Obstetrics

The author reports no financial relationships relevant to this article.

Venous thromboembolism (VTE)—deep vein thrombosis (DVT) and pulmonary embolism (PE)—remains a major cause of morbidity and mortality in the United States, resulting in an estimated 200,000 deaths each year.¹ VTE is especially common among inpatients; hospitalization increases the risk of VTE eightfold,² and VTE is the most common preventable cause of hospital-associated deaths.^2,3 Most general medical and surgical inpatients have risk factors for VTE and, without prophylaxis, between 10% and 40% will develop DVT or PE.³ VTE is estimated to cost the US economy $4 billion annually in direct costs and substantially more in indirect costs, including lost productivity and subsequent medical expenses.⁴

There is no doubt that thromboprophylaxis is effective in preventing VTE in high-risk patients.^2,3,5-7 For this reason, the Agency for Healthcare Research and Quality ranks VTE prophylaxis as the single most important patient safety initiative deserving of more widespread implementation.⁸ The importance of this intervention has also been acknowledged by the Joint Commission,⁹ and by the Centers for Medicare & Medicaid Services, which include VTE prophylaxis in their Surgical Care Improvement Project (SCIP) quality measures that guide hospital reimbursement.¹⁰

All patients undergoing surgery (including cesarean delivery) should be considered at high risk for VTE. Additional risk factors include, among others:

• personal or family history of VTE
• known inherited or acquired thrombophilia
• obesity
• advancing age
• prolonged immobility or bed rest
• cancer.^2,3,5-7

Although there is general consensus that high-risk patients require thromboprophylaxis, exactly what form of prophylaxis to recommend remains controversial.

Graduated compression stockings may cause harm

Graduated compression stockings (also known as TED stockings) are commonly regarded as a safe and noninvasive method for preventing VTE. However, evidence in support of their efficacy is lacking. A recent consensus statement from the American College of Physicians recommended “against the use of mechanical prophylaxis with graduated compression stockings for prevention of venous thromboembolism (Grade: strong recommendation, moderate-quality evidence)” in medical and stroke patients.⁵ In support of their recommendation, the authors of this consensus statement cite a lack of evidence of benefit and significant evidence of patient harm related to skin breakdown from compression stockings. This recommendation is likely relevant also for obstetric and gynecologic patients. For this reason, I propose that the use of graduated compression stockings for DVT prophylaxis be abandoned.

Chemoprophylaxis should be routine in high-risk inpatients

VTE chemoprophylaxis with low molecular weight heparin (LMWH; eg, dalteparin or enoxaparin) or low-dose unfractionated heparin remains the most effective prophylactic measure and should be routine in all high-risk obstetric and gynecologic inpatients.^2,3,5-7 Pneumatic compression devices and chemoprophylaxis may provide synergistic protection against VTE.⁵

Cesarean delivery affects need for prophylaxis

Although pregnancy is an independent risk factor for VTE, the absolute risk of VTE in an otherwise healthy patient is only about 0.05% in both the antepartum and postpartum periods.¹¹ For this reason, routine VTE prophylaxis in pregnant patients would certainly cause more harm than good, and is not recommended. However, cesarean delivery doubles the risk of VTE, with an absolute risk in low-risk parturients of approximately 1 in 1,000 patients.¹² And 85% of fatal PE cases in pregnancy follow cesarean delivery. For these reasons, placement of pneumatic compression devices and/or administration of LMWH is recommended before cesarean delivery for all women not already receiving chemoprophylaxis.⁷

One clarification. Although the use of graduated compression stockings to prevent VTE should be abandoned entirely, there is some evidence that compression stockings with an ankle pressure of 30 to 40 mm Hg may help reduce the risk of long-term phlebitis syndrome in patients with established DVT in pregnancy.¹³ Therefore, use of compression stockings may be considered in this setting.

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The author reports no financial relationships relevant to this article.

Venous thromboembolism (VTE)—deep vein thrombosis (DVT) and pulmonary embolism (PE)—remains a major cause of morbidity and mortality in the United States, resulting in an estimated 200,000 deaths each year.¹ VTE is especially common among inpatients; hospitalization increases the risk of VTE eightfold,² and VTE is the most common preventable cause of hospital-associated deaths.^2,3 Most general medical and surgical inpatients have risk factors for VTE and, without prophylaxis, between 10% and 40% will develop DVT or PE.³ VTE is estimated to cost the US economy $4 billion annually in direct costs and substantially more in indirect costs, including lost productivity and subsequent medical expenses.⁴

There is no doubt that thromboprophylaxis is effective in preventing VTE in high-risk patients.^2,3,5-7 For this reason, the Agency for Healthcare Research and Quality ranks VTE prophylaxis as the single most important patient safety initiative deserving of more widespread implementation.⁸ The importance of this intervention has also been acknowledged by the Joint Commission,⁹ and by the Centers for Medicare & Medicaid Services, which include VTE prophylaxis in their Surgical Care Improvement Project (SCIP) quality measures that guide hospital reimbursement.¹⁰

All patients undergoing surgery (including cesarean delivery) should be considered at high risk for VTE. Additional risk factors include, among others:

• personal or family history of VTE
• known inherited or acquired thrombophilia
• obesity
• advancing age
• prolonged immobility or bed rest
• cancer.^2,3,5-7

Although there is general consensus that high-risk patients require thromboprophylaxis, exactly what form of prophylaxis to recommend remains controversial.

Graduated compression stockings may cause harm

Graduated compression stockings (also known as TED stockings) are commonly regarded as a safe and noninvasive method for preventing VTE. However, evidence in support of their efficacy is lacking. A recent consensus statement from the American College of Physicians recommended “against the use of mechanical prophylaxis with graduated compression stockings for prevention of venous thromboembolism (Grade: strong recommendation, moderate-quality evidence)” in medical and stroke patients.⁵ In support of their recommendation, the authors of this consensus statement cite a lack of evidence of benefit and significant evidence of patient harm related to skin breakdown from compression stockings. This recommendation is likely relevant also for obstetric and gynecologic patients. For this reason, I propose that the use of graduated compression stockings for DVT prophylaxis be abandoned.

Chemoprophylaxis should be routine in high-risk inpatients

VTE chemoprophylaxis with low molecular weight heparin (LMWH; eg, dalteparin or enoxaparin) or low-dose unfractionated heparin remains the most effective prophylactic measure and should be routine in all high-risk obstetric and gynecologic inpatients.^2,3,5-7 Pneumatic compression devices and chemoprophylaxis may provide synergistic protection against VTE.⁵

Cesarean delivery affects need for prophylaxis

Although pregnancy is an independent risk factor for VTE, the absolute risk of VTE in an otherwise healthy patient is only about 0.05% in both the antepartum and postpartum periods.¹¹ For this reason, routine VTE prophylaxis in pregnant patients would certainly cause more harm than good, and is not recommended. However, cesarean delivery doubles the risk of VTE, with an absolute risk in low-risk parturients of approximately 1 in 1,000 patients.¹² And 85% of fatal PE cases in pregnancy follow cesarean delivery. For these reasons, placement of pneumatic compression devices and/or administration of LMWH is recommended before cesarean delivery for all women not already receiving chemoprophylaxis.⁷

One clarification. Although the use of graduated compression stockings to prevent VTE should be abandoned entirely, there is some evidence that compression stockings with an ankle pressure of 30 to 40 mm Hg may help reduce the risk of long-term phlebitis syndrome in patients with established DVT in pregnancy.¹³ Therefore, use of compression stockings may be considered in this setting.

We want to hear from you! Tell us what you think.

The author reports no financial relationships relevant to this article.

Venous thromboembolism (VTE)—deep vein thrombosis (DVT) and pulmonary embolism (PE)—remains a major cause of morbidity and mortality in the United States, resulting in an estimated 200,000 deaths each year.¹ VTE is especially common among inpatients; hospitalization increases the risk of VTE eightfold,² and VTE is the most common preventable cause of hospital-associated deaths.^2,3 Most general medical and surgical inpatients have risk factors for VTE and, without prophylaxis, between 10% and 40% will develop DVT or PE.³ VTE is estimated to cost the US economy $4 billion annually in direct costs and substantially more in indirect costs, including lost productivity and subsequent medical expenses.⁴

There is no doubt that thromboprophylaxis is effective in preventing VTE in high-risk patients.^2,3,5-7 For this reason, the Agency for Healthcare Research and Quality ranks VTE prophylaxis as the single most important patient safety initiative deserving of more widespread implementation.⁸ The importance of this intervention has also been acknowledged by the Joint Commission,⁹ and by the Centers for Medicare & Medicaid Services, which include VTE prophylaxis in their Surgical Care Improvement Project (SCIP) quality measures that guide hospital reimbursement.¹⁰

All patients undergoing surgery (including cesarean delivery) should be considered at high risk for VTE. Additional risk factors include, among others:

• personal or family history of VTE
• known inherited or acquired thrombophilia
• obesity
• advancing age
• prolonged immobility or bed rest
• cancer.^2,3,5-7

Although there is general consensus that high-risk patients require thromboprophylaxis, exactly what form of prophylaxis to recommend remains controversial.

Graduated compression stockings may cause harm

Graduated compression stockings (also known as TED stockings) are commonly regarded as a safe and noninvasive method for preventing VTE. However, evidence in support of their efficacy is lacking. A recent consensus statement from the American College of Physicians recommended “against the use of mechanical prophylaxis with graduated compression stockings for prevention of venous thromboembolism (Grade: strong recommendation, moderate-quality evidence)” in medical and stroke patients.⁵ In support of their recommendation, the authors of this consensus statement cite a lack of evidence of benefit and significant evidence of patient harm related to skin breakdown from compression stockings. This recommendation is likely relevant also for obstetric and gynecologic patients. For this reason, I propose that the use of graduated compression stockings for DVT prophylaxis be abandoned.

Chemoprophylaxis should be routine in high-risk inpatients

VTE chemoprophylaxis with low molecular weight heparin (LMWH; eg, dalteparin or enoxaparin) or low-dose unfractionated heparin remains the most effective prophylactic measure and should be routine in all high-risk obstetric and gynecologic inpatients.^2,3,5-7 Pneumatic compression devices and chemoprophylaxis may provide synergistic protection against VTE.⁵

Cesarean delivery affects need for prophylaxis

Although pregnancy is an independent risk factor for VTE, the absolute risk of VTE in an otherwise healthy patient is only about 0.05% in both the antepartum and postpartum periods.¹¹ For this reason, routine VTE prophylaxis in pregnant patients would certainly cause more harm than good, and is not recommended. However, cesarean delivery doubles the risk of VTE, with an absolute risk in low-risk parturients of approximately 1 in 1,000 patients.¹² And 85% of fatal PE cases in pregnancy follow cesarean delivery. For these reasons, placement of pneumatic compression devices and/or administration of LMWH is recommended before cesarean delivery for all women not already receiving chemoprophylaxis.⁷

One clarification. Although the use of graduated compression stockings to prevent VTE should be abandoned entirely, there is some evidence that compression stockings with an ankle pressure of 30 to 40 mm Hg may help reduce the risk of long-term phlebitis syndrome in patients with established DVT in pregnancy.¹³ Therefore, use of compression stockings may be considered in this setting.

We want to hear from you! Tell us what you think.

The two most commonly utilized methods of skin closure after cesarean delivery are nonabsorbable metal staples and absorbable suture.¹ A number of investigators have explored these methods of closure in regard to wound complications, pain perception, patient satisfaction, and physician assessment of cosmesis.²

A recent Cochrane meta-analysis of these studies revealed that there were no significant differences between these two methods with respect to wound infection, patient satisfaction, pain perception, or physician assessment of cosmesis.² However, there was a significant difference between methods in terms of skin separation: Incisions closed with staples were almost four times as likely to be complicated by skin separation.²

Details of the trial

Participants had a viable pregnancy at 24 weeks’ gestation or beyond and were undergoing scheduled or unscheduled cesarean delivery. Of these, 198 women were randomly assigned to staples, and 200 were allocated to suture (Monocryl) for skin closure. Staples were removed 3 to 4 days after delivery for low transverse incisions and 7 to 10 days after delivery for vertical incisions.

