Obstetrics

Women with high-quality diets during the year before pregnancy were at lower risk than were those with poor diets for delivering a baby with orofacial clefts or neural tube defects, according to a study.

This finding, from an analysis of data in the ongoing National Birth Defects Prevention Study (NBDPS), is “notable” because previous analyses of the same data, “which assessed single-nutrient intakes in isolation, had not been informative.

“In particular, maternal intake of folic acid–containing vitamin/mineral supplements was not associated in the NBDPS with a reduced risk of neural tube defects, and findings for dietary folate were inconsistent” in these previous analyses, said Suzan L. Carmichael, Ph.D., of Stanford (Calif.) University and her associates.

“[Our] findings suggest that overall diet quality is more predictive of birth defect risk than intake of single nutrients,” they noted.

Dr. Carmichael and her colleagues developed two indexes of dietary quality, one modeled after the Mediterranean Diet Score and the second after the Diet Quality Index for Pregnancy. They then assessed how each of these indexes performed in predicting risk for isolated (nonsyndromic) neural tube defects and orofacial clefts using data on 9,558 pregnancies in the NBDPS.

The NBDPS is an ongoing multistate, population-based case-control study of well-defined birth defects. For this analysis, the researchers assessed 3,411 pregnancies involving isolated neural tube defects (936) or orofacial clefts (2,475), and 6,147 pregnancies that served as controls. All the deliveries occurred between 1997 and 2005.

For both indexes of dietary quality, “we observed reduced birth defects risks associated with higher dietary quality scores. That is, after adjusting for all covariates, increasing diet quality based on either index was associated with reduced risk of each birth defect studied,” the researchers said (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.185]).

“The strongest associations were observed for anencephaly,” they added.

The findings were similar in further analyses of important subgroups of patients, including an assessment restricted to women who took vitamin/mineral supplements.

These results likely are generalizable to other women “because of [our] study's population-based design, active case ascertainment, and the racial/ethnic, geographic, and socioeconomic diversity” of the subjects.

“Although the focus on folic acid has enabled substantial reductions in the prevalence of neural tube defects and perhaps other birth defects, the population burden of birth defects remains extensive. If increased dietary quality can indeed have a greater impact than individual nutrients, appropriate public health messages may need to be developed that convey this broader perspective,” Dr. Carmichael and her associates said.

This study was supported in part by the National Institutes of Health and the Centers for Disease Control and Prevention. Dr. Carmichael and her associates reported no relevant financial disclosures.

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Eating Well Is the Best Defense

“The lesson from the article by Carmichael et al. is an important one: People, including women of childbearing age, should eat good food,” said David R. Jacobs Jr., Ph.D., and his associates.

“A nutrient [supplement] may correct a deficiency condition but not necessarily be of benefit at higher doses in well-nourished people,” they added.

“Reduction of neural tube defects may be achievable by diet alone, at the same time reducing potential risk for other chronic diseases in the rest of the population,” they said.

DR. JACOBS and his associates are in the division of epidemiology and community health at the University of Minnesota School of Public Health, Minneapolis. They reported no relevant financial disclosures. These remarks were taken from their editorial accompanying Dr. Carmichael's report (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.184]).

Women with high-quality diets during the year before pregnancy were at lower risk than were those with poor diets for delivering a baby with orofacial clefts or neural tube defects, according to a study.

This finding, from an analysis of data in the ongoing National Birth Defects Prevention Study (NBDPS), is “notable” because previous analyses of the same data, “which assessed single-nutrient intakes in isolation, had not been informative.

“In particular, maternal intake of folic acid–containing vitamin/mineral supplements was not associated in the NBDPS with a reduced risk of neural tube defects, and findings for dietary folate were inconsistent” in these previous analyses, said Suzan L. Carmichael, Ph.D., of Stanford (Calif.) University and her associates.

“[Our] findings suggest that overall diet quality is more predictive of birth defect risk than intake of single nutrients,” they noted.

Dr. Carmichael and her colleagues developed two indexes of dietary quality, one modeled after the Mediterranean Diet Score and the second after the Diet Quality Index for Pregnancy. They then assessed how each of these indexes performed in predicting risk for isolated (nonsyndromic) neural tube defects and orofacial clefts using data on 9,558 pregnancies in the NBDPS.

The NBDPS is an ongoing multistate, population-based case-control study of well-defined birth defects. For this analysis, the researchers assessed 3,411 pregnancies involving isolated neural tube defects (936) or orofacial clefts (2,475), and 6,147 pregnancies that served as controls. All the deliveries occurred between 1997 and 2005.

For both indexes of dietary quality, “we observed reduced birth defects risks associated with higher dietary quality scores. That is, after adjusting for all covariates, increasing diet quality based on either index was associated with reduced risk of each birth defect studied,” the researchers said (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.185]).

“The strongest associations were observed for anencephaly,” they added.

The findings were similar in further analyses of important subgroups of patients, including an assessment restricted to women who took vitamin/mineral supplements.

These results likely are generalizable to other women “because of [our] study's population-based design, active case ascertainment, and the racial/ethnic, geographic, and socioeconomic diversity” of the subjects.

“Although the focus on folic acid has enabled substantial reductions in the prevalence of neural tube defects and perhaps other birth defects, the population burden of birth defects remains extensive. If increased dietary quality can indeed have a greater impact than individual nutrients, appropriate public health messages may need to be developed that convey this broader perspective,” Dr. Carmichael and her associates said.

This study was supported in part by the National Institutes of Health and the Centers for Disease Control and Prevention. Dr. Carmichael and her associates reported no relevant financial disclosures.

View on the News

Eating Well Is the Best Defense

“The lesson from the article by Carmichael et al. is an important one: People, including women of childbearing age, should eat good food,” said David R. Jacobs Jr., Ph.D., and his associates.

“A nutrient [supplement] may correct a deficiency condition but not necessarily be of benefit at higher doses in well-nourished people,” they added.

“Reduction of neural tube defects may be achievable by diet alone, at the same time reducing potential risk for other chronic diseases in the rest of the population,” they said.

DR. JACOBS and his associates are in the division of epidemiology and community health at the University of Minnesota School of Public Health, Minneapolis. They reported no relevant financial disclosures. These remarks were taken from their editorial accompanying Dr. Carmichael's report (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.184]).

Women with high-quality diets during the year before pregnancy were at lower risk than were those with poor diets for delivering a baby with orofacial clefts or neural tube defects, according to a study.

This finding, from an analysis of data in the ongoing National Birth Defects Prevention Study (NBDPS), is “notable” because previous analyses of the same data, “which assessed single-nutrient intakes in isolation, had not been informative.

“In particular, maternal intake of folic acid–containing vitamin/mineral supplements was not associated in the NBDPS with a reduced risk of neural tube defects, and findings for dietary folate were inconsistent” in these previous analyses, said Suzan L. Carmichael, Ph.D., of Stanford (Calif.) University and her associates.

“[Our] findings suggest that overall diet quality is more predictive of birth defect risk than intake of single nutrients,” they noted.

Dr. Carmichael and her colleagues developed two indexes of dietary quality, one modeled after the Mediterranean Diet Score and the second after the Diet Quality Index for Pregnancy. They then assessed how each of these indexes performed in predicting risk for isolated (nonsyndromic) neural tube defects and orofacial clefts using data on 9,558 pregnancies in the NBDPS.

The NBDPS is an ongoing multistate, population-based case-control study of well-defined birth defects. For this analysis, the researchers assessed 3,411 pregnancies involving isolated neural tube defects (936) or orofacial clefts (2,475), and 6,147 pregnancies that served as controls. All the deliveries occurred between 1997 and 2005.

For both indexes of dietary quality, “we observed reduced birth defects risks associated with higher dietary quality scores. That is, after adjusting for all covariates, increasing diet quality based on either index was associated with reduced risk of each birth defect studied,” the researchers said (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.185]).

“The strongest associations were observed for anencephaly,” they added.

The findings were similar in further analyses of important subgroups of patients, including an assessment restricted to women who took vitamin/mineral supplements.

These results likely are generalizable to other women “because of [our] study's population-based design, active case ascertainment, and the racial/ethnic, geographic, and socioeconomic diversity” of the subjects.

“Although the focus on folic acid has enabled substantial reductions in the prevalence of neural tube defects and perhaps other birth defects, the population burden of birth defects remains extensive. If increased dietary quality can indeed have a greater impact than individual nutrients, appropriate public health messages may need to be developed that convey this broader perspective,” Dr. Carmichael and her associates said.

This study was supported in part by the National Institutes of Health and the Centers for Disease Control and Prevention. Dr. Carmichael and her associates reported no relevant financial disclosures.

View on the News

Eating Well Is the Best Defense

“The lesson from the article by Carmichael et al. is an important one: People, including women of childbearing age, should eat good food,” said David R. Jacobs Jr., Ph.D., and his associates.

“A nutrient [supplement] may correct a deficiency condition but not necessarily be of benefit at higher doses in well-nourished people,” they added.

“Reduction of neural tube defects may be achievable by diet alone, at the same time reducing potential risk for other chronic diseases in the rest of the population,” they said.

DR. JACOBS and his associates are in the division of epidemiology and community health at the University of Minnesota School of Public Health, Minneapolis. They reported no relevant financial disclosures. These remarks were taken from their editorial accompanying Dr. Carmichael's report (Arch. Pediatr. Adolesc. Med. 2011 [doi:10.1001/archpediatrics.2011.184]).

In-utero exposure to diethylstilbestrol was associated with a high lifetime risk of a broad spectrum of adverse outcomes in a follow-up study of patients now in their 40s, 50s, and 60s.

Most of these risks were increased by a factor of more than two, compared with the risks in women of the same age who were not exposed to diethylstilbestrol (DES), said Dr. Robert N. Hoover of the National Cancer Institute, Bethesda, Md., and his associates. “Although DES has not been prescribed for pregnant women in the United States for 40 years, adverse outcomes continue to occur in women exposed in utero, and continued monitoring … for established and unexpected adverse outcomes seems prudent,” they noted.

In the early 1990s, Dr. Hoover and his colleagues combined three cohort studies of DES-exposed women that had begun in the mid-1970s, so that the pooled subjects could be followed periodically with self-report questionnaires. Their Combined Cohort Study of DES Exposure involved 4,001 DES-exposed women and 1,683 nonexposed control subjects from the original cohorts, who were born between the late 1940s and the early 1960s and whose average age at last follow-up was 48 years.

Twelve adverse health outcomes that were significantly associated with DES in previous studies were assessed in the combined cohort, and all 12 were found to be significantly associated with DES in this combined analysis.

The hazard ratios (HRs) associated with DES exposure, compared with nonexposure, ranged from a low of 1.42 for preeclampsia to a high of 8.12 for neonatal death (usually related to preterm delivery). In ascending order, the HRs were 1.64 for spontaneous abortion; 1.82 for breast cancer diagnosed at age 40 or older; 2.28 for cervical intraepithelial neoplasia of grade 2 or higher; 2.35 for early menopause; 2.37 for infertility; 2.45 for stillbirth; 3.72 for ectopic pregnancy; 3.77 for loss of second-trimester pregnancy; and 4.68 for preterm delivery, the investigators wrote (N. Engl. J. Med. 2011;365:1304-14).

DES-exposed women who had clinical evidence of vaginal epithelial changes at a young age – a marker of high DES dose and exposure early in gestation – were found to have significantly higher risks for adverse outcomes than did exposed women who showed no vaginal epithelial changes. This finding provides additional support for the argument that DES exposure caused, and was not just linked to, the adverse outcomes, they said.

The researchers also calculated the excess risk of adverse outcomes that could be attributed directly to DES exposure. This excess risk was 1.7% for breast cancer, 3.4% for early menopause, 3.5% for CIN, 6.3% for stillbirth, 7.2% for neonatal death, 11.7% for both spontaneous abortion and ectopic pregnancy, 12.7% for preeclampsia, 14.7% for loss of second-trimester pregnancy, 17.8% for infertility, and 35.4% for preterm delivery.

The Combined Cohort Study of DES Exposure was supported by the National Cancer Institute. Dr. Robboy reports receiving consulting fees from UCB, Belgium. Dr. Karlan reports holding stock in and receiving board membership fees from IRIS International. Dr. Hatch receives royalties as a reviewer of the DES card on the UpToDate medical information site.

In-utero exposure to diethylstilbestrol was associated with a high lifetime risk of a broad spectrum of adverse outcomes in a follow-up study of patients now in their 40s, 50s, and 60s.

Most of these risks were increased by a factor of more than two, compared with the risks in women of the same age who were not exposed to diethylstilbestrol (DES), said Dr. Robert N. Hoover of the National Cancer Institute, Bethesda, Md., and his associates. “Although DES has not been prescribed for pregnant women in the United States for 40 years, adverse outcomes continue to occur in women exposed in utero, and continued monitoring … for established and unexpected adverse outcomes seems prudent,” they noted.

In the early 1990s, Dr. Hoover and his colleagues combined three cohort studies of DES-exposed women that had begun in the mid-1970s, so that the pooled subjects could be followed periodically with self-report questionnaires. Their Combined Cohort Study of DES Exposure involved 4,001 DES-exposed women and 1,683 nonexposed control subjects from the original cohorts, who were born between the late 1940s and the early 1960s and whose average age at last follow-up was 48 years.

Twelve adverse health outcomes that were significantly associated with DES in previous studies were assessed in the combined cohort, and all 12 were found to be significantly associated with DES in this combined analysis.

The hazard ratios (HRs) associated with DES exposure, compared with nonexposure, ranged from a low of 1.42 for preeclampsia to a high of 8.12 for neonatal death (usually related to preterm delivery). In ascending order, the HRs were 1.64 for spontaneous abortion; 1.82 for breast cancer diagnosed at age 40 or older; 2.28 for cervical intraepithelial neoplasia of grade 2 or higher; 2.35 for early menopause; 2.37 for infertility; 2.45 for stillbirth; 3.72 for ectopic pregnancy; 3.77 for loss of second-trimester pregnancy; and 4.68 for preterm delivery, the investigators wrote (N. Engl. J. Med. 2011;365:1304-14).

DES-exposed women who had clinical evidence of vaginal epithelial changes at a young age – a marker of high DES dose and exposure early in gestation – were found to have significantly higher risks for adverse outcomes than did exposed women who showed no vaginal epithelial changes. This finding provides additional support for the argument that DES exposure caused, and was not just linked to, the adverse outcomes, they said.

