Correlation of umbilical cord blood haematopoietic stem and progenitor cell levels with birth weight: implications for a prenatal influence on cancer risk.

We examined the relation with birth weight and umbilical cord blood concentrations of haematopoietic stem and progenitor populations in 288 singleton infants. Across the whole range of birth weight, there was a positive relation between birth weight and CD34+CD38(-) cells, with each 500 g increase in birth weight being associated with a 15.5% higher (95% confidence interval: 1.6-31.3%) cell concentration. CD34+ and CD34+c-kit+ cells had J-shaped relations and CFU-GM cells had a U-shaped relation with birth weight. Among newborns with >or=3000 g birth weights, concentrations of these cells increased with birth weight, while those below 3000 g had higher stem cell concentrations than the reference category of 3000-3499 g. Adjustment for cord blood plasma insulin-like growth factor-1 levels weakened the stem and progenitor cell-birth weight associations. The positive associations between birth weight and stem cell measurements for term newborns with a normal-to-high birth weight support the stem cell burden hypothesis of cancer risk.

Rupture of the renal pelvis associated with intravenous fluid bolus.

Previously reported cases of spontaneous rupture of the kidney or ureter reflect underlying renal pathology and have been reported both spontaneously and in relationship to delivery, but not in relation to other operative procedures. A 27-year-old woman at 19 weeks' gestation developed severe right flank pain in the operating room immediately prior to cerclage placement. Postoperative renal ultrasound examination and intravenous pyelogram performed to evaluate persistent flank pain demonstrated renal pelvis rupture. No other renal abnormality was present. We postulated that increased urine flow from the fluid bolus for the spinal anesthetic precipitated the rupture.

Accuracy of the TDx-FLM assay of amniotic fluid: a comparison of vaginal pool samples with amniocentesis.

OBJECTIVE: The purpose of this study was to evaluate the use of the TDx-FLM fluorescence polarization assay on vaginal pool fluid in patients with preterm premature rupture of membranes (PPROM). METHODS: A prospective matched-pairs study was performed at a tertiary care center. For each patient enrolled, amniotic fluid samples were obtained by sterile speculum examination and by amniocentesis within 12 h of each other. Inclusion criteria were the presence of PPROM and a gestational age of 30-36 weeks. The samples were analyzed separately using the TDx-FLM assay in the same laboratory. The results were compared using a paired Student t test. RESULTS: A total of 16 patients received both amniocentesis and vaginal collection of amniotic fluid. The mean gestational age at amniocentesis was 33.3 weeks (SD 1.9). In every case, the vaginal pool TDx-FLM result was lower than the amniocentesis result. The mean difference in the assays between the two fluid sources was 35% (range 17-63%, p < 0.001). Amniocentesis suggested a mature result in 12 cases (75%), an indeterminate result in two cases (12.5%), and an immature result in two cases (12.5%). Vaginal pool fluid suggested a mature result in four cases (25%), an indeterminate result in nine cases (56%), and an immature result in three cases (19%). Using the cut-off values validated for amniocentesis specimens as a standard for comparison, vaginal pool TDx-FLM assay had 42% sensitivity, 100% specificity, 100% positive predictive value and 36% negative predictive value for predicting lung maturity. CONCLUSIONS: The TDx-FLM assay on vaginal pool samples of amniotic fluid yielded results that were significantly different from those of amniocentesis samples. At this point, the assay is only clinically useful for vaginal pool samples when a mature result is obtained.

Closure of the subcutaneous dead space and wound disruption after Cesarean delivery.

