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ABSTRACT: To estimate the incidence of maternal cardiovascular and pulmonary events and the prevalence of other comorbid conditions among pregnant smokers.
We queried the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ) for pregnancy-related discharge codes for the years 2000-2004. The prevalence of various conditions and the incidence of various complications were compared between smokers and nonsmokers.
The majority of smokers were young and white and had public insurance. Smokers were more likely to have experienced deep vein thrombosis (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1, 1.6), stroke (OR 1.7, 95% CI 1.2, 2.5), pulmonary embolus (OR 2.5, 95% CI 2.1, 3.0), and myocardial infarction (OR 4.6, 95% CI 3.3, 6.4). They were 3 times more likely to have experienced influenza or pneumonia (OR 2.9, 95% CI 2.7, 3.2) and 15 times more likely to have bronchitis (OR 15.2, 95% CI 12.8, 18.2). They were more likely to suffer from a number of comorbidities, including asthma (OR 4.0, 95% CI 3.7, 4.2) and gastrointestinal ulcers (OR 3.7, 95% CI 2.6, 5.5). Although they were less likely to have experienced gestational diabetes (OR 0.9, 95% CI 0.9, 1.0), preeclampsia (OR 0.8, 95% CI 0.8, 0.9), or eclampsia (OR 0.7, 95% CI 0.6, 0.9), they were more than 5 times as likely to have experienced an ectopic pregnancy (OR 5.4, 95% CI 4.6, 6.3).
Smoking has a negative impact on maternal health. Counseling about the risks of smoking in pregnancy should include not only fetal risks but maternal risks as well.
Journal of Women s Health 07/2009; 18(6):867-72. · 1.57 Impact Factor
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ABSTRACT: The purpose of this study was to identify morbidity that is associated with sickle cell disease (SCD) in pregnancy.
The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000-2003 was queried for all pregnancy-related discharges with a diagnosis of SCD.
There were 17,952 deliveries (0.1% of the total) to women with SCD. There were 10 deaths (72.4 per 100,000 deliveries). Cerebral vein thrombosis, pneumonia, pyelonephritis, deep venous thrombosis, transfusion, postpartum infection, sepsis, and systemic inflammatory response syndrome were much more common among women with SCD. They were more likely to undergo cesarean delivery, to experience pregnancy-related complications (such as gestational hypertension/preeclampsia, eclampsia, abruption, antepartum bleeding, preterm labor, and fetal growth restriction), and to have cardiomyopathy or pulmonary hypertension at the time of delivery.
Women with sickle cell disease are at greater risk for morbidity in pregnancy than previously estimated.
American journal of obstetrics and gynecology 07/2008; 199(2):125.e1-5. · 3.28 Impact Factor
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ABSTRACT: The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.
International Urogynecology Journal 01/2008; 18(12):1395-8. · 1.83 Impact Factor
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ABSTRACT: Objective: Evaluate possible association of genetic variability detected via single nucleotide polymorphisms (SNPs) and pelvic organ prolapse (POP).
Methods: Thirty six women with stage III-IV POP and 36 controls matched for race, age, parity, and body mass index were recruited. Blood DNA was genotyped for 9 SNPs (matrix metalloproteinases, MMP1, 2, 3, 8, 9, 10, 11, and TIMP1 and 2). Association of each SNP and gene frequencies by group were computed, and haplotype frequencies were estimated.
Results: All subjects were white with comparable age, parity, and weight. Sixty-two percent of cases and 38% of controls had previous hysterectomy (P < 0.00). Genotypic frequencies differed between groups for MMP10 (P = 0.01). The C allele for MMP10 was present in 19.4% of controls and absent in cases. Haplotyping indicated significant linkage between MMP10 and all others except MMP2.
Conclusions: The C allele for MMP10 may provide some protection against prolapse. MMP10 demonstrates significant linkage with multiple metalloproteinases tested in this study: MMP1, MMP3, MMP8, MMP9, TIMP1, and TIMP3. Further studies will be necessary to test the clinical significance of this observation.
Journal of Pelvic Medicine and Surgery 12/2007; 14(1):37-43.
