot be used as a proxy for liver dysfunction in severe preeclampsia with HELLP syndrome.

Intrapartum fetal heart rate patterns in the prediction of neonatal acidemia.

OBJECTIVE: This study was undertaken to correlate changes in the intrapartum electronic fetal heart rate patterns with the development of significant neonatal acidemia. STUDY DESIGN: We identified 488 fetuses at a gestational age of >37 weeks' gestation who had continuous electronic fetal monitoring during labor for the last 2 hours and umbilical artery cord gas analysis performed at delivery. One investigator blinded to the cord gas outcome reviewed all 488 tracings using the National Institute of Child Health and Human Development guidelines for fetal heart rate monitoring. All fetal heart rate tracings with bradycardia were removed from further analysis. The patients were placed in six groups, depending on the absence or presence of normal variability (amplitude >5 beats) during the last hour of monitoring combined with the absence of decelerations or the presence of variable or late decelerations. The relationship between changes in variability and the outcome variables of pH and base deficit in the six groups was assessed with analysis of variance and chi(2) test. Significance was set at the P <.05 level. RESULTS: Patients with normal variability and accelerations, even in the presence of late decelerations or variable decelerations, maintained an umbilical artery pH 7.0 or greater in more than 97% of cases. In the presence of minimal/absent variability (amplitude <5) for at least an hour, the incidence of significant acidemia (pH <7.0) ranged from (12%-31%). CONCLUSION: The most significant intrapartum fetal heart rate parameter to predict the development of significant acidemia is the presence of minimal/absent variability for at least 1 hour as a solitary abnormal finding or in conjunction with late decelerations in the absence of accelerations. Urgent delivery should be considered in these cases after appropriate ancillary testing.

A review of the UK metals recycling industry.

This paper reviews the volatile nature of the price of recycled metals over the past decade and examines legislative and fiscal drivers that have affected the industry. Results from this study have shown that the UK scrap metals markets are presently seeing some of the lowest scrap prices for nearly a decade for both ferrous and non-ferrous metals, in many cases halving in value in less than a year. Scrap metals and other recycled materials prices were high in 1994-96, which have since fallen back to more traditional low levels. World recessions and the steady decline of the UK manufacturing and engineering sectors have effected prices. With tougher new Government legislation, such as the Climate Change Levy and the proposed End of Life Vehicles Directive, small and medium sized scrap merchants are finding it increasingly difficult to compete.

Fetal heart rate parameters predictive of neonatal outcome in the presence of a prolonged deceleration.

OBJECTIVE: To correlate the presence of baseline variability and the duration of a prolonged deceleration/bradycardia in intrapartum fetal heart rate (FHR) tracings with the development of neonatal acidemia. METHODS: We identified 186 patients with term gestations who had continuous electronic fetal monitoring for at least 2 hours before delivery, with an identified bradycardia during that period. Each patient had umbilical artery cord analysis done and delivery within 30 minutes of that bradycardia. One investigator blinded to the cord gas outcome reviewed the last 2 hours of the tracing using the National Institute of Child Health and Human Development guidelines for FHR monitoring. We assessed the presence or absence of variability before the bradycardia and recovery or no recovery of the bradycardia and placed the patients into four groups. Group 1 (128 patients) with normal variability and recovery, group 2 (40 patients) with normal variability and no recovery, group 3 (nine patients) with decreased variability and recovery, and group 4 (nine patients) with decreased variability and no recovery. We compared the incidence of neonatal acidosis defined as a pH of less than 7.0 at birth among the four groups. The relationship between the various groups was assessed using analysis of variance and the chi(2) test. In addition, a multiple logistic regression model was developed with the parameters of amplitude and recovery used to predict pH at birth. RESULTS: The presence of decreased variability and no recovery of the FHR of a bradycardia was associated with the lowest pH 6.83 +/- 0.16 and a 78% incidence of significant acidosis. Decreased variability before FHR bradycardia was the FHR parameter significantly correlated with low pH. CONCLUSION: The most significant factor predicting the development of pathologic neonatal acidemia and indicating the need for urgent delivery in the presence of a bradycardia is decreased variability before the bradycardia.

The correlation of seizures in newborn infants with significant acidosis at birth with umbilical artery cord gas values.