The researchers also calculated the excess risk of adverse outcomes that could be attributed directly to DES exposure. This excess risk was 1.7% for breast cancer, 3.4% for early menopause, 3.5% for CIN, 6.3% for stillbirth, 7.2% for neonatal death, 11.7% for both spontaneous abortion and ectopic pregnancy, 12.7% for preeclampsia, 14.7% for loss of second-trimester pregnancy, 17.8% for infertility, and 35.4% for preterm delivery.

The Combined Cohort Study of DES Exposure was supported by the National Cancer Institute. Dr. Robboy reports receiving consulting fees from UCB, Belgium. Dr. Karlan reports holding stock in and receiving board membership fees from IRIS International. Dr. Hatch receives royalties as a reviewer of the DES card on the UpToDate medical information site.

In-utero exposure to diethylstilbestrol was associated with a high lifetime risk of a broad spectrum of adverse outcomes in a follow-up study of patients now in their 40s, 50s, and 60s.

Most of these risks were increased by a factor of more than two, compared with the risks in women of the same age who were not exposed to diethylstilbestrol (DES), said Dr. Robert N. Hoover of the National Cancer Institute, Bethesda, Md., and his associates. “Although DES has not been prescribed for pregnant women in the United States for 40 years, adverse outcomes continue to occur in women exposed in utero, and continued monitoring … for established and unexpected adverse outcomes seems prudent,” they noted.

In the early 1990s, Dr. Hoover and his colleagues combined three cohort studies of DES-exposed women that had begun in the mid-1970s, so that the pooled subjects could be followed periodically with self-report questionnaires. Their Combined Cohort Study of DES Exposure involved 4,001 DES-exposed women and 1,683 nonexposed control subjects from the original cohorts, who were born between the late 1940s and the early 1960s and whose average age at last follow-up was 48 years.

Twelve adverse health outcomes that were significantly associated with DES in previous studies were assessed in the combined cohort, and all 12 were found to be significantly associated with DES in this combined analysis.

The hazard ratios (HRs) associated with DES exposure, compared with nonexposure, ranged from a low of 1.42 for preeclampsia to a high of 8.12 for neonatal death (usually related to preterm delivery). In ascending order, the HRs were 1.64 for spontaneous abortion; 1.82 for breast cancer diagnosed at age 40 or older; 2.28 for cervical intraepithelial neoplasia of grade 2 or higher; 2.35 for early menopause; 2.37 for infertility; 2.45 for stillbirth; 3.72 for ectopic pregnancy; 3.77 for loss of second-trimester pregnancy; and 4.68 for preterm delivery, the investigators wrote (N. Engl. J. Med. 2011;365:1304-14).

DES-exposed women who had clinical evidence of vaginal epithelial changes at a young age – a marker of high DES dose and exposure early in gestation – were found to have significantly higher risks for adverse outcomes than did exposed women who showed no vaginal epithelial changes. This finding provides additional support for the argument that DES exposure caused, and was not just linked to, the adverse outcomes, they said.

The researchers also calculated the excess risk of adverse outcomes that could be attributed directly to DES exposure. This excess risk was 1.7% for breast cancer, 3.4% for early menopause, 3.5% for CIN, 6.3% for stillbirth, 7.2% for neonatal death, 11.7% for both spontaneous abortion and ectopic pregnancy, 12.7% for preeclampsia, 14.7% for loss of second-trimester pregnancy, 17.8% for infertility, and 35.4% for preterm delivery.

The Combined Cohort Study of DES Exposure was supported by the National Cancer Institute. Dr. Robboy reports receiving consulting fees from UCB, Belgium. Dr. Karlan reports holding stock in and receiving board membership fees from IRIS International. Dr. Hatch receives royalties as a reviewer of the DES card on the UpToDate medical information site.

LISBON – Women with a history of gestational diabetes had an overall 50% higher risk for cardiovascular events later in life, and the risk was doubled among overweight women, based on the results of a large, population-based, case-control study in Sweden.

Gestational diabetes is associated with increased risk for type 2 diabetes later in life. The relationship between gestational diabetes mellitus (GDM) and cardiovascular disease has been less well studied.

Also, this appears to be the first analysis to adjust for possible confounders. The increased risk for cardiovascular disease among women with previous GDM was significant among women with body mass indexes (BMIs) of at least 25 kg/m

Moreover, hypertension and smoking during pregnancy were stronger risk factors for later cardiovascular disease than was GDM. “Preventive strategies after pregnancy might need to be individualized depending on each woman's characteristics and risk profile,” said Dr. Erik Schwarcz, an endocrinologist and senior physician at University Hospital Orebro, Sweden.

Cases in the study, which used data from Swedish National Healthcare Quality registers from 1991 through 2008, were 4,590 women who died of cardiovascular disease or had a first cardiovascular event – ischemic heart disease, ischemic stroke, peripheral arterial disease, or atherosclerosis – and who gave birth to at least one child during the study period. Each of those women was matched with about five age-matched controls – total 22,398 – who did not have cardiovascular disease and who gave birth during the same year.

At the time of the cardiovascular event, the cases' mean age was 41 years (range 19-61), with a mean of 9 years between the pregnancy and the event. There were 130 deaths among the 2,660 cases, compared with 2 in the 13,357 controls. Ischemic heart disease and stroke were the most common diagnoses, affecting 56% and 35%, respectively.

A history of GDM was present for 2.4% of the cases, compared with 1.2% of the controls, a significant difference. Also significantly increased among the cases were chronic hypertension (2.1% vs. 0.3%), smoking (35.3% vs. 18.1%), non-Nordic ethnicity (14.1% vs. 11.5%), mean BMI (25.4 vs. 23.9 kg/m

After adjustment for hypertension, smoking, BMI, parity, education level, and ethnicity, all of the risk factors remained significant except for non-Nordic ethnicity, with odds ratios of 1.50 for GDM, 5.15 for chronic hypertension, and 2.24 for smoking. Using a BMI of 20-25 as the referent, a BMI of 25-29 gave an odds ratio of 1.32, while a BMI of 30 or greater doubled the risk (OR, 2.00).

Dr. Schwarcz disclosed that he has received lecture fees and has conducted clinical trials for Sanofi-Aventis, Novo-Nordisk, and AstraZeneca.

LISBON – Women with a history of gestational diabetes had an overall 50% higher risk for cardiovascular events later in life, and the risk was doubled among overweight women, based on the results of a large, population-based, case-control study in Sweden.

Gestational diabetes is associated with increased risk for type 2 diabetes later in life. The relationship between gestational diabetes mellitus (GDM) and cardiovascular disease has been less well studied.

Also, this appears to be the first analysis to adjust for possible confounders. The increased risk for cardiovascular disease among women with previous GDM was significant among women with body mass indexes (BMIs) of at least 25 kg/m

Moreover, hypertension and smoking during pregnancy were stronger risk factors for later cardiovascular disease than was GDM. “Preventive strategies after pregnancy might need to be individualized depending on each woman's characteristics and risk profile,” said Dr. Erik Schwarcz, an endocrinologist and senior physician at University Hospital Orebro, Sweden.

Cases in the study, which used data from Swedish National Healthcare Quality registers from 1991 through 2008, were 4,590 women who died of cardiovascular disease or had a first cardiovascular event – ischemic heart disease, ischemic stroke, peripheral arterial disease, or atherosclerosis – and who gave birth to at least one child during the study period. Each of those women was matched with about five age-matched controls – total 22,398 – who did not have cardiovascular disease and who gave birth during the same year.

At the time of the cardiovascular event, the cases' mean age was 41 years (range 19-61), with a mean of 9 years between the pregnancy and the event. There were 130 deaths among the 2,660 cases, compared with 2 in the 13,357 controls. Ischemic heart disease and stroke were the most common diagnoses, affecting 56% and 35%, respectively.

A history of GDM was present for 2.4% of the cases, compared with 1.2% of the controls, a significant difference. Also significantly increased among the cases were chronic hypertension (2.1% vs. 0.3%), smoking (35.3% vs. 18.1%), non-Nordic ethnicity (14.1% vs. 11.5%), mean BMI (25.4 vs. 23.9 kg/m

After adjustment for hypertension, smoking, BMI, parity, education level, and ethnicity, all of the risk factors remained significant except for non-Nordic ethnicity, with odds ratios of 1.50 for GDM, 5.15 for chronic hypertension, and 2.24 for smoking. Using a BMI of 20-25 as the referent, a BMI of 25-29 gave an odds ratio of 1.32, while a BMI of 30 or greater doubled the risk (OR, 2.00).

Dr. Schwarcz disclosed that he has received lecture fees and has conducted clinical trials for Sanofi-Aventis, Novo-Nordisk, and AstraZeneca.

LISBON – Women with a history of gestational diabetes had an overall 50% higher risk for cardiovascular events later in life, and the risk was doubled among overweight women, based on the results of a large, population-based, case-control study in Sweden.

Gestational diabetes is associated with increased risk for type 2 diabetes later in life. The relationship between gestational diabetes mellitus (GDM) and cardiovascular disease has been less well studied.

Also, this appears to be the first analysis to adjust for possible confounders. The increased risk for cardiovascular disease among women with previous GDM was significant among women with body mass indexes (BMIs) of at least 25 kg/m

Moreover, hypertension and smoking during pregnancy were stronger risk factors for later cardiovascular disease than was GDM. “Preventive strategies after pregnancy might need to be individualized depending on each woman's characteristics and risk profile,” said Dr. Erik Schwarcz, an endocrinologist and senior physician at University Hospital Orebro, Sweden.

Cases in the study, which used data from Swedish National Healthcare Quality registers from 1991 through 2008, were 4,590 women who died of cardiovascular disease or had a first cardiovascular event – ischemic heart disease, ischemic stroke, peripheral arterial disease, or atherosclerosis – and who gave birth to at least one child during the study period. Each of those women was matched with about five age-matched controls – total 22,398 – who did not have cardiovascular disease and who gave birth during the same year.

At the time of the cardiovascular event, the cases' mean age was 41 years (range 19-61), with a mean of 9 years between the pregnancy and the event. There were 130 deaths among the 2,660 cases, compared with 2 in the 13,357 controls. Ischemic heart disease and stroke were the most common diagnoses, affecting 56% and 35%, respectively.

A history of GDM was present for 2.4% of the cases, compared with 1.2% of the controls, a significant difference. Also significantly increased among the cases were chronic hypertension (2.1% vs. 0.3%), smoking (35.3% vs. 18.1%), non-Nordic ethnicity (14.1% vs. 11.5%), mean BMI (25.4 vs. 23.9 kg/m

After adjustment for hypertension, smoking, BMI, parity, education level, and ethnicity, all of the risk factors remained significant except for non-Nordic ethnicity, with odds ratios of 1.50 for GDM, 5.15 for chronic hypertension, and 2.24 for smoking. Using a BMI of 20-25 as the referent, a BMI of 25-29 gave an odds ratio of 1.32, while a BMI of 30 or greater doubled the risk (OR, 2.00).

Dr. Schwarcz disclosed that he has received lecture fees and has conducted clinical trials for Sanofi-Aventis, Novo-Nordisk, and AstraZeneca.

BOULDER, COLO. – A buzz of excitement – a sense of history in the making – was palpable as the newly incorporated Society of Ob/Gyn Hospitalists held its first-ever annual meeting here.

“We are all witnessing the birth of a new subspecialty,” declared Dr. Brigid McCue, an ob.gyn. hospitalist at Jordan Hospital in Plymouth, Mass., and a member of the Society of Ob/Gyn Hospitalists (SOGH) steering committee.

Present at the birth were officials from both the American College of Obstetricians and Gynecologists (ACOG) and the Society of Hospital Medicine (SHM), two organizations interested in having close ties with the new medical society.

“ACOG recognizes this is the new paradigm of care,” said Dr. J. Joshua Kopelman, chair of ACOG District VIII. “We absolutely want you to be people who provide input about what you do to all of the committees at the executive level of the college.”

“Ob.gyn. hospitalists in this country are the wave of the future. There's no question about it. The model has been going on for a long time in Great Britain, for example, where you have people whose practices are office-based, and you have people who work full time in the hospital and that's all they do. They've had to learn how to do patient handoffs between these two groups of physicians,” he added.

Dr. Shaun Frost, president-elect of the SHM, observed that “it's kind of mind-boggling” to see the parallels between the birth of that organization and the SOGH. Both groups began with a small cadre of enthusiastic people full of outside-the-box ideas about how to improve patient care in the hospital.

Hospital medicine has experienced astronomical growth. The SHM consisted of 23 members in 1997, the year of its birth. Membership climbed to 800 just 2 years later, then to 3,200 in 2003, 6,300 in 2006, and now sits at about 12,000.

“I would anticipate that you're going to experience the same thing we did in terms of rapid and significant growth. Tighten your seat belts – it can be a wild ride sometimes, but I can tell you that for me, after 14 years, it has been nothing short of profoundly gratifying,” said Dr. Frost, who is chief medical officer for the Northeast region of Cogent HMG Healthcare and an internist at the University of Minnesota, Minneapolis.

In an interview, meeting cochair Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each. Most work 12-hour shifts, some 24-hour shifts.

“Right now hospitalists are doing a very small percentage of all deliveries, maybe 2%. I project in 5 years we'll be doing 20% or 25%,” predicted Dr. Olson, an ob.gyn. hospitalist in Bellingham, Wash., and founder of www.obgynhospitalist.com

The primary mission of ob.gyn. hospitalists is to enhance patient safety in the hospital, he explained. If an emergency requiring cesarean section occurs, the hospitalist can start the operation while the private obstetrician is en route, shifting to second assistant when the private physician arrives and takes over the procedure. Or if a woman who has been in labor for a few hours begins progressing rapidly at 2 a.m., the hospitalist can step in and do the delivery if the private physician can't get to the hospital promptly.

Hospitalists can also provide support when a midwife or family physician has a complicated delivery requiring a vacuum extraction, forceps, or a cesarean section.

“It's kind of like being a lifeguard, where you're sitting at the beach waiting for the problem,” he said.

Ordinarily a hospitalist will never see a patient antepartum. The exception is the unassigned patient who may drop in to the hospital with no prenatal care, who then becomes the hospitalist's responsibility.

