Preventive health care for adults with HIV infection.

OBJECTIVE: To assess the level of evidence for preventive health interventions for adults with human immunodeficiency virus (HIV) infection. DATA SOURCES: A MEDLINE literature search for each intervention, supplemented by reviewing conference proceedings and the recommendations of experts. STUDY SELECTION: English-language studies of interventions that contribute to one of the following goals were reviewed: (1) prevention of complications of HIV infection; (2) early detection of complications, before symptoms develop, at a stage in which early treatment could lead to improved outcome; (3) slowing of HIV disease progression; (4) reduction in the risk of transmission of infectious agents, such as HIV itself; and (5) prevention of psychological distress and improvement in the quality of life. DATA EXTRACTION: The importance of interventions and quality of supporting evidence were evaluated using criteria modified from the US Preventive Services Task Force. DATA SYNTHESIS: Existing evidence strongly supports the efficacy of some preventive measures: primary and secondary Pneumocystis carinii pneumonia prophylaxis; secondary prophylaxis of Cryptococcus, Toxoplasma, and cytomegalovirus infections; tuberculin testing, with chemotherapy for individuals with positive test results; syphilis screening; Papanicolaou tests; educational measures to reduce the transmission of HIV and other infections; T-lymphocyte monitoring; and antiretroviral therapy in selected patients. Recommended measures of possible, but less certain, effectiveness include vaccines to prevent influenza, Haemophilus influenzae, pneumococcal, and hepatitis B infections; prophylaxis for recurrent esophageal and vaginal candidiasis; primary prophylaxis of Mycobacterium avium complex; tuberculosis prophylaxis for anergic, high-risk individuals; routine physical examination; screening for gonorrhea and Chlamydia in high-risk women; monitoring Toxoplasma titers, complete blood cell counts, and serum chemistry values; attempting to maintain weight through nutritional interventions; and exercise. Mental health and substance abuse interventions are probably very important, but documentation of their benefits is limited. Some measures require further study before they can routinely be recommended, including vitamin and mineral supplementation; specific nutritional diets; and laboratory tests, other than CD4 counts, for monitoring disease progression. CONCLUSIONS: Persons with HIV infection have different stage-specific health maintenance needs that form an important part of comprehensive care for people in all stages of infection.

Cancer-related maternal mortality in Massachusetts, 1954-1985.

Cancer-related maternal mortality is a rare event. We report the first population-based study of this issue using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The incidence of cancer-related maternal mortality during the study period fell from 3.16 to 0 per 100,000 live births. The most common cancer-associated maternal deaths were due to central nervous system tumors and hematological cancers. To determine the effects of pregnancy on cancer mortality, we compared our data with figures from the Connecticut Register of Mortality for Women aged 15-44. In the pregnant group there was a significantly higher incidence of mortality due to central nervous system tumors and a significantly lower incidence of mortality due to breast cancer. The data suggest that pregnancy may not be contraindicated for a woman with a history of breast cancer, but may be contraindicated for a woman with a history of a central nervous system tumor.

Anesthetic-related maternal mortality, 1954 to 1985.

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Maternal mortality in the United States: report from the Maternal Mortality Collaborative.

To better define the incidence, causes, and risk factors associated with maternal deaths, the Maternal Mortality Collaborative in 1983 initiated national voluntary surveillance of maternal mortality. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 37% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Older women and women of black and other races continued to have higher mortality than younger women and white women. The five most common causes of death for all reported cases were embolism, nonobstetric injuries, hypertensive disease of pregnancy, ectopic pregnancy, and obstetric hemorrhage. Compared with national maternal mortality for 1974-1978, ratios were lower for all causes except for indirect causes, anesthesia, and cerebrovascular accidents. Fatal injuries among pregnant women are not commonly reported to maternal mortality committees. As maternal mortality from direct obstetric causes continues to decline, clinicians will need to emphasize preventing deaths from nonobstetric causes.

Hemorrhage, infection, toxemia, and cardiac disease, 1954-85: causes for their declining role in maternal mortality.

Hemorrhage, infection, toxemia, and cardiac disease are no longer the leading causes of maternal death. We studied factors causing their decline in incidence using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The dramatic decline in incidence of these conditions in the Commonwealth during the study period appears to have been due to both legislative actions and improvements in medical practice. The legislative actions included licensing of maternity services, blood banks, and legalization of abortion. Cardiac-related mortality has declined due to a reduction in the prevalence of rheumatic heart disease. Changes in clinical practice that stand out were the aggressive control of the hypertensive component of toxemia leading to a reduced incidence of intracranial hemorrhage, the prompt recourse to blood transfusion for hemorrhage, and the use of broad spectrum antibiotics.

