The relationship between alcohol consumption during pregnancy and infant birthweight. An epidemiologic study.

Heavy alcohol consumption during pregnancy has been consistently associated with inhibited intra-uterine growth; however, the effect of social drinking is not yet clear. The relationship between moderate drinking and low birth weight (less than 2,500 g) among a nationally representative sample of white married mothers who gave birth to singletons infants in the National Natality Survey (1980) is analysed here. Alcohol consumption during pregnancy was significantly associated with birth weight (p less than 0.02). Moreover, there was a gradient of risk in low birth weight associated with increasing amount of alcohol ingestion during pregnancy. There was a significant association between the mean birth weight of the singletons across different categories of alcohol intake (p less than 0.0001). The difference between the mean birth weight of the singletons among moderate drinkers compared with nondrinkers was also statistically significant (p less than 0.005). These relationships remained after simultaneously adjusting effects of the confounding variables gestational age, parity, smoking, weight gain, maternal age and education in multiple regression analyses. These findings confirm earlier reports of a relationship between alcohol use during pregnancy and decreased birth weight. Additionally, it is shown here that for moderate alcohol use during pregnancy, there is an adverse effect on the birth weight.     

Pre-eclampsia: maternal risk factors and perinatal outcome

OBJECTIVE: The aim of this study was to throw light on the incidence of pre-eclampsia (PE) in women attending for care and delivery at a hospital in Saudi Arabia, and analyze the maternal risk factors and outcome of mothers and neonates in pregnancies complicated by PE. METHODS: This retrospective study involved almost all women (n = 27,787) who delivered at King Fahad Hospital of the University in a 10-year period (1992-2001). The maternal records were reviewed for age, parity, gestational age, mode of delivery, antenatal care, onset of PE, severity of proteinuria, and the frequency of antenatal and intrapartum complications. The neonatal records were reviewed for perinatal outcome including birth weight, frequency of stillbirths, and neonatal deaths. RESULTS: Among the study cohort of pregnancies, 685 women, i.e. 2.47%, were diagnosed as having PE among whom a high proportion (42.0%) were nulliparous women. Similarly, PE was encountered at a high percentage (40.0%) in women at the extreme of their reproductive age (< 20 and >40 years), and more women with PE delivered prematurely (30.2%) as compared to healthy controls (13.5%). Spontaneous vaginal deliveries were less frequent in women with PE (69.2%) as compared with healthy controls (86.2%). Instrumental deliveries, with spontaneous labor, amounted to 15.9% in women with PE, but they comprised only 2.9% in healthy women. The deliveries were more likely to be induced (22.8%) or be performed by cesarean section (14.9%) in women with PE than in healthy controls (6.8% and 9.6%). Placental abruption was the most common maternal complication (12.6%) in women with PE, followed by oligouria (7.9%), coagulopathy (6.0%), and renal failure (4.1%). The perinatal outcome of pregnancies with PE shows that stillbirths (2.34%) and early neonatal deaths (1.02%) comprised an overall mortality rate of 33.6 per 1,000. More stillbirths and neonatal deaths showed a tendency to be associated with the severe form of PE (diastolic BP > or =120), as compared with the mild form (diastolic BP 90-110). Stillbirths and neonatal deaths appear to be associated with women who had no or irregular antenatal care and whose proteinuria amounted to or exceeded 3 g per 24 h, when delivery occurred at 28th gestational week or less, and when the birth-weight of the neonates was between 500 and 1,000 g. CONCLUSION: We document a hospital-based incidence rate of PE of 2.47%, with a high proportion of PE cases occurring among nulliparous women and those at the extreme ends of the reproductive age. More maternal and neonatal complications were encountered in women with PE when the PE was severe, when the pregnancy had to be terminated early, when there was no regular antenatal care, the birth-weight was low, or the proteinuria was severe.     