Hospitalists also support private physicians by letting them sign out patients as a convenience. “A private physician may say, 'I've got a big surgery tomorrow. Can you take care of all of my patients between midnight and 6 a.m. so I can sleep?' That's another way of utilizing us,” Dr. Olson continued.

In the initial months following introduction of an ob.gyn. hospitalist program, however, patient sign-outs typically aren't a substantial part of the job. “At the beginning the private doctors are a little worried about it. They don't want to sign out. They're suspicious. They're afraid that they're going to give up not only their patients but their revenue. When they realize how helpful check outs are, though, then they sign out,” he explained.

Some ob.gyn. hospitalists are laborists only and prefer it that way. Others also cover gynecologic cases in the emergency department. “I have diagnosed more horrific cancers in 18 months as a hospitalist than in 13 years of private practice,” Dr. McCue said, adding that she feels good about covering gynecologic cases in the ER because it enables her to maintain some of her hard-earned gynecologic skills.

Several audience members voiced discomfort about leaving the labor and delivery area to take on emergency department gynecologic surgical cases because it distracts from the primary hospitalist focus of saving babies. Dr. McCue responded that the answer is to negotiate boundaries.

“What most of the hospitalist programs are coming to is making a deal with the privates,” she explained. “You say, 'I am doing the vast majority of your nighttime work by covering the labor floor for you and covering the first calls for you. All that I ask is that you be available on an emergency basis for the ER overload that I can't handle. I am happy to get the ectopics and incompletes started for you, but if I call that's because I need you to be there to cover.'”

Conference attendees heard best-practice updates from authorities on obstetric triage and evidence-based cesarean section techniques. They also began planning SOGH's future course. Dr. Bob Fagnant circulated a rough draft of proposed core competencies defining what ob.gyn. hospitalists need to be able to do. (See box.)

The society will eventually have to formally settle on a group of core competencies, a program for attaining them, and a means of tracking them to attain subspecialty status from the American Board of Obstetrics and Gynecology. The board will want to see evidence that being an ob.gyn. hospitalist requires a special set of skills not taught to physicians who graduate residency as general ob.gyns., explained Dr. Fagnant, an ob.gyn. hospitalist at Intermountain Health Care in St. George, Utah, who is also vice chair of the ACOG Committee on Ambulatory Practice.

The SOGH leadership believes simulation training will play a key role in demonstrating ob.gyn. hospitalist competencies. Toward that end, SOGH's first annual meeting featured a half-day of participation in a three-station obstetrical emergency simulation workshop focused on management of obstetric hemorrhage, maneuvers and techniques to relieve shoulder dystocia, and operative deliveries.

Dr. Arthur Townsend, medical director of the ob.gyn. hospitalist program at Methodist Le-Bonheur Hospital in Germantown, Tenn., stressed that hospitalists are “perfectly positioned” to support the quality initiatives hospitals take on to improve outcomes, decrease liability, attract patients, and meet the requirements of outside national organizations that report on quality indicators, such as the National Perinatal Information Center/Quality Analytic Services.

A significant part of what he and his hospitalist colleagues do is gather statistics. These include hospital-wide cesarean rates, vaginal births after cesarean, incidence of episiotomy, third- and fourth-degree laceration rates, postpartum hemorrhage, vaginal deliveries with shoulder dystocia, and a host of others.

He and his fellow hospitalists also carefully track their own performance. They file a detailed online report at a secure website upon completing every shift. These shift reports are compiled into monthly reports totaling the number of deliveries the hospitalists have performed, assists provided at cesarean and vaginal deliveries, the emergencies hospitalists responded to, the number of gynecologic surgeries performed, unassigned patients they've seen, and nurse and physician satisfaction survey results. These reports go to the hospital CEO, the board of directors, and the hospital risk management and quality committees.

“We've got some data to show that we really make a difference. What we do in these reports is tell how we save people. Everyone wants to know how many patients we're saving,” he explained.

The hospitalists track and submit individual physician-level statistics. When the data point to a problem physician – for example, an ob.gyn. who doesn't return phone calls from a nighttime nurse in timely fashion or who regularly scores poorly in patient satisfaction – Dr. Townsend leaves it to the hospital quality committee to do something about it. “I don't want to be the sheriff,” he explained.

These data-filled reports document the progress the hospital has made in achieving safety. This in turn has led to a reduction in the cost of the hospital's risk insurance. Moreover, when Dr. Townsend made a presentation to the hospital's risk underwriter, the company was so favorably impressed by what ob.gyn. hospitalists do that it provided them with a $60,000 grant to purchase obstetrical emergency simulators.

Dr. Townsend asked audience members to think about which hospitalist quality measures they consider to be most important yet practical for hospitalist practices to routinely collect at the national level. This is an issue where SOGH would like to be able to provide recommendations.

Dr. Suneet P. Chauhan, a non-hospitalist guest speaker at the conference, recommended focusing initially on two key statistics where he believes ob.gyn. hospitalists could make an impact with maximum “wow” factor: time to cesarean section for nonreassuring fetal heart rate tracings, and time spent in obstetric triage for preterm labor.

“As everyone knows, in one-third of cases the decision-to-incision time in an emergency c-section is not met. The lawyers know that, too. You, more than any other person in the hospital, can decrease the decision-to-incision time,” he told the hospitalists.

“You can also really help in obstetric triage. Triage is a very expensive place. In our hospital a patient could be there 3-6 hours before being seen. But if hospitalists routinely adopted the use of transvaginal cervical length measurement and/or fetal fibronectin, it would really shorten the stay at triage,” predicted Dr. Chauhan, director of maternal-fetal medicine and professor of ob.gyn. at Eastern Virginia Medical School, Norfolk.

Dr. Frost, the SHM president-elect, shared five key lessons he believes to be essential in building a hospitalist medical society from scratch, based upon the SHM experience: focus keenly on quality improvement; seek to be recognized by external stakeholders as health care reform facilitators, not obstructionists; respect the power of 'branding” as hospitalists; define your members' uniqueness; and be an inclusive “big tent” organization rather than exclusive in terms of membership.

ACOG District VIII Chair Dr. Kopelman urged SOGH members to make their viewpoint heard at ACOG by becoming active at the section and district level, then applying for one of the roughly 50 new committee appointments made each year. Natural fits for SOGH members might be the Committee on Patient Safety and Quality Improvement, the Committee on Obstetric Practice, the Committee on Professional Liability, and the Council on Resident Education in Obstetrics and Gynecology. He also urged SOGH leaders to enroll in ACOG's Robert C. Cefalo National Leadership Institute.

SOGH leaders urged their members to seriously consider belonging to both ACOG and SHM, two organizations having the ear of health policy makers.

Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each.

Source Courtesy Ianthe Andress

'It can be a wild ride sometimes, but … it has been nothing short of profoundly gratifying.'

Source DR. FROST

Rough Draft of Core Competencies

Obstetric triage

Emergency medical examination

Outpatient prenatal care

Management of labor

Fetal heart rate interpretation

Labor ultrasound

Vaginal delivery and laceration repair

Management of obstetric complications including eclampsia, shoulder dystocia, breech presentation, twins, and postpartum hemorrhage

Operative deliveries

Surgical skills entailed in tubal ligation, cesarean section, and immediate postpartum hemorrhage

Gynecologic competencies including deep vein thrombosis prevention, diagnosis, and management; the gynecologic examination including the pelvic exam; and postoperative hemorrhage management.

Source: SOGH

BOULDER, COLO. – A buzz of excitement – a sense of history in the making – was palpable as the newly incorporated Society of Ob/Gyn Hospitalists held its first-ever annual meeting here.

“We are all witnessing the birth of a new subspecialty,” declared Dr. Brigid McCue, an ob.gyn. hospitalist at Jordan Hospital in Plymouth, Mass., and a member of the Society of Ob/Gyn Hospitalists (SOGH) steering committee.

Present at the birth were officials from both the American College of Obstetricians and Gynecologists (ACOG) and the Society of Hospital Medicine (SHM), two organizations interested in having close ties with the new medical society.

“ACOG recognizes this is the new paradigm of care,” said Dr. J. Joshua Kopelman, chair of ACOG District VIII. “We absolutely want you to be people who provide input about what you do to all of the committees at the executive level of the college.”

“Ob.gyn. hospitalists in this country are the wave of the future. There's no question about it. The model has been going on for a long time in Great Britain, for example, where you have people whose practices are office-based, and you have people who work full time in the hospital and that's all they do. They've had to learn how to do patient handoffs between these two groups of physicians,” he added.

Dr. Shaun Frost, president-elect of the SHM, observed that “it's kind of mind-boggling” to see the parallels between the birth of that organization and the SOGH. Both groups began with a small cadre of enthusiastic people full of outside-the-box ideas about how to improve patient care in the hospital.

Hospital medicine has experienced astronomical growth. The SHM consisted of 23 members in 1997, the year of its birth. Membership climbed to 800 just 2 years later, then to 3,200 in 2003, 6,300 in 2006, and now sits at about 12,000.

“I would anticipate that you're going to experience the same thing we did in terms of rapid and significant growth. Tighten your seat belts – it can be a wild ride sometimes, but I can tell you that for me, after 14 years, it has been nothing short of profoundly gratifying,” said Dr. Frost, who is chief medical officer for the Northeast region of Cogent HMG Healthcare and an internist at the University of Minnesota, Minneapolis.

In an interview, meeting cochair Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each. Most work 12-hour shifts, some 24-hour shifts.

“Right now hospitalists are doing a very small percentage of all deliveries, maybe 2%. I project in 5 years we'll be doing 20% or 25%,” predicted Dr. Olson, an ob.gyn. hospitalist in Bellingham, Wash., and founder of www.obgynhospitalist.com

The primary mission of ob.gyn. hospitalists is to enhance patient safety in the hospital, he explained. If an emergency requiring cesarean section occurs, the hospitalist can start the operation while the private obstetrician is en route, shifting to second assistant when the private physician arrives and takes over the procedure. Or if a woman who has been in labor for a few hours begins progressing rapidly at 2 a.m., the hospitalist can step in and do the delivery if the private physician can't get to the hospital promptly.

Hospitalists can also provide support when a midwife or family physician has a complicated delivery requiring a vacuum extraction, forceps, or a cesarean section.

“It's kind of like being a lifeguard, where you're sitting at the beach waiting for the problem,” he said.

Ordinarily a hospitalist will never see a patient antepartum. The exception is the unassigned patient who may drop in to the hospital with no prenatal care, who then becomes the hospitalist's responsibility.

Hospitalists also support private physicians by letting them sign out patients as a convenience. “A private physician may say, 'I've got a big surgery tomorrow. Can you take care of all of my patients between midnight and 6 a.m. so I can sleep?' That's another way of utilizing us,” Dr. Olson continued.

In the initial months following introduction of an ob.gyn. hospitalist program, however, patient sign-outs typically aren't a substantial part of the job. “At the beginning the private doctors are a little worried about it. They don't want to sign out. They're suspicious. They're afraid that they're going to give up not only their patients but their revenue. When they realize how helpful check outs are, though, then they sign out,” he explained.

Some ob.gyn. hospitalists are laborists only and prefer it that way. Others also cover gynecologic cases in the emergency department. “I have diagnosed more horrific cancers in 18 months as a hospitalist than in 13 years of private practice,” Dr. McCue said, adding that she feels good about covering gynecologic cases in the ER because it enables her to maintain some of her hard-earned gynecologic skills.

Several audience members voiced discomfort about leaving the labor and delivery area to take on emergency department gynecologic surgical cases because it distracts from the primary hospitalist focus of saving babies. Dr. McCue responded that the answer is to negotiate boundaries.

“What most of the hospitalist programs are coming to is making a deal with the privates,” she explained. “You say, 'I am doing the vast majority of your nighttime work by covering the labor floor for you and covering the first calls for you. All that I ask is that you be available on an emergency basis for the ER overload that I can't handle. I am happy to get the ectopics and incompletes started for you, but if I call that's because I need you to be there to cover.'”

Conference attendees heard best-practice updates from authorities on obstetric triage and evidence-based cesarean section techniques. They also began planning SOGH's future course. Dr. Bob Fagnant circulated a rough draft of proposed core competencies defining what ob.gyn. hospitalists need to be able to do. (See box.)

The society will eventually have to formally settle on a group of core competencies, a program for attaining them, and a means of tracking them to attain subspecialty status from the American Board of Obstetrics and Gynecology. The board will want to see evidence that being an ob.gyn. hospitalist requires a special set of skills not taught to physicians who graduate residency as general ob.gyns., explained Dr. Fagnant, an ob.gyn. hospitalist at Intermountain Health Care in St. George, Utah, who is also vice chair of the ACOG Committee on Ambulatory Practice.

The SOGH leadership believes simulation training will play a key role in demonstrating ob.gyn. hospitalist competencies. Toward that end, SOGH's first annual meeting featured a half-day of participation in a three-station obstetrical emergency simulation workshop focused on management of obstetric hemorrhage, maneuvers and techniques to relieve shoulder dystocia, and operative deliveries.

Dr. Arthur Townsend, medical director of the ob.gyn. hospitalist program at Methodist Le-Bonheur Hospital in Germantown, Tenn., stressed that hospitalists are “perfectly positioned” to support the quality initiatives hospitals take on to improve outcomes, decrease liability, attract patients, and meet the requirements of outside national organizations that report on quality indicators, such as the National Perinatal Information Center/Quality Analytic Services.

A significant part of what he and his hospitalist colleagues do is gather statistics. These include hospital-wide cesarean rates, vaginal births after cesarean, incidence of episiotomy, third- and fourth-degree laceration rates, postpartum hemorrhage, vaginal deliveries with shoulder dystocia, and a host of others.

He and his fellow hospitalists also carefully track their own performance. They file a detailed online report at a secure website upon completing every shift. These shift reports are compiled into monthly reports totaling the number of deliveries the hospitalists have performed, assists provided at cesarean and vaginal deliveries, the emergencies hospitalists responded to, the number of gynecologic surgeries performed, unassigned patients they've seen, and nurse and physician satisfaction survey results. These reports go to the hospital CEO, the board of directors, and the hospital risk management and quality committees.

“We've got some data to show that we really make a difference. What we do in these reports is tell how we save people. Everyone wants to know how many patients we're saving,” he explained.

