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Biomedical subjects

E Lieberman

Publications and source records attributed to E Lieberman.

At least 37 records · Page 2Linked to original sources
PubMed2000

Intrapartum fever and unexplained seizures in term infants.

OBJECTIVE: Early-onset neonatal seizures are a strong predictor of later morbidity and mortality in term infants. Although an association of noninfectious intrapartum fever with neonatal seizures in term infants has been reported, it was based on only a small number of neonates with seizures. We therefore conducted a case control study to investigate this association further. METHODS: All term infants with neonatal seizures born at Brigham and Women's Hospital between 1989 and 1996 were identified. For this study, cases consisted of all term neonates with a confirmed diagnosis of seizure born after a trial of labor for whom no proximal cause of seizure could be identified. Infants with sepsis or meningitis were excluded. Four controls matched by parity and date of birth were identified for each case. The rate of intrapartum maternal temperature >100.4 degrees F was compared for case infants and controls. Potential confounding was controlled in logistic regression analysis. RESULTS: Cases comprised 38 term infants with unexplained seizures after a trial of labor. We identified 152 controls. Infants with seizures were more likely to be born to mothers who were febrile during labor (31.6% vs 9.2%). In almost all cases, the fever developed during labor (94.7% cases, 97.4% controls). At admission, mothers of infants with seizures were not significantly more likely to have factors associated with concern about infection such as a white blood cell count >15 000/mm(3) (28. 9% vs 19.1%) and premature rupture of the membranes (15.8% vs 17.8%). In a logistic regression analysis controlling for confounding factors, intrapartum fever was associated with a 3.4-fold increase in the risk of unexplained neonatal seizures (odds ratio = 3.4, 95% confidence interval = 1.03-10.9). CONCLUSION: Our data indicate that intrapartum fever, even when unlikely to be caused by infection, is associated with a fourfold increase in the risk of unexplained, early-onset seizures in term infants.

Adult↗
PubMed1999

Alternative methods of diagnosing gestational diabetes mellitus.

OBJECTIVE: In an attempt to find more efficacious alternatives for the diagnosis of gestational diabetes mellitus, we evaluated whether (1) there is a glucose loading test value above which all glucose tolerance test results are positive, (2) omission of the third-hour plasma glucose measurement of the glucose tolerance test alters the sensitivity of the test, and (3) the presence of a fasting plasma glucose concentration >/=105 mg/dL suffices as a diagnostic standard after an abnormal glucose loading test result. STUDY DESIGN: The charts of 512 patients who underwent 3-hour glucose tolerance tests at our institution between January 1995 and December 1996 were reviewed. Only subjects for whom the glucose loading test yielded plasma glucose levels >/=140 mg/dL were selected. The positive predictive value of a glucose loading test result >/=185 mg/dL was calculated. Results of glucose tolerance tests of subjects with elevated fasting plasma glucose concentrations were then evaluated to determine the positive predictive value for gestational diabetes mellitus of an elevated fasting plasma glucose concentration. RESULTS: Among the subjects who underwent glucose tolerance tests, 22% (114/512) met positive test criteria for gestational diabetes mellitus. The positive predictive value for a glucose loading test result >/=185 mg/dL was 57% (25/44), whereas a glucose loading test result >199 mg/dL showed a positive predictive value of 69% (4/13). Omission of the third-hour glucose tolerance test value yielded a sensitivity of 87% (99/114). Among the 24 women with fasting plasma glucose concentrations >/=105 mg/dL, 96% had positive glucose tolerance test results. An elevated fasting plasma glucose concentration was highly associated with gestational diabetes mellitus necessitating insulin therapy (65%). CONCLUSION: An elevated glucose loading test result was associated with but not highly predictive of gestational diabetes mellitus. Omission of the 3-hour glucose tolerance test measurement resulted in failure to diagnose 13% of gestational diabetes mellitus cases. A fasting plasma glucose concentration >/=105 mg/dL was highly predictive of an abnormal glucose tolerance test result among patients with an elevated glucose loading test value.

Adult↗
PubMed1999

Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries.

OBJECTIVE: We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries. STUDY DESIGN: The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses. RESULTS: Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2) CONCLUSIONS: Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.