Hyperemesis gravidarum in relation to estradiol levels, pregnancy outcome, and other maternal factors: a seroepidemiologic study

Two studies were conducted to assess factors associated with increased risk of hyperemesis gravidarum during pregnancy with data and serum samples collected from participants in the Collaborative Perinatal Study. In the case-control study, 419 pregnant women with hyperemesis gravidarum were matched on medical center, date of study registration, and race with 836 pregnant women who did not vomit during the index pregnancy. Younger age, nulliparity, and high body weight were significantly associated with increased risk of hyperemesis. Women with hyperemesis had significantly reduced risk of fetal loss; however, their infants had higher risk of central nervous system malformations. In the second study, first-trimester pregnancy hormones were measured in the serum of 35 women with hyperemesis and 35 control women who were individually matched to cases on age, parity, and medical center. After adjusting for length of gestation, mean levels of total estradiol were 26% higher and mean levels of sex hormone binding-globulin binding capacity were 37% higher in patients with hyperemesis gravidarum than in control subjects. These differences were statistically significant. Although human chorionic gonadotropin concentrations were higher in control pregnancies, the differences were not statistically significant. The average amount of estradiol that was nonprotein bound (adjusted for length of gestation) was also higher in patients than in control subjects. These results are consistent with the hypothesis that elevated estrogen levels are responsible for excessive vomiting in pregnancy.     

The relationship between maternal hematocrit and pregnancy outcome

The relationship between maternal hematocrit and pregnancy outcome at various times in pregnancy was studied in 17,149 iron- and folate-supplemented pregnant women. On univariate analysis, early-pregnancy hematocrits below 37% were associated with preterm delivery. However, this relationship was not confirmed by multivariate analysis controlling for other risk factors. On both univariate and multivariate analyses, both early and later in pregnancy, hematocrits above 40% were associated with preterm delivery. In every gestational time period, at least part of the excess of preterm births was explained by an increase in indicated preterm deliveries. In both early and late pregnancy, and in both the univariate and multivariate analyses, only high hematocrits were associated with fetal growth retardation. The strongest association (odds ratio above 2) between high hematocrit and both fetal growth retardation and preterm delivery occurred with hematocrits at or above 43% at 31-34 weeks' gestation.     

Placenta previa: obstetric risk factors and pregnancy outcome.

OBJECTIVE: To determine the incidence, obstetric risk factors and perinatal outcome of placenta previa. STUDY DESIGN: All singleton deliveries at our institution between 1990 and 1998 complicated with placenta previa were compared with those without placenta previa. RESULTS: Placenta previa complicated 0.38% (n = 298) of all singleton deliveries (n = 78 524). A back-step multiple logistic regression model found the following factors to be independently correlated with the occurrence of placenta previa: maternal age above 40 years (OR 3.1, 95% CI 2.0-4.9), infertility treatments (OR 3.1, 95% CI 1.8-5.6), a previous Cesarean section (OR 1.8, 95% CI 1.4-2.4), a history of habitual abortions (OR 1.3, 95% CI 1.3-2.7) and Jewish ethnicity (OR 1.3, 95% CI 1.1-1.8). Pregnancies complicated with placenta previa had significantly higher rates of second-trimester bleeding (OR 156.0, 95% CI 87.2-277.5), pathological presentations (OR 7.6, 95% CI 5.7-10.1), abruptio placentae (OR 13.1, 95% CI 8.2-20.7), congenital malformations (OR 2.6, 95% CI 1.5-4.2), perinatal mortality (OR 2.6, 95% CI 1.1-5.6), Cesarean delivery (OR 57.4, 95% CI 40.7-81.4), Apgar scores at 5 min lower than 7 (OR 4.4, 95% CI 2.3-8.3), placenta accreta (OR 3.6, 95% CI 1.1-9.9) postpartum hemorrhage (OR 3.8, 95% CI 1.2-10.5), postpartum anemia (OR 5.5, 95% CI 4.4-6.9) and delayed maternal and infant discharge from the hospital (OR 10.9, 95% CI 7.3-16.1) as compared to pregnancies without placenta previa. In a multivariable analysis investigating risk factors for perinatal mortality, the following were found to be independent significant factors: congenital malformations, placental abruption, pathological presentations and preterm delivery. In contrast, placenta previa and Cesarean section were found to be protective factors against the occurrence of perinatal mortality while controlling for confounders. CONCLUSION: Although an abnormal implantation per se was not an independent risk factor for perinatal mortality, placenta previa should be considered as a marker for possible obstetric complications. Hence, the detection of placenta previa should encourage a careful evaluation with timely delivery in order to reduce the associated maternal and perinatal complications.     