Standardized physical examination of the wound was performed at hospital discharge (days 3–4) and 4 to 6 weeks postoperatively. The primary outcome was a composite of wound disruption or infection that occurred 4 to 6 weeks postoperatively; secondary outcomes included operative time, pain, cosmesis, and patient satisfaction with the scar.

Strengths of the trial include sample size

Of the studies that have been published to date, this trial by Figueroa and colleagues is the second largest to compare staples with suture for closure of cesarean skin incisions.

Another strength of this study is its intention-to-treat analysis and the low rate of patients who were lost to follow-up.

This study is similar to the largest study, by Basha and colleagues, that examined skin closure after cesarean, in that women undergoing cesarean delivery via vertical or low transverse incisions were allocated to closure of the skin with staples or absorbable (Monocryl) suture.³ In both studies, staples were removed 3 or 4 days after delivery, although Figueroa and colleagues specified that staples be removed on days 7 to 10 for women who had vertical incisions.³

A few weaknesses may limit generalizability of the findings

Figueroa and colleagues noted that women in their study received prophylactic antibiotics at the time of cord clamping, rather than preoperatively, although the latter approach now is considered more appropriate in terms of reducing wound morbidity.⁴

Another limitation: Enrollment was terminated early, after enrolling only approximately one-third of the intended sample size. Figueroa and colleagues explain that this decision was based on the findings of Basha and colleagues, which were published during active enrollment of the Figueroa study.³ Not only did Basha and colleagues report a higher incidence of wound complications than Figueroa and colleagues had used to calculate the required sample size, but the Basha study also concluded that sutures may be more optimal for skin closure with respect to skin separation.³

In the study by Figueroa and colleagues, the primary outcome was defined as a composite of wound disruption or infection. However, there was no specification as to length of skin dehiscence that would qualify as disruption—although the investigators did note that the difference in wound disruption remained statistically significant when analyses were limited to wounds involving disruption of more than 1 cm.

As have earlier studies, Figueroa and colleagues found that operative time was longer when sutures were used, compared with staples.

Most earlier studies that assessed cosmesis utilized the Physician Observer Scar Assessment Scale, but this study did not, so it is unclear whether the findings can be compared with prior investigations on this point.

We want to hear from you! Tell us what you think.

The two most commonly utilized methods of skin closure after cesarean delivery are nonabsorbable metal staples and absorbable suture.¹ A number of investigators have explored these methods of closure in regard to wound complications, pain perception, patient satisfaction, and physician assessment of cosmesis.²

A recent Cochrane meta-analysis of these studies revealed that there were no significant differences between these two methods with respect to wound infection, patient satisfaction, pain perception, or physician assessment of cosmesis.² However, there was a significant difference between methods in terms of skin separation: Incisions closed with staples were almost four times as likely to be complicated by skin separation.²

Details of the trial

Participants had a viable pregnancy at 24 weeks’ gestation or beyond and were undergoing scheduled or unscheduled cesarean delivery. Of these, 198 women were randomly assigned to staples, and 200 were allocated to suture (Monocryl) for skin closure. Staples were removed 3 to 4 days after delivery for low transverse incisions and 7 to 10 days after delivery for vertical incisions.

Standardized physical examination of the wound was performed at hospital discharge (days 3–4) and 4 to 6 weeks postoperatively. The primary outcome was a composite of wound disruption or infection that occurred 4 to 6 weeks postoperatively; secondary outcomes included operative time, pain, cosmesis, and patient satisfaction with the scar.

Strengths of the trial include sample size

Of the studies that have been published to date, this trial by Figueroa and colleagues is the second largest to compare staples with suture for closure of cesarean skin incisions.

Another strength of this study is its intention-to-treat analysis and the low rate of patients who were lost to follow-up.

This study is similar to the largest study, by Basha and colleagues, that examined skin closure after cesarean, in that women undergoing cesarean delivery via vertical or low transverse incisions were allocated to closure of the skin with staples or absorbable (Monocryl) suture.³ In both studies, staples were removed 3 or 4 days after delivery, although Figueroa and colleagues specified that staples be removed on days 7 to 10 for women who had vertical incisions.³

A few weaknesses may limit generalizability of the findings

Figueroa and colleagues noted that women in their study received prophylactic antibiotics at the time of cord clamping, rather than preoperatively, although the latter approach now is considered more appropriate in terms of reducing wound morbidity.⁴

Another limitation: Enrollment was terminated early, after enrolling only approximately one-third of the intended sample size. Figueroa and colleagues explain that this decision was based on the findings of Basha and colleagues, which were published during active enrollment of the Figueroa study.³ Not only did Basha and colleagues report a higher incidence of wound complications than Figueroa and colleagues had used to calculate the required sample size, but the Basha study also concluded that sutures may be more optimal for skin closure with respect to skin separation.³

In the study by Figueroa and colleagues, the primary outcome was defined as a composite of wound disruption or infection. However, there was no specification as to length of skin dehiscence that would qualify as disruption—although the investigators did note that the difference in wound disruption remained statistically significant when analyses were limited to wounds involving disruption of more than 1 cm.

As have earlier studies, Figueroa and colleagues found that operative time was longer when sutures were used, compared with staples.

Most earlier studies that assessed cosmesis utilized the Physician Observer Scar Assessment Scale, but this study did not, so it is unclear whether the findings can be compared with prior investigations on this point.

We want to hear from you! Tell us what you think.

The two most commonly utilized methods of skin closure after cesarean delivery are nonabsorbable metal staples and absorbable suture.¹ A number of investigators have explored these methods of closure in regard to wound complications, pain perception, patient satisfaction, and physician assessment of cosmesis.²

A recent Cochrane meta-analysis of these studies revealed that there were no significant differences between these two methods with respect to wound infection, patient satisfaction, pain perception, or physician assessment of cosmesis.² However, there was a significant difference between methods in terms of skin separation: Incisions closed with staples were almost four times as likely to be complicated by skin separation.²

Details of the trial

Participants had a viable pregnancy at 24 weeks’ gestation or beyond and were undergoing scheduled or unscheduled cesarean delivery. Of these, 198 women were randomly assigned to staples, and 200 were allocated to suture (Monocryl) for skin closure. Staples were removed 3 to 4 days after delivery for low transverse incisions and 7 to 10 days after delivery for vertical incisions.

Standardized physical examination of the wound was performed at hospital discharge (days 3–4) and 4 to 6 weeks postoperatively. The primary outcome was a composite of wound disruption or infection that occurred 4 to 6 weeks postoperatively; secondary outcomes included operative time, pain, cosmesis, and patient satisfaction with the scar.

Strengths of the trial include sample size

Of the studies that have been published to date, this trial by Figueroa and colleagues is the second largest to compare staples with suture for closure of cesarean skin incisions.

Another strength of this study is its intention-to-treat analysis and the low rate of patients who were lost to follow-up.

This study is similar to the largest study, by Basha and colleagues, that examined skin closure after cesarean, in that women undergoing cesarean delivery via vertical or low transverse incisions were allocated to closure of the skin with staples or absorbable (Monocryl) suture.³ In both studies, staples were removed 3 or 4 days after delivery, although Figueroa and colleagues specified that staples be removed on days 7 to 10 for women who had vertical incisions.³

A few weaknesses may limit generalizability of the findings

Figueroa and colleagues noted that women in their study received prophylactic antibiotics at the time of cord clamping, rather than preoperatively, although the latter approach now is considered more appropriate in terms of reducing wound morbidity.⁴

Another limitation: Enrollment was terminated early, after enrolling only approximately one-third of the intended sample size. Figueroa and colleagues explain that this decision was based on the findings of Basha and colleagues, which were published during active enrollment of the Figueroa study.³ Not only did Basha and colleagues report a higher incidence of wound complications than Figueroa and colleagues had used to calculate the required sample size, but the Basha study also concluded that sutures may be more optimal for skin closure with respect to skin separation.³

In the study by Figueroa and colleagues, the primary outcome was defined as a composite of wound disruption or infection. However, there was no specification as to length of skin dehiscence that would qualify as disruption—although the investigators did note that the difference in wound disruption remained statistically significant when analyses were limited to wounds involving disruption of more than 1 cm.

As have earlier studies, Figueroa and colleagues found that operative time was longer when sutures were used, compared with staples.

Most earlier studies that assessed cosmesis utilized the Physician Observer Scar Assessment Scale, but this study did not, so it is unclear whether the findings can be compared with prior investigations on this point.

We want to hear from you! Tell us what you think.

Recommended use of several vaccines, including pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPSV23), and Tdap vaccine, are updated in the 2013 adult immunization schedule, issued by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. The schedule was published online Jan. 28 in Morbidity and Mortality Weekly Report.

PCV13 is now recommended for adults 19 years and older who have immunocompromising conditions such as chronic renal failure, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.

Two doses of PPSV23 given before age 65 now are recommended for patients with certain conditions. For those who have received two doses before age 65, the vaccine is still recommended, as long as it has been 5 years since the most recent dose (MMWR 2013;62:1-19).

Individuals not vaccinated with PCV13 or PPSV23 should receive a single dose of PCV13, followed by a dose of PPSV23 at least 8 weeks apart. If already vaccinated with PPSV23, they should receive PCV13 vaccination 1 year or more later.

The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is now recommended as routine for adults 65 years and older (one dose), and for pregnant women during 27 to 36 weeks’ gestation, regardless of the interval since prior Td/Tdap vaccination.

The zoster vaccine is now recommended for adults starting at age 60 years, with or without underlying health conditions, as long the vaccines is not contraindicated for them.

The complete schedule and footnotes can be found here.

Recommended use of several vaccines, including pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPSV23), and Tdap vaccine, are updated in the 2013 adult immunization schedule, issued by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. The schedule was published online Jan. 28 in Morbidity and Mortality Weekly Report.

PCV13 is now recommended for adults 19 years and older who have immunocompromising conditions such as chronic renal failure, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.

Two doses of PPSV23 given before age 65 now are recommended for patients with certain conditions. For those who have received two doses before age 65, the vaccine is still recommended, as long as it has been 5 years since the most recent dose (MMWR 2013;62:1-19).

Individuals not vaccinated with PCV13 or PPSV23 should receive a single dose of PCV13, followed by a dose of PPSV23 at least 8 weeks apart. If already vaccinated with PPSV23, they should receive PCV13 vaccination 1 year or more later.

The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is now recommended as routine for adults 65 years and older (one dose), and for pregnant women during 27 to 36 weeks’ gestation, regardless of the interval since prior Td/Tdap vaccination.

The zoster vaccine is now recommended for adults starting at age 60 years, with or without underlying health conditions, as long the vaccines is not contraindicated for them.

The complete schedule and footnotes can be found here.

Recommended use of several vaccines, including pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPSV23), and Tdap vaccine, are updated in the 2013 adult immunization schedule, issued by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. The schedule was published online Jan. 28 in Morbidity and Mortality Weekly Report.

PCV13 is now recommended for adults 19 years and older who have immunocompromising conditions such as chronic renal failure, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.

Two doses of PPSV23 given before age 65 now are recommended for patients with certain conditions. For those who have received two doses before age 65, the vaccine is still recommended, as long as it has been 5 years since the most recent dose (MMWR 2013;62:1-19).

Individuals not vaccinated with PCV13 or PPSV23 should receive a single dose of PCV13, followed by a dose of PPSV23 at least 8 weeks apart. If already vaccinated with PPSV23, they should receive PCV13 vaccination 1 year or more later.

The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is now recommended as routine for adults 65 years and older (one dose), and for pregnant women during 27 to 36 weeks’ gestation, regardless of the interval since prior Td/Tdap vaccination.

The zoster vaccine is now recommended for adults starting at age 60 years, with or without underlying health conditions, as long the vaccines is not contraindicated for them.

The complete schedule and footnotes can be found here.

The new Centers for Disease Control and Prevention immunization schedule, released in late January, recommends that a dose of the Tdap vaccine be administered to all women during each pregnancy, whether or not she has received the vaccine previously (Pediatrics 2013;131:397-404 [doi: 10.1542/peds.2012-3706]). This is a change from the 2011 recommendation that only women who have not had the Tdap vaccine should be vaccinated during pregnancy, preferably during the third or late second trimester. Like the 2011 recommendation, the 2013 recommendation states that a dose of Tdap should be administered immediately after delivery if a woman has not received the vaccine during pregnancy.

