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Food recalls highlight risk of listeriosis
Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.
According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.
Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.
Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.
While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.
In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.
More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.
Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).
The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.
Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.
Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.
Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.
Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.
“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”
The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.
That’s food for thought.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures.
Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.
According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.
Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.
Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.
While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.
In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.
More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.
Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).
The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.
Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.
Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.
Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.
Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.
“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”
The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.
That’s food for thought.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures.
Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.
According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.
Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.
Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.
While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.
In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.
More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.
Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).
The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.
Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.
Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.
Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.
Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.
“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”
The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.
That’s food for thought.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures.
DDW: Gestational diabetes linked to increased NAFLD risk in middle age
WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.
This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.
The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.
At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.
Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.
At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.
In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.
“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.
Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.
The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.
Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.
“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.
Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.
Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.
Nonalcoholic fatty liver disease is the most common and fastest growing liver disease worldwide. Identifying individuals at high risk for NAFLD remains challenging. Dr. Ajmera and his colleagues highlight the association between gestational diabetes mellitus (GDM) and NAFLD. Their work confirms and extends earlier studies that reported increased hepatic fat content and a substantially increased risk for NAFLD, in women with a prior history of GDM. In the present study, a more racially diverse U.S.-based population was followed for a much longer duration than was previous cohorts. After adjusted multivariate analysis, GDM remained a strong, independent predictor of future NAFLD. Indeed, GDM was a a better NAFLD predictor than the diagnosis of diabetes alone was. It is unclear if prepregnancy NAFLD might have affected the risk for GDM, as subjects were not assessed for hepatic steatosis or liver test elevations at baseline. Also, the percentage of 50-year-old women with NAFLD was much lower in this cohort (7%) than in the general U.S. population (at least 25%), perhaps because the study population was enriched with individuals who are typically at low risk for NAFLD (i.e., African Americans, people with low body mass index, and/or low serum triglycerides).
Additional research is needed to clarify these issues and to investigate how maternal GDM affected the health of their children. Intrauterine exposure to metabolic stresses increases the risk for obesity and other metabolic disorders later in life, suggesting that offspring of mothers with GDM may require specialized surveillance or other precautions during childhood. Given that more young women are entering their reproductive years affected by diabetes and obesity, increased attention to these issues will be required to curb the growing public health burden of NAFLD.
Dr. Cynthia A. Moylan, M.H.S., is assistant professor of medicine, Duke University Medical Center and Veterans Affairs Medical Center, Durham, N.C. She is has no relevant financial conflicts of interests.
Nonalcoholic fatty liver disease is the most common and fastest growing liver disease worldwide. Identifying individuals at high risk for NAFLD remains challenging. Dr. Ajmera and his colleagues highlight the association between gestational diabetes mellitus (GDM) and NAFLD. Their work confirms and extends earlier studies that reported increased hepatic fat content and a substantially increased risk for NAFLD, in women with a prior history of GDM. In the present study, a more racially diverse U.S.-based population was followed for a much longer duration than was previous cohorts. After adjusted multivariate analysis, GDM remained a strong, independent predictor of future NAFLD. Indeed, GDM was a a better NAFLD predictor than the diagnosis of diabetes alone was. It is unclear if prepregnancy NAFLD might have affected the risk for GDM, as subjects were not assessed for hepatic steatosis or liver test elevations at baseline. Also, the percentage of 50-year-old women with NAFLD was much lower in this cohort (7%) than in the general U.S. population (at least 25%), perhaps because the study population was enriched with individuals who are typically at low risk for NAFLD (i.e., African Americans, people with low body mass index, and/or low serum triglycerides).
Additional research is needed to clarify these issues and to investigate how maternal GDM affected the health of their children. Intrauterine exposure to metabolic stresses increases the risk for obesity and other metabolic disorders later in life, suggesting that offspring of mothers with GDM may require specialized surveillance or other precautions during childhood. Given that more young women are entering their reproductive years affected by diabetes and obesity, increased attention to these issues will be required to curb the growing public health burden of NAFLD.
