Age and the ovarian follicle pool assessed with transvaginal ultrasonography

OBJECTIVE

We tested whether transvaginal ultrasonography could detect the age-related decrease in follicle counts that has been observed in autopsy studies.

STUDY DESIGN

Thirty-one healthy volunteers in three age groups (22 to 25, 30 to 33, and 39 to 42 years) underwent ultrasonography in the follicular and luteal phases of the menstrual cycle. At the conclusion of the study the 124 ovarian scans were randomly ordered and antral follicles > or = 2 mm were counted by an evaluator unaware of age. Ordinary least-squares linear regression was used to estimate the associations of age with the total antral follicle count and with ln (1 + follicle count).

RESULTS

The numbers of antral follicles > or = 2 mm decreased by about 60% between 22 and 42 years. Age-related decreases were similar for both phases of the cycle and held for both smaller (2 to 3.5 mm) and larger (>3.5 mm) follicles.

CONCLUSION

We hypothesize that ultrasonographically derived counts of follicles provide a measure of reproductive age that may help to predict age-related phenomena.

Cigarette smoking and spontaneous abortion of known karyotype. Precise data but uncertain inferences

Data from the first phase (1974-1979) of this New York City case-control study showed that 1) cigarette smoking during pregnancy was associated positively with chromosomally normal spontaneous abortion and 2) both past and current smoking were associated inversely with trisomic loss in women under age 30 years and positively in older women. The authors used data from two subsequent study phases (1979-1982 and 1982-1986) to test the stability of these associations over time and the homogeneity between payment groups (private vs. public). Spontaneous abortions (cases) were classified as chromosomally normal (n = 1,388), trisomic (n = 557), or other chromosomally aberrant (n = 409). Controls (n = 4,165) were women who had registered for prenatal care before 22 weeks' gestation and delivered at 28 weeks or later. For chromosomally normal loss, later data gave modest support to prior observations. In the total sample, current smoking (defined as smoking during the month of the last menstrual period) of 14 or more cigarettes per day was increased among chromosomally normal cases in comparison with controls (adjusted odds ratio (OR) = 1.3, 95% confidence interval (CI) 1.1-1.7) and in comparison with other aberrant cases (adjusted OR = 1.2, 95% CI 0.8-1.8). Stronger associations in public patients than in private patients (adjusted odds ratios of 1.4-1.5 versus 0.8-0.9, respectively) might indicate either a mediating effect of social disadvantage or a chance fluctuation. For trisomic loss, later data did not support prior observations. Associations between trisomy and past or current smoking did not vary significantly with age in either payment group; assuming no effect modification of age, adjusted odds ratios for smoking in relation to trisomy were 0.9-1.0.

Physicians' attitudes toward a new gynecological examination gown

Gynecologists' attitudes toward an examination gown found in previous studies to reduce patients' distress during examination were investigated. Twenty-six gynecologists in four cities volunteered to use the new examination gown and complete a questionnaire evaluating the gown for adequacy of design and perceived patient comfort. Participants rated the gown positively overall. Favorability ratings were highly correlated with ratings of the structural adequacy of the gown for performing the breast, back, and pelvic exams. Favorability was also highly correlated with physicians' perceptions of the patients' comfort with the gown. The new gynecological examination gown is well accepted by gynecologists. It appears that gynecologists are open to changes in examination procedures that do not interfere with the exam and increase patient comfort. This new gown offers a strategy for decreasing patient distress during examination, which may reduce delay in seeking examinations.

Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use

OBJECTIVES

The purpose of this study was to examine factors associated with heroin use during methadone maintenance treatment.

METHODS

Logistic regression statistical models were used to examine data obtained in a cross-sectional sample of 652 methadone patients.

RESULTS

Heroin use during the 3 months prior to interview was shown to be greatest among (1) patients maintained on methadone dosages of less than 70 mg/day (adjusted odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.3, 3.4) and (2) patients who used cocaine during treatment (adjusted OR = 5.9, 95% CI = 3.8, 9.1). These results were independent of treatment duration, treatment compliance, alcohol use, and socioeconomic factors. Cocaine users were more likely than nonusers of cocaine to use heroin at all methadone dosage levels.

CONCLUSIONS

This study confirms and extends past research showing high-dose methadone maintenance to be important to heroin abstinence. Further investigation of the independent association between heroin use and cocaine use is needed.

Previous use of oral contraceptives and spontaneous abortion

This analysis tests the hypothesis that women who conceive within 3 months after stopping oral contraceptives ("the pill") have an intrinsically lower risk of chromosomally normal loss. About 30% of women show evidence of endocrine dysfunction, including anovulation, for 1-3 months after stopping the pill. In women who recover rapidly, and therefore are at risk of pregnancy, a common endocrinologic factor may account for both the quick return to normal functioning and improved intrauterine survival of the chromosomally normal conceptus. The hypothesis was tested in women with chromosomally normal (N = 334) and chromosomally aberrant (N = 239) spontaneous abortions. Women were classified according to the number of months between last pill use and last menstrual period. The adjusted odds ratios relating conception in months 0 and 1 after stopping the pill to chromosomally normal (vs chromosomally aberrant) loss were each 0.4, with upper 95% confidence limits of 1.0 and 0.9, respectively. The odds ratios for conception at longer intervals after stopping were 1.1 [95% confidence interval (CI) = 0.4-3.1], 0.7 (95% CI = 0.3-1.2), and 0.9 (95% CI = 0.5-1.5) for 2, 3-11, and > or = 12 months, respectively. Rates of spontaneous abortion in previous pregnancies were lowest in women who conceived quickly after stopping the pill. Further support for an endocrinologic explanation requires direct measures of endocrine functioning in the post-pill period among women with varying reproductive histories.