妊娠合并系统性红斑狼疮患者孕期病情活动的影响因素及其与妊娠结局的关系

目的 探讨妊娠合并系统性红斑狼疮（SLE）患者孕期病情活动的影响因素及其与妊娠结局的关系.方法 对1991年至2005年收治的66例妊娠合并SLE患者的临床资料进行回顾性分析.结果 （1）孕前病情不稳定、孕期新发病及孕期泼尼松用药不规范者均出现SLE病情活动;孕期S比病情活动者32例（活动组）,非活动者34例（非活动组）.（2）活动组患者发生子痫前期9例、胎儿生长受限（FGR）13例、治疗性流产7例和早产15例,非活动组分别为1例、5例、1例和4例,两组分别比较,差异有统计学意义（P均＜0.05）.（3）活动组患者不同器官损伤中,以肾损害对妊娠的影响最大;用logistic回归前进法筛选变量结果显示,肾损害是子痫前期、FGR的独立危险因素.（4）孕期泼尼松用量每天≤15 mg者子痫前期及胎儿丢失发生率分别为4.7%（2/43）及9.3%（4/43）,用量每天≥20 mg者的子痫前期及胎儿丢失发生率分别为33.3%（6/18）及44.4%（8/18）,两者比较,差异有统计学意义（P＜0.01）.结论 孕前SLE比病情不稳定、孕期新发病及孕期泼尼松用药不规范为SLE病情活动的重要影响因素.孕期SLE病情活动特别是肾损害与不良妊娠结局有密切关系.孕期泼尼松用量每天≥20 mg者发生子痫前期及胎儿丢失的几率大于每天≤15 mg者.     

Elevated maternal serum alpha-fetoprotein levels and maternal risk factors. Their association with pregnancy complications.

Maternal serum alpha-fetoprotein (MS-AFP) screening programs identify a population of pregnant women with elevated MS-AFP values. When the levels are unassociated with a fetal anomaly, those women have a high incidence of pregnancy complications. Such patients were compared to a population with normal MS-AFP values to determine the incidence of historical risk factors and to ascertain if their presence affected the rate of pregnancy complications. A total of 358 patients were followed prospectively, 23 with elevated MS-AFP levels and 335 with normal levels (control group). Historical risk factors were more frequent in the patients with elevated MS-AFP levels. There was a fourfold increase in the rate of pregnancy complications when a patient had both risk factors and elevated MS-AFP levels as compared with elevated MS-AFP levels alone. In the control group, patients with known risk factors experienced twice the incidence of pregnancy complications as did patients with no risk factors. Using multiple logistic regression analysis, elevated MS-AFP levels were shown to be an independent variable in the risk assessment. The results of this study have wide application in the counseling and follow-up of patients identified by MS-AFP screening programs.     

Uterine rupture: risk factors and pregnancy outcome

OBJECTIVES: This study aimed at determining risk factors and pregnancy outcome in women with uterine rupture. STUDY DESIGN: We conducted a population-based study, comparing all singleton deliveries with and without uterine rupture between 1988 and 1999. RESULTS: Uterus rupture occurred in 0.035% (n=42) of all deliveries included in the study (n=117,685). Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean section (odds ratio [OR]=6.0, 95% CI 3.2-11.4), malpresentation (OR=5.4, 95% CI 2.7-10.5), and dystocia during the second stage of labor (OR=13.7, 95% CI 6.4-29.3). Women with uterine rupture had more episodes of postpartum hemorrhage (50.0% vs 0.4%, P<.01), received more packed cell transfusions (54.8% vs 1.5%, P<.01), and required more hysterectomies (26.2% vs 0.04%, P<.01). Newborn infants delivered after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P<.01; 19.0% vs 1.4%, P<.01, respectively). CONCLUSION: Uterine rupture, associated with previous cesarean section, malpresentation, and second-stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.     

Cigarette,alcohol, and caffeine consumption: risk factors for spontaneous abortion

OBJECTIVE: To study the association between cigarette, alcohol, and caffeine consumption and the occurrence of spontaneous abortion. METHODS: The study population consisted of 330 women with spontaneous abortion and 1168 pregnant women receiving antenatal care. A case-control design was utilized; cases were defined as women with a spontaneous abortion in gestational week 6-16 and controls as women with a live fetus in gestational week 6-16. The variables studied comprise age, parity, occupational situation, cigarette, alcohol, and caffeine consumption. The association between cigarette, alcohol, and caffeine consumption was studied using logistic regression analyzes while controlling for confounding variables. In addition stratified analyzes of the association between caffeine consumption and spontaneous abortion on the basis of cigarette and alcohol consumption were performed. RESULTS: Women who had given birth twice or more previously had increased odds ratio (OR), 1.78 (1.27-2.49), whereas women who were students had decreased OR, 0.55 (0.34-0.91) for having spontaneous abortions. Regarding lifestyle factors, the adjusted ORs among women who consumed 5 units or more alcohol per week or 375 mg or more caffeine per day were 4.84 (2.87-8.16) and 2.21 (1.53-3.18), respectively. Women who smoked 10-19 cigarettes and 20 or more cigarettes per day did not have significantly increased ORs for having spontaneous abortions, after adjusting for other risk factors. CONCLUSION: Consumption of 5 or more units alcohol per week and 375 mg or more caffeine per day during pregnancy may increase the risk of spontaneous abortion.     

