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It was hypothesized that prenatal exposure to cocaine and other substances would be related to delayed expressive language development. Speech and language data were available for 458 6-year olds (204 were exposed to cocaine). No significant univariate or multivariate differences by cocaine exposure group were observed. Classification and regression tree modeling was then used to identify language variable composites predictive of cocaine exposure status. Meaningful cut points for two language measures were identified and validated. Children with a type token ratio of less than 0.42 and with fewer than 97 word types were classified into a low language group. Low language children (n = 57) were more likely to be cocaine exposed (63.1%), with cocaine-exposed children 2.4 times more likely to be in the low language group compared with control children after adjustment for covariates. Prenatal cigarette, but not alcohol exposure, was also significantly related to expressive language delays.

Although many studies have examined the development of children of male alcoholics, few studies have considered substance use by the female caregiver. This study evaluated the relationship between substance use by female caregivers and factors that affect the child-rearing environment.A total of 480 inner-city African-American women were recruited during pregnancy for a longitudinal study of the effects of prenatal alcohol use and substance use by caregivers on the development of their children. All women were screened for alcohol consumption at their first prenatal visit to a large urban maternity hospital. Those who averaged seven or more drinks per week (0.5 oz absolute alcohol per day) at the time of conception were invited to participate in the study, as was a 5% random sample of lighter drinkers and abstainers. At the 7.5-year follow-up assessment, the quantity and frequency of alcohol consumption and drug use, as well as several measures of the child-rearing environment, were assessed for 231 of the caregivers.Current alcohol use was uncorrelated with standard demographic factors, such as socioeconomic status, but was related to poorer family functioning, lower quality of parental intellectual stimulation, and higher levels of domestic violence. There were independent effects of illicit drug use on family environment, domestic violence, and caregiver depression. History of drinking during pregnancy, however, was not related to the current child-rearing environment. Poorer parental functioning generally was found only among the caregivers who currently drank both heavily (six or more drinks/occasion) and frequently (three or more days/week). After controlling for lifetime alcohol problems, current drinking still predicted a less cohesive and organized family environment and higher levels of domestic violence.Current heavy, frequent drinking in this relatively homogenous, economically disadvantaged sample was unrelated to demographics and seemed to have an important negative impact on the quality of the child-rearing environment, whereas drinking during pregnancy was unrelated to the current child-rearing environment.

Considerable variation in offspring outcome is observed after intrauterine alcohol exposure. The underlying mechanism may include genetic diversity in the enzymes responsible for alcohol metabolism. Of the known genetic polymorphisms, differences at the alcohol dehydrogenase-2 locus (ADH2) are likely most critical because the resulting enzymes are30-fold different in their kinetic constants. To test whether differences in maternal or offspring ADH2 genotype are determinants of risk for alcohol-related birth defects, maternal-infant pairs (n = 243) were enrolled on the basis of maternal alcohol intake during pregnancy and maternal ADH2 genotype. Infant outcome was measured using the Bayley Scales of Infant Development Mental Index (MDI) at 12 months of age. Drinking during pregnancy was associated with lower MDI scores but only in the offspring of mothers without an ADH2*3 allele (P.01, analysis of variance, post hoc). The offspring of drinking women with at least one ADH2*3 allele had MDI scores similar to those of nondrinking women of either ADH2 genotype. Lower MDI scores were associated with the three-way interaction among increasing alcohol intake and maternal and offspring absence of the ADH2*3 allele (P.01, multiple linear regression). We suggest that the protection afforded by this allele is secondary to its encoding of the high-Km/high-Vmax ADH beta3 isoenzyme, which would provide more efficient alcohol metabolism at high blood alcohol concentrations. These observations are supportive of alcohol, rather than acetaldehyde, being the more important proximate teratogen and are the first observations of a specific genetic explanation for susceptibility differences to alcohol-related birth defects.

Regular, heavy alcohol intake results in transferrin that is deficient in carbohydrate moieties. Carbohydrate-deficient transferrin (CDT) has been used as a biologic marker of heavy alcohol exposure in nonpregnant humans. There have been no reports of CDT levels in pregnancy. Our objective was to determine maternal and cord blood levels of CDT. Parturients were recruited at delivery based on graded representative alcohol consumption, from abstainers to heavy drinkers, as determined by screeners skilled at eliciting drug and alcohol histories. Maternal and cord blood serum samples were obtained at delivery. A double antibody radioimmunoassay was used to determine CDT in each sample. There were 83 paired specimens analyzed by paired t tests and stepwise regression analysis. Cord blood CDT units/liter (44.0 +/- 29.5) were significantly (P0.0001) higher than maternal (18.4 +/- 7.0). Maternal and cord CDT did not correlate with race, perinatal risk score, gestational age at delivery, birth weight, Apgar scores, or reported alcohol intake. Maternal CDT levels had a significant negative correlation with cigarette smoking. Cord blood CDT levels are significantly higher than maternal. While regular, heavy alcohol consumption by adults results in serum transferrin deficient in carbohydrate moieties, the reason for elevated fetal CDT is unknown.

