Maternal birth weight and cesarean delivery in four race-ethnic groups.

OBJECTIVE: We hypothesized that maternal birth weight was associated with the risk of cesarean delivery for nulliparous women. STUDY DESIGN: In a population-based cohort study, maternal birth data were linked to a Washington State database, including the birth certificates of 18,905 first-born singleton infants (1987-1995). RESULTS: Among non-Hispanic white subjects, maternal birth weight of 2500 to 3999 g was associated with a 20.9% risk of cesarean delivery, which was the lowest risk, compared with 24.5% for a maternal birth weight <2500 g (P <.05) and 24.0% for a maternal birth weight > or =4000 g (P <.05). Similar patterns of risk were noted among Hispanic and Native American subjects, although the associations did not reach statistical significance. Risk of cesarean delivery was not associated with maternal birth weight among African American subjects. Among non-Hispanic white subjects, the risk of cesarean delivery was 3.23 times greater with a maternal birth weight <2500 g and an infant birth weight > or =4000 g compared with pregnancies with both maternal and infant birth weights between 2500 and 3999 g (P <. 001). Adjustment for socioeconomic factors did not alter these results. CONCLUSION: Low and high maternal birth weights exert an intergenerational risk of cesarean delivery in nulliparous non-Hispanic white women.

Is color Doppler ultrasound useful in diagnosing ovarian cancer?

In summary, the emergence of CDUS presented an interesting new technical approach to the study of neovascularization in ovarian cancers. Techniques for CDUS are technically difficult and plagued with artifacts making correct interpretation difficult. Measures of blood flow (such as the resistive index) overlap significantly between ovarian cancers and benign ovarian tumors. Wide differences in estimates of the sensitivity and specificity of CDUS have been published, and fundamental norms such as resistive index also vary greatly among studies. Explanations for these differences are lacking. Most studies were performed in academic centers with referrals of high risk patients. This limits the ability to generalize results to the community. Data are insufficient to include CDUS in diagnostic protocols for ovarian cancer.

Evaluation of a public-private certified nurse-midwife maternity program for indigent women.

OBJECTIVES: This study assessed the impact of a public-private certified nurse-midwife program on prenatal and delivery outcomes among medically indigent women. METHODS: A population-based quasi-experimental design was used to compare 1 intervention county with 2 nonintervention counties. RESULTS: The program significantly reduced the number of women who received no prenatal care and the risk of acquiring less than adequate prenatal care. Reductions in the proportion of infants born premature or with low birth-weights were of borderline significance. The use of induction and/or stimulation of labor was statistically elevated. CONCLUSIONS: These results suggest that the intervention program was instrumental in reducing some, but not all, negative prenatal and delivery outcomes.

Overexpression and relationships of HER-2/neu, epidermal growth factor receptor, p53, Ki-67, and tumor necrosis factor alpha in epithelial ovarian cancer.

OBJECTIVE: To determine the frequency and possible relationships of overexpression of oncogenes, cytokines, and cellular proliferation proteins in ovarian cancer. METHODS: Sixty-four epithelial ovarian cancer specimens were obtained from the GOG tumor bank. Using immunocytochemistry, tumors were stained for overexpression of HER-2/neu, epidermal growth factor receptor (EGFR), p53, tumor necrosis factor alpha (TNF alpha), and Ki-67 (a marker of cellular proliferation). RESULTS: Twenty-one tumors were Stage I/II and 43 were Stage III/IV. HER-2/neu was overexpressed in 7 cases (11%), EGFR in 12 cases (19%), and p53 in 32 cases (50%). Ki-67 was expressed in all but one case, and high indices (expression in over 50% of cells) were seen in 18 cases (28%). TNF alpha was expressed in all but one case. Comparison between Stage I/II and Stage III/IV cases revealed no difference in the expression of these oncoproteins. Comparison by histologic grade also revealed no difference in the expression of the oncoproteins, except for EGFR, which was overexpressed only in Grade 3 tumors (p = 0.01). Comparison between tumors that did or did not overexpress p53 revealed insignificant differences in the expression of HER-2/neu, EGFR and TNF alpha. In addition there were no differences with respect to stage, grade, or histology when tumors where analyzed with respect to p53 overexpression. There was a trend towards an association between p53 overexpression and high levels of Ki-67 (p = 0.10). Comparison of tumors with high Ki-67 indices to those with lower indices also revealed no association with the expression of HER-2/neu, or EGFR, and there were no differences in stage or grade distribution. CONCLUSION: Ki-67 and p53 were frequently overexpressed in this representative sample of ovarian cancers from the GOG tumor bank; however, their expression was not associated with stage, grade, histology, or overexpression of other oncoproteins. Lack of a recognizable pattern of oncogene overexpression emphasizes the underlying biologic complexity of ovarian cancer.