Beta-blocker and calcium channel blocker toxicity

Toxicity from beta-blocker and calcium channel blocker drugs is a challenging medical emergency with steadily increasing incidence. Clinical manifestations of intoxication with these drugs are presented in light of known pharmacologic and pharmacokinetic properties, as well as the physiology of the beta-adrenoreceptor and calcium channel. Review of clinical and basic science literature provides the basis for specific management guidelines for beta-blocker and calcium channel blocker toxicity.

Modulation of the QT interval: effects of graded exercise and reflex cardiovascular stimulation

During exercise, as heart rate (HR) increases, the QT interval of the electrocardiogram shortens. The mechanism(s) involved in this QT shortening has not been clearly defined. To distinguish the influence of increased circulating catecholamines from myocardial efferent stimulation, the relationship between HR and QT interval was investigated during exercise and cardiovascular reflex stimulation in cardiac transplant patients and normal control subjects. Because of cardiac denervation, increases in HR in these patients are solely due to circulating catecholamines and thus allow isolation of their effect on the QT interval. Twenty-one cardiac transplant patients were studied and compared with 16 normal control subjects. The QT-HR relationship was determined according to an exponential model during treadmill exercise in both groups [QT = 0.12 + 0.492e(-0.008.HR) and QT = 0.12 + 0.459e(-0.007.HR) in normal subjects and transplant patients, respectively] and was statistically similar between groups, suggesting similar QT interval shortening in both groups. During cold pressor and Valsalva maneuvers, HR increased significantly in normal subjects only, whereas QT interval changed minimally in both groups. These results suggest that during exercise the QT interval is influenced predominantly by increases in circulating catecholamines rather than by neurally mediated reflex autonomic changes.

Enhancement in vitro of the low interferon-gamma production of leukocytes from human newborn infants

Interferon-gamma (IFN-gamma), a lymphokine produced by lymphocytes with the help of monocytes, is essential for host resistance to intracellular pathogens. Leukocytes from normal term newborn infants cannot produce IFN-gamma in vitro in response to stimulation by antigen or mitogens in vitro or in vivo. We investigated the production of IFN-gamma in vitro using endotoxin from Salmonella typhimurium as a stimulus. In contrast to those from adults, mononuclear cells derived from the cord blood of newborn infants did not produce IFN-gamma in response to this endotoxin. We investigated the contribution of the functional immaturity of cord blood monocytes to this relative inability to produce IFN-gamma. Aging of the monocytes for 2 weeks in vitro or treatment of freshly isolated cord blood monocytes with conditioned medium (from cultures of mononuclear cells from healthy adults) greatly enhanced IFN-gamma production stimulated by endotoxin. Furthermore, recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF), or IFN-gamma was able to substitute in part for the conditioned medium from adult cells. Thus correction of the functional immaturity of monocytes derived from newborn infants can result in enhanced production of IFN-gamma in vitro.

Analysis of factors determining the selection of repeated cesarean section or trial of labor in patients with histories of prior cesarean delivery

We investigated the motivation behind procedures in 241 patients with prior cesarean births; 120 had elective repeat cesarean sections and 121 had vaginal birth after cesarean section (VBAC). Patients were of similar age, gravity and parity, but significantly more patients in the repeat cesarean group had their initial surgery because of failure to progress in labor; significantly more patients in the VBAC group had their initial cesarean section because of fetal distress. The main factors behind the decision to attempt VBAC were patient's desire (81.0%), patient's desire and physician's advice (12.4%) and physician's advice (6.6%). The main factors behind the decision to have repeat cesarean sections were medical or obstetric indication (45.8%), patient's desire (31.6%), patient's desire and physician's advice (9.1%) and physician's advice (13.3%). We conclude that it will be difficult to substantially decrease the present rate of repeat cesarean births, and that preventive efforts should be directed toward decreasing the incidence of primary cesarean deliveries.

