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BACKGROUND: Prevalence estimates of illicit drug use by teens are typically generated from confidential or anonymous self-report. While data comparing teen self-report with biological measures are limited, adult studies identify varying degrees of under-reporting. METHODS: Hair analyses for cocaine, opiates and marijuana were compared to confidential teen self- and parent-reported teen drug use in a longitudinal cohort of >400 high-risk urban teens and parents. RESULTS: Both teens and parents substantially underreported recent teen cocaine and opiate use. However, compared with parents, teens were more likely to deny biomarker-verified cocaine use. Teen specimens (hair) were 52 times more likely to identify cocaine use compared with self-report. Parent hair analyses for cocaine and opiate use were 6.5 times and 5.5 times, respectively, more likely to indicate drug use than were parental self-report. The lack of concordance between self-report and bioassay occurred despite participant's knowledge that a “certificate of confidentiality” protected both teen and adult participants, and that the biological specimens would be tested for drugs. CONCLUSIONS: These findings confirm prior reports of adult under-reporting of their own drug use while extending our understanding of teen's self-admitted drug use. The lack of concordance between teen self- or parent-reported teen drug use and biomarkers confirm our concerns that both teen- and parent-reported teen drug use is limited, at least for youth in high-risk urban settings. Methods of ascertainment other than self- or parent-report must be considered when health care providers, researchers and public health agencies attempt to estimate teen drug-use prevalence.

To identify the main determinants of mode of delivery preference among urban dwelling women of lower socioeconomic status (SES).Over a 12-month period, a self-completion 36-item questionnaire was administered to a convenience sample of 308 women within the first 3 postpartum days. Non-parametric tests were used for analysis.Study participants were mostly African American (85%), single mothers (75%), and unemployed (≥55%). Among the women, 85.7% had vaginal delivery (VD) and 14.3% had cesarean delivery (CD). Women who preferred CD (10%) were more likely to be concerned about a vaginal tear/episiotomy during VD, forceps, and a "big" baby compared with women who preferred VD, for whom "pushing the baby out myself" and "fear of cesarean" were the most important factors. In the final model of 7 factors, the 3 main factors found to positively impact maternal preference for CD were a vaginal cut during VD (P0.001), higher mean BMI (P=0.001), and cesarean as the most recent delivery type (P0.001). The total explained variance by this model was 46%.Short-term complications of a VD, higher BMI, and a previous cesarean delivery are the most significant factors that impact the preferences of women of lower SES for future mode of delivery.

THE FETAL ALCOHOL spectrum disorders (FASD; Bertrand et al., 2004; Hoyme et al., 2005; Sokol et al., 2003), including fetal alcohol syndrome (FAS), include specific neural and craniofacial malformations, growth restriction, and neurobehavioral and cognitive deficits (Hoyme et al., 2005; Kodituwakku, 2007; Nash et al., 2006; Sokol et al., 2003; Spadoni et al., 2007). The estimated incidence of FAS ranges from 0.3 to 2.0 per 1,000 live births in the general population (CDC, 2002a, 2002b; May and Gossage, 2001), with a higher incidence among certain groups depending upon socio-demographic, behavioral, clinical, and other risk factors (Abel, 1995; CDC, 2002a, 2002b; May et al., 2007, 2008). The combined incidence of all FASD is higher and estimated at about 10 per 1,000 live births (Manning and Hoyme, 2007; O’Leary, 2004; Sampson et al., 1997). While awareness of the risk of alcohol use during pregnancy has increased substantially since 1989 when warning labels began to appear on alcohol beverage containers, more than half of women of child-bearing age continue to consume alcoholic beverages, and over 11% report continued drinking during pregnancy (CDC, 2009; Stratton et al., 1996). The rates of certain patterns of consumption that put fetuses at greater risk for FASD, especially self-reported binge drinking—defined as 5 or more drinks per occasion (CDC, 2002a, 2002b)—have remained essentially unchanged at around 2% since 1991 (CDC, 2009). However, levels of drinking also vary with maternal age. Older pregnant women (>34 years old) are 37% more likely to report drinking during pregnancy than younger women (CDC, 2009). However, self-reported rates of binge drinking were not significantly different between younger pregnant women (18 to 24 years old), at 2.5%, and older pregnant women (>34 years old), at 1.8%(CDC, 2009). In this paper, we are examining attention problems because they are among the more frequently reported outcomes associated with FASD (Brown et al., 1991; Carmichael Olson et al., 1998; Coles et al., 1997; Fryer et al., 2007; Kodituwakku, 2007). Deficits have been identified in sustained attention (Coles et al., 2002; Lee et al., 2004), as well as executive function, memory, IQ, fine motor skills, and other neurodevelopmental domains (Coles et al., 1997; Kodituwakku, 2007; Kodituwakku et al., 1995; Mattson et al., 1998). Coles and colleagues (1997) reported other alcohol-related attention deficits in visual / spatial skills, encoding of information, and flexibility in problem solving. Yet there are inconsistencies in the occurrence of attention problems and hyperactivity in prenatal alcohol-exposed children. Nanson and Hiscock (1990) reported increased hyperactivity and slower reaction times, while Roebuck and colleagues (1999) and Coles and colleagues (1997) did not.Carmichael Olson and colleagues (1992) found deficits in focused attention but not as severe as those found in children diagnosed with attention deficit hyperactivity disorder (ADHD). These variations in reported attention deficits may be related to multiple factors including which prenatal alcohol exposure variable was assessed, differential difficulty of the task assessing attention (Kodituwakku, 2007), sample size, or additional moderating variables, such as maternal age. In addition to maternal age and how risk drinking is assessed, several other factors are influential in the variable expression of attention effects in FASD and ADHD, such as how attention is measured and cohort characteristics (e.g., age, demographics, etc.). These are considered further in the Discussion. Alcohol-related neurobehavioral deficits are certainly also influenced by differences in vulnerability and individual susceptibility, even at comparable levels and rates of maternal drinking. The variable expression of prenatal alcohol-related effects may be because of differential genetic susceptibility, exposure periods, or drinking patterns (Abel, 1995; American College of Obstetrics & Gynecology, 2006; Chiodo et al., 2009; Ernhart et al., 1987; Henderson et al., 2007; Jacobson and Jacobson, 1994, 1999; Maier and West, 2001; Martinez-Frias et al., 2004; NIAAA, 2005a; Olney, 2004; Sokol et al., 1986; Stratton et al., 1996; West et al., 1994), as well as nutritional or other risk factors. One factor that may influence the impact of prenatal alcohol on neurobehavioral outcome is the pattern of alcohol consumption. Detection of patterns of maternal drinking that place fetuses at risk for FASD is critical to diagnosis, treatment, and prevention but is challenging and often insufficient during pregnancy. We recently showed that outcomes depend on which measure of prenatal alcohol exposure is used and that a metric that accounts for several different measures of risk-level drinking during pregnancy is a better predictor of neurobehavioral effects of prenatal alcohol, including focus and divided attention, than the individual alcohol consumption measures alone (Chiodo et al., 2010). Older age appears to be another maternal characteristic that is related to differential susceptibility to the effects of prenatal alcohol exposure. Jacobson and colleagues (1998, 2004) and Burden and colleagues (2005) showed greater adverse performance in attention and working memory tasks for infants and children born to older drinking mothers (≥30 years old) compared to younger mothers (Burden et al., 2005). Prenatal alcohol exposure-related deficits in working memory were greater among children born to women ≥30 years of age. Despite a small sample, children born to older mothers performed significantly-worse in 4 of 7 measures of attention, memory and general cognitive ability. For example, there were increased errors of omission in a Digit Cancellation task, working memory deficits in the digit span test, and lower scores on the Wechsler Intelligence Scale for Children–Revised (WISC-R) Arithmetic subscale, and others, while only one outcome—executive function measured by the Tower of London task—was significantly impaired for children whose mothers were

