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

Objective: To examine knowledge, attitudes, current clinical practices, and educational needs of obstetrician–gynecologists regarding patients’ alcohol use during pregnancy. Methods: A 20-item, self-administered questionnaire on patients’ prenatal alcohol use was sent to 1000 active ACOG fellows. Responses were analyzed using univariate and multivariate statistical techniques. Results: Of the 60% of the obstetrician–gynecologists who responded to the survey, 97% reported asking their pregnant patients about alcohol use. When a patient reports alcohol use, most respondents reported that they always discuss adverse effects and always advise abstinence. One fifth of the respondents (20%) reported abstinence to be the safest way to avoid all four of the adverse pregnancy outcomes cited (ie, spontaneous abortion, central nervous system impairment, birth defects, and fetal alcohol syndrome); 13% were unsure about levels associated with all of the adverse outcomes; and 4% reported that consumption of eight or more drinks per week did not pose a risk for any of the four adverse outcomes. The two resources that respondents said they needed most to improve alcohol-use assessment were information on thresholds for adverse reproductive outcomes (83%) and referral resources for patients with alcohol problems (63%). Conclusion: Efforts should be made to provide practicing obstetrician–gynecologists with updates on the adverse effects of alcohol use by pregnant women and with effective methods for screening and counseling women who report alcohol use during pregnancy.

This study examined the effects of maternal periconceptional alcohol intake on polyunsaturated fatty acid (PUFA) concentrations in human neonates. The area percentage of each fatty acid in cord blood serum from 12 infants born to control women (who consumed

Objective.The aim of this study was to evaluate previous teacher reports that children exposed to cocaine prenatally have more problem behaviors.Methods.A historical, prospective design was used. Maternal subjects (n = 116) of 6-year-old singleton, term (≥36 weeks) children, and the children's first-grade teachers (n = 102) agreed to participate. The child's first-grade teacher, blinded to study design and exposure status, rated the child's behavior with the Conners' Teacher Rating Scales (CTRS) and an investigator-developed scale, the Problem Behavior Scale (PROBS 14), measuring behaviors reported by educators to be specific to cocaine exposure. Mothers were interviewed by telephone regarding demographic and socioeconomic factors.Results.Although the cocaine-exposed group had higher (more problem behaviors) for each of the CTRS subscales, the overall multivariate analysis of variance for the CTRS was not significant. Children exposed to cocaine prenatally had higher scores (more problem behaviors) for 11 of the 14 PROBS items and the overall multivariate analysis of variance relating prenatal cocaine exposure to the PROBS was significant (Wilkes' λ =.775), even after controlling for gender and prenatal exposure to alcohol and cigarettes.Conclusions.This pilot study supports that teachers blinded to exposure status of early elementary students did rate the cocaine-exposed group as demonstrating significantly more problem behaviors than control children. Although an important first step, postnatal factors that also may influence behavior were not evaluated; hence, causation is not addressed.

Prospective studies of the effects of prenatal alcohol exposure on development have focused primarily on the detection of subtle deficits. This study was designed to extend those findings by evaluating dose-response, functional significance, and pattern of drinking in greater detail. 480 African-American infants, recruited to overrepresent prenatal exposure at moderate-to-heavy levels, were assessed. For the five outcomes tested, nonparametric and hockey stick regression analyses both indicated essentially no relation between pregnancy drinking and developmental outcome below a median threshold of 0.5 oz absolute alcohol/day, with the impact of the exposure increasing gradually above threshold. Functional deficit was defined in terms of performance in the bottom 10th percentile of the distribution. For four of the five outcomes tested, there was no increased incidence of functionally significant deficit in infants born to moderate-to-heavy drinking mothers

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

Surveillance by parental concern has been advocated to assess whether formal child developmental testing is needed. To determine whether alcohol intake or illicit drug use in pregnancy is associated with differences in maternal perception of infant development, mothers with acknowledged alcohol and drug habits during pregnancy (N=120) were interviewed at 11 months' postpartum, within 1 month before infant testing by use of the Bayley Scales of Infant Development. Women with heavy alcohol intake during pregnancy (&gt3.5 oz absolute alcohol per week) were 15-fold more likely to overestimate their infant's mental development ( P&lt0.05), whereas mothers using illicit drugs were 4-fold more likely to overestimate their infant's physical development ( P=0.02). Given the frequent denial of substance abuse, we suggest that health care providers be cautious in accepting a lack of parental concern about a child's development and rely more heavily on formal testing, particularly in high-risk populations.

