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Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

Objective This study was undertaken to determine whether there is any difference in the rate of error of estimated fetal weight (EFW) in cases of shoulder dystocia compared with controls. Study design Women whose delivery was complicated by shoulder dystocia were studied and compared with a control group matched for parity, race, labor type (spontaneous or induced), and birth weight (BW). Accuracy (%) was defined as [(EFW-BW)/BW] × 100. The primary outcome of the study was rate of EFW underestimation error 20% or greater. Results During the 5-year study period, there were 206 cases of shoulder dystocia that met all study criteria. There was no difference in the number of patients that had EFW underestimation error 20% or greater (shoulder dystocia 9.8% vs control 12.8%; P = .38). There was also no difference in the number of patients that had EFW underestimation error 20% or greater between shoulder dystocia with and without injury (injury 8.3% vs no injury 7.1%; P = .79). Conclusion EFW underestimation error in cases of shoulder dystocia is an infrequent event and does not occur more often than in deliveries without shoulder dystocia.

Objective The goal of this study was to examine differential effects of amount and pattern of prenatal alcohol exposure on child outcome. Study design Alcohol use was assessed at each prenatal visit, and IQ and behavior were measured at age 7 years. Results After control for confounders, the amount of exposure was unrelated to IQ score and behavior for >500 black 7-year-old children. However, children who were exposed to binge drinking were 1.7 times more likely to have IQ scores in the mentally retarded range and 2.5 times more likely to have clinically significant levels of delinquent behavior. Conclusion During prenatal care, clinicians should attend not only to amount but also to the pattern of alcohol intake, because of the elevated risk for cognitive deficits and long-term behavioral abnormality.

This study was undertaken to examine the relationship between labor abnormalities and shoulder dystocia in nulliparous women.Nulliparous women whose delivery was complicated by shoulder dystocia were studied and compared with a control group selected based on the best possible match for race, labor type (spontaneous or induced), and birth weight. The duration of first and second stage of labor, as well as the rates of labor progress, were calculated and compared between groups.During this 4-year study period, there were 8010 nulliparous singleton deliveries of which 65 (0.8%) were complicated by shoulder dystocia. Compared with controls, there was no difference in the rate of cervical dilation in the active phase of the first stage of labor. In the shoulder dystocia group, more patients had a second stage of labor greater than 2 hours (22% vs 3%; P.05) and had operative vaginal deliveries (26% vs 1.5%; P.001). In shoulder dystocia cases with birth weight greater than 4000 g, 33% had a second stage of labor greater than 2 hours.In our population, the combination of fetal macrosomia, second stage of labor longer than 2 hours and the use of operative vaginal delivery were associated with shoulder dystocia in nulliparous women.

Objective The purpose of this study was to examine the effects of prolonged in utero meconium exposure on adult learning and memory, as measured by the Morris water maze. Study design Timed pregnant Long-Evans rats were studied. On gestational day 20 (term, 21 days of gestation), laparotomy was performed, and each maternal animal received an injection of clear amniotic fluid or meconium-stained amniotic fluid into each gestational sac. The laparotomy incision was closed, and the animals received postoperative monitoring through delivery. On postnatal days 145 to 148, the offspring underwent Morris water maze testing. The mean (±SEM) for the latency time was reported for each day's trial and compared between groups. Results There were significant differences between meconium-stained amniotic fluid group and clear amniotic fluid group in the mean time to platform on day 1 (82.7 ± 1.8 seconds vs 75.9 ± 3.0 seconds; P =.04), day 2 (60.5 ± 3.5 seconds vs 47. 8 ± 4.6 seconds; P =.03), and day 3 (56.5 ± 4.5 seconds vs 34.7 ± 4.4 seconds; P =.001). However, there were no differences on days 4 and 5. There were also no differences between recall and response learning trials that were done after a 12-day retention period. Conclusion In the absence of hypoxia or infection, prolonged in utero meconium exposure is associated with a delay of spatial learning in the adult rat.