The hospitalists track and submit individual physician-level statistics. When the data point to a problem physician – for example, an ob.gyn. who doesn't return phone calls from a nighttime nurse in timely fashion or who regularly scores poorly in patient satisfaction – Dr. Townsend leaves it to the hospital quality committee to do something about it. “I don't want to be the sheriff,” he explained.

These data-filled reports document the progress the hospital has made in achieving safety. This in turn has led to a reduction in the cost of the hospital's risk insurance. Moreover, when Dr. Townsend made a presentation to the hospital's risk underwriter, the company was so favorably impressed by what ob.gyn. hospitalists do that it provided them with a $60,000 grant to purchase obstetrical emergency simulators.

Dr. Townsend asked audience members to think about which hospitalist quality measures they consider to be most important yet practical for hospitalist practices to routinely collect at the national level. This is an issue where SOGH would like to be able to provide recommendations.

Dr. Suneet P. Chauhan, a non-hospitalist guest speaker at the conference, recommended focusing initially on two key statistics where he believes ob.gyn. hospitalists could make an impact with maximum “wow” factor: time to cesarean section for nonreassuring fetal heart rate tracings, and time spent in obstetric triage for preterm labor.

“As everyone knows, in one-third of cases the decision-to-incision time in an emergency c-section is not met. The lawyers know that, too. You, more than any other person in the hospital, can decrease the decision-to-incision time,” he told the hospitalists.

“You can also really help in obstetric triage. Triage is a very expensive place. In our hospital a patient could be there 3-6 hours before being seen. But if hospitalists routinely adopted the use of transvaginal cervical length measurement and/or fetal fibronectin, it would really shorten the stay at triage,” predicted Dr. Chauhan, director of maternal-fetal medicine and professor of ob.gyn. at Eastern Virginia Medical School, Norfolk.

Dr. Frost, the SHM president-elect, shared five key lessons he believes to be essential in building a hospitalist medical society from scratch, based upon the SHM experience: focus keenly on quality improvement; seek to be recognized by external stakeholders as health care reform facilitators, not obstructionists; respect the power of 'branding” as hospitalists; define your members' uniqueness; and be an inclusive “big tent” organization rather than exclusive in terms of membership.

ACOG District VIII Chair Dr. Kopelman urged SOGH members to make their viewpoint heard at ACOG by becoming active at the section and district level, then applying for one of the roughly 50 new committee appointments made each year. Natural fits for SOGH members might be the Committee on Patient Safety and Quality Improvement, the Committee on Obstetric Practice, the Committee on Professional Liability, and the Council on Resident Education in Obstetrics and Gynecology. He also urged SOGH leaders to enroll in ACOG's Robert C. Cefalo National Leadership Institute.

SOGH leaders urged their members to seriously consider belonging to both ACOG and SHM, two organizations having the ear of health policy makers.

Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each.

Source Courtesy Ianthe Andress

'It can be a wild ride sometimes, but … it has been nothing short of profoundly gratifying.'

Source DR. FROST

Rough Draft of Core Competencies

Obstetric triage

Emergency medical examination

Outpatient prenatal care

Management of labor

Fetal heart rate interpretation

Labor ultrasound

Vaginal delivery and laceration repair

Management of obstetric complications including eclampsia, shoulder dystocia, breech presentation, twins, and postpartum hemorrhage

Operative deliveries

Surgical skills entailed in tubal ligation, cesarean section, and immediate postpartum hemorrhage

Gynecologic competencies including deep vein thrombosis prevention, diagnosis, and management; the gynecologic examination including the pelvic exam; and postoperative hemorrhage management.

Source: SOGH

BOULDER, COLO. – A buzz of excitement – a sense of history in the making – was palpable as the newly incorporated Society of Ob/Gyn Hospitalists held its first-ever annual meeting here.

“We are all witnessing the birth of a new subspecialty,” declared Dr. Brigid McCue, an ob.gyn. hospitalist at Jordan Hospital in Plymouth, Mass., and a member of the Society of Ob/Gyn Hospitalists (SOGH) steering committee.

Present at the birth were officials from both the American College of Obstetricians and Gynecologists (ACOG) and the Society of Hospital Medicine (SHM), two organizations interested in having close ties with the new medical society.

“ACOG recognizes this is the new paradigm of care,” said Dr. J. Joshua Kopelman, chair of ACOG District VIII. “We absolutely want you to be people who provide input about what you do to all of the committees at the executive level of the college.”

“Ob.gyn. hospitalists in this country are the wave of the future. There's no question about it. The model has been going on for a long time in Great Britain, for example, where you have people whose practices are office-based, and you have people who work full time in the hospital and that's all they do. They've had to learn how to do patient handoffs between these two groups of physicians,” he added.

Dr. Shaun Frost, president-elect of the SHM, observed that “it's kind of mind-boggling” to see the parallels between the birth of that organization and the SOGH. Both groups began with a small cadre of enthusiastic people full of outside-the-box ideas about how to improve patient care in the hospital.

Hospital medicine has experienced astronomical growth. The SHM consisted of 23 members in 1997, the year of its birth. Membership climbed to 800 just 2 years later, then to 3,200 in 2003, 6,300 in 2006, and now sits at about 12,000.

“I would anticipate that you're going to experience the same thing we did in terms of rapid and significant growth. Tighten your seat belts – it can be a wild ride sometimes, but I can tell you that for me, after 14 years, it has been nothing short of profoundly gratifying,” said Dr. Frost, who is chief medical officer for the Northeast region of Cogent HMG Healthcare and an internist at the University of Minnesota, Minneapolis.

In an interview, meeting cochair Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each. Most work 12-hour shifts, some 24-hour shifts.

“Right now hospitalists are doing a very small percentage of all deliveries, maybe 2%. I project in 5 years we'll be doing 20% or 25%,” predicted Dr. Olson, an ob.gyn. hospitalist in Bellingham, Wash., and founder of www.obgynhospitalist.com

The primary mission of ob.gyn. hospitalists is to enhance patient safety in the hospital, he explained. If an emergency requiring cesarean section occurs, the hospitalist can start the operation while the private obstetrician is en route, shifting to second assistant when the private physician arrives and takes over the procedure. Or if a woman who has been in labor for a few hours begins progressing rapidly at 2 a.m., the hospitalist can step in and do the delivery if the private physician can't get to the hospital promptly.

Hospitalists can also provide support when a midwife or family physician has a complicated delivery requiring a vacuum extraction, forceps, or a cesarean section.

“It's kind of like being a lifeguard, where you're sitting at the beach waiting for the problem,” he said.

Ordinarily a hospitalist will never see a patient antepartum. The exception is the unassigned patient who may drop in to the hospital with no prenatal care, who then becomes the hospitalist's responsibility.

Hospitalists also support private physicians by letting them sign out patients as a convenience. “A private physician may say, 'I've got a big surgery tomorrow. Can you take care of all of my patients between midnight and 6 a.m. so I can sleep?' That's another way of utilizing us,” Dr. Olson continued.

In the initial months following introduction of an ob.gyn. hospitalist program, however, patient sign-outs typically aren't a substantial part of the job. “At the beginning the private doctors are a little worried about it. They don't want to sign out. They're suspicious. They're afraid that they're going to give up not only their patients but their revenue. When they realize how helpful check outs are, though, then they sign out,” he explained.

Some ob.gyn. hospitalists are laborists only and prefer it that way. Others also cover gynecologic cases in the emergency department. “I have diagnosed more horrific cancers in 18 months as a hospitalist than in 13 years of private practice,” Dr. McCue said, adding that she feels good about covering gynecologic cases in the ER because it enables her to maintain some of her hard-earned gynecologic skills.

Several audience members voiced discomfort about leaving the labor and delivery area to take on emergency department gynecologic surgical cases because it distracts from the primary hospitalist focus of saving babies. Dr. McCue responded that the answer is to negotiate boundaries.

“What most of the hospitalist programs are coming to is making a deal with the privates,” she explained. “You say, 'I am doing the vast majority of your nighttime work by covering the labor floor for you and covering the first calls for you. All that I ask is that you be available on an emergency basis for the ER overload that I can't handle. I am happy to get the ectopics and incompletes started for you, but if I call that's because I need you to be there to cover.'”

Conference attendees heard best-practice updates from authorities on obstetric triage and evidence-based cesarean section techniques. They also began planning SOGH's future course. Dr. Bob Fagnant circulated a rough draft of proposed core competencies defining what ob.gyn. hospitalists need to be able to do. (See box.)

The society will eventually have to formally settle on a group of core competencies, a program for attaining them, and a means of tracking them to attain subspecialty status from the American Board of Obstetrics and Gynecology. The board will want to see evidence that being an ob.gyn. hospitalist requires a special set of skills not taught to physicians who graduate residency as general ob.gyns., explained Dr. Fagnant, an ob.gyn. hospitalist at Intermountain Health Care in St. George, Utah, who is also vice chair of the ACOG Committee on Ambulatory Practice.

The SOGH leadership believes simulation training will play a key role in demonstrating ob.gyn. hospitalist competencies. Toward that end, SOGH's first annual meeting featured a half-day of participation in a three-station obstetrical emergency simulation workshop focused on management of obstetric hemorrhage, maneuvers and techniques to relieve shoulder dystocia, and operative deliveries.

Dr. Arthur Townsend, medical director of the ob.gyn. hospitalist program at Methodist Le-Bonheur Hospital in Germantown, Tenn., stressed that hospitalists are “perfectly positioned” to support the quality initiatives hospitals take on to improve outcomes, decrease liability, attract patients, and meet the requirements of outside national organizations that report on quality indicators, such as the National Perinatal Information Center/Quality Analytic Services.

A significant part of what he and his hospitalist colleagues do is gather statistics. These include hospital-wide cesarean rates, vaginal births after cesarean, incidence of episiotomy, third- and fourth-degree laceration rates, postpartum hemorrhage, vaginal deliveries with shoulder dystocia, and a host of others.

He and his fellow hospitalists also carefully track their own performance. They file a detailed online report at a secure website upon completing every shift. These shift reports are compiled into monthly reports totaling the number of deliveries the hospitalists have performed, assists provided at cesarean and vaginal deliveries, the emergencies hospitalists responded to, the number of gynecologic surgeries performed, unassigned patients they've seen, and nurse and physician satisfaction survey results. These reports go to the hospital CEO, the board of directors, and the hospital risk management and quality committees.

“We've got some data to show that we really make a difference. What we do in these reports is tell how we save people. Everyone wants to know how many patients we're saving,” he explained.

The hospitalists track and submit individual physician-level statistics. When the data point to a problem physician – for example, an ob.gyn. who doesn't return phone calls from a nighttime nurse in timely fashion or who regularly scores poorly in patient satisfaction – Dr. Townsend leaves it to the hospital quality committee to do something about it. “I don't want to be the sheriff,” he explained.

These data-filled reports document the progress the hospital has made in achieving safety. This in turn has led to a reduction in the cost of the hospital's risk insurance. Moreover, when Dr. Townsend made a presentation to the hospital's risk underwriter, the company was so favorably impressed by what ob.gyn. hospitalists do that it provided them with a $60,000 grant to purchase obstetrical emergency simulators.

Dr. Townsend asked audience members to think about which hospitalist quality measures they consider to be most important yet practical for hospitalist practices to routinely collect at the national level. This is an issue where SOGH would like to be able to provide recommendations.

Dr. Suneet P. Chauhan, a non-hospitalist guest speaker at the conference, recommended focusing initially on two key statistics where he believes ob.gyn. hospitalists could make an impact with maximum “wow” factor: time to cesarean section for nonreassuring fetal heart rate tracings, and time spent in obstetric triage for preterm labor.

“As everyone knows, in one-third of cases the decision-to-incision time in an emergency c-section is not met. The lawyers know that, too. You, more than any other person in the hospital, can decrease the decision-to-incision time,” he told the hospitalists.

“You can also really help in obstetric triage. Triage is a very expensive place. In our hospital a patient could be there 3-6 hours before being seen. But if hospitalists routinely adopted the use of transvaginal cervical length measurement and/or fetal fibronectin, it would really shorten the stay at triage,” predicted Dr. Chauhan, director of maternal-fetal medicine and professor of ob.gyn. at Eastern Virginia Medical School, Norfolk.

Dr. Frost, the SHM president-elect, shared five key lessons he believes to be essential in building a hospitalist medical society from scratch, based upon the SHM experience: focus keenly on quality improvement; seek to be recognized by external stakeholders as health care reform facilitators, not obstructionists; respect the power of 'branding” as hospitalists; define your members' uniqueness; and be an inclusive “big tent” organization rather than exclusive in terms of membership.

ACOG District VIII Chair Dr. Kopelman urged SOGH members to make their viewpoint heard at ACOG by becoming active at the section and district level, then applying for one of the roughly 50 new committee appointments made each year. Natural fits for SOGH members might be the Committee on Patient Safety and Quality Improvement, the Committee on Obstetric Practice, the Committee on Professional Liability, and the Council on Resident Education in Obstetrics and Gynecology. He also urged SOGH leaders to enroll in ACOG's Robert C. Cefalo National Leadership Institute.

SOGH leaders urged their members to seriously consider belonging to both ACOG and SHM, two organizations having the ear of health policy makers.

Dr. Rob Olson said at present there are 143 ob.gyn. hospitalist groups spread throughout the country, typically with four to six hospitalists each.

Source Courtesy Ianthe Andress

'It can be a wild ride sometimes, but … it has been nothing short of profoundly gratifying.'

Source DR. FROST

Rough Draft of Core Competencies

Obstetric triage

Emergency medical examination

Outpatient prenatal care

Management of labor

Fetal heart rate interpretation

Labor ultrasound

Vaginal delivery and laceration repair

Management of obstetric complications including eclampsia, shoulder dystocia, breech presentation, twins, and postpartum hemorrhage

Operative deliveries

Surgical skills entailed in tubal ligation, cesarean section, and immediate postpartum hemorrhage

Gynecologic competencies including deep vein thrombosis prevention, diagnosis, and management; the gynecologic examination including the pelvic exam; and postoperative hemorrhage management.

Source: SOGH

LISBON – Use of the recently proposed International Association of Diabetes and Pregnancy Study Group criteria for identifying women with gestational diabetes would increase the diagnosis by 240%, compared with the World Health Organization's criteria, according to the findings of a population-based multiethnic cohort study of 823 healthy pregnant women in Norway.