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ABSTRACT: Our study evaluated medical conditions, level of physical functioning, and psychological health as correlates of urinary continence (UI) for four different age groups of women. Survey questions from the 1996 MIDUS survey were used in three domains of health: medical conditions, physical functioning, and psychological health. Mean questionnaire scores or prevalence percentages for individual and total medical conditions, physical functioning, and psychological health were computed. Two-sample independent t tests or chi-square tests were used to compare women with UI to those without. Prevalence of UI was as follows: 25-39 years: 13.3%, 40-49 years: 24.0%, 50-59 years: 32.7%, and 60-74 years: 32.8%. Lower psychological resilience scores were significantly associated with UI in all age groups. Significant correlates (p<0.02) for women 25-39 years were hysterectomy, weak core muscles, and lack of psychological resilience. In older women, more chronic conditions and parity were significantly (p<0.01) associated with UI. Although each age group had specific medical associations with UI, lack of resilience and poor core muscle strength are particularly correlated with UI in young women.
International Urogynecology Journal 10/2007; 18(10):1127-32. · 1.83 Impact Factor
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ABSTRACT: Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-hour pad weight test (24PWT) is a reproducible test for quantifying incontinence volumes. We investigated whether PPD validly reports the magnitude of urinary incontinence.
This was a retrospective review of patients undergoing stress incontinence surgery from July 2002 to 2005. Inclusion criteria were a documented 24PWT and patient-reported PPD usage. Grams of urine loss per pad (GPP) provided a third measure of incontinence. Descriptive statistics and correlations between all variables and significance were noted. Factor analysis was performed on the three measures of leakage and age for all patients over age 50.
One hundred forty-five male and 116 female patients met inclusion criteria. Correlated against 24PWT, GPP has the strongest association with a correlation of 0.80 for males and 0.88 for females. PPD has a weaker correlation of 0.64 for males and 0.61 for females (R2 = 0.38 overall). Factor analysis identified two components associated with incontinence. A "leakage" component correlated best with 24PWT and GPP. Additionally, an "age" component implies that despite stable 24PWT values, older patients increase GPP while PPD decreases.
Self-reported PPD is an unreliable measure of incontinence as this variable only measures 38% of the variation of urinary incontinence volume. Patients at a given PPD level present with a wide range of 24PWT values. Older patients have higher per-pad leakage. Future incontinence studies should report 24PWT to ensure the most reliable and uniform data.
Neurourology and Urodynamics 02/2007; 26(1):3-7. · 2.96 Impact Factor
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ABSTRACT: The purpose of this study was to estimate the incidence, risk factors, and mortality from pregnancy-related venous thromboembolism.
The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000 to 2001 was queried for all pregnancy-related discharges with a diagnosis of venous thromboembolism.
The rate of venous thromboembolism was 1.72 per 1000 deliveries with 1.1 deaths per 100,000. The risk of venous thromboembolism was 38% higher for women ages 35 and older and 64% higher for black women. Other significant risk factors included thrombophilia, lupus, heart disease, sickle cell disease, obesity, fluid and electrolyte imbalance, postpartum infection, and transfusion. The risk factor with the highest odds ratio, 51.8 (38.7-69.2) was thrombophilia.
The incidence of pregnancy-related venous thromboembolism was higher than generally quoted. Women ages 35 and older, black women, and women with certain medical conditions and obstetric complications appear to be at increased risk.
American journal of obstetrics and gynecology 06/2006; 194(5):1311-5. · 3.28 Impact Factor
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ABSTRACT: The purpose of this study was to determine the incidence, mortality, and risk factors for pregnancy-related acute myocardial infarction in the United States.
The Nationwide Inpatient Sample for the years 2000 to 2002 was queried for all pregnancy-related discharges. A total of 859 discharges included a diagnosis of acute myocardial infarction, for a rate of 6.2 (95% confidence interval [CI] 3.0 to 9.4) per 100,000 deliveries. Among these, there were 44 deaths, for a case fatality rate of 5.1%. The odds of acute myocardial infarction were 30-fold higher for women aged 40 years and older than for women <20 years of age. Single independent variables that were statistically and clinically significant, including age, race, and certain medical conditions and obstetric complications, were entered into a multivariable logistic regression model. Hypertension (odds ratio [OR] 21.7, 95% CI 6.8 to 69.1), thrombophilia (OR 25.6, 95% CI 9.2 to 71.2), diabetes mellitus (OR 3.6, 95% CI 1.5 to 8.3), smoking (OR 8.4, 95% CI 5.4 to 12.9), transfusion (OR 5.1, 95% CI 2.0 to 12.7), postpartum infection (OR 3.2, 95% CI 1.2 to 10.1), and age 30 years and older remained as significant risk factors for pregnancy-related acute myocardial infarction. Black race was eliminated as a risk factor in the multivariable analysis, which suggests that the increased incidence among black women is explained by an increased prevalence of other cardiovascular risk factors.