Objective This study was undertaken to determine the effect of advanced ultrasound equipment on the ability to visualize fetal cardiac structures in obese gravid women. Study design Singleton pregnancies undergoing initial ultrasound examination between 14 weeks and 23 weeks 6 days were included. Patients were classified by body mass index (BMI) (nonobese [BMI 2 ] and obese [BMI ≥30 kg/m 2 ]). The rate of suboptimal ultrasound visualization (SUV) of the fetal heart (cardiac axis, cardiac position, 4-chamber, and outflow tracts views) was compared between patients examined by standard (HDI 3000) or advanced ultrasound equipment (HDI 5000) (ATL, Philips Medical Systems, Bothell, Wash). Results Over a 5-year period, 7029 singleton gestations met inclusion criteria; 2498 (35.5%) were clinically obese. There was no difference in gestational age, rate of low amniotic fluid volume, anterior placenta, or vertex fetal presentation between the groups. When the advanced ultrasound equipment was used, SUV of the fetal heart was lower in the nonobese population (20.8% vs 16.4%; P P =.27). However, obese patients who were examined by advanced ultrasound equipment after 18 weeks had less SUV of the outflow tracts (28.5% vs 23.1%, P =.04) but not of the 4-chamber view. Conclusion Despite advanced ultrasound equipment, maternal obesity significantly limits visualization of the fetal heart. However, the advanced ultrasound equipment may somewhat benefit obese gravid women examined after 18 weeks' gestation

It seems, if one can believe presidential addresses, as if our specialty is always at some crossroads or other. In this “opinion piece,” uniquely, I don’t complain about managed care. I do attempt to identify some of the issues that will be of import for obstetrics and gynecology in the near and not-so-near futures. With regard to research, we await breakthroughs, for example, in the early detection of ovarian cancer, so as to finally be able to improve outcomes. A problem, though, is our failure to focus enough effort on developing a cadre of clinician scientists, who can work out research findings with direct clinical application; this is an issue with which the specialty needs to come to grips. Regarding education, I believe we need to refocus from what type of practitioners we might want to produce to best meet the needs of our patients. The bottom line should be more flexibility in training and emphasis on clinical competence, so that excellent practitioners with competence across the breadth of our specialty are available to provide a full range of appropriate women’s health care. The concept of “women’s health” is controversial and evolving rapidly. Review of several available sources suggests that reproductive medicine will remain an important component of women’s health but that our specialty must now evolve to include other areas, as the major health problems of women change. We need to shift from an organ-based paradigm to a more holistic view, reflecting the woman-centered focus for our specialty. This “paradigm shift” will need to entail continuation of first-rate surgical and obstetrics services but will be expanded to include a full range of services, probably offered by highly trained and competent individuals with specific areas of expertise, practicing in a multi-single-specialty group. Obstetrics and gynecology at the crossroads, indeed! (Am J Obstet Gynecol 2001;184:1313-9.)

Objective: This study was undertaken to better define the timing of neurologic insult in neonates with early-onset seizures through evaluation of neonatal nucleated red blood cell levels. Study Design: Medical records and the International Classification of Diseases, Ninth Revision codes were used to identify all term neonates with neonatal convulsions who were delivered at our institution (January 1, 1990–December 31, 1995). Each neonate with early-onset seizures was matched to the next 3 neonates who met the following criteria: gestational age ≥37 weeks, no early-onset seizures, birth weight ≥2800 g, umbilical artery pH ≥7.25, and a 5-minute Apgar score >7. Demographic characteristics, clinical factors, and mean initial nucleated red blood cell counts were compared between groups. Results: During the 6-year study period, there were a total of 36,490 singleton term deliveries of infants who were alive at birth. Forty-five (0.1%) of these neonates had early-onset seizures. Thirty neonates with early-onset seizures met the inclusion criteria. Mean nucleated red blood cell counts (number of nucleated red blood cells per 100 white blood cells) for neonates with early-onset seizures were significantly increased compared with those of control neonates (18.4 ± 22.0 vs 4.6 ± 4.5; P Conclusions: Our findings are suggestive of the hypothesis that neurologic injury leading to early-onset seizures often occurs before the intrapartum period. (Am J Obstet Gynecol 2000;182:1452-7.)

Medical malpractice lawsuits, generally require expert testimony. Defendants and plaintiffs deserve expert testimony that is exacting, accurate, and consistent. A study of four frequently testifying experts was undertaken with review of depositions, reports, and trial transcripts of those experts. Contradictions in claimed medical principles from one case to the next were found and examples were cited for each expert. The review suggested that expert testimony regarding the standard of care may be neither reliable nor accurate for the purposes of judging physician conduct is lawsuits. Presently, no peer review or sanction process has been implemented to ensure accuracy and reliability of expert testimony used in medical malpractice lawsuits. We recommend changes that would include independent court-appointed experts, central filing of opinion letters by experts with authoritative text citations, and a sanction process by courts and/or authorized boards for testimony that is deemed inaccurate, false, or contradictory to the standard of care.