Cigarette smoking and trisomy 21 at amniocentesis

Several studies raise the possibility that smoking during pregnancy is associated with a slightly decreased odds of trisomy 21 at birth. If it is, associations may reflect decreased incidence at conception, increased intrauterine loss (at one or several times in gestation), or both. Women (n = 13,729) undergoing prenatal diagnosis completed a questionnaire before learning karyotype results. For each women with a trisomy, up to 4 controls with chromosomally normal pregnancies, matched for age and hospital, were selected. Analyses drew on the 89 trisomy 21-control matched m-tuples in which diagnosis was by amniocentesis at 14-26 weeks. We compared the odds of smoking at last menstrual period and in the past in cases and controls. The odds of current smoking versus never smoking were decreased [adjusted odds ratio = 0.8, 95% confidence interval (CI) 0.4-1.6] and the odds of exsmoking increased (adjusted odds ratio = 1.4, 95% CI 0.9-2.4) in trisomy 21 cases. The association with current smoking was essentially unchanged when the unexposed reference group was defined as exsmokers and women who never smoked (adjusted odds ratio = 0.7, 95% CI 0.4-1.4). These results for current smoking agree well with a summary estimate based on combined studies of births. One interpretation is that at amniocentesis, as has been reported for births, current smoking is associated with a slightly decreased odds of trisomy 21. If associations at amniocentesis and birth are of equal magnitude, the explanation that observations at birth reflect increased loss in the second half of pregnancy with current smoking is unlikely to be correct.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of late-life schizophrenia with neuroleptics

There is a death of literature on the effects of neuroleptics in older schizophrenia patients. In this article, we review the available literature and present findings from our own studies. Neuroleptics are effective in the treatment of late-life schizophrenia, although older patients generally need lower dosages than younger subjects. Neuroleptics, however, carry a relatively high risk of side effects such as tardive dyskinesia (TD) in middle-aged and elderly patients. By the end of 1 year of a prospective longitudinal study of neuroleptic treatment, we found a 26 percent cumulative incidence of TD among schizophrenia patients over age 45. If neuroleptics are withdrawn, there is a significant risk of a schizophrenic relapse; however, that risk is no greater in older patients than in younger ones. We offer clinical recommendations for the use of neuroleptics in the treatment of late-life schizophrenia.

Reducing Distress Associated with Pelvic Examinations: A Replication

A previous study of the effect of a new examination gown on patients' experienced discomfort during pelvic examination demonstrated that the gown was effective. This study replicated the previous study with a younger group of subjects. It was hypothesized that the new gown would reduce reported distress. Subjects were 147 patients at a university student health center. Age ranged from 18 to 31. Informed consent was obtained and patients were randomly assigned to either the experimental gown or the standard drape condition. Following examination, subjects completed questionnaires assessing demographic characteristics, state and trait anxiety, desired changes in pelvic examination procedures, and reactions to the examination. The attending nurse recorded blood pressure. Results supported the hypotheses. Experimental subjects rated the gown as more comfortable than control subjects rated the drape. Results indicate that this simple stimulus control intervention reduces one source of distress associated with pelvic examinations.

Determinants of depressive symptoms in the early weeks after miscarriage

OBJECTIVES

We tested whether and under what conditions miscarriage increases depressive symptoms in the early weeks following loss.

METHODS

We interviewed 232 women within 4 weeks of miscarriage and 283 pregnant women and 318 community women who had not recently been pregnant. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

Among women who had miscarried, the proportion who were highly symptomatic on the CES-D was 3.4 times that of pregnant women and 4.3 times that of community women. Among childless women, the proportion of women who had miscarried who were highly symptomatic was 5.7 times that of pregnant women and 11.0 times that of community women. Women who had miscarried were equally depressed regardless of length of gestation; among pregnant women, depressive symptoms declined with length of gestation. Among women who had miscarried, symptom levels did not vary with attitude toward the pregnancy; among pregnant women, depressive symptoms were elevated in those with unwanted pregnancies. Prior reproductive loss and advanced maternal age (35+ years) were not associated with symptom levels in any cohort.

CONCLUSIONS

Depressive symptoms are markedly increased in the early weeks following miscarriage. This effect is substantially modified by number of living children, length of gestation at loss, and attitude toward pregnancy.

Reducing distress associated with pelvic examinations: a stimulus control intervention

The effect of a new pelvic examination gown on patients' experienced discomfort during pelvic examination was tested. It was hypothesized that a better designed gown would reduce reported distress. Subjects were 87 patients at a private gynecology clinic. Age ranged from 17 to 72. Informed consent was obtained and patients were randomly assigned to either the experimental gown or the standard drape condition. Following examination, subjects completed questionnaires assessing demographic characteristics, state and trait anxiety, desired changes in pelvic examination procedures, and reactions to the examination. The attending nurse recorded heart rate and blood pressure. Results supported the hypotheses. Experimental subjects rated the gown as more comfortable than control subjects rated the drape. Experimental subjects desired fewer changes in exam procedures than control subjects, indicating that the gown provided them with an overall more comfortable experience.

Trisomy and age at menopause: predicted associations given a link with rate of oocyte atresia

The association of trisomy with advancing maternal chronological age suggests that some aspect of physiological aging is accelerated in women with trisomic pregnancies. This paper develops a quantitative theoretical model based on the hypothesis that trisomy risk is primarily a function of the size of the oocyte pool and, in particular, that risk is increased in women with accelerated rates of oocyte atresia and hence smaller pools at given chronological ages. Since the rate of oocyte atresia is a determinant of age at menopause, this hypothesis leads to the prediction that women who have had trisomic pregnancies reach menopause earlier than women who have not. We used data relating chronological age to oocyte number, trisomy and menopause to deduce the distribution of oocyte atresia rates in all women and in women with trisomic pregnancies. Given certain simplifying assumptions, we predict that associations between trisomy and age at menopause will vary with a woman's age at the time of trisomy such that trisomies at 34-43 years will be associated with a 1-3.4 year earlier onset of menopause, while trisomies at younger or older ages will have no or little association with age at menopause. This model, while vulnerable to the uncertainties that attend its assumptions, provides a testable prediction that permits separation of one aspect of physiological age from chronological age.

