Risk Of Subsequent Pregnancy Research Articles

Adolescent Girls with Negative Pregnancy Tests

Study Objectives and Design This descriptive study assessed background characteristics and attitudes about pregnancy held by adolescent girls presenting for pregnancy tests and receiving negative results. An additional aim was to determine types of health care services that would be of perceived benefit to them to reduce their risk of subsequent pregnancy. Setting Two health care sites in an urban community included a hospital-based adolescent clinic and a hospital-based women's health care clinic. Participants Sixty-five adolescent, low-income, single women with negative pregnancy test results in a consecutive sample were included in the study. Participants had a mean age of 16.9 (±1.3) years and described themselves as 64.1% African American, 26.6% Latina and 9.4% white, with 81.5% enrolled or recently graduated from high school. Main Outcome Measures The following variables were included: demographic characteristics, reproductive health history, personal and perceived partner attitude about the negative pregnancy test result, perceived parental influences, and teens' suggestions for health care services to prevent unintended pregnancy. Results Health history data revealed high risk status for unintended pregnancy and sexually transmitted infections (STI); 28.5% of participants were ambivalent or disappointed with their negative result, 71.4% were pleased and the majority felt that their partners would be more disappointed with the negative result than they were. Health care services that teens felt would be most helpful were one-on-one contraceptive education and discussion sessions with their own health care provider. Conclusions Sexually active teen women with negative pregnancy test results are at high risk of subsequent pregnancy and STIs, and present important opportunities for preventive reproductive health care during visits with health care providers.

Poor obstetric outcome in subsequent pregnancies in women with prior fetal death.

Patients with recurrent first-trimester spontaneous abortion have been the subject of intensive investigation. However, relatively little is known about second- and third-trimester pregnancy loss. Thus, it is difficult for clinicians to optimally counsel, evaluate, and manage women with previous unexplained fetal death. Our objective was to ascertain the outcome of subsequent pregnancies in patients with prior fetal death. Subjects were identified from patients referred for evaluation of fetal death (occurring at >/= 10 weeks of gestation) and having at least one subsequent pregnancy. Patients with antiphospholipid antibodies were excluded. Logistic regression analysis was performed to determine the association of clinical variables with pregnancy outcome. Two hundred thirty subjects met inclusion criteria. Up through the time of their first fetal death, these women had a total of 721 pregnancies, resulting in 268 (37%) live births, 230 (32%) fetal deaths, and 200 (28%) spontaneous abortions. In total, these women had 839 subsequent pregnancies, resulting in 202 (24%) live births, 209 (25%) fetal deaths, and 372 (44%) spontaneous abortions. Univariate logistic regression analysis identified older age at pregnancy (P =.009, odds ratio 0.63, 95% confidence interval 0.42-1.03) and treatment with low-dose aspirin (P =.001, odds ratio 0.41, 95% confidence interval 0.25-0.68) to be associated with a decreased risk for subsequent pregnancy loss. Women with prior fetal death are at high risk for subsequent pregnancy loss and recurrent fetal death, with fewer than 25% of pregnancies resulting in surviving infants. These data underscore the need for additional research into the pathophysiology and prevention of recurrent fetal death.

Antenatal care of women with previous preterm delivery

Preterm delivery (PTD), caused by preterm labour (PTL), preterm prelabour rupture of membranes (PPROM) or cervical incompetence, is associated with significant perinatal morbidity and mortality and maternal morbidity. Importantly, these conditions are also associated with a recurrence risk in subsequent pregnancies: 20–35% for PTD, 25% for PTL and 20% for PPROM. However, there is controversy on the optimum antenatal management of women identified to be at high risk of PTD based on these historical risk factors. An individualized risk assessment approach by combining sociodemographic factors, cervical ultrasonography, fetal fibronectin and vaginal bacteriological colonization, has improved our ability to predict women at risk of PTD. However, there are only a few proven treatment options to prevent PTL and PPROM. This article presents an evidence-based overview and suggests an antenatal management plan for women with previous PTD before they present with PTL or PPROM.

