Prenatal three-dimensional ultrasound: perception of sonographers, sonologists and undergraduate students.

OBJECTIVE: To assess the perception of non-pregnant sonographers, sonologists and undergraduate students on the use of three-dimensional (3D) ultrasound technology in fetal medicine. METHODS: This was a study of two groups of non-pregnant subjects. Group I included 520 (305 female, 215 male) medical professionals who completed a questionnaire after attending a lecture on 3D imaging. Factors such as gender, career and having children were analyzed with respect to the attendee's responses about use of 3D ultrasound for medical purposes and for reassurance. Group II included 137 (75 female, 60 male, two unknown) undergraduate students from bioengineering, psychology and physiology classes who completed a questionnaire after attending a brief presentation on two-dimensional and 3D fetal imaging. Factors such as gender and area of educational interest were analyzed with respect to the students' responses about the use of 3D ultrasound for medical purposes and for parental-fetal attachment. RESULTS: In Group I, 63% said that they would like to have a 3D ultrasound examination in the future, while 14% said that they would not. Common reasons given for wanting a 3D ultrasound exam in the future were for medical purposes (39%) or reassurance (18%). The main differences perceived between two-dimensional (2D) and 3D ultrasound were medical advantages (65%) and parental reassurance (28%). 62.4% of Group I thought 3D technology should be in wide use in obstetric ultrasound and 73.6% thought that 3D ultrasound would reassure parents carrying normal fetuses. Gender, age and career did not have a significant influence on perception of 3D ultrasound. In Group II, the majority (91%) said they could see a remarkable difference between 2D and 3D ultrasound. 83% responded that they would like to have a 3D ultrasound examination of their own baby in the future for the following reasons: 34% for the detailed picture, 31% for increased abnormality detection, 13% for reassurance or curiosity; 8% thought it would be unnecessary or a negative experience. Concerning parental-fetal attachment, 72% thought 3D ultrasound would have a positive effect. The majority of Group II (93%) thought 3D ultrasound would be valuable and 56% thought 3D ultrasound would assist in diagnosing fetal abnormalities. There was no significant relationship between gender, age or area of interest and the perception of 3D ultrasound. CONCLUSIONS: Responses by sonographers and physicians suggest that 3D ultrasound will have a role in the future for medical indications and in reassuring patients carrying normal fetuses. Our results also suggest that undergraduate students believe that 3D ultrasound will be a valuable technique in obstetrics and that it will have a positive effect on parental-fetal attachment.

Effects of ultrasound on maternal-fetal bonding: a comparison of two- and three-dimensional imaging.

OBJECTIVES: The purpose of this study was to evaluate the effect of two-dimensional (2DUS) compared to three-dimensional ultrasound (3DUS) imaging on the maternal-fetal bonding process. METHODS: Fifty mothers who had 2DUS and 50 who had 2DUS and 3DUS were included in the study. A postpartum survey by telephone interview was carried out to assess maternal-fetal bonding. Bonding was evaluated by analysis of extent of prenatal image sharing, maternal ability to form a mental picture of the baby and mother's comments about their ultrasound images. Data were analyzed using the independent t-test, Chi-square and Mann-Whitney U-tests. RESULTS: Mothers who received 3DUS showed their ultrasound images to more people (median, 27.5; interquartile range, 14.5-40.0) than mothers receiving 2DUS alone (median, 11.0; interquartile range, 5.0-25.5) (P < 0.001, Z = -3.539). Eighty-two percent of the subjects screened with 3DUS had a greater tendency to form a mental picture of the baby postexamination compared to 39% of the 2DUS subjects (P < 0.001, Z = -3.614). Mothers receiving a 3DUS study were more likely to receive comments on the similarities/differences of the neonate compared to those having 2DUS studies. Furthermore, 70% of the mothers receiving 3DUS felt they 'knew' the baby immediately after birth vs. 56% of the mothers receiving 2DUS (P = 0.009, Z = -2.613). Both 2DUS and 3DUS experiences were positive, however, the comments made by the mothers undergoing 3DUS (n = 18) were more exclamatory (amazed, wonderful, fabulous) than those undergoing 2DUS (n = 4). Patients having a 3DUS examination consistently scored higher than those having a 2DUS examination alone for all categories of maternal-fetal bonding. CONCLUSION: 3DUS appears to more positively influence the perceptions of mothers to their babies postbirth compared to 2DUS. Specifically, mothers who had 3DUS showed their ultrasound images to a greater number of people compared to mothers who had 2DUS alone and this may represent mother's social support system. 3DUS may have a greater impact on the maternal-fetal bonding process.

