Increased risk of recurrence of pregnancies complicated by fetal neural tube defects in mothers receiving poor diets,and possible benefit of dietary counselling.

One hundred and seventy-four women who had previously had a child with a neural-tube defect were assessed retrospectively on the quality of their diets during the first trimester of that pregnancy, between pregnancies, and during the first trimester of other pregnancies. They were then studied prospectively during the first trimester of 186 following pregnancies and the outcome of these was recorded. One hundred and three women (with 109 pregnancies) were given dietary counselling before the pregnancy, the remaining 71 (with 77 pregnancies) not being counselled. Seventy-eight (72%) of the counselled women improved their diet compared with only nine (12%) of the uncounselled women. The difference was significant (p < 0.001). There were three recurrences of neural-tube defects in the counselled women (3%) and five recurrences in the uncounselled (7%). Although this difference was not significant, the relative risk in the counselled group was reduced to less than half of that in the uncounselled group. All eight recurrences occurred in the 45 pregnancies in women taking poor diets (18%), whereas there were no recurrences in the 141 other pregnancies. This difference is significant (p < 0.001). It is concluded that women receiving adequate diets have a lower incidence and recurrence of fetal neural-tube defects than women receiving poor diets and that dietary counselling may be effective in reducing the incidence of fetal neural-tube defects.     

Sequelae and support after termination of pregnancy for fetal malformation.

A retrospective study examined the reactions to the termination of pregnancy for fetal malformation and the follow up services that were available. Women resident in Mid Glamorgan who had had a termination between 1977 and 1981 because of positive findings after midtrimester prenatal diagnostic tests for neural tube defect or chromosome abnormalities were interviewed at home using a semistructured interview schedule. Three retrospective internal comparison groups were formed from those women who had also had a spontaneous abortion, previous stillbirth, or neonatal death or previous termination for medicosocial reasons early in pregnancy. Of the 48 women interviewed, 37 (77%) experienced an acute grief reaction after the index pregnancy was ended. This reaction was akin to that documented after stillbirth or neonatal death. Twenty two women (46%) remained symptomatic six months after the pregnancy had been ended, some requiring psychiatric support, compared with no such reaction after spontaneous abortion or termination for medicosocial reasons. All the women who had previously had a stillbirth or neonatal death were visited at home either by the general practitioner or by the midwife after that event but such follow up was limited to only eight of the study group after termination for fetal malformation. The findings suggest that support is inadequate for these patients and that improved follow up and counselling services may lessen the adverse sequelae of termination for fetal malformation.     

Breast-feeding after vertical mammaplasty with medial pedicle

A retrospective study was performed in which the breast-feeding success of women of childbearing age (15 to 40 years) with macromastia but no prior breast surgery was compared with that of women of similar age who had undergone medial pedicle/vertical pattern reduction mammaplasty. All women completed a self-administered questionnaire that provided information on their breast-feeding success. The control group consisted of 149 women with macromastia (mean age, 27 years) who had been evaluated for possible breast reduction surgery and who had children before their consultation. The study group consisted of 58 women (mean age, 29 years) who had children after their vertical mammaplasty. The mean weight of breast tissue removed was 610 g per breast. None of the patients had absent nipple sensation. A period of 2 weeks or more was chosen as the defining duration of a successful breast-feeding attempt. Those individuals judged able to breast-feed were further classified on the basis of having breast-fed exclusively or with supplementation. The results demonstrated that, of the women who attempted to breast-feed, 61 percent in the control group and 65 percent in the study group were successful, with no significant difference between the groups (p > 0.05). The breakdown of the successful groups indicated that 36 percent in the control group and 38 percent in the study group supplemented their breast-feeding with formula. The groups were not significantly different (p > 0.05). In conclusion, this study found no significant difference in the rate of breast-feeding success between women who had medial pedicle/vertical pattern reduction mammaplasty and women who had no prior breast surgery.     

Prevalence and duration of breast-feeding in Manitoba.