Teenage pregnancy: risk factors for adverse perinatal outcome.

OBJECTIVES: To assess the perinatal outcome of teenage pregnancy in a large cohort and to determine risk factors for low birth weight (LBW) in teenage pregnancy. STUDY DESIGN: All singleton first deliveries to mothers of age 16-24 years between 1990 and 1997 were included. The deliveries were subdivided into three maternal age groups (16-17 and 18-19 compared to 20-24 years) and parameters of perinatal outcomes were compared. To adjust for potential confounding effects on the association between young maternal age and birth weight, logistic regression analysis was performed for LBW with maternal ethnicity, pregnancy-induced hypertension, lack of prenatal care and malformations of the newborn. RESULTS: Among a total of 11 496 patients, 600 (5.2%) were 16-17 years old, 2097 (18.2%) were 18-19 years old and the remaining 8799 (76.6%) were 20-24 years old. Bedouin ethnicity and lack of prenatal care were common in the youngest mothers. Rates of preterm delivery were 14.2%, 9.8% and 8.8% in the three age groups, respectively (p < 0.05). Rates of malformations, small for gestational age, LBW and very LBW were also significantly higher in the youngest mothers. Rates of pregnancy-induced hypertension, operative delivery and Cesarean delivery were not significantly different among the three age groups. A multivariate analysis on LBW was performed to assess the unique contribution of young maternal age, adjusted for potential confounders. Adjusted ORs for LBW were 1.25 (95% CI 1.00-1.56) for maternal age < 18 years, 1.80 (95% CI 1.54-2.03) for Bedouin ethnicity, 2.57 (95% CI 2.14-3.07) for pregnancy-induced hypertension, 1.55 (95% CI 1.30-1.84) for lack of prenatal care and 4.09 (95% CI 3.2-5.2) for malformations. CONCLUSIONS: Teenage pregnancy was found to be associated with adverse outcome such as LBW, preterm delivery, small for gestational age and malformations. The risk for LBW was affected mainly by demographic factors (maternal ethnicity, lack of prenatal care) and medical factors (pregnancy-induced hypertension, malformations).     

Maternal risk status and postdate pregnancy outcome

Using a 1982-1985 regional perinatal network data base of 69,746 infants, a retrospective study was conducted to compare the perinatal outcome of 7,729 postdate infants (greater than or equal to 42 weeks' gestation) by maternal risk status. Due to additional antenatal complications, of which 8.0% were hypertension and/or diabetes, 48.4% of the postdate pregnancies were classified as at risk. As expected, high-risk women experienced a higher incidence of adverse perinatal outcomes than did low-risk women. The incidence of meconium staining, low five-minute Apgar scores and perinatal mortality increased beyond term and was found most commonly in infants from high-risk pregnancies, especially those involving hypertension and diabetes mellitus. These results suggest that high-risk pregnancies probably should not enter the postdate period since their doing so places the infant at serious risk.     

Trends,risk factors and pregnancy outcome in women with uterine rupture

Objective  

This study aimed at determining trends, risk factors and pregnancy outcome in women with uterine rupture.     

