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Objective To determine whether previous cesarean delivery is an independent risk factor for ectopic pregnancy. Methods We analyzed data collected between October 1988 and August 1990 from a case-control study of ectopic pregnancy among parous, black, non-Hispanic women, 18–44 years old, at a major metropolitan hospital in Georgia. Cases were 138 women with confirmed ectopic pregnancy; controls were 842 women either seeking abortion or delivering an infant. Unconditional logistic regression was used to estimate the relative risk while controlling for the effects of potential confounders selected a priori. Results Adjusted for age, parity, marital status, history of pelvic inflammatory disease, infertility, douching, and smoking, the odds ratio was 0.6 (95% confidence interval 0.4–1.1), indicating no significant association. Conclusion: We found no evidence of an increased risk of ectopic pregnancy related to previous cesarean delivery.

OBJECTIVE: We assessed the prevalence of and defined the relationship between other sexually transmitted diseases and human immunodeficiency virus infection. STUDY DESIGN: We performed a case-control study among 121 human immunodeficiency virus—infected and 222 randomly selected seronegative parturient women. These women were identified from a prenatal population undergoing routine voluntary antibody screening in a large urban hospital in the southeastern United States. RESULTS: During the 24-month study period, 16,868 women consented to human immunodeficiency virus antibody screening; 121 (7.2/1000) were infected with human immunodeficiency virus. Cases were significantly more likely than controls to be infected with at least one sexually transmitted disease during pregnancy (48% vs 21%; odds ratio 3.4, 95% confidence interval 2.1 to 5.7). The prevalence of Chlamydia trachomatis and hepatitis B infection did not differ significantly among the groups. Cases were significantly more likely than controls to be infected with Treponema pallidum (29% vs 4%; odds ratio 9.6, 95% confidence interval 4.2 to 22.4). This relationship persisted after we controlled for confounding risk factors (odds ratio 9.2, 95% confidence interval 2.1 to 13.3). In addition, cases were significantly more likely than controls to be infected with Neisseria gonorrhoeae (17.2% vs 4%; odds ratio 5.2, 95% confidence interval 2.1 to 13.3). This relationship also persisted after we controlled for confounders (odds ratio 3.7, 95% confidence interval 1.4 to 10.0). CONCLUSION: Human immunodeficiency virus-infected parturient women in our center are at substantial risk of having other sexually transmitted diseases.

OBJECTIVE: The objective of this study was to characterize blood and amniotic fluid contact sustained by obstetric personnel during deliveries. STUDY DESIGN: Trained observers collected data on 1376 person procedures during 230 deliveries at Grady Memorial Hospital from May to October 1989. Rates of contact were compared by means of the χ 2 test. RESULTS: At least one blood or amniotic fluid contact occurred during 79 (39.1%) of 202 vaginal and 14 (50.0%) of 28 cesarean deliveries; a needle stick occurred in 4 (2.0%) of the vaginal deliveries. Obstetricians and midwives had the highest rates of blood and amniotic fluid contact (18.7% and 28.8% of person procedures, respectively). Half of the contacts sustained by midwives might have been prevented by the use of gowns. Most contacts sustained by obstetricians might have been prevented by face shields, impervious gowns, and impervious shoe covers. CONCLUSIONS: Obstetricians and midwives had substantial risk of blood and amniotic fluid contact during delivery; many of their contacts were potentially preventable.

To assess the knowledge, training and attitudes of obstetricians concerning management of breast-feeding.A survey was sent to 1,200 fellows of the American College of Obstetricians and Gynecologists; 397 practicing obstetricians responded.Obstetricians who were satisfied with their patients' behavior (69.5%) estimated that on average70% of their patients planned to breast-feed, while those who were unsatisfied (21.4%) estimated that60% of their patients planned to breast-feed. African American race and eligibility for Medicaid both appear to predict low rates of breast-feeding among patients. Most physicians considered that they were very well qualified to treat mastitis, prescribe maternal medications and advise their patients regarding contraception. They were less certain of their qualifications regarding educating their patients about breast-feeding and aiding them in solving breast-feeding problems. Personal breast-feeding experience was a significant predictor of female physician confidence. Four of 10 physicians regarded their residency training as inadequate in terms of breast-feeding management.The perceptions of obstetricians regarding breast-feeding practices of their patients appear consistent with national surveys. Obstetricians consider counseling their patients and managing breast-feeding care to be important parts of their clinical responsibilities, but further training and educational materials are warranted.