The rate of breast-feeding in the first 3 months post partum was studied in a group of 456 mothers. At 3 months 58% had been or still were breast-feeding their infants. The mothers who breast-fed were older, had a higher level of education, had a higher socioeconomic status, and were more likely to live on farms or in small towns, to have attended prenatal education classes and to have previously breast-feds. There were no significant differences between the method of feeding and the sex or birthweight of the infant, the maternal weight/height ratio or the participation of the father in the prenatal education classes. At 1 month 45% of the infants, at 2 months 35% and at 3 months 28% were being breast-fed. Public programs to promote breast-feeding as normal, beneficial and satisfying to both mother and infant are necessary so that more mothers will attempt to breast-feed their infants. Support for continuance of breast-feeding is needed in the hospital as well as in the home and the community.     

Infant feeding practices: 1984-85 versus 1977-78.

In 1979 and 1980 the Canadian Paediatric Society''s Nutrition Committee published guidelines for professionals counselling mothers of infants on feeding practices. The practices in 1984-85 of mothers in Toronto were determined for comparison with the practices identified in a similar study conducted in Toronto and Montreal in 1977-78 to ascertain if practices had changed in favour of the recommendations. Between July 1984 and February 1985, 404 metropolitan Toronto mothers of infants were interviewed. Compared with the 1977-78 group of mothers, more of the 1984-85 mothers had chosen to breast-feed and fewer had stopped breast-feeding in the first month. As well, fewer of the 1984-85 infants had been fed unmodified cow''s milk in the first 6 months of life and introduced to solid foods before 4 months of age. We conclude that major changes in infant feeding practices had occurred since 1977-78 and that the 1984-85 practices corresponded closely to the infant feeding guidelines.     

Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression.

OBJECTIVE--To determine whether counselling by health visitors is helpful in managing postnatal depression. DESIGN--Controlled, random order trial. SETTING--Health centres in Edinburgh and Livingston. PATIENTS--Sixty women identified as depressed by screening at six weeks post partum and by psychiatric interview at about 13 weeks post partum. Five women did not wish to participate, and a further five did not complete the trial. Age, social and obstetric factors, and diagnosis were similar in women who completed the trial and those who withdrew. INTERVENTION--Eight weekly counselling visits by health visitors who had been given a short training in counselling for postnatal depression. END POINT--Reduction of depression. MEASUREMENTS and main results--Standardised psychiatric interviews and a 10 point self report scale were used to identify depression before and after intervention. The psychiatrist was not told to which group women were allocated. After three months 18 (69%) of the 26 women in the treatment group had fully recovered compared with nine (38%) of the 24 in the control group. The difference between the groups was thus 32% (95% confidence interval 5 to 58). CONCLUSIONS--Counselling by health visitors is valuable in managing non-psychotic postnatal depression.     

High Uptake of HIV Testing in Pregnant Women in Ontario,Canada

In 1999, Ontario implemented a policy to offer HIV counseling and testing to all pregnant women and undertook measures to increase HIV testing. We evaluated the effectiveness of the new policy by examining HIV test uptake, the number of HIV-infected women identified and, in 2002, the HIV rate in women not tested during prenatal care. We analyzed test uptake among women receiving prenatal care from 1999 to 2010. We examined HIV test uptake and HIV rate by year, age and health region. In an anonymous, unlinked study, we determined the HIV rate in pregnant women not tested. Prenatal HIV test uptake in Ontario increased dramatically, from 33% in the first quarter of 1999 to 96% in 2010. Test uptake was highest in younger women but increased in all age groups. All health regions improved and experienced similar test uptake in recent years. The HIV rate among pregnant women tested in 2010 was 0.13/1,000; in Toronto, the rate was 0.28 per 1,000. In the 2002 unlinked study, the HIV rate was 0.62/1,000 among women not tested in pregnancy compared to 0.31/1,000 among tested women. HIV incidence among women who tested more than once was 0.05/1,000 person-years. In response to the new policy in Ontario, prenatal HIV testing uptake improved dramatically among women in all age groups and health regions. A reminder to physicians who had not ordered a prenatal HIV test appeared to be very effective. In 2002, the HIV rate in women who were not tested was twice that of tested women: though 77% of pregnant women had been tested, only 63% of HIV-infected women were tested. HIV testing uptake was estimated at 98% in 2010.     