Depressive symptoms in women in the six months after miscarriage

This study, the first systematic investigation of the psychiatric impact of miscarriage, tests whether miscarriage markedly increases depressive symptoms in the 6 months after loss. We interviewed 382 miscarrying women entering the study at 2 weeks, 6 weeks, or 6 months after loss and, for comparison, 283 pregnant women and 318 community women not recently pregnant. Among women interviewed 2 weeks after miscarriage the proportion highly symptomatic on the Center for Epidemiologic Studies-Depression scale was 3.4 times that of pregnant women (95% confidence limits 2.0 and 5.0) and 4.3 times that of community women (95% confidence limits 3.0 and 5.8). Among women first interviewed 6 weeks and 6 months after miscarriage the proportion highly symptomatic was three times that of the community women. Women reinterviewed at 6 weeks and 6 months did not have elevated symptom levels, a result attributed to the unintended therapeutic and test effects of study interviews. Interviews were fully structured, readily administered by telephone by nonmedical personnel. The possibility that such interviews afford miscarrying women substantial psychologic benefits merits future investigation.

Caffeine and spontaneous abortion of known karyotype

We tested associations of caffeine from beverages with spontaneous abortions of known karyotype. Spontaneous abortions (cases) were classified as chromosomally normal (n = 510) or chromosomally aberrant (n = 389) and, within the latter category, by type of aberration (237 trisomies, 54 monosomies X, 49 triploidies, 49 others). Controls registered for prenatal care before 22 weeks gestation and delivered at 28 weeks or later (n = 1,423). Caffeine intake in the perifertilization period did not differ among case groups and controls. For the highest category, 225+ mg/day, odds ratios (OR), adjusted for payment group and maternal age, were 1.0 for chromosomally normal cases, 0.9 for trisomies, 1.6 for monosomies X, and 0.8 for triploidies. Caffeine intake during pregnancy was tested for associations with chromosomally normal loss using the chromosomally aberrant cases to provide a robust comparison group. Although the proportion of subjects with intake of 225+ mg/day of caffeine intake in the perifertilization period does not influence the risk of chromosomally normal loss or trisomy. For monosomy X and triploidy, no strong associations were observed, but numbers were insufficient to rule out moderate effects. For caffeine intake during pregnancy, we found little evidence to support an influence on chromosomally normal loss.

Marijuana and spontaneous abortion of known karyotype

We tested whether marijuana use in the 2 months before the last menstrual period and during pregnancy affects the risk of spontaneous abortions of known karyotype. Spontaneous abortions (cases) were defined as chromosomally normal (n = 567) or chromosomally aberrant (n = 393) and, within the latter, by type of aberration (212 trisomies, 71 monosomies X, 49 triploidies, 61 others). Controls were women with prenatal care before 22 weeks gestation and delivering at 28 weeks or later (n = 2042). In comparison with controls, adjusted odds (OR) of reported marijuana use in chromosomally normal cases were 1.1 (95% confidence interval (CI) 0.7, 1.5) and in chromosomally aberrant cases combined 1.2 (95% CI 0.7, 1.9). With respect to specific aberrations, use in the perifertilisation period did not differ significantly from that in controls for trisomies (adjusted OR = 0.8, 95% CI 0.4, 1.8), monosomies X (adjusted OR = 1.8, 95% CI 0.7, 4.3), and triploidies (adjusted OR = 1.3, 95% CI 0.4, 4.5). Comparison of karyotype groups with each other yielded similar results. Our data do not support causal associations of marijuana use, at the levels represented in our sample, with either chromosomally normal or trisomic spontaneous abortion. With monosomy X and triploidy, no statistically significant associations were detected although numbers were insufficient to rule out moderate effects.

Pre-pregnant body size and spontaneous abortion of known karyotype

We examined the relation of pre-pregnancy body size to chromosomally normal and chromosomally aberrant spontaneous abortion. Data derive from a hospital based case-control study of spontaneous abortion in the public and private facilities of three New York City hospitals. Chromosomally normal (n = 1265) and chromosomally aberrant (n = 872) spontaneous abortions (cases) were compared with 3795 women attending prenatal care before 22 weeks of gestation and delivering at 28 weeks or later (controls). Data on height and pre-pregnant weight were obtained by interview and Body Mass Index (BMI, weight/height squared) was computed. Associations were consistent across payment strata with disparate sociodemographic characteristics. BMI was similar in chromosomally normal cases and controls (pooled adjusted mean difference = 0.21 kg/m squared, 95% CI -0.06, 0.48) and reduced in chromosomally aberrant cases compared with controls (pooled adjusted mean difference = -0.29 kg/m squared, 95% CI -0.58, 0.00). These associations are unlikely to be due to reporting bias. However, they were of small magnitude and the association with chromosomally aberrant loss did not differ from that with chromosomally normal loss, nor was it specific to one, or even two, types of aberration. We therefore infer that, in relatively well nourished populations, low pre-pregnant body size does not increase the risk of either chromosomally normal or chromosomally aberrant spontaneous abortion.