Objective: To ascertain the current knowledge base and screening practices of obstetrician-gynecologists in the area of domestic violence. Methods: We mailed a survey to 189 ACOG Fellows who are members of the Collaborative Ambulatory Research Network. Questionnaires were also mailed to a random sample of 1250 nonmember Fellows. Results: Obstetrician-gynecologists are aware of the nature of domestic violence and are familiar with common symptomatology that may be associated with domestic violence. For pregnant patients, 39% of respondents routinely screen at the first prenatal visit; 27% of respondents routinely screen nonpregnant patients at the initial visit. Screening is most likely to occur when the obstetrician-gynecologist suspects a patient is being abused, both during pregnancy (68%) and when the patient is not pregnant (72%). Only 30% of obstetrician-gynecologists received training on domestic violence during medical school; 37% received such instruction during residency training. The majority (67%) have received continuing education on the subject. Years since training and personal experiences with intimate-partner violence were associated with increased screening practices. Conclusion: Routine screening of all women for domestic violence has been recommended by ACOG for more than a decade. The majority of obstetrician-gynecologists screen both pregnant and nonpregnant patients when they suspect abuse. However, with universal screening, more female victims of violence can be identified and can receive needed services.

Objective: To examine relationships among human immunodeficiency virus (HIV) serostatus, postpartum contraceptive choice, and the rate of repeat pregnancy within a short interval. Methods: This retrospective cohort study was performed in 83 seropositive and 218 seronegative women identified from an inner-city prenatal population undergoing routine voluntary HIV antibody screening from July 1987 through June 1989. Postpartum contraceptive choices and rate of repeat pregnancies were compared based on HIV serostatus. Results: Seropositive women were significantly more likely than seronegative women to undergo tubal sterilization (27 versus 15%; odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.9). This relationship persisted after controlling for age, race, marital status, and parity by logistic regression modeling (adjusted OR 2.9, 95% CI 1.4–5.9). Seropositive women were significantly less likely than seronegative women to select oral contraceptives (34 versus 68%; OR 0.2, 95% CI 0.1–0.4), a relationship that persisted after controlling for age, race, marital status, parity, and foam and condom use (adjusted OR 0.2, 95% CI 0.1–0.5). Seropositive women were significantly more likely than seronegative women to select foam and condoms as their primary method of contraception (30 versus 15%; OR 2.4, 95% CI 1.2–4.5), a relationship that did not persist after controlling for age, race, marital status, and parity (adjusted OR 0.7, 95% CI 0.4–1.3). The risk of repeat pregnancy was slightly lower in seropositive versus seronegative women (34 versus 44%; OR 0.7, 95% CI 0.4–1.3). Most repeat pregnancies among sera positive and seronegative women were unplanned (90 and 82%, respectively). Conclusion: There was a relationship between the method of postpartum contraception and HIV serostatus, but no significant difference in repeat pregnancy rates associated with choice of method.

OBJECTIVE To determine the extent of human immunodeficiency virus (HIV) infection risk factors and the relationship to the clinical diagnosis in women seen in a busy inner-city gynecology emergency department. METHODS We performed a cross-sectional survey by offering routine voluntary HIV-1 antibody screening and obtaining HIV risk behavior profiles in 1033 (35%) of 2952 women seeking care in our gynecology emergency department during a 5-week period. RESULTS The HIV seroprevalence was 2%. Six (35%) of the infected women reported a history of intravenous drug use, five (29%) reported a history of crack cocaine use, and five (29%) reported no risk factors for infection. Seropositive women were more likely than were seronegative women to have clinical symptoms consistent with pelvic inflammatory disease (18 versus 3%; P < .01). CONCLUSION These data suggest that women attending the gynecology emergency room in our hospital are at substantial risk for HIV infection.