The Prevalence of von Willebrand disease in women with abnormal uterine bleeding.

Although a common symptom of von Willebrand disease is menorrhagia or metrorrhagia, the prevalence of this inherited bleeding disorder in women with heavy bleeding is not known. This pilot study compared the prevalence rate of von Willebrand disease in women with dysfunctional uterine bleeding with the prevalence rate in the general population. On average, these women bled for 11.5 days per month and experienced heavy bleeding for >16 years. Over 60% had been treated previously for heavy bleeding. One woman was diagnosed with type 1 von Willebrand disease (5% prevalence rate). Larger studies are needed to confirm this increased rate of von Willebrand disease in women with abnormal uterine bleeding.

Feasibility of performing a virtual patient examination using three-dimensional ultrasonographic data acquired at remote locations.

OBJECTIVE: To evaluate the feasibility of performing three-dimensional ultrasonographic studies that meet American Institute of Ultrasound in Medicine and American College of Radiology ultrasonographic examination guidelines with review off-line and at remote locations. METHODS: One hundred patients were studied at 2 institutions using high-end two-dimensional clinical ultrasonographic scanners and commercially available three-dimensional ultrasonography for a variety of organ systems (first- and second-trimester fetus, abdomen, and female pelvis). We evaluated several parameters, including measurements, completeness of organ visualization, abnormalities identified, image quality, number of volumes required, and discrepancies between interpretations. RESULTS: Overall, three-dimensional ultrasonography could produce diagnostic-quality results comparable with those of two-dimensional ultrasonography. Three-dimensional ultrasonographic image quality was lower than that of two-dimensional ultrasonography. Two- and three-dimensional ultrasonographic measurements were comparable (<5% difference), as was the extent of organ visualization, although some structures were challenging for both two- and three-dimensional ultrasonography. In general, organs completely imaged in the scanner field of view required 1 to 1.5 volumes, whereas larger organs required between 3 and 6 volumes. Differences among reviewers' interpretations highlighted the need for standardization of acquisition and reviewing protocols for sonographers and physicians. CONCLUSIONS: Our results show that it is clinically feasible to acquire three-dimensional ultrasonographic data at one site and to obtain accurate interpretation by off-line review at another within the context of providing high-quality clinical diagnostic studies.

Reduction in fat intake is not associated with weight loss in most women after breast cancer diagnosis: evidence from a randomized controlled trial.

BACKGROUND: A reduction in dietary fat intake has been suggested as a method to promote weight loss in women at risk for breast cancer recurrence. METHODS: Weight change in response to diet intervention was examined in 1010 women who had completed treatment for Stage I, Stage II, or Stage IIIA (American Joint Committee on Cancer staging system) primary operable breast cancer during their first year of participation in a randomized, controlled, diet intervention trial to reduce risk of recurrence. Diet intervention was performed by telephone counseling and promoted a low fat diet that also was high in fiber, vegetables, and fruit. The comparison group was provided with general dietary guidelines to reduce disease risk. Multiple linear regression models were used to examine the relations among demographic and personal characteristics, changes in diet composition and exercise level, and change in body weight or body mass index. RESULTS: The average weight change in the 1-year period was 0.04 kg for the intervention group and 0.46 kg for the comparison group. For the total group, body weight was stable (+/- 5% baseline weight) for 743 women (74%), whereas 114 (11%) lost weight, and 153 (15%) gained weight. These distributions were similar in the two study groups inclusive of all study participants and for only those women with a baseline body mass index of > or = 25 kg/m2. Initial body mass index and changes in fiber and vegetable intakes, but not change in percent of energy obtained from fat, were associated independently with change in weight or body mass index. CONCLUSIONS: For most women at risk for breast cancer recurrence, diet intervention to promote a reduction in fat intake was not associated with significant weight loss. Testing the effect of a substantial change in diet composition on risk for breast cancer recurrence is unlikely to be confounded by weight loss in subjects who were the recipients of intensive intervention efforts.