Most studies of prenatal cocaine exposure have found gestational age or intrauterine growth deficits but few, if any, cognitive effects. In a large, well-controlled study we detected cognitive deficits in relation to heavy cocaine exposure. These findings demonstrate that prenatal exposure to cocaine at sufficiently high doses early in pregnancy has the potential to produce cognitive changes in infants and that more focused, narrow-band tests may be necessary to detect these subtle neurobehavioral effects. A total of 464 inner-city, black infants whose mothers were recruited prenatally on the basis of pregnancy alcohol and cocaine use were tested at 6.5, 12, and 13 months of age. Standard analyses, based on presence or absence of cocaine use during pregnancy, confirmed effects on gestational age but failed to detect cognitive effects. A new approach to identifying heavy users found that heavy exposure early in pregnancy was related to faster responsiveness on an infant visual expectancy test but to poorer recognition memory and information processing, deficits consistent with prior human and animal findings. These persistent neurobehavioral effects of heavy prenatal cocaine exposure appear to be direct effects of exposure and independent of effects on gestational age.

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

OBJECTIVES: This study investigated the efficacy of screening for risk drinking during pregnancy with two brief questionnaires, TWEAK and T-ACE. Both include an assessment of tolerance based on the number of drinks women report they can hold. METHODS: Subjects were disadvantaged African-American obstetric patients in Detroit, Mich. Traditional alcoholism screens (Michigan Alcohol Screening Test [MAST], CAGE) and the tolerance question were administered (n = 2717); TWEAK and T-ACE were constructed from tolerance and embedded MAST and CAGE items. In a separate sample (n = 1420), only the T-ACE was administered. Periconceptional risk drinking was the gold standard. Screen evaluations were based on receiver-operating characteristic analyses. RESULTS: At the cutpoint of 2, sensitivity/specificity for embedded screens were 91/77 for TWEAK and 88/79 for T-ACE; comparable values for T-ACE alone were 67/86. TWEAK and T-ACE screened more effectively than CAGE or MAST. CONCLUSIONS: Embedded versions of TWEAK and T-ACE were both highly sensitive to periconceptional risk drinking in this population. Administering T-ACE alone reduced its sensitivity; this suggests that MAST and CAGE administration improves its performance.

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

The risk of fetal alcohol syndrome (FAS) is known to increase with increased maternal age and parity. This study investigated the hypothesis that the deficits in growth and intellectual function seen in non-FAS infants exposed to alcohol at moderate-to-heavy levels are also found disproportionately in the offspring of older mothers. Mothers of 480 African-American, inner-city infants were interviewed at each prenatal clinic visit regarding their use of alcohol during pregnancy. Infants were assessed for physical growth and cognitive development repeatedly through age 13 months. In analyses run separately for the infants of younger and older mothers, alcohol-related deficits were seen most strongly in the offspring of women over 30 years of age. This pattern was not caused by lower levels of drinking by the younger mothers. Age-related increases in maternal body fat-to-water ratio and a faster rate of alcohol metabolism in chronic drinking women may account for the greater vulnerability of the offspring of the older mothers. These data suggest that physiological changes associated with aging and/or chronic drinking may play an important role in the alcohol-related birth defects seen in infants exposed at moderate-to-heavy levels.

The objective of the study was to assess whether the association known in singleton pregnancies of high maternal serum α-fetoprotein (AFP) or human chorionic gonadotropin (HCG) with adverse outcomes applies also to multifetal gestations. Maternal serum AFP and HCG were evaluated in 207 multifetal pregnancies. High values were defined as a maternal serum AFP of > 4.5 and a HCG of > 4.0 multiples of the median (MoM), with appropriate adjustments. Results were correlated with premature delivery, stillbirths, or pregnancy termination for fetal anomalies. There were 10 stillbirths, 7 terminations of pregnancy for fetal anomalies, and 66 premature deliveries in the study group. Maternal serum AFP was somewhat higher in abnormal pregnancies than in those with normal outcome (3.4 vs. 2.5 MoM, respectively, NS). A high AFP level was found in 6% of pregnancies with adverse outcomes and in 4% of uncomplicated gestations (NS). High HCG values, also observed in 5% of cases, were all associated with normal outcome. Multiple marker screening suggested an increased risk for aneuploidy in 9% of patients, all of whom were euploid on amniocentesis karyotypes. Maternal serum screening in multiple gestations is confounded by the differing contributions of fetuses, and abnormal results cannot reliably predict adverse pregnancy outcomes.