To examine the relationship between maternal methadone exposure and neonatal head circumference and abstinence syndrome, we examined the records of 172 opiate-addicted gravidas enrolled in a methadone maintenance program in an urban hospital over a 2-year period. Higher doses of methadone in the third trimester were associated with increased head circumference reflecting both increased gestational duration and improved overall growth. Neonatal withdrawal was positively correlated with gestational age at delivery and race, with nonblack infants exhibiting higher neonatal abstinence scores than blacks following adjustment for maternal dose and gestational age at delivery. Selection of optimal methadone dosage is a complex problem in which the favorable neurobehavioral outcome associated with increased growth and gestational age must be weighed against the risks associated with more severe neonatal withdrawal. Our findings of improved overall fetal growth and gestational duration associated with higher methadone doses suggest that more liberal methadone dosing in pregnancy may improve long-term neonatal outcome.

Traditional Gaussian approaches to biochemical screening make calculations very cumbersome. We have sought to develop a logistic regression mathematical model for the calculation of risk for trisomy 21 in multiple marker screening that would be more "user friendly." Biochemical screening data from 15,444 patients with confirmed normal outcomes and 28 with trisomy 21 were analyzed by logistic regression analysis (LRA) to produce a direct mathematical approach to risk calculation that combines the improvements in sensitivity and specificity already demonstrated by us with extreme value cumulative function surface fittings, but which can be extended for other exploratory variables. LRA yields a 71.4% sensitivity with a 95% specificity which is comparable to our previously published discriminant aneuploidy detection (DADs) approach; both are an improvement over the commonly used Gaussian approach of risk assessment. In our study population, LRA performed as well as DADs; both performed better than the Gaussian method, and LRA is a simpler approach.

In order to study red cell autoantibodies with ABO specificity, the records of 4668 patients seen over 32 years were examined. Five group A patients had high thermal amplitude cold agglutinins showing anti-A, -A1 or -AI specificity; none had ever received blood or blood products. They presented as chronic cold haemagglutinin disease, autoimmune haemolytic anaemia or were discovered during investigation of pregnancy, carcinomatosis or anaemia. In vivo haemolysis was evident in all but the antenatal case; only the patient with autoimmune haemolytic anaemia required treatment, responding well to steroids. ABO-specific autoantibodies thus appear similar in reactions and clinical manifestations to autoantibodies in general.

403 black, inner-city infants born to women recruited prenatally on the basis of their alcohol consumption during pregnancy were assessed on a battery focusing on information processing and complexity of play. Prenatal alcohol exposure was not related to visual recognition memory or cross-modal transfer of information but was associated with longer fixation duration, a measure indicative of slower, less efficient information processing; lower scores on elicited play; and longer periods of toy exploration, possibly also due to slower cognitive processing. The effects on processing speed and elicited play were dose-dependent and not attributable to maternal depression, parental intellectual stimulation, other prenatal drug exposure, or postpartum maternal drinking. The processing speed deficit is consistent with deficits in older children prenatally exposed to alcohol; the present study is the first to identify slower cognitive processing in infancy and in tasks not dependent on motoric proficiency.

To assess the increased public assistance costs resulting from Michigan's 1988 ban on Medicaid funding of abortions.The increased number of births resulting from the Medicaid abortion funding ban was estimated. The costs of this increase in births to the state and federal governments were then calculated.Using low and high estimates for the numbers of additional children born as a result of Michigan's prohibition of Medicaid abortion funding (2120 and 5800), and the likelihood of these children's remaining on welfare, the 1991 cohort of infants will cost the state's taxpayers $23.1-63.2 million--several times the $6-7 million cost of the abortions, had they taken place. Including the federally paid share, total incremental costs are $50.2-137.4 million.Those who have advocated banning Medicaid funding of abortions to reduce government spending, as in Michigan in 1988, have ignored the much greater cost of requiring that those pregnancies be carried to term.