Eating pathology and obesity in women at risk for breast cancer recurrence.

OBJECTIVE: This cross-sectional study investigated the relationship among obesity, depressive symptoms, eating attitudes and behaviors, and dietary intake. It compared women at risk for recurrence of breast cancer and women who had not been diagnosed with breast cancer and were recruited from the same community and age group (middle-aged and older). METHOD: Body mass index (BMI), dietary intake, self-reported depressive symptoms, and eating disorder psychopathology (assessed with the Eating Disorder Examination - Questionnaire [EDE-Q]) were examined in women who had been diagnosed with breast cancer (n = 56) and the comparison group of women with no breast cancer history (n = 52). Multivariate regression analysis was used to identify factors independently associated with global and subscale EDE-Q scores and BMI. RESULTS: BMI and depressive symptoms were significantly and independently associated with global and subscale EDE-Q scores in women at risk for breast cancer recurrence and women with no breast cancer history. Dietary restriction was also significantly associated with EDE-Q scores in the group with no breast cancer history. CONCLUSIONS: An association among obesity, depressive symptomatology, and abnormal eating attitudes and behavior may affect response to standard nutritional interventions in women at risk for breast cancer recurrence.

Reduced charges and costs associated with outpatient autologous stem cell transplantation.

High-dose chemotherapy and stem cell rescue is increasingly being delivered in the outpatient setting. Such intensive outpatient management programs have reduced the total hospital length of stay without compromising clinical outcomes. However, a detailed financial analysis of outpatient programs has not been performed. These data are the results of a prospective study of 94 patients receiving high-dose chemotherapy and autologous peripheral blood stem cell transplant in one of three settings: traditional inpatient, partial outpatient, total outpatient. Patients were allowed to choose their own treatment setting based upon the availability of a caregiver and personal preference. Total hospital length of stay and the actual cost and charges for each patient were monitored prospectively. The patients in the three groups were well balanced with regard to age and functional status prior to high-dose chemotherapy. The average length of stay was reduced from 17.3 to 8.2 to 2.7 days in the three different treatment settings (P < 0.01). Mean procedure costs were reduced from $39.7 thousand (US dollars) to $36.2 thousand to $29.4 thousand in the three treatment settings (P < 0.029). No differences in toxicity or overall response to therapy was noted. High-dose chemotherapy and stem cell rescue can be safely administered in the outpatient setting and results in significant cost savings.

Use of prenatal services by Hispanic women in San Diego County. A comparison of urban and rural settings.

The purpose of this study was to investigate patterns of prenatal care use among urban and rural Hispanic women in San Diego County, California. A cohort study of Hispanic women delivering at one of five San Diego County hospitals between July 1991 and January 1992 was conducted (N = 587). Data were collected by in-person interview and medical record abstraction. Logistic regression was used to identify variables associated with late entry into prenatal care, while simultaneously adjusting for important confounding variables. Three factors were found to be significantly associated with late entry into prenatal care. Women who resided in urban areas were two times more likely to enter prenatal care late as compared to women who lived in rural areas (odds ratio = 2.11; 95% confidence intervals (CI) = 1.12, 4.0). Women who reported not having initially "wanted" the pregnancy were 2.2 times more likely to enter prenatal care late (95% CI = 1.05, 4.59). The risk of entering prenatal care late increased by 20% for each additional barrier to care that was reported (95% CI = 1.09, 1.34). Results indicate that timely entry into prenatal care may be improved among San Diego Hispanic women by targeting specific barriers to prenatal care identified in this study and by providing greater family planning assistance to this population to decrease unwanted pregnancies.

Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women.