OBJECTIVE: Intrauterine growth retardation associated with fetal chromosome anomalies is usually documented on ultrasonography late in the second trimester. However, we believe and attempt to document here that the impact of aneuploidy on fetal growth is evident much earlier (i.e., the aneuploid fetus may appear smaller than dates on ultrasonography even in the first trimester). STUDY DESIGN: For the population referred to our center for chorionic villus sampling from January 1988 to July 1991, we compared gestational age as calculated from the last menstrual period to that derived from fetal size as measured by crown-rump length. A cutoff of 7 days was chosen to select the study group. The remainder of our chorionic villus sampling population in which fetal size was expected was used as controls. We also divided those chorionic villus sampling patients by when a fetal death was observed by size. RESULTS: In the study period 3194 chorionic villus sampling procedures were performed and in 277 (8.7%) fetal length was smaller than expected by at least 7 days. Sixty (1.9%) chromosome anomalies were diagnosed by first trimester chorionic villus sampling in the study period. The frequency of chromosome anomalies was 4.3% in the study group and 1.7% in controls (p \lt 0.004). The more aberrant the karyotype on “postmortem chorionic villus sampling,” the greater the growth retardation tended to be. CONCLUSIONS: In our chorionic villus sampling population a fetal crown-rump length smaller than dates is associated with a significant increase in risk of chromosome anomalies. Moreover, the larger the size-dates discrepancy, the higher the possibility that the aneuploidy affecting that pregnancy is of the severe or lethal type. (AM J OBSTET GYNECOL 1992;167:1525-8.)

Objective The purpose of this study was to determine the impact of operative vaginal delivery (forceps or vacuum) and midline episiotomy on the risk of severe perineal trauma. Study design In this retrospective cohort study, we assessed the impact of maternal and obstetric factors on the risk of development of severe perineal trauma (third- and fourth-degree perineal lacerations) for all singleton, vertex vaginal live births (n = 33,842) between 1996 and 2003. Results Among nulliparous women, 12.1% had operative vaginal delivery, 22.4% had midline episiotomy, and 8.1% experienced severe perineal trauma. Among multiparous women, 3.4% had operative vaginal delivery, 4.2% had midline episiotomy, and 1.2% experienced severe perineal trauma. Controlling for maternal age, ethnicity, birth weight and head circumference, evaluation of the interaction of episiotomy and delivery method revealed that forceps (nulliparous women: odds ratio [OR] 8.6, 95% CI 6.5-10.7; multiparous women: OR 26.3, 95% CI 18.1-34.5) and episiotomy (nulliparous women: OR 4.5, 95% CI 3.7-5.4; multiparous women: OR 14.6, 95% CI 10.4-20.5) were consistently associated with the increased risk of anal sphincter trauma. In fact, the magnitude of effect of the statistically significant synergistic interaction was evidenced by more than 3-fold excess of risk of using operative vaginal delivery alone. Conclusion The use of operative vaginal delivery, particularly in combination with midline episiotomy, was associated with a significant increase in the risk of anal sphincter trauma in both primigravid and multigravid women. Given the reported substantial long-term adverse consequences for anal function, this combination of operative modalities should be avoided if possible.

Objective The release of nitric oxide by tumor cells, through the stimulation of inducible nitric oxide synthase expression, may play a critical role in ovarian cancer progression. In this study we have sought to determine the effects of inhibiting inducible nitric oxide synthase on angiogenesis that was induced by 2 ovarian cancer cell lines, SKOV and MDAH2774. Study design Real-time polymerase chain reaction and enzyme-linked immunosorbent assay techniques were used to determine the expression levels of inducible nitric oxide synthase and vascular endothelial growth factor in the ovarian cancer cell lines in response to treatments with l -NAME, an inhibitor of nitric oxide synthase, and SNAP, and nitric oxide donor. Ovarian cancer–induced angiogenesis was assessed in vitro with an established assay that is based on the ability of human umbilical vein endothelial cells to form a tubular network in response to angiogenic agents. Results SKOV and MDAH2774 cell lines exhibited over-expression of inducible nitric oxide synthase and have high baseline nitric oxide levels. This was associated with high levels of vascular endothelial growth factor production and angiogenesis induction. Treatment of the ovarian cancer cell lines with l -NAME significantly reduced vascular endothelial growth factor levels production and completely inhibited angiogenesis. In contrast, treatment with SNAP significantly increased vascular endothelial growth factor levels and increased angiogenesis in both cell lines. Conclusion Our data suggest that the inhibition of inducible nitric oxide synthase may form a basis for a novel therapeutic treatment option for ovarian cancer therapy.