Dr. Cynthia A. Moylan, M.H.S., is assistant professor of medicine, Duke University Medical Center and Veterans Affairs Medical Center, Durham, N.C. She is has no relevant financial conflicts of interests.
Nonalcoholic fatty liver disease is the most common and fastest growing liver disease worldwide. Identifying individuals at high risk for NAFLD remains challenging. Dr. Ajmera and his colleagues highlight the association between gestational diabetes mellitus (GDM) and NAFLD. Their work confirms and extends earlier studies that reported increased hepatic fat content and a substantially increased risk for NAFLD, in women with a prior history of GDM. In the present study, a more racially diverse U.S.-based population was followed for a much longer duration than was previous cohorts. After adjusted multivariate analysis, GDM remained a strong, independent predictor of future NAFLD. Indeed, GDM was a a better NAFLD predictor than the diagnosis of diabetes alone was. It is unclear if prepregnancy NAFLD might have affected the risk for GDM, as subjects were not assessed for hepatic steatosis or liver test elevations at baseline. Also, the percentage of 50-year-old women with NAFLD was much lower in this cohort (7%) than in the general U.S. population (at least 25%), perhaps because the study population was enriched with individuals who are typically at low risk for NAFLD (i.e., African Americans, people with low body mass index, and/or low serum triglycerides).
Additional research is needed to clarify these issues and to investigate how maternal GDM affected the health of their children. Intrauterine exposure to metabolic stresses increases the risk for obesity and other metabolic disorders later in life, suggesting that offspring of mothers with GDM may require specialized surveillance or other precautions during childhood. Given that more young women are entering their reproductive years affected by diabetes and obesity, increased attention to these issues will be required to curb the growing public health burden of NAFLD.
Dr. Cynthia A. Moylan, M.H.S., is assistant professor of medicine, Duke University Medical Center and Veterans Affairs Medical Center, Durham, N.C. She is has no relevant financial conflicts of interests.
WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.
This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.
The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.
At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.
Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.
At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.
In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.
“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.
Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.
The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.
Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.
“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.
Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.
Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.
WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.
This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.
The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.
At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.
Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.
At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.
In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.
“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.
Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.
The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.
Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.
“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.
Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.
Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.
AT DDW® 2015
Key clinical point: Gestational diabetes could be used to identify young women at increased risk of having non-alcoholic fatty liver disease (NAFLD) in middle age.
Major finding: Having been diagnosed with gestational diabetes was associated with about a two-fold increased risk of having NAFLD in middle age.
Data source: The research involved 1,115 women enrolled in the 25-year Coronary Artery Risk Development in Young Adults (CARDIA) study.
Disclosures: Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute.
ACOG: Immediate postpartum IUD the ‘next big thing’
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
EXPERT ANALYSIS FROM THE ACOG ANNUAL CLINICAL MEETING
Are birthing centers a safe alternative for women?
Yes: Time to design seamless care
Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.
The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).
The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).
The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.
In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.
The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.
Dr. Breedlove is president of the American College of Nurse-Midwives.
No: Hospitals are still the safest choice
According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.
How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.
Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.
However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.
The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.
In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.
One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?
Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.
Yes: Time to design seamless care
Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.
The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).
The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).
The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.
In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.
The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.
Dr. Breedlove is president of the American College of Nurse-Midwives.
No: Hospitals are still the safest choice
According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.
How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.
Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.
However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.
The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.
In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.
One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?
Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.
Yes: Time to design seamless care
Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.
The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).
The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).
The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.
In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.
The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.
Dr. Breedlove is president of the American College of Nurse-Midwives.
No: Hospitals are still the safest choice
According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.
How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.
Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.
However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.
The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.
In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.
One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?
Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.
ACOG: Survey finds few have experience in third-trimester terminations
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: Many abortion providers lack knowledge and experience in the third-trimester management of lethal fetal anomalies.
Major finding: In a survey of abortion providers, only 19% reported participating in the care of a woman undergoing a third-trimester termination.
Data source: A survey of 112 abortion providers affiliated with family planning fellowship programs.