Background: Fetal Alcohol Spectrum Disorders (FASDs), including Fetal Alcohol Syndrome, continue to be high-incidence developmental disorders. Detection of patterns of maternal drinking that place fetuses at risk for these disorders is critical to diagnosis, treatment, and prevention, but is challenging and often insufficient during pregnancy. Various screens and measures have been used to identify maternal risk drinking but their ability to predict child outcome has been inconsistent. This study hypothesized that a metric of fetal “at-risk” alcohol exposure (ARAE) derived from several indicators of maternal self-reported drinking would predict alcohol-related neurobehavioral dysfunctions in children better than individual measures of maternal alcohol consumption alone. Methods: Self-reported peri-conceptional and repeated maternal drinking during pregnancy were assessed with semi-structured interviews and standard screens, i.e., the CAGE, T-ACE, and MAST, in a prospective sample of 75 African-American mothers. Drinking volumes per beverage type were converted to standard quantity and frequency measures. From these individual measures and screening instruments, a simple dichotomous index of prenatal ARAE was defined and used to predict neurobehavioral outcomes in the 4- to 5-year-old offspring of these women. Study outcomes included IQ, attention, memory, visual-motor integration, fine motor skill, and behavior. Statistical analyses controlled for demographic and other potential confounders. Results: The current “at-risk” drinking metric identified over 62% of the mothers as drinking at risk levels—23% more than the selection criterion identified—and outperformed all individual quantity and frequency consumption measures, including averages of weekly alcohol use and “binge” alcohol exposures (assessed as intake per drinking occasion), as well as an estimate of the Maternal Substance Abuse Checklist (Coles et al., 2000), in predicting prenatal alcohol-related cognitive and behavioral dysfunction in 4- to 5-year-old children. Conclusions: A metric reflecting multiple indices of “at-risk” maternal alcohol drinking in pregnancy had greater utility in predicting various prenatal alcohol-related neurobehavioral dysfunction and deficits in children compared to individual measures of maternal self-reported alcohol consumption or a previous maternal substance abuse index. Assessing fetal risk drinking in pregnant women was improved by including multiple indicators of both alcohol consumption and alcohol-related consequences and, if appropriate practical applications are devised, may facilitate intervention by health care workers during pregnancy and potentially reduce the incidence or severity of FASDs.