StORQS: Washington's Statewide Obstetrical Review and Quality System: overview and provider evaluation.

The Foundation for Health Care Quality (Washington) used three administrative public databases and indicators recommended by the Joint Commission and the American College of Obstetrics and Gynecology to build algorithms to measure quality of obstetric care in the state of Washington. Analyses demonstrated a high degree of variability across hospitals for major processes of care such as cesarean section, vaginal birth after cesarean section, and forceps deliveries. Eighty-five percent of the participating hospitals concluded that important aspects of care were being measured. Ninety-four percent found the information useful in describing their performance compared with other hospitals. Sixty-two percent believed the information was useful for initiating quality improvement projects. Of the 25 indicators tested in the project, indicators rated as most useful were the same 10 obstetric indicators chosen by the Joint Commission after alpha testing.

Amyl nitrite: use as a smooth muscle relaxant in difficult preterm cesarean section.

Amyl nitrite is a smooth muscle relaxant that has been used clinically to facilitate uterine relaxation in difficult deliveries. In this retrospective study, we evaluate the safety of amyl nitrite use during preterm cesarean deliveries, and we assess possible advantageous effects on surgical incision choice. Women who received amyl nitrite cesarean section were compared to a control group matched for gestational age, fetal presentation, and mode of delivery who did not receive amyl nitrite. There were no statistical differences between the groups in the independent variables (maternal age, parity, medical or obstetric history, type of anesthesia, anesthesia or obstetric attending physician, antepartum hematocrit, or neonatal weight). Outcome (dependent) variables (estimated blood loss, Apgar scores, postpartum hematocrit, cord gases, or postpartum complications) were assessed, and there were no significant differences between the groups. Low transverse cesarean section was performed more frequently in the amyl nitrite group (58 of 64) than in the comparison group (48 of 64) (p less than 0.03). Considering the 128 women with and without amyl nitrite together, the decrease in hematocrit observed postpartum was greater after classic section (7%) than after low transverse section (4%) (p less than 0.002). We conclude that the use of amyl nitrite during preterm cesarean section poses no threat to mother or fetus and may facilitate delivery by allowing the performance of a low transverse rather than a classic cesarean section without maternal or neonatal complications.

Tubal sterilization and risk of subsequent hospital admission for menstrual disorders.

OBJECTIVE: Our objective was to investigate tubal sterilization and subsequent hospitalization for menstrual disorders. STUDY DESIGN: Automated discharge data were used in a population-based cohort study of 7253 women aged 20 to 49 years with tubal sterilization (1968 through 1983) at Group Health Cooperative of Puget Sound. Comparisons were with an age-matched cohort of 25,448 nonsterilized women and a nonmatched cohort of 5283 spouses of men with vasectomies. RESULTS: In the sterilization cohort, 282 had hospitalization for menstrual disorders (curettage, n = 191; hysterectomy, n = 66; nonsurgical, n = 25). Risk of hospitalization for menstrual disorders was 2.4 times greater after tubal sterilization (95% confidence interval 2.0 to 2.9). This risk was 6.1 times greater for sterilized women aged 20 to 24 years (95% confidence interval 0.72 to 3.2). Compared with the risk for nonsterilized women whose spouses had a vasectomy, the risk was 1.6 times greater (95% confidence interval 1.3 to 2.1). Hospitalization for menstrual disorders was not more common after unipolar sterilization than after other methods, as might have been expected if the menstrual disorder was related to impaired uteroovarian circulation. CONCLUSIONS: Tubal sterilization is associated with a greater risk of hospitalization for menstrual disorders. A biologic association is not supported by these results.