Objective The purpose of this study was to evaluate pregnancy outcomes before and after diagnosis of lupus. Study design Successive selection criterion applied to 148 lupus and 78,905 non-lupus pregnancies, generated 3 groups: lupus group, 84 pregnancies (not-yet-diagnosed group, 15 women; already-diagnosed group, 69 women), and control group, 51,000 pregnancies. Three-way analysis of variance and the chi-squared test were used for analyses. Results Stillbirth outcome was increased in the lupus group compared with the control group (odds ratio, 4.84 [95% CI, 1.72,11.08]); the not-yet-diagnosed group (odds ratio, 9.89 [95% CI, 1.09,42.63]), and the already-diagnosed group (odds ratio, 3.85 [95% CI, 1.02,10.31]). Considering >1 pregnancy per patient would have overestimated the stillbirth rate. Stillbirth risk was increased significantly in severe maternal disease that was marked by central nervous system involvement. The already-diagnosed group had more hypertensive complications (P = .001 and .0001). Both lupus groups showed a significantly greater proportion of preterm births (P = .03), growth restriction (P = .019), and infants in the very low birth weight category (P = .021) compared with the control group. Conclusion Poor fetal outcomes are seen in pregnancies that are complicated by lupus, even before clinical appearance of disease, which supports a predisease state.

The purpose of this study was to examine the effects of prolonged in utero meconium exposure on adult learning and memory, as measured by the Morris water maze.Timed pregnant Long-Evans rats were studied. On gestational day 20 (term, 21 days of gestation), laparotomy was performed, and each maternal animal received an injection of clear amniotic fluid or meconium-stained amniotic fluid into each gestational sac. The laparotomy incision was closed, and the animals received postoperative monitoring through delivery. On postnatal days 145 to 148, the offspring underwent Morris water maze testing. The mean (+/-SEM) for the latency time was reported for each day's trial and compared between groups.There were significant differences between meconium-stained amniotic fluid group and clear amniotic fluid group in the mean time to platform on day 1 (82.7 +/- 1.8 seconds vs 75.9 +/- 3.0 seconds; P=.04), day 2 (60.5 +/- 3.5 seconds vs 47. 8 +/- 4.6 seconds; P=.03), and day 3 (56.5 +/- 4.5 seconds vs 34.7 +/- 4.4 seconds; P=.001). However, there were no differences on days 4 and 5. There were also no differences between recall and response learning trials that were done after a 12-day retention period.In the absence of hypoxia or infection, prolonged in utero meconium exposure is associated with a delay of spatial learning in the adult rat.

We studied 1991 Gulf War (GW)-related environmental exposures and adverse birth outcomes in Iraqis. A random cross-sectional sample of 307 Iraqi families that immigrated to the United States respon ...

Objective: Our aim was to determine whether cocaine use increases neonatal morbidity in patients with preterm premature rupture of membranes. Study Design: We reviewed records of pregnancies that were complicated with preterm premature rupture of membranes between 24 weeks to 34 weeks of gestation. Clinical characteristics and neonatal outcomes of patients who had positive results for cocaine in the urine were compared with patients with negative test results. Results: During the study period, 16.1% (85/528 patients) had a positive result in a urine screen for cocaine use. Patients who used cocaine were older and of higher gravidity and parity. When major neonatal morbidities were compared, there was improvement in morbidities that were linked to neonatal infection in patients with positive test results for cocaine, including pneumonia (3.5% vs 11.7%; P =.012) and sepsis (5.9% vs 14.7%; P =.016). Jointly, neonatal outcomes were significantly worse in the negative cocaine group (χ 2 = 5.143; P =.023). Conclusion: The association of preterm premature rupture of membranes with major neonatal morbidity was unexpectedly and significantly weaker in pregnancies complicated by cocaine use. (Am J Obstet Gynecol 2002;186:1150-4.)

As we have previously published, small-for-gestational-age (3% birthweight [BW]) newborns exhibit catch-up cognitive functioning by age 2 years. Our objective was to compare cognitive functioning in children born with ≥90% vs 5-89% BW for gestational age (WGA) between 9 months and kindergarten.Nonanomalous singletons from Early Childhood Longitudinal Study-Birth Cohort with BW ≥90% vs 5-89% were compared. Cognitive and academic functioning was measured at 4 time points: 9 months, and 2, 3.5, and 5.5 years. Associations between WGA and cognitive functioning at each time point was examined using confounder-adjusted general linear model-based methods.Of 2930 cases, 271 (9.2%) were ≥90% WGA. In terms of cognitive performance, children ≥90% WGA were not statistically different (P = .068) from normal WGA at any time point, nor did they change at different rates across early childhood.There is no difference in cognitive function in children with BW 5-89% vs ≥90% for GA.