A neonatal examination for fetal alcohol syndrome (FAS) should promote the guidance of parents, the planning of remediation for affected children, and the collection of prevalence data. A blinded examination of FAS characteristics conducted as part of a large prospective study of disadvantaged alcohol-exposed infants identified eight neonates who met the published criteria for FAS. These children were followed through the preschool years with a blinded assessment protocol. Seven of these children were found to have no impairment in cognitive and language development, when compared with their peers, and to be of average size. The one child who was mentally and growth retarded at follow-up who had been diagnosed as FAS might not have been diagnosed FAS using clinical criteria (as opposed to blinded research criteria), because his mother provided in-pregnancy reports of only low alcohol intake; she later acknowledged drinking an average of over 21 drinks/week during the pregnancy. The findings are positive in that they provide hope for children who present FAS at birth, although concern with adverse outcomes is certainly not dispelled. In particular, the possibility of later-emerging impairment in more complex tasks is not ruled out.

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

Fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) are fully preventable if alcohol use is separated from pregnancy. However, accomplishing this can be much harder than it might seem. This article describes some strategies for identification and treatment of women who drink during pregnancy.

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

There is evidence that hyperinsulinemia and insulin resistance play a role in the development of hypertension. Accordingly, in our ongoing longitudinal study of pregnancy-induced hypertension, we have measured fasting levels of insulin and glucose at 18 to 25 weeks gestation in 140 nulliparous African-American women followed prospectively to delivery. To test the hypothesis that hyperinsulinemia may be related to the development of preeclampsia, discriminant analysis of mean arterial pressure (MAP), fasting plasma insulin levels, insulin to glucose ratios, and left lateral forearm vascular resistance were examined as predictors of preeclampsia. Statistical analysis controlled for two factors known to be related to insulin levels, gestational age and pregestational body mass index. Gestational hypertensives were not different with regard to blood pressure and metabolic factors from normals and thus were placed in the control group. Women who subsequently developed preeclampsia had mean (+/- SE) fasting plasma insulin levels of 51.0 +/- 12.0 microU/mL at 20 weeks and controls had values of 29.0 +/- 2.8. Only MAP [F(4,135) = 8.8, P.01] and insulin [F(1,135) = 6.5, P.05] were related to the development of preeclampsia [F(4,135) = 4.39, R2 = 11.5%]. The finding that elevated second-trimester insulin levels characterize the subsequent development of preeclampsia with control for increased MAP supports the hypothesis that hyperinsulinemia and associated insulin resistance may contribute to the pathogenesis of preeclampsia.

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

The efficacy of alcohol screening questionnaires, the TWEAK, T-ACE, NET, MAST, and CAGE, in detecting periconceptional risk-drinking, > or = 1 oz absolute alcohol/day, was investigated in 4743 African-American women attending an inner-city prenatal clinic who had reported ever drinking. Sensitivity, specificity, positive predictive value, efficiency, follow-up rates, and receiver operating characteristics of the questionnaires were examined to compare the overall effectiveness of the questionnaires and their performance at cut-points defining positive scores ranging from 1 to 3. Relatively little difference between TWEAK, T-ACE, and MAST was seen in the receiver operating characteristic accuracy indices; NET and CAGE lagged behind. Sensitivity/specificity scores for the two questionnaires most sensitive at cut-point 1 were TWEAK (87/72) and T-ACE (83/75). At cut-point 2, sensitivity was optimized with respect to specificity; TWEAK (79/83) was significantly more sensitive than T-ACE (70/85; p = 0.002). At cut-point 3, the two most sensitive tests were MAST (61/92) and TWEAK (59/94). In general, measures of merit were not greatly affected by the time between conception and the administration of the screens. Screening was most sensitive for women interviewed during the first 15 weeks of pregnancy; risk-drinkers tended to delay entry into prenatal care, increasing positive predictive values associated with screening later in pregnancy. This study confirms the utility, when screening for risk-drinking during pregnancy, of brief questionnaires that assess alcohol intake indirectly by asking women about their tolerance to alcohol's effects, psychological consequences of drinking, and significant others' concern about their drinking. It validates T-ACE and provides preliminary data indicating that TWEAK may outperform T-ACE.