Placenta previa: obstetric risk factors and pregnancy outcome

Objective: To determine the incidence, obstetric risk factors and perinatal outcome of placenta previa. Study design: All singleton deliveries at our institution between 1990 and 1998 complicated with placenta previa were compared with those without placenta previa. Results: Placenta previa complicated 0.38% ( n = 298) of all singleton deliveries ( n = 78 524). A back-step multiple logistic regression model found the following factors to be independently correlated with the occurrence of placenta previa: maternal age above 40 years (OR 3.1, 95% CI 2.0-4.9), infertility treatments (OR 3.1, 95% CI 1.8-5.6), a previous Cesarean section (OR 1.8, 95% CI 1.4-2.4), a history of habitual abortions (OR 1.3, 95% CI 1.3-2.7) and Jewish ethnicity (OR 1.3, 95% CI 1.1-1.8). Pregnancies complicated with placenta previa had significantly higher rates of second-trimester bleeding (OR 156.0, 95% CI 87.2-277.5), pathological presentations (OR 7.6, 95% CI 5.7-10.1), abruptio placentae (OR 13.1, 95% CI 8.2-20.7), congenital malformations (OR 2.6, 95% CI 1.5-4.2), perinatal mortality (OR 2.6, 95% CI 1.1-5.6), Cesarean delivery (OR 57.4, 95% CI 40.7-81.4), Apgar scores at 5 min lower than 7 (OR 4.4, 95% CI 2.3-8.3), placenta accreta (OR 3.6, 95% CI 1.1-9.9) postpartum hemorrhage (OR 3.8, 95% CI 1.2-10.5), postpartum anemia (OR 5.5, 95% CI 4.4-6.9) and delayed maternal and infant discharge from the hospital (OR 10.9, 95% CI 7.3-16.1) as compared to pregnancies without placenta previa. In a multivariable analysis investigating risk factors for perinatal mortality, the following were found to be independent significant factors: congenital malformations, placental abruption, pathological presentations and preterm delivery. In contrast, placenta previa and Cesarean section were found to be protective factors against the occurrence of perinatal mortality while controlling for confounders. Conclusion: Although an abnormal implantation per se was not an independent risk factor for perinatal mortality, placenta previa should be considered as a marker for possible obstetric complications. Hence, the detection of placenta previa should encourage a careful evaluation with timely delivery in order to reduce the associated maternal and perinatal complications.     

Inflammatory bowel disease: risk factors for adverse pregnancy outcome and the impact of maternal weight gain

Objective: To identify risk factors for adverse pregnancy outcome in women with inflammatory bowel disease (IBD) and to assess the effect of maternal pre-pregnancy weight and weight gain during pregnancy on pregnancy outcome. Methods: A retrospective, matched control study of all gravid women with IBD treated in a single tertiary center. Data were compared with healthy controls matched to by age, parity and pre-pregnancy BMI in a 3:1 ratio. Results: Overall, 300 women were enrolled, 75 women in the study group (28 with ulcerative colitis and 47 with Crohn’s disease) and 225 in the control group. The rates of preterm delivery and small for gestational age were higher in the study group (13.3 vs. 5.3% p = 0.02 and 6.7 vs. 0.9%, p = 0.004). The rate of cesarean section (36 vs. 19.1%; p = 0.002), NICU admission (10.7 vs. 4.0%, p = 0.03) and low 5-Min Apgar (4.0 vs. 0.4%, p = 0.02) were increased in the study group. Disease activity within 3 months of conception [OR 8.4 (1.3–16.3)] and maternal weight gain of less than 12 kg. [OR 3.6 (1.1–12.2)] were associated with adverse pregnancy outcome. Conclusion: Active disease at conception and inappropriate weight gain during pregnancy are associated with increased adverse pregnancy outcome in patients with IBD.     

Failed vacuum extraction. Maternal risk factors and pregnancy outcome

OBJECTIVE: To evaluate obstetric risk factors associated with a failed trial of vacuum extraction and to assess its pregnancy outcome. STUDY DESIGN: All attempted vacuum extractions between the years 1990 and 1998 were identified, and a comparison of successful and failed trials of vacuum extraction in singleton, vertex deliveries was performed. RESULTS: Of 2,111 trials of vacuum extraction, 113 (5.4%) cases were complicated by failed extraction and underwent cesarean section. Those neonates were significantly more likely to be large for gestational age, specifically to weigh > 4,000 g as compared to the controls. Patients lacking prenatal care had significantly higher rates of failed vacuum extraction trials. While cervical and uterine tears were rather rare, parturients who had failed trials of vacuum extraction had significantly higher rates of cervical and uterine tears as compared to those with successful vacuum extractions. This association remained significant after controlling for a previous cesarean section using the Mantel-Hanszel technique. Women from the failed vacuum extraction group had significantly higher rates of postpartum anemia. Pregnancies complicated by failed vacuum extraction had significantly higher rates of intrapartum and postpartum fetal death. Those neonates had significantly higher rates of Apgar scores < 7 at one and five minutes. CONCLUSION: Failed trial of vacuum extraction is associated with adverse maternal and fetal outcomes. Risk factors associated with such failures are fetal weight and lack of prenatal care. Thus, careful estimation of fetal weight should be performed before the procedure, and estimated fetal weight > 4,000 g might be considered a relative contraindication to vacuum extraction, especially among patients who did not have prenatal care.