“Before endorsing the IADPSG criteria, the impact of diagnosing nearly one-third of all pregnant women should be considered,” said Dr. Kjersti Morkrid of the department of endocrinology at Oslo University Hospital and the Institute of Clinical Medicine at the University of Oslo.

The IADPSG criteria were derived from an international workshop held in Pasadena, Calif., in which 225 conferees from 40 countries reviewed the results of the HAPO (Hyperglycemia and Adverse Pregnancy Outcome) study and other data suggesting that there is a risk for adverse fetal outcomes below current gestational diabetes mellitus (GDM) diagnostic thresholds. Indeed, currently used criteria were either chosen to identify women at risk for the later development of diabetes (Diabetes Care 2007;30:[Suppl. 2]:S251-60), or were derived from nonpregnant individuals (World Health Org. Tech. Rep. Ser. 1980;646:1-80) and were not primarily aimed at identifying pregnancies with increased risk for adverse perinatal outcome, the IADPSG authors noted (Diabetes Care 2010;33:676-91).

The newly proposed criteria, which have been endorsed by the American Diabetes Association but not the American College of Obstetricians and Gynecologists (ACOG), were aimed at identifying women who have a 75% increased risk for adverse fetal outcomes, including birth weight greater than the 90th percentile, primary cesarean delivery, neonatal hypoglycemia, and cord C-peptide above the 90th percentile (the primary HAPO outcomes).

The IADPSG criteria call for an initial measurement of fasting plasma glucose (FPG), random glucose, or hemoglobin A_1c level in all or just high-risk women at the first prenatal visit. If the results do not detect overt diabetes but the FPG is 92-126 mg/dL, then GDM is diagnosed. If the FPG is less than 92 mg/dL, then a single 75-g, 2-hour oral glucose tolerance test (OGTT) is performed at 24-28 weeks' gestation. The OGTT should be performed after an overnight fast, with overt diabetes diagnosed if the fasting plasma glucose level is at least 126 mg/dL. GDM is diagnosed if the FPG is greater than 92 mg/dL, if the 1-hour value exceeds 180 mg/dL, or if the 2-hour value exceeds 153 mg/dL.

The IADPSG authors acknowledged that the criteria would “substantially increase the frequency of hyperglycemic disorders in pregnancy,” compared with other criteria such as those of the World Health Organization, which diagnose GDM at 24-28 weeks by either an FPG of at least 126 mg/dL or a 2-hour value of at least 140 mg/dL or higher following a 75-g glucose load.

The Norwegian Stork Groruddalen Research Program quantified that increase in a multiethnic population, including 41% of the 823 from Scandinavia, 24% from South Asia (primarily Pakistan and Sri Lanka), and 15% from the Middle East (mainly from Iraq, Morocco, and Turkey), as well as others from Eastern Europe, East Asia, Somalia, sub-Saharan Africa, and South America.

Compared with women from Scandinavia, those of South Asian and Middle Eastern origin were significantly younger on average (aged 28 and 29 years, respectively, vs. 30 years for Scandinavian women). South Asian women had lower prepregnancy body mass indexes compared with Scandinavian women (23.7 vs. 24.6 kg/m

Of the 759 women who completed the OGTT at visit 2, GDM prevalence rates were 32% by the IADPSG criteria, compared with just 13% by the WHO criteria. The overall increase in GDM diagnosis was by a factor of 2.4, ranging from 2.2 for Scandinavian and Middle Eastern women to a 2.8-fold increase among Southeast Asian women.

There was poor overlap between the two criteria, with just 9% identified by both, 4% by only the WHO criteria, and 22% by only the IADPSG criteria. More than two-thirds who were identified by the IADPSG were not identified by WHO criteria, Dr. Morkrid pointed out.

After adjustment for ethnicity, age, BMI, body height, parity, education level, and first-degree relatives with diabetes, factors significantly associated with GDM by the WHO criteria were body height per cm (odds ratio, 0.92), low education level (OR, 1.83), and having a first degree relative with diabetes (OR, 2.28). With the IADPSG criteria, prepregnancy BMI (OR, 1.09) and South Asian origin (OR, 2.48) were the most significant factors.

In response to a question from the audience about fetal outcome, Dr. Morkrid responded that those data are available but have not yet been analyzed.

The IADPSG criteria have been adopted by some countries, including Japan and Germany, but not widely in the United States. In September 2010, the ACOG Committee on Obstetric Practice issued a committee opinion restating its recommendation for a “two-step” method that differs from both the IADPSG and WHO criteria, utilizing a 50-g, 1-hour “loading” test at 24-28 weeks' gestation, followed by a confirmatory 100-g, 3-hour OGTT.

In addition to concerns regarding the dramatic increase in the number of women diagnosed with GDM that would occur with adoption of the IADPSG criteria – ACOG estimates the proportion would be 18% of all pregnant women – the ACOG committee opinion also cited the lack of evidence regarding impact on outcomes.

“There is no evidence that the identification and treatment of women based on the new [IADPSG] recommendations will lead to clinically significant improvements in maternal and neonatal outcomes and it would lead to a significant increase in health care costs,” the ACOG authors noted, adding “Significant questions remain regarding the implications on health care costs, the effect of GDM diagnosis on the pregnant woman and her family, the effect of diagnosis on obstetric interventions in pregnancy, and whether the identification and treatment of GDM will improve meaningful perinatal, neonatal, and maternal outcomes.”

ACOG and other organizations are looking ahead to the National Institutes of Health's Consensus Development Conference on Diagnosing Gestational Diabetes Mellitus scheduled for October 29-31, 2012, to develop a uniform diagnostic standard. “Consensus regarding optimal diagnostic criteria among the many groups and professional organizations will further much needed research regarding the benefits and harms of screening and diagnosis of GDM,” the ACOG opinion statement said.

The Norwegian study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, and the Norwegian Directorate of Health. Dr. Morkrid had no financial disclosures.

View on the News

Changing Criteria Is Tough

The diagnostic criteria for gestational diabetes have been disputed for decades. We are forced to think more of those now that women from certain countries are more obese and are having their first children later in life. With diagnostic criteria, you first have to think about what you “win” by designating over 200% more women as having diabetes, investing in seeing them on a regular basis, deciding whether to treat this marginally increased glycemia, and determining what will be the outcome for these women and for their children, as well as the perinatal consequences, including delivery complications. I think you need to study all of this before you can decide to change the criteria.

It's similar to the recent decision to use hemoglobin A_1c criteria to diagnose diabetes, another controversial area. It's one thing to look simply at the increased risk with elevated HbA_1c. But from a political standpoint, HbA_1c tests are best done in the West, and are more expensive. Would we have two standards, one for the West and one for Africa? That's very difficult to sell. Also, does it apply to all forms of diabetes? No. And also, how do you convince the politicians that it's a big epidemic, when they could respond that the reason the numbers are so large is that the diagnostic criteria were changed?

Changing criteria is tough, and it has to be done based on evidence.

MICHAELA DIAMANT, M.D., is associate professor of endocrinology and scientific director of the diabetes center at Free University Medical Center, Amsterdam. She had no relevant financial disclosures.

Vitals

LISBON – Use of the recently proposed International Association of Diabetes and Pregnancy Study Group criteria for identifying women with gestational diabetes would increase the diagnosis by 240%, compared with the World Health Organization's criteria, according to the findings of a population-based multiethnic cohort study of 823 healthy pregnant women in Norway.

“Before endorsing the IADPSG criteria, the impact of diagnosing nearly one-third of all pregnant women should be considered,” said Dr. Kjersti Morkrid of the department of endocrinology at Oslo University Hospital and the Institute of Clinical Medicine at the University of Oslo.

The IADPSG criteria were derived from an international workshop held in Pasadena, Calif., in which 225 conferees from 40 countries reviewed the results of the HAPO (Hyperglycemia and Adverse Pregnancy Outcome) study and other data suggesting that there is a risk for adverse fetal outcomes below current gestational diabetes mellitus (GDM) diagnostic thresholds. Indeed, currently used criteria were either chosen to identify women at risk for the later development of diabetes (Diabetes Care 2007;30:[Suppl. 2]:S251-60), or were derived from nonpregnant individuals (World Health Org. Tech. Rep. Ser. 1980;646:1-80) and were not primarily aimed at identifying pregnancies with increased risk for adverse perinatal outcome, the IADPSG authors noted (Diabetes Care 2010;33:676-91).

The newly proposed criteria, which have been endorsed by the American Diabetes Association but not the American College of Obstetricians and Gynecologists (ACOG), were aimed at identifying women who have a 75% increased risk for adverse fetal outcomes, including birth weight greater than the 90th percentile, primary cesarean delivery, neonatal hypoglycemia, and cord C-peptide above the 90th percentile (the primary HAPO outcomes).

The IADPSG criteria call for an initial measurement of fasting plasma glucose (FPG), random glucose, or hemoglobin A_1c level in all or just high-risk women at the first prenatal visit. If the results do not detect overt diabetes but the FPG is 92-126 mg/dL, then GDM is diagnosed. If the FPG is less than 92 mg/dL, then a single 75-g, 2-hour oral glucose tolerance test (OGTT) is performed at 24-28 weeks' gestation. The OGTT should be performed after an overnight fast, with overt diabetes diagnosed if the fasting plasma glucose level is at least 126 mg/dL. GDM is diagnosed if the FPG is greater than 92 mg/dL, if the 1-hour value exceeds 180 mg/dL, or if the 2-hour value exceeds 153 mg/dL.

The IADPSG authors acknowledged that the criteria would “substantially increase the frequency of hyperglycemic disorders in pregnancy,” compared with other criteria such as those of the World Health Organization, which diagnose GDM at 24-28 weeks by either an FPG of at least 126 mg/dL or a 2-hour value of at least 140 mg/dL or higher following a 75-g glucose load.

The Norwegian Stork Groruddalen Research Program quantified that increase in a multiethnic population, including 41% of the 823 from Scandinavia, 24% from South Asia (primarily Pakistan and Sri Lanka), and 15% from the Middle East (mainly from Iraq, Morocco, and Turkey), as well as others from Eastern Europe, East Asia, Somalia, sub-Saharan Africa, and South America.

Compared with women from Scandinavia, those of South Asian and Middle Eastern origin were significantly younger on average (aged 28 and 29 years, respectively, vs. 30 years for Scandinavian women). South Asian women had lower prepregnancy body mass indexes compared with Scandinavian women (23.7 vs. 24.6 kg/m

Of the 759 women who completed the OGTT at visit 2, GDM prevalence rates were 32% by the IADPSG criteria, compared with just 13% by the WHO criteria. The overall increase in GDM diagnosis was by a factor of 2.4, ranging from 2.2 for Scandinavian and Middle Eastern women to a 2.8-fold increase among Southeast Asian women.

There was poor overlap between the two criteria, with just 9% identified by both, 4% by only the WHO criteria, and 22% by only the IADPSG criteria. More than two-thirds who were identified by the IADPSG were not identified by WHO criteria, Dr. Morkrid pointed out.

After adjustment for ethnicity, age, BMI, body height, parity, education level, and first-degree relatives with diabetes, factors significantly associated with GDM by the WHO criteria were body height per cm (odds ratio, 0.92), low education level (OR, 1.83), and having a first degree relative with diabetes (OR, 2.28). With the IADPSG criteria, prepregnancy BMI (OR, 1.09) and South Asian origin (OR, 2.48) were the most significant factors.

In response to a question from the audience about fetal outcome, Dr. Morkrid responded that those data are available but have not yet been analyzed.

The IADPSG criteria have been adopted by some countries, including Japan and Germany, but not widely in the United States. In September 2010, the ACOG Committee on Obstetric Practice issued a committee opinion restating its recommendation for a “two-step” method that differs from both the IADPSG and WHO criteria, utilizing a 50-g, 1-hour “loading” test at 24-28 weeks' gestation, followed by a confirmatory 100-g, 3-hour OGTT.

In addition to concerns regarding the dramatic increase in the number of women diagnosed with GDM that would occur with adoption of the IADPSG criteria – ACOG estimates the proportion would be 18% of all pregnant women – the ACOG committee opinion also cited the lack of evidence regarding impact on outcomes.

“There is no evidence that the identification and treatment of women based on the new [IADPSG] recommendations will lead to clinically significant improvements in maternal and neonatal outcomes and it would lead to a significant increase in health care costs,” the ACOG authors noted, adding “Significant questions remain regarding the implications on health care costs, the effect of GDM diagnosis on the pregnant woman and her family, the effect of diagnosis on obstetric interventions in pregnancy, and whether the identification and treatment of GDM will improve meaningful perinatal, neonatal, and maternal outcomes.”

ACOG and other organizations are looking ahead to the National Institutes of Health's Consensus Development Conference on Diagnosing Gestational Diabetes Mellitus scheduled for October 29-31, 2012, to develop a uniform diagnostic standard. “Consensus regarding optimal diagnostic criteria among the many groups and professional organizations will further much needed research regarding the benefits and harms of screening and diagnosis of GDM,” the ACOG opinion statement said.

The Norwegian study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, and the Norwegian Directorate of Health. Dr. Morkrid had no financial disclosures.

View on the News

Changing Criteria Is Tough

The diagnostic criteria for gestational diabetes have been disputed for decades. We are forced to think more of those now that women from certain countries are more obese and are having their first children later in life. With diagnostic criteria, you first have to think about what you “win” by designating over 200% more women as having diabetes, investing in seeing them on a regular basis, deciding whether to treat this marginally increased glycemia, and determining what will be the outcome for these women and for their children, as well as the perinatal consequences, including delivery complications. I think you need to study all of this before you can decide to change the criteria.

It's similar to the recent decision to use hemoglobin A_1c criteria to diagnose diabetes, another controversial area. It's one thing to look simply at the increased risk with elevated HbA_1c. But from a political standpoint, HbA_1c tests are best done in the West, and are more expensive. Would we have two standards, one for the West and one for Africa? That's very difficult to sell. Also, does it apply to all forms of diabetes? No. And also, how do you convince the politicians that it's a big epidemic, when they could respond that the reason the numbers are so large is that the diagnostic criteria were changed?

Changing criteria is tough, and it has to be done based on evidence.

MICHAELA DIAMANT, M.D., is associate professor of endocrinology and scientific director of the diabetes center at Free University Medical Center, Amsterdam. She had no relevant financial disclosures.