This recommendation for a Tdap dose during every pregnancy may initially strike both clinicians and patients as somewhat extreme, but the basis of the new recommendation is quite clear: A huge pertussis epidemic is currently affecting parts of the United States, with more than 41,000 cases reported last year and infants disproportionately affected. Most pertussis deaths and hospitalizations between 2000 and 2012 occurred among children under age 3 months, according to the Centers for Disease Control and Prevention (CDC).

Logically, the CDC’s Advisory Committee for Immunization Practices (ACIP) Pertussis Working Group concluded that one dose during one pregnancy was not sufficient to provide protection during subsequent pregnancies, and revised the recommendation based on considerations that included the continued high number of pertussis cases, evidence that less than 3% of women are getting the vaccine during pregnancy as recommended, and hesitancy of health care providers to vaccinate when a patient’s Tdap vaccine history is not known.

To highlight the importance of this new guideline, the working group described a 40-day-old baby who died from pertussis, whose mother had received a postpartum Tdap dose 2 years earlier but developed a cough illness a week before delivery. A dose of Tdap in the late second or third trimester provides immunity to the mother, with effective antibody response and placental transfer of pertussis antibodies, and is likely to provide passive immunity for infants until the first Tdap dose given to them becomes protective. This is a powerful example of the "cocooning" strategy, whereby the mother is vaccinated to allow protection of the newborn.

Other examples of cocooning include tetanus toxoid vaccination during pregnancy (two doses during the first pregnancy and one dose during other pregnancies), recommended in countries where tetanus is endemic to protect newborns from tetanus; and trivalent influenza vaccine administered during pregnancy.

While both clinicians and parents may be concerned about potential, unknown risks, particularly with repeated vaccination in subsequent pregnancies, the risk of pertussis in the newborn and young infants is by far greater. As painfully demonstrated in the present epidemic, the increased risk of respiratory failure and death associated with pertussis in infants is not theoretical.

To date, there are no data to suggest increased fetal, maternal, or pregnancy risks with exposure to the vaccine. Moreover, the recommendation is that the vaccine be administered in the second or third trimester, after the completion of embryogenesis. In March 2012, the ACOG Committee on Obstetric Practice’s Opinion on Tdap Vaccination stated that "there is no evidence of adverse fetal effects from the vaccination of pregnant women with an inactivated virus, bacterial vaccine, or toxoid, and these should be administered as indicated" (Committee Opinion No. 521. March 2012).

As for the safety of repeated vaccination, there is no biological basis for concern, although no data have yet been collected. The working group described the safety data on two Tdap doses as "reassuring," noting that the tetanus toxoid vaccine has not been associated with an excess risk of adverse events. Recently published studies in nonpregnant adults and adolescents found that a repeat Tdap dose 5 or 10 years after the first dose was well tolerated and immunogenic. In addition, the risk of severe hypersensitivity reactions associated with multiple Tdap doses in pregnancy is "unlikely," based on a recent study of tetanus and diphtheria toxoids (Vaccine 2012;30:974-82; Vaccine 2011;29:8459-65).

In reality, most women are not likely to receive more than two doses, and only about 5% of women would receive four or more doses, based on U.S. data indicating that most women who have children have fewer than three.

The safety of Tdap given during pregnancy should continue to be closely monitored with good pharmacovigilance through the Food and Drug Administration’s Vaccine Safety Datalink and studies evaluating adverse pregnancy and birth outcomes. In Motherisk, we plan to follow up women who receive the Tdap in pregnancy.

In summary, all health care professionals caring for pregnant women should adopt these new guidelines to ensure that the epidemic outbreak of this old disease that kills newborn babies is prevented.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. Dr. Koren said he had no relevant financial disclosures. E-mail him at [email protected].

The new Centers for Disease Control and Prevention immunization schedule, released in late January, recommends that a dose of the Tdap vaccine be administered to all women during each pregnancy, whether or not she has received the vaccine previously (Pediatrics 2013;131:397-404 [doi: 10.1542/peds.2012-3706]). This is a change from the 2011 recommendation that only women who have not had the Tdap vaccine should be vaccinated during pregnancy, preferably during the third or late second trimester. Like the 2011 recommendation, the 2013 recommendation states that a dose of Tdap should be administered immediately after delivery if a woman has not received the vaccine during pregnancy.

This recommendation for a Tdap dose during every pregnancy may initially strike both clinicians and patients as somewhat extreme, but the basis of the new recommendation is quite clear: A huge pertussis epidemic is currently affecting parts of the United States, with more than 41,000 cases reported last year and infants disproportionately affected. Most pertussis deaths and hospitalizations between 2000 and 2012 occurred among children under age 3 months, according to the Centers for Disease Control and Prevention (CDC).

Logically, the CDC’s Advisory Committee for Immunization Practices (ACIP) Pertussis Working Group concluded that one dose during one pregnancy was not sufficient to provide protection during subsequent pregnancies, and revised the recommendation based on considerations that included the continued high number of pertussis cases, evidence that less than 3% of women are getting the vaccine during pregnancy as recommended, and hesitancy of health care providers to vaccinate when a patient’s Tdap vaccine history is not known.

To highlight the importance of this new guideline, the working group described a 40-day-old baby who died from pertussis, whose mother had received a postpartum Tdap dose 2 years earlier but developed a cough illness a week before delivery. A dose of Tdap in the late second or third trimester provides immunity to the mother, with effective antibody response and placental transfer of pertussis antibodies, and is likely to provide passive immunity for infants until the first Tdap dose given to them becomes protective. This is a powerful example of the "cocooning" strategy, whereby the mother is vaccinated to allow protection of the newborn.

Other examples of cocooning include tetanus toxoid vaccination during pregnancy (two doses during the first pregnancy and one dose during other pregnancies), recommended in countries where tetanus is endemic to protect newborns from tetanus; and trivalent influenza vaccine administered during pregnancy.

While both clinicians and parents may be concerned about potential, unknown risks, particularly with repeated vaccination in subsequent pregnancies, the risk of pertussis in the newborn and young infants is by far greater. As painfully demonstrated in the present epidemic, the increased risk of respiratory failure and death associated with pertussis in infants is not theoretical.

To date, there are no data to suggest increased fetal, maternal, or pregnancy risks with exposure to the vaccine. Moreover, the recommendation is that the vaccine be administered in the second or third trimester, after the completion of embryogenesis. In March 2012, the ACOG Committee on Obstetric Practice’s Opinion on Tdap Vaccination stated that "there is no evidence of adverse fetal effects from the vaccination of pregnant women with an inactivated virus, bacterial vaccine, or toxoid, and these should be administered as indicated" (Committee Opinion No. 521. March 2012).

As for the safety of repeated vaccination, there is no biological basis for concern, although no data have yet been collected. The working group described the safety data on two Tdap doses as "reassuring," noting that the tetanus toxoid vaccine has not been associated with an excess risk of adverse events. Recently published studies in nonpregnant adults and adolescents found that a repeat Tdap dose 5 or 10 years after the first dose was well tolerated and immunogenic. In addition, the risk of severe hypersensitivity reactions associated with multiple Tdap doses in pregnancy is "unlikely," based on a recent study of tetanus and diphtheria toxoids (Vaccine 2012;30:974-82; Vaccine 2011;29:8459-65).

In reality, most women are not likely to receive more than two doses, and only about 5% of women would receive four or more doses, based on U.S. data indicating that most women who have children have fewer than three.

The safety of Tdap given during pregnancy should continue to be closely monitored with good pharmacovigilance through the Food and Drug Administration’s Vaccine Safety Datalink and studies evaluating adverse pregnancy and birth outcomes. In Motherisk, we plan to follow up women who receive the Tdap in pregnancy.

In summary, all health care professionals caring for pregnant women should adopt these new guidelines to ensure that the epidemic outbreak of this old disease that kills newborn babies is prevented.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. Dr. Koren said he had no relevant financial disclosures. E-mail him at [email protected].

The new Centers for Disease Control and Prevention immunization schedule, released in late January, recommends that a dose of the Tdap vaccine be administered to all women during each pregnancy, whether or not she has received the vaccine previously (Pediatrics 2013;131:397-404 [doi: 10.1542/peds.2012-3706]). This is a change from the 2011 recommendation that only women who have not had the Tdap vaccine should be vaccinated during pregnancy, preferably during the third or late second trimester. Like the 2011 recommendation, the 2013 recommendation states that a dose of Tdap should be administered immediately after delivery if a woman has not received the vaccine during pregnancy.

This recommendation for a Tdap dose during every pregnancy may initially strike both clinicians and patients as somewhat extreme, but the basis of the new recommendation is quite clear: A huge pertussis epidemic is currently affecting parts of the United States, with more than 41,000 cases reported last year and infants disproportionately affected. Most pertussis deaths and hospitalizations between 2000 and 2012 occurred among children under age 3 months, according to the Centers for Disease Control and Prevention (CDC).

Logically, the CDC’s Advisory Committee for Immunization Practices (ACIP) Pertussis Working Group concluded that one dose during one pregnancy was not sufficient to provide protection during subsequent pregnancies, and revised the recommendation based on considerations that included the continued high number of pertussis cases, evidence that less than 3% of women are getting the vaccine during pregnancy as recommended, and hesitancy of health care providers to vaccinate when a patient’s Tdap vaccine history is not known.

To highlight the importance of this new guideline, the working group described a 40-day-old baby who died from pertussis, whose mother had received a postpartum Tdap dose 2 years earlier but developed a cough illness a week before delivery. A dose of Tdap in the late second or third trimester provides immunity to the mother, with effective antibody response and placental transfer of pertussis antibodies, and is likely to provide passive immunity for infants until the first Tdap dose given to them becomes protective. This is a powerful example of the "cocooning" strategy, whereby the mother is vaccinated to allow protection of the newborn.

Other examples of cocooning include tetanus toxoid vaccination during pregnancy (two doses during the first pregnancy and one dose during other pregnancies), recommended in countries where tetanus is endemic to protect newborns from tetanus; and trivalent influenza vaccine administered during pregnancy.

While both clinicians and parents may be concerned about potential, unknown risks, particularly with repeated vaccination in subsequent pregnancies, the risk of pertussis in the newborn and young infants is by far greater. As painfully demonstrated in the present epidemic, the increased risk of respiratory failure and death associated with pertussis in infants is not theoretical.

To date, there are no data to suggest increased fetal, maternal, or pregnancy risks with exposure to the vaccine. Moreover, the recommendation is that the vaccine be administered in the second or third trimester, after the completion of embryogenesis. In March 2012, the ACOG Committee on Obstetric Practice’s Opinion on Tdap Vaccination stated that "there is no evidence of adverse fetal effects from the vaccination of pregnant women with an inactivated virus, bacterial vaccine, or toxoid, and these should be administered as indicated" (Committee Opinion No. 521. March 2012).

As for the safety of repeated vaccination, there is no biological basis for concern, although no data have yet been collected. The working group described the safety data on two Tdap doses as "reassuring," noting that the tetanus toxoid vaccine has not been associated with an excess risk of adverse events. Recently published studies in nonpregnant adults and adolescents found that a repeat Tdap dose 5 or 10 years after the first dose was well tolerated and immunogenic. In addition, the risk of severe hypersensitivity reactions associated with multiple Tdap doses in pregnancy is "unlikely," based on a recent study of tetanus and diphtheria toxoids (Vaccine 2012;30:974-82; Vaccine 2011;29:8459-65).

In reality, most women are not likely to receive more than two doses, and only about 5% of women would receive four or more doses, based on U.S. data indicating that most women who have children have fewer than three.

The safety of Tdap given during pregnancy should continue to be closely monitored with good pharmacovigilance through the Food and Drug Administration’s Vaccine Safety Datalink and studies evaluating adverse pregnancy and birth outcomes. In Motherisk, we plan to follow up women who receive the Tdap in pregnancy.