Adult↗
PubMed1999

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.

Cesarean Section↗
PubMed1999

Interpregnancy interval and disparity in term small for gestational age births between black and white women.

OBJECTIVE: To examine the influence of interpregnancy interval on the elevated risk of term small for gestational age (SGA) births to black women. METHODS: This study is a secondary analysis of data from the Delivery Interview Program, a hospital-based cohort study of 12,718 women conducted at the Boston Hospital for Women from 1977 to 1980. The current analysis was limited to black and white parous women who gave birth to term infants during the study and whose last previous pregnancies had also resulted in term, live births. There were 578 black and 3400 white women who met these criteria. The rates of term SGA births for black and white women were calculated according to six interpregnancy intervals (6 or less, 6-12, 12-24, 24-36, 36-60, or longer than 60 months). Multiple logistic regression was used to control for confounding. RESULTS: The overall rate of term SGA births was 6.4% for black women compared with 3.9% for white women (relative risk [RR] 1.7, 95% confidence interval [CI] 1.2, 2.4). Black women were also more likely than white women to have interpregnancy intervals of 6 months or less (9.2% black, 4.8% white; RR 1.9, 95% CI 1.4, 2.6). At every interpregnancy interval, black women had a higher rate of term SGA births than white women. After controlling for interpregnancy interval in a logistic regression analysis, the increased risk of SGA delivery among black women remained unchanged (odds ratio 1.7, 95% CI 1.1, 2.5). CONCLUSION: Although black women were more likely than white women to have SGA births and short interpregnancy intervals, differences in interpregnancy intervals between the races did not explain the disparity in term SGA births.

Adolescent↗
PubMed1999

Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions.

OBJECTIVE: To determine whether gravidas with prior low vertical uterine incision(s) are at a higher risk for uterine rupture during a trial of labor after cesarean delivery than women with prior low transverse uterine incision(s). METHODS: The medical records of women undergoing a trial of labor after prior cesarean delivery over a 12-year period (July 1984-June 1996) at a tertiary-care hospital were reviewed. Maternal and perinatal outcomes for women with prior low transverse and low vertical incision were compared. Women whose low vertical incision was noted to extend into the corpus of the uterus were excluded. All uterine scar disruptions, which included both symptomatic ruptures and detected asymptomatic dehiscences, were analyzed together, and ruptures were examined separately. RESULTS: The outcomes of 2912 patients undergoing trial of labor for the low transverse group and 377 patients undergoing trial of labor for the low vertical group were compared. Overall, there were 38 (1.3%) scar disruptions in the low transverse group and six (1.6%) in the low vertical group, P = .6. There were 28 (1.0%) symptomatic ruptures in the low transverse group and 3 (0.8%) in the low vertical group, P > .999. The study had a power of 80% to detect an increase in the low vertical rupture rate from 1% (as noted for low transverse incisions) to 3%. CONCLUSION: Gravidas with a prior low vertical uterine incision are not at increased risk for uterine rupture during a trial of labor compared with women with a prior low transverse uterine incision.

Adult↗
PubMed1999

Predicting the risk of cystic fibrosis with echogenic fetal bowel and one cystic fibrosis mutation.

OBJECTIVE: To assess fetal risk for cystic fibrosis when echogenic bowel and one cystic fibrosis mutation are detected. METHODS: A hypothetical cohort of 1000 women with singleton pregnancies and echogenic fetal bowel during the second trimester was used to determine the probability of cystic fibrosis when one cystic fibrosis transmembrane conductance regulator mutation was detected. The risk of cystic fibrosis was calculated using the range of prevalence of cystic fibrosis in fetuses with echogenic bowel reported in the literature. Risk calculations for fetuses of Ashkenazi Jewish, Northern European, African-American, Hispanic, and Asian descent accounted for carrier frequencies and mutation detection rates specific to each ethnic group. RESULTS: As the assumed prevalence of cystic fibrosis increases from 1-25%, the probability that a white fetus with one mutation and echogenic fetal bowel actually has cystic fibrosis increases from 4.8% to 62.5%. Assuming a 2% risk of cystic fibrosis with echogenic fetal bowel, an Ashkenazi Jewish fetus and an Asian fetus with echogenic bowel and one mutation have a 3.1% and 72% risk of cystic fibrosis, respectively. The probability of cystic fibrosis in a nonwhite fetus is between those two extremes. CONCLUSION: The probability of cystic fibrosis after detection of echogenic bowel and one cystic fibrosis mutation varied among ethnic groups. Even at the highest prevalence of cystic fibrosis, most white fetuses will not have cystic fibrosis. In nonwhite populations almost half of these fetuses will have cystic fibrosis, even at the lowest prevalence of cystic fibrosis.