PIP: This study investigated tubal sterilization and subsequent hospitalization for menstrual disorders. Automated discharge data were used in a population-based cohort study of 7253 women aged 20-49 years with tubal sterilization (1968-83) at Group Health Cooperative of Puget Sound. Comparisons were with an age-matched cohort of 25,448 nonsterilized women and a nonmatched cohort of 5283 spouses of men with vasectomies. In the sterilization cohort, 282 were hospitalized for menstrual disorders (curettage, n=191: hysterectomy, n=66; nonsurgical, n=25). Risk of hospitalization for menstrual disorders was 2.4 times greater after tubal sterilization (95% confidence interval 2.0-2.9), a risk 6 times greater for sterilized women aged 20-24 years (95% confidence interval 0.72-3.2). Compared with the risk for nonsterilized women whose husbands had a vasectomy, the risk was 1.6 times greater (95% confidence interval 1.3-2.1). Hospitalization for menstrual disorders was not more common after unipolar sterilization than after other methods, as might have been expected if the menstrual disorder was related to impaired utero-ovarian circulation. Tubal sterilization is associated with a greater risk of hospitalization for menstrual disorders. A biologic association is not supported by these results.

Identification of neurodevelopmental abnormality at four and eight months by the movement assessment of infants.

The predictive validity of infant neuromotor evaluation by the Movement Assessment of Infants (MAI) was investigated in low-birthweight infants. Motor performance at four and eight months was examined in relation to neurodevelopmental outcome at 18 months of age. Correlations were equally strong between total MAI risk scores at four and eight months and performance on the Bayley Scales. Muscle tone observations were more discriminating at four months, and automatic reactions and volitional movement were most predictive at eight months. The MAI was highly sensitive to neurodevelopmental abnormality at four and eight months and more sensitive than the Bayley Motor Scale; both assessment tools had lower specificity at eight months. The high false-positive rate is attributed to transient neuromotor abnormalities and immaturity of motor function in low-birthweight infants with normal outcome.

Tubal sterilization and the long-term risk of hysterectomy.

To assess the effect of tubal sterilization on the risk of hysterectomy, we studied 7414 women aged 20 to 49 years who had had a tubal sterilization at a health maintenance organization between January 1, 1968, and December 31, 1983. Compared with a population-based cohort of nonsterilized women, women sterilized while 20 to 29 years old were 3.4 times more likely to have had a subsequent hysterectomy (95% confidence interval, 2.4 to 4.7). Adjustment for the effects of potential confounders with a subset of 276 women did not appreciably alter this association. For multivariate comparisons with 5323 wives of vasectomized men, there was no significant elevation in the risk of hysterectomy following sterilization among women sterilized while 20 to 29 years old. Tubal sterilization was not associated with hysterectomy for married women who underwent tubal sterilization at age 30 or older. These results do not support a biological basis for the relationship between tubal sterilization and hysterectomy.

Supraumbilical upper abdominal midline incision for pelvic surgery in the morbidly obese patient.

An upper abdominal midline incision was used for pelvic surgery in 16 morbidly obese patients (229-401 lb). When this approach is used, a Bookwalter retractor displaces the incision inferiorly and compresses the abdominal wall over the pelvis, and is then secured to the operating-room table. This approach provides adequate exposure of the pelvic organs and avoids an incision in the panniculus with its associated complications. No wound infections, postoperative dehiscences, or other serious postoperative morbidity occurred in these patients.

Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants.

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Papanicolaou smear screening interval and risk of cervical cancer.