In summary, all health care professionals caring for pregnant women should adopt these new guidelines to ensure that the epidemic outbreak of this old disease that kills newborn babies is prevented.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He also holds the Ivey Chair in Molecular Toxicology at the department of medicine, University of Western Ontario, London. Dr. Koren said he had no relevant financial disclosures. E-mail him at [email protected].

Obstetricians and gynecologists should routinely screen teenagers and women during annual, new-patient, and obstetric visits for sexual and reproductive coercion, according to a new committee opinion from the American College of Obstetricians and Gynecologists.

Sexual and reproductive coercion – a pattern of physical violence or psychologically coercive behaviors intended to control a woman’s sexual decision-making, contraceptive use, or pregnancy – is an "under-recognized" problem, according to Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, and one of the opinion’s authors (Obstet. Gynecol. 2013;121:411-5).

The coercion can play out as contraceptive sabotage, pressure to become pregnant unwillingly, or forcing a woman to continue or end a pregnancy against her will. "Some male partners go so far as to forcefully remove intrauterine devices and vaginal rings, poke holes in condoms, or destroy birth control pills. Repeated pressure to have sex, forcing sex without a condom, and intentionally exposing a partner to an STI are examples of sexual coercion," according to an ACOG written statement. Unintended pregnancies, sexually transmitted infections (STI), and HIV can be red flags.

Ob.gyns. "are in a unique position to address" the problem, the ACOG opinion states.

If women answer yes to screening questions such as, "Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?" ob.gyns. should do the following:

• Offer hotline numbers and referrals to local domestic violence shelters and agencies, letting women use the office phone to make the calls.

• Offer long-acting methods of contraception less detectable to partners, such as IUDs, contraceptive implants, or injections.

• Trim IUD strings inside the cervical canal so they are undetectable and are harder for partners to remove, and send emergency contraceptive pills home in plain envelopes.

• Counsel these patients on harm-reduction strategies and safety planning.

The opinion by the ACOG Committee on Health Care for Underserved Women also suggests that ob.gyns. get more education about reproductive and sexual coercion and "include reproductive and sexual coercion and [intimate partner violence] as part of the differential diagnosis when patients are seen for STI testing, emergency contraception, or unintended pregnancies."

Other screening questions can be included: "Has your partner ever tried to get you pregnant when you did not want to be pregnant?" "Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?" and "Does your partner support your decision about when or if you want to become pregnant?" the opinion noted. Additional questions can be found in "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion."

"If a patient responds affirmatively ... the health care provider should validate her experience and commend her for discussing and evaluating her health and relationships. She should be reassured that the situation is not her fault, and further assessment of her safety should be elicited and discreet contraceptive options reviewed," according to the opinion.

"Anybody can be in this situation, but it disproportionally affects disempowered, underserved women," Dr. Espey said in an interview.

Sexual and reproductive coercion tends to travel with physical or sexual violence. In one study, 66% of battered adolescent mothers on public assistance reported birth control sabotage by their dating partner (School Nurse News 2006;23:38-40).

The opinion "is an expansion of ACOG’s long-standing work on intimate partner violence in general," said Dr. Espey, noting that the organization offers educational sessions on sexual and reproductive coercion at its annual meetings.

There is no specific ICD-9/ICD-10 code for screening for sexual and reproductive coercion. Because the physician initially will be performing a screening service, the contraceptive counseling codes would not be the most appropriate codes to report, according to ACOG’s coding department. Code V82.89 (Special screening for other conditions; Other specified conditions) would be a better bet for routine screening.

If coercion seems likely, counseling may be reported with code V65.49 (Other specified counseling) or code V62.89 (Other psychological or physical stress, not elsewhere classified; Other). Payer reimbursement policies will vary, according to ACOG.

Women wouldn’t have a copay for screening and counseling because sexual and reproductive coercion is a subset of intimate partner violence, which is a no-copay preventive care service under the Affordable Care Act.

The National Domestic Violence Hotline is 1-800-799-SAFE (7233); the Rape Abuse & Incest National Network Hotline is at 1-800-656-HOPE (4673). Several websites offer help and guidance as well, including Futures Without Violence, the National Coalition Against Domestic Violence, and the U.S. Department of Justice Office on Violence Against Women.

Dr. Espey said that she has no relevant disclosures.

Obstetricians and gynecologists should routinely screen teenagers and women during annual, new-patient, and obstetric visits for sexual and reproductive coercion, according to a new committee opinion from the American College of Obstetricians and Gynecologists.

Sexual and reproductive coercion – a pattern of physical violence or psychologically coercive behaviors intended to control a woman’s sexual decision-making, contraceptive use, or pregnancy – is an "under-recognized" problem, according to Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, and one of the opinion’s authors (Obstet. Gynecol. 2013;121:411-5).

The coercion can play out as contraceptive sabotage, pressure to become pregnant unwillingly, or forcing a woman to continue or end a pregnancy against her will. "Some male partners go so far as to forcefully remove intrauterine devices and vaginal rings, poke holes in condoms, or destroy birth control pills. Repeated pressure to have sex, forcing sex without a condom, and intentionally exposing a partner to an STI are examples of sexual coercion," according to an ACOG written statement. Unintended pregnancies, sexually transmitted infections (STI), and HIV can be red flags.

Ob.gyns. "are in a unique position to address" the problem, the ACOG opinion states.

If women answer yes to screening questions such as, "Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?" ob.gyns. should do the following:

• Offer hotline numbers and referrals to local domestic violence shelters and agencies, letting women use the office phone to make the calls.

• Offer long-acting methods of contraception less detectable to partners, such as IUDs, contraceptive implants, or injections.

• Trim IUD strings inside the cervical canal so they are undetectable and are harder for partners to remove, and send emergency contraceptive pills home in plain envelopes.

• Counsel these patients on harm-reduction strategies and safety planning.

The opinion by the ACOG Committee on Health Care for Underserved Women also suggests that ob.gyns. get more education about reproductive and sexual coercion and "include reproductive and sexual coercion and [intimate partner violence] as part of the differential diagnosis when patients are seen for STI testing, emergency contraception, or unintended pregnancies."

Other screening questions can be included: "Has your partner ever tried to get you pregnant when you did not want to be pregnant?" "Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?" and "Does your partner support your decision about when or if you want to become pregnant?" the opinion noted. Additional questions can be found in "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion."

"If a patient responds affirmatively ... the health care provider should validate her experience and commend her for discussing and evaluating her health and relationships. She should be reassured that the situation is not her fault, and further assessment of her safety should be elicited and discreet contraceptive options reviewed," according to the opinion.

"Anybody can be in this situation, but it disproportionally affects disempowered, underserved women," Dr. Espey said in an interview.

Sexual and reproductive coercion tends to travel with physical or sexual violence. In one study, 66% of battered adolescent mothers on public assistance reported birth control sabotage by their dating partner (School Nurse News 2006;23:38-40).

The opinion "is an expansion of ACOG’s long-standing work on intimate partner violence in general," said Dr. Espey, noting that the organization offers educational sessions on sexual and reproductive coercion at its annual meetings.

There is no specific ICD-9/ICD-10 code for screening for sexual and reproductive coercion. Because the physician initially will be performing a screening service, the contraceptive counseling codes would not be the most appropriate codes to report, according to ACOG’s coding department. Code V82.89 (Special screening for other conditions; Other specified conditions) would be a better bet for routine screening.

If coercion seems likely, counseling may be reported with code V65.49 (Other specified counseling) or code V62.89 (Other psychological or physical stress, not elsewhere classified; Other). Payer reimbursement policies will vary, according to ACOG.

Women wouldn’t have a copay for screening and counseling because sexual and reproductive coercion is a subset of intimate partner violence, which is a no-copay preventive care service under the Affordable Care Act.

The National Domestic Violence Hotline is 1-800-799-SAFE (7233); the Rape Abuse & Incest National Network Hotline is at 1-800-656-HOPE (4673). Several websites offer help and guidance as well, including Futures Without Violence, the National Coalition Against Domestic Violence, and the U.S. Department of Justice Office on Violence Against Women.

Dr. Espey said that she has no relevant disclosures.

Obstetricians and gynecologists should routinely screen teenagers and women during annual, new-patient, and obstetric visits for sexual and reproductive coercion, according to a new committee opinion from the American College of Obstetricians and Gynecologists.

Sexual and reproductive coercion – a pattern of physical violence or psychologically coercive behaviors intended to control a woman’s sexual decision-making, contraceptive use, or pregnancy – is an "under-recognized" problem, according to Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, and one of the opinion’s authors (Obstet. Gynecol. 2013;121:411-5).

The coercion can play out as contraceptive sabotage, pressure to become pregnant unwillingly, or forcing a woman to continue or end a pregnancy against her will. "Some male partners go so far as to forcefully remove intrauterine devices and vaginal rings, poke holes in condoms, or destroy birth control pills. Repeated pressure to have sex, forcing sex without a condom, and intentionally exposing a partner to an STI are examples of sexual coercion," according to an ACOG written statement. Unintended pregnancies, sexually transmitted infections (STI), and HIV can be red flags.

Ob.gyns. "are in a unique position to address" the problem, the ACOG opinion states.

If women answer yes to screening questions such as, "Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?" ob.gyns. should do the following:

• Offer hotline numbers and referrals to local domestic violence shelters and agencies, letting women use the office phone to make the calls.

• Offer long-acting methods of contraception less detectable to partners, such as IUDs, contraceptive implants, or injections.

• Trim IUD strings inside the cervical canal so they are undetectable and are harder for partners to remove, and send emergency contraceptive pills home in plain envelopes.

• Counsel these patients on harm-reduction strategies and safety planning.

The opinion by the ACOG Committee on Health Care for Underserved Women also suggests that ob.gyns. get more education about reproductive and sexual coercion and "include reproductive and sexual coercion and [intimate partner violence] as part of the differential diagnosis when patients are seen for STI testing, emergency contraception, or unintended pregnancies."

Other screening questions can be included: "Has your partner ever tried to get you pregnant when you did not want to be pregnant?" "Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?" and "Does your partner support your decision about when or if you want to become pregnant?" the opinion noted. Additional questions can be found in "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion."

"If a patient responds affirmatively ... the health care provider should validate her experience and commend her for discussing and evaluating her health and relationships. She should be reassured that the situation is not her fault, and further assessment of her safety should be elicited and discreet contraceptive options reviewed," according to the opinion.

"Anybody can be in this situation, but it disproportionally affects disempowered, underserved women," Dr. Espey said in an interview.

Sexual and reproductive coercion tends to travel with physical or sexual violence. In one study, 66% of battered adolescent mothers on public assistance reported birth control sabotage by their dating partner (School Nurse News 2006;23:38-40).

The opinion "is an expansion of ACOG’s long-standing work on intimate partner violence in general," said Dr. Espey, noting that the organization offers educational sessions on sexual and reproductive coercion at its annual meetings.

There is no specific ICD-9/ICD-10 code for screening for sexual and reproductive coercion. Because the physician initially will be performing a screening service, the contraceptive counseling codes would not be the most appropriate codes to report, according to ACOG’s coding department. Code V82.89 (Special screening for other conditions; Other specified conditions) would be a better bet for routine screening.

If coercion seems likely, counseling may be reported with code V65.49 (Other specified counseling) or code V62.89 (Other psychological or physical stress, not elsewhere classified; Other). Payer reimbursement policies will vary, according to ACOG.

Women wouldn’t have a copay for screening and counseling because sexual and reproductive coercion is a subset of intimate partner violence, which is a no-copay preventive care service under the Affordable Care Act.

The National Domestic Violence Hotline is 1-800-799-SAFE (7233); the Rape Abuse & Incest National Network Hotline is at 1-800-656-HOPE (4673). Several websites offer help and guidance as well, including Futures Without Violence, the National Coalition Against Domestic Violence, and the U.S. Department of Justice Office on Violence Against Women.

Dr. Espey said that she has no relevant disclosures.

Certain pregnant women who are carrying a fetus with severe spina bifida should be counseled about the potential benefits and risks of maternal-fetal surgery, according to the American College of Obstetricians and Gynecologists.