OBJECTIVE: To determine whether suture closure of subcutaneous dead space decreases wound disruption after Cesarean delivery. METHODS: All patients undergoing Cesarean delivery at the New England Medical Center from September 1995 to June 1997 were eligible. One group (162 patients) was randomly assigned to have the subcutaneous fat layer closed with a running 3-0 plain suture. The other group (165 patients) had this layer left unclosed. Both groups had careful hemostasis of this layer with cautery and copious irrigation. All laboring and ruptured patients received prophylactic antibiotics. The patients were followed for 6 weeks after delivery for wound disruption. RESULTS: No significant differences were noted between the two groups with respect to demographic, obstetric, or surgical characteristics or loss to follow-up. Excluding those lost to follow-up (27 closed vs. 22 unclosed), there was no difference in wound infection (11 (8.1%) closed vs. 13 (9.1%) unclosed, RR 0.90, 95% CI 0.14, 2.08). There were decreases in risk of skin separation (three (2.2%) vs. six (4.2%), RR 0.53, 95% CI 0.42, 1.93) and seroma or hematoma formation (two (1.5%) vs. seven (4.9%), RR 0.30, 95% CI 0.06, 1.43) that were not statistically significant. Decreases that were not statistically significant were also noted for any wound disruption (14 (10.4%) vs. 21 (14.7%), RR 0.71, 95% CI 0.37, 1.33) and non-infected wound complication (three (2.2%) vs. eight (5.6%), RR 0.40, 95% CI 0.11, 1.47). Increasing gravidity and parity, and Cesarean delivery performed for failure to progress were independent risk factors for any wound complication. Controlling for these factors did not alter the effect of subcutaneous closure. CONCLUSIONS: Closure of the subcutaneous space does not increase and may protect against wound complications in patients undergoing Cesarean delivery.

Pregnancy outcomes after prenatal diagnosis of aneuploidy.

OBJECTIVE: To determine the benefits of antenatal diagnoses of fetal aneuploidy in women who continued their pregnancies. METHODS: A questionnaire was mailed to 51 mothers of children with aneuploidy. Women whose fetuses were diagnosed prenatally comprised the study group and those whose infants were diagnosed at birth were controls. Outcomes measured included an assessment of pregnancy management, neonatal outcome, subjective measures of depression and anxiety, and evaluation of women's emotional and physical experience of the pregnancy. For outcomes measured by nonparametric survey questions, 20 women were needed in each arm to achieve a power of 80% to detect a 2-point difference on a 6-point scale; for our neonatal outcomes, 100 women were needed in each arm to achieve 80% power to detect a difference in length of stay (less than 1 week versus greater than 1 week) or need for surgery. RESULTS: Thirty-eight women (75%) responded. Most (86%) had children with trisomy 21. Seventeen women (45%) received their child's diagnosis at birth; 21 (55%) had prenatal diagnoses. Demographic measures were similar except that women with prenatal diagnoses attended religious services more frequently (1--3 times per month versus once to several times per year, P =.04). Women with prenatal diagnosis had better perceptions of their physical experience of pregnancy (median score of 10 versus 6 on a 10-point visual analog scale, P =.005) and their emotional experience of the birth (median score of 7.5 versus 2, P =.001). Mental Health Inventory scores were similar between groups. Neonates without prenatal diagnoses were more likely to be transferred to tertiary centers after birth (70% versus 24%, P =.004); lengths of hospital stays and need for surgery were similar. Seventy-one percent (95% confidence interval [CI] 48, 89%) of women with prenatal diagnoses said they would have done nothing differently in the pregnancy compared with 29% (95% CI 10, 56%) of women with diagnoses at birth. CONCLUSION: Early knowledge of fetal aneuploidy is beneficial to women who continue their pregnancies. These results might be useful when counseling women who do not intend to terminate abnormal pregnancies, but are considering prenatal diagnosis.

Prophylactic use of antibiotics for nonlaboring patients undergoing cesarean delivery with intact membranes: a meta-analysis.

OBJECTIVE: We performed a meta-analysis to examine the role of antibiotic prophylaxis in preventing postoperative infections among nonlaboring women undergoing cesarean delivery with intact membranes. STUDY DESIGN: A computerized literature search was performed with MEDLINE. Studies were included if they contained data on patients undergoing cesarean delivery in the absence of labor and ruptured membranes. Only randomized trials with a placebo control group were included. RESULTS: Seven studies were found. Use of antibiotics decreased the risk of all infectious outcomes reported. When the results of 4 studies were pooled, prophylactic antibiotic use was associated with a significant reduction in postoperative fever (relative risk, 0.25; 95% confidence interval, 0.14-0.44). A similar reduction was noted for endometritis in 4 studies (relative risk, 0.05; 95% confidence interval, 0.01-0.38). Two studies reported on wound infection and showed a trend toward a protective effect (relative risk, 0.59; 95% confidence interval, 0.24-1.45). CONCLUSION: The prophylactic use of antibiotics reduces the risk of postoperative infectious complications after cesarean delivery even in the population at lowest risk.

Impact of hormone replacement therapy on the body mass and fat compositions of menopausal women: a cross-sectional study.