To characterize the epidemiologic characteristics of human immunodeficiency virus type 1 infection in an urban prenatal population in the southeastern United States, we conducted serial routine voluntary antenatal human immunodeficiency virus antibody testing and obtained self-reported human immunodeficiency virus risk behavior profiles on women registering for prenatal care. From July 1987 to June 1990, 23,432 women registered for prenatal care. The majority of women (95%) consented to human immunodeficiency virus antibody testing and completed risk behavior profiles. The cumulative incidence of human immunodeficiency virus infection increased from 3.5 per 1000 in 1987 and 1988 to 5.3 per 1000 in 1989 and 1990. A history of “crack” cocaine use emerged as a significant risk factor for infection (p \lt 0.01). The majority (70%) of human immunodeficiency virus-infected women did not self-acknowledge risk factors for infection and would not have been identified if screening had been targeted. The increasing incidence of human immunodeficiency virus type 1 infection in our prenatal population reinforces the need for our continued routine voluntary antenatal human immunodeficiency virus screening and risk behavior assessment.

THE INCIDENCE of and mortality from cervical cancer in the United States have decreased dramatically over the past 40 years, in part because of early diagnosis and treatment of cervical cancer precursor lesions. The success of cervical cytological screening has served as a model for early diagnosis of other types of cancer. Although numerous studies have shown that lack of cytological screening is a major risk factor for the development of invasive cervical cancer, 1-3 it is important to emphasize that none of the screening, diagnostic, or therapeutic techniques used in medicine are perfect. Accordingly, a few women will develop cervical cancer despite adherence to accepted screening protocols . In addition, problems inherent with sampling, interpretation, and effective clinical follow-up preclude total prevention of cervical cancer. In recent years it has become evident that the cost and morbidity associated with the detection and treatment of low-grade cervical lesions have escalated, probably

The objective of our study was to describe the human immunodeficiency virus epidemic among pregnant adolescents undergoing follow-up in a large inner-city hospital.We conducted a case-control study comparing demographic and risk behaviors of seropositive and seronegative adolescents (aged 13 to 20) identified from a population undergoing routine voluntary antibody screening at Grady Memorial Hospital in Atlanta, Georgia, between July 1987 and March 1991.Of 10,794 pregnant adolescents screened, 51 (4.7/1000) were infected with human immunodeficiency virus. More than one fourth of case patients wereor = 17 years old. Significantly more case patients than controls reported a history of crack cocaine use (10 [19.6%] vs 23 [8.2%] p0.05). A majority (58.8%) of case patients reported no risk factors for infection, and the remainder (41.2%) were presumably infected by heterosexual contact. Thirty-nine controls (13.8%) had self-identified risk factors for infection.Pregnant adolescents in our center are at risk for human immunodeficiency virus infection and should be targeted for human immunodeficiency virus education and risk reduction counseling.This study sought to describe the HIV epidemic among pregnant adolescents undergoing follow up in a large inner city hospital. The authors conducted this case-control study which compared demographic and risk behaviors of seropositive and seronegative adolescents ages 13-20 who were identified from a population undergoing routine voluntary antibody screening at Grady Memorial Hospital in Atlanta, Georgia between July 1987 and March 1991. Of 10,794 pregnant adolescents screened, 51 (4.7/1000) were infected with HIV. More than 1/4 of the case patients were or= 17 years of age. Significantly more case patients than controls reported a history of crack cocaine use (10 [19.6%] vs. 23 [8.2%], p0.05). A majority (58.8%) of case patients reported no risk factors for infection, and the remainder (41.2%) were presumably infected by heterosexual contact. 39 controls (13.8%) had self-identified risk factors for infection. Pregnant adolescents in this center are at risk for HIV infection and should be targeted for HIV education and risk reduction counseling.