The MST appears to have theoretical rationale, predictive utility, simplicity, safety, and low cost that suggests that its routine use in prematurity prevention may ultimately save significant health care dollars. Presently, the MST should be used as an adjunct to prenatal care until further and more definitive investigation has been conducted; however, it seems promising that the MST will provide some reassurance in patients with negative tests and signify patients that are at significant risk for premature delivery (positive MST). It is hoped that further investigation will validate the MST's use in prematurity prevention in order to help decrease the incidence of preterm delivery.

Late pregnancy fetal karyotyping is not employed often because a clinical decision about labor and delivery may be required before the results would be available. However, percutaneous umbilical blood sampling (PUBS) has been used recently to obtain fast karyotypes. We have extended our chorionic villus sampling (CVS) procedure to the second and third trimesters and compared the results obtained with late CVS and PUBS. CVS karyotypes were obtained faster and may be technically easier to perform.

A revised estimate of the national economic impact of fetal alcohol syndrome (FAS)-related abnormalities was conducted. The present evaluation included "corrections" for background rates of low birth weight, and costs normally incurred for housing and food regardless of whether an individual requires institutionalization or not. Additional anomalies were included along with hospital costs provided for in diagnostic-related groups. The current estimate for annual costs related to FAS is $249.7 million, which is about $80 million less than our previous estimate. This estimate is lower due to a slightly lower number of cases with low birth weight, a correction for costs that would otherwise have occurred, and exclusion of costs (about $75 million) for annual semi-independent support for individuals with IQs in the 70-85 range. Nonetheless, mental retardation accounts for almost 60% of the estimated total cost. A quarter of a billion dollars per year remains a high economic incremental cost by any reasonable standard and represents a benchmark against which costs of potential prevention strategies may be judged.

Recognition of alcohol-related birth defects is less successful in the neonate than in older children. Clarren et al. (1987) were able to describe the geometry of the FAS face at age 7. To define neonatal facial features of FAS, 3 reference points were used to map 7 frontal and 7 profile landmarks coded as standardized cartesian coordinates. These landmarks were digitized from snapshots of 21 neonates, prospectively diagnosed as FAS blinded for prenatal alcohol exposure, and 76 non-FAS controls. In the controls, race was found to be a significant determinant of landmarks, as expected. Using discriminant analysis and controlling for race, the FAS face was characterized by landmark measurements which correspond to short palpebral fissure, scooping out of the nasal bridge and thin vermilion [F(4,71)-7.8, r sq-30%, p.01]. Jackknifed sensitivity was 75%, specificity, 79%. These findings suggest that FAS-defining features can be quantified in the neonate via computer-based screening of infants from at-risk pregnancies.

Sonograms from 1622 consecutively scanned singleton pregnancies at a mean gestational age of 28.5 weeks were analyzed to determine whether maternal obesity affected visualization of fetal anatomy. Fetal head (cerebral ventricles), heart (four-chamber view), stomach, kidneys, bladder, diaphragm, intestines, spinal column, extremities, and umbilical cord were classified as visualized or suboptimally visualized. Maternal body mass index was used as a measure of relative leanness. No significant impairment of ultrasound visualization was noted until a body mass index above the 90th percentile, when visualization fell by an average of 14.5%. Reduction in visualization was most marked for the fetal heart, umbilical cord, and spine. Among non-obese women, advancing gestation and decreasing body mass index were the most important determinants of visualization. However, among obese women, body mass index was the best predictor of visualization, with no improvement seen with advancing gestation or duration of examination.

Two hundred two poor, mainly black women were studied to assess the effects of selected social, behavioral, and biologic factors on birth weight. A path analysis was used to model hypotheses about the interrelationships among these variables. Six sociocultural factors had direct paths to quality of prenatal care: amount of insurance, delay in telling others about the pregnancy, attitudes toward health professionals, month of gestation in which the pregnancy was suspected, perception of the importance of prenatal care, and initial attitude toward the pregnancy. Together, these factors accounted for 64% of the variance in the quality of prenatal care received. Four variables had direct paths to birth weight: month in which the pregnancy was suspected, quality of prenatal care, hypertension, and substance abuse, which together accounted for 13% of the variance in birth weight. The key findings were the relative impact that the quality of prenatal care, especially the source of care, had on birth weight, and the potential for improving birth outcomes by addressing the negative effects of underlying social factors.