Although acute myocardial infarction is a rare event in women of reproductive age, pregnancy increases the risk 3- to 4-fold. Certain medical conditions and complications of pregnancy increase the risk further and are potentially modifiable risk factors.
Circulation 04/2006; 113(12):1564-71. · 14.74 Impact Factor
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ABSTRACT: Circulating angiogenic growth factors (such as vascular endothelial growth factor [VEGF] and placental growth factor [PlGF]) and their interaction may be associated with vascular remodeling of spiral arteries in normal pregnancy. Soluble Flt-1, an antagonist of both VEGF and PlGF, has been shown to be increased, while PlGF is decreased in women prior to the onset of preeclampsia. The purpose of this study was to compare maternal soluble Flt-1 and PlGF levels in the second trimester with a marker of abnormal placentation, abnormal uterine artery Doppler (UAD).
A prospective cohort of women, 16 to 24 weeks estimated gestational age (EGA), with singleton pregnancies, underwent UAD and phlebotomy. Maternal soluble Flt-1 and free PlGF were measured by ELISA in samples from women with abnormal UAD with a group, controlled for EGA, with normal UAD. Mann-Whitney Rank-Sum test was used to compare maternal serum levels of both soluble Flt-1 and PlGF between women with abnormal uterine artery Doppler versus women with normal uterine artery Doppler.
Of the 222 study subjects enrolled, 34 (15%) had abnormal UAD. The mean EGA at enrollment of subjects in each group was 18 weeks. There was no difference in PlGF between subjects with abnormal UAD (median, 191 pg/mL; range, 187 to 337 pg/mL) versus controls (median, 171 pg/mL; range, 169 to 289 pg/mL) (p = 0.59) or soluble Flt-1 (median, 780 pg/mL; range, 280 to 3200 pg/mL) or between subjects with abnormal UAD versus controls (median, 720 pg/mL; range, 220 to 1980 pg/mL) (p = 0.36).
Concentrations of maternal soluble Flt-1 and free PlGF in the second trimester do not appear to be altered in women with abnormal UAD. This suggests that these biochemical markers are independent of the increased placental resistance seen with abnormal uterine artery Doppler.
Hypertension in Pregnancy 02/2006; 25(3):183-92. · 1.69 Impact Factor
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ABSTRACT: This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery.
We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated.
Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03).
Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.
American journal of obstetrics and gynecology 01/2006; 193(6):2083-7. · 3.28 Impact Factor
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ABSTRACT: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation.
This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant.
The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated.
Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.
Urology 11/2005; 66(4):746-50. · 2.43 Impact Factor
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ABSTRACT: To test the hypothesis that pregnancy rates are low if grade Z1 pre-embryos are not available for transfer and to determine if pronuclear morphology is a better predictor of pregnancy than traditional embryo morphology.
Prospective clinical study.
Academic human reproduction laboratory.
One hundred couples undergoing IVF with conventional insemination or ICSI.
Embryo quality was assessed using both pre-embryo pronuclear morphology (zygote scoring or Z-scoring) at the time of fertilization evaluation and standard day 2 and day 3 embryo morphology (number of blastomeres and grading based on degree of fragmentation and blastomere size).
We tested two decision models, one based on Z-scores and another on morphology, to determine which grading system better predicted pregnancy outcomes in assisted reproductive technique. Zygote score and embryo morphology were measured for all embryos and the transferred embryo pool. Implantation and pregnancy rates resulting from the embryo transfers of all cycles were calculated.