BACKGROUND: Among nulliparous women, there appears to be an association between the use of epidural analgesia during labor and an increased risk of dystocia. We tested the hypothesis that combined spinal-epidural analgesia, which permits ambulation during labor, is associated with a lower incidence of dystocia than continuous lumbar epidural analgesia. METHODS: Between July 1995 and September 1996, we randomly assigned 761 nulliparous women in spontaneous labor at term who requested epidural analgesia to receive either continuous lumbar epidural analgesia or a combination of spinal and epidural analgesia. Among the women who received combined spinal-epidural analgesia, some were discouraged from walking and others were encouraged to walk. Maternal and neonatal outcomes, the incidence of dystocia necessitating cesarean section, and measures of patients' satisfaction were compared in the two groups. RESULTS: There were no significant differences in the overall rate of cesarean section, the incidence of dystocia, the frequency of maternal or fetal complications, the patients' or nursing staff's assessment of the adequacy of analgesia, or the degree of overall satisfaction between the two groups. Significantly more women receiving combined spinal-epidural analgesia had pruritus (P<0.001) and requested additional epidural bolus doses of local anesthetic (P=0.01). For all the women, dystocia necessitating cesarean section was significantly more likely when analgesia was administered with the fetal vertex at a negative station (odds ratio, 2.5; P<0.001) or at less than 4 cm of cervical dilatation (odds ratio, 2.2; P<0.001). CONCLUSIONS: As compared with continuous lumbar epidural analgesia, the combination of spinal and epidural analgesia is not associated with an overall decrease in the incidence of cesarean delivery.

Placental cord insertion visualization with prenatal ultrasonography.

Color Doppler and gray scale sonography can be used prenatally to identify the location of the cord insertion into the placenta. The purposes of this paper were to (1) relate sonographic identification of placental cord insertion with placental pathology; (2) evaluate the possibility that a marginal cord insertion may evolve into a velamentous cord insertion; and (3) determine the frequency and factors affecting sonographic visualization of cord insertion. Our results show that the sonographic assessment of cord insertion correlated with the pathologic outcome in 83% (106 of 128) of singleton pregnancies and at least one of the fetuses in 72% (8 of 11) of twin or triplet pregnancies. Although the sensitivity for identification of an abnormal cord insertion was low (42%), the specificity was high (95%). Our data suggest that marginal cord insertion evolved into velamentous cord insertion in one singleton and one twin. Our results showed that cord insertion was visualized in 54% of fetuses scanned in a routine clinical practice. Cord insertion visualization was possible at all gestational ages, although it was more difficult at later gestational ages. In conclusion, this study provides evidence that (1) ultrasonography (either gray scale or color Doppler) is useful in identifying normal, marginal, and velamentous cord insertion; (2) marginal cord insertion may evolve into velamentous cord insertion as pregnancy progresses; (3) in clinical practice the cord insertion site was visualized in just over half of the cases, and (4) prenatal identification of marginal and velamentous cord insertion potentially may be useful for planning obstetrical management.

Short contact 70% glycolic acid peels as a treatment for photodamaged skin. A pilot study.

BACKGROUND: Glycolic acid has been one of the more commonly used alpha hydroxy acids for the treatment of photodamaged skin. Its value as a quick "skin refreshing" peeling agent has been widely touted. This type of peel differs from a conventional therapeutic peel (eg, phenol, trichloroacetic acid, or a longer time exposure alpha hydroxy acid peel) in that there is little skin reaction and patients can go about their daily routine without concern. OBJECTIVE: To assess the potential value of glycolic acid-based refresher peels as a cosmetic procedure. METHODS: Twelve healthy subjects with at least a moderate degree of photodamage were treated with monthly serial 70% glycolic acid peels over a period of 4 months. In addition to the "peels," six subjects were randomized to a 10% glycolic acid-based moisturizer twice daily. Patients were evaluated monthly and graded on a clinical scale using objective measures. RESULTS: No conclusive differences were noted on histologic evaluation. Ninety percent (9/10) of patients felt that overall they noticed significant improvement, however, there was no distinction between the two treatment options. The improvement in fine wrinkling and pigmentation was primarily seen in the patients who additionally received 10% glycolic emollient twice daily. CONCLUSION: In this limited pilot study, no specific benefit could be assigned to the concomitant use of monthly glycolic acid refresher "peels" in the treatment of photodamaged skin.

Practice styles. A comparison of obstetricians and nurse-midwives.