Objective: This study was undertaken to compare the birth outcomes of a multifetal pregnancy reduction population with those of other patients delivered at Hutzel Hospital, Detroit, and to determine the fiscal impact of the multifetal pregnancy reduction program. Study Design: In a retrospective review patients who were delivered after multifetal pregnancy reduction were compared with a general obstetric population who were delivered at Hutzel Hospital from January 1, 1986, through June 30, 1998. Outcome data were determined through a comprehensive perinatal database. The χ 2 analysis was used to examine the relationship between gestational age and delivery group. Financial data were estimated from published reports of neonatal intensive care unit admissions, cost estimates for neonatal intensive care unit care, and charges for multifetal pregnancy reduction. Results: Pregnancies reduced to triplets, twins, and singletons had outcomes at least comparable to unreduced pregnancies starting at these numbers and substantially better than unreduced pregnancies with the same starting number. Financial estimates of hospitalization costs averted in the multifetal pregnancy reduction population exceeded $28 million. Conclusion: Use of multifetal pregnancy reduction improved obstetric outcomes for pregnancies with multiple gestations and also was associated with significant fiscal savings. (Am J Obstet Gynecol 2000;182:1575-80.)

Objective: Our goal was to improve the accuracy of estimating fetal weights among macrosomic fetuses with the traditional measurements of abdominal circumference, femur length, and head circumference. Study Design: We used 4831 cases without anomalies from an ultrasonography laboratory database with an estimated fetal weight obtained a maximum of 14 days before delivery. Abdominal circumference, femur length, and head circumference were each regressed on birth weight to obtain estimated fetal weight by abdominal circumference, femur length, and head circumference, respectively. We compared the individual variation for estimated fetal weight by abdominal circumference, femur length, and head circumference by calculating a within-subject standard deviation to quantify the level of disparity. We adjusted the estimated fetal weight to the date of delivery and for dependencies on maternal diabetes mellitus, weight, and height. We then weighted cases with birth weight >4500 g and diabetic cases with birth weight >4000 g 20-fold (weighted estimated fetal weight) for the purpose of creating a favorable bias for classifying these cases. The equation of Hadlock et al, with abdominal circumference, femur length, and head circumference, was applied as a benchmark estimated fetal weight. Results: Of the 4831 newborns, 308 (6.4%) had a birth weight >4000 g, and 56 (1.2%) had a birth weight >4500 g. There were 154 pregnancies complicated by diabetes mellitus; 26 (16.9%) of the resulting infants weighed >4000 g, and 5 (3.2%) weighed >4500 g. At 95% specificity, the weighted estimated fetal weight had a sensitivity of 85.7% at a cut point of 3912 g, compared with a sensitivity of 71.4% at 3604 g by use of the estimated fetal weight of Hadlock et al. Conclusions: We were able to improve the accuracy of identifying the macrosomic fetus compared to reliance on the equation by Hadlock et al. A fetus was found to be at significantly increased risk for birth weight >4000 g when the estimated fetal weight based on abdominal circumference is larger than that based on either head circumference or femur length or when there is a large within-subject variance in estimated fetal weight based on abdominal circumference, femur length, and head circumference. We also found that there were significantly different groups of patients whose estimated fetal weights require different equations for better estimates. Even given ultrasonographic measurements, taking into account maternal height, weight, and presence of diabetes mellitus can improve macrosomia detection. Although these findings remain to be optimized and validated, the approach used here appears to yield better predictions than the current "one function fits all" approach. (Am J Obstet Gynecol 2000;182:1489-95.)

OBJECTIVE: Gaussian equation curves are used to generate baseline curves against which a priori maternal age Down syndrome risks are adjusted to develop likelihood ratios for individual patients. We sought to evaluate the accuracy of these calculations, minimize the affects of outliers, and to make improvements. STUDY DESIGN: Gaussian distribution functions were used to investigate the best model for α-fetoprotein and free β-human chorionic gonadotropin multiples of the median with use of nonlinear regressions. Parameters from distribution functions can be used to compute a more precise likelihood ratio for the decision logic for trisomy 21. A total of 58,297 normal cases and 348 cases of trisomy 21 were computed. RESULTS: Log normal distribution functions generated by nonlinear regression produced excellent but exaggerated goodness of fit R 2 to the frequency distributions of the data. For normal cases values were as follows (in mean, SD, and R 2 , respectively): log α-fetoprotein –0.07199, 0.15681, and 0.9970; log β-human chorionic gonadotropin –0.15203, 0.24284, and 0.9987. For trisomy 21 cases the values were (in mean, SD, and R 2 , respectively) for log α-fetoprotein –0.19303, 0.15802, and 0.9828 and for log β-human chorionic gonadotropin 0.19996, 0.29760, and 0.9669. Distributions reconstructed with use of statistical means and SDs generated goodness of fit R 2 from 0.585 to 0.914. Use of means and SDs derived from distribution functions increased the R 2 to 0.855 and 0.999. The change in the model produces, at a 5% false-positive rate, a sensitivity of 57.18% (199/348). A 1 in 113 cutoff point risk is obtained and is tighter than the 1 in 251 without the distribution functions, as versus 1 in 270 by age calculations alone. CONCLUSIONS: Our data suggest that (1) normality of log transforms of α-fetoprotein and normality of log transforms of β-human chorionic gonadotropin are reasonable models, (2) distribution functions can minimize the effect of outliers, which produces more realistic risk estimates, and (3) the effect of distribution functions versus standard mean and SDs cannot automatically be extrapolated to other parameters, which must be tested individually. (Am J Obstet Gynecol 1997;177:882-6.)

