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Biomedical subjects

A Biringer

Publications and source records attributed to A Biringer.

13 recordsLinked to original sources
PubMed1998

Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial Health Assessment.

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form's reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.

Domestic Violence↗
PubMed1998

The Toronto Tri-Hospital Gestational Diabetes Project. A preliminary review.

In this study, we assessed maternal-fetal outcomes in untreated patients with increasing carbohydrate intolerance not meeting the current criteria for the diagnosis of gestational diabetes mellitus (GDM), examined the relationship between birth weight and mode of delivery among women with untreated borderline GDM, treated overt GDM, and normoglycemia, and established more efficient screening strategies for detection of GDM. This was a prospective analytic cohort study in which nondiabetic women aged > or = 24 years were eligible for enrollment. A 50-g glucose challenge test (GCT) and a 100-g oral glucose tolerance test (OGTT) were administered at 26 and 28 weeks gestational age, respectively. Risk factors for unfavorable maternal-fetal outcomes were recorded. Time since the last meal prior to the screening test was recorded, as well. Caregivers and patients were blinded to glucose values except when test results met the National Diabetes Data Group criteria for GDM. Maternal and fetal outcomes, including the mode of the delivery, were recorded in the postpartum period. Of 4,274 patients screened, 3,836 (90%) continued to the diagnostic oral glucose tolerance test. GDM was seen in 145 women. Increasing carbohydrate intolerance in women without overt gestational diabetes was associated with a significantly increased incidence of cesarean section, preeclampsia, macrosomia, and need for phototherapy, as well as an increased length of maternal and neonatal hospital stay. Multivariate analysis showed that increasing carbohydrate intolerance remained an independent predictor for various unfavorable outcomes, but the strength of the associations was diminished. Compared with normoglycemic control subjects, the untreated borderline GDM group had increased rates of macrosomia (28.7 vs. 13.7%, P < 0.001) and cesarean delivery (29.6 vs. 20.2%, P = 0.03). Usual care of known GDM patients normalized birth weights, but the cesarean delivery rate was about 33%, whether macrosomia was present or absent. An increased risk of cesarean delivery among treated patients compared with normoglycemic control subjects persisted after adjustment for multiple maternal risk factors. As for the screening tests, time since the last meal had a marked effect on mean plasma glucose. Receiver operating characteristic curve analysis allowed the selection of the most efficient cut points for the GCT based on the time since the last meal. These cut points were 8.2, 7.9, and 8.3 mmol/l (1 mmol/l = 18.015 mg/dl) for elapsed postprandial time of < 2, 2-3, and > 3 h, respectively. With this change from the current threshold of 7.8 mmol/l, the number of patients with a positive screening test dropped from 18.5 to 13.7%. There was an increase in positive predictive value from 14.4 to 18.7%. The overall rate of patient misclassification fell from 18.0 to 13.1%. In conclusion, increasing maternal carbohydrate intolerance in pregnant women without GDM is associated with a graded increase in adverse maternal and fetal outcomes. Infant macrosomia is an important factor in high cesarean delivery rates for women with untreated borderline GDM. Although detection and treatment of GDM normalizes birth weights, rates of cesarean delivery remain inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery. The efficiency of screening for GDM can be enhanced by adjusting the current GCT threshold of 7.8 mmol/l to new values related to time since the last meal before screening. Further analyses are underway to elucidate whether maternal risk factors can be used to achieve additional efficiency gains in screening.

Birth Weight↗
PubMed1997

Can pregnant women obtain their own specimens for group B streptococcus? A comparison of maternal versus physician screening. The Mount Sinai GBS Screening Group.