Disclosures: Dr. Atrio reported having no financial disclosures.
PAS: Supplemental iron during and after pregnancy affects infant behavior
SAN DIEGO – Iron supplementation, especially in pregnancy, improved toddler communication and social behaviors at 18 months in a large Chinese study.
“Iron deficiency in infancy is associated with altered social and emotional development,” Ming Li, Ph.D., said at the annual meeting of the Pediatric Academic Societies. “Some randomized, controlled trials of iron supplementation in infancy show social and emotional benefits.”
In an effort to assess the effects of iron supplementation and maternal iron status on infant communication and social interaction, Dr. Li of Peking University First Hospital in Beijing, China, in collaboration with Dr. Betsy Lozoff and her associates at the University of Michigan, Ann Arbor, used the 23-item Modified Checklist for Autism in Toddlers (M-CHAT) in 993 children in rural China who were part of two linked randomized, controlled trials. Their mothers had been randomized 1:1 to iron (300 mg ferrous sulfate) plus folate (400 micrograms) or placebo plus folate in pregnancy. As infants, they were randomized 1:1 to iron (liquid iron protein succinylate, about 1 mg Fe/kg per day) or placebo from 6 weeks to 9 months. In all, the two trials yielded four groups of prenatal or postnatal iron: placebo/placebo, placebo/iron, iron/placebo, and iron/iron.
The researchers administered the M-CHAT at 18 months to assess behaviors related to communication and social-emotional functioning, including imitation, joint attention, pretend play, and social referencing. The major outcome was the number of M-CHAT items failed. The threshold was two or more failed of the tool’s six most discriminating items or three or more failed of all 23 M-CHAT items. Bivariate correlation was used to consider the relation with maternal iron status.
The mean age of mothers was 25 years, and 78% were primiparous. More than 98% of the infants were born at term; mean birth weight was 3.36 kg. Their weight-for-age Z score was .90 at 9 months, and .53 at 18 months. Anemia, iron deficiency, and iron deficiency anemia declined with prenatal supplementation, but the majority of mothers were still iron deficient at term.
Dr. Li reported that the number of failed M-CHAT items varied depending on iron supplementation group, and was highest for the placebo/placebo group (3.1) and lowest for the iron/iron group (2.8) (P = 0.04 for linear trend). Mother’s iron status at enrollment was not associated with number of failed M-CHAT items, but late pregnancy iron status was. Lower maternal hemoglobin and higher soluble transferrin receptor predicted a higher number of failed M-CHAT items (P= .01 and P= .02, respectively).
Dr. Li emphasized that the study’s randomized, controlled design supports causal inferences. “These are best considered as behaviors [that are impacted], rather than autistic spectrum disorders,” he said. “The results suggest that iron supplementation in pregnancy has more effect than in infancy, but the infancy dose was low (1 mg/kg per day) and the impact on iron status at 9 months was minimal. Still, the combination of iron supplementation in pregnancy and infancy provided the greatest benefit.”
The pregnancy randomized, controlled trial was funded by Vifor Pharma, Ltd. The infancy randomized controlled trial and all iron measures were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development with the Office of Dietary Supplements. Dr. Li reported having no relevant financial conflicts.
On Twitter @dougbrunk
SAN DIEGO – Iron supplementation, especially in pregnancy, improved toddler communication and social behaviors at 18 months in a large Chinese study.
“Iron deficiency in infancy is associated with altered social and emotional development,” Ming Li, Ph.D., said at the annual meeting of the Pediatric Academic Societies. “Some randomized, controlled trials of iron supplementation in infancy show social and emotional benefits.”