Our aim was to better define the coagulation abnormalities in patients with systemic lupus erythematosus who had thrombosis or high-risk clinical settings for thrombosis. Clinical and laboratory data of 111 patients with lupus referred for coagulation assessment because of thrombosis, pregnancy loss or high-risk clinical settings for thrombosis were reviewed retrospectively. Increased activity of procoagulant factors and decreased activity of anti-coagulant factors were observed well above the expected 5% prevalence. All comparisons were significant at the P

According to the National Center for Health Statistics, an estimated 68% of U.S. adults are either overweight or obese, the majority being female.1 The effect of weight gain on female health is pervasive and is linked to such prevalent diseases as diabetes, arthritis, cardiovascular disease, and pelvic organ prolapse (POP). Pelvic organ prolapse, consisting of anterior, apical, and posterior support defects, affects, on average, up to 50% of the female population in the United States, with prevalence rates varying among different populations from 30% to 93%.2,3 The estimated lifetime risk of surgery for POP and/or urinary incontinence by age 80 years is approximately 11%.4 In 1997, almost 226,000 (22.7 per 10,000) inpatient surgical procedures were performed in the United States to correct this condition,5 costing more than 1 billion dollars. Indeed, POP is one of the three most common reasons for hysterectomy in the United States, accounting for 15-18% of procedures in all age groups, and is the leading indication for hysterectomy in postmenopausal women.6,7 Further, an estimated 13-30% of women who have prolapse surgeries will need a reoperation within 5 years.4,8 Numerous factors, including age, ethnicity, parity, obesity, and history of hysterectomy, have been found to be associated with POP.9,10 One recent study demonstrated that hysterectomy, particularly performed vaginally, nearly quadrupled the risk for subsequent prolapse surgery.11 Despite our knowledge of the natural history of POP disorders, little is known about the effect of weight change on prolapse progression or regression. In a cross-sectional study of postmenopausal women who enrolled in the Women's Health Initiative (WHI) Hormone Therapy Clinical Trial, the risk of having uterine prolapse, rectocele, or cystocele was 30-50% higher in women with body mass indexes (BMIs) of 25 or higher than in those with BMIs of 24.9 or lower (BMI is calculated as weight (kg)/[height (m)]2).9 However, longitudinal effects of being overweight or obese on prolapse development are less well studied. Of particular interest to clinicians is the question of whether being overweight or obese is a modifiable risk factor for POP. The purpose of this secondary analysis of the WHI Estrogen plus Progestin (E+P) Clinical Trial was to evaluate the relationship between change in weight and POP progression/regression in postmenopausal women during a 5-year period.

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.

We determined if the “relative age” effect, wherein older students in an age cohort in early grades do better academically, extends to birthdates of applicants to medical schools, and if birthdates are related to the success of their applications. We examined birthdays of applicants from Michigan to Wayne State University’s School of Medicine, relative to December 1, the cut‐off date for eligibility to enter kindergarten in Michigan. Significantly fewer applicants ≤22 years of age were born in the three‐month period (September, October, November) immediately preceding the December 1 cut‐off date, but there was no statistically significant difference in the probability of their acceptance. We conclude that delayed entry to kindergarten influences applications for medical school acceptance, but does not affect the success of their applications.

Pregnancy alcohol consumption has been linked to poor birth outcomes and long-term developmental problems. Despite this, a significant number of women drink during pregnancy. Although most prenatal care providers are asking women about alcohol use, validated screening tools are infrequently employed. Research has demonstrated that currently available screening methods and intervention techniques are effective in identifying and reducing pregnancy drinking. Implementing universal screening and appropriate intervention for pregnancy alcohol use should be a priority for prenatal care providers, as these efforts could substantially improve pregnancy, birth, and longer term developmental outcomes for those affected.

Since fetal alcohol syndrome was first reported, studies have demonstrated a range of perinatal/developmental abnormalities that fall under the umbrella term fetal alcohol spectrum disorders. Of these, low birth weight in exposed children is among the most commonly observed and widely accepted. However, in the past, assertion of an association between prenatal alcohol exposure and preterm birth was controversial. Methodological difficulties may have contributed to failure to consistently detect such a relationship. However, new evidence suggests that pregnancy drinking may be a major contributor to extreme, but not mild prematurity. Extreme prematurity is a major cause of severe perinatal morbidity and mortality. If recent findings are confirmed, it suggests that extreme prematurity might be reduced by eliminating prenatal alcohol exposure.

In developed countries, smoking during pregnancy appears to be a major determinant of birth weight. In addition, it may increase the risk of congenital abnormalities. Maternal blood levels of folate are reduced in parturients who smoke. There is evidence that exposure to cigarette smoke compromises maternal folate status through altered dietary intake, and possibly through nondietary effects such as increased turnover of folate. The goal of this study was to learn whether and how maternal smoking influences plasma levels of 5-methyltetrahydrofolic acid (5-MTHFA) in umbilical cord blood from 58 pregnant African American women. Demographic features including smoking status were ascertained in structured interviews. Venous cord plasma 5-MTHFA concentrations correlated with maternal plasma 5-MTHFA concentrations, although the venous cord levels were significantly higher. After controlling for maternal plasma 5-MTHFA concentrations, cigarettes smoked by the mothers at the first prenatal visit correlated negatively with venous cord 5-MTHFA concentrations. Both of these correlations were confirmed by multivariate analysis. Prepregnancy smoking was negatively associated with venous cord 5-MTHFA, and the mean 5-MTHFA concentration in venous cord plasma was significantly lower in the 32 mothers who smoked (15.1 ng/mL) than in the 26 nonsmokers (19.0 ng/mL). Prepregnancy smoking status did not correlate significantly with maternal plasma 5-MTHFA levels. Maternal smoking significantly influenced birth weight when controlling for gender and gestational age. These findings suggest that maternal smoking may impair folate transport to the fetus, and may help to explain why folic acid fortification of foods seems to have a suboptimal effect in preventing neural tube defects in certain populations such as inner-city African American women.