Women who receive little or no prenatal care are at increased risk of adverse pregnancy outcome. Although many of these women are disadvantaged and presumably at increased risk for human immunodeficiency virus (HIV) infection, few data are available to describe risk behaviors and infection prevalence in this population. To better characterize HIV infection in unregistered inner-city parturients in Atlanta, we offered routine voluntary screening for HIV antibody and requested HIV risk-behavior profiles on all unregistered and registered parturients seen at Grady Memorial Hospital from July 1, 1987 to June 30, 1988. Of the 834 unregistered and 7356 registered parturients screened, significantly more unregistered parturients were seropositive on enzyme-linked immunosorbent assay and Western blot testing, 12 (1.4%) versus 26 (0.4%) (odds ratio 4.06; 95% confidence interval 1.93-8.43). Five unregistered and 15 registered parturients were seropositive by repeat enzyme-linked immunosorbent assay testing but were Western blot-negative. Significantly more unregistered parturients reported both a history of intravenous drug use, 4.4 versus 1.5% (odds ratio 3.09; 95% confidence interval 2.10-4.54), and crack cocaine use, 3 versus 0.8% (odds ratio 3.96; 95% confidence interval 2.42-6.44). Significantly more unregistered parturients acknowledged risk factors for HIV infection, 14.3 versus 9.9% (odds ratio 1.46; 95% confidence interval 1.19-1.80). Nearly all registered and 86% of unregistered parturients consented to HIV testing. Nearly all parturients completed HIV risk-behavior questionnaires. These data suggest that unregistered inner-city parturients in Atlanta are at greater risk of being HIV-infected and are more likely to report risk behaviors for infection.

Infection with the human immunodeficiency virus (HIV) among reproductive-age women occurs disproportionately among inner-city minority populations. These women are at risk because of intravenous drug abuse and heterosexual transmission from partners infected through drug abuse. From July 1, 1988 to December 31, 1988, we conducted routine voluntary screening for HIV antibody among 923 women who requested induced first-trimester abortion at Grady Memorial Hospital. Eight (8.7 per 1000) women were seropositive on repeat enzyme-linked immunosorbent assay and Western blot testing. Two infected women had had heterosexual contact with a person at risk for HIV infection, two others reported "crack" cocaine use, and four acknowledged no risk factors. Thirteen percent of seronegative women reported risk factors for HIV infection. Nearly all women consented to HIV testing, and most completed the risk-behavior questionnaire. These data suggest that women seeking first-trimester abortion at our hospital are at risk for HIV infection.

Human immunodeficiency virus (HIV) infection occurs disproportionately among inner-city minority women of reproductive age. Once pregnant, these women have a high risk of delivering infants with perinatally acquired infection. Identification and counseling of HIV-infected parturients may be an effective means of preventing perinatal HIV infection. Few data are available on the seroprevalence of HIV infection in the inner-city population or on the clinical and demographic determinants of risk. To better characterize HIV infection in inner-city parturients in Atlanta, we conducted routine antepartum screening for HIV antibody in 3472 women. Ten (2.8 per 1000) were seropositive on enzyme-linked immunosorbent assay (ELISA) and Western blot testing. Four women were seropositive on repeat ELISA but negative on Western blot. Four infected women had had heterosexual contact with a person at risk for HIV, three were intravenous drug users, one had possibly become infected via blood transfusion, and two had no apparent risk factors. Seven of the seropositive women had no self-identified risk factors and would not have been identified if screening had been performed using current Centers for Disease Control criteria. Ten percent of the women screened had self-identified risk factors for HIV infection and were seronegative. Ninety-six percent of women consented to HIV testing. These data suggest that inner-city parturients in Atlanta are at risk for HIV infection and that routine antepartum HIV screening can be performed provided the appropriate multidisciplinary team is in place for counseling and follow-up.

Antecedent factors operative in the causation of adolescent pregnancy include: The sexuality of contemporary society, especially the media. Prolongation of educational any vocational preparation in industrialized western society. Normal physical maturation at an early age. Peer and social pressure. Low expectations of life among minority and economically poor individuals. The conspiracy of silence surrounding sexuality and the inability of society to admit and deal realistically with the sexual activity of adolescents. Failure to provide sex education, clarification of values, family-life education, preparation for parenthood, and knowledge of birth-control and family-planning services targeted to teenagers, including adolescent males. Psychological and emotional problems. Failure to provide available and accessible early pregnancy-detection services with adequate counseling and support services. Failure to provide abortion services. Failure to provide supportive services to adolescents who have a child in order to prevent repeated pregnancy. Pregnancy, childbearing, and motherhood represent ultimate feminine fulfillment to many in our society, and unless attainable expectations and desirable alternatives are available, adolescents will continue to see little reason to postpone pregnancy and childbearing.