Cystic Fibrosis↗
PubMed1999

Nulliparas' preferences for epidural analgesia: their effects on actual use in labor.

BACKGROUND: Few studies have directly examined the reasons for choices of pain relief during labor. The purpose of this study was to investigate if women's preferences for epidural analgesia in labor have an impact on the use of intrapartum epidural analgesia. METHODS: Nulliparous women attending childbirth classes completed questionnaires about their antenatal preferences for the use of intrapartum epidural analgesia. Data on actual use of analgesia was obtained by chart review. The analysis included 303 women with either spontaneous or induced labor at term. RESULTS: The 185 women who planned to receive epidural analgesia had a markedly higher rate of epidural use (91%) than the 110 women who hoped to avoid it (57%) (p = 0.001). Of 237 epidurals administered, 169 (71%) were planned during the antenatal period. Among women receiving epidural analgesia, those planning to receive it tended to have more frequent early administration (< or = 3 cm cervical dilation) than women who unsuccessfully tried to avoid epidural use (54% vs. 24%, p = 0.003). CONCLUSION: In our population of nulliparas, a woman's antenatal plan to receive epidural analgesia is strongly associated with her likelihood of receiving it. Women who plan to receive epidural analgesia have earlier administration.

Adult↗
PubMed1999

Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery.

OBJECTIVES: This study investigated the association of intrapartum temperature elevation with cesarean delivery and assisted vaginal delivery. METHODS: Participants were 1233 nulliparous women with singleton, term pregnancies in vertex presentations who had spontaneous labors and were afebrile (temperature: 99.5 degrees F [37.5 degrees C]) at admission for delivery. Rates of cesarean and assisted vaginal deliveries according to highest intrapartum temperature were examined by epidural status. RESULTS: Women with maximum intrapartum temperatures higher than 99.5 degrees F were 3 times as likely to experience cesarean (25.2% vs 7.2%) or assisted vaginal delivery (25.2% vs 8.5%). The association was present in epidural users and nonusers and persisted after birthweight, epidural use, and labor length had been controlled. In adjusted analyses, temperature elevation was associated with a doubling in the risk of cesarean delivery (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5, 3.4) and assisted vaginal delivery (OR = 2.1, 95% CI = 1.4, 3.1). CONCLUSIONS: Modest temperature elevation developing during labor was associated with higher rates of cesarean and assisted vaginal deliveries. More frequent temperature elevation among women with epidural analgesia may explain in part the higher rates of cesarean and assisted vaginal deliveries observed with epidural use.

Adult↗
PubMed1998

The prenatal detection of significant alcohol exposure with maternal blood markers.

OBJECTIVE: To examine the efficacy of a combination of 4 blood markers of alcohol use in detecting alcohol-abusing pregnant women. STUDY DESIGN: Two new markers of alcohol use, whole blood-associated acetaldehyde and carbohydrate-deficient transferrin, and 2 traditional markers of alcohol use, gamma-glutamyl transpeptidase and mean red blood cell volume, were measured in the blood of pregnant women. Each woman was interviewed about alcohol and drug use, medical and obstetric histories, and nutrition. Each infant was examined by a clinician who was blinded to exposure status. RESULTS: All of the women who reported drinking an average of 1 or more ounces of absolute alcohol per day had at least 1 positive blood marker. The infants of mothers with 2 or more positive markers had significantly smaller birth weights, lengths, and head circumferences than the infants with negative maternal screens. The presence of 2 or more positive markers was more predictive of infant outcome than any self-reporting measure. CONCLUSIONS: These markers, which detect more at-risk pregnant women than self-reporting methods, could lead to better efforts at detection and prevention of alcohol-induced fetal damage.