Diabetic retinopathy is the leading cause of blindness between the ages of 24-64 years. The first half of this period corresponds to peak fertility and the childbearing years. The effects of pregnancy on diabetic retinopathy are unclear, but recent studies suggest that pregnancy may be less harmful to the retina of the diabetic subject than was thought previously. Nevertheless, there is reason to believe that at least some women experience a worsening of their retinopathy as a result of pregnancy. Thus, careful ophthalmic evaluation and follow-up are essential for the pregnant woman with diabetes. This should include a minimum of one complete eye examination every trimester and within 3 months postpartum. Color fundus photography and laser treatment are safe, whereas fluorescein angiography, although commonly used to evaluate retinal vascular disease, can usually be avoided during pregnancy.

A multiple regression-based statistical model capable of quantitatively comparing two or more sonographic parameters for the effects of gestational age, variation in fetal growth and error in sonographic measurement is presented and then used to compare the biparietal diameter and femur length as estimators of gestational age in late pregnancy. A total of 311 patients were studied between 24 and 42 weeks' gestation. Variation in fetal growth was expressed as the birth weight percentile for gestational age. Biparietal diameter and femur length correlated equally well with gestational age. However, the biparietal diameter was more than twice as sensitive as the femur length to variation in fetal growth. Femur length had a larger error associated with its measurement. These results suggest that the biparietal diameter and femur length in late pregnancy are equal estimators of gestational age; that the femur length is a more stable estimator of gestational age when fetal growth deviates from normal; and that the femur length is technically more difficult to obtain.

The effect of methadone treatment on the nonstress test (NST) was studied. Thirty narcotic-addicted gravidas on methadone maintenance underwent NSTs, performed and interpreted in a standard manner, before and 1 hour after taking the usual methadone dose. Urines were screened for commonly abused substances on the day of testing. Mean gestation when tested was 34 weeks and mean methadone dose was 26 mg/day. All urines were positive for methadone, six for cocaine, two for opiates, and one for amphetamines. The reactivity of the NSTs performed 1 hour after methadone ingestion was decreased significantly compared with that of tests performed before medication (P less than .04). Decreases in the frequencies of fetal movements and fetal heart rate accelerations were significant (P less than .001 and P less than .01, respectively). These results suggest that methadone treatment altered the morphology of the NST, which may limit the reliability of this test for determining fetal well-being in these high-risk gravidas if time of medication is not taken into consideration.

The etiology of postpartum eclampsia and hypertension remains controversial. Recent reports have suggested a possible idiosyncratic hypertensive reaction associated with the use of bromocriptine mesylate. The purpose of this study was to determine whether bromocriptine, used for lactation suppression, is a risk factor for postpartum hypertension. In 1813 consecutively delivered staff patients, blood pressures at three separate home visits were obtained between 3-21 days postpartum. Postpartum hypertension, defined for the purposes of this study as systolic pressure of 140 mmHg or greater and/or diastolic pressure of 90 mmHg or greater on any of the three home visits, was the dependent variable; bromocriptine exposure was the independent variable. Covariates included age, race, chronic hypertension, pregnancy-induced hypertension, and antihypertensive medication. Discriminant analysis, including the first-order interactions, revealed that race, history of chronic hypertension, pregnancy-induced hypertension, and antihypertensive medication contributed significantly to postpartum hypertension (F (7, 1803) = 107.9; P less than .001, explained variance 30%). Of all the interaction terms, only the bromocriptine by pregnancy-induced hypertension interaction was significant. These findings support the contention that patients with antepartum pregnancy-induced hypertension who receive bromocriptine for lactation suppression are at increased risk for postpartum hypertension. Avoiding the elective use of this drug in patients with pregnancy-induced hypertension might constitute a reasonable clinical response to these findings.

As more women postpone childbearing into their later reproductive years (M. A. Adams, G. P. Oakley, and J. S. Marks, J. Amer. Med. Assoc. 247, 493, 1982), the incidence of cancer in pregnancy is likely to increase. Information regarding the placental transfer and pharmacokinetics of antineoplastic agents is limited. The purpose of this study was to determine the kinetics of 5-fluorouracil, a fluorinated pyrimidine with known nonlinear kinetics (J. M. Collins, R. L. Dedrick, F. G. King, et al., Clin. Pharmacol. Ther. 28, 235, 1980) in a pregnant rat model and compare maternal and fetal disposition. A significant amount of 5-fluorouracil crosses the placenta and the relative fetal exposure increases in a dose-dependent fashion. In the pregnant rat model, 5-FU exhibited nonlinear pharmacokinetics as reflected by an increasing half-life, and a greater than proportional increase in the area under the concentration-time curve (AUC) with increasing dose. Fetal saturation of elimination occurred at a lower dose than in the maternal compartment. The significance of these findings to observed embryotoxicity is discussed in a pharmacodynamic model relating the pharmacokinetic behavior of a drug to its embryotoxic effects.