The ACOG Committee on Obstetric Practice recently recommended counseling about maternal-fetal surgery for myelomeningocele, the most severe form of spina bifida, following promising results from the procedure in an 8-year randomized controlled trial (Obstet. Gynecol. 2013;121:218-9).

In the Management of Myelomeningocele Study (MOMS), prenatal repair before 26 weeks of gestation reduced the need for a shunt at 12 months and also decreased the rate of hindbrain herniation by one-third at 12 months of age. The procedure also doubled the rate of independent walking and produced higher levels of functioning than were expected based on anatomic levels (N. Engl. J. Med. 2011;364:993-1004).

But the study, which was sponsored by the National Institutes of Health, also found significant maternal and fetal risks. For example, the surgery was associated with high rates of preterm birth, fetal bradycardia, oligohydramnios, placental abruption, pulmonary edema, maternal transfusion at delivery, and an increased incidence of uterine thinning.

ACOG cautions that the MOMS trial used stringent inclusion criteria and rigorous requirements for the experience of the surgeons involved. As a result, outcomes from the trial should be considered a "best-case scenario," the committee members wrote. They urged physicians to use the same inclusion criteria as the researchers when considering which women to counsel about the maternal-fetal surgery. The criteria were a singleton pregnancy, myelomeningocele with the upper boundary between T-1 and S-1, evidence of hindbrain herniation, gestational age between 19.0 and 25.9 weeks, and a normal karyotype. The major exclusion criteria included a fetal anomaly unrelated to the myelomeningocele; severe kyphosis; risk of preterm birth; a maternal body mass index of 35 kg/m² or more; and contraindications to surgery, including previous hysterotomy in the active uterine segment.

Women should also be counseled about the implications of the surgery for future pregnancies, the ACOG committee recommended.

"It is a highly technical procedure with potential for significant morbidity and possibly mortality, even in the best and most experienced hands," they wrote. "Maternal-fetal surgery for myelomeningocele should only be offered at facilities with the expertise, multidisciplinary teams, services, and facilities to provide the intensive care required for these patients."

The study authors declared that they received funding from the National Institutes of Health. One of the authors reported receiving funding from Vanderbilt University in Nashville, Tenn.

[email protected]

Certain pregnant women who are carrying a fetus with severe spina bifida should be counseled about the potential benefits and risks of maternal-fetal surgery, according to the American College of Obstetricians and Gynecologists.

The ACOG Committee on Obstetric Practice recently recommended counseling about maternal-fetal surgery for myelomeningocele, the most severe form of spina bifida, following promising results from the procedure in an 8-year randomized controlled trial (Obstet. Gynecol. 2013;121:218-9).

In the Management of Myelomeningocele Study (MOMS), prenatal repair before 26 weeks of gestation reduced the need for a shunt at 12 months and also decreased the rate of hindbrain herniation by one-third at 12 months of age. The procedure also doubled the rate of independent walking and produced higher levels of functioning than were expected based on anatomic levels (N. Engl. J. Med. 2011;364:993-1004).

But the study, which was sponsored by the National Institutes of Health, also found significant maternal and fetal risks. For example, the surgery was associated with high rates of preterm birth, fetal bradycardia, oligohydramnios, placental abruption, pulmonary edema, maternal transfusion at delivery, and an increased incidence of uterine thinning.

ACOG cautions that the MOMS trial used stringent inclusion criteria and rigorous requirements for the experience of the surgeons involved. As a result, outcomes from the trial should be considered a "best-case scenario," the committee members wrote. They urged physicians to use the same inclusion criteria as the researchers when considering which women to counsel about the maternal-fetal surgery. The criteria were a singleton pregnancy, myelomeningocele with the upper boundary between T-1 and S-1, evidence of hindbrain herniation, gestational age between 19.0 and 25.9 weeks, and a normal karyotype. The major exclusion criteria included a fetal anomaly unrelated to the myelomeningocele; severe kyphosis; risk of preterm birth; a maternal body mass index of 35 kg/m² or more; and contraindications to surgery, including previous hysterotomy in the active uterine segment.

Women should also be counseled about the implications of the surgery for future pregnancies, the ACOG committee recommended.

"It is a highly technical procedure with potential for significant morbidity and possibly mortality, even in the best and most experienced hands," they wrote. "Maternal-fetal surgery for myelomeningocele should only be offered at facilities with the expertise, multidisciplinary teams, services, and facilities to provide the intensive care required for these patients."

The study authors declared that they received funding from the National Institutes of Health. One of the authors reported receiving funding from Vanderbilt University in Nashville, Tenn.

[email protected]

Certain pregnant women who are carrying a fetus with severe spina bifida should be counseled about the potential benefits and risks of maternal-fetal surgery, according to the American College of Obstetricians and Gynecologists.

The ACOG Committee on Obstetric Practice recently recommended counseling about maternal-fetal surgery for myelomeningocele, the most severe form of spina bifida, following promising results from the procedure in an 8-year randomized controlled trial (Obstet. Gynecol. 2013;121:218-9).

In the Management of Myelomeningocele Study (MOMS), prenatal repair before 26 weeks of gestation reduced the need for a shunt at 12 months and also decreased the rate of hindbrain herniation by one-third at 12 months of age. The procedure also doubled the rate of independent walking and produced higher levels of functioning than were expected based on anatomic levels (N. Engl. J. Med. 2011;364:993-1004).

But the study, which was sponsored by the National Institutes of Health, also found significant maternal and fetal risks. For example, the surgery was associated with high rates of preterm birth, fetal bradycardia, oligohydramnios, placental abruption, pulmonary edema, maternal transfusion at delivery, and an increased incidence of uterine thinning.

ACOG cautions that the MOMS trial used stringent inclusion criteria and rigorous requirements for the experience of the surgeons involved. As a result, outcomes from the trial should be considered a "best-case scenario," the committee members wrote. They urged physicians to use the same inclusion criteria as the researchers when considering which women to counsel about the maternal-fetal surgery. The criteria were a singleton pregnancy, myelomeningocele with the upper boundary between T-1 and S-1, evidence of hindbrain herniation, gestational age between 19.0 and 25.9 weeks, and a normal karyotype. The major exclusion criteria included a fetal anomaly unrelated to the myelomeningocele; severe kyphosis; risk of preterm birth; a maternal body mass index of 35 kg/m² or more; and contraindications to surgery, including previous hysterotomy in the active uterine segment.

Women should also be counseled about the implications of the surgery for future pregnancies, the ACOG committee recommended.

"It is a highly technical procedure with potential for significant morbidity and possibly mortality, even in the best and most experienced hands," they wrote. "Maternal-fetal surgery for myelomeningocele should only be offered at facilities with the expertise, multidisciplinary teams, services, and facilities to provide the intensive care required for these patients."

The study authors declared that they received funding from the National Institutes of Health. One of the authors reported receiving funding from Vanderbilt University in Nashville, Tenn.

[email protected]

The H1N1 influenza vaccine did not raise the risk of fetal death when given to pregnant women, according to a report published online Jan. 16 in the New England Journal of Medicine.

In a study analyzing data from Norwegian national health registries following the 2009 pandemic, "we found no evidence that influenza vaccination of pregnant women increased the risk of fetal death. However, influenza virus itself posed a major risk; among pregnant women who received a clinical diagnosis of influenza, the risk of fetal death nearly doubled," said Dr. Siri E. Hâberg of the Norwegian Institute of Public Health, Oslo, and her associates.

©Micah Young/istockphoto.com

Moreover, "vaccination appeared to provide some protection against excess fetal mortality during the pandemic," they noted.

"Our study adds to growing evidence that vaccination of pregnant women during an influenza pandemic does not harm – and may benefit – the fetus."

At the time of the pandemic the vaccine was considered safe and was recommended for pregnant women, who were at particular risk from H1N1. Early anecdotal reports of fetal losses in pregnant women, however, including 30 cases in Norway, raised concerns.

Dr. Hâberg and her colleagues used data from nationwide health registries to examine the issue.

There were 113,331 singleton births among women who became pregnant in Norway during the 2009-2010 flu season. A total of 492 fetal deaths occurred, for an overall rate of 4.3 fetal deaths per 1,000 births. Among 99,539 women who delivered outside the pandemic window, there were 410 fetal deaths, for a rate of 4.1 deaths per 1,000 births.

Just over half (54%) of women pregnant during the pandemic received the flu vaccine. As expected, vaccination substantially reduced the risk that they would contract influenza, they said.

There were 78 fetal deaths among the 25,976 (0.3%) women who were vaccinated during pregnancy and 414 among the 87,335 (0.5%) who were unvaccinated.

Compared with the reference group of women who were pregnant either before or after the pandemic, those who were pregnant during the pandemic and acquired influenza showed a markedly increased risk of fetal death, with an adjusted hazard ratio of 1.91. In contrast, the risk of fetal death was slightly lower in women who were pregnant during the pandemic and were vaccinated, with an adjusted HR of 0.88, the investigators said (N. Engl. J. Med. 2013 Jan. 16 [doi:10.1056/NEJMoa1207210]).

These findings remained robust in several further analyses, including a substudy that included women with multiple births; another that excluded cases in which the vaccine was administered during the first trimester; and another analysis that adjusted for variables such as maternal diabetes, chronic illness, body mass index, and smoking status.

"We also considered nonfatal birth outcomes (preterm delivery, low birth weight at term, and low Apgar score at term) and found no evidence of an association between vaccination and these outcomes," Dr. Hâberg and her associates wrote.

"We found no basis for withholding influenza vaccination from pregnant women in their second or third trimester – an important group, given that these women can be particularly vulnerable to the severe effects of influenza virus infection," they said.

Recent studies in Denmark and Canada "have likewise shown no evidence that influenza vaccination during the 2009 pandemic increased the risk of stillbirth or other adverse birth outcomes," the researchers added.

This study was supported by the Norwegian Institute of Public Health and the U.S. National Institute of Environmental Health Sciences. Disclosures for Dr. Hâberg and her associates were not available. The makers of the vaccines assessed in this study had no role in the study design, implementation, or funding.

The H1N1 influenza vaccine did not raise the risk of fetal death when given to pregnant women, according to a report published online Jan. 16 in the New England Journal of Medicine.

In a study analyzing data from Norwegian national health registries following the 2009 pandemic, "we found no evidence that influenza vaccination of pregnant women increased the risk of fetal death. However, influenza virus itself posed a major risk; among pregnant women who received a clinical diagnosis of influenza, the risk of fetal death nearly doubled," said Dr. Siri E. Hâberg of the Norwegian Institute of Public Health, Oslo, and her associates.

©Micah Young/istockphoto.com

Moreover, "vaccination appeared to provide some protection against excess fetal mortality during the pandemic," they noted.

"Our study adds to growing evidence that vaccination of pregnant women during an influenza pandemic does not harm – and may benefit – the fetus."

At the time of the pandemic the vaccine was considered safe and was recommended for pregnant women, who were at particular risk from H1N1. Early anecdotal reports of fetal losses in pregnant women, however, including 30 cases in Norway, raised concerns.

Dr. Hâberg and her colleagues used data from nationwide health registries to examine the issue.

There were 113,331 singleton births among women who became pregnant in Norway during the 2009-2010 flu season. A total of 492 fetal deaths occurred, for an overall rate of 4.3 fetal deaths per 1,000 births. Among 99,539 women who delivered outside the pandemic window, there were 410 fetal deaths, for a rate of 4.1 deaths per 1,000 births.

Just over half (54%) of women pregnant during the pandemic received the flu vaccine. As expected, vaccination substantially reduced the risk that they would contract influenza, they said.

There were 78 fetal deaths among the 25,976 (0.3%) women who were vaccinated during pregnancy and 414 among the 87,335 (0.5%) who were unvaccinated.

Compared with the reference group of women who were pregnant either before or after the pandemic, those who were pregnant during the pandemic and acquired influenza showed a markedly increased risk of fetal death, with an adjusted hazard ratio of 1.91. In contrast, the risk of fetal death was slightly lower in women who were pregnant during the pandemic and were vaccinated, with an adjusted HR of 0.88, the investigators said (N. Engl. J. Med. 2013 Jan. 16 [doi:10.1056/NEJMoa1207210]).