Determinants of elevated blood lead during pregnancy in a population surrounding a lead smelter in Kosovo, Yugoslavia

We are prospectively examining the relation between environmental lead exposure and pregnancy outcome in cohorts of women exposed to a wide range of air lead concentrations. Titova Mitrovica, Yugoslavia, is the site of a large lead smelter, refinery, and battery factory. At midpregnancy, 602 women in T. Mitrovica and 900 women in Pristina, a non-lead-exposed control town, were interviewed. Blood was obtained for blood lead (PbB), hemoglobin, erythrocyte protoporphyrin, and serum ferritin measurements. Women were seen again at delivery, at which time maternal and umbilical cord blood samples were obtained. While many demographic and social characteristics were similar across the two towns, women in Pristina were more likely to report employment outside the home, cigarette smoking, and alcohol use during pregnancy. As expected, PbB levels were substantially higher in the smelter town. At midpregnancy, PbB geometric means were 17.1 micrograms/dL in T. Mitrovica and 5.1 micrograms/dL in Pristina; 86% of the pregnant women in T. Mitrovica, compared to 3.4% of those in Pristina, had PbB levels greater than 10 micrograms/dL. Within T. Mitrovica, distance between the home and the smelter was the most important predictor of PbB at mid-pregnancy and delivery. Husband's employment in the lead industry was associated with a significant increase in maternal PbB levels independent of place of residence. Higher maternal serum ferritin concentrations were associated with lower PbB levels, suggesting that dietary iron inhibits lead absorption. Overall, the placenta was a poor barrier to lead; the relationship between maternal PbB and umbilical cord PbB was linear across a wide range of PbB levels.

Paternal age and trisomy among spontaneous abortions

The relationship of paternal age to specific types of trisomy and to chromosomally normal loss was investigated in data drawn from a case-control study of spontaneous abortions. Differences in paternal age between karyotype groups and controls delivering after 28 weeks gestation were tested using an urn model analysis which adjusted, by regression, for maternal age and, by stratification, for the effects of design variables (payment status, phase of study) and demographic factors (language, ethnicity). The magnitude of paternal age differences was estimated using least squares regression analysis. For chromosomally normal cases there was no association with paternal age. Among the fourteen trisomy categories examined, four (7, 9, 18, 21) showed increased paternal age (greater than or equal to 1 year above expectation), three (13, 20, 22) showed decreased paternal age and the rest, including the most common, trisomy 16, showed negligible differences. Only the association with trisomy 22 was statistically significant (P = 0.012), with a predicted reduction in paternal age of 2.1 years (95% CI -4.9, -0.5 years). This association did not vary with maternal age, payment status, phase of study, language or ethnicity. Because previous observations are extensive, the relation of paternal age to trisomy 21 was examined further. The overall association was not significant (beta = 0.8 years; 95% CI -0.8, 2.4 years). Moreover, there was evidence that the magnitude and direction of paternal age associations vary significantly within the sample, although not between subgroups defined on the basis of payment, phase of study, language or ethnicity. With respect to maternal age, the trend is towards a greater paternal age difference for trisomy 21 losses in younger women (P = 0.058). Given the number of tests performed, the finding for trisomy 22 and reduced paternal age could be due to chance. Among trisomy types, the direction of paternal age associations was not consistent for chromosomes grouped according to characteristics that might relate to the probability of nondisjunction, such as size, arm ratio, or nucleolar organizer region content, or to the potential viability of the trisomy. Thus, neither on statistical nor biological grounds do the data provide compelling evidence of paternal age effects on the trisomies found among spontaneous abortions, or on chromosomally normal losses.

Spermicide use and pregnancy outcome

The relation between periconceptional vaginal spermicide use and sex ratio at birth, birthweight, and the frequency of congenital anomalies was examined in a cohort of 2,712 New York City obstetric patients, 149 of whom (5.5 per cent) became pregnant while using spermicides or had used spermicides before and after conception. Periconceptional spermicide use was not associated with any important variation in the expected sex ratio at birth, nor with major or minor congenital anomalies. Exposure to spermicides in the periconceptional period, defined dichotomously as present or absent, was not associated with decreased birthweight in male or female infants. There was a slight decrease in birthweight among female infants with increasing duration of postconceptional spermicide use; an estimated 7.4 grams decrease with each day of use. The size of the effect and its selectivity by sex suggest a chance finding.

Duration of vaginal bleeding and trisomy at prenatal diagnosis

In the case-control study of 118 women with autosomal trisomy identified at prenatal diagnosis and their 442 karyotypically normal matched controls, we found that there was no overall association between risk of trisomy and the presence of vaginal bleeding during pregnancy. However, a lengthy duration of bleeding appears to predict increased risk of trisomy.