Studies on perceived breast-milk insufficiency: relation to attitude and practice.

Fifty-one mother-infant pairs were followed prospectively by home visits and telephone contacts during the first 6 months post-partum. Comparisons between mothers who experienced lactation crises because of perceived breast-milk insufficiency (crisis group) and those who did not (non-crisis group) revealed differences in attitudes to breast-feeding, breast-feeding behaviour and sexual life. The crisis group tended to initiate breast-feeding for infant-related reasons more frequently than the non-crisis group, which more frequently gave mother-related reasons. During the course of breast-feeding attitude changes in a negative direction were significantly more common in the crisis group. No difference was found between the groups in the resumption of sexual life, but 59% of all the women claimed that they experienced less or no desire compared to before pregnancy and, of these, a significantly higher proportion belonged to the crisis group.     

Time course of deacclimatization to cold water immersion in Korean women divers

Seasonal basal metabolic rates (BMR), critical water temperature (Tcw), maximal body insulations (Imax), and finger blood flow during hand immersion in 6 degrees C water (Q finger) were measured periodically during the course of a 3-yr longitudinal study (1980-1982) of modern Korean diving women (ama), who have been wearing wet suits since 1977 to avoid cold stress during work. Methods and protocols were identical to previous studies of cotton-suited ama from 1961-1974. The BMR of modern ama did not undergo seasonal fluctuation (1980-1981) and was within the DuBois standard and comparable to nondivers year around Tcw of ama was still reduced by 2-3 degrees C in 1980 but increased progressively to equal that of nondivers in 1982, when compared at comparable subcutaneous fat thickness (SFT). Since modern ama and nondivers have 2.4 times thicker SFT (i.e., 4-13 mm) than in 1962 the absolute Tcw is significantly reduced. Q finger of ama was also significantly lower than controls in 1980 but in 1981-1982 was identical to controls. Imax of modern ama was identical to controls of comparable SFT in 1980-1982. The time course of cold deacclimatization thus was BMR, 3 yr; Imax, 3 yr; Q finger, 4 yr; and Tcw, 5 yr. This longitudinal study provides further evidence that acclimatization to cold did at one time exist in these diving women.     

The recovery of ovarian function during breast-feeding

The pattern of breast-feeding was daily recorded and the serum concentrations of prolactin (PRL), FSH, LH, estradiol (E2) and progesterone (prog) were measured at weekly intervals in 26 breast-feeding mothers from the time of delivery and up to the resumption of regular ovulation or to the end of the first postpartum year. Twelve postpartum non-breast-feeding women were similarly studied as controls. An algorithm was used to characterize ovulatory events into three types: the first, with evidence highly suggestive of normal ovulation (EHSO), the second, with evidence of probable ovulation (EPO) and the third with evidence indicating questionable ovulation or deficient corpus luteum function (QO/DCT). Pregnancy preceded the first menstruation in one woman in each of the breast-feeding and control groups. Of the 19 breast-feeding women who started to menstruate during the first postpartum year, five had EHSO, one had EPO, 5 had EQO/DCL and 7 had anovulatory (AO) menstruation. The corresponding figures in the 11 controls were 6, 2, 3 and 0. Pregnancy occurred before a second menstruation in one woman in both the study group and the controls. In 18 breast-feeding women observed, the second menstruation was preceded by EHSO in 7, by EPO in 3, by EQO/DCL in one and AO in 7. In 10 controls the corresponding figures were 7, 3, 0 and 0. Out of a total of 79 menstruations observed during breast-feeding the incidence of AO was 30% and of QO/DCL was 15%. In actively breast-feeding mothers, hyperprolactinemia persisted for more than 1 yr. However, menstruation and ovulation occasionally occurred before the drop of PRL to concentrations seen during the normal menstrual cycle. In the majority of women, low E2 levels were present during lactational amenorrhea, but with occasional spikes in some. A few women maintained somewhat high values of E2 for several weeks before the resumption of menstruation. The implications of these hormonal findings to the attempts to improve on the contraceptive effect of breast-feeding are discussed.     