Cesarean section-related maternal mortality in Massachusetts, 1954-1985.

We analyzed the data of the Maternal Mortality Committee of the Massachusetts Medical Society to investigate cesarean section-associated maternal deaths. Between 1954-1985, the number of cesarean section-related deaths per 100,000 live births did not significantly change despite a quadrupling of the cesarean section rate. Between 1976-1984, there were 649,375 births and 121,217 cesarean sections in the state. Seven deaths were directly related to cesarean section, a rate of 5.8 per 100,000 cesarean sections. In contrast, the rate for vaginal deliveries was 10.8 per 100,000 vaginal deliveries. We conclude that the risk of maternal death from cesarean section is low.

Maternal mortality in Massachusetts. Trends and prevention.

To identify ways in which the safety of childbirth might be increased, we investigated the causes of death among the 886 women who died during pregnancy or within 90 days post partum ("maternal deaths") in Massachusetts from 1954 through 1985. The maternal mortality rate declined from 50 per 100,000 live births in the early 1950s to the current rate of 10 per 100,000 live births. Between one third and one half of the maternal deaths were considered to have been preventable. The leading causes of maternal death from 1954 through 1957 were infection, cardiac disease, pregnancy-induced hypertension, and hemorrhage. In contrast, from 1982 through 1985 the leading causes of death were trauma (suicide, homicide, and motor vehicle accidents) and pulmonary embolus. We observed a rapid increase in the frequency of death among women who received little or no antenatal care. From 1980 through 1984 the maternal mortality rate for white women was 9.6 per 100,000 live births, whereas for nonwhites it was 35 per 100,000 live births (relative risk, 2.9; 95 percent confidence limits, 2.5 and 3.2). Fifty percent of the nonwhite women who died during pregnancy or within 90 days post partum received little or no antenatal care, in contrast to only 15 percent of the white women. These data show that the leading causes of maternal death have changed markedly in Massachusetts during the past 30 years. Although the overall maternal mortality rate has declined sharply, further improvement may occur with better antenatal care and specific efforts to prevent trauma and pulmonary embolus.

Reproductive mortality in Massachusetts in 1981.

PIP: This study analyzed reproductive deaths (all deaths from pregnancy-related causes, including abortion and ectopic pregnancy, as well as from causes related to contraception) among women 15-44 years of age in the state of Massachusetts in 1981. Of the 971 deaths recorded in this age group, 14 were classified as reproductive deaths, for an overall reproductive mortality rate of 1.8/10,000 live births (1/100,000 women). 10 of these deaths were pregnancy related, and 4 were due to pregnancy prevention (oral contraception). 4 of the pregnancy-related and 3 of the contraception-related deaths were considered preventable since they occurred in women in whom oral contraception (OC) had been contraindicated. The risks related to OC use were higher than those related to pregnancy for women over 35 years of age, suggesting that the reproductive mortality rate could be reduced by proscribing OC use in women in this age group, especially in women who smoke or have hypertension. It is concluded that the reproductive mortality rate is a better measure of the risk associated with reproduction that the maternal mortality rate, and it is recommended that committees on maternal mortality expand their surveillance to include deaths due to the side effects of contraception.^ieng

Pancreatic alpha cell response to alanine during and after normal and diabetic pregnancies.

Pancreatic alpha cell response to oral alanine was assessed in the third trimester of pregnancy and in the puerperium in 16 insulin-dependent diabetic and 7 normal pegnant women. Insulin response was also measured in the nondiabetic subjects. The nondiabetic subjects had higher basal glucagon and insulin levels as well as a greater response to oral alanine stimulation at 34 weeks' gestation than at 6 weeks post partum. In addition, basal levels of both hormones remained low at a time remote from pregnancy (9 months post partum), indicating both hyperinsulinemia and hyperglucagonemia in the postabsorptive state in normal human pregnancy. The secretory response of glucagon and insulin or oral alanine was blunted at 6 weeks post partum in the nondiabetic subjects. This suggests that the late puerperium may not be an appropriate "nonpregnant control period" for metabolic studies. During pregnancy, basal and stimulated glucagon levels were not significantly different in diabetic and normal women. Despite higher concentrations of blood glucose in diabetic women, basal and stimulated glucagon secretion was equivalent in the 2 groups. No pegnancy-induced increment in glucagon secretion was evident in insulin-treated diabetic subjects. Thus hyperglucagonemia does not contribute to the increased requirements for insulin during pregnancy in these women.