A study was made of increased accessibility of genetic services to low-income obstetric patients in Atlanta, Georgia. The proportion of black patients averaged 83%. Of 522 patients counseled from August, 1976, through 1978, 157 were offered amniocentesis, and 95 (61%) elected the procedure. For most of the patients (120, or 76%) who were eligible for amniocentesis, age (greater than or equal to 35 years at delivery) was an indication; and of these, only six (5%) had any prior knowledge of genetic risk. During the same time interval, 188 patients over 35 years of age who initiated prenatal care too late for prenatal diagnosis were counseled in the hospital after delivery; 101 (54%) indicated that they would have accepted amniocentesis. The conclusion was that (1) genetic services are acceptable to this socioeconomic group, and (2) accessibility and publicity are needed to promote utilization in this population.

Sociologic and socioeconomic data from a group of 978 nonregistered patients were compared to data from 1,000 registered patients, and the outcome of pregnancy was recorded for the 978 nonregistered and 5,445 registered patients. Mortality rates of both mothers and infants were higher among patients who failed to register for prenatal care, premature birth was more frequent. Nonregistered patients were more likely to be older and multigravid and have a larger family than registered patients. There was a larger percentage of white patients among the nonregistered patient population. Educational attainment and family income were lower, and household size was larger among patients receiving no antepartum care. Most nonregistered patients had never used any form of contraception, and their postpartum return rate was extremely low.

Suicide is the fourth leading cause of death during the teenage years, preceded in frequency only by trauma, malignancy, and homicide.1 Recent statistics indicate that the number of suicides in adolescents has risen dramatically in the past decade, resulting in approximately 5,000 deaths per year. For youths 15 to 19 years old, the figures have actually doubled from 1968 to 1976; 11 boys per 100,000 in the population are now dying by suicide each year.2 Even among adolescents 10 to 14 years old, the trend is increasing and went from 116 to 158 deaths per year between 1968 and 1976. As distressing as these data appear, it is more alarming to realize that suicides are notoriously under-reported. Suicide affects youngsters from all races and socioeconomic groups. For every suicide completed, between 50 and 200 are attempted. Boys succeed in their suicide attempts more frequently than girls, mainly because they use more lethal methods, such as firearms or hanging. Girls generally attempt suicide by ingesting pills and are more frequently resuscitated. The pediatrician can provide a significant resource in preventing adolescent suicide by identifying youngsters at high risk and recognizing behavioral clues in youngsters contemplating suicide. CLINICAL PRESENTATIONS OF ADOLESCENTS CONTEMPLATING SUICIDE Youngsters planning suicide frequently provide behavioral clues to their intent, such as giving away prized possessions or writing notes or poems expressing death themes. If the pediatrician suspects that a teenager is contemplating suicide, he should ask the adolescent directly about suicidal thoughts. Inquiring about suicide does not cause suicide! Quite the contrary, the adolescent may be relieved that someone has heard his cry for help.

A total of 1,824 births to patients aged 16 and under during 1971 and 1972 were examined. Premature birth, and fetal, neonatal, and perinatal death were more common in this young age group. Contraceptive acceptance was high at postpartum visit. Approximately half of the patients registered for continuing interconceptional care. The population is described and contraceptive acceptance, contraceptive continuation, and repeat pregnancy are recorded.

To study the involvement of 6 keto prostaglandin F1 alpha (6 keto PGF1 alpha) and thromboxane B2 (TxB2) in mild pregnancy-induced hypertension (PIH), we measured amniotic fluid and plasma concentration of these prostanoids by radioimmunoassay in PIH subjects and normotensive pregnant controls. The results suggest no difference in plasma or amniotic fluid 6 keto PGF1 alpha or plasma TxB2 in PIH and control subjects. The concentration of TxB2 (mean +/- SE) in amniotic fluid, however, were 189.5 +/- 27.7 for PIH and 107.4 +/- 9.7 for controls (P less than 0.05). This increase in vasoconstrictor TxB2 over vasodilator 6 keto PGF1 alpha may have implications in the hypertensive vascular response of mild PIH.