Changes in maternal age distribution and their possible impact on demand for prenatal diagnostic services

Between 1977 and 1985 there was a 65% increase in births to women aged 35 or more in England and Wales, but only a 15% increase in all births. Two factors of roughly equal importance were responsible for this differential increase. Firstly, the proportion of older women (35-44) among all women of reproductive age (15-44) increased from 28% in 1977 to 31% in 1985; and, secondly, in the same period the fertility rate for women aged 35-39 increased from 18·2 to 24·1 per 1000 and for women aged 40-44 from 4·1 to 4·6 per 1000.The increased fertility rate among older women is not due to an extension of the reproductive period but to a delay in childbearing. This delay was seen in women married only once and also in those who had remarried.As prenatal diagnosis for the exclusion of chromosome abnormalities is customarily offered to older mothers the increased numbers of women aged 35 or more and their increased fertility rate have important implications for the provision of obstetric and laboratory services. There were 51 859 live births to women aged 35 and over in 1985; the projected figure for 2001 is 85 000. If the use of prenatal diagnosis continues to increase facilities for about 70 000 prenatal cytogenetic analyses will be needed in 2001.     

Support after perinatal death: a study of support and counselling after perinatal bereavement.

After an earlier study into the practical aspects of the management of perinatal death, a counselling service was introduced for parents whose baby had died in the perinatal period. The service was monitored, and the parents who received the service were compared with a group that did not. Fifty families were allocated randomly either to the counselling (supported) group or to the contrast group, who received routine hospital care. Assessment was carried out at six and 14 months after the death, using a semi-structured interview and two self-rating scales (the general health questionnaire and the Leeds scales). Two of 16 mothers in the supported group showed psychiatric disorder at six months, compared with 10 of 19 in the contrast group (p less than 0.01, Fisher''s exact test). There was no significant difference between the two groups at 14 months, when 80% of all the women studied had recovered psychiatric symptoms. Socially isolated women and those who marital relations lacked intimacy had a higher incidence of psychiatric symptoms at six months. Early pregnancy (within six months) was associated with a higher incidence of psychiatric symptoms in the unsupported group. The duration of bereavement reaction after perinatal death was appreciably shortened by support and counselling.     

Increasing prevalence of breast-feeding.

Two studies were performed to gauge the prevalence of and attitudes towards breast-feeding. Mothers delivered in one month in 1975 and in one month in 1977 were sent a questionnaire one month later to determine whether they were breast-feeding their babies; those that were received a second questionnaire at three months. The prevalence of breast-feeding increased significantly between 1975 and 1977, and in both periods primiparas were more likely to breast-feed than multiparas. A survey of mothers'' intentions to breast-feed showed that there were no significant racial differences, but that 82% of women in social classes I and II intended to breast-feed compared with 54% in classes IV and V. These results show that, although the level of breast-feeding was high in 1975, a campaign directed at mothers, doctors, midwives, and health visitors did increase the prevalence of breast-feeding.     

An evaluation of a national breast-feeding promotion programme in Honduras

A significant increase occurred in the initiation and duration of breast-feeding among Honduran women between 1981 and 1987. Changes in population characteristics (e.g. level of education of women) would be expected to lead to a decrease in breast-feeding at each infant age, but these were offset by behavioural changes that led to an increase in the likelihood of initiation and continuation of breast-feeding. An exploration of relevant factors suggests that the PROALMA breast-feeding promotion programme has had a profound effect on the breast-feeding behaviour of Honduran mothers.     