Does the karyotype of a spontaneous abortion predict the karyotype of a subsequent abortion? Evidence from 273 women with two karyotyped spontaneous abortions

At least two spontaneous abortions were karyotyped in 273 women during cytogenetic surveys in New York City and Honolulu. These pairs were analyzed using maximum-likelihood logistic-regression analysis to adjust for maternal age and location. There was a significantly increased risk for a chromosomally normal spontaneous abortion after a previous abortion with a normal karyotype. There was no increased risk for trisomy in a second spontaneous abortion following either a previous trisomic abortion or an abortion with another abnormal karyotype. This is unexpected, given the increased risk for trisomy found among live births and at prenatal diagnosis in young women with a previous trisomic birth. The most likely explanation is that the increased recurrence risk for trisomy is restricted to trisomy for only one or a few chromosomes, for reasons such as parental trisomy mosaicism. These data predict no increased risk of chromosome abnormality in future pregnancies after either (1) spontaneous abortions with trisomies of a kind that are always lethal in utero or (2) multiple early abortions in the presence of normal parental karyotypes.

Lack of association between spermicide use and trisomy

It has been suggested that the maternal use of spermicidal contraceptives increases the frequency of certain congenital anomalies, including trisomy, but this issue is in dispute. This controversy led us to examine whether the use of spermicidal contraceptives is associated with an increased risk of fetal trisomy. A questionnaire concerning contraceptive use was completed by 13,729 women who were undergoing prenatal fetal chromosome studies but were as yet unaware of the results. Most women were at increased risk of having a trisomic fetus because of their advanced age. Of 154 fetuses with trisomy, 98 had trisomy 21. For each woman (case) with an affected fetus, four controls were selected from among women with chromosomally normal fetuses, matched for maternal age and medical center. Cases and controls were compared by matched-sample maximum-likelihood logistic regression, to examine the association between fetal trisomy and four measures of spermicide use: periconceptional use, timing of last use, duration of last use, and total lifetime use. No evidence was found for an association, either when all types of trisomy were combined or when trisomy 21 alone was considered. All point estimates of odds ratios relating spermicidal exposure to trisomy were approximately 1, and an effect greater than a twofold increase was excluded with 95 percent confidence in the combined-trisomy group for all measures of spermicide use.

Staphylococcal adherence to polyvinyl chloride and heparin-bonded polyurethane catheters is species dependent and enhanced by fibronectin

Intravenous hyperalimentation has improved the survival of premature infants. However, long-term placement of intravenous catheters may result in the development of catheter-related sepsis. Fibronectin in plasma contains binding sites for staphylococcal species as well as marked affinity for inert plastics and therefore may provide a substrate for bacterial adherence to indwelling catheters. We determined the adherence of labeled [( 3H]leucine) coagulase-positive (CPS) and coagulase-negative (CNS) staphylococci to untreated and fibronectin-coated polyvinyl chloride (PVC) and heparin-bonded polyurethane (HBP) catheter segments and quantitated the binding of 14C-labeled, purified fibronectin to these catheters. PVC catheter segments bound significantly more CNS than CPS (P less than 0.05), while HBP catheters bound more CPS than CNS (P less than 0.05). Fibronectin significantly increased the adherence of CPS to PVC catheters (P less than 0.05) and CNS to HBP catheters (P less than 0.05). PVC catheters bound more fibronectin (P less than 0.0001) than did HBP catheters. Catheter composition may influence the spectrum of nosocomial pathogens to which infants are susceptible through different bacterial adherences and interactions with adhesive proteins.

Cigarettes, alcohol and marijuana: varying associations with birthweight

The relations of cigarette smoking, alcohol drinking and marijuana use during pregnancy to birthweight were examined in two prospectively studied pregnancy cohorts (Phases I and II). After analytic adjustment in ordinary least squares regressions for other factors that influence birthweight, cigarette smoking during at least half the pregnancy was associated with a significant decrease in mean birthweight (159 grams in Phase I, 202 grams in Phase II). In Phase II only, beer drinking was associated with a significant decrement of 8.4 grams in estimated birthweight per ounce of absolute alcohol per month. Neither wine nor liquor drinking in the Phase II data nor any of the three beverages in the Phase I data was associated with significant decrements in predicted birthweight. Furthermore, with one exception (drinking once a week in Phase II only), alcohol drinking, defined as the number of occasions per month on which any alcoholic beverage was consumed, was not associated with a change in birthweight. Regarding marijuana use, the data are not consistent between the two phases. In the Phase I data, no coherent trend in association with birthweight was observed. In the Phase II data, marijuana use 2-3 times per week, 4-6 times per week and daily was associated with increasing decrements in estimated birthweight: 127 g, 143 g and 230 g respectively. The inconsistent findings for alcohol drinking and marijuana use between phases stand in marked contrast to the consistent findings for cigarette smoking.

Characteristics of women with recurrent spontaneous abortions and women with favorable reproductive histories

Women with a history of recurrent spontaneous abortions (repeaters) are compared with women who have had live births and no spontaneous abortions (multiparae) and women who have had live births and only one spontaneous abortion (sporadics) to identify characteristics of the women and their abortuses that might predict subsequent fetal loss. A number of risk factors for recurrent spontaneous abortion have been identified: the loss of a chromosomally normal conception, loss after the first trimester of pregnancy, a delay in conceiving prior to the study pregnancy, a diagnosis of cervical incompetence, and a history of very low birthweight deliveries. The odds ratios associated with being a repeater vary from 1.4 to 5.6 depending on the number of characteristics present.