Ethanol use by pregnant women increased, in a dose-dependent manner, the rate of sheep erythrocyte rosette (E-rosette) formation with T lymphocytes. The time curve for E-rosette formation by T cells from nondrinking subjects was biphasic, with a rapid formation of half the E-rosettes within the first 16 min, followed by a much slower rate for E-rosette formation until the maximal T-cell percentage was reached overnight. For pregnant drinkers, greater than 85% of the E-rosettes formed during the initial rate period, with a concomitant smaller number forming during the overnight incubation. Despite the faster initial rate of E-rosette formation in the drinking subjects, the total percentage T cells was the same for both groups. Other demographic factors, like tobacco or marijuana use, or trimester, did not significantly contribute to the observed differences. An increase in the rate of E rosetting was also obtained by incubating lymphocytes from nondrinkers overnight in physiologically attainable concentrations of ethanol (less than or equal to 0.1%). These results demonstrate that drinking by pregnant women, even at relatively moderate levels (2 oz/week absolute ethanol), causes alterations in their cellular immune systems. With the ability of ethanol to cross the placental barrier and persist in utero, it is apparent that these levels of ethanol have the potential to affect the developing fetal immune system.

T HE purpose of the study was to do serial measurements of total c~~hangeable body sodium in women throughout the menstrual cycle to determinc~ whether there is a sodium retention during normal menstrual cycles. It is common belief that there are changes in body sodium content in pregnancy, tosemia of pregnancy, the premenstrual tension syndrome,g and perhaps also in the normal menstrual cycle. The intent was to establish normal control values and ranges for body sodium content, and to determine the daily pattern of body sodium for possible changes concomitant with the endocrinologic changes of the normal menstrual cycle. Serial measurements of total exchangeable hod? sodium were made on a daily basis with the use of isotope dilution techniques. Sodium metabolism can be studied by metabolic balance methods, or, as has been done more recently, by isotope dilution techniques.4, 16-19 When a known amount of radioactive isotope is administered, it exchanges or is diluted by the naturally occurring element in the body, and the total amount of bod3 element with which the tracer isotope has exchanged or mixed can bc calculated by the dilution principle. That is, if the concentration of radioactive isotope is known or measured before and after dilution in the body, t,he volume. or weight of the diluting substance can be calculated. The basis of the method is the chemical dilution principle that the weight or mass of the diluted solute or tracer substance remains constant before and after dilution, expressed by the formula C,V, = &V,, where C and V represc>nt concentration and volume before and after dilut,ion. The method is suitable for volume or ‘ ‘space, ’ ’ and solid or weight studies using either dyes ot’ isotopes, and was first used by Keith, Rowntrec, and Geraghty” in 1915 for dye studies measuring plasma volume. The method has been popularized in the United States by F. D. &loore and his co-workrrs. Dilution studies with the radioactive isotopes are based on observations that the tracer isotopes behave chemically and physically in the body in a maw ner identical with that of the natural isotopes of an element, except that a proportion of the radioactive atoms will (lisintegl-ale with the cmissiwl of ~xdiatiolr which can be detected, measured, and rc~c’otde(l.“”

Traditionally, both families and physicians have considered having or delivering a baby a local event and have expected a maternity unit to be available nearby. In rural states, a significant portion of births continue to take place in small maternity services, and nationwide there is little evidence of consolidation of maternity services or closure of hospital maternity services with small numbers of annual births. 1 Small rural maternity services provide the benefit of the social, psychological, and family support of the local community and avoid prolonged hasty travel at the onset of labor. It is these maternity services, provided by local community hospitals, that are the subject of the study by Hein 2 published in this issue ofThe Journal. Most small maternity units cannot provide the full range of services for high-risk patients. They can provide the necessary services according to the risk status of the mother and the