A prospective controlled study of the effect of fetal alcohol on infant development was performed. Twelve infants were identified as possibly having fetal alcohol effects based on the maternal history of alcohol abuse and the neonatal physical examination. Physical characteristics, growth, and development of these infants were compared with those of 12 control infants at birth and at a mean age of 12 months; control infants were matched for gestational age, sex, and race. Data were evaluated by descriptive statistics and analysis of differences between matched pairs of study and control infants. The results showed a significant correlation between the history of heavy antenatal maternal alcohol use and delayed mental and motor development, physical abnormalities, and growth retardation in the infants. This study suggests that infants with fetal alcohol effects can be correctly classified at birth and their outcome accurately predicted.

Herpes simplex virus hepatitis in pregnancy was first reported in 1969. Seven other cases have since been reported, and this communication describes two additional cases. The clinical presentation and laboratory profiles of these two cases parallel those described. Unreported, however, is the sharp contrast between the presentation of pregnant patients with herpes simplex virus hepatitis and the presentation of pregnant patients with other life-threatening forms of hepatitis. Nine of ten patients reported to date have been anicteric with peak total bilirubin levels of less than 1.3 mg/dL before cesarean section or laparotomy. That this presentation may not be unique to pregnancy is suggested by three case reports of fatal, anicteric herpes simplex virus hepatitis in previously healthy, nonpregnant adults. The cause of this phenomenon is unknown.

Advanced extrauterine pregnancy occurs rarely and may present diagnostic difficulty. Failure to induce uterine contractions during oxytocin infusion is a well-established diagnostic technic. The present case suggests that additional newer technics for fetal assessment, including sonography, unstressed monitoring of the fetal heart rate, uterine contractions, fetal movements, and serial urinary estriol determinations may also be useful in diagnosing and managing such complex cas-s.

Quantitative labor data have been reported piecemeal in the literature; there is no previous unified report of the frequencies of each of the dysfunctional labor patterns (DLPs). In order to describe the labor process more clearly a labor diagnostic computer program was used to prospectively study an unselected series of 3,682 nearly consecutive labors from one institution. Cervicometric data for nulliparous and multiparous labor were very similar to the results of others. The absolute frequency with which each DLP was found to occur is compared with results in the literature. Protracted active phase dilatation was the most frequently occurring DLP and prolonged deceleration phase the least frequently occurring one. The relative frequencies of the DLPs, defined as the percentage of all DLPs that occurred, remained reasonably constant, regardless of parity or the absolute frequencies of the DLPs in a group of patients.

An increase in cocaine abuse by pregnant women has been associated with a range of maternal/fetal cardiovascular complications. Intracerebral hemorrhage has been reported as a cocaine-related complication, but has not previously been associated with pregnancy. We report a case of cocaine-associated intracerebral hemorrhage in the postpartum period which complicated the differential diagnosis and management of hypertension and seizures.

Amniotic fluid alpha-fetoprotein (AF-AFP) was measured in 68 pairs of normal twins. Acetylcholinesterase (ACHE) was measured in 23 of those pairs. A significant difference in AF-AFP levels was found in 9/49 (19.4%) of twin pairs of the same sex and 9/19 (47.3%) of twin pairs of opposite sexes (P = .015). Differences in fetal size or gestational age at amniocentesis did not influence the rate of discordant AFP results. ACHE activity was identical in all amniotic fluid samples in twin pairs. In five additional patients, fetal anomalies (three), fetal death or fetal blood in the sample could have affected AFP levels, which were found to be discordant in three of them. Using fetal sex to represent zygosity, the study indicated that discordance in AF-AFP is more common in dizygous twins. The odds ratio for having a discordant AFP result if twins are of different sexes was 4.0. Implications of our data are: (1) in same-sex twins, discordance between sacs is less common, even if only one fetus is affected; (2) the difference in AFP results in twins of the same sex and of different sexes suggests variability in AFP transfer between twin gestational sacs; and (3) ACHE readily diffuses between sacs and cannot be used to determine which twin has an abnormality.