In an effort to assess the effects of iron supplementation and maternal iron status on infant communication and social interaction, Dr. Li of Peking University First Hospital in Beijing, China, in collaboration with Dr. Betsy Lozoff and her associates at the University of Michigan, Ann Arbor, used the 23-item Modified Checklist for Autism in Toddlers (M-CHAT) in 993 children in rural China who were part of two linked randomized, controlled trials. Their mothers had been randomized 1:1 to iron (300 mg ferrous sulfate) plus folate (400 micrograms) or placebo plus folate in pregnancy. As infants, they were randomized 1:1 to iron (liquid iron protein succinylate, about 1 mg Fe/kg per day) or placebo from 6 weeks to 9 months. In all, the two trials yielded four groups of prenatal or postnatal iron: placebo/placebo, placebo/iron, iron/placebo, and iron/iron.
The researchers administered the M-CHAT at 18 months to assess behaviors related to communication and social-emotional functioning, including imitation, joint attention, pretend play, and social referencing. The major outcome was the number of M-CHAT items failed. The threshold was two or more failed of the tool’s six most discriminating items or three or more failed of all 23 M-CHAT items. Bivariate correlation was used to consider the relation with maternal iron status.
The mean age of mothers was 25 years, and 78% were primiparous. More than 98% of the infants were born at term; mean birth weight was 3.36 kg. Their weight-for-age Z score was .90 at 9 months, and .53 at 18 months. Anemia, iron deficiency, and iron deficiency anemia declined with prenatal supplementation, but the majority of mothers were still iron deficient at term.
Dr. Li reported that the number of failed M-CHAT items varied depending on iron supplementation group, and was highest for the placebo/placebo group (3.1) and lowest for the iron/iron group (2.8) (P = 0.04 for linear trend). Mother’s iron status at enrollment was not associated with number of failed M-CHAT items, but late pregnancy iron status was. Lower maternal hemoglobin and higher soluble transferrin receptor predicted a higher number of failed M-CHAT items (P= .01 and P= .02, respectively).
Dr. Li emphasized that the study’s randomized, controlled design supports causal inferences. “These are best considered as behaviors [that are impacted], rather than autistic spectrum disorders,” he said. “The results suggest that iron supplementation in pregnancy has more effect than in infancy, but the infancy dose was low (1 mg/kg per day) and the impact on iron status at 9 months was minimal. Still, the combination of iron supplementation in pregnancy and infancy provided the greatest benefit.”
The pregnancy randomized, controlled trial was funded by Vifor Pharma, Ltd. The infancy randomized controlled trial and all iron measures were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development with the Office of Dietary Supplements. Dr. Li reported having no relevant financial conflicts.
On Twitter @dougbrunk
SAN DIEGO – Iron supplementation, especially in pregnancy, improved toddler communication and social behaviors at 18 months in a large Chinese study.
“Iron deficiency in infancy is associated with altered social and emotional development,” Ming Li, Ph.D., said at the annual meeting of the Pediatric Academic Societies. “Some randomized, controlled trials of iron supplementation in infancy show social and emotional benefits.”
In an effort to assess the effects of iron supplementation and maternal iron status on infant communication and social interaction, Dr. Li of Peking University First Hospital in Beijing, China, in collaboration with Dr. Betsy Lozoff and her associates at the University of Michigan, Ann Arbor, used the 23-item Modified Checklist for Autism in Toddlers (M-CHAT) in 993 children in rural China who were part of two linked randomized, controlled trials. Their mothers had been randomized 1:1 to iron (300 mg ferrous sulfate) plus folate (400 micrograms) or placebo plus folate in pregnancy. As infants, they were randomized 1:1 to iron (liquid iron protein succinylate, about 1 mg Fe/kg per day) or placebo from 6 weeks to 9 months. In all, the two trials yielded four groups of prenatal or postnatal iron: placebo/placebo, placebo/iron, iron/placebo, and iron/iron.
The researchers administered the M-CHAT at 18 months to assess behaviors related to communication and social-emotional functioning, including imitation, joint attention, pretend play, and social referencing. The major outcome was the number of M-CHAT items failed. The threshold was two or more failed of the tool’s six most discriminating items or three or more failed of all 23 M-CHAT items. Bivariate correlation was used to consider the relation with maternal iron status.