Vitals

LISBON – Use of the recently proposed International Association of Diabetes and Pregnancy Study Group criteria for identifying women with gestational diabetes would increase the diagnosis by 240%, compared with the World Health Organization's criteria, according to the findings of a population-based multiethnic cohort study of 823 healthy pregnant women in Norway.

“Before endorsing the IADPSG criteria, the impact of diagnosing nearly one-third of all pregnant women should be considered,” said Dr. Kjersti Morkrid of the department of endocrinology at Oslo University Hospital and the Institute of Clinical Medicine at the University of Oslo.

The IADPSG criteria were derived from an international workshop held in Pasadena, Calif., in which 225 conferees from 40 countries reviewed the results of the HAPO (Hyperglycemia and Adverse Pregnancy Outcome) study and other data suggesting that there is a risk for adverse fetal outcomes below current gestational diabetes mellitus (GDM) diagnostic thresholds. Indeed, currently used criteria were either chosen to identify women at risk for the later development of diabetes (Diabetes Care 2007;30:[Suppl. 2]:S251-60), or were derived from nonpregnant individuals (World Health Org. Tech. Rep. Ser. 1980;646:1-80) and were not primarily aimed at identifying pregnancies with increased risk for adverse perinatal outcome, the IADPSG authors noted (Diabetes Care 2010;33:676-91).

The newly proposed criteria, which have been endorsed by the American Diabetes Association but not the American College of Obstetricians and Gynecologists (ACOG), were aimed at identifying women who have a 75% increased risk for adverse fetal outcomes, including birth weight greater than the 90th percentile, primary cesarean delivery, neonatal hypoglycemia, and cord C-peptide above the 90th percentile (the primary HAPO outcomes).

The IADPSG criteria call for an initial measurement of fasting plasma glucose (FPG), random glucose, or hemoglobin A_1c level in all or just high-risk women at the first prenatal visit. If the results do not detect overt diabetes but the FPG is 92-126 mg/dL, then GDM is diagnosed. If the FPG is less than 92 mg/dL, then a single 75-g, 2-hour oral glucose tolerance test (OGTT) is performed at 24-28 weeks' gestation. The OGTT should be performed after an overnight fast, with overt diabetes diagnosed if the fasting plasma glucose level is at least 126 mg/dL. GDM is diagnosed if the FPG is greater than 92 mg/dL, if the 1-hour value exceeds 180 mg/dL, or if the 2-hour value exceeds 153 mg/dL.

The IADPSG authors acknowledged that the criteria would “substantially increase the frequency of hyperglycemic disorders in pregnancy,” compared with other criteria such as those of the World Health Organization, which diagnose GDM at 24-28 weeks by either an FPG of at least 126 mg/dL or a 2-hour value of at least 140 mg/dL or higher following a 75-g glucose load.

The Norwegian Stork Groruddalen Research Program quantified that increase in a multiethnic population, including 41% of the 823 from Scandinavia, 24% from South Asia (primarily Pakistan and Sri Lanka), and 15% from the Middle East (mainly from Iraq, Morocco, and Turkey), as well as others from Eastern Europe, East Asia, Somalia, sub-Saharan Africa, and South America.

Compared with women from Scandinavia, those of South Asian and Middle Eastern origin were significantly younger on average (aged 28 and 29 years, respectively, vs. 30 years for Scandinavian women). South Asian women had lower prepregnancy body mass indexes compared with Scandinavian women (23.7 vs. 24.6 kg/m

Of the 759 women who completed the OGTT at visit 2, GDM prevalence rates were 32% by the IADPSG criteria, compared with just 13% by the WHO criteria. The overall increase in GDM diagnosis was by a factor of 2.4, ranging from 2.2 for Scandinavian and Middle Eastern women to a 2.8-fold increase among Southeast Asian women.

There was poor overlap between the two criteria, with just 9% identified by both, 4% by only the WHO criteria, and 22% by only the IADPSG criteria. More than two-thirds who were identified by the IADPSG were not identified by WHO criteria, Dr. Morkrid pointed out.

After adjustment for ethnicity, age, BMI, body height, parity, education level, and first-degree relatives with diabetes, factors significantly associated with GDM by the WHO criteria were body height per cm (odds ratio, 0.92), low education level (OR, 1.83), and having a first degree relative with diabetes (OR, 2.28). With the IADPSG criteria, prepregnancy BMI (OR, 1.09) and South Asian origin (OR, 2.48) were the most significant factors.

In response to a question from the audience about fetal outcome, Dr. Morkrid responded that those data are available but have not yet been analyzed.

The IADPSG criteria have been adopted by some countries, including Japan and Germany, but not widely in the United States. In September 2010, the ACOG Committee on Obstetric Practice issued a committee opinion restating its recommendation for a “two-step” method that differs from both the IADPSG and WHO criteria, utilizing a 50-g, 1-hour “loading” test at 24-28 weeks' gestation, followed by a confirmatory 100-g, 3-hour OGTT.

In addition to concerns regarding the dramatic increase in the number of women diagnosed with GDM that would occur with adoption of the IADPSG criteria – ACOG estimates the proportion would be 18% of all pregnant women – the ACOG committee opinion also cited the lack of evidence regarding impact on outcomes.

“There is no evidence that the identification and treatment of women based on the new [IADPSG] recommendations will lead to clinically significant improvements in maternal and neonatal outcomes and it would lead to a significant increase in health care costs,” the ACOG authors noted, adding “Significant questions remain regarding the implications on health care costs, the effect of GDM diagnosis on the pregnant woman and her family, the effect of diagnosis on obstetric interventions in pregnancy, and whether the identification and treatment of GDM will improve meaningful perinatal, neonatal, and maternal outcomes.”

ACOG and other organizations are looking ahead to the National Institutes of Health's Consensus Development Conference on Diagnosing Gestational Diabetes Mellitus scheduled for October 29-31, 2012, to develop a uniform diagnostic standard. “Consensus regarding optimal diagnostic criteria among the many groups and professional organizations will further much needed research regarding the benefits and harms of screening and diagnosis of GDM,” the ACOG opinion statement said.

The Norwegian study was funded by the Research Council of Norway, the South-Eastern Norway Regional Health Authority, and the Norwegian Directorate of Health. Dr. Morkrid had no financial disclosures.

View on the News

Changing Criteria Is Tough

The diagnostic criteria for gestational diabetes have been disputed for decades. We are forced to think more of those now that women from certain countries are more obese and are having their first children later in life. With diagnostic criteria, you first have to think about what you “win” by designating over 200% more women as having diabetes, investing in seeing them on a regular basis, deciding whether to treat this marginally increased glycemia, and determining what will be the outcome for these women and for their children, as well as the perinatal consequences, including delivery complications. I think you need to study all of this before you can decide to change the criteria.

It's similar to the recent decision to use hemoglobin A_1c criteria to diagnose diabetes, another controversial area. It's one thing to look simply at the increased risk with elevated HbA_1c. But from a political standpoint, HbA_1c tests are best done in the West, and are more expensive. Would we have two standards, one for the West and one for Africa? That's very difficult to sell. Also, does it apply to all forms of diabetes? No. And also, how do you convince the politicians that it's a big epidemic, when they could respond that the reason the numbers are so large is that the diagnostic criteria were changed?

Changing criteria is tough, and it has to be done based on evidence.

MICHAELA DIAMANT, M.D., is associate professor of endocrinology and scientific director of the diabetes center at Free University Medical Center, Amsterdam. She had no relevant financial disclosures.

Vitals

PROVIDENCE, R.I. – Compared with cesarean birth without labor, undergoing vaginal birth increased the risk of stress incontinence and prolapse in women who were examined 5–10 years after childbirth, Dr. Victoria L. Handa reported.

The risk of all pelvic disorders, including prolapse, was elevated even further in women who had undergone operative vaginal delivery, she said.

“The results suggest no measurable differences in the relative odds of any pelvic floor disorder for women delivering by cesarean section, including those who labored into the second stage. For vaginal birth, the picture is very different,” said Dr. Handa, director of the advanced training program in female pelvic medicine and reconstructive surgery at Johns Hopkins University, Baltimore.

In this longitudinal cohort study based on hospital obstetric records, 8,285 women who had their first child 5–10 years previously were recruited for the study and 1,011 were enrolled. Women were selected if their obstetric history met one of five categories: cesarean without labor (considered the reference group; n = 192), cesarean during active labor (n = 228), cesarean after complete cervical dilation (n = 140), spontaneous vaginal birth (n = 325), and operative vaginal birth (n = 126). Groups were matched for age at first delivery and interval from first delivery, and were similar with respect to parity and smoking status. At enrollment, a validated questionnaire (Epidemiology of Prolapse and Incontinence Questionnaire) was used to assess pelvic floor symptoms, and the women were examined for pelvic organ support using the Pelvic Organ Prolapse Quantification (POP-Q) System.

“One of the strengths of our study is that [obstetric] exposures were verified by chart review with validated outcomes, and there was [anatomical] evidence of prolapse,” Dr. Handa said.

Overall, 11% of the 1,011 women had stress urinary incontinence, 8% had overactive bladder, and 11% had anal incontinence; 3% reported prolapse symptoms, and 7% had prolapse upon examination (Obstet. Gynecol. 2011;118:777–84).

Compared with women who had a cesarean birth before active labor, women who had a vaginal birth (but no operative vaginal births) had almost a threefold increased risk of stress incontinence and symptomatic prolapse. The odds ratio for prolapse was increased more than fivefold.

Women who had undergone operative vaginal birth fared even worse. The adjusted odds of stress incontinence and overactive bladder were more than quadrupled. There was almost an eightfold increased risk of prolapse upon exam.

In her report, Dr. Handa noted that in addition to demonstrating the dramatic increase in pelvic floor disorders in women with a history of at least one operative vaginal birth, the results showed an increase in urinary incontinence after operative delivery – a finding that had not been definitively documented before. For those who had undergone cesarean delivery, the results showed no association between active labor and pelvic floor disorders.

The study was also the first to demonstrate an association between operative vaginal birth and prolapse, even in asymptomatic women. By continuing to monitor these women, Dr. Handa hopes to be able to document the natural history of prolapse over time, especially in those women who were unaware of their condition.

Dr. Handa did not report any relevant financial disclosures.

PROVIDENCE, R.I. – Compared with cesarean birth without labor, undergoing vaginal birth increased the risk of stress incontinence and prolapse in women who were examined 5–10 years after childbirth, Dr. Victoria L. Handa reported.

The risk of all pelvic disorders, including prolapse, was elevated even further in women who had undergone operative vaginal delivery, she said.

“The results suggest no measurable differences in the relative odds of any pelvic floor disorder for women delivering by cesarean section, including those who labored into the second stage. For vaginal birth, the picture is very different,” said Dr. Handa, director of the advanced training program in female pelvic medicine and reconstructive surgery at Johns Hopkins University, Baltimore.

In this longitudinal cohort study based on hospital obstetric records, 8,285 women who had their first child 5–10 years previously were recruited for the study and 1,011 were enrolled. Women were selected if their obstetric history met one of five categories: cesarean without labor (considered the reference group; n = 192), cesarean during active labor (n = 228), cesarean after complete cervical dilation (n = 140), spontaneous vaginal birth (n = 325), and operative vaginal birth (n = 126). Groups were matched for age at first delivery and interval from first delivery, and were similar with respect to parity and smoking status. At enrollment, a validated questionnaire (Epidemiology of Prolapse and Incontinence Questionnaire) was used to assess pelvic floor symptoms, and the women were examined for pelvic organ support using the Pelvic Organ Prolapse Quantification (POP-Q) System.

“One of the strengths of our study is that [obstetric] exposures were verified by chart review with validated outcomes, and there was [anatomical] evidence of prolapse,” Dr. Handa said.

Overall, 11% of the 1,011 women had stress urinary incontinence, 8% had overactive bladder, and 11% had anal incontinence; 3% reported prolapse symptoms, and 7% had prolapse upon examination (Obstet. Gynecol. 2011;118:777–84).

Compared with women who had a cesarean birth before active labor, women who had a vaginal birth (but no operative vaginal births) had almost a threefold increased risk of stress incontinence and symptomatic prolapse. The odds ratio for prolapse was increased more than fivefold.

Women who had undergone operative vaginal birth fared even worse. The adjusted odds of stress incontinence and overactive bladder were more than quadrupled. There was almost an eightfold increased risk of prolapse upon exam.

In her report, Dr. Handa noted that in addition to demonstrating the dramatic increase in pelvic floor disorders in women with a history of at least one operative vaginal birth, the results showed an increase in urinary incontinence after operative delivery – a finding that had not been definitively documented before. For those who had undergone cesarean delivery, the results showed no association between active labor and pelvic floor disorders.

The study was also the first to demonstrate an association between operative vaginal birth and prolapse, even in asymptomatic women. By continuing to monitor these women, Dr. Handa hopes to be able to document the natural history of prolapse over time, especially in those women who were unaware of their condition.

Dr. Handa did not report any relevant financial disclosures.

PROVIDENCE, R.I. – Compared with cesarean birth without labor, undergoing vaginal birth increased the risk of stress incontinence and prolapse in women who were examined 5–10 years after childbirth, Dr. Victoria L. Handa reported.

The risk of all pelvic disorders, including prolapse, was elevated even further in women who had undergone operative vaginal delivery, she said.

“The results suggest no measurable differences in the relative odds of any pelvic floor disorder for women delivering by cesarean section, including those who labored into the second stage. For vaginal birth, the picture is very different,” said Dr. Handa, director of the advanced training program in female pelvic medicine and reconstructive surgery at Johns Hopkins University, Baltimore.

In this longitudinal cohort study based on hospital obstetric records, 8,285 women who had their first child 5–10 years previously were recruited for the study and 1,011 were enrolled. Women were selected if their obstetric history met one of five categories: cesarean without labor (considered the reference group; n = 192), cesarean during active labor (n = 228), cesarean after complete cervical dilation (n = 140), spontaneous vaginal birth (n = 325), and operative vaginal birth (n = 126). Groups were matched for age at first delivery and interval from first delivery, and were similar with respect to parity and smoking status. At enrollment, a validated questionnaire (Epidemiology of Prolapse and Incontinence Questionnaire) was used to assess pelvic floor symptoms, and the women were examined for pelvic organ support using the Pelvic Organ Prolapse Quantification (POP-Q) System.