Although cancer complicates pregnancy infrequently, its occurrence jeopardizes maternal and fetal well-being. Treatment with chemotherapeutic agents may adversely affect rapidly dividing fetal tissue, while physiologic changes in pregnancy may alter maternal drug disposition. Previous work on placental transfer and pregnancy-specific kinetics of antineoplastic agents is limited, making the establishment of treatment guidelines for the pregnant cancer patient difficult. Using a pregnant rat model and sensitive HPLC methodology we quantitated the placental transfer and resulting fetal exposure of mitomycin-C (MMC), an alkylating agent. Following maternal dosing, the relative fetal exposure was 6.4%, indicating that MMC does cross the placenta, although to a limited degree. Significant pregnancy-specific alterations in drug disposition, including higher plasma concentrations and decreased clearances in pregnant animals, highlight the need for drug-level monitoring and possible dosage modification when these agents are used in pregnancy.

Human papillomavirus (HPV) has been implicated in the development of cervical intraepithelial neoplasia (CIN). To test the hypothesis that the known relationship between HPV and CIN might be modified by the altered immune status of pregnancy the cytologic, colposcopic and histologic findings in 176 pregnant and 515 nonpregnant patients referred to a colposcopy clinic were prospectively compared. No difference between the two groups was found regarding the frequency with which CIN and HPV were detected cytologically, colposcopically and histologically. Confidence intervals for the probability of CIN in the presence of HPV for the two groups were calculated. At the 80% confidence interval the two groups were reassuringly similar. Pregnancy did not alter the relationship of CIN to HPV. Despite the relatively small size of our study population, it is unlikely that a larger study would demonstrate a difference. Interestingly a 3% cervical carriage rate of HPV in pregnancy was demonstrated. What, if any, effect this has upon the unborn child is unknown at this time.

Intrauterine growth retardation (IUGR) is associated with increased fetal and neonatal morbidity and mortality. In a previous study from the authors' laboratory, it was found that a grade 3 placenta on ultrasound examination was helpful in diagnosing the growth-retarded fetus. The present study was designed to evaluate whether this technique would be applicable in clinical practice. In the present study of 191 pregnancies, positive sonographic screening, defined as a fetal biparietal diameter of 87 mm or less, and a grade 3 placenta were found to detect 59% of all growth-retarded fetuses; in addition, half of the identifications of growth-retarded fetuses were correct. Overall risk for IUGR was increased 8.5 times in the presence of a positive sonographic screen--3.5 times for the preterm (less than 38 weeks' gestation) fetus and 18 times for the term fetus. This suggests that information readily available from real-time ultrasound examination--placental maturity grading and biparietal diameter--can improve the detection of IUGR.

Elevated levels of maternal serum alpha-fetoprotein (MSAFP) will identify a population at increased risk for specific congenital malformations, which are accurately diagnosed by amniotic fluid AFP and acetylcholinesterase. The risk for spontaneous abortion related to amniocentesis, combined with increasing confidence in the accuracy of ultrasound diagnosis, has caused us to question the need for amniocentesis in the diagnostic workup of pregnancies complicated by elevated levels of AFP in maternal serum. A retrospective study of 257 pregnancies evaluated for elevated serum AFP levels revealed 16 fetal malformations diagnosed by amniotic fluid AFP and acetylcholinesterase. Only 12 of these malformations were diagnosed on the initial ultrasound study. All malformations were diagnosed when ultrasound examination was repeated for increased acetylcholinesterase activity. Earlier gestational age at scanning, smaller defects, and pure technical failure were implicated as causes of misdiagnosis. The rate of fetal malformations identified in this high-risk population (6.23%) and the rate of ultrasound misdiagnosis (1.5% of the population with elevated levels of MSAFP) imply that amniocentesis should still be considered an essential part of the diagnostic workup in these situations.

We analyzed the job setting, professional activities, and satisfaction of subspecialists in maternal-fetal medicine. A two-page questionnaire was mailed to all members of the Society of Perinatal Obstetricians. The results were analyzed by multiple regression and multivariate analysis. Of 603 questionnaires mailed, 496 (80%) were returned; 70% of all certified maternal-fetal medicine subspecialists responded. The job setting of respondents was university hospital-based faculty in 66%, community hospital-based salaried in 15%, private practice in 10%, and other in 9%. The average percent of professional time devoted to each area was as follows: clinical work, 57% of all professional time; research, 18%; administrative, 15%; and educational, 11%. Time distribution, volume of hysterectomies, and number of peer-review publications were the only significant differences among job settings. For university hospital-based faculty, the time distribution was 50% clinical, 23% research, 16% administrative, and 11% educational. For community hospital-based salaried physicians, it was 63% clinical, 10% research, 16% administrative, and 11% educational; for private practice, it was 84% clinical, 7% research, 5% administrative, and 6% educational. Types of activities of maternal-fetal medicine subspecialists included ultrasound (75% of respondents, mean 436 studies per year), gynecologic procedures (71% of subspecialists, volume of 8.7 hysterectomies per year), genetic procedures (83%; 125 procedures per year), research (87%), recent peer-review publications (80%), grants (40%), and medicolegal reviews (64%). Ninety-five percent had a medical-school faculty appointment.(ABSTRACT TRUNCATED AT 250 WORDS)