To determine whether children with language delays are more likely to have been exposed to cocaine in utero than children with normal language development, a case-control study was undertaken. Based on routine office screening in our primary-care clinic over a 1-year period, we identified 29 consecutive children, aged 24 to 48 months, as language-delayed. They were compared with an approximate 2:1 match of children without language delay who had been seen in the clinic on the same days and who were of similar age. There was more reported cocaine use during pregnancy (six of 29, 21%) among the language-delayed children than among the controls (five of 71, 7%). This difference is statistically significant ( P < 0.05, χ2= 3.92; odds ratio = 3.4 ± 2.2). Discriminant analysis revealed that both cocaine and nicotine exposure were associated with delayed language development — with an unexpected negative, i.e., an antagonistic, protective, interactive effect (F[3,96] = 4.66, R2= 12.7%, P

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

Facial dysmorphology related to Fetal Alcohol Syndrome (FAS) has been studied from neonatal snapshots with computer-aided imaging tools by looking at facial landmarks and silhouettes. Statistical methods were used to characterize FAS-related midfacial hypoplasia by using standardized landmark coordinates of frontal and profile snapshots. Additional analyses were performed by tracing a segment of the facial silhouettes from the profile snapshots. In spite of inherent distortions due to the coordinate standardization procedure, controlled for race, three significant facial landmark coordinates accounted for 30.6% of the explained variance of FAS. Residualized for race, eight points along the silhouettes were shown to be significant in explaining 45.8% of the outcome variance. Combining the landmark coordinates and silhouettes points, 57% of the outcome variance was explained. Finally, including birthweight with landmark coordinates and silhouettes, 63% of the outcome variance was explained, with a jackknifed sensitivity of 95% (19/20) and a specificity of 92.9% (52/56).© (1993) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

One hundred forty-two low income women were interviewed postpartum to determine their attitudes regarding the potential effects of a punitive law on the behavior of substance-using pregnant women. The convenience sample was primarily black (85.2%) and single (81%) and 14.8% admitted use of illicit drugs during pregnancy. A goodness-of-fit chi-square analysis revealed that subjects believed a punitive law would be a significant deterrent to substance-using gravida seeking prenatal care, drug testing or drug treatment (P < 0.01). Comments indicated that substance-using pregnant women would ‘go underground’ to avoid detection and treatment for fear of incarceration and loss of their children.

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

To determine gestational age-dependent neonatal morphometrics based on last menstrual periods (LMPs), Ballard examinations, and obstetric estimates of gestational age.Cross-sectional survey of 38,818 live-born neonates at a tertiary care center in Detroit, Mich.Consecutive sample of all viable, structurally normal, singleton neonates delivered at Hutzel Hospital from 1984 through 1991.Neonatal weights, lengths, and head circumferences were recorded at birth. Gestational age-dependent morphometrics were based solely on LMPs and compared with those based on obstetric estimates (using LMPs corrected by fetal ultrasound). Ballard examination had an 85.4% concurrence (within 14 days) with obstetric estimates of gestational age, but only a 69.9% (P less than .0001) agreement with LMP. Dating only by LMP significantly overestimated the prevalence of prematurity (odds ratio [OR], 1.3; 99% confidence interval [CI], 1.3 to 1.4) and postmaturity (OR, 5.0; 99% CI, 4.6 to 5.4), distorting apparent growth patterns, especially for preterm neonates. In contrast to previous studies based solely on LMPs, morphometric measurements increased beyond 40 weeks when dated by obstetric estimates.Gestational age-dependent neonatal morphometrics should not be based solely on LMPs.

Strategic planning for rational development of perinatal computing capabilities for the year 2000 should be driven by anticipated trends in (1) the health care business, (2) computer technology and (3) medicine, as well as (4) the needs of perinatal practitioners. In the USA, health care is the fastest growing segment of the economy. This will produce increasing attention from hardware and software developers, and vendors, and will lead to a proliferation of computing platforms, operating systems and specific medical application software. Desktop computers, already capable of 20 million instructions per second (MIPS) with massive storage capacities, will continue to evolve and fall in price. Increasingly, perinatologists will develop software packages to facilitate patient care in their own environments. All of these trends will lead to severe fragmentation in medical computing. Simultaneously, however, the need for integrated institutional computer-based data access for quality assurance and fiscal and operations management will increase. Perinatal care will be more regionalized, complex and rigorous with new clinical trial- and effectiveness research-based interventions, as well as molecular diagnosis and therapy. To practice appropriately, clinicians will need to be familiar with computer capabilities. Having been exposed to computer-aided instruction (CAI) at the undergraduate and postgraduate levels, they will expect on-line access to detailed and accurate patient information with linkage to laboratory, radiology and other medical databases, as well as to reference databases, such as Medlines and the Oxford Database of Perinatal Trials. Artificial intelligence (AI) software may support perinatal decision making; computerized professional and facility billing will be available. Realization of this vision for perinatal computing for the millennium very likely will be based on an infrastructure of networked distributed-computing with parallel processing network servers and interfaces to “meta-systems” to achieve an integrated medical informatics environment.