Management of Rhesus Alloimmunization in Pregnancy

Rhesus immune globulin has decreased the prevalence of rhesus D alloimmunization in pregnancy so that only approximately six cases occur in every 1,000 live births. The rarity of this condition warrants consideration of consultation with or referral to a maternal-fetal medicine specialist with experience in the monitoring and treatment of patients with red cell alloimmunization in pregnancy. Evaluation for the presence of maternal anti-D antibody should be undertaken at the first prenatal visit. First-time sensitized pregnancies are followed with serial maternal titers and, when necessary, serial Doppler assessment of the peak systolic velocity in the middle cerebral artery. In cases of a heterozygous paternal genotype, new DNA techniques now make it possible to diagnose the fetal blood type through free fetal DNA in maternal plasma. When there is a history of an affected fetus or infant, maternal titers are no longer predictive of risk in subsequent pregnancies. Serial peak middle cerebral artery velocities using Doppler ultrasonography can be used in these pregnancies to detect fetal anemia. In some situations, intrauterine transfusion is necessary through ultrasound-directed puncture of the umbilical cord with the direct intravascular injection of red cells. Perinatal survival rates of more than 90% have been reported; hydrops fetalis reduces the chance for a viable outcome by up to 11%. Neonatal and infant outcomes are complicated by the need for repeated transfusions secondary to suppressed erythropoiesis. Long-term studies have revealed normal neurologic outcomes in more than 90% of cases. Future therapy will involve selective modulation of the maternal immune system, making the need for intrauterine transfusions a rarity.

Predicting pregnancy risk in women attending an STD clinic.

Although sexually transmitted disease (STD) clinics focus mainly on STD treatment and prevention, women attending these clinics are also at high risk for pregnancy. To evaluate the relationship between certain demographic and behavioral characteristics and the probability of pregnancy in women attending an urban STD clinic. Non-contraceptive-using women in an STD clinic-initiated randomized controlled contraception study (n = 877) were interviewed at baseline, and incident pregnancies within 1 year of enrollment were measured. Association between baseline demographic and behavioral characteristics with incident pregnancy was assessed by chi-square analysis, and logistic regression was used to assess factors associated with an incident pregnancy. Among the 673 women (76.7%) for whom follow-up pregnancy information was available, 220 (32.7%) incident pregnancies occurred within 1 year. By logistic regression controlling for study assignment, incident pregnancy was associated with age < or =19 years (odds ratio [OR], 2.8; 95% CI: 1.5-5.2), previous abortion (OR, 3.1; 95% CI: 1.7-5.4), frequency of sexual encounters of at least once a week (OR, 1.8; 95% CI: 1.2-2.6), and having a chlamydial infection at the time of enrollment (OR, 1.8; 95% CI: 1.0-3.2). With a combination of demographic and behavioral characteristics correlated by univariate analysis with incident pregnancy (i.e., age < or =19 years, nonwhite race, high school/general equivalency diploma or less education, previous pregnancy, no use of birth control with last intercourse, sex at least once a week, previous abortion, > or =3 partners within the past month, and <17 years of age at first pregnancy), the cumulative risk of pregnancy with 6 or more of the 9 characteristics was 51%, compared with 25.6% for women with < or =5 characteristics. For this STD clinic population, a combination of demographic and behavioral characteristics was useful when combined for identifying a subgroup of women at higher risk for subsequent pregnancy. Targeted intervention by STD care providers should include the provision for both pregnancy and STD prevention counseling.