The efficacy of Papanicolaou smear screening intervals of longer than 1 year is uncertain. Ninety-two symptomatic cases of invasive cervical cancer diagnosed between 1978-1983 in western Washington were identified with a population-based tumor registry. Using a random-digit-dialing technique, 178 controls from the same geographic area were selected. A structured telephone interview was used to ascertain screening history and risk factors for cervical cancer. The mean interval between papanicolaou smears in the 10 years preceding diagnosis (cases) or the reference date (controls) was calculated. The risk of squamous cell cervical cancer was increased 3.9 times (95% confidence interval 1.2-12.3) for women with Papanicolaou smears at 3-year intervals compared with women with annual screening. For women who had not had a Papanicolaou smear in the preceding 10 years, this risk increased 12.3 times (95% confidence interval 2.5-60.6). For screening intervals of 2 years, the risk of cervical cancer (all cell types) was not increased (relative risk 1.01; 95% confidence interval 0.43-2.37). The presence of well-known risk factors for cervical cancer did not modify these results. These data suggest an increasing risk of cervical cancer if Papanicolaou smear screening intervals exceed 2 years.

Fetal monitoring and predictions by clinicians: observations during a randomized clinical trial in very low birth weight infants.

Predictions about perinatal outcome in very low birth weight infants were studied in a randomized clinical trial of electronic fetal monitoring and periodic auscultation to assess the effect of diagnostic monitoring information on clinicians' ability to predict perinatal outcomes. The only predictions consistently correct before monitoring information was available were those regarding infant survival (88% correct, kappa [kappa] = 0.40, P less than .001 for the electronic fetal monitoring group; 80% correct, kappa = 0.35, P less than .01 for the periodic auscultation group). After monitoring, predictions of 5-minute Apgar scores and arterial cord pH were significantly more accurate, and clinicians' confidence in their predictions increased significantly in both the electronic fetal monitoring and the auscultation groups. Predictions of 5-minute Apgar scores were significantly more accurate in the electronic fetal monitoring group (92% correct, kappa = 0.80) than in the periodic auscultation group (61% correct, kappa = 0.28) (Z difference = 3.04; P less than .01). We conclude that clinicians gain information during intrapartum monitoring that generally leads to improved predictions and increased confidence in predictions. In this study, they made more accurate predictions about 5-minute Apgar scores with electronic fetal monitoring, suggesting that electronic fetal monitoring may provide better information about neonatal well-being than does periodic auscultation. Improved information, as measured by clinical predictions, is probably highly valued by patients and clinicians and may be an important determinant of acceptance of this diagnostic technology.

Quantitation of photic driving in dementia with normal EEG.

The EEG is frequently normal when early dementia is clinically suspected. The presence or absence of occipital driving with intermittent photic stimulation is not helpful in detecting cerebral pathology, but quantitation of photic driving was shown to distinguish between dementia and depression in geriatric patients. We quantified photic driving in twenty clinically demented patients without diffuse or focal EEG abnormality, and compared this in 20 age-matched normal controls. Intermittent stimulation at odd-numbered frequencies between 1 and 31 Hz was carried out. The product of frequency of stimulation and duration of driving response was determined, and the incidence of absent, subharmonic and supraharmonic photic driving was determined. The quantitative measure of frequency times following duration was significantly greater in the nondemented individuals than in demented patients with normal EEGs. More nondemented individuals demonstrated supraharmonic and subharmonic responses than did demented patients. The range of normal variability in persistence, duration, and symmetry of photic driving is great, and caution in determining abnormality on this basis is appropriate. Subtle but measurable changes in photic driving may occur early in dementing illnesses, however.

A case-control study of diet and invasive cervical cancer.