“One of the strengths of our study is that [obstetric] exposures were verified by chart review with validated outcomes, and there was [anatomical] evidence of prolapse,” Dr. Handa said.

Overall, 11% of the 1,011 women had stress urinary incontinence, 8% had overactive bladder, and 11% had anal incontinence; 3% reported prolapse symptoms, and 7% had prolapse upon examination (Obstet. Gynecol. 2011;118:777–84).

Compared with women who had a cesarean birth before active labor, women who had a vaginal birth (but no operative vaginal births) had almost a threefold increased risk of stress incontinence and symptomatic prolapse. The odds ratio for prolapse was increased more than fivefold.

Women who had undergone operative vaginal birth fared even worse. The adjusted odds of stress incontinence and overactive bladder were more than quadrupled. There was almost an eightfold increased risk of prolapse upon exam.

In her report, Dr. Handa noted that in addition to demonstrating the dramatic increase in pelvic floor disorders in women with a history of at least one operative vaginal birth, the results showed an increase in urinary incontinence after operative delivery – a finding that had not been definitively documented before. For those who had undergone cesarean delivery, the results showed no association between active labor and pelvic floor disorders.

The study was also the first to demonstrate an association between operative vaginal birth and prolapse, even in asymptomatic women. By continuing to monitor these women, Dr. Handa hopes to be able to document the natural history of prolapse over time, especially in those women who were unaware of their condition.

Dr. Handa did not report any relevant financial disclosures.

Healthy prepubescent children with mothers who smoked during pregnancy have lower levels of high density lipoprotein (HDL) cholesterol compared with children born to women who do not smoke during pregnancy, Dr. Julian G. Ayer of the University of Sydney, and his colleagues, reported.

Previous studies have shown an association between environmental tobacco smoke (ETS) exposure in adults and cardiovascular disease (CVD) and an increase of the thickening of the arterial wall and lipid alterations associated with atherosclerosis. Thus, Dr. Ayer and associates decided to examine the effects of maternal smoking in pregnancy on the lipoprotein levels and arterial wall thickness in 8-year-old children and to determine whether smoking during pregnancy could increase the risk of CVD in children later in life (Eur. Heart J. 2011 [doi:10.1093/eurheartj/ehr174]).

“Cholesterol levels tend to track from childhood to adulthood, and studies have shown that for every 0.025-mmol/L increase in HDL levels, there is an approximately 2%-3% reduction in the risk of coronary heart disease,” Dr. David Celermajer, Scandrett Professor of Cardiology at the university, who led the study, said in a written statement. “If we extrapolate this, we can suggest that the difference of 0.15 mmol/L between children of smoking mothers versus nonsmoking mothers might result in a 10%-15% higher risk for coronary disease in the children of smoking mothers. This is an approximation only, but the best one we have.”

Results showed that children born to mothers who smoked during pregnancy had lower HDL cholesterol (1.32 vs. 1.50 mmol/L), higher triglycerides (1.36 vs.1.20 mmol/L) and higher systolic blood pressure (102.1 vs. 99.9 mm Hg).

When postnatal ETS exposure and other confounders such as breastfeeding duration, physical inactivity, and maternal exposure to passive smoking during pregnancy were factored into the study, the children still had lower HDL cholesterol, (difference of 0.22 mmol/L) but had no significant difference in systolic blood pressure. When excluding postnatal ETS exposure and including all other confounders, the difference was about −0.14 mmol/L. There was no significant difference in carotid intima-media thickness (CIMT) due to smoking in pregnancy or postnatal ETS exposure.

The participants in the study included 616 newborns from Sydney who were enrolled into the Childhood Asthma Prevention Study (CAPS), a randomized controlled trial investigating for asthma and allergic disease in children from birth to 5 years of age between September 1997 and December 1999. At 8 years of age, 405 of the 616 children (66%) had parental consent to participate in a cardiovascular substudy that examined the effect of the dietary intervention on CVD risk factors. Three hundred twenty-eight children (53%) had permission to participate in the lipoprotein examination.

Using a questionnaire at an in-person interview, mothers were asked about their smoking habits during all three trimesters of their pregnancy as “1–10/day,” “11–20/day,” “20–40/day,” or “greater than or equal to 41/day.” The smoking average was then calculated during midpoint values for each range (5, 15, 30, and 50, respectively).

Dr. Ayer and associates reported that results may be important in the prevention of atherosclerosis as about 15% of women in Western countries smoke during pregnancy.

“Children born to mothers who have smoked during pregnancy will need to be watched particularly carefully for other coronary risk factors, like high blood pressure, high LDL, 'bad' cholesterol levels, and especially cigarette smoking themselves,” Dr. Celermajer said in the statement.

He suggested that HDL levels can be increased with frequent physical activity and medications such as niacin.

Researchers received funding from an Australian Government National Health and Medical Research Council Project Grant and a Pfizer CVL Grant. Funding was also provided by the National Health and Medical Research Council of Australia; Cooperative Research Centre for Asthma, New South Wales; Department of Health; and Children's Hospital at Westmead.

The researchers reported no relevant financial disclosures.

Healthy prepubescent children with mothers who smoked during pregnancy have lower levels of high density lipoprotein (HDL) cholesterol compared with children born to women who do not smoke during pregnancy, Dr. Julian G. Ayer of the University of Sydney, and his colleagues, reported.

Previous studies have shown an association between environmental tobacco smoke (ETS) exposure in adults and cardiovascular disease (CVD) and an increase of the thickening of the arterial wall and lipid alterations associated with atherosclerosis. Thus, Dr. Ayer and associates decided to examine the effects of maternal smoking in pregnancy on the lipoprotein levels and arterial wall thickness in 8-year-old children and to determine whether smoking during pregnancy could increase the risk of CVD in children later in life (Eur. Heart J. 2011 [doi:10.1093/eurheartj/ehr174]).

“Cholesterol levels tend to track from childhood to adulthood, and studies have shown that for every 0.025-mmol/L increase in HDL levels, there is an approximately 2%-3% reduction in the risk of coronary heart disease,” Dr. David Celermajer, Scandrett Professor of Cardiology at the university, who led the study, said in a written statement. “If we extrapolate this, we can suggest that the difference of 0.15 mmol/L between children of smoking mothers versus nonsmoking mothers might result in a 10%-15% higher risk for coronary disease in the children of smoking mothers. This is an approximation only, but the best one we have.”

Results showed that children born to mothers who smoked during pregnancy had lower HDL cholesterol (1.32 vs. 1.50 mmol/L), higher triglycerides (1.36 vs.1.20 mmol/L) and higher systolic blood pressure (102.1 vs. 99.9 mm Hg).

When postnatal ETS exposure and other confounders such as breastfeeding duration, physical inactivity, and maternal exposure to passive smoking during pregnancy were factored into the study, the children still had lower HDL cholesterol, (difference of 0.22 mmol/L) but had no significant difference in systolic blood pressure. When excluding postnatal ETS exposure and including all other confounders, the difference was about −0.14 mmol/L. There was no significant difference in carotid intima-media thickness (CIMT) due to smoking in pregnancy or postnatal ETS exposure.

The participants in the study included 616 newborns from Sydney who were enrolled into the Childhood Asthma Prevention Study (CAPS), a randomized controlled trial investigating for asthma and allergic disease in children from birth to 5 years of age between September 1997 and December 1999. At 8 years of age, 405 of the 616 children (66%) had parental consent to participate in a cardiovascular substudy that examined the effect of the dietary intervention on CVD risk factors. Three hundred twenty-eight children (53%) had permission to participate in the lipoprotein examination.

Using a questionnaire at an in-person interview, mothers were asked about their smoking habits during all three trimesters of their pregnancy as “1–10/day,” “11–20/day,” “20–40/day,” or “greater than or equal to 41/day.” The smoking average was then calculated during midpoint values for each range (5, 15, 30, and 50, respectively).

Dr. Ayer and associates reported that results may be important in the prevention of atherosclerosis as about 15% of women in Western countries smoke during pregnancy.

“Children born to mothers who have smoked during pregnancy will need to be watched particularly carefully for other coronary risk factors, like high blood pressure, high LDL, 'bad' cholesterol levels, and especially cigarette smoking themselves,” Dr. Celermajer said in the statement.

He suggested that HDL levels can be increased with frequent physical activity and medications such as niacin.

Researchers received funding from an Australian Government National Health and Medical Research Council Project Grant and a Pfizer CVL Grant. Funding was also provided by the National Health and Medical Research Council of Australia; Cooperative Research Centre for Asthma, New South Wales; Department of Health; and Children's Hospital at Westmead.

The researchers reported no relevant financial disclosures.

Healthy prepubescent children with mothers who smoked during pregnancy have lower levels of high density lipoprotein (HDL) cholesterol compared with children born to women who do not smoke during pregnancy, Dr. Julian G. Ayer of the University of Sydney, and his colleagues, reported.

Previous studies have shown an association between environmental tobacco smoke (ETS) exposure in adults and cardiovascular disease (CVD) and an increase of the thickening of the arterial wall and lipid alterations associated with atherosclerosis. Thus, Dr. Ayer and associates decided to examine the effects of maternal smoking in pregnancy on the lipoprotein levels and arterial wall thickness in 8-year-old children and to determine whether smoking during pregnancy could increase the risk of CVD in children later in life (Eur. Heart J. 2011 [doi:10.1093/eurheartj/ehr174]).

“Cholesterol levels tend to track from childhood to adulthood, and studies have shown that for every 0.025-mmol/L increase in HDL levels, there is an approximately 2%-3% reduction in the risk of coronary heart disease,” Dr. David Celermajer, Scandrett Professor of Cardiology at the university, who led the study, said in a written statement. “If we extrapolate this, we can suggest that the difference of 0.15 mmol/L between children of smoking mothers versus nonsmoking mothers might result in a 10%-15% higher risk for coronary disease in the children of smoking mothers. This is an approximation only, but the best one we have.”

Results showed that children born to mothers who smoked during pregnancy had lower HDL cholesterol (1.32 vs. 1.50 mmol/L), higher triglycerides (1.36 vs.1.20 mmol/L) and higher systolic blood pressure (102.1 vs. 99.9 mm Hg).

When postnatal ETS exposure and other confounders such as breastfeeding duration, physical inactivity, and maternal exposure to passive smoking during pregnancy were factored into the study, the children still had lower HDL cholesterol, (difference of 0.22 mmol/L) but had no significant difference in systolic blood pressure. When excluding postnatal ETS exposure and including all other confounders, the difference was about −0.14 mmol/L. There was no significant difference in carotid intima-media thickness (CIMT) due to smoking in pregnancy or postnatal ETS exposure.

The participants in the study included 616 newborns from Sydney who were enrolled into the Childhood Asthma Prevention Study (CAPS), a randomized controlled trial investigating for asthma and allergic disease in children from birth to 5 years of age between September 1997 and December 1999. At 8 years of age, 405 of the 616 children (66%) had parental consent to participate in a cardiovascular substudy that examined the effect of the dietary intervention on CVD risk factors. Three hundred twenty-eight children (53%) had permission to participate in the lipoprotein examination.

Using a questionnaire at an in-person interview, mothers were asked about their smoking habits during all three trimesters of their pregnancy as “1–10/day,” “11–20/day,” “20–40/day,” or “greater than or equal to 41/day.” The smoking average was then calculated during midpoint values for each range (5, 15, 30, and 50, respectively).

Dr. Ayer and associates reported that results may be important in the prevention of atherosclerosis as about 15% of women in Western countries smoke during pregnancy.

“Children born to mothers who have smoked during pregnancy will need to be watched particularly carefully for other coronary risk factors, like high blood pressure, high LDL, 'bad' cholesterol levels, and especially cigarette smoking themselves,” Dr. Celermajer said in the statement.

He suggested that HDL levels can be increased with frequent physical activity and medications such as niacin.

Researchers received funding from an Australian Government National Health and Medical Research Council Project Grant and a Pfizer CVL Grant. Funding was also provided by the National Health and Medical Research Council of Australia; Cooperative Research Centre for Asthma, New South Wales; Department of Health; and Children's Hospital at Westmead.

The researchers reported no relevant financial disclosures.

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

Major Finding: Cases and controls had nearly identical birth weights (3,208 g vs. 3,219 g) and gestational ages at delivery (38.5 weeks vs. 38.7 weeks).

Data Source: Retrospective cohort analysis of 147 pregnant patients with 2009 H1N1 influenza and 740 pregnant controls.

Disclosures: Dr. Naresh and her coauthors reported no relevant financial disclosures.

CHICAGO – H1N1 influenza infection during the 2009 pandemic did not impact pregnancy outcomes in a retrospective cohort study of 887 women.

Subtle differences were observed, however, among women with severe infection or delayed treatment, Dr. Amber Naresh reported at the meeting.

She presented a retrospective cohort study performed at three tertiary care medical centers of all inpatient and outpatient cases of pregnant women with laboratory-confirmed 2009 H1N1 influenza. For each case, five pregnant women who tested negative for H1N1 influenza or were untested were randomly chosen from each site's database and matched by estimated date of confinement and site.

Based on a preliminary analysis, the 147 H1N1 cases and 740 controls had nearly identical birth weights (average 3,208 g vs. 3,219 g) and gestational ages at delivery (average 38.5 vs. 38.7 weeks).

After the investigators controlled for study site, age, race, multiples, primiparity, medical conditions, and smoking, the cases and controls also had similar rates of the following:

▸ Term low birth weight (5.6% vs. 3.6%; odds ratio, 1.45).

▸ Preterm delivery less than 37 weeks' gestation (13.3% vs. 11.6%; OR, 1.10).

▸ Premature rupture of membranes (1.7% vs. 2.6%; OR, 0.61).

▸ Abruption (0.9% vs. 1.2%; OR, 0.49).

▸ Cesarean section (27.5% vs. 30%; OR, 0.82).

▸ Induction (36% vs. 39%; OR, 0.83).

▸ Fetal anomalies (4.7% vs. 4.9%; OR, 1.24).

▸ Hypertensive disorders of pregnancy (14.3% vs. 13.2%; OR, 0.98).

▸ Neonatal ICU admission (13% vs. 11%; OR, 1.21).

“There did not appear to be any significant differences in pregnancy outcomes between cases and controls,” said Dr. Naresh of Magee-Women's Hospital of the University of Pittsburgh.