To investigate how the 2009 Institute of Medicine (IOM) guidelines for pregnancy weight gain for obese women relate to the longer-term outcome of childhood obesity.Maternal, neonatal, soioeconomic, and nutritional histories were collected for mothers with children age 2-5 years old. Women in each body mass index (BMI) category were categorized based on under, appropriate (AG), and over weight gain per IOM guidelines and compared with rates of childhood obesity in each category.A total of 502 mother-child pairs were enrolled; 36.4% of women were obese at the start of pregnancy. Obese women who were AG by IOM guidelines were more likely than underweight, normal weight, and overweight women to have obese offspring (29.5% vs. 14.2%, p = 0.04). The BMI percentiles of the offspring of obese AG women were 10 percentile points higher than the 55th percentile of the other groups.The 2009 IOM pregnancy weight gain guidelines for obese women may still be too high when considering longer-term outcomes such as childhood obesity. Further studies are needed.

Introduction: Results from the Women's Health Initiative clinical trials demonstrated no increase in the risk of lung cancer in postmenopausal women treated with hormone therapy (HT). We conducted a joint analysis of the Women's Health Initiative observational study data and clinical trials data to further explore the association between estrogen and estrogen-related reproductive factors and lung cancer risk. Methods: Reproductive history, oral contraceptive use, and postmenopausal HT were evaluated in 160,855 women with known HT exposures. Follow-up for lung cancer was through September 17, 2012; 2467 incident lung cancer cases were ascertained, with median follow-up of 14 years. Results: For all lung cancers, women with previous use of estrogen plus progestin of less than 5 years (hazard ratio=0.84; 95% confidence interval=0.71–0.99) were at reduced risk. A limited number of reproductive factors demonstrated associations with risk. There was a trend toward decreased risk with increasing age at menopause ( p trend = 0.04) and a trend toward increased risk with increasing number of live births ( p trend = 0.03). Reduced risk of non–small-cell lung cancer was associated with age 20–29 years at first live birth. Risk estimates varied with smoking history, years of HT use and previous bilateral oophorectomy. Conclusions: Indirect measures of estrogen exposure to lung tissue, as used in this study, provide only weak evidence for an association between reproductive history or HT use and risk of lung cancer. More detailed mechanistic studies and evaluation of risk factors in conjunction with estrogen receptor expression in the lung should continue as a role for estrogen cannot be ruled out and may hold potential for prevention and treatment strategies.

Systemic lupus erythematosus is a chronic multi-system autoimmune disease that occurs predominantly in women of childbearing age. The risk of complications and adverse fetal outcomes in pregnant women with lupus is high. Moreover, pregnancy can cause flares of lupus disease activity necessitating maternal immunosuppressive intervention. Interestingly, many potential complications of pregnancy present as symptoms of lupus making diagnosis and treatment a challenge. Advancing technology and better understanding of the maternal-fetal dyad in lupus have improved outcomes in lupus pregnancies over the last 40 years. This article will briefly review the important issues in pregnancies complicated by lupus and provide a general guideline to physicians for monitoring and treatment.

To examine whether alcohol abuse (ALC) continued to be a health hazard to pregnant women in the 1990s.Analysis of a perinatal data base comprising 170,258 women with singleton pregnancies. Univariate cross table analysis and logistic regression were conducted to examine the association between alcohol abuse and congenital malformations coded according to the International Classification of Diseases (ICD).14,727/170,258 mothers (8.6%) admitted to ALC during pregnancy and 36,705/170,258 (21.6%) to smoking. Anomaly rates for ALC (365/14,092, 4.3%) vs. Non-ALC (6187/149,344, 4.0%) differed significantly (p0.001). The rates of specific anomalies varied between0.1% and 1.1%. Odds ratios for 16 ICD 9 anomaly categories were1 in 14 instances overall (Sign test, p=0.004), in 12 instances in women30 years (p=0.08), and in 13 instances in women over 30 years (p=0.02). Congenital anomalies of the "respiratory system" (ICD9 748), of "genital organs" (ICD9 752.1), of the "integument" (ICD9 757), and "other anomalies of limbs/other musculoskeletal anomalies" (ICD 755/756) were statistically significantly associated with ALC, especially in women30 years.ALC in pregnancy continued to be an important factor independently associated with an increased incidence of a broader range of congenital anomalies than previously recognized. Risk for anatomic anomalies was increased in offspring of ALC women over age 30, consistent with previous reports of increased risk of neurobehavioral abnormality in offspring of women over 30.

Fetal alcohol spectrum disorders (FASDs) are among the leading preventable causes of developmental disorders in the United States; however, recognition and prevention of these conditions cannot be achieved without informed and educated health providers. This commentary addresses the importance of recognition and prevention of FASDs through the use of well-established standardized practices of diagnosis, screening, and brief alcohol reduction counseling. It is hoped that more knowledge on currently available procedures will encourage their use in the provision of routine health care to all women of childbearing age.

Children in the United States are exposed to considerable community violence that has been linked to child functioning. However, not all those exposed, experience negative outcomes. Recent research has focused on factors that "buffer" or protect children from negative consequences of violence exposure. The purpose of this investigation was to examine the potential buffering or moderating role of maternal acceptance in the relationship between community violence exposure and internalizing and externalizing problems. Subjects were 268 urban African American first graders. Community violence exposure was significantly related to symptoms of post-traumatic stress, but did not correlate with either internalizing or externalizing problems for all children, after control for demographics, maternal mental health, and general life stress. However, children's perceptions of maternal acceptance moderated the relationship between violence exposure and internalizing and externalizing problems which included being withdrawn, anxious-depressed, and demonstrating delinquent behavior. Children with the lowest levels of self-reported maternal acceptance were most impacted by community violence. In this sample of urban first graders, low levels of maternal acceptance placed children at greater risk for adverse outcomes associated with community violence exposure compared to moderate and high levels of maternal acceptance.