OBJECTIVE: Our purpose was to determine the specific likelihood of different aneuploidies by gestational age in patients with nuchal folds and simple and septated nuchal membranes. STUDY DESIGN: Retrospective database analysis was performed of 158 consecutive patients with a nuchal fold or simple or septated nuchal membrane on either abdominal or vaginal ultrasonography. RESULTS: Thirty-eight patients with nuchal folds, 65 with simple nuchal membranes, and 55 with septated nuchal membranes were evaluated. Septated nuchal membranes were associated with the highest incidence of karyotypic abnormalities (>50%). A peak incidence of trisomy 21 (27%) was found in the early midtrimester, leveling off to 11% by the late midtrimester. The late first trimester had a high incidence of trisomy 18 (22%), occurring more frequently than 45,X. CONCLUSION: Ultrasonographic anomalies in the posterior neck are associated with aneuploidy from 21% to 58% of the patients in this selected population. Each anomaly has different risks for aneuploidy type, varying with gestational age at diagnosis. (Am J Obstet Gynecol 1996;175:995-9.)

OBJECTIVE: There has been a gradual shift of the focus of prenatal diagnosis from genetics to ultrasonography. We assessed our primary genetics approach to determine what would be missed without the genetics component. STUDY DESIGN: We evaluated referral indications for patients with normal and abnormal prenatal findings from Jan. 1, 1990, to March 31, 1995, and categorized them according to type of fetal anomalies and genetic abnormalities found. Discordance among initial indication, identified risk factors, and observed abnormalities was assessed. RESULTS: The proportion of patients referred for very-high-risk indications increased over time; 13.5% of all patients (1992 of 14,725) had abnormalities. Abnormal outcomes were categorized as 26% chromosomal, 58% ultrasonographic dysmorphologic features, 11% biochemical or deoxyribonucleic acid disorders, 5% infectious, and 11% other. Of the cases of ultrasonographic dysmorphism (exclusive of the aneuploidies), 3.5% were ultimately determined to be syndromic and 2.5% to be discrepant, that is, having a different abnormality than the referred diagnosis. Including the whole spectrum of disorders seen, half of the abnormalities would not be detectable with even high-quality ultrasonography. CONCLUSION: A large number of abnormal findings were not consistent with initial indication for referral. Correct diagnosis depended on increased acuity provided by genetic pedigree analysis and recognition of syndromes. Diligence in the search for associated anomalies, aneuploidy, pedigree analysis, and syndromic abnormalities remain critical components in the differential diagnosis. The elucidation of unexpected findings suggests the advantages of early counseling and a genetics-based approach combined with tertiary ultrasonography rather than primary ultrasonography with counseling only when anomalies are detected. (Am J Obstet Gynecol 1996;174:1925-33.)

We examined the accuracy of computer-generated admission forms to standardized handwritten admission forms for 40 patient records. There was a mean of 8.3 errors among handwritten forms but only 0.9 errors among computerized forms (p < 0.0001). Written forms had seven serious errors versus one for computerized forms (p < 0.05). We conclude that computerized admission forms have superior accuracy.