These findings remained robust in several further analyses, including a substudy that included women with multiple births; another that excluded cases in which the vaccine was administered during the first trimester; and another analysis that adjusted for variables such as maternal diabetes, chronic illness, body mass index, and smoking status.

"We also considered nonfatal birth outcomes (preterm delivery, low birth weight at term, and low Apgar score at term) and found no evidence of an association between vaccination and these outcomes," Dr. Hâberg and her associates wrote.

"We found no basis for withholding influenza vaccination from pregnant women in their second or third trimester – an important group, given that these women can be particularly vulnerable to the severe effects of influenza virus infection," they said.

Recent studies in Denmark and Canada "have likewise shown no evidence that influenza vaccination during the 2009 pandemic increased the risk of stillbirth or other adverse birth outcomes," the researchers added.

This study was supported by the Norwegian Institute of Public Health and the U.S. National Institute of Environmental Health Sciences. Disclosures for Dr. Hâberg and her associates were not available. The makers of the vaccines assessed in this study had no role in the study design, implementation, or funding.

The H1N1 influenza vaccine did not raise the risk of fetal death when given to pregnant women, according to a report published online Jan. 16 in the New England Journal of Medicine.

In a study analyzing data from Norwegian national health registries following the 2009 pandemic, "we found no evidence that influenza vaccination of pregnant women increased the risk of fetal death. However, influenza virus itself posed a major risk; among pregnant women who received a clinical diagnosis of influenza, the risk of fetal death nearly doubled," said Dr. Siri E. Hâberg of the Norwegian Institute of Public Health, Oslo, and her associates.

©Micah Young/istockphoto.com

Moreover, "vaccination appeared to provide some protection against excess fetal mortality during the pandemic," they noted.

"Our study adds to growing evidence that vaccination of pregnant women during an influenza pandemic does not harm – and may benefit – the fetus."

At the time of the pandemic the vaccine was considered safe and was recommended for pregnant women, who were at particular risk from H1N1. Early anecdotal reports of fetal losses in pregnant women, however, including 30 cases in Norway, raised concerns.

Dr. Hâberg and her colleagues used data from nationwide health registries to examine the issue.

There were 113,331 singleton births among women who became pregnant in Norway during the 2009-2010 flu season. A total of 492 fetal deaths occurred, for an overall rate of 4.3 fetal deaths per 1,000 births. Among 99,539 women who delivered outside the pandemic window, there were 410 fetal deaths, for a rate of 4.1 deaths per 1,000 births.

Just over half (54%) of women pregnant during the pandemic received the flu vaccine. As expected, vaccination substantially reduced the risk that they would contract influenza, they said.

There were 78 fetal deaths among the 25,976 (0.3%) women who were vaccinated during pregnancy and 414 among the 87,335 (0.5%) who were unvaccinated.

Compared with the reference group of women who were pregnant either before or after the pandemic, those who were pregnant during the pandemic and acquired influenza showed a markedly increased risk of fetal death, with an adjusted hazard ratio of 1.91. In contrast, the risk of fetal death was slightly lower in women who were pregnant during the pandemic and were vaccinated, with an adjusted HR of 0.88, the investigators said (N. Engl. J. Med. 2013 Jan. 16 [doi:10.1056/NEJMoa1207210]).

These findings remained robust in several further analyses, including a substudy that included women with multiple births; another that excluded cases in which the vaccine was administered during the first trimester; and another analysis that adjusted for variables such as maternal diabetes, chronic illness, body mass index, and smoking status.

"We also considered nonfatal birth outcomes (preterm delivery, low birth weight at term, and low Apgar score at term) and found no evidence of an association between vaccination and these outcomes," Dr. Hâberg and her associates wrote.

"We found no basis for withholding influenza vaccination from pregnant women in their second or third trimester – an important group, given that these women can be particularly vulnerable to the severe effects of influenza virus infection," they said.

Recent studies in Denmark and Canada "have likewise shown no evidence that influenza vaccination during the 2009 pandemic increased the risk of stillbirth or other adverse birth outcomes," the researchers added.

This study was supported by the Norwegian Institute of Public Health and the U.S. National Institute of Environmental Health Sciences. Disclosures for Dr. Hâberg and her associates were not available. The makers of the vaccines assessed in this study had no role in the study design, implementation, or funding.

Binge drinking, which is the most dangerous form of alcohol consumption, is a serious, yet under-recognized health risk for women, according to a federal report that showed one in eight U.S. adult women and one in five high school girls binge drank in 2011.

The issue is not new, officials said, but they expressed concern with the statistics, saying that the rates of binge drinking among high school girls is now almost equal to that of boys, and the rates have remained almost the same among U.S. adult women for more than a decade.

© CDC

In 2011, nearly 13% of U.S. adult women binge drank more than three times a month and with roughly six drinks during each occasion. Meanwhile, close to 20% of high school girls reported binge drinking, according to the analysis of two national databases, which was published in the Centers for Disease Control and Prevention’s Vital Signs (MMWR 2013 Jan. 3;62:1-5).

CDC director Thomas R. Frieden said that there were no data showing whether women are aware of the dangers of binge drinking, and he stressed the importance of raising awareness.

"Health-care providers have an important role to play in reducing binge drinking," Dr. Frieden said during a news conference. "They can talk to all patients, including pregnant women about their alcohol consumption, and advise those who drink too much, to do so less."

The report, which analyzed data from the 2011 Behavioral Risk Factor Surveillance System (278,000 women) and the national Youth Risk Behavior Survey (7,500 girls), also showed:

• During each year, between 2001 and 2005, alcohol use accounted for nearly 23,000 deaths and 633,000 years of potential life lost among U.S. girls and adult women. Binge drinking accounted for half of these statistics.

• Binge drinking was most prevalent among women aged 18- to 24-years-old (24%) and 25- to 34-years-old (20%), and then gradually decreased with increasing age.

• Binge drinking was most prevalent among women whose annual household income was $75,000 or more (16%).

• Although non-Hispanic white women had the highest rate of binge drinking (13%), compared with 11% among Hispanic women, and 10% among black women, the frequency and intensity of binge drinking was similar across the racial and ethnic groups.

• Women without a high school degree had the lowest prevalence of binge drinking (8.5%), yet the ones who binge drank reported the highest frequency (more than four times a month), and intensity (more than six drinks per occasion), compared with women who had higher levels of education.

• Roughly 38% of high school girls consumed alcohol, more than half of whom said that they binge drank.

• The prevalence of binge drinking among Hispanic (22.4%) and non-Hispanic white (21.7%) high school girls was nearly twice as much as that of non-Hispanic black girls (10.3%).

Binge drinking was defined as consumption of four or more drinks in a row for women, and five or more drinks in a row for high school girls. Officials said that the rates would have been higher by one-third or more if the number of drinks for girls was reduced from 5 to 4 in the survey.

Federal officials said that binge drinking is a risk factor for many health and social problems among women, because their bodies respond to alcohol differently from men. Women generally reach higher blood alcohol levels than do men at the same consumption level, even after adjustment for body size, food eaten, and other factors. Binge drinking has been associated with heart disease, breast cancer, behaviors that could lead to contracting sexually transmitted diseases, and unintended pregnancy, in addition to fetal alcohol spectrum disorders and sudden infant death syndrome.

Officials urged physicians, states, and communities to implement evidence-based interventions, such as recommendations by the Guide to Community Preventive Services, and the U.S. Preventive Services Task Force.

[email protected]

On Twitter @naseemsmiller

Binge drinking, which is the most dangerous form of alcohol consumption, is a serious, yet under-recognized health risk for women, according to a federal report that showed one in eight U.S. adult women and one in five high school girls binge drank in 2011.

The issue is not new, officials said, but they expressed concern with the statistics, saying that the rates of binge drinking among high school girls is now almost equal to that of boys, and the rates have remained almost the same among U.S. adult women for more than a decade.

© CDC

In 2011, nearly 13% of U.S. adult women binge drank more than three times a month and with roughly six drinks during each occasion. Meanwhile, close to 20% of high school girls reported binge drinking, according to the analysis of two national databases, which was published in the Centers for Disease Control and Prevention’s Vital Signs (MMWR 2013 Jan. 3;62:1-5).

CDC director Thomas R. Frieden said that there were no data showing whether women are aware of the dangers of binge drinking, and he stressed the importance of raising awareness.

"Health-care providers have an important role to play in reducing binge drinking," Dr. Frieden said during a news conference. "They can talk to all patients, including pregnant women about their alcohol consumption, and advise those who drink too much, to do so less."

The report, which analyzed data from the 2011 Behavioral Risk Factor Surveillance System (278,000 women) and the national Youth Risk Behavior Survey (7,500 girls), also showed:

• During each year, between 2001 and 2005, alcohol use accounted for nearly 23,000 deaths and 633,000 years of potential life lost among U.S. girls and adult women. Binge drinking accounted for half of these statistics.

• Binge drinking was most prevalent among women aged 18- to 24-years-old (24%) and 25- to 34-years-old (20%), and then gradually decreased with increasing age.

• Binge drinking was most prevalent among women whose annual household income was $75,000 or more (16%).

• Although non-Hispanic white women had the highest rate of binge drinking (13%), compared with 11% among Hispanic women, and 10% among black women, the frequency and intensity of binge drinking was similar across the racial and ethnic groups.

• Women without a high school degree had the lowest prevalence of binge drinking (8.5%), yet the ones who binge drank reported the highest frequency (more than four times a month), and intensity (more than six drinks per occasion), compared with women who had higher levels of education.

• Roughly 38% of high school girls consumed alcohol, more than half of whom said that they binge drank.

• The prevalence of binge drinking among Hispanic (22.4%) and non-Hispanic white (21.7%) high school girls was nearly twice as much as that of non-Hispanic black girls (10.3%).

Binge drinking was defined as consumption of four or more drinks in a row for women, and five or more drinks in a row for high school girls. Officials said that the rates would have been higher by one-third or more if the number of drinks for girls was reduced from 5 to 4 in the survey.

Federal officials said that binge drinking is a risk factor for many health and social problems among women, because their bodies respond to alcohol differently from men. Women generally reach higher blood alcohol levels than do men at the same consumption level, even after adjustment for body size, food eaten, and other factors. Binge drinking has been associated with heart disease, breast cancer, behaviors that could lead to contracting sexually transmitted diseases, and unintended pregnancy, in addition to fetal alcohol spectrum disorders and sudden infant death syndrome.

Officials urged physicians, states, and communities to implement evidence-based interventions, such as recommendations by the Guide to Community Preventive Services, and the U.S. Preventive Services Task Force.

[email protected]

On Twitter @naseemsmiller

Binge drinking, which is the most dangerous form of alcohol consumption, is a serious, yet under-recognized health risk for women, according to a federal report that showed one in eight U.S. adult women and one in five high school girls binge drank in 2011.

The issue is not new, officials said, but they expressed concern with the statistics, saying that the rates of binge drinking among high school girls is now almost equal to that of boys, and the rates have remained almost the same among U.S. adult women for more than a decade.

© CDC

In 2011, nearly 13% of U.S. adult women binge drank more than three times a month and with roughly six drinks during each occasion. Meanwhile, close to 20% of high school girls reported binge drinking, according to the analysis of two national databases, which was published in the Centers for Disease Control and Prevention’s Vital Signs (MMWR 2013 Jan. 3;62:1-5).

CDC director Thomas R. Frieden said that there were no data showing whether women are aware of the dangers of binge drinking, and he stressed the importance of raising awareness.

"Health-care providers have an important role to play in reducing binge drinking," Dr. Frieden said during a news conference. "They can talk to all patients, including pregnant women about their alcohol consumption, and advise those who drink too much, to do so less."

The report, which analyzed data from the 2011 Behavioral Risk Factor Surveillance System (278,000 women) and the national Youth Risk Behavior Survey (7,500 girls), also showed:

• During each year, between 2001 and 2005, alcohol use accounted for nearly 23,000 deaths and 633,000 years of potential life lost among U.S. girls and adult women. Binge drinking accounted for half of these statistics.

• Binge drinking was most prevalent among women aged 18- to 24-years-old (24%) and 25- to 34-years-old (20%), and then gradually decreased with increasing age.

