Screening for substance use in pregnancy: a practical approach for the primary care physician

Our goal was to identify risk factors for substance use during pregnancy for primary care physicians so that we could assess a woman's risk of alcohol or illicit drug use. Participants were 2002 Medicaid-eligible pregnant women with < or =2 visits to prenatal care clinics in South Carolina and Washington State. Structured interviews were used to collect data. Logistic regressions and classification and regression trees identified predictors for pregnant women at high risk for substance use. Approximately 9% of the sample reported current use of either drugs or alcohol or both. Past use of alcohol or cigarettes, including during the month before pregnancy, most differentiated current drug or alcohol users from current nonusers. Our analysis suggests that primary care physicians can ask 3 questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.     

Clinical impact of mild carbohydrate intolerance in pregnancy: a study of 2904 nondiabetic Danish women with risk factors for gestational diabetes mellitus

OBJECTIVE: The objective was to study the clinical impact of mild carbohydrate intolerance in pregnant women with risk factors for gestational diabetes mellitus. STUDY DESIGN: This was a historical cohort study of 2904 pregnant women examined for gestational diabetes on the basis of risk factors. Information on oral glucose tolerance test results and clinical outcomes was collected from laboratory charts and medical records. RESULTS: The following outcomes increased significantly with increasing glucose values during the oral glucose tolerance test: shoulder dystocia, macrosomia, emergency cesarean section, assisted delivery, hypertension, and induction of labor. However, when corrections were made for other risk factors, hypertension and induction of labor were only marginally associated with glucose levels. CONCLUSION: In a group of nondiabetic pregnant women with risk factors for gestational diabetes, there was a graded increase in the frequency of shoulder dystocia and other maternal-fetal complications with increasing glucose levels during an oral glucose tolerance test.     

Hemoglobinopathy screening in pregnancy: comparison of two protocols.

This study was designed to determine the ability of a hemoglobinopathy screening protocol involving sickle solubility testing and red blood cell (RBC) indices to identify at-risk pregnancies. Retrospective chart review of all patients registering for prenatal care at the New York Hospital/Cornell Medical Center prenatal clinic in 1996 was the study design. All patients had RBC indices as well as hemoglobin electrophoresis. RBC indices of those with normal and abnormal electrophoreses were compared. Comparison of protocols involving universal hemoglobin electrophoresis and selective use of hemoglobin electrophoresis were compared. Student's t-test was used for statistical analysis. There were 36 carriers of hemoglobinopathy traits in 631 patients screened (5.7%). Four (three with hemoglobin C trait and one with hemoglobin D trait) had normal RBC indices and presumably would have had negative sickle solubility testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a protocol with selective use of hemoglobin electrophoresis would have been 88.9, 79.4, 20.8, and 99.2%, respectively. Cost analysis reveals a difference of $11,384 or $18/patient less in a protocol with selective use of hemoglobin electrophoresis. Although a protocol involving solubility testing with RBC indices will not identify every carrier of a hemoglobinopathy trait, it may be appropriate in some populations.     

Detection of glucose intolerance in pregnancy

Between 6 and 28 weeks of gestation, 2-hour postprandial blood glucose determinations were performed on 66 pregnant patients who had no history of diabetes. Each patient received two methods of carbohydrate loading on separate occasions in a random, crossover fashion. One group received a 100-g carbohydrate meal and then a 50-g glucose load (Glucola). The order of the test regimens was reversed for the second group. The average 2-hour postprandial glucose value following a meal was 103.1 +/- 3.7 mg/dL, and the mean value for the 2-hour postprandial glucose following Glucola was 102.5 +/- 3.8 mg/dL. The difference in glucose values obtained with the two methods was not statistically significant. A 12% incidence of emesis was encountered after Glucola but none was encountered after the meal. The 100-g carbohydrate meal is recommended as the method of testing for glucose intolerance.     

A comparison of serial quantitative serum and urine tests in early pregnancy

Serial urinary beta human chorionic gonadotropin (beta-hCG) immunoassay was performed on 60 patients during early pregnancy. Results were expressed as tube dilutions positive and were compared with quantitative serum beta human chorionic gonadotropin radioimmunoassay (beta-hCG-RIA) values. The parallel rise of human chorionic gonadotropin (hCG) measured by serum beta-hCG-RIA and a macroflocculation beta-specific urinary immunoassay in early pregnancy was confirmed. The ability of each to predict abortion prior to the onset of patient symptoms or clinical signs of disturbed gestation was quantitated. Results were expressed for each method according to standard regression lines or doubling time for individuals. Utilizing either statistical method, urinary testing was as accurate as serum testing for the prediction of normal pregnancy (about 90% for each). Serum testing was 78% correct in predicting abortion; urinary testing was 63% accurate.     