Neonatal Lupus Is More Than a Skin Disease

Neonatal lupus erythematosus (NLE), a transient skin disorder, occurs in infants born to mothers with and without collagen vascular disorders. NLE may also manifest as complete congenital heart block (CHB). CHB and skin disease may coexist. Using a national NLE registry, these authors analyzed data on infants with skin disease alone. They also evaluated maternal outcomes and risks in subsequent pregnancies. The registry enrolls fetal, neonate, and …

Risk of subsequent pregnancies in women with a history of peripartum cardiomyopathy

Risk of subsequent pregnancies in women with a history of peripartum cardiomyopathy

Cystic Fibrosis Newborn Screening: Impact on Reproductive Behavior and Implications for Genetic Counseling

To evaluate the impact of newborn screening for cystic fibrosis (CF) on the reproductive knowledge and behavior of CF families and to determine if heterozygote detection with the immunoreactive trypsinogen (IRT) method in conjunction with DNA analysis (IRT/DNA) influences knowledge and attitudes about reproduction in false-positive families. The Wisconsin CF Neonatal Screening Project investigated 650 340 infants from 1985 to 1994 in a comprehensive randomized controlled trial to study both benefits and risks of newborn screening and to determine if early diagnosis would improve the prognosis of children with CF. Assessments of reproductive knowledge, attitudes, and behaviors of 135 families of children diagnosed as having CF in both the early treatment group and control groups were made 3 months after diagnosis using a questionnaire which was completed by 100 families. The same questionnaire was administered 1 year later to evaluate retention of information. It was completed by 71 families. A follow-up assessment tool was also administered in 1994 and responses obtained from 73 families. Knowledge, attitudes, and behavior among false-positive families were also assessed at the time of the sweat test in 206 families who experienced IRT screening and 109 families tested with the IRT/DNA method. Follow-up assessments were completed 1 year later in 106 IRT families and 63 IRT/DNA families. In families with a CF child, 95% initially understood that there was a 1 in 4 risk in subsequent pregnancies, and there was good retention of this information 1 year later. At the 1994 assessment, 52% of families had not yet conceived more children, but 74% of these already had children. In the couples in whom CF was diagnosed in the first child, 70% (95% confidence interval = 54% to 85%) conceived more children. There were 43 subsequent pregnancies in 31 families. Prenatal diagnosis was used by 26% of the families (8/31) for 21% of the pregnancies (9/43). There were 3 pregnancies with CF detected, all of which were carried to term. In the false-positive groups, >95% of families initially understood that their child definitely did not have CF. There was no difference between false-positive IRT and IRT/DNA groups, and the information was retained at 1 year. Follow-up assessment 1 year after negative sweat tests revealed that 7% of the IRT and 10% of the IRT/DNA families still thought about the results often or constantly. When asked whether the experience of screening affected feelings about having more children, an affirmative response was obtained in 4% of IRT families but in 17% of IRT/DNA families. One year later, more than half of the false-positive IRT/DNA families did not understand that they were at increased risk of having a child with CF. We conclude that CF neonatal screening does not have a significant impact on the reproductive behavior of most families and that prenatal diagnosis is not used by the majority of CF families. IRT/DNA testing experiences seem to affect attitudes about having more children, and some parents are confused about the implications of the results, even with genetic counseling. However, persistent concerns about the sweat test result are limited. Questions raised by this study confirm the need for more research regarding the process of genetic counseling and its impact on reproductive attitudes and behavior in the newborn screening setting.

Maternal syphilis: the next pregnancy.

We sought to determine: (1) the perinatal outcomes in the subsequent pregnancy; (2) the natural history of serologic titers over the course of the two pregnancies; and (3) the incidence and risk factors for delivering an infant with congenital syphilis in the subsequent pregnancy. Over a five-year period, we reviewed the charts of 46 women with maternal syphilis during pregnancy who had a subsequent pregnancy and delivered in our institution. The initial and subsequent pregnancy outcomes were contrasted. To characterize the subsequent pregnancy risk of congenital syphilis, those women with recurrent congenital syphilis were contrasted to women who delivered infants without congenital syphilis. Rapid plasma reagin (RPR) titers in the initial and subsequent pregnancy were analyzed by neonatal outcome. Forty percent of the women who delivered an infant with congenital syphilis in their first pregnancy delivered yet another infant with congenital syphilis in the subsequent pregnancy. Continued cocaine use was the single most important risk factor for delivering another infant with congenital syphilis (p < 0.0001). Forty-two percent of the women who delivered an infant without congenital syphilis in the initial pregnancy delivered an infant with congenital syphilis in the subsequent pregnancy. Birthweight, the number of neonatal hospital days, and the incidence of respiratory distress syndrome (RDS), neonatal pneumonia, abruption, and positive meconium drug screens were not significantly different between the initial and subsequent pregnancies. As with the initial pregnancy, women continued to experience poor pregnancy outcomes in the subsequent pregnancy.