The value of any fetal monitoring technic is in its ability to predict infant outcome. In the present study, the ability of fetal heart rate (FHR) monitoring data to "predict" a measure of short-term infant outcome, the 1-minute Apgar score, was evaluated using univariate and multivariate statistical analyses. Of 61 monitored high-risk infants, 46 had high (7 to 10) and 15 had low (1 to 6) 1-minute Apgar scores. Computer analysis of FHR/intrauterine pressure (IUP) data for these 61 infants revealed that the infants with low Apgar scores had more than the expected number of late decelerations (LD). Using a threshold of ten LD and univariate analysis, 74% of the infants could be properly classified for high or low Apgar scores, but 60% of the infants with low Apgar scores were not identified. Using discriminant function (multivariate) analysis for the numbers of LD and uterine contractions, 47% of the depressed infants were appropriately identified and simple risk scoring equations were devised. Using additional observation vectors, including the number of accelerations and early decelerations, 67% of the depressed infants could be identified. The results of this study suggest that using multiple observation vectors improves the predictive capacity and, thus, the value of fetal monitoring data. Clinical experience suggests that the value of monitoring data can be further enhanced by simultaneous evaluation of other observation vectors from additional perinatal data sets using the technics of this study.

A Title V Maternity and Infant Care (MI) Project has been operating from Cleveland Metropolitan General Hospital for more than 13 years. To evaluate the effectiveness of its program of antepartum care, social and medical-obstetric risk factors and perinatal outcome were evaluated for pregnant women delivered during a 2-year period. After the potential biases of patient referral and failure to obtain antepartum care were excluded, patients who received either MI or non-MI care were compared. Despite the similar social and antepartum/intrapartum risk of these groups, the MI patients experienced 60% less perinatal mortality than the non-MI group (P less than .0001). These results suggest that MI antepartum care is of considerable value, possibly ameliorating the risks for preterm delivery. MI patients receive more patient education, nutrition counseling, social service assessment and intervention, special services for adolescents, and delinquent appointment follow-up. Thus, this study further suggests that these components of antepartum care may be important in producing the observed improvement in fetal-infant outcome.

Fetal electroencephalogram (FEEG), recorded during labor, produces very large volumes of data for visual interpretation. An established terminology, developed for the interpretation of neonatal electroencephalogram, has been found to be useful for visual pattern recognition of FEEG. A program, which identifies FEEG patterns within ten second epochs and provides direct comparison between visual and programmed analysis, has been developed using an interactive computer system. This program provides 85-90 percent consistency with visual interpretation.

A computer program for pattern recognition of fetal electroencephalogram has been used to analyze the records of nine fetuses, known to be neurologically abnormal at 1 year of age. In 4,913 10 second epochs of adequate FEEG, Low Voltage Irregular (LVI) accounted for 17.8 per cent, Mixed activity (MIX) for 30.5 per cent, High Voltage Slow (HVS) for 18.1 per cent, and Trace Alternant (T/A) for 33.2 per cent of the epochs. The numbers of observed FEEG patterns in these abnormal cases appear to be significantly different from those in 11 normal cases (p less than 0.001)3. Specifically, the relative frequency of LVI was found to be increased in the abnormal cases (p congruent to 0.05). Moreover, LVI was significantly associated with visually interpreted prolonged voltage suppression (p less than 0.025) and lowered one-minute Apgar score (p congruent to 0.025). Using discriminant function analysis for LVI, MIX, HVS, and T/A patterns from FEEG recorded during labor, 10 of 11 infants were correctly classified as being neurologically normal at one year of age and 6 of 9 infants were correctly classified as being neurologically abnormal at 1 year of age. These studies confirm previous associations based on visual analysis of FEEG and suggest that the relative frequencies of FEEG patterns may be useful in the prediction of neurologic outcome 1 year later.