The complete form of fetal alcohol syndrome (FAS) reportedly occurs in only 4% to 10% of children whose mothers drink heavily during pregnancy. Fetal alcohol spectrum disorder includes cases with some alcohol-related problems but not the full syndrome and is thus more common. Vulnerability to alcohol-related neurodevelopmental disorders is influenced by genetic polymorphisms of the class I alcohol dehydrogenase ADH1B, which affects the rate of alcohol metabolism. Expression of one of the 3 possible alleles, ADH1B*3, is associated with relatively rapid alcohol metabolism. This study sought to learn the degree to which the maternal ADH1B*3 allele may moderate the effects of in utero alcohol exposure on fetal growth and a range of cognitive and behavioral outcomes. The study population included 263 black mother-child pairs in whom moderate and heavy drinking were overrepresented. Most study participants were socioeconomically disadvantaged. The Michigan Alcoholism Screening Test (MAST) was administered to all mothers during the first prenatal visit, and blood was obtained for ADH genotyping; the children were genotyped at the 7.5- or 14-year visits. Fetal exposure to alcohol was assessed by interviewing the mothers about preconception drinking at the first prenatal visit and then at each subsequent visit asking about the amount of alcohol ingested daily since the previous visit. The children were evaluated at 6 and 12 months and 7.5 and 14 years of age. Infants were assessed using the Mental Development Index from the Bayley Scales of Infant Development. They also were tested for processing speed, visual reaction time, and complexity of play. At age 7.5 years, the children were tested for working memory by the Digit Span and Arithmetic subtests from the Wechsler Intelligence Scale for Children. The Verbal Fluency subtest of the McCarthy Scales of Children's Abilities served to measure executive function and working memory. The Continuous Performance Test quantified sustained attention. In addition, teachers were asked to assess social competence and behavior problems. Women who continued to drink during pregnancy decreased the frequency from 1.9 to 0.9 days a week, but the number of drinks consumed per occasion decreased only 20%, from 4.5 to 3.6 drinks. One third of the women also used cocaine, one third used marijuana, and almost two thirds smoked cigarettes. The most prominent genotype was homozygosity for the ADH1B*1 allele (64.5%), and the rest were either heterozygous (31.4%) or homozygous (4.6%) for the ADH1B*3 allele. At the time of conception, women who carried at least one copy of the ADH1B*3 allele drank half as much absolute alcohol per day (0.57 vs 0.96 ounces) and drank on fewer days per week (1.82 vs 2.45 days) than those who did not carry the allele. During pregnancy, both women who did and did not carry the ADH1B*3 allele reduced their drinking such that there was no difference between the groups in the amount of alcohol ingested per occasion (0.18 and 0.26 ounces, respectively) or the number of drinking days per week (0.67 and 0.85 days). Children whose mothers lacked the ADH1B*3 allele exhibited adverse effects of alcohol during infancy, scoring poorly on all tests, whereas the adverse effects on children whose mothers carried the ADH1B*3 allele were limited to reduced birth weight and processing speed on the FTII. At age 7.5 years, when focused attention, working memory, and efficiency of information processing were assessed, prenatal drinking was associated with poorer Category Fluency (the ability to monitor information retrieved from long-term memory) only in children whose mothers lacked the ADH1B*3 allele. These children also had poorer teacher ratings for attention, aggressive behavior, and social problems. In contrast, no consistent pattern of increased vulnerability during infancy was evident in children who themselves lacked the ADH1B*3 allele. When assessed at 7.5 years, children who carried at least one ADH1B*3 allele had fewer cognitive problems.

Community violence exposure (CVE), a critical urban problem, is associated with negative academic outcomes. Children who report feeling safe, however, may perform better than those who do not. The purpose of this study was to examine the relations among CVE, feelings of safety, and cognitive outcomes among 6- and 7-year-olds born to women receiving prenatal care at an inner-city maternity hospital who participated in a prospective pregnancy study. In addition to obtaining measures of child CVE, IQ, reading, standardized school achievement, and grades, we also evaluated the primary caregiver in order to assess the home and family environment. Greater violence exposure and victimization were related to poorer child outcomes; however, feelings of safety were positively related to most of the cognitive measures, and positive caregiving was related to more optimal cognitive functioning. Increased feelings of safety may allow children to focus on critical school tasks to which they may otherwise be unable to attend.

This study examined the relationship between maternal expressed emotion (EE) and children’s perceived self‐competence, behavior and intelligence in a community sample of 190 urban, African American children ages 6–7. Maternal EE was measured by the Five Minute Speech Sample. Self reports and standardized measures were used to examine other mother and child variables. Compared with Low EE, High EE was associated with children’s decreased cognitive self‐concept, increased anxiety, and greater levels of hyperactivity. EE was unrelated to children’s intelligence. The study suggests that for African American children at early school age, maternal EE predicts child anxiety, perceived cognitive competence, and hyperactive behavior. Further investigation appears warranted to evaluate the relationship, over time, between EE and child outcomes.

This study examined the relative importance of caregiver substance abuse as a correlate of child-reported exposure to violence. A total of 407 female African-American primary caregivers and their children age 6 to 7 were evaluated. The association between child report of violence and exposure to substance abuse by others (both within and outside the home) was considered after controlling for variance accounted for by child characteristics, caregiver characteristics, home environment, and neighborhood environment (including neighborhood crime). Caregiver alcohol abuse, children's witnessing of drug use in the home, and children's witnessing of drug deals all explained significant additional variance in violence exposure. These findings suggest that for early elementary-age children, meaningful prevention of violence exposure may be possible via addressing their exposure to substance abuse in their home and community.