Clinical evaluation of two urine tests for the early diagnosis of pregnancy

We compared the performance of two immunologic tests for hCG in urine with a qualitative serum hCG assay. The latex agglutination assay ( Sensi -Tex) was found to be superior to a hemagglutination assay (Beta-Stat) in that fewer equivocal results were obtained with it. Excluding equivocal results, both urine tests agreed well with the results of the serum qualitative hCG assay. Interference by human menopausal gonadotropins occurred at higher concentrations with Sensi -Tex than with Beta-Stat, suggesting that the Sensi -Tex reagents have greater specificity. We recommend that laboratories examine the performance of available urine pregnancy tests on site before selecting a reagent system for routine use.     

Screening for toxoplasmosis in pregnancy

Randomly collected sera from 386 pregnant women attending obstetric and gynecology clinics at Kind Khalid University Hospital, Riyadh, Saudi Arabia, were examined for toxoplasma antibodies by five serological methods, i.e. latex agglutination test (LAT), two indirect hemagglutination tests (IHAT) (Carter-Wallace, USA and Ismunit, Italy), enzyme immunoassay (EIA) and indirect fluorescent antibody test (IFAT). The percentage of sensitivity, specificity and coincidence value of these tests were compared with IFAT which was used as a reference test. For routine screening of toxoplasmosis, LAT has proved in this study to be the most suitable test. The LAT is cost effective and easy to perform. In this study of the three tests (IFAT, EIA, immunosorbent agglutination assay) to demonstrate specific IgM for toxoplasmosis, the EIA test proved to be the most satisfactory because of its 99% specificity. If EIA equipment is available, it can be used for routine screening (IgG) as well as IgM determination. The incidence of toxoplasmosis in pregnant women varied between 25.4% and 36.3% depending on the method used.     

Microlaparoscopy: a new approach to the reassessment of ovarian cancer patients

BACKGROUND: The purpose of the work was to determine the feasibility and accuracy of microlaparoscopy as diagnostic method for the reassessment of ovarian cancer patients. METHODS: Eight patients scheduled for second-look laparoscopy who had undergone primary surgery for ovarian cancer followed by 6 cycles of chemotherapy were included in the study. Microlaparoscopy was performed using a 2.8 mm laparoscope followed by conventional 10-mm laparoscopy. Three additional 5-mm ancillary trocars were inserted to perform intraabdominal biopsies. Pelvic washings were performed in all cases. RESULTS: Microlaparoscopy was feasible in all cases and as accurate as conventional laparoscopy in seven cases. In one case the procedure was terminated before conventional laparoscopy because of positive biopsies at frozen section examination. There were no intra-operative complications related to microlaparoscopy. The median time from skin incision to the removal of the microlaparoscope was 47 minutes (range 30-70). CONCLUSION: Microlaparoscopy seems to be a safe, accurate, minimally invasive method and therefore we suggest its use as primary approach to the reassessment of ovarian cancer patients.     

Acute intermittent porphyria in pregnancy: a common misdiagnosis

Acute intermittent porphyria (AIP) is inherited in an autosomal dominant fashion. Only 10% to 15% of the gene carriers have the clinical syndrome. The prevalence of AIP in Europe is 1/20,000. Pregnancy represents an essential risk factor in patients suffering from AIP. The clinical syndrome in AIP presents mainly with acute attacks, especially during the first trimester. Misdiagnosis of AIP unfortunately is very common. Pregnancy in women with AIP is associated with higher rates of spontaneous abortion, hypertension, low birth weight infants and considerable mortality (2-42%). Pregnancy, despite the major hormonal alterations it causes, is seldom associated with porphyric symptoms. There are only limited reports supporting the use of hemin during pregnancy, but experience indicates that it can be safely administered in pregnant women. Until clinical improvement is achieved, symptomatic treatment is recommended. Despite the fact that pregnancy in women suffering from AIP is related to higher rates of morbidity and complications, close management throughout the pregnancy could ensure a good outcome.