OBJECTIVE: We aimed to compare the Group B Streptococcus (GBS) detection rate when pregnant women performed their own vaginal/anorectal swabs with that from the standard practice of physician-performed swabs. METHOD: The research involved a comparison of maternally obtained swabs for GBS with the current gold standard of physician-obtained swabs performed on the same patient. The women were surveyed about who they would prefer to do their swabs. This research was carried out in the offices of five family physicians and eight obstetricians at Mount Sinai Hospital, Toronto--a tertiary-care teaching hospital--between 1 November 1995 and 31 March 1996. The patients were consecutive pregnant women presenting for their 26-28 weeks antenatal visit. Patients were given a questionnaire and instructions describing how to perform a vaginal/anorectal swab. After each patient completed the survey and obtained her own GBS culture, the physician collected a GBS specimen in their usual manner. The main outcome measures were the results of self-performed and physician-obtained combined vaginal/anorectal culture specimens. RESULTS: Sixty-three matched pairs of GBS swab results and 161 patient surveys were collected. Using any positive result as the gold standard, the prevalence of GBS was 39 out of 163 (24%). Patients detected 38 cases for a sensitivity of 97% (lower 95% confidence limit 92), while physicians identified 32 cases for a sensitivity of 82% (95% confidence limit 70-94). Twenty-five per cent of the women preferred that the physician take the swab, while 75% were indifferent or preferred to self-swab. CONCLUSIONS: Patient-collected vaginal/anorectal swabs for GBS are at least as sensitive as the current practice of physician-performed swabs. The majority of participating patients were interested or willing to perform their own swab. Self-swabbing involves women more actively in their obstetrical care and may improve physician compliance with screening guidelines.

Adolescent↗
PubMed1996

Antenatal psychosocial risk factors associated with adverse postpartum family outcomes.

OBJECTIVE: To determine the strength of the association between antenatal psychosocial risk factors and adverse postpartum outcomes in the family, such as assault of women by their partner, child abuse, postpartum depression, marital dysfunction and physical illness. DATA SOURCES: MEDLINE, Cinahl, Famli, Psych Abstracts and the Oxford Database of Perinatal Trials were searched from relevant articles published from Jan. 1, 1980, to Dec. 31, 1993, with the use of MeSH terms "depression, involutional," "child abuse," "child neglect," "domestic violence," "family," "marital adjustment," "family health," "newborn health," "child health," "physical illness," "social support," "psychosocial risk," "prediction," "risk factors," "obstetrics" and "prenatal care." Further articles were identified from bibliographies. STUDY SELECTION: Of the 370 articles identified through the search, 118 were included for review. Studies were included if they examined the association between psychosocial risk factors and the outcomes of interest. Articles were excluded if they were reviews of poor quality or they had one or more of the following features: insufficient description of the sample, a high attrition rate, a lack of standardized outcome measures, outcomes other than the ones of interest or results that had already been reported in a previous study. DATA EXTRACTION: The strength of evidence of each study was evaluated. On the basis of the evidence, each risk factor was assigned a rating of the strength of its association with each of the postpartum outcomes. The ratings were class A (good evidence of association), class B (fair evidence) and class C (no clear evidence). Of the 129 antenatal psychosocial risk factors studied, 15 were found to have a class A association with at least one of the postpartum outcomes. DATA SYNTHESIS: Child abuse and abuse of the mother by her partner were most strongly correlated (class A evidence) with a history of lack of social support, recent life stressors, psychiatric disturbance in the mother and an unwanted pregnancy. Child abuse was also strongly associated with a history of childhood violence in the mother or her partner, previous child abuse by the mother's partner, a poor relationship between the mother and her parents, low self-esteem in the mother and lack of attendance at prenatal classes. Postpartum abuse of the mother was also associated with a history of abuse of the mother, prenatal care not started until the third trimester and alcohol or drug abuse by the mother or her partner (class A evidence). Child abuse had a fair (class B) association with poor marital adjustment or satisfaction, current or past abuse of the mother and alcohol or drug abuse by the mother or her partner. There was class B evidence supporting an association between abuse of the mother and poor marital adjustment, traditional sex-role expectations, a history of childhood violence in the mother or her partner and low self-esteem in the mother. Postpartum depression was most strongly associated with poor marital adjustment, recent life stressors, antepartum depression (class A evidence), but was also associated with lack of social support, abuse of the mother and a history of psychiatric disorder in the mother (class B evidence). Marital dysfunction was associated with poor marital adjustment before the birth and traditional sex-role expectations (class A evidence), and physical illness was correlated with recent life stressors (class B evidence). CONCLUSIONS: Psychosocial risk factors during the antenatal period may herald postpartum morbidity. Research is required to determine whether detection of these risk factors may lead to interventions that improve postpartum family outcomes.

Child↗
PubMed1995

Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project.