• Binge drinking was most prevalent among women whose annual household income was $75,000 or more (16%).

• Although non-Hispanic white women had the highest rate of binge drinking (13%), compared with 11% among Hispanic women, and 10% among black women, the frequency and intensity of binge drinking was similar across the racial and ethnic groups.

• Women without a high school degree had the lowest prevalence of binge drinking (8.5%), yet the ones who binge drank reported the highest frequency (more than four times a month), and intensity (more than six drinks per occasion), compared with women who had higher levels of education.

• Roughly 38% of high school girls consumed alcohol, more than half of whom said that they binge drank.

• The prevalence of binge drinking among Hispanic (22.4%) and non-Hispanic white (21.7%) high school girls was nearly twice as much as that of non-Hispanic black girls (10.3%).

Binge drinking was defined as consumption of four or more drinks in a row for women, and five or more drinks in a row for high school girls. Officials said that the rates would have been higher by one-third or more if the number of drinks for girls was reduced from 5 to 4 in the survey.

Federal officials said that binge drinking is a risk factor for many health and social problems among women, because their bodies respond to alcohol differently from men. Women generally reach higher blood alcohol levels than do men at the same consumption level, even after adjustment for body size, food eaten, and other factors. Binge drinking has been associated with heart disease, breast cancer, behaviors that could lead to contracting sexually transmitted diseases, and unintended pregnancy, in addition to fetal alcohol spectrum disorders and sudden infant death syndrome.

Officials urged physicians, states, and communities to implement evidence-based interventions, such as recommendations by the Guide to Community Preventive Services, and the U.S. Preventive Services Task Force.

[email protected]

On Twitter @naseemsmiller

Some psychiatric disorders appear to be associated with lower fecundity in both men and women, suggesting that natural selection attempts to discourage the perpetuation of genetic variants associated with them.

Instead, new mutations could be one reason that the disorders continue to exist, Robert A. Power and his colleagues wrote in the January issue of JAMA Psychiatry (formerly Archives of General Psychiatry).

The authors also found that psychiatric disorders affected men’s fecundity more than women’s. "This sex-specific effect suggests that psychiatric morbidity impairs interest or ability to find suitable mating partners or inhibits biological fertility to a greater extent in men," wrote Mr. Power of Kings College, London.

The study data were extracted from two of Sweden’s population registries – the Multi-Generation Register and the Swedish Hospital Discharge Register. More than 2.3 million people born from 1950-1970 were cross-linked by individual patient identification numbers, which allowed the researchers to trace not only patients but also their siblings. At the time of the analysis, no patient was younger than 40 years (JAMA Psychiatry 2013;70:22-30).

The authors tracked fecundity in about 177,000 patients who had schizophrenia, autism, bipolar disorder, anorexia nervosa, or substance abuse. Rates were compared with fecundity in 261,000 siblings. The researchers then compared these rates with those found in the general population.

About 19,000 patients had schizophrenia. They had significantly fewer children than the general population’s (fecundity rate [FR] 0.23 for men and 0.47 for women). In a univariate analysis, sisters of the patients had a significantly higher fecundity rate (FR, 1.02), but this difference disappeared once comorbidities were factored into the analysis. Brothers also had significantly decreased fecundity (FR, 0.97).

"Our results suggest a strong selection pressure to remove genetic variants associated with schizophrenia from the population," the authors said. "This is further evidence for the role of recent or de novo mutations in the genetic susceptibility to schizophrenia that has neither reached the frequency of nor existed long enough to be removed from the population."

Autism was present in 2,947 patients; these had 4,471 siblings. Fecundity was significantly lower in both men and women (FR, 0.25 and 0.48, respectively). Among the siblings, brothers also had fewer children (FR, 0.94). Among sisters, the rate was not significantly different than the general population.

"Individuals with autism showed the greatest reduction in fecundity among all examined disorders. This was not unexpected because previous investigations have shown that few individuals with autism ever married or had children.

"We propose that rare highly deleterious variants and sexually antagonistic polymorphisms may contribute to the genetic disposition to autism. The similarity to schizophrenia is notable because it has been proposed that the autistic and psychotic spectrums reflect two extremes of social cognition."

Bipolar disorder was present in 14,439 patients, among whom were 22,986 siblings. Fecundity was significantly lower than the general population in both men (FR, 0.75) and women (FR, 0.85). While brothers had similar rates to that of the general population, sisters had significantly more children (FR, 1.03). But incorporating comorbidities into the analysis changed the significance for both patients and sisters, with the patient rate increasing to just below that of the general population (FR, 0.94), and the sisters’ rate increased rate no longer being significant (FR, 0.95).

"It has been suggested that the introduction of lithium as a treatment for bipolar disorder has led to improved functioning and, as a result, greater fecundity in those populations where treatment is available."

There were 81,295 patients with depression, among who were 119,645 siblings. While men with depression had significantly lower rates (FR, 0.93), women with the disorder were not significantly different than the general population. Siblings had significantly more children than the general population (FR, brothers 1.01, sisters 1.04) – a difference that was unchanged by factoring in comorbidities. The addition of comorbidities to the analysis did not change the decreased fecundity rate for male patients, but actually increased the rate for female patients (FR, 1.03).

"Notably, depression was an exception to the five other studied disorders ... genes associated with depression seems to be maintained in the population by balancing selection because the cost to affected individuals is roughly equal to the benefit to their siblings. If this is the case, it would be the first strong evidence for balancing selection in a psychiatric disorder."

There were 3,275 patients with anorexia, who had a total of 5,172 siblings. Both men and women with the disorder had significantly reduced fecundity (0.54 and 0.58, respectively). In the sibling group, there were no significant differences for either brothers or sisters. None of the findings changed when comorbidities were factored in.

"Our calculations suggest that anorexia is under weaker negative selection relative to schizophrenia and autism," the authors said.

Substance abuse was present in 55,933 patients, who had a total of 81,592 siblings. The fecundity rate was significantly lower in both men and women (FR, 0.78 and 0.93, respectively). Siblings had significantly more children than the general population (FR, 1.03 for brothers and 1.05 for sisters).

"Our findings suggest that this increased fecundity in siblings almost entirely accounts for the cost to affected individuals, with only a slight decrease in the frequency of these individuals’ genes predicted each generation. Considering that most drugs are a new environmental exposure when seen from an evolutionary perspective, it is possible that there has been insufficient time for selection to act on risk alleles. ... It has also been suggested that substance abuse is associated with risk-taking behavior in both sexes, including sexual risk taking."

The study was funded by the Medical Research Council of the United Kingdom. One of the coauthors reported having received consulting fees and honoraria from GlaxoSmithKline and Lundbeck.

[email protected]

Some psychiatric disorders appear to be associated with lower fecundity in both men and women, suggesting that natural selection attempts to discourage the perpetuation of genetic variants associated with them.

Instead, new mutations could be one reason that the disorders continue to exist, Robert A. Power and his colleagues wrote in the January issue of JAMA Psychiatry (formerly Archives of General Psychiatry).

The authors also found that psychiatric disorders affected men’s fecundity more than women’s. "This sex-specific effect suggests that psychiatric morbidity impairs interest or ability to find suitable mating partners or inhibits biological fertility to a greater extent in men," wrote Mr. Power of Kings College, London.

The study data were extracted from two of Sweden’s population registries – the Multi-Generation Register and the Swedish Hospital Discharge Register. More than 2.3 million people born from 1950-1970 were cross-linked by individual patient identification numbers, which allowed the researchers to trace not only patients but also their siblings. At the time of the analysis, no patient was younger than 40 years (JAMA Psychiatry 2013;70:22-30).

The authors tracked fecundity in about 177,000 patients who had schizophrenia, autism, bipolar disorder, anorexia nervosa, or substance abuse. Rates were compared with fecundity in 261,000 siblings. The researchers then compared these rates with those found in the general population.

About 19,000 patients had schizophrenia. They had significantly fewer children than the general population’s (fecundity rate [FR] 0.23 for men and 0.47 for women). In a univariate analysis, sisters of the patients had a significantly higher fecundity rate (FR, 1.02), but this difference disappeared once comorbidities were factored into the analysis. Brothers also had significantly decreased fecundity (FR, 0.97).

"Our results suggest a strong selection pressure to remove genetic variants associated with schizophrenia from the population," the authors said. "This is further evidence for the role of recent or de novo mutations in the genetic susceptibility to schizophrenia that has neither reached the frequency of nor existed long enough to be removed from the population."

Autism was present in 2,947 patients; these had 4,471 siblings. Fecundity was significantly lower in both men and women (FR, 0.25 and 0.48, respectively). Among the siblings, brothers also had fewer children (FR, 0.94). Among sisters, the rate was not significantly different than the general population.

"Individuals with autism showed the greatest reduction in fecundity among all examined disorders. This was not unexpected because previous investigations have shown that few individuals with autism ever married or had children.

"We propose that rare highly deleterious variants and sexually antagonistic polymorphisms may contribute to the genetic disposition to autism. The similarity to schizophrenia is notable because it has been proposed that the autistic and psychotic spectrums reflect two extremes of social cognition."

Bipolar disorder was present in 14,439 patients, among whom were 22,986 siblings. Fecundity was significantly lower than the general population in both men (FR, 0.75) and women (FR, 0.85). While brothers had similar rates to that of the general population, sisters had significantly more children (FR, 1.03). But incorporating comorbidities into the analysis changed the significance for both patients and sisters, with the patient rate increasing to just below that of the general population (FR, 0.94), and the sisters’ rate increased rate no longer being significant (FR, 0.95).

"It has been suggested that the introduction of lithium as a treatment for bipolar disorder has led to improved functioning and, as a result, greater fecundity in those populations where treatment is available."

There were 81,295 patients with depression, among who were 119,645 siblings. While men with depression had significantly lower rates (FR, 0.93), women with the disorder were not significantly different than the general population. Siblings had significantly more children than the general population (FR, brothers 1.01, sisters 1.04) – a difference that was unchanged by factoring in comorbidities. The addition of comorbidities to the analysis did not change the decreased fecundity rate for male patients, but actually increased the rate for female patients (FR, 1.03).

"Notably, depression was an exception to the five other studied disorders ... genes associated with depression seems to be maintained in the population by balancing selection because the cost to affected individuals is roughly equal to the benefit to their siblings. If this is the case, it would be the first strong evidence for balancing selection in a psychiatric disorder."

There were 3,275 patients with anorexia, who had a total of 5,172 siblings. Both men and women with the disorder had significantly reduced fecundity (0.54 and 0.58, respectively). In the sibling group, there were no significant differences for either brothers or sisters. None of the findings changed when comorbidities were factored in.

"Our calculations suggest that anorexia is under weaker negative selection relative to schizophrenia and autism," the authors said.

Substance abuse was present in 55,933 patients, who had a total of 81,592 siblings. The fecundity rate was significantly lower in both men and women (FR, 0.78 and 0.93, respectively). Siblings had significantly more children than the general population (FR, 1.03 for brothers and 1.05 for sisters).

"Our findings suggest that this increased fecundity in siblings almost entirely accounts for the cost to affected individuals, with only a slight decrease in the frequency of these individuals’ genes predicted each generation. Considering that most drugs are a new environmental exposure when seen from an evolutionary perspective, it is possible that there has been insufficient time for selection to act on risk alleles. ... It has also been suggested that substance abuse is associated with risk-taking behavior in both sexes, including sexual risk taking."

The study was funded by the Medical Research Council of the United Kingdom. One of the coauthors reported having received consulting fees and honoraria from GlaxoSmithKline and Lundbeck.

[email protected]

Some psychiatric disorders appear to be associated with lower fecundity in both men and women, suggesting that natural selection attempts to discourage the perpetuation of genetic variants associated with them.

Instead, new mutations could be one reason that the disorders continue to exist, Robert A. Power and his colleagues wrote in the January issue of JAMA Psychiatry (formerly Archives of General Psychiatry).

The authors also found that psychiatric disorders affected men’s fecundity more than women’s. "This sex-specific effect suggests that psychiatric morbidity impairs interest or ability to find suitable mating partners or inhibits biological fertility to a greater extent in men," wrote Mr. Power of Kings College, London.