Acetaldehyde↗
PubMed1998

Assessing the role of case mix in cesarean delivery rates.

OBJECTIVE: Implicit in comparisons of unadjusted cesarean rates for hospitals and providers is the assumption that differences result from management practices rather than differences in case mix. This study proposes a method for comparison of cesarean rates that takes the effect of case mix into account. METHODS: All women delivered of infants at our institution from December 1, 1994, through July 31, 1995, were classified according to whether they received care from community-based practitioners (N=3913) or from the hospital-based practice that serves a higher-risk population (N=1556). Women were categorized according to both obstetric history (nulliparas, multiparas without a previous cesarean, multiparas with a previous cesarean) and the presence of obstetric conditions influencing the risk of cesarean delivery (multiple birth, breech presentation or transverse lie, preterm, no trial of labor for a medical indication). We determined the percent of women in each parity-obstetric condition subgroup and calculated a standardized cesarean rate for the hospital-based practice using the case mix of the community-based practitioners as the standard. RESULTS: The crude cesarean rate was higher for the hospital-based practice (24.4%) than for the community-based practitioners (21.5%), a rate difference of 2.9% (95% confidence interval=0.4%, 5.4%; P=.02). However, the proportion of women falling into categories conferring a high risk of cesarean delivery (multiple pregnancy, breech presentation or transverse lie, preterm, no trial of labor permitted) was twice as high for the hospital-based practice (24.4% hospital, 12.1% community). The standardization indicates that if the hospital-based practitioners had the same case mix as community-based practitioners, their overall cesarean rate would be 20.1%, similar to the 21.5% rate of community providers (rate difference=-1.4%, 95% confidence interval =-3.1%, 0.3%; P=.11). CONCLUSION: Standardization for case mix provides a mechanism for distinguishing differences in cesarean rates resulting from case mix from those relating to differences in practice. The methodology is not complex and could be applied to facilitate fairer comparisons of rates among providers and across institutions.

Cesarean Section↗
PubMed1998

The second-trimester fetal iliac angle as a sign of Down's syndrome.

OBJECTIVE: To determine whether the iliac angle of second-trimester fetuses is a useful sonographic marker for the detection of fetuses with Down's syndrome. METHODS: We prospectively measured the iliac angle for all fetuses karyotyped over a 17-month period. A transverse view of the upper fetal pelvis was obtained at the time of amniocentesis and, by means of a protractor, the angle between the two iliac bones was measured. The angles of all those fetuses with Down's syndrome and the first 500 fetuses with normal karyotypes were compared, as was gestational age and maternal age. RESULTS: Nineteen fetuses with Down's syndrome and 1167 fetuses with normal karyotypes underwent genetic amniocentesis over the study period. The mean gestational age of the fetuses with Down's syndrome was 16.6 weeks (+/- 1.9 weeks), and for the controls, 16.1 weeks (+/- 1.4 weeks) (p = 0.3). The mean maternal ages were 34.7 years (+/- 4.8 years) and 35.4 years (+/- 4.1 years) for those pregnancies with Down's syndrome and with normal karyotypes, respectively (p = 0.5). The mean iliac angle was 80.1 degrees (+/- 19.7 degrees) for those fetuses with Down's syndrome, and 63.1 degrees (+/- 20.3 degrees) for those fetuses with normal karyotypes (p = 0.0004). The iliac angle was at least 90 degrees in 36.8% (seven of 19 fetuses) with Down's syndrome and in 12.8% (64 of 500 fetuses) with normal karyotypes (p = 0.003). CONCLUSION: Fetuses with Down's syndrome have a significantly larger iliac angle than fetuses with normal karyotypes. Use of an iliac angle cut-off point of 90 degrees would identify over one-third of second-trimester fetuses with Down's syndrome. However, because of the high false-positive rate (12.8%), the iliac angle is not useful in a high-risk population as a screening test when used in isolation.

Adult↗
PubMed1998

Significance of an echogenic intracardiac focus in fetuses at high and low risk for aneuploidy.