OBJECTIVE: Our purpose was to assess maternal-fetal outcomes in patients with increasing carbohydrate intolerance not meeting the current criteria for the diagnosis of gestational diabetes. STUDY DESIGN: We conducted a prospective analytic cohort study in which nondiabetic women aged > or = 24 years, receiving prenatal care in three Toronto teaching hospitals, were eligible for enrollment. A glucose challenge test and an oral glucose tolerance test were administered at 26 and 28 weeks' gestation, respectively; risk factors for unfavorable maternal-fetal outcomes were recorded. Caregivers and patients were blinded to glucose values except when test results met the current criteria for gestational diabetes. RESULTS: Of 4274 patients screened, 3836 (90%) continued to the diagnostic oral glucose tolerance test. The study cohort was formed by the 3637 (95%) patients without gestational diabetes, carrying singleton fetuses. Increasing carbohydrate intolerance in women without overt gestational diabetes was associated with a significantly increased incidence of cesarean sections, preeclampsia, macrosomia, and need for phototherapy, as well as an increased length of maternal and neonatal hospital stay. Multivariate analysis showed that increasing carbohydrate intolerance is an independent predictor for various unfavorable outcomes. CONCLUSION: Increasing maternal carbohydrate intolerance in pregnant women without gestational diabetes is associated with a graded increase in adverse maternal-fetal outcomes.

Adult↗
PubMed1994

Impact of time since last meal on the gestational glucose challenge test. The Toronto Tri-Hospital Gestational Diabetes Project.

OBJECTIVE: The purpose of the study was to evaluate the impact of time since the last meal on the glucose challenge test and to find cut points that are most likely to predict the outcome of the oral glucose tolerance test in patients screened for gestational diabetes. STUDY DESIGN: This prospective analytic cohort study was carried out at the University of Toronto Perinatal Complex. A 50 gm glucose load was given at 26 weeks' gestation and the time since previous meal ingestion was recorded. At 28 weeks' gestation a 100 gm oral glucose tolerance test was administered. A total of 4274 eligible patients were screened. RESULTS: Time since the last meal had a marked effect on mean plasma glucose. Receiver-operator characteristic curve analysis with National Diabetes Data Group criteria to interpret the oral glucose tolerance allowed the selection of the most efficient cut points for the glucose challenge test on the basis of time since the last meal. These cut points were 8.2, 7.9, and 8.3 mmol/L for elapsed postprandial times of < 2, 2 to 3, and > 3 hours, respectively. With this change from the current threshold of 7.8 mmol/L the number of patients with a positive screening test dropped from 18.5% to 13.7%. There was an increase in positive predictive value from 14.4% to 18.7%. The rate of patient misclassification fell from 18.0% to 13.1%. CONCLUSION: We suggest that screening strategies for detection of gestational diabetes be reconsidered, to account for the impact of variable postprandial status on the test results.

Adult↗
PubMed1994

Psychosocial risk factors during pregnancy. What do family physicians ask about?

OBJECTIVE: To determine whether physician characteristics affect attitudes or practices regarding assessment of psychosocial risk factors during pregnancy, and to evaluate whether an antenatal psychosocial risk factor assessment form would help family physicians. DESIGN AND SETTING: A questionnaire asking physicians to rate the importance of information on a scale of one to five was mailed to all active members of the University of Toronto Department of Family and Community Medicine's Survey Network of Attitudes and Practice (SNAP). PARTICIPANTS: A volunteer sample of physicians doing prenatal and intrapartum obstetrics who are active members of SNAP. The network is made up of full-time faculty in the University of Toronto's family practice units and teaching practice physicians (rural, suburban, and urban) who are interested in participating in research projects. MAIN OUTCOME MEASURES: Response rate was 78%. Responses of the 45 SNAP members who did not practise obstetrics were excluded; 125 of 218 questionnaires mailed were analyzed. RESULTS: Women family physicians rated the form potentially helpful more frequently than their male colleagues. Urban and suburban physicians' concerns differed from those of rural physicians. Alcohol and drug abuse, abuse in the relationship, and acceptance of the pregnancy were rated highly important by physicians. Of the physicians surveyed, 77% thought that an antenatal psychosocial risk assessment form would be of some benefit or very helpful. Only 15% indicated it would be useless or not helpful. CONCLUSION: The importance respondents accorded to risk factors showed little correspondence to the frequency of inquiry about them. The survey confirmed our plan to design an antenatal psychosocial risk factor assessment form.

Adult↗