The mean age of mothers was 25 years, and 78% were primiparous. More than 98% of the infants were born at term; mean birth weight was 3.36 kg. Their weight-for-age Z score was .90 at 9 months, and .53 at 18 months. Anemia, iron deficiency, and iron deficiency anemia declined with prenatal supplementation, but the majority of mothers were still iron deficient at term.
Dr. Li reported that the number of failed M-CHAT items varied depending on iron supplementation group, and was highest for the placebo/placebo group (3.1) and lowest for the iron/iron group (2.8) (P = 0.04 for linear trend). Mother’s iron status at enrollment was not associated with number of failed M-CHAT items, but late pregnancy iron status was. Lower maternal hemoglobin and higher soluble transferrin receptor predicted a higher number of failed M-CHAT items (P= .01 and P= .02, respectively).
Dr. Li emphasized that the study’s randomized, controlled design supports causal inferences. “These are best considered as behaviors [that are impacted], rather than autistic spectrum disorders,” he said. “The results suggest that iron supplementation in pregnancy has more effect than in infancy, but the infancy dose was low (1 mg/kg per day) and the impact on iron status at 9 months was minimal. Still, the combination of iron supplementation in pregnancy and infancy provided the greatest benefit.”
The pregnancy randomized, controlled trial was funded by Vifor Pharma, Ltd. The infancy randomized controlled trial and all iron measures were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development with the Office of Dietary Supplements. Dr. Li reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE PAS ANNUAL MEETING
Key clinical point: Prenatal iron supplementation was more important than postnatal supplementation in improving communication and social interaction behaviors among toddlers.
Major finding: The number of failed M-CHAT items varied depending on iron supplementation group, and was highest for the placebo/placebo group (3.1) and lowest for the iron/iron group (2.8) (P = 0.04 for linear trend).
Data source: A study of 993 children in rural China who were part of two linked randomized, controlled trials.
Disclosures: The pregnancy randomized, controlled trial was funded by Vifor Pharma, Ltd. The infancy randomized controlled trial and all iron measures were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development with the Office of Dietary Supplements. Dr. Li reported having no relevant financial conflicts.
Postpartum codeine use declines
The percentage of postpartum women who filled codeine prescriptions significantly declined after regulatory bodies announced that breastfeeding by mothers taking the opioids may cause infant death, according to a study.
Infants who are breastfed are at elevated risk of death, if their mothers carry polymorphisms for increased activity of an enzyme that metabolizes codeine to morphine, Kate Smolina, Ph.D., and her colleagues reported in a research letter in JAMA.
The study included 320,351 live births to 224,532 women in British Columbia, Canada, between January 1, 2002 and December 31, 2011. The researchers studied dispensation rates of codeine and other opioid drugs to women during the first 6 months after giving birth. New mothers’ use of cephalexin and hydrocortisone cream, which are commonly prescribed to postpartum women, served as the control measure. The announcements on the risks of breastfeeding while taking codeine were made by the U.S. Food and Drug Administration in August 2007 and Health Canada in October 2008. Prior to the FDA announcement, on average, nearly 17% of the postpartum mothers filled at least one codeine prescription. Between September and December 2011, the monthly average was down to 9% – representing a relative reduction of 45% over 4 years. Postpartum use of the opioids tramadol, hydromorphone, oxycodone, and morphine increased, but not at a large enough rate “to offset the reduction in codeine use,” according to the researchers.
The rates of prescription filling did not significantly change for cephalexin and hydrocortisone cream.
Read the study in JAMA 2015 May 12 (doi:10.1001/jama.2015.3642).
The percentage of postpartum women who filled codeine prescriptions significantly declined after regulatory bodies announced that breastfeeding by mothers taking the opioids may cause infant death, according to a study.
Infants who are breastfed are at elevated risk of death, if their mothers carry polymorphisms for increased activity of an enzyme that metabolizes codeine to morphine, Kate Smolina, Ph.D., and her colleagues reported in a research letter in JAMA.