Our objective was to evaluate the significance of an echogenic intracardiac focus in a mixed population of fetuses at high and low risk for aneuploidy. Over a 1 year period, we prospectively identified all fetuses with an echogenic intracardiac focus seen during prenatal sonography. A detailed structural evaluation was performed on each fetus as permitted by gestational age. The location and number of foci were tabulated prospectively, as were associated abnormalities. Follow-up was obtained by review of the medical record. Of the 290 fetuses who had an echogenic intracardiac focus, 14 of them were aneuploid (4.8%). Of the 290 mothers, 125 women were aged 35 years or older and 165 women were younger than 35 years old. Among the 125 fetuses born to women 35 years or older, eight were aneuploid fetuses (6.4%), while among the 165 fetuses of younger mothers, six were aneuploid fetuses (3.6%) (rate ratio = 1.8; 95% confidence interval [extremes] = 0.6, 4.9). Only one of the 14 aneuploid fetuses had an echogenic intracardiac focus as the only sonographic finding, and this occurred in a woman aged 41 years. The majority of the echogenic intracardiac foci (87.6%) were located in the left ventricle, while 4.8% of the foci were right-sided and 7.6% were bilateral. Among the 14 aneuploid fetuses, 14% had bilateral echogenic intracardiac foci and 7% had right-sided foci. Among the euploid fetuses, 7.3% had bilateral echogenic intracardiac foci and 4.7% had right-sided foci. In conclusion, we have shown that the presence of an echogenic intracardiac focus does raise the risk that the fetus has a chromosomal abnormality, most commonly Down syndrome, although all but one aneuploid fetus in our study had other sonographic findings.

Adult↗
PubMed1998

Linking death reports from the Malaysian Family Life Survey-2 with birth and death certificates.

The Malaysian Family Life Survey--2 (MFLS-2) was a population-based survey conducted in Peninsular Malaysia in 1988-89. Through detailed birth histories, it attempted to collect information on all pregnancies and their outcomes from ever-married women, as well as socioeconomic and health services-utilization data that might have affected mortality. The survey did not, however, collect information on the causes of infant death. The two objectives of this study were to assess the feasibility of linking all reported deaths among live births of women interviewed in the MFLS-2 to the birth and death certificates kept by the National Registration Department, and to determine the causes of death from the successfully matched death certificates. This information could be used in the development of specific health programs to decrease infant and child mortality. In this study, the success rates for linking survey data to birth and death certificates were 34.5% and 31.8% respectively. Methodological problems faced during the study are discussed, as are the strengths and limitations of record linking as a means of increasing the utility of birth histories for studying the causes of death. Ways to improve linkage rates of survey data with the national birth and death registration are also suggested.

Birth Certificates↗
PubMed1997

The association of fetal sex with the rate of cesarean section.

OBJECTIVE: Our purpose was to evaluate the rate of cesarean deliveries according to fetal sex. STUDY DESIGN: We evaluated method of delivery, indication for cesarean section, and infant outcome according to fetal sex in 2439 low-risk nulliparous women in spontaneous labor. Crude odds ratios and 95% confidence intervals were calculated. Confounding was controlled with use of logistic regression. RESULTS: The overall cesarean section rate was 13.2% among 1246 women carrying male fetuses compared with 9.6% among 1193 women carrying female fetuses (odds ratio 1.4, 95% confidence interval 1.1 to 1.8). There was a 30% increase in cesarean sections for failure to progress (odds ratio 1.3, 95% confidence interval 1.0 to 1.8) and a 70% increase in those for fetal distress (odds ratio 1.7, 95% confidence interval 1.0 to 3.0). When adjusted for gestational age and fetal size, male fetal sex no longer predicted the risk of cesarean delivery for failure to progress (adjusted odds ratio 1.04, 95% confidence interval 0.8 to 1.4) but continued to predict the risk of cesarean section for fetal distress (adjusted odds ratio 2.2, 95% confidence interval 1.3 to 4.0). Among infants delivered by cesarean section for fetal distress, males were more than three times as likely than females to have an Apgar score < or = 7 at both 1 and 5 minutes. CONCLUSION: Increased cesarean deliveries for failure to progress among women with male fetuses is related to the larger size of males, whereas the increase for fetal distress is not, and may relate to other developmental differences between male and female fetuses.

Birth Weight↗