Fetal mortality at the time of chorionic villi sampling

Summary To estimate the background fetal loss rates among women who might be candidates for chorionic villi sampling (CVS) for prenatal diagnosis, we examined the frequency of spontaneous abortion and of non-viable fetuses in two groups of women thought to be pregnant at 8–12 weeks' gestation. Among 1519 women over 35 years given an appointment for amniocentesis 1978–1981, 9.8% had a spontaneous abortion prior to 16 weeks' gestation. For those under observation before week 12, the loss rate by 16 weeks was 15.3%. Among all 190 candidates for elective termination of pregnancy between 6 and 12 weeks' gestation, 12.6% were found to have a non-viable fetus at the scheduled date of abortion. The frequency of non-viability was 14% among those seen before week 12. The data suggest that the background loss rate between the time of CVS and the time of amniocentesis is approximately 1–2% and is unlikely to be higher than 9%. Until randomized clinical trials of the procedure are completed we will not know how much, if at all, the loss rate associated with CVS is increased above this background. Nevertheless, knowledge of these background risk estimates may be useful in counseling women considering participating in trials of CVS.     

Prevalence of congenital anomalies at birth among offspring of women at risk for a genetic disorder and with a normal second-trimester ultrasound.

The goal of this study was to determine the prevalence and the nature of congenital anomalies found at birth in offspring of women who had a normal second-trimester ultrasound and/or amniocentesis. Two groups of women were studied in our prenatal diagnosis clinic between 1991-1997. Group 1 consisted of pregnant women who had an amniocentesis for advanced maternal age (AMA), or for familial chromosomal or monogenic disorders. Group 2 consisted of pregnant women attending the prenatal diagnosis clinic and who had no indication for amniocentesis. Those with an abnormal ultrasound and/or amniocentesis were excluded. At the time of delivery, a questionnaire was sent pertaining to perinatal complications and the anomalies detected during the neonatal period. From a total of 15, 370 questionnaires sent from 1991-1997, 10,823 (group 1, n = 8,877; group 2, n = 1,946) were returned (overall response rate, 70.4%). Mean maternal age was 36 years in group 1 and 29 years in group 2. The prevalence of perinatal complications was similar in the two groups. In each group, the prevalence of all unforeseen anomalies was 2.9%. In group 1, the distribution of those anomalies was: major anomalies, 67.7%; minor anomalies, 23.9%; and multiple congenital anomalies (MCA), 8.3%. In group 2, the distribution was: major anomalies, 70.7%; minor anomalies, 24.1%; and MCA, 5.2%. In patients at risk for a genetic disease and consulting in a prenatal diagnosis clinic, the prevalence of all anomalies diagnosed at birth was 2.9%, even if the second-trimester ultrasound and amniocentesis results were normal. Therefore, it is important to inform those couples of this remaining risk.     

Bilateral breast cancer in northern Alberta: risk factors and survival patterns.

Of 2231 women with stage I, II or III breast cancer who were registered and seen between 1971 and 1979 and followed to the end of 1981, 48 (2.2%) had synchronous and 58 (2.6%) asynchronous bilateral breast cancer. The unadjusted incidence rate for a second breast cancer was 6.4/1000 breast-years at risk, compared with a rate of 0.70 for the risk of a first breast cancer in women. When calculated from the date of diagnosis of the first breast cancer the survival rate was better for the group with asynchronous disease than for the group with synchronous disease or for a group with unilateral disease, but when calculated from the date of diagnosis of the second cancer the rate was the same in all three groups. Comparison of known risk factors showed a significant association between the development of bilateral cancer and a later age at the birth of the first child and a longer interval between menarche and that birth. There was a trend towards greater age and more stage III cancer in the group with synchronous disease. There was no correlation between receiving radiotherapy for the first breast cancer and development of the second cancer. Annual mammography and clinical examination of asymptomatic women at a cancer centre resulted in the detection of a significantly higher proportion of minimal breast cancers in the second breast compared with the first. Such screening practices should be even more valuable in the earlier detection of unilateral breast cancer in asymptomatic women who have not had breast cancer.     