OBJECTIVE: Our purpose was to assess the efficacy of double- and triple-screening paradigms for Down syndrome and to develop a more logical, statistical approach to risk prediction that will decrease the cost of screening and allow the incorporation of new parameters appropriately weighted for their contribution. STUDY DESIGN: Data from 24,504 patients who had biochemical screening for Down syndrome by single (α-fetoprotein), double (α-fetoprotein, β-human chorionic gonadotropin), or triple screening (α-fetoprotein, β-human chorionic gonadotropin, unconjugated estriol) who had complete outcome information were analyzed by (1) existing guassian-based methods, (2) the Glasgow ratio method, and (3) a new statistical approach (i.e., directly adjusted data sets for discriminant eneuploidy detection [DADs]). RESULTS: By use of individual risk-based thresholds for “at risk” status, both double and triple screening performed far better than single screening, but the percentages of patients at risk varied widely. When the percentages at risk were held constant, the sensitivity of double and triple screenings was similar, suggesting that there are no benefits of using estriol as a third marker. For 25,000 patients the use of only α-fetoprotein and β-human chorionic gonadotropin would save about $500,000, with no decrease in sensitivity. With the DADs approach a statistically sound model giving more stable estimates was developed that permits each factor to be analyzed for its own explained proportion of variance and allows each parameter to have different weighting. For this data set the same sensitivity was seen with, conservative, a 1% reduction in the percentage of patients at risk, which would reduce by 250 the number of amniocenteses, at a further savings of about $400,000. CONCLUSIONS: By use of existing methods, double screening is equally as effective as triple screening, so that the expense of estriol is unnecessary. The DADs approach, by allowing for variable weighting of parameters, lowers the at risk percentage and will permit a much more flexible approach as new parameters become available. Changing to DADs and eliminating estriol should achieve higher specificity for the same sensitivity and save, conservatively, about $900,000 in this series. Extrapolated nationally, if confirmed, the annual savings could approach $72,000,000.

T-ACER3 reduces T-ACE false positives Lisa Chiodo, Robert Sokol, John Hannigan, James Janisse, Grace Patterson, Virginia Delaney-Black Wayne State University School of Medicine, Pediatrics, Detroit, MI, Wayne State University School of Medicine, Obstetrics and Gynecology, Detroit, MI, Wayne State University School of Medicine, Family Medicine, Detroit, MI, Wayne State University School of Medicine, Children’s Research Center of Michigan, Detroit, MI OBJECTIVE: Preventing Fetal Alcohol Spectrum Disorders (FASD) depends on obstetricians detecting maternal risk drinking during antenatal care. ACOG and NIAAA recommend using the T-ACE, an economical/sensitive screen. We have reported that a more stringent T-ACE total score cut-point (3 vs. 2) increased specificity in identifying maternal risk drinking & alcohol-related neurobehavioral dysfunction in children (Chiodo et al, 2010). Our aim was to assess how increasing the T-ACE cut-point could increase efficiency of clinical practice. STUDY DESIGN: Self-reported peri-conceptional & in-pregnancy drinking were assessed with semi-structured interviews and alcohol screens in a prospective sub-sample of 239 African-American mothers given an in-pregnancy T-ACE. The original T-ACE risk criterion (total score of 2) and the revised T-ACER3 criterion with a total score of 3 were analyzed. ANOVA and post-hoc comparisons compared preand in-pregnancy alcohol consumption quantity and frequency measures by risk category. Categories were: 1) No Risk Group (NRG) no risk for pregnancy alcohol use based on both T-ACE and T-ACER3 criteria (n 140); 2) At Risk Group (ARG) based on both T-ACE and T-ACER3 criteria (n 28); and 3) Change Risk Group (CRG) identified as at-risk with the original T-ACE criterion but not at-risk using the revised T-ACER3 criterion (n 71). RESULTS: The 71 women (30%) in the Change Risk Group (CRG) had patterns of alcohol use similar to the no risk group (NRG). As predicted, post-hoc analysis revealed that the at-risk group (ARG) had significantly more alcohol use both prior to and during pregnancy than either the NRG or CRG groups. CONCLUSION: The results provide further evidence that adjusting the T-ACE total score cut-point to 3 in the T-ACER3 is clinically appropriate. Using the T-ACER3 criteria, only 12% of women would require intervention, compared with 41% for T-ACE. Increasing the total T-ACE score criterion from 2 to 3 results in fewer “false positives,” allowing a more intensive targeted clinical response with pregnant women correctly identified by the T-ACER3 as drinking at fetal risk levels. 576 Excess gestational weight gain leads to post-partum weight retention Shilpi Mehta-Lee, Linzhi Xu, Jennifer Lischewski Goel, Mindy Brittner, Peter Bernstein, Karen Bonuck NYU Langone Medical Center, Obstetrics & Gynecology, New York, NY, Albert Einstein College of Medicine, Department of Family and Social Medicine, Bronx, NY, UMDNJRobert Wood Johnson Medical School, Medical School, New Brunswick, NJ, Albert Einstein College of Medicine/Montefiore Medical Center, Obstetrics & Gynecology and Women’s Health, Bronx, NY OBJECTIVE: Excessive gestational weight gain (GWG) has been linked to post-partum weight retention and long-term adverse health outcomes. We sought to determine if patients at 2 Bronx health clinics with excess GWG by Institute of Medicine (IOM) guidelines were more likely to have post-partum weight retention than those who gained at or under the recommended guidelines. STUDY DESIGN: Data are from participants in 2 randomized, controlled trials of pre-natal care based breastfeeding interventions. 941 women with 12-26 week, singleton pregnancies, were enrolled from 2008-2010. Those with pre-pregnancy self-reported weight and height, and a post-partum weight available were included. 2009 IOM guidelines were used to define excess GWG by BMI category. Postpartum weight retention was calculated using a measured weight at the first post-partum visit minus self-reported pre-pregnancy weight. Multivariate analysis of covariance was employed to compare the mean post-partum weight retention by normal v. excess GWG. RESULTS: 404 women met inclusion criteria. Demographic characteristics were similar between groups. Women with excess GWG were more likely to have higher pre-pregnancy BMI (28.6[6.2] v. 27.3[6.2]; p 0.041), deliver at a later gestational age (39.2[1.8] v. 38.6[2.4] weeks; p 0.009) and enroll in WIC (54% v 37%; p 0.001). (Table) In multivariate analysis adjusted for age, parity, race, pre-pregnancy BMI, WIC use, employment, education and the number of weeks post-partum, women gaining within recommended IOM guidelines had retained a mean of 7.2 lbs. at their first post-partum visit, whereas those with excess GWG had mean weight retention of 23.7 lbs, a difference of 16.6 lbs (p 0.001). CONCLUSION: In an urban prenatal population, excess GWG was predictive of higher post-partum weight retention regardless of age, weight, BMI, race, socioeconomic indicators, or weeks post-partum. This weight retention can have long-term consequences. This increased risk of weight retention should be added to the list of poor outcomes associated with excess GWG, and interventions are needed to address this issue postpartum. PosterSessionIV Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health www.AJOG.org