Several design criteria for computer support of clinical imaging ultrasonography are discussed.

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

OBJECTIVE-To determine if a policy of early amniotomy resulted in a reduction in mean labour duration when compared to a policy of conservation of the membranes. DESIGN-A single-centre randomized controlled trial. SETTING-A tertiary care teaching hospital in Alberta, Canada. SUBJECTS-Ninety-seven term nulliparae in spontaneous labour, baby in cephalic presentation. INTERVENTION-Early amniotomy versus intent to keep membranes intact. MAIN OUTCOME MEASURES-Interval from randomization to delivery, rate of abnormalities of fetal heart rate tracings, cord artery blood pH, Apgar scores. RESULTS-The mean interval from randomization to delivery was 390.9 (SE 29.1) min in the amniotomy group and 442.9 (SE 34.1) min in the control group (P = 0.251). There were no differences between groups in the occurrence of fetal heart rate tracing abnormalities, nor was there a difference in the proportion of babies with abnormal Apgar scores, or abnormal cord pH (less than 7.20). CONCLUSION-The results of the study fail to support the long held belief that early amniotomy is an effective method for reducing labour duration.

The effects of fetal alcohol exposure on sustained attention in the preschool years were investigated in a sample of socioeconomically disadvantaged urban children. The 245 children examined were the 4-year 10-month-old follow-up cohort of a prospective study begun while their mothers were pregnant. Sustained attention was assessed by an automated, computer-administered vigilance task. Indices of fetal alcohol exposure included three measures of maternal drinking and two early indicators of fetal alcohol damage. The data were analyzed using univariate and multivariate regression techniques, both with and without adjustment for covariates. None of the analyses supported the hypothesis that fetal alcohol exposure adversely affects sustained attention performance in preschool children. We infer that, if there is an effect of prenatal alcohol exposure on vigilance task performance, that effect is small.

Gestational age estimation from the measurements of the fetal head from the ultrasound images can be of great importance in management decisions during pregnancy. Biparietal diameter (BPD), occipital frontal diameter (OFD), and the head circumference (HC) are the most common parameters used for estimating the gestational age. Since the fetal head has an elliptical shape in the two dimensional image plane, extracting the ellipse and measuring the major axis (OFC), minor axis (BPD), and circumference (HC) are the task of image processing which will be discussed in this paper.

Several morphometric measures have been used to identify infants at greatest risk from aberrant intrauterine growth. 119 near-term infants were studied to answer the more basic question of how well measures, such as birthweight percentile, ponderal index, the body mass index and the weight/length ratio reflect body fat in the neonate. Skinfold thicknesses were measured as an estimate of fat stores. Multiple regression analysis revealed that the weight/length ratio showed the strongest correlation with relative adiposity, explaining 52% of the variance. Further, sequential exponentiation of the crown-heel length in body mass index and ponderal index decreased the correlation with estimates of body fat. The simple weight/length ratio, exhibiting both a close correlation with body fat and independence of gestational age, race and sex, in near-term infants may be the best morphometric measure of the nutritional component of intrauterine growth in the neonate.

Normal pregnancy is associated with a poorly understood loss of vascular responsiveness to the pressor effects of infused angiotensin II. Since cellular cation metabolism appears to be a critical determinant of basal vascular tone and vascular reactivity, we have evaluated platelet ionized calcium, erythrocyte sodium, calcium and magnesium levels, and erythrocyte Ca-ATPase and Na/K ATPase activity in 15 normal black pregnant women (37.5 +/- 0.6 weeks gestation) and 10 normal age-matched nonpregnant black women. Plasma levels of factors potentially affecting vascular reactivity (endoxin, renin activity (PRA), and atrial natriuretic peptide (ANP] were measured by RIA and peripheral vascular resistance by biolectrical impedance. Peripheral vascular resistance was almost twice as high (P less than .003) in the normal group as in the pregnant women. Intracellular calcium concentrations were not significantly different in erythrocytes or platelets of the two groups. Although erythrocyte membrane Ca-ATPase was similar, Na/K ATPase activity was significantly higher in the pregnant subjects than in the nonpregnant controls, and intracellular sodium was lower. All three measured plasma factors, ANP, endoxin and PRA, were significantly elevated in the pregnant women. Our results suggest that the decrease in peripheral vascular resistance seen in normal pregnancy is probably not the result of alterations in cellular cation concentrations and/or cell membrane pump activity. However, the significant correlation between vascular reactivity and circulating ANP indicates this potent vasodilator may play a role in the observed decrease in peripheral vascular resistance associated with pregnancy.