OBJECTIVE: The purpose of the study was to compare the body mass and fat compositions of menopausal women who were taking conventional doses of hormone replacement therapy (HRT) with that of menopausal women who were not taking any hormones. DESIGN: The body fat composition of 169 healthy postmenopausal women was measured using a noninvasive handheld machine, the Electrolipograph (BioAnalogics ELG, Beaverton, OR, USA). Impedance to electrical flow in tissues is lower with increasing water content of the tissue. Information on HRT, lifestyle, diet, smoking, and alcohol was obtained from the medical record and by a telephone interview before women were invited to participate. HRT and non-HRT groups were compared. Multivariate linear regression, which included age, years since menopause, type of menopause, and use of HRT, was performed for each of the two major outcomes: body mass index (BMI) and percentage of body fat. RESULTS: Comparisons between subgroups showed a large number of significant differences reflecting differences in age since menopause, baseline BMIs, and baseline waist to hip ratios. In the regression model, however, the only factor significantly associated with lower fat and BMI was the use of HRT. Women who were taking HRT had significantly lower percentages of body fat (-4.8%; p < 0.001) and BMI (-2.6 kg/m2; p < 0.001) compared with nonusers. Age and duration and type of menopause were not significant predictors of weight and BMI in this group of postmenopausal women. CONCLUSIONS: In this study, HRT seems to be associated with a significant reduction in postmenopausal weight and fat mass gains. This may be an important mechanism by which HRT exerts its beneficial long-term effects on cardiovascular health.

Impact of gestational age at delivery of the economics of triplet pregnancy.

OBJECTIVE: To establish the charges associated with triplet pregnancies managed at a single tertiary center, over a 5-year time period, and to evaluate the impact of prematurity on these charges. METHODS: All triplet pregnancies that reached at least 20 weeks gestation and received prenatal and neonatal care at our center from 1992 to 1996 were included. Charges for these mothers and neonates were extracted from two separate hospital billing computer systems, encompassing all inpatient, outpatient, technical, and professional charges. Linear regression was used to evaluate the relationship between gestational age at delivery and total charges. RESULTS: Fifty-five triplet pregnancies were included, resulting in the admission of 149 liveborn neonates. The median gestational age at delivery was 32.1 weeks. The mean charges per triplet mother were: $6,899 (professional), $3,959 (hospital outpatient), and $32,686 (hospital inpatient). The mean charges per neonatal sibling set were: $20,107 (professional) and $124,163 (hospital inpatient). The mean charges per complete triplet pregnancy was $187,814 (maternal plus neonatal). There was a significant inverse relationship between gestational age at delivery and total charges per triplet family, with a decrease of $16,584 for each additional gestational week reached (P = 0.006). CONCLUSIONS: Triplet pregnancy charges averaged almost $190,000 each, which does not include charges associated with assisted reproductive technologies. These charges are almost all related to the expense of prolonged neonatal intensive care, and are significantly related to the gestational age at delivery. Efforts at containing these costs should focus on reducing the incidence of multiple gestation and preventing prematurity.

Myomectomy fever: testing the dogma.

OBJECTIVE: To test the hypothesis that elevated temperature is more common after abdominal myomectomy than after hysterectomy. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): One hundred one women who underwent abdominal myomectomy and 160 women who underwent total abdominal hysterectomy for benign disease from 1988-1993. INTERVENTION(S): Abdominal myomectomy. MAIN OUTCOME MEASURE(S): Temperature of > or = 38.5 degrees C within 48 hours after operation. RESULT(S): Although univariate analysis showed that the incidence of elevated temperature was slightly greater among patients who underwent myomectomy (33% versus 26%, relative risk 1.29, 95% confidence interval 0.88-1.90), multivariate logistic regression analysis showed a 3.29 relative risk of elevated temperature (95% confidence interval 1.56-6.96) with myomectomy after controlling for age, parity, estimated blood loss, and treatment by the general gynecology service. CONCLUSION(S): After controlling for confounders, myomectomy was found to be an independent predictor for fever in the first 48 hours after operation.

Neonatal morbidity and mortality associated with triplet pregnancy.

OBJECTIVE: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time. METHODS: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period. RESULTS: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [CI] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins. CONCLUSION: When stratified by gestational age, triplet neonates delivered at 24-34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.