Objective The purpose of this study was to investigate the association between large-for-gestational-age (LGA) infants and the development of childhood obesity in an inner-city primarily African American population. Study Design Maternal, neonatal, socioeconomic, and nutritional histories were collected for mothers with children who were 2-5 years old. Associations between Alexander and customized birthweight percentiles and body mass index for the age of the child were examined. Results One hundred ninety-five mother-child pairs were enrolled; the childhood obesity rate was 18%. Increasing Alexander and customized birthweight percentiles were related to increasing obesity. LGA newborn infants were 2.5 times more likely to be obese in childhood than average size newborn infants. Maternal smoking was also associated with childhood obesity. Conclusion LGA infants have the highest likelihood of childhood obesity in this inner-city predominantly African American population. Customized growth percentiles perform best in the identification of the highest risk population.

Objective The objective of the study was to estimate the maternal and neonatal morbidities associated with obstructive sleep apnea (OSA) in pregnancy. Study Design Women delivering between 2000–2008 with confirmed OSA in an academic center were included. Normal-weight and obese controls were randomly selected at a 2:1 ratio. Maternal and neonatal morbidities were compared between the groups. Multivariate analyses were performed to evaluate maternal morbidity and preterm birth (PTB). Results The analysis included 57 pregnancies complicated by OSA. Compared with normal-weight (n = 114) controls, OSA patients had more preeclampsia (PET) (19.3% vs 7.0%; P = .02) and PTB (29.8% vs 12.3%; P = .007). Controlling for comorbid conditions, OSA was associated with an increased risk of PTB (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.02–6.6), mostly secondary to PET (63%). Cesarean delivery (OR, 8.1; 95% CI, 2.9–22.1) and OSA were associated with maternal morbidity (OR, 4.6; 95% CI, 1.5–13.7). Conclusion Pregnancies complicated by OSA are at increased risk for preeclampsia, medical complications, and indicated PTB.

To describe maternal body mass index and to compare the use of maternal weight and body mass index for risk assessment at the initial prenatal visit, 6270 gravid women who were consecutively delivered of infants were studied. Body mass index increased with advancing maternal age, parity, and advancing gestational age and was significantly greater in black women than in nonblack women. Risks for the development of adverse outcome associated with maternal obesity, including development of gestational diabetes, preeclampsia, fetal macrosomia, and shoulder dystocia, were comparably predicted by either maternal weight or body mass index greater than 90th percentile. Maternal weight was as predictive of preeclampsia, macrosomia, and shoulder dystocia as was body mass index when these factors were analyzed as continuous variables, whereas increasing body mass index was more predictive of gestational diabetes. The prediction of factors associated with low maternal weights, small-for-gestational-age birth, prematurity, low birth weight, and perinatal death was equivalent for maternal weight and body mass index that was less than 10th percentile. This study indicates that in the initial risk assessment of outcomes related to maternal weight, the calculation of maternal body mass index offers no advantage over simply weighing the patient. This finding contrasts with results in nonpregnant women.