Objective The objective of this study was to examine the risk of adverse neonatal outcomes after twin delivery according to gestational age. Materials and Methods The U.S. Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were twin deliveries and gestational age of 37 to 42 weeks. Exclusion criteria were congenital anomalies and missing/incomplete data. Cases were subdivided by gestational age into early term, term, and late term. Singleton pregnancies matched by delivery time and location were selected as controls. Outcome variables included were low Apgar score, assisted ventilation, neonatal intensive care unit admission, surfactant/antibiotic use, seizures, and birth injury. Logistic regression analysis was used to calculate adjusted odds ratios according to gestational age and plurality, using singleton term as reference. Results A total of 220,169 twin and 270,540 singleton deliveries were identified. The risk of adverse neonatal outcomes for twins was higher than for singletons. For twins, the distribution of the risks of the composite of adverse neonatal outcomes was linear, being the lowest at early term and the highest at late term, whereas the distribution for singletons was u -shaped being lowest at term compared with early and late term. Conclusions Twins are at higher risk of suboptimal neonatal outcomes than singletons, but do better when delivered at early term rather than term or late term.

Alcohol use among women of childbearing age is prevalent in the United States, with approximately 1 in 5 nonpregnant women reporting binge drinking (5 or more drinks on any one occasion) and 1 in 25 pregnant women reporting binge drinking. Alcohol use during pregnancy results in a spectrum of adverse outcomes known as fetal alcohol spectrum disorders. Fetal alcohol syndrome (FAS) is one of these disorders. Fetal alcohol syndrome is characterized by specific facial abnormalities and significant impairments in neurodevelopment and physical growth. Early identification of children with FAS has been shown to enhance their long-term outcomes. In an effort to improve clinical recognition of children with this condition, Centers for Disease Control and Prevention (CDC) was directed by Congress in 2002 to lead the development of uniform diagnostic criteria for FAS and other prenatal alcohol-related conditions. The purpose of this commentary is to provide clinicians a summary of the report released by CDC describing the current diagnostic criteria for FAS. In addition, advancements have been made in screening and brief interventions for alcohol use disorders in women who have the potential to make significant strides in the prevention of FAS spectrum disorders. Knowledge of the diagnostic criteria for FAS can lead to increased identification of the syndrome in infants and children and the provision of appropriate medical and support services. Screening for and intervening with women at risk for an alcohol-exposed pregnancy can prevent FAS and other fetal alcohol spectrum disorders.

Somatic complaints of children in primary care settings often go unexplained despite attempts to determine a cause. Recent research has linked violence exposure to stress symptomatology and associated somatic problems. Unknown, however, is whether specific physical symptom complaints can be attributed, at least in part, to violence exposure. Urban African-American 6- and 7-year-old children (N = 268), residing with their biological mothers, recruited before birth, and without prenatal exposure to hard illicit drugs participated. Children and mothers were evaluated in our hospital-based research laboratory, with teacher data collected by mail. Community violence exposure (Things I Have Seen and Heard), stress symptomatology (Levonn), and somatic complaints (teacher-and self-report items) were assessed. Additional data collected included prenatal alcohol exposure, socioeconomic status, domestic violence, maternal age, stress, somatic complaints and psychopathology, and child depression, abuse, and gender. Community violence witnessing and victimization were associated with stress symptoms (r = .26 and .25, respectively, p < .001); violence victimization was related to decreased appetite (r = .16, p < .01), difficulty sleeping (r = .21, p < .001), and stomachache complaints (r = .13, p < .05); witnessed violence was associated with difficulty sleeping (r = .13, p < .05) and headaches (r = .12, p < .05). All associations remained significant after control for confounding. Community violence exposure accounted for 10% of the variance in child stress symptoms, and children who had experienced community violence victimization had a 28% increased risk of appetite problems, a 94% increased risk of sleeping problems, a 57% increased risk of headaches, and a 174% increased risk of stomachaches. Results provide yet another possibility for clinicians to explore when treating these physical symptoms in children.

Objective. The purpose of this study was to determine whether a repeated antenatal ultrasound examination improves fetal cardiac visualization for the obese and nonobese population. Methods. A computerized ultrasound database (October 1999-June 2003) was used to identify singleton pregnancies undergoing repeated prenatal ultrasound examinations because of initial suboptimal ultrasonographic visualization (SUV) of the 4-chamber view, outflow tracts, or both. Women with maternal diabetes, abnormal maternal serum screening results, or known fetal anomalies at the initial examination were excluded. Patients were classified by maternal body mass index (BMI): less than 30 kg/mg 2 (nonobese), 30 to 34.9 kg/mg 2 (class I obesity), 35 to 39.9 kg/mg 2 (class II obesity), and 40 kg/mg 2 or greater (morbid obesity). The association between maternal BMI and SUV of the fetal heart was analyzed. Results. Three hundred seventy-two patients were abstracted from the database. The median gestational age was 19.0 weeks at the initial visit (range, 18.0-21.9 weeks) and 21.4 weeks at the second visit (range, 18.9-23.9 weeks). The median BMI was 32.6 kg/m 2 (range, 164-58.7 kg/m 2 ). Sixty-three percent of patients were obese (BMI ≥30). Cardiac anatomy continued to have SUV in 11 % of the women. The rate of SUV was associated with the obesity class (1.5% for nonobese, 12% for obesity I, 17% for obesity II, and 20% for morbid obesity; P