Recent increases in cesarean birth rates are of concern to obstetricians and to the public. Previous studies often focused on indications for abdominal delivery, described in such broad categories as repeat cesarean, breech presentation, dystocia, and fetal distress, without detailed information concerning medical/obstetric risk factors. In this study of 2744 consecutively delivered mothers who received antenatal care, the problem was approached differently by evaluating approximately 100 pregnancy risk factors recorded in a computerized uniform perinatal record system before making a decision for delivery. Excluding repeat cesareans, relative risks for primary cesarean birth were calculated for each risk factor. For the large majority of patients, the need for primary cesarean birth could not be predicted before the onset of labor. Approximately 70% of primary cesareans could be accounted for on the basis of single pregnancy risks--antepartum problems, 11%; abnormal fetal presentation, 30%; abnormal labor, 14%, and fetal distress, 15%. This leaves 30% of primary cesareans without a single major preceding risk. Along with the facts that 80% of primary cesareans in this series were performed for normal-size infants and that dystocia appears to account for a 3.4-fold greater proportion of cesareans in the national experience than in the current study, this suggests that critical evaluation and study of obstetric management of dystocia may be most fruitful in responding to the question of rising cesarean birth rates.

Thousands of children are born each year with alcohol-related birth defects. However, despite comparable levels of prenatal alcohol exposure, some children are affected less severely than others, whereas others do not appear to be affected at all. Epidemiological investigations and experimental studies in animals suggest that maternal or fetal genetic factors, maternal age or parity, and pattern of drinking are important risk factors affecting alcohol's actions on the embryo/fetus. Identifying these and other risk factors may provide a means for cost-effective prevention efforts.

Studies examining the increased surgical morbidity among obese gravidas have focused mainly on differences in outcome between obese and nonobese mothers. Little is known, however, about the cause for worsened operative outcome in obese mothers or the potential impact of perioperative interventions. To define more precisely the clinical determinants of postoperative morbidity, multivariate analysis was used to relate antepartum and intrapartum variables to three measures of morbidity in 107 consecutively delivered obese women undergoing cesarean. Although obesity is clearly an operative risk factor, this study suggested that among obese gravidas, varying degrees of maternal obesity and accompanying medical complications, such as diabetes and hypertension, were not associated with greater operative morbidity. Furthermore, neither choice of skin incision nor type of anesthesia appeared to be related to operative morbidity. However, two factors potentially under the control of the clinician, increased length of surgery and operative blood loss, were associated significantly with measures of operative morbidity. A finding of worsened outcome with prophylactic antibiotics and heparin requires further study.

Intrapartum fetal monitoring may be useful in discriminating short-term and long-term infant outcomes. In order to develop a model for the classification of infants for measures of outcome and to evaluate the discriminatory value of selected perinatal data, 61 data files, which included computer interpreted fetal electroencephalogram and fetal heart rate, one and five minute Apoar scores, results of neonatal neurologic examination, and results of neurologic examination at one year of age, were submitted to computerized discriminant function analysis. For the classification of infants for neurologic status at one year, using FEEG patterns alone, 64% of the 42 normal infnats and 63% of the 19 abnormal infants were correctly classified. Using intrapartum FEEG and FHR patterns simultaneously, 69% of the 42 normal infants and 63% of the 19 abnormal infants were correctly classified. Combining intrapartum data with postpartum data, including one minute and five minute Apgar scores and neonatal neurologic examinations, 81% of the 42 normal infants and 79% of the 19 abnormal infants could be correctly classified. These results suggest that brain damage may already be present before birth, during labor, and that the risk of abnormal neurologic outcome at one year can be detected for a large percentage of infants using computer interpreted monitoring data during labor.

Data from 2,913 antepartum gravidas screened for alcohol problems during the first year of a large prospective study designed to relate antenatal drinking behavior to infant outcome have been analyzed. The Michigan Alcoholism Screening Test (MAST) appears to separate two populations of pregnant patients. Differences between positive and negative MAST responders indicate variables, such as ethnicity, previous pregnancies, nutrition and cigarette smoking, which will require control when infant outcome data are evaluated. Positive MAST responders were found to be more likely to drink alcohol, to drink greater volumes and to drink more frequently than matched negative responders. They obtained a smaller proportion of their alcohol intake from wine and were more likely to drink a combination of beer, wine and/or liquor than the negative responders. The positive responders significantly decreased their alcohol intake as pregnancy progressed, while negative responders did not, suggesting the possibility that abstinence oriented therapy may be helpful. Problems with quantitating alcohol intake by humans and strategies for separating chronic and acute alcohol effects are discussed.