The study included 320,351 live births to 224,532 women in British Columbia, Canada, between January 1, 2002 and December 31, 2011. The researchers studied dispensation rates of codeine and other opioid drugs to women during the first 6 months after giving birth. New mothers’ use of cephalexin and hydrocortisone cream, which are commonly prescribed to postpartum women, served as the control measure. The announcements on the risks of breastfeeding while taking codeine were made by the U.S. Food and Drug Administration in August 2007 and Health Canada in October 2008. Prior to the FDA announcement, on average, nearly 17% of the postpartum mothers filled at least one codeine prescription. Between September and December 2011, the monthly average was down to 9% – representing a relative reduction of 45% over 4 years. Postpartum use of the opioids tramadol, hydromorphone, oxycodone, and morphine increased, but not at a large enough rate “to offset the reduction in codeine use,” according to the researchers.
The rates of prescription filling did not significantly change for cephalexin and hydrocortisone cream.
Read the study in JAMA 2015 May 12 (doi:10.1001/jama.2015.3642).
The percentage of postpartum women who filled codeine prescriptions significantly declined after regulatory bodies announced that breastfeeding by mothers taking the opioids may cause infant death, according to a study.
Infants who are breastfed are at elevated risk of death, if their mothers carry polymorphisms for increased activity of an enzyme that metabolizes codeine to morphine, Kate Smolina, Ph.D., and her colleagues reported in a research letter in JAMA.
The study included 320,351 live births to 224,532 women in British Columbia, Canada, between January 1, 2002 and December 31, 2011. The researchers studied dispensation rates of codeine and other opioid drugs to women during the first 6 months after giving birth. New mothers’ use of cephalexin and hydrocortisone cream, which are commonly prescribed to postpartum women, served as the control measure. The announcements on the risks of breastfeeding while taking codeine were made by the U.S. Food and Drug Administration in August 2007 and Health Canada in October 2008. Prior to the FDA announcement, on average, nearly 17% of the postpartum mothers filled at least one codeine prescription. Between September and December 2011, the monthly average was down to 9% – representing a relative reduction of 45% over 4 years. Postpartum use of the opioids tramadol, hydromorphone, oxycodone, and morphine increased, but not at a large enough rate “to offset the reduction in codeine use,” according to the researchers.
The rates of prescription filling did not significantly change for cephalexin and hydrocortisone cream.
Read the study in JAMA 2015 May 12 (doi:10.1001/jama.2015.3642).
FROM JAMA
PAS: Getting a grip on glucokinase MODY
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
EXPERT ANALYSIS FROM THE PAS ANNUAL MEETING
3 clear dos, and 3 specific don'ts, of vacuum extraction
Dr. Gimovsky is a Maternal-Fetal Medicine Specialist at Newark Beth Israel Medical Center in Newark, New Jersey, and Clinical Professor of Obstetrics, Gynecology, and Reproductive Medicine at Mount Sinai School of Medicine in New York City.
Dr. Gimovsky reports that he has no financial relationships relevant to this audiocast.
Dr. Gimovsky is a Maternal-Fetal Medicine Specialist at Newark Beth Israel Medical Center in Newark, New Jersey, and Clinical Professor of Obstetrics, Gynecology, and Reproductive Medicine at Mount Sinai School of Medicine in New York City.
Dr. Gimovsky reports that he has no financial relationships relevant to this audiocast.
Dr. Gimovsky is a Maternal-Fetal Medicine Specialist at Newark Beth Israel Medical Center in Newark, New Jersey, and Clinical Professor of Obstetrics, Gynecology, and Reproductive Medicine at Mount Sinai School of Medicine in New York City.
Dr. Gimovsky reports that he has no financial relationships relevant to this audiocast.
ACOG presidents highlight their visions for the College at the 2015 clinical meeting
The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.
“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.
“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”
Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.
“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.
Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.
“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”
Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.
“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”
The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.
“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.
“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”
Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.
“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.
Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.
“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”
Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.
“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”
The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.
“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.
“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”
Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.
“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.
Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.
“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”
Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.
“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”