Iain Chalmers and the National Perinatal Epidemiology Unit, Oxford, England, developed a comprehensive listing of perinatal care procedures shown to reduce the frequency of adverse outcomes during pregnancy and childbirth. This list was used as a framework for a pilot study conducted in 1992 that reviewed similarities and differences in opinion and practice style between certified nurse-midwives (CNMs) and obstetrician/gynecologists. Twenty CNMs and 57 obstetrician/gynecologists who were active clinical practitioners in San Diego commented on 24 items drawn from Chalmers' work. The CNMs were more likely to favor the availability of social and psychological support variables and to use them in their practice. The groups were more alike than different in their views concerning preventive interventions during the prenatal period. CNMs were more likely to support the availability of alternatives to maternal positions for labor and birth, exhalatory breathing, and delayed pushing and less likely to support the availability of electronic fetal monitoring, epidural anesthesia, episiotomy, and active management of the third stage. A small sample size and limited response rate restricted interpretation and generalizability of these data. Nevertheless the data offer support for other studies with similar findings. They also suggest that health system administrators should inform women and families about differences in practice styles before families select from among the various insurance options that may, in the end, restrict the choice of provider or birth setting.

Evaluation of normal and abnormal lips in fetuses: comparison between three- and two-dimensional sonography.

OBJECTIVE: The purpose of this study was to determine if three-dimensional (3D) sonography could improve prenatal evaluation of fetal lips in comparison with conventional two-dimensional (2D) sonography. MATERIALS AND METHODS: Sixty-one high-risk pregnant women and 10 low-risk pregnant women were examined with conventional 2D sonography followed by 3D sonography with a volume transducer. The ability to visualize cleft lips and normal lips was compared between the two techniques. RESULTS: Of the 71 fetuses studied, faces were seen in 68 and not seen in three by either 2D or 3D sonography. Abnormal lips were seen in five fetuses on both 2D and 3D sonograms. Of the remaining fetuses, 3D sonography was able to confirm the presence of a normal lip in 92% (58/63) compared with 76% (48/63) with 2D sonography. In the subgroup of fetuses less than 24 weeks' estimated gestational age, 3D sonography confirmed a normal lip in 93% (38/41) of fetuses as compared with 68% (28/41) for 2D sonography. There was no difference between 3D and 2D in the subgroup of fetuses older than 24 weeks. One false-positive finding of cleft lip was observed at 36 weeks' gestational age with the rendered surface display on 3D sonography, whereas the 3D planar views of the same volume showed the lips to be normal. CONCLUSION: 3D sonography was able to confirm the presence of normal lips more frequently than did 2D sonography in fetuses less than 24 weeks' gestational age. Abnormal lips were seen on both 2D and 3D sonograms; however, 3D images of cleft lip were easier to understand for both the family and clinical colleagues.

Cigarette smoking and bone mineral density in older men and women.

OBJECTIVES: The association between cigarette smoking and bone mineral density was examined prospectively in a population-based study of older Caucasian men and women. METHODS: Smoking patterns were determined at a 1972-1974 baseline evaluation and, again, 16 years later when 544 men and 822 women had bone mineral density measurements taken. RESULTS: Men and women who were cigarette smokers at baseline demonstrated significantly reduced bone mineral density of the hip compared with nonsmokers. Baseline smoking was not associated with significantly lower bone density at non-hip sites. Women demonstrated a significant dose-response relationship between baseline smoking status at all hip sites measured. Both sexes exhibited significant dose-response relationships between hip bone mineral density and change in smoking status between baseline and follow-up, demonstrating that smoking cessation in later life was beneficial in halting bone density loss associated with smoking. CONCLUSIONS: Smoking was positively and significantly associated with decreased hip bone mineral density in old age. Bone loss associated with smoking would be expected to predict an increased risk of hip fracture in those who do not succumb earlier to another complication of tobacco use.

Induction of labor and risk of sudden infant death syndrome.

OBJECTIVE: To investigate whether induction of labor is related to the occurrence of sudden infant death syndrome (SIDS) using a population-based, case-control study. METHODS: Cases comprised infants born between 1984-1988 in Washington state who died of SIDS according to their death certificate (ICD-9-CM 798.0) (N = 728). For comparison, we randomly selected a group of infants born in these same years who did not die of SIDS (N = 3021). Information regarding the pregnancy, labor, delivery, and condition of the newborn was obtained from the infants' birth certificates. RESULTS: Among the indications for induction that were examined, we found a slightly elevated risk of SIDS associated with advanced gestational age (greater than 41 completed menstrual weeks) (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.0-1.8). A similar proportion of cases and controls had induced labors (OR 1.2, 95% CI 0.7-2.1). Although there was little or no apparent risk associated with induction among infants who had term gestations (37-41 completed menstrual weeks; OR 1.2, 95% CI 0.6-2.2), an increased risk was found among infants who had gestations of 42 weeks or greater (OR 3.0, 95% CI 0.7-12.5). We did not observe this trend with augmentation of labor. CONCLUSION: Our findings do not support an overall association between the methods used for induction of labor in the United States and the occurrence of SIDS. The elevated risk of SIDS observed in relation to induction of labor among infants who had post-term gestations raises the possibility that infants who do not spontaneously initiate labor may suffer some neuroregulatory or other abnormality involved in the pathogenesis of SIDS.