The relationship between maternal age and chromosome size in autosomal trisomy

The pattern of maternal age-specific incidence of autosomal trisomy in spontaneous abortions was examined for each chromosome for which a sufficient number of trisomies was observed. This included chromosomes 2, 4, 7-10, 13-16, 18, and 20-22. The rate of increase after age 30 for each of the small chromosomes (groups D-G) was similar, with the exception of chromosome 16, which showed a significantly shallower rate. The C group chromosomes tended to have an intermediate rate of increase after age 30, with the exception of chromosome 7, which had a pattern similar to the smaller chromosomes. The larger chromosomes (2 and 4) had the smallest rate of increase. There was a significant relationship between chromosome size and rate of increase after age 30 (after excluding chromosome 16), but not with rate of increase before age 30. The results suggest that autosomal trisomies may be of heterogeneous origin, with a maternal age-related factor associated with chromosome size and other sources unrelated to chromosome size. Additional evidence for and against this hypothesis is discussed.

Induced abortion and the chromosomal characteristics of subsequent miscarriages (spontaneous abortions)

Data from a case-control study of miscarriages (spontaneous abortions) were used to test whether single and multiple induced abortions are associated with miscarriage in subsequent euploid (chromosomally normal) pregnancies. Cases and controls were identified in three New York City hospitals between April 1974 and November 1982. It was hypothesized that, if induced abortion increased the risk of subsequent miscarriage, an association would be observed with euploid but not aneuploid (chromosomally abnormal) miscarriage. The frequencies of single and multiple induced abortions among euploid cases and aneuploid cases were compared with those among controls. Among both private and public patients, the proportion of women reporting a single induced abortion was similar in euploid cases and in aneuploid cases compared to controls. Among public patients only, the proportions reporting multiple induced abortions were also similar in euploid cases and in aneuploid cases compared to controls (odds ratios = 0.9 and 1.0, respectively). In contrast, among private patients, the proportion reporting multiple induced abortions was raised among euploid cases (odds ratio = 2.2, 95% confidence interval = 1.3-3.7), although not among aneuploid cases. This association was strongest when the first induced abortion was carried out before 1973, at a young age, or with a procedure other than suction curettage. In public patients, the associations with miscarriage did not vary with characteristics of the first induced abortion, but multiple induced abortion histories when the first two induced abortions occurred before 1973 were in excess among euploid cases compared to controls. These results suggest that, for both private and public patients, neither single nor multiple induced abortions as now performed are likely to increase the risk of miscarriage in subsequent pregnancies. They also suggest a mechanical origin for some miscarriages.

Vaginal spermicides and spontaneous abortion of known karyotype

The relationship between spermicide use and spontaneous abortion was examined in a New York City case-control study carried out during 1974-1982. In a series of matched sample analyses, case groups categorized by karyotype of the abortus were compared to a control group of prenatal patients with respect to spermicide use. Spermicide use was defined in terms of proximity to the date of conception of the study pregnancy and duration of the episode of use most recent to the study pregnancy. There was no association between spermicide use defined either in terms of recency or duration of use and chromosomally normal abortions, which comprise about 60% of all spontaneous abortions. Similarly, there was no association between spermicide use and the various types of chromosomally abnormal abortions, with the exception of trisomic abortion. Spermicide use for more than one year at any time prior to conception was more common in the cases aborting trisomic conceptions than in the control group (odds ratio = 1.9, confidence limits = 1.2, 3.0). There was evidence to suggest that the association varied with maternal age and phase of entrance into the study.

Morphology of early fetal deaths and their chromosomal characteristics

The morphologic features of a consecutive series of 3,472 singleton spontaneous abortions are described. Of the total, 21% consisted of well-formed fetuses (over 30 mm long), 27.9% had no identifiable fetal tissues, 34.2% consisted of fetal membranes only, and the remainder, 16.8%, consisted of a variety of embryonic types. The rate of focal malformations among embryos over 10 mm in length and among fetuses was 16.4%. The overall rate of chromosome anomalies in the 1,356 karyotyped specimens was 39.8%. The vast majority, 94%, occurred in embryos less than 30 mm, and in specimens whose development had not proceeded beyond differentiation of fetal membranes. The rate of chromosome anomalies among nonmalformed fetuses (greater than 30 mm) was only 1.7%. However, the presence of limited embryonic development was not a good predictor of the presence of a chromosome anomaly. Slightly over half (56%) of all specimens less than 30 mm long had chromosome anomalies; for individual classes of such specimens the rate ranged from 45% to 81%. The morphologic category with the highest rate of karyotypic anomalies had an excess of monosomy X abortuses. A gradient of developmental level could be associated with the degree of intrauterine mortality of each chromosome anomaly; i.e., conceptuses with karyotypes that occur at term had a greater degree of embryonic development than karyotypes that are never seen among term births. Thus, trisomies 13, 18, and 21 were more often associated with fetuses, and less often with tissue fragments than other trisomies. Focal malformations were multiple and severe in abortuses with triploidy, trisomies 13 and 18, and monosomy X and mild in trisomy 21. With the exception of monosomy X the malformations were similar to, and not more severe than those reported from, term births with the same anomaly. The high rate of intrauterine mortality in conceptuses with chromosome anomalies could be ascribed to their failure to develop past the embryonic stages. However, the presence of an equally large fraction of chromosomally normal abortions with the same degree of rudimentary development suggests the existence of early and profound developmental problems that are not associated with anomalies of the chromosome complement.

