Macrosomic births in the united states: determinants,outcomes, and proposed grades of risk

OBJECTIVE: We describe maternal risk factors for macrosomia and assess birth weight categories to determine predictive thresholds of adverse outcomes. STUDY DESIGN: We analyzed linked live birth and infant death cohort files from 1995 to 1997 for the United States with the use of selected term (37-44 weeks of gestation) single live births to mothers who were US residents. We compared macrosomic infants (4000-4499 g, 4500-4999 g, and >5000 g infants) with a normosomic control group of infants who weighed 3000 to 3999 g. RESULTS: Maternal risk factors for macrosomia included nonsmoking, advanced age, married, diabetes mellitus, hypertension, and previous macrosomic infant or pregnancy loss. The risks of labor complications, birth injuries, and newborn morbidity rose with each gradation of macrosomic birth weight. Infant mortality rates increased significantly among infants weighing >5000 g. CONCLUSION: Although a definition of macrosomia as >4000 g (grade 1) may be useful for the identification of increased risks of labor and newborn complications, >4500 g (grade 2) may be more predictive of neonatal morbidity, and >5000 g (grade 3) may be a better indicator of infant mortality risk.     

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.     

The abortion paradox in Uganda: fertility regulator or cause of maternal mortality.

Both fertility and maternal mortality indices are high among Ugandan mothers. The expected benefits in fertility and maternal mortality reduction from a rising contraceptive uptake in the country (from 5% in 1991 to 23% by the year 2000) have not been forthcoming because the increase in contraceptive prevalence rate (CPR) was below the critical level required to cause any meaningful change in overall fertility and maternal mortality. The strong desire among couples to limit family size coupled with the lack of access to modern methods of contraception by many women, especially in the rural areas of the country, have contributed to the increasing use of abortion as a means of averting unplanned or mistimed motherhood. In contrast to the expected results of a typical fertility regulator, however, abortion seems to up-regulate instead of down-regulate the occurrence of maternal mortality. This paradoxical relationship is explained mainly by the illegality of the procedure, which converts it to a clandestine activity performed by poorly trained individuals operating, in many instances, in septic settings. A practical solution is to make modern and effective methods of contraception widely available, especially among rural-dwellers. Through this and coupled with training of personnel, as well as demystification of abortion by dismantling the stigma of "illegality" associated with it, down-regulation of fertility and maternal mortality can both be achieved in a country like Uganda where population explosion is further complicated by a high incidence of maternal demise.     

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.     

Survival of triplets who are born to teen mothers in the United States

OBJECTIVE: The purposes of this study were to assess survival among triplets who are born to teen mothers and to determine whether fetal number influences the mortality rates of the offspring of teen mothers when compared with the offspring of older women. STUDY DESIGN: A retrospective cohort study of 354 triplet births to teenage mothers and 6858 to young mature mothers (20-29 years) who were delivered from 1995 through 1998. We compared the occurrence of stillbirth and neonatal and infant mortality rates between the 2 categories by means of the generalized estimating equation. Similar analyses were conducted for singleton pregnancies and twin pregnancies. RESULTS: Triplets of teenage mothers experienced a higher level of stillbirth (odds ratio, 3.24; 95% CI, 1.44-7.24), neonatal mortality (odds ratio, 2.00; 95% CI, 1.11-3.61), and infant death (odds ratio, 1.66; 95% CI, 1.01-2.87). Moreover, as the plurality increased from singleton infant to triplet, the offspring of teenagers fared progressively worse ( P < .0001). CONCLUSION: This study confirms the association between teenage motherhood and feto-infant death and indicates that this mortality relationship varies in a dose-dependent fashion.