A child with cystic fibrosis: I. Parental knowledge about the genetic transmission of CF and about DNA‐diagnostic procedures

In 1984, we interviewed 105 Belgian families with a Cystic Fibrosis (CF) child in order to evaluate their knowledge about the genetic aspect of CF. Three years later, in 1987, they received a mailed questionnaire to assess how well they were informed about the new possibilities of DNA diagnosis. In 1984, three out of the four families were aware of their 25% recurrence risk in subsequent pregnancies. The proportion of correct answers rose to 87% in 1987. The risk that relatives may be asymptomatic carriers was less well known. Only 17% knew that the risk that their own brothers and sisters are carriers of the CF-gene was 1 in 2. The probability that their own healthy children would be carriers of the CF-gene was not known at all. Half of the families who returned the questionnaire thought they were well informed about the new possibilities of DNA-analysis for prenatal diagnosis. The limitations of DNA analysis, however, were poorly understood. The information transfer about the genetic transmission of CF and related topics within the family was also investigated.

Culture and Karyotyping of Amniotic Fluid Cells

Introduction Prenatal diagnosis for an increasing variety of genetic disorders and congenital defects has been possible since about 1970. During the last decade the demand for prenatal diagnostic services has increased almost logarithmically and has become an overwhelming service load for many cytogenetic laboratories. This demand will probably continue to grow during the 1980s. Requests for chromosome studies are the most common. followed by requests to diagnose errors of morphogenesis (mostly neural tube defects), inborn errors of metabolism, and other Mendelian disorders. The most common indication for a prenatal cytogenetic study is advanced maternal age, which has an associated increased risk for trisomy 21 (Down syndrome) and other aneuploid conditions (Table 1). Prenatal diagnosis is indicated for pregnant women 35 years of age or more. The incidence of trisomy 21 is greater in amniotic fluid samples than at birth partly because about 65% of trisomy 21 fetuses abort spontane~usly,~ many after the 16th week of gestation.= Couples who have had a child with karyotype abnormality may be at increased risk in subsequent pregnancies; the recurrence risk for trisomy 21 is about 1 % . Individuals who carrv a balanced chromosome rearrangement are also at risk of having offspring or abortuses with unbalanced karyotypes. The risk of the amniocentesis procedure to the mother and fetus has been the subiect of considerable discussion. Only about 2% of women experience apparent complication such as vaginal bleeding, leakage of amniotic fluid, or abdominal cramping. The chance of miscarriage or problems associated with labor and delivery have not been shown to be significantly increased, and injury to the fetus from the needle appears very rare. A study undertaken in the United States concluded that

Adolescent Mourning Reactions to Infant and Fetal Loss

Adolescents who do not fully address the process of mourning after abortion, miscarriage, or infant loss may face a greater risk of subsequent pregnancy