The purpose of this study was to determine the frequency of prescription and over-the-counter (OTC) medications, and herbal remedies used by pregnant women. A prospective observational study was performed at a single tertiary-care hospital. Postpartum women completed a questionnaire that included a list of more than 120 medications, herbal remedies, and alternative therapies listed by both brand and common name. Patients were asked to identify any and all medications or treatments used during pregnancy. Of 418 patients who completed questionnaires, 96.9% took at least one medication during their pregnancy. After excluding prenatal vitamins and iron supplements, 76.5% took at least one other medication; 62.8% used OTC medications, and 4.1% used herbal and/or alternative remedies. Multiple drug use occurred in 33.5% of patients, with up to 13.6% consuming four or more medications. The use of prescribed and OTC, medications, and herbal/alternative therapy, is common in pregnancy, with many patients consuming more than one agent at a time.

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.

Background: In contrast to the extensive literature documenting IQ deficits in patients with fetal alcohol syndrome, effects on IQ have not generally been reported for children with alcohol-related neurodevelopmental disorder (ARND). This study examined the role of maternal age, MAST, and quality of parenting in moderating the effects of prenatal alcohol exposure on the WISC-III IQ test in moderate-to-heavily exposed children. Methods: A total of 337 inner-city African American children whose mothers were recruited prenatally were administered the WISC-III at 7.5 years. Alcohol exposure was assesed with a timeline follow-back interview administered at every prenatal clinic visit. Moderating effects of the three risk factors were examined by adding interaction terms to regression analyses and dichotomizing the moderators and performing separate regressions on the two groups. Results: Prenatal alcohol exposure was related to WISC-III Freedom from Distractibility but not to Full Scale IQ for the sample as a whole. However, among children born to older mothers, an alcohol effect emerged on Full Scale IQ and five of seven composite IQ scores. Similarly, adverse effects were seen among children of MAST-positive mothers and children whose parents provided less optimal cognitive stimulation. Each additional ounce of absolute alcohol consumed per day during pregnancy was associated with a 2.9-point decrease in Full Scale IQ and a 5.6-point decrement on Freedom from Distractibility. Conclusions: This study is the first to demonstrate IQ effects among children with ARND born to older and MAST-positive mothers, particularly in relation to first-trimester drinking. These findings suggest that there are subgroups of more vulnerable and severely affected children whose intellectual performance is compromised. A moderate- to heavy-drinking mother who has given birth to an unaffected child when she was younger needs to be warned that her risk of having an adversely affected child increases as she grows older.

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.

OBJECTIVE: To examine the impact of maternal obesity on the rate of suboptimal ultrasound visualization (SUV) of fetal anatomy and determine the optimal timing of prenatal ultrasound examination for the obese gravida. METHODS: A computerized ultrasound database was used to identify ultrasound examinations for singleton gestations performed between 140/7 and 236/7 weeks at a tertiary care, university-based hospital. Patients were divided into four groups and categorized based on body mass index (BMI): nonobese (BMI

Animal but few human studies have demonstrated gender-influenced differences in outcome related to prenatal cocaine exposure. Pregnant participants in a prospective pregnancy study were interviewed for drug use. Exposure was considered positive if history or laboratory tests were positive. An ordinal measure of exposure was also constructed. Six years later, the child and primary caretaker were tested to assess drug use in the home since birth and teacher-assessed child behavior. Data were complete for 473 children (204 cocaine exposed). Twenty-four of the exposed children (12%) were considered to have persistent pregnancy exposure based on positive urine screen at delivery. Boys with any prenatal cocaine exposure scored significantly higher (more problem behaviors) than nonexposed boys on the hyperactivity item. In contrast, no similar cocaine effect was observed for girls. When cocaine exposure was expressed as the three-level ordinal variable, boys, but not girls, with persistent exposure had more behavior problems (0.5 to 1.0 SD higher). Even after control for important covariates, boys with persistent exposure had more problems in central processing, motor skills, handling abstract concepts, and passivity to the environment. The magnitude of the relations reported in this research were moderate to large. In summary, both gender and the level of exposure had a significant behavioral effect on school-age behavior. In these analyses, the behavior of boys, but not girls, prenatally exposed to cocaine was significantly and negatively affected, and these findings remained after control for covariates, including prenatal alcohol or other illicit drug exposures and postnatal drug use in the home.

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

Background Multiple factors can influence blood alcohol levels (BALs) after oral ethanol intake. To minimize the variability in BALs, an alcohol “clamping” method in which alcohol is administered intravenously has been previously reported. We have modified this method and developed a multistage alcohol clamp procedure in humans. Methods Infusion of alcohol to achieve sequentially increasing steady-state BALs at 50, 100, and 150 mg/dl (e.g., an alcohol clamp procedure) was performed in five subjects. The method used intravenous infusion of 6% alcohol in saline and followed a protocol generated by a physiologically based pharmacokinetic model for alcohol infusion. Real-time measurement of BALs was used to base decisions for necessary adjustments in the infusion rates on a negative feedback principle to achieve and maintain the desired BALs. Additionally, in three of these subjects, breath alcohol levels were determined simultaneously with BAL measurements. Results A three-stage alcohol clamp procedure was used to achieve BALs of 50, 100, and 150 mg/dl. The intra-assay and interassay variations for measurement of BALs were 1.6 and 2.1%, respectively. The coefficients of variation for the 50, 100, and 150 mg/dl alcohol clamps were 9.8, 5.6, and 4.6%, respectively. The deviation from target BALs for the three clamps were less than 5%. Breath alcohol levels were lower than BALs across all time points, with the mean ratio between the two being 0.84. Correlation analysis showed a very strong correlation between the two alcohol measurement methods (r= 0.96;p < 0.001). Conclusions A three-stage alcohol clamp procedure (50, 100, and 150 mg/dl) has been developed by following a protocol generated with a physiologically based pharmacokinetic model for alcohol infusion in human subjects. This is a suitable procedure to examine the responses on cognitive measures and physiologic parameters under steady states of desired BALs.