Prenatal substance use in a Western urban community.

To assess the extent of prenatal substance use in a predominantly white population in an urban area of the western United States and to develop a risk profile for this population, a cross-sectional prevalence study was done. Prenatal clinics (10 public and 10 private) anonymously recorded demographic information about and collected aliquots of routinely obtained urine specimens from women during prenatal visits. Urine specimens were screened by enzyme immunoassay for amphetamines, marijuana, cocaine, opiates, and ethanol. Of the 935 women screened, 92 (9.8%) had urine specimens positive for one or more of these substances. Urine screens were positive in 56 (10.0%) of 562 women attending private clinics and 36 (9.6%) of 373 women attending public clinics. Only 7 of the 935 women (0.7%) had screens positive for cocaine. Ethanol was the most frequently detected substance in the private clinic group (6.4%), whereas marijuana was most common among women attending public clinics (5.1%). Although substance use in this group of pregnant women occurs at a lower rate and a different pattern from those found in other more densely populated areas, the rate is high enough to be of concern to all prenatal care professionals, who should incorporate substance use history taking and selective urine drug screening into their routine prenatal practices.     

Performance of a new, liquid-based cervical screening technique in the clinical setting of a large French laboratory

OBJECTIVE: To compare the performance of liquid-based cytology with the CYTO-screen System (SEROA) with that of conventional smears through a secondary analysis of a large database covering the activity of an independent French laboratory during the period 1998-2002. STUDY DESIGN: The study was performed with a retrospective, comparative, historical design on 2 subgroups of women having been screened by gynecologists who switched from conventional smears to the CYTO-screen System in the period 1998-2002. The first cohort population consisted of women who had at least 4 subsequent screening tests over the period with half conventional and half with the CYTO-screen System. A control group consisted of smears collected by gynecologists who fully maintained activity with a conventional method over the same period. The second group consisted of women who had their first screening test performed over the study period by gynecologists who modified their technique. Specimen adequacy, endocervical cell content and epithelial cell abnormality detection rates were compared between the groups. RESULTS: As compared with the conventional smear, the CYTO-screen System showed a reduction in unsatisfactory reports, especially in the second group of first-screened (0.14% versus 1.3%, P < .0001). The rate of atypical squamous cells of undetermined significance increased significantly after the switch to the CYTO-screen System (2.5% versus 1.3%, P = .004) and in the second group of first-screened women (2.05% versus 1.4%, P = .0014), with higher histologic confirmation in both situations. There was a non-significant increase in the detection rates of low and high grade squamous intraepithelial lesions after the switch to the CYTO-screen System and in the second group of first-screened women. CONCLUSION: The CYTO-screen System gives higher-quality specimens and has a higher detection rate for squamous intraepithelial lesions, but that rate was significant only for atypical squamous cells of undetermined significance.     

Five-year survival of women with breast cancer in northern Alberta.

Five-year survival rates for all 519 women with breast carcinoma in northern Alberta in 1971 and 1972 were analysed with the use of data from the computerized northern Alberta breast registry and the Alberta cancer registry. The relative 5-year survival was 73%, which is higher than most rates reported from other centres. Lymph node involvement was significant as a prognostic factor, with the relative 5-year survival falling from 92% in the group without lymph node involvement to 58% in the group with three or more involved nodes. The prognosis was also significantly affected by the stage of the disease according to the 1973 TNM classification: the 5-year survival rates ranged from 88% for patients with stage 1 disease to 17% for those with stage IV disease. Women 40 to 59 years of age had a higher survival rate (79%) than those under 40 years (65%) or over 60 years (66%) of age. Analyses by 5-year age groups showed that women 35 to 39 years old had a particularly poor survival rate (59%). Postmenopausal women less than 55 years old had a higher survival rate than did perimenopausal or premenopausal women in the same age group. Further follow-up is indicated to correlate possible high-risk factors with survival.