The Cerebral Lipidoses

The disorders presented consist of those clinical entities in which a reasonably well defined lipid storage material accumulated within nervous tissue. Many other progressive, degenerative disorders are suspected of being storage disorders, but their chemical pathology remains unclear. Collectively this group could be designated the sphingolipidoses. In each case, the disease is a genetic disturbance and transmitted as an autosomal recessive. Sphingolipid storage in each disorder is associated with deficient activity of a specific degradative enzyme or enzyme system, and these deficient enzymes are all lysosomal hydrolases. Lysosomal hydrolases catalyze the breakdown of complex molecules in digestive vacuoles (phagocytic or autophagic) within the cells. Lysosomes show structural latency (requiring osmotic shock or freeze thawing in vitro); their enzymes show maximal activity at acidic pH ranges, and on electron microscopic examination they appear as small, electron-dense intracellular bodies. These hydrolytic enzymes seem to have some form of biological vulnerability in terms of their genetic expression, and this vulnerability underlies the sphingolipidoses. Diagnosis in each case is primarily a clinical problem. The presentation of these disorders, especially in intermediate or advanced forms, is sufficiently distinctive to permit a reasonably accurate diagnosis on the basis of history, physical examination, and routine laboratory data. Patients seen in early stages may be more difficult to recognize but follow-up evaluations usually clarify the problem. Specific enzyme assays are now available for confirmation of the diagnosis in these disorders. A frequent finding in this connection is an increase in the activities of noninvolved lysosomal hydrolases in the storage disorders. Once a case is clinically diagnosed, the clinician has the responsibility of ensuring that proper genetic counseling is made available to the affected families. Considerable supportive care is needed in each case. These patients can survive for prolonged periods, and great stress is placed on their families by these prolonged, hopeless illnesses. Since the disorders affect infants or young children, their parents are usually young adults in their early reproductive years. It is essential that they receive information concerning the risk of subsequent pregnancies. Specific diagnosis of the fetus in early pregnancy can be made now by amniocentesis and enzyme assays on cultured fibroblasts. If the fetus is a homozygote on the basis of enzyme assays, the option of therapeutic abortion should be discussed with the family. For many parents there will be considerable sensitivity to the ethical implications of this course and, if any doubt arises, ethical or pastoral consultation should be sought. Although there are no specific therapeutic approaches, a considerable degree of supportive care can and should be given. In the gangliosidoses and late in the course of the leukodystrophies, seizures will present management problems...

SELECTIVE TREATMENT OF ANTEPARTUM HEMORRHAGE

Abstract 1. 1. There are presented the results of selective treatment of 191 cases of placenta previa with a mortality of 2.6 per cent, and 139 cases of accidental hemorrhage with a mortality of 2.9 per cent. 2. 2. These results, we believe, are comparable to those obtained by routine section in the treatment of these conditions and may avoid the additional risk of subsequent pregnancies by patients who have undergone cesarean section. 3. 3. All cases of antepartum hemorrhage should be treated in the hospital if at all possible, and as the diagnosis cannot always be accurately made when the first bleeding is only slight, this will entail hospitalizing patients who may subsequently be proved to have neither placenta previa nor accidental hemorrhage. 4. 4. In most emergencies of medical practice, where special skill is not available, conservative measures of treatment are usually in the best interests of the patient, but in placenta previa and probably in accidental hemorrhage, if skilled judgment is not available, radical method of treatment, namely cesarean section, is probably advisable.

Selective treatment of antepartum hemorrhage

1.1. There are presented the results of selective treatment of 191 cases of placenta previa with a mortality of 2.6 per cent, and 139 cases of accidental hemorrhage with a mortality of 2.9 per cent.2.2. These results, we believe, are comparable to those obtained by routine section in the treatment of these conditions and may avoid the additional risk of subsequent pregnancies by patients who have undergone cesarean section.3.3. All cases of antepartum hemorrhage should be treated in the hospital if at all possible, and as the diagnosis cannot always be accurately made when the first bleeding is only slight, this will entail hospitalizing patients who may subsequently be proved to have neither placenta previa nor accidental hemorrhage.4.4. In most emergencies of medical practice, where special skill is not available, conservative measures of treatment are usually in the best interests of the patient, but in placenta previa and probably in accidental hemorrhage, if skilled judgment is not available, radical method of treatment, namely cesarean section, is probably advisable.