Reductions in birth weight and length have been independently attributed to prenatal exposure to alcohol, cigarettes and cocaine. While pregnant women often use multiple substances, studies have not consistently controlled for exposure to other agents or other important differences in maternal lifestyle associated with the use of these substances. Despite these difficulties, the preponderance of evidence suggests that prenatal alcohol and cocaine independently reduce birth measurements. This review synthesizes the scientific literature focusing on prenatal exposures and the relationship to child growth. First examined are studies that investigated the link between prenatal exposures and birth weight and length, followed by the effects of these substances on childhood growth. Studies vary in the number of subjects, cohort characteristics, measurement of exposure and control for potential confounders. Differences in sample characteristics and size, as well as degree of statistical control for potential confounders and the examination of moderating characteristics, have led to differing conclusions regarding the long-term effect of prenatal substance exposure on growth. Large-scale, well-designed studies are needed to clearly examine the unique contribution of both varying prenatal exposures and the magnitude and timing of these exposures on childhood growth deficits.

Objective To determine whether intrapartum mean platelet volume (MPV) can predict new-onset delayed postpartum pre-eclampsia. Methods In a retrospective study, data were obtained for women with delayed postpartum pre-eclampsia (≥ 48 hours after delivery) who attended the Detroit Medical Center, Detroit, MI, USA, between January 2002 and July 2010. Patients were divided into two subgroups: new-onset delayed postpartum pre-eclampsia (no history of hypertensive disorder before 48 hours after delivery) and other late-onset/delayed postpartum pre-eclampsia (history of hypertensive disorders). Cases with no hypertensive disorders paired by delivery date were selected as controls. Receiver operating characteristic (ROC) curves were used to determine whether MPV could distinguish between cases and controls. Results Data for 130 cases of new-onset delayed postpartum pre-eclampsia, 71 cases of other late-onset/delayed postpartum pre-eclampsia, and 405 controls were collected. MPV was significantly different between the pre-eclampsia subgroups (P = 0.007). ROC curves showed that MPV significantly distinguished new-onset delayed postpartum pre-eclampsia cases (area under the curve 0.6, 95% confidence interval 0.5–0.6; P = 0.02), with a sensitivity and specificity of 58.1% and 55.4%, respectively. Conclusion Although MPV was significantly lower in women who went on to develop new-onset delayed postpartum pre-eclampsia than among controls, it is not a useful predictor. The low MPV suggests a different mechanism for the development of new-onset delayed postpartum pre-eclampsia.

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.

The current recommendation is to delay elective repeat cesarean deliveries (ERCD) until 39 weeks to decrease prematurity risks. Prior reports suggest accelerated maturity of fetuses according to race (African-Americans and Asians).To analyze the effect of the Hispanic ethnicity on the prematurity risk after ERCD.The US Natality Database from 2004 to 2008 was reviewed. Inclusion criteria were singleton delivery, no trial of labor, repeat cesarean. Exclusion criteria were fetal anomalies, history of diabetes/hypertension related disorders. Outcomes analyzed were Apgar score, assisted ventilation, intensive care admission, surfactant/antibiotic use and seizures. Two groups were identified: non-Hispanic Whites (NHW) and Hispanic Whites (HW). Regression analysis was performed to calculate adjusted odds ratios. Deliveries at 36-40 weeks were studied with 40 weeks as the reference group.A total of 930421 ERCDs were identified, 396823 NHW and 236733 HW. For NHW, the risk of prematurity was lower at 39 weeks. For HW, there was no difference in the risks of prematurity at/beyond 38 weeks.There appears to be accelerated maturity with no increase in prematurity risk at 38 weeks in HW delivered by ERCD. Ethnicity can be considered for patient counseling and decision making regarding optimal timing of elective interventions.

Background Pregnancy substance use is linked to low birth weight. However, less is known about relative contributions of various substances and whether effects are due to decreased gestational duration, restriction of fetal growth, or both. The study goal was to use causal modeling to evaluate the individual impact of alcohol, tobacco, cocaine, and marijuana on gestational duration and fetal growth. Methods Participants were 3164 urban black women recruited at entry to prenatal care and followed to delivery, with all gestational dating ultrasound supported. Pregnancy substance use was assessed via self-report (alcohol, tobacco, cocaine, and marijuana). Results Alcohol, cigarette, and cocaine use were all individually and negatively related to gestational age at delivery. However, only alcohol, cigarette, and marijuana use predicted fetal growth, with effects for alcohol and cigarette greater and more discrepant for older women. Overall, heavy cigarette smoking had the greatest individual impact on birth weight (up to 431 g). Heavy levels of use of all 4 substances by older women decreased birth weight by 26% (806 g). Conclusions For perhaps the first time, reduced birth weight is apportioned both by type of substance and mechanism of effect. The use of alcohol and/or cigarettes was clearly more harmful to fetal growth than cocaine use. Findings demonstrate the need for continued emphasis on intervention efforts to address legal and illicit pregnancy substance use.

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.)

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.