OBJECTIVE: To correlate umbilical blood gas variables with neonatal seizures in neonates with significant acidosis at birth (pH < or = 7.1). METHODS: We reviewed the maternal and neonatal charts of 238 patients at a gestational age of 32 weeks or more with cord gases done at delivery and an umbilical artery pH of 7.1 or less. All infants transferred to the neonatal intensive care unit were studied, and those with neonatal seizures secondary to hypoxic ischemic encephalopathy were identified. We used the perinatal outcome of early neonatal seizures secondary to hypoxic ischemic encephalopathy to divide the patients into two groups. The relationship between the umbilical artery parameters of pH, base deficit, partial oxygen pressure (pO(2)), partial carbon dioxide pressure (pCO(2)), and the neonatal outcome of seizures were determined with Student t tests and multiple logistic regression analysis. RESULTS: Umbilical artery base deficit, pO(2), and pCO(2) were significantly elevated in newborns who had seizures, whereas cord pH was decreased. Using multiple regression analysis the variable neonatal seizure was predicted only by low umbilical artery pH. A pH of less than 7 was more sensitive (73.8%) than a base excess of -16 (52.5%) in predicting the development of neonatal seizures. CONCLUSION: Our data suggest that severe fetal acidemia identified by a pH less than 7.0 was the most important umbilical blood gas variable for predicting early onset of neonatal seizures.

The role of serum uric acid as a prognostic indicator of the severity of maternal and fetal complications in hypertensive pregnancies.

OBJECTIVE: To examine whether an elevated serum uric acid level in hypertensive pregnant women is a useful prognostic indicator of severe hypertension; hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome; and small for gestational age (SGA) infants. METHODS: A total of 459 women newly diagnosed with hypertension in pregnancy were categorized into "gestational hypertension" and "hypertension with proteinuria (preeclampsia)" groups. Their serum uric acid levels were correlated with the development of HELLP syndrome, severity of hypertension, and incidence of SGA newborns (< 10th percentile birth weight). HELLP syndrome was divided into 3 classes depending on the severity of the thrombocytopenia. Prior to this study, serum uric acid levels had been measured in a group of normotensive women. Mean and standard deviation of serum uric acid levels for each group were compared using analysis of variance and student t-tests, where necessary. RESULTS: Significant elevation in serum uric acid levels over normotensive pregnant women (285 +/- 72 micromol/L) was observed in both the gestational hypertensive group (341 +/- 83 micromol/L) and the preeclamptic group (384 +/- 93 micromol/L) of women (p < 0.001 and p < 0.05 respectively). Serum uric acid levels were also significantly elevated (p < 0.001) in women with gestational hypertension with HELLP syndrome (382 +/- 78 micromol/L) compared to those without HELLP syndrome (330 +/- 80 micromol/L). Preeclamptic women with HELLP syndrome (412 +/- 99 micromol/L) also demonstrated elevated uric acid levels (p < 0.05) over those without HELLP syndrome (374 +/- 87 micromol/L). However, the level of uric acid did not predict the severity of HELLP syndrome. The presence of SGA infants in the gestational hypertensive group was not associated with increased uric acid levels. CONCLUSION: Uric acid levels, although significantly elevated in women with gestational hypertension and preeclampsia as compared to normotensive pregnant women, are not good prognostic indicators of the severity of the maternal or fetal complications.

The impact of parity on the incidence of HELLP syndrome and small for gestational age infants in hypertensive pregnant women.

OBJECTIVES: To determine whether maternal and fetal complications such as HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome and the incidence of small for gestational age infants in women with preeclampsia and gestational hypertension differ with both gravidity and parity. STUDY DESIGN: The charts of 441 hypertensive women, 182 with preeclampsia and 259 with gestational hypertension, presenting for delivery at B.C. Women's Hospital were retrospectively reviewed. Multiple clinical parameters, including gestational age at presentation, the incidence of small for gestational age (SGA) infants, HELLP syndrome, and the severity of pre-eclampsia, were compared among three groups of women: (A) primigravid primiparous, (B) multigravid primiparous, and (C) multiparous. Mean values between the groups were compared using analysis of variance with pair-wise comparison using the Tukey test. RESULTS: The incidence of HELLP syndrome among the women with preeclampsia was similar in groups A and B (35% and 50%, respectively), but significantly lower (p < 0.012) in group C (19%). The incidence of small for gestational age infants among the women with preeclampsia was similar for groups A, B, and C (27%, 31%, and 19%, respectively). In the gestational hypertensive group the incidence of SGA infants was similar for groups A, B, and C (14%, 11%, and 12% respectively). CONCLUSIONS: The preeclamptic primigravid primiparous and multigravid primiparous groups behaved similarly in their clinical expression of hypertensive complications but differed from the multiparous group by having a higher incidence of HELLP syndrome. The incidence of complications in hypertensive pregnant women varied by parity but not by gravidity. The gestational hypertensive groups did not differ in their clinical expression of hypertensive complications.