The cusum test of homogeneity with an application in spontaneous abortion epidemiology

We test the hypothesis of homogeneity over time in the rate of an event with a modification of Page's cumulative sum (cusum) procedure. The modification draws on an indifference zone approach to testing that is well suited to the epidemiologic study of retrospective data. We provide procedures for evaluating the significance level of the largest observed cusum value occurring in a sequence of fixed length. We draw inferences unconditionally with a known baseline rate of the event, and conditionally on observed margins with unknown baseline rate. Data collected over a five year period from one New York City hospital serve to illustrate the modified cusum test in a study of fluctuations in the proportions of chromosomally normal, trisomic, X-monosomic and triploid spontaneous abortions.

Maternal employment and the chromosomal characteristics of spontaneously aborted conceptions

The employment histories of 1,252 women experiencing a spontaneous abortion and 2,126 controls were compared to examine the relation between maternal employment before and during pregnancy and karyotype of the spontaneously aborted conceptus. Among private patients, there was no evidence of a positive association of work only before pregnancy, only during pregnancy, or both before and during pregnancy (v no work) with either chromosomally normal or abnormal abortions. In contrast, among public patients the odds of working only during pregnancy or both before and during pregnancy were raised for chromosomally abnormal abortions (adjusted odds ratios = 3.11 and 1.86, respectively) and slightly raised for chromosomally normal abortions (adjusted odds ratios = 1.35 and 1.31, respectively). Among workers, the frequencies of work before pregnancy in specific employment circumstances were compared among karyotyped cases and controls. For two work locations--factory and hospital/nursing facility--the data were of sufficient size to suggest that associations of twofold or greater with most types of abortion are unlikely.

Fever during pregnancy and spontaneous abortion

The hypothesis that maternal fever during pregnancy is a risk factor for spontaneous abortion was tested in a case-control study by comparing the frequencies and timing of fevers of 100 F (37.78 C) or more among three groups of women: women having euploid abortions, women having aneuploid abortions, and women delivering at 28 weeks gestation or later (controls). Cases and controls were identified in three New York City hospitals between August 1979 and June 1982. It was hypothesized that if fever was an antecedent, rather than a symptom of spontaneous abortion, an association would be detected with euploid but not with aneuploid abortions. Among public patients, reported fevers were significantly more frequent among euploid abortions than among controls (18% vs. 7.1%, odds ratio = 2.96), whereas reported fevers were not more frequent among aneuploid abortions (3.9% vs. 7.1%, odds ratio = 0.52). It was also postulated that variation in the strength of the association of fever with euploid abortion with the duration of the interval between the fever and the abortion might yield insight about mechanisms underlying an association. The odds ratios for fever occurring at three intervals--in the same calendar month as a euploid abortion, one month before, and two or more months before--were 6.04, 3.28, and 1.41, respectively. The findings for private patients--for whom a control group was not recruited--are compatible with those for public patients although not statistically significant: the odds of fever with euploid abortion were 2.18 times those with aneuploid abortion.

The relationship of maternal age and trisomy among trisomic spontaneous abortions

The relationship between maternal age and trisomy was examined by comparing mean ages of 954 trisomic spontaneous abortions with those of live births ascertained at the same study center. The overall mean for trisomy was highly significantly elevated over that of the newborns. The age effect was most pronounced for trisomies involving the small chromosomes, with trisomies 13, 14, 15, 16, 17, 18, 20, 21, and 22 all having significantly increased ages by comparison with the control population. However, the majority of trisomies involving large or medium-sized chromosomes also had elevated mean maternal ages, suggesting that most, if not all, human trisomies are associated with increasing age of the mother. Additional variation in the age effect was observed among trisomies involving similar-sized chromosomes, indicating that factors other than chromosome size also influence the relationship between increasing age and trisomy.

Variability of bregma in 300 gram Long-Evans and Sprague-Dawley rats

Bregma is used as an anatomical reference point for most freehand and some stereotaxic injections into the rat brain. The variability of bregma with respect to the intraaural line has been examined previously for rats of a wide range of weights. We examined this variability in 282-326 gram male rats of the Long-Evans and Sprague-Dawley strains. In both strains, mean bregma was less than that stated in a widely used stereotaxic atlas. Furthermore, the mean bregma of the Sprague-Dawley rats was significantly greater than that for the Long-Evans strain. The results suggest that bregma is inadequate as an anatomical reference for intraventricular injections in rats unless the volume injected is a substantial fraction of ventricular volume.