Pregnancy and lactation as determinants of bone mineral density in postmenopausal women.

The relation of pregnancy and breast feeding to bone mineral density of the wrist, radius, hip, and spine was examined in a white, upper middle-class, homogeneous sample of 741 postmenopausal women ranging in age from 60 to 89 years. Number of pregnancies ranged from 0 to 14, with a mean of 2.0 pregnancies and 1.5 live births. Almost two thirds of the women who had had a live birth reported breast feeding. Unadjusted comparisons indicated that bone mineral density of the wrist, radius, and hip increased with increasing numbers of pregnancies, and women who had breast-fed had higher bone mineral densities at these sites. However, after adjustment for age or age and body mass index, these associations were no longer significant. Multiple regression analyses adjusted for age, age at menopause, obesity, cigarette smoking, and estrogen and thiazide use also indicated that number of pregnancies and breast feeding were not significantly associated with bone mineral density at any of the four sites measured. Results of the present study suggest that reproductive history and breast feeding are not long-term determinants of bone mineral density.

Glaucoma screening in primary care: the role of noncontact tonometry.

BACKGROUND: Guidelines for glaucoma screening by the primary care physician have not been firmly established. Despite its limitations as a screening test, intraocular pressure measurement by tonometry remains the mainstay of glaucoma monitoring but is not widely used in the primary care setting. The purpose of this study was to compare the effectiveness of noncontact tonometry using the Pulsair instrument with that of conventional tonometry using the Goldmann applanation tonometer as a screening tool for glaucoma. METHODS: Intraocular pressure was measured by non-contact and Goldmann applanation tonometry in both eyes of 50 volunteers who enrolled in a glaucoma screening program at a primary care clinic. RESULTS: Noncontact tonometry correctly identified over 90% of the patients with intraocular pressures greater than 22 mm Hg. CONCLUSIONS: Noncontact tonometry is an easy, practical, and well-tolerated method of intraocular pressure measurement. When combined with direct ophthalmoscopy, noncontact tonometry can easily be used in routine primary care health examinations to detect glaucoma.

Transcervical chorionic villus sampling and midtrimester oligohydramnios.

To study the possible association between transcervical chorionic villus sampling and midtrimester oligohydramnios, we conducted a prospective cohort study of all women who were seen for genetic counseling in the first trimester during a 2-year period. Women who chose chorionic villus sampling were compared with women who chose traditional amniocentesis for incidence of midtrimester oligohydramnios. Of 442 women exposed to chorionic villus sampling with a normal fetal karyotype, severe oligohydramnios developed in 12 (2.7%) at 16 to 23 weeks' gestation. None of the 391 women with normal fetal karyotypes who were counseled at the same time in pregnancy but who chose amniocentesis had oligohydramnios at the time of amniocentesis (p = 0.01). A nested case-control analysis was performed within the chorionic villus sampling group to evaluate risk factors associated with midtrimester oligohydramnios. Midtrimester oligohydramnios occurring after chorionic villus sampling was associated with postprocedure bleeding and elevated maternal serum alpha-fetoprotein (p less than 0.01). There were no perinatal survivors with midtrimester oligohydramnios.

Maternal smoking and placenta previa.

We conducted a case-control study of the relation between smoking and placenta previa, using Washington State birth certificate data from 1984 through 1987. The study population was comprised of live, singleton births to women whose pregnancies were complicated by placenta previa (N = 598) and randomly selected controls (N = 2,422) from the same time period. We used logistic regression to estimate odds ratios (OR) and their 95% confidence intervals (CI). Maternal smoking approximately doubled the risk of placenta previa after adjustment for the confounding effect of maternal age (OR = 2.1, 95% CI: 1.7-2.5).