A population-based case-control study was conducted to assess the relation of diet, especially intake of vitamins A, C and E and of folic acid, to the risk of invasive cervical cancer. Cases were 189 women diagnosed with cervical carcinoma between 1979 and 1983 in 3 counties of the Seattle area. Controls (N = 227) were selected through random digit dialling. Diet during the year preceding diagnosis was assessed by interview, using a food frequency questionnaire covering the intake of 66 food items. After adjustment for known risk factors, frequent consumption of dark green or yellow vegetables and of fruit juices was related to a reduced risk of cervical cancer. Similarly, high dietary intake of carotene was associated with a lower risk of the disease, especially of the squamous-cell type. There was an inverse relationship between vitamin C intake and the risk of cervical carcinoma. The adjusted relative risk (RR) was 0.5 (95% confidence interval: 0.2-1.0) for the highest quartile of intake compared to a RR of 1.0 for the first quartile. High vitamin E intake was also related to a reduced risk, the risk for women in the highest quartile being only one-third of the risk for those in the first quartile. Intake of pre-formed vitamin A and of folic acid was not related to the risk of cervix cancer. Thus, our study suggests that the risk of invasive cervical carcinoma might be influenced by some aspects of diet.

A randomized trial of electronic fetal monitoring in preterm labor: mothers' views.

To determine if perceptions of preterm labor and birth differed between women who were monitored by electronic fetal monitoring (EFM) or by periodic auscultation, 135 subjects were randomly assigned to one of two treatment groups on admission to a tertiary perinatal care setting. The first group received external monitoring by continuous Doppler and tocodynamometer when membranes were intact, and with an internal fetal scalp electrode and pressure catheter once membranes were ruptured. The second group received periodic monitoring with a DeLee fetoscope or amplified Doppler. All women were cared for on a one-to-one basis by expert study nurses. Subjects completed a questionnaire about their labor experience during their postpartum hospital stay. There was no statistically significant difference between the two groups on the study measures [T2(7,81) = 13.65; F = 1.82; P greater than 0.05]. Forty-four percent of the variance in women's global evaluation of labor was explained by their perceptions of nursing support. These findings suggest that mothers' perceptions of their preterm labor are less influenced by the technologic interventions used than by the supportive care received from nurses.

Predictive value of electroencephalography for electroconvulsive therapy.

The EEG has been a widely-used screening procedure before ECT. Previous studies have correlated seizures and post-ECT slowing with ECT efficacy. We investigated the utility of pre-ECT EEG in predicting therapeutic response and post-ECT confusion. EEGs were normal in 54 of 100 patients undergoing first courses of ECT for refractory depression. Patterns within the normal range, were present in 26/100 while 2/100 had paroxysmal discharges without clinical evidence of epilepsy. Focal and generalized EEG slowing were each present in 9/100 records. Full recovery occurred after ECT in 66.6 per cent of those with normal pre-ECT records, 61.5 per cent with borderline EEGs, 55.5 per cent of patients with diffuse EEG slowing, and 22.2 of cases with focal slow waves. Of those with EEG slowing 22.2 percent had little or no response to ECT as compared to 19.2 per cent with EEGs within normal limits and 9.3 per cent with normal EEGs. Four of 6 patients with prolonged confusion had normal EEGs, while 1 each had focal and generalized slowing. EEG slowing was related to incomplete ECT response, but not to therapeutic failure or post-ECT confusion. The limited predictive power of pre-ECT EEG may reflect the prevalence of normal or nonspecifically abnormal EEGs in psychiatric patients and the general efficacy of ECT. Other neurophysiologic methods may yield more definitive information about the mechanism and use of ECT.

EEG evidence of epileptiform paroxysms in rapid cycling bipolar patients.

Electroencephalographic (EEG) abnormalities have been described in patients with mood disorders. In an effort to determine if rapid cycling bipolar affective disorder patients may demonstrate more prevalent EEG paroxysmal activity than patients with non-rapid cycling mood disorders, we studied five consecutively identified bipolar patients who cycled at least four times a year. They were compared with 25 consecutive affective disorder patients who received an EEG before electroconvulsive therapy. Three of the five rapid cycling patients had bitemporal paroxysmal sharp waves as demonstrated by EEG but no psychomotor evidence of epilepsy. None of the 25 comparison patients had EEG abnormalities. Four of the five rapid cyclers reported a family history of affective disorder, including the three who had paroxysms.