Extreme parity and the risk of stillbirth

OBJECTIVE: We examined the relationship between extreme parity and risk for stillbirth in the United States. METHODS: Singleton deliveries at 20 weeks of gestation or later in the United States from 1989 through 2000 were analyzed. Risk for stillbirth in women with 1-4 (moderate parity, category I), 5-9 (high parity, category II), 10-14 (very high parity, category III), and 15 or more (extremely high parity, category IV) prior live births were computed using logistic regression. RESULTS: Overall, 27,069,385 births, including 1,206 to extremely high parity mothers, were analyzed. Of the 81,386 stillbirths, 71,623 (2.8/1,000), 9,206 (5.0/1,000), 531 (14.4/1,000), and 26 (21.6/1,000) cases occurred among category I, category II, category III, and category IV gravidas, respectively. With category I as referent category, the odds ratio for stillbirth increased consistently with ascending parity after adjusting for potential confounders: category II (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02-1.07), category III (OR 1.97, 95% CI 1.81-2.15), and category IV (OR 2.31, 95% CI 1.56-3.42) (P for trend < .001). Among extremely high parity women (category IV), the odds ratio for stillbirth also increased with unit increment in the number of prior live births: 15 (OR 2.72, 95% CI 1.29-5.74), 16 (OR 3.14, 95% CI 1.17-8.41), 17 (OR 6.11, 95% CI 2.56-16.5), and 18 or more prior live births (OR 16.17, 95% CI 8.77-29.82) (P for trend < .001). CONCLUSIONS: The risk for stillbirth is substantially elevated among very high and extremely high parity women, and care providers may consider these groups for targeted periconceptional counseling. Level of Evidence: II-2.     

Advanced maternal age and fetal growth inhibition in triplets

OBJECTIVE: To determine whether advanced maternal age is associated withfetal growth inhibition in triplets. STUDY DESIGN: We conducted a retrospective cohort study on triplet live births in the United States from 1995 through 1998. The outcomes of fetal growth inhibition measured were low birth weight, very low birth weight, preterm birth, very preterm birth and smallnessfor gestational age. We generated adjusted ORs after taking into account intracluster correlations using the generalized estimating equation framework. RESULTS: As compared to women of younger maternal age (20-29), mature (30-39) and older women (> or =40 years) with triplet gestations tended to have a lower likelihood offetal growth inhibition. Mean birth weight and mean gestational age at delivery increased with increasing maternal age in a dose-dependent pattern (p for trend < 0.0001). As compared to triplets born to younger mothers, those of older women were less likely to have low birth weight (OR=0.51, 95% CI=0.37-0.69) or very low birth weight (OR = 0.58, 95% CI = 0.47-0.72) or to be preterm (OR = 0.39, 95% CI = 0.27-0.56) or very preterm (OR = 0.67, 95% CI = 0.55-0.80). The riskfor small-for-gestational-age infants was comparable. CONCLUSION: Older maternal age is associated with morefavorable triplet fetal growth parameters, although the exact mechanisms of this paradox remain poorly understood.     

In utero nicotine exposure and fetal growth inhibition among twins

We examined the impact of cigarette smoking on fetal growth among twins by analyzing matched twin live births in the United States from 1995 through 1998. The outcomes of interest were low and very low birthweight, preterm and very preterm birth, and small for gestational age. Out of a total of 163,901 mothers, 19,234 reported active smoking during pregnancy (11.7%). Twins born to smokers weighed an average of 182 g less than their counterparts born to nonsmokers (p<0.001). The risk for fetal growth inhibition was greater among twins of smokers: low birthweight (adjusted odds ratio [OR], 1.84; 95% confidence Interval [CI], 1.79 to 1.89), very low birthweight (OR, 1.27; 95% CI, 1.21 to 1.32), preterm (OR, 1.3; 95% CI, 1.09 to 1.16), very preterm (OR, 1.18; 95% CI, 1.13 to 1.23), and small for gestational age (OR, 1.91; 95% CI, 1.84 to 1.98). In conclusion, prenatal smoking significantly inhibits fetal growth among twins, and small for gestational age appeared more affected than shortened gestation.     

Female genital tuberculosis: a global review

Female genital tuberculosis is a symptomless disease inadvertently uncovered during investigation for infertility. The condition is relatively rare and often arises secondary to a primary focus elsewhere. The fallopian tube is the organ most commonly affected. Symptomatic disease usually presents with infertility, pelvic pain or menstrual irregularities. Diagnosis is daunting, even where grounds for suspicion exist. Molecular-based diagnostic methods are likely to play a prominent role in the future. Drug treatment is similar to that of pulmonary tuberculosis, although criteria for assessing the effectiveness of therapy are lacking. Return to fertility after treatment is not encouraging. In-vitro fertilization with embryo transfer remains the most effective method of treating associated infertility. Clinicians need to be aware of the existence of this important cause of infertility in women, in view of the continuing HIV epidemic and the current upsurge in tuberculosis worldwide, as well as the continuing migration of large numbers of women and their families out of areas where tuberculosis is endemic.     

Prune belly syndrome and associated malformations. A 13-year experience from a developing country

A retrospective investigation was conducted to describe clinical features and birth outcomes among babies with prune belly syndrome detected ante-natally and at birth at the University Teaching Hospital in Cameroon. A total of 11 cases were identified over a period of 13 years, and the majority of affected fetuses were male (10 of 11). Most of the mothers were less than 30 years of age, had singleton pregnancies, and about two-thirds were complicated by placenta praevia, genital infections, preeclampsia, and anaemia associated with hookworm infestations. The most prominent findings related to prune belly syndrome among our patients were clubfoot (45%), pulmonary hypoplasia (27%), Potter facies (27%), imperforate anus (27%), and arthrogryposis (18%). About two-thirds of the affected pregnancies did not reach the age of viability either due to voluntary termination (three of seven cases) or spontaneous abortion (four of seven cases). Of the remaining four viable pregnancies, two cases each of stillbirth and neonatal death were recorded. Among pregnancies that were not voluntarily terminated (n = 8), multiple concomitant anomalies and bilateral renal lesions were apparently the cause of fetal/infant death in the majority of cases (75%). In conclusion, Cameroonian babies with prune belly syndrome presented with clinical features that were comparable to those observed in developed nations.     

Physician hearing loss

PURPOSE: Hearing is an important sense for physicians, making communication and stethoscope use possible, yet not much is known about the impact of hearing loss on professional function. The purpose of this study was to explore hearing-related issues affecting physicians. MATERIALS AND METHODS: We administered a hearing test and questionnaire to 107 physicians and medical students. RESULTS: The proportion of physicians reporting trouble with their hearing increased with age, reaching almost 100% in those older than 60 years. Audiometric hearing loss also increased with age. Perceived hearing trouble was significantly associated with audiometric hearing loss, yet 46% of physicians with hearing loss described their hearing as good. Older physicians more frequently reported difficulty communicating with patients, staff, and colleagues owing to hearing problems (P = .007). Reported stethoscope difficulties did not significantly increase with age; there was no association with hearing thresholds. No physician reported use of electronic stethoscopes or hearing aids. Noise exposures were common, yet 51% of respondents never used hearing protection. Younger physicians were less likely to use protection (P = .002). CONCLUSION: Physicians lose hearing with age but may not notice or report the loss. Physician hearing loss is associated with difficulty communicating with patients, staff, and colleagues. Neither age nor hearing level predicts problems with stethoscope use; possible explanations include a training effect or denial. Many physicians, especially younger ones, never use hearing protection around noise. Strategies to recognize and reduce the impact of hearing loss on professional function throughout a physician's career deserve greater attention.