The study data were extracted from two of Sweden’s population registries – the Multi-Generation Register and the Swedish Hospital Discharge Register. More than 2.3 million people born from 1950-1970 were cross-linked by individual patient identification numbers, which allowed the researchers to trace not only patients but also their siblings. At the time of the analysis, no patient was younger than 40 years (JAMA Psychiatry 2013;70:22-30).

The authors tracked fecundity in about 177,000 patients who had schizophrenia, autism, bipolar disorder, anorexia nervosa, or substance abuse. Rates were compared with fecundity in 261,000 siblings. The researchers then compared these rates with those found in the general population.

About 19,000 patients had schizophrenia. They had significantly fewer children than the general population’s (fecundity rate [FR] 0.23 for men and 0.47 for women). In a univariate analysis, sisters of the patients had a significantly higher fecundity rate (FR, 1.02), but this difference disappeared once comorbidities were factored into the analysis. Brothers also had significantly decreased fecundity (FR, 0.97).

"Our results suggest a strong selection pressure to remove genetic variants associated with schizophrenia from the population," the authors said. "This is further evidence for the role of recent or de novo mutations in the genetic susceptibility to schizophrenia that has neither reached the frequency of nor existed long enough to be removed from the population."

Autism was present in 2,947 patients; these had 4,471 siblings. Fecundity was significantly lower in both men and women (FR, 0.25 and 0.48, respectively). Among the siblings, brothers also had fewer children (FR, 0.94). Among sisters, the rate was not significantly different than the general population.

"Individuals with autism showed the greatest reduction in fecundity among all examined disorders. This was not unexpected because previous investigations have shown that few individuals with autism ever married or had children.

"We propose that rare highly deleterious variants and sexually antagonistic polymorphisms may contribute to the genetic disposition to autism. The similarity to schizophrenia is notable because it has been proposed that the autistic and psychotic spectrums reflect two extremes of social cognition."

Bipolar disorder was present in 14,439 patients, among whom were 22,986 siblings. Fecundity was significantly lower than the general population in both men (FR, 0.75) and women (FR, 0.85). While brothers had similar rates to that of the general population, sisters had significantly more children (FR, 1.03). But incorporating comorbidities into the analysis changed the significance for both patients and sisters, with the patient rate increasing to just below that of the general population (FR, 0.94), and the sisters’ rate increased rate no longer being significant (FR, 0.95).

"It has been suggested that the introduction of lithium as a treatment for bipolar disorder has led to improved functioning and, as a result, greater fecundity in those populations where treatment is available."

There were 81,295 patients with depression, among who were 119,645 siblings. While men with depression had significantly lower rates (FR, 0.93), women with the disorder were not significantly different than the general population. Siblings had significantly more children than the general population (FR, brothers 1.01, sisters 1.04) – a difference that was unchanged by factoring in comorbidities. The addition of comorbidities to the analysis did not change the decreased fecundity rate for male patients, but actually increased the rate for female patients (FR, 1.03).

"Notably, depression was an exception to the five other studied disorders ... genes associated with depression seems to be maintained in the population by balancing selection because the cost to affected individuals is roughly equal to the benefit to their siblings. If this is the case, it would be the first strong evidence for balancing selection in a psychiatric disorder."

There were 3,275 patients with anorexia, who had a total of 5,172 siblings. Both men and women with the disorder had significantly reduced fecundity (0.54 and 0.58, respectively). In the sibling group, there were no significant differences for either brothers or sisters. None of the findings changed when comorbidities were factored in.

"Our calculations suggest that anorexia is under weaker negative selection relative to schizophrenia and autism," the authors said.

Substance abuse was present in 55,933 patients, who had a total of 81,592 siblings. The fecundity rate was significantly lower in both men and women (FR, 0.78 and 0.93, respectively). Siblings had significantly more children than the general population (FR, 1.03 for brothers and 1.05 for sisters).

"Our findings suggest that this increased fecundity in siblings almost entirely accounts for the cost to affected individuals, with only a slight decrease in the frequency of these individuals’ genes predicted each generation. Considering that most drugs are a new environmental exposure when seen from an evolutionary perspective, it is possible that there has been insufficient time for selection to act on risk alleles. ... It has also been suggested that substance abuse is associated with risk-taking behavior in both sexes, including sexual risk taking."

The study was funded by the Medical Research Council of the United Kingdom. One of the coauthors reported having received consulting fees and honoraria from GlaxoSmithKline and Lundbeck.

[email protected]

Maternal use of selective serotonin reuptake inhibitors during pregnancy showed no association with stillbirth, neonatal mortality, or infant death up to 1 year of age in a large epidemiologic study reported in the Jan. 2 issue of JAMA.

An unadjusted preliminary analysis of the data, which covered 1.6 million recent singleton births in five Nordic countries, showed an association between SSRI use and both stillbirth and 1-year mortality. But that association disappeared once the data were adjusted to account for the severity of the mother’s underlying psychiatric disease and other maternal factors such as advanced age and smoking status, said Dr. Olof Stephansson of the Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, and his associates.

Creatas Images

"To our knowledge, only two studies have specifically addressed the risk of stillbirth or infant death after prenatal SSRI exposure," and neither one accounted for underlying maternal psychiatric disease. The findings of these two studies were somewhat equivocal.

Dr. Stephansson and his colleagues examined the issue using information in national registries of the entire populations of Denmark, Finland, Iceland, Norway, and Sweden. They analyzed prospectively collected data regarding 1,633,877 singleton births during several time periods between 1996 and 2007. In 29,228 (2%) of these cases, the mother had filled prescriptions for SSRIs during pregnancy.

The most frequently used SSRI was citalopram (6.49 prescriptions per 1,000 population), followed by fluoxetine (4.66/1,000) and sertraline (3.93/1,000). Paroxetine, fluvoxamine, and escitalopram also were included in the study.

There were 135 stillbirths, 74 neonatal deaths, and 40 postneonatal deaths among women who took SSRIs during pregnancy.

In a preliminary analysis, rates of stillbirth and postneonatal death were higher among women who took the antidepressants than among women who didn’t. However, in the final analysis that accounted for maternal characteristics including previous psychiatric hospitalizations, SSRI exposure was no longer associated with stillbirth or postneonatal death.

A sensitivity analysis produced essentially the same results, the investigators said (JAMA 2013;309:48-54).

In a further analysis of SSRI exposure by trimester, the risk of stillbirth appeared to be slightly elevated if exposure occurred during the first trimester, while the risks of neonatal and postneonatal death were not affected by trimester of exposure. However, this finding must be interpreted with caution because of the small number of study subjects in each category of exposure, the researchers said.

This study also was limited in that it did not include information on several variables that could affect rates of stillbirth, neonatal mortality, and infant mortality, such as the mothers’ alcohol intake or use of illegal drugs during pregnancy, their use of medications other than SSRIs, and the dosage levels of their SSRIs, Dr. Stephansson and his associates added.

This study was funded by the Swedish Pharmacy Co. and the investigators’ affiliated organizations. No financial conflicts of interest were reported.

Maternal use of selective serotonin reuptake inhibitors during pregnancy showed no association with stillbirth, neonatal mortality, or infant death up to 1 year of age in a large epidemiologic study reported in the Jan. 2 issue of JAMA.

An unadjusted preliminary analysis of the data, which covered 1.6 million recent singleton births in five Nordic countries, showed an association between SSRI use and both stillbirth and 1-year mortality. But that association disappeared once the data were adjusted to account for the severity of the mother’s underlying psychiatric disease and other maternal factors such as advanced age and smoking status, said Dr. Olof Stephansson of the Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, and his associates.

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"To our knowledge, only two studies have specifically addressed the risk of stillbirth or infant death after prenatal SSRI exposure," and neither one accounted for underlying maternal psychiatric disease. The findings of these two studies were somewhat equivocal.

Dr. Stephansson and his colleagues examined the issue using information in national registries of the entire populations of Denmark, Finland, Iceland, Norway, and Sweden. They analyzed prospectively collected data regarding 1,633,877 singleton births during several time periods between 1996 and 2007. In 29,228 (2%) of these cases, the mother had filled prescriptions for SSRIs during pregnancy.

The most frequently used SSRI was citalopram (6.49 prescriptions per 1,000 population), followed by fluoxetine (4.66/1,000) and sertraline (3.93/1,000). Paroxetine, fluvoxamine, and escitalopram also were included in the study.

There were 135 stillbirths, 74 neonatal deaths, and 40 postneonatal deaths among women who took SSRIs during pregnancy.

In a preliminary analysis, rates of stillbirth and postneonatal death were higher among women who took the antidepressants than among women who didn’t. However, in the final analysis that accounted for maternal characteristics including previous psychiatric hospitalizations, SSRI exposure was no longer associated with stillbirth or postneonatal death.

A sensitivity analysis produced essentially the same results, the investigators said (JAMA 2013;309:48-54).

In a further analysis of SSRI exposure by trimester, the risk of stillbirth appeared to be slightly elevated if exposure occurred during the first trimester, while the risks of neonatal and postneonatal death were not affected by trimester of exposure. However, this finding must be interpreted with caution because of the small number of study subjects in each category of exposure, the researchers said.

This study also was limited in that it did not include information on several variables that could affect rates of stillbirth, neonatal mortality, and infant mortality, such as the mothers’ alcohol intake or use of illegal drugs during pregnancy, their use of medications other than SSRIs, and the dosage levels of their SSRIs, Dr. Stephansson and his associates added.

This study was funded by the Swedish Pharmacy Co. and the investigators’ affiliated organizations. No financial conflicts of interest were reported.

Maternal use of selective serotonin reuptake inhibitors during pregnancy showed no association with stillbirth, neonatal mortality, or infant death up to 1 year of age in a large epidemiologic study reported in the Jan. 2 issue of JAMA.

An unadjusted preliminary analysis of the data, which covered 1.6 million recent singleton births in five Nordic countries, showed an association between SSRI use and both stillbirth and 1-year mortality. But that association disappeared once the data were adjusted to account for the severity of the mother’s underlying psychiatric disease and other maternal factors such as advanced age and smoking status, said Dr. Olof Stephansson of the Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, and his associates.

Creatas Images

"To our knowledge, only two studies have specifically addressed the risk of stillbirth or infant death after prenatal SSRI exposure," and neither one accounted for underlying maternal psychiatric disease. The findings of these two studies were somewhat equivocal.

Dr. Stephansson and his colleagues examined the issue using information in national registries of the entire populations of Denmark, Finland, Iceland, Norway, and Sweden. They analyzed prospectively collected data regarding 1,633,877 singleton births during several time periods between 1996 and 2007. In 29,228 (2%) of these cases, the mother had filled prescriptions for SSRIs during pregnancy.

The most frequently used SSRI was citalopram (6.49 prescriptions per 1,000 population), followed by fluoxetine (4.66/1,000) and sertraline (3.93/1,000). Paroxetine, fluvoxamine, and escitalopram also were included in the study.

There were 135 stillbirths, 74 neonatal deaths, and 40 postneonatal deaths among women who took SSRIs during pregnancy.

In a preliminary analysis, rates of stillbirth and postneonatal death were higher among women who took the antidepressants than among women who didn’t. However, in the final analysis that accounted for maternal characteristics including previous psychiatric hospitalizations, SSRI exposure was no longer associated with stillbirth or postneonatal death.

A sensitivity analysis produced essentially the same results, the investigators said (JAMA 2013;309:48-54).

In a further analysis of SSRI exposure by trimester, the risk of stillbirth appeared to be slightly elevated if exposure occurred during the first trimester, while the risks of neonatal and postneonatal death were not affected by trimester of exposure. However, this finding must be interpreted with caution because of the small number of study subjects in each category of exposure, the researchers said.

This study also was limited in that it did not include information on several variables that could affect rates of stillbirth, neonatal mortality, and infant mortality, such as the mothers’ alcohol intake or use of illegal drugs during pregnancy, their use of medications other than SSRIs, and the dosage levels of their SSRIs, Dr. Stephansson and his associates added.

This study was funded by the Swedish Pharmacy Co. and the investigators’ affiliated organizations. No financial conflicts of interest were reported.