The Z-score distribution of 552 embryos was 27% Z1, 8% Z2, 50% Z3, and 15% Z4. Z1 and Z3 embryos had significantly (P approximately .03) higher quality over Z2 and Z4 embryos. Using the Z-score decision model with Z1 embryos having highest priority for transfer, pregnancy rates were similar between Z1 and Z3 embryos. Using embryo morphology as a decision model, pregnancy rates were highest in transfers containing one or two "best"-quality embryos.
Z1 and Z3 embryos had similar morphology and pregnancy rates. The decision model based on the Z-score model was not better than standard embryo morphology in predicting pregnancy outcome.
Fertility and sterility 11/2005; 84(4):900-9. · 3.97 Impact Factor
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ABSTRACT: To estimate the incidence, mortality, and risk factors for pregnancy-related stroke in the United States.
The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, for the years 2000-2001 was queried for International Classification of Diseases, 9th Revision, codes for stroke among all pregnancy-related discharges.
A total of 2,850 pregnancy-related discharges included a diagnosis of stroke for a rate of 34.2 per 100,000 deliveries. There were 117 deaths or 1.4 per 100,000 deliveries. Twenty-two percent of survivors were discharged to another facility. The risk of stroke increased with age, particularly ages 35 years and older. African-American women were at a higher risk, odds ratio (OR) 1.5 (95% confidence interval [CI] 1.2-1.9). Medical conditions that were strongly associated with stroke included migraine headache, OR 16.9 (CI 9.7-29.5), thrombophilia, OR 16.0 (CI 9.4-27.2), systemic lupus erythematosus, OR 15.2 (CI 7.4-31.2), heart disease, OR 13.2 (CI 10.2-17.0), sickle cell disease, OR 9.1 (CI 3.7-22.2), hypertension, OR 6.1(CI 4.5-8.1) and thrombocytopenia, OR 6.0 (CI 1.5-24.1). Complications of pregnancy that were significant risk factors were postpartum hemorrhage, OR 1.8 (CI 1.2-2.8), preeclampsia and gestational hypertension, OR 4.4 (CI 3.6-5.4), transfusion OR 10.3 (CI 7.1-15.1) and postpartum infection, OR 25.0 (CI 18.3-34.0).
The incidence, mortality and disability from pregnancy related-stroke are higher than previously reported. African-American women are at an increased risk, as are women aged 35 years and older. Risk factors, not previously reported, include lupus, blood transfusion, and migraine headaches. Specific strategies, not currently employed, may be required to reduce the devastation caused by stroke during pregnancy and the puerperium.
II-2.
Obstetrics and Gynecology 10/2005; 106(3):509-16. · 4.73 Impact Factor
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ABSTRACT: To test the hypothesis that couples with sperm chromatin structure assay (SCSA) DNA fragmentation index (DFI) values >27% would not achieve pregnancy with assisted reproductive techniques (ART) and to investigate how DFI and high DNA stainability (HDS), as measured by the SCSA, affect fertilization, cleavage, implantation, and pregnancy rates in IVF cycles.
Prospective clinical study.
Academic human reproduction laboratory.
One hundred couples undergoing IVF with conventional insemination or intracytoplasmic sperm injection.
Testing with SCSA was performed by SCSA Diagnostics (Brookings, South Dakota) on a semen aliquot taken from ejaculate used for ART.
Relating total DFI and HDS to conventional semen parameters and cycle-specific outcomes after ART.
Nine of nineteen couples achieved clinical pregnancy when DFI was > or =27%, and 2 of 22 couples achieved clinical pregnancy when DFI was < or =9%. One of nine couples achieved clinical pregnancy with HDS >17%. The DFI was negatively correlated with sperm density (r = -0.23, P<.03) and motility (r = -0.55, P<.00), and HDS was negatively correlated with sperm density (r = -0.37, P<.00).
Sperm chromatin structure assay failed to identify elevated DFI thresholds for negative pregnancy outcome after ART. Patients with low DFI (< or =9%) were least likely to become pregnant, which is also contradictory to SCSA marketing, which states that DFIs of < or =15% have excellent fertility potential. Patients with HDS > or =17% had low pregnancy rates, indicating decreased fertility potential, which deserves further investigation. Larger studies are necessary to confirm that low DFI is associated with decreased fertility and, if proved, might redefine the use of the SCSA in evaluating infertility.
Fertility and sterility 08/2005; 84(2):356-64. · 3.97 Impact Factor