Pregnancy outcomes also did not differ when stratified by trimester, although more infections occurred in the second trimester, followed by the third and first trimesters, she said.

Previous case series have suggested an increased rate of preterm delivery, reaching 30% in an early report of H1N1 influenza in pregnancy and 60% among critically ill women. A recent study also reported lower birth weights among 16 women with proven H1N1 infection, compared with 25 women with influenzalike illness (Am. J. Obstet. Gynecol. 2011;204[suppl. 1]:S58–63), she said.

A subgroup analysis of women in the current study with severe disease, defined as requiring hospitalization, identified a nonsignificant trend for lower birth weight, compared with controls (3,013 g vs. 3,219 g), and lower gestational age (37.9 weeks vs. 38.7 weeks).

The combined outcome of term low birth weight, preterm birth, and abruption was significantly more common among the severe H1N1 cases than controls after study site, age, race, multiples, primiparity, medical conditions, and smoking were controlled for (31.4% vs. 15.7%; OR, 2.45). In addition, more than 30% of women in the severe group had complications, compared with only 15% in the control group.

All cases of H1N1 infection were significantly more likely than controls to be black (27% vs. 19%), and to have prepregnancy diabetes (4% vs. 1%), seizure disorder (3.4% vs. 0.8%), and asthma (17% vs. 9%). The average age of the cohort was 28 years.

Major Finding: Cases and controls had nearly identical birth weights (3,208 g vs. 3,219 g) and gestational ages at delivery (38.5 weeks vs. 38.7 weeks).

Data Source: Retrospective cohort analysis of 147 pregnant patients with 2009 H1N1 influenza and 740 pregnant controls.

Disclosures: Dr. Naresh and her coauthors reported no relevant financial disclosures.

CHICAGO – H1N1 influenza infection during the 2009 pandemic did not impact pregnancy outcomes in a retrospective cohort study of 887 women.

Subtle differences were observed, however, among women with severe infection or delayed treatment, Dr. Amber Naresh reported at the meeting.

She presented a retrospective cohort study performed at three tertiary care medical centers of all inpatient and outpatient cases of pregnant women with laboratory-confirmed 2009 H1N1 influenza. For each case, five pregnant women who tested negative for H1N1 influenza or were untested were randomly chosen from each site's database and matched by estimated date of confinement and site.

Based on a preliminary analysis, the 147 H1N1 cases and 740 controls had nearly identical birth weights (average 3,208 g vs. 3,219 g) and gestational ages at delivery (average 38.5 vs. 38.7 weeks).

After the investigators controlled for study site, age, race, multiples, primiparity, medical conditions, and smoking, the cases and controls also had similar rates of the following:

▸ Term low birth weight (5.6% vs. 3.6%; odds ratio, 1.45).

▸ Preterm delivery less than 37 weeks' gestation (13.3% vs. 11.6%; OR, 1.10).

▸ Premature rupture of membranes (1.7% vs. 2.6%; OR, 0.61).

▸ Abruption (0.9% vs. 1.2%; OR, 0.49).

▸ Cesarean section (27.5% vs. 30%; OR, 0.82).

▸ Induction (36% vs. 39%; OR, 0.83).

▸ Fetal anomalies (4.7% vs. 4.9%; OR, 1.24).

▸ Hypertensive disorders of pregnancy (14.3% vs. 13.2%; OR, 0.98).

▸ Neonatal ICU admission (13% vs. 11%; OR, 1.21).

“There did not appear to be any significant differences in pregnancy outcomes between cases and controls,” said Dr. Naresh of Magee-Women's Hospital of the University of Pittsburgh.

Pregnancy outcomes also did not differ when stratified by trimester, although more infections occurred in the second trimester, followed by the third and first trimesters, she said.

Previous case series have suggested an increased rate of preterm delivery, reaching 30% in an early report of H1N1 influenza in pregnancy and 60% among critically ill women. A recent study also reported lower birth weights among 16 women with proven H1N1 infection, compared with 25 women with influenzalike illness (Am. J. Obstet. Gynecol. 2011;204[suppl. 1]:S58–63), she said.

A subgroup analysis of women in the current study with severe disease, defined as requiring hospitalization, identified a nonsignificant trend for lower birth weight, compared with controls (3,013 g vs. 3,219 g), and lower gestational age (37.9 weeks vs. 38.7 weeks).

The combined outcome of term low birth weight, preterm birth, and abruption was significantly more common among the severe H1N1 cases than controls after study site, age, race, multiples, primiparity, medical conditions, and smoking were controlled for (31.4% vs. 15.7%; OR, 2.45). In addition, more than 30% of women in the severe group had complications, compared with only 15% in the control group.

All cases of H1N1 infection were significantly more likely than controls to be black (27% vs. 19%), and to have prepregnancy diabetes (4% vs. 1%), seizure disorder (3.4% vs. 0.8%), and asthma (17% vs. 9%). The average age of the cohort was 28 years.

Major Finding: Cases and controls had nearly identical birth weights (3,208 g vs. 3,219 g) and gestational ages at delivery (38.5 weeks vs. 38.7 weeks).

Data Source: Retrospective cohort analysis of 147 pregnant patients with 2009 H1N1 influenza and 740 pregnant controls.

Disclosures: Dr. Naresh and her coauthors reported no relevant financial disclosures.

CHICAGO – H1N1 influenza infection during the 2009 pandemic did not impact pregnancy outcomes in a retrospective cohort study of 887 women.

Subtle differences were observed, however, among women with severe infection or delayed treatment, Dr. Amber Naresh reported at the meeting.

She presented a retrospective cohort study performed at three tertiary care medical centers of all inpatient and outpatient cases of pregnant women with laboratory-confirmed 2009 H1N1 influenza. For each case, five pregnant women who tested negative for H1N1 influenza or were untested were randomly chosen from each site's database and matched by estimated date of confinement and site.

Based on a preliminary analysis, the 147 H1N1 cases and 740 controls had nearly identical birth weights (average 3,208 g vs. 3,219 g) and gestational ages at delivery (average 38.5 vs. 38.7 weeks).

After the investigators controlled for study site, age, race, multiples, primiparity, medical conditions, and smoking, the cases and controls also had similar rates of the following:

▸ Term low birth weight (5.6% vs. 3.6%; odds ratio, 1.45).

▸ Preterm delivery less than 37 weeks' gestation (13.3% vs. 11.6%; OR, 1.10).

▸ Premature rupture of membranes (1.7% vs. 2.6%; OR, 0.61).

▸ Abruption (0.9% vs. 1.2%; OR, 0.49).

▸ Cesarean section (27.5% vs. 30%; OR, 0.82).

▸ Induction (36% vs. 39%; OR, 0.83).

▸ Fetal anomalies (4.7% vs. 4.9%; OR, 1.24).

▸ Hypertensive disorders of pregnancy (14.3% vs. 13.2%; OR, 0.98).

▸ Neonatal ICU admission (13% vs. 11%; OR, 1.21).

“There did not appear to be any significant differences in pregnancy outcomes between cases and controls,” said Dr. Naresh of Magee-Women's Hospital of the University of Pittsburgh.

Pregnancy outcomes also did not differ when stratified by trimester, although more infections occurred in the second trimester, followed by the third and first trimesters, she said.

Previous case series have suggested an increased rate of preterm delivery, reaching 30% in an early report of H1N1 influenza in pregnancy and 60% among critically ill women. A recent study also reported lower birth weights among 16 women with proven H1N1 infection, compared with 25 women with influenzalike illness (Am. J. Obstet. Gynecol. 2011;204[suppl. 1]:S58–63), she said.

A subgroup analysis of women in the current study with severe disease, defined as requiring hospitalization, identified a nonsignificant trend for lower birth weight, compared with controls (3,013 g vs. 3,219 g), and lower gestational age (37.9 weeks vs. 38.7 weeks).

The combined outcome of term low birth weight, preterm birth, and abruption was significantly more common among the severe H1N1 cases than controls after study site, age, race, multiples, primiparity, medical conditions, and smoking were controlled for (31.4% vs. 15.7%; OR, 2.45). In addition, more than 30% of women in the severe group had complications, compared with only 15% in the control group.

All cases of H1N1 infection were significantly more likely than controls to be black (27% vs. 19%), and to have prepregnancy diabetes (4% vs. 1%), seizure disorder (3.4% vs. 0.8%), and asthma (17% vs. 9%). The average age of the cohort was 28 years.

Major Finding: Following training on a birth simulator, the percentage of clinicians pulling with more than 150 N during simulated shoulder dystocia deliveries fell from 75% to 43%.

Data Source: A nonrandomized educational intervention involving 40 clinicians.

Disclosures: Dr. Guise said she had no relevant financial disclosures. The project was funded by the Agency for Healthcare Research and Quality (AHRQ).

SEATTLE – Use of a birth force simulator taught clinicians better how to modulate how much force they use when handling a case of shoulder dystocia to avoid brachial plexus and other injuries.

The pull should be no more than 100 newtons (N), a gentle but firm traction, according to Dr. Jeanne-Marie Guise, an obstetrician and gynecologist at Oregon Health and Science University, Portland. It's hard to know, however, exactly how much that is. Shoulder dystocia occurs in only 0.2%-3.0% of births, so training opportunities are rare, and shoulder dystocia emergencies are not very teachable moments. Dr. Guise and her colleagues wanted to see if training on a birth simulator would help clinicians get a feel for how much force to use.

Twenty-eight obstetricians, six family physicians, and six certified midwives, with experience ranging from 6 months to 34 years, were trained on a PROMPT birthing simulator with force monitoring, made by Limbs & Things Ltd. (Bristol, England). Initially, they were blinded to the force-monitoring screen; 38 (95%) pulled with more than 100 N, 30 (75%) with more than 150 N, and 21 (53%) with more than 200 N. Greater force was used as time wore on.

Then, while watching the screen and then from memory, participants pulled with 50 N and then 100 N several times, to get a feel for what those levels of force felt like. At 100 N, Dr. Guise told them, “this is the most you should ever feel, so pay attention” to what it feels like: “If you're starting to shake, how your facial muscles feel,” and so on.

To see if the training took, participants went through surprise simulations. During their shifts, a nurse came running up saying, “I need a doctor, I need a doctor!” Trainees were pulled into a triage room, “but didn't exactly know why,” Dr. Guise said. In the room, they faced the PROMPT simulator again, but this time with an actress playing the part of a frantic mother during a shoulder dystocia delivery. Participants couldn't see the force-monitoring screen. “We plummeted the heart rate and tried to get everything as realistic as it could be. The actress was really acting it up,” she said.

Even under pressure, training made a significant difference. Although 33 (82%) of the participants used more than 100 N, only 17 (43%) used more than 150 N, and 11 (28%) used more than 200 N. “There was a reduction in overall forces applied after simulation training. Participants were able to gauge forces applied after training,” Dr. Guise and her colleagues concluded in the study abstract.

“It's nice to find a way to teach providers to modulate the amount of force in a moment that's not as critical,” she said.

Major Finding: Following training on a birth simulator, the percentage of clinicians pulling with more than 150 N during simulated shoulder dystocia deliveries fell from 75% to 43%.

Data Source: A nonrandomized educational intervention involving 40 clinicians.

Disclosures: Dr. Guise said she had no relevant financial disclosures. The project was funded by the Agency for Healthcare Research and Quality (AHRQ).

SEATTLE – Use of a birth force simulator taught clinicians better how to modulate how much force they use when handling a case of shoulder dystocia to avoid brachial plexus and other injuries.

The pull should be no more than 100 newtons (N), a gentle but firm traction, according to Dr. Jeanne-Marie Guise, an obstetrician and gynecologist at Oregon Health and Science University, Portland. It's hard to know, however, exactly how much that is. Shoulder dystocia occurs in only 0.2%-3.0% of births, so training opportunities are rare, and shoulder dystocia emergencies are not very teachable moments. Dr. Guise and her colleagues wanted to see if training on a birth simulator would help clinicians get a feel for how much force to use.

Twenty-eight obstetricians, six family physicians, and six certified midwives, with experience ranging from 6 months to 34 years, were trained on a PROMPT birthing simulator with force monitoring, made by Limbs & Things Ltd. (Bristol, England). Initially, they were blinded to the force-monitoring screen; 38 (95%) pulled with more than 100 N, 30 (75%) with more than 150 N, and 21 (53%) with more than 200 N. Greater force was used as time wore on.

Then, while watching the screen and then from memory, participants pulled with 50 N and then 100 N several times, to get a feel for what those levels of force felt like. At 100 N, Dr. Guise told them, “this is the most you should ever feel, so pay attention” to what it feels like: “If you're starting to shake, how your facial muscles feel,” and so on.

To see if the training took, participants went through surprise simulations. During their shifts, a nurse came running up saying, “I need a doctor, I need a doctor!” Trainees were pulled into a triage room, “but didn't exactly know why,” Dr. Guise said. In the room, they faced the PROMPT simulator again, but this time with an actress playing the part of a frantic mother during a shoulder dystocia delivery. Participants couldn't see the force-monitoring screen. “We plummeted the heart rate and tried to get everything as realistic as it could be. The actress was really acting it up,” she said.

Even under pressure, training made a significant difference. Although 33 (82%) of the participants used more than 100 N, only 17 (43%) used more than 150 N, and 11 (28%) used more than 200 N. “There was a reduction in overall forces applied after simulation training. Participants were able to gauge forces applied after training,” Dr. Guise and her colleagues concluded in the study abstract.

“It's nice to find a way to teach providers to modulate the amount of force in a moment that's not as critical,” she said.

Major Finding: Following training on a birth simulator, the percentage of clinicians pulling with more than 150 N during simulated shoulder dystocia deliveries fell from 75% to 43%.

Data Source: A nonrandomized educational intervention involving 40 clinicians.

Disclosures: Dr. Guise said she had no relevant financial disclosures. The project was funded by the Agency for Healthcare Research and Quality (AHRQ).

SEATTLE – Use of a birth force simulator taught clinicians better how to modulate how much force they use when handling a case of shoulder dystocia to avoid brachial plexus and other injuries.

The pull should be no more than 100 newtons (N), a gentle but firm traction, according to Dr. Jeanne-Marie Guise, an obstetrician and gynecologist at Oregon Health and Science University, Portland. It's hard to know, however, exactly how much that is. Shoulder dystocia occurs in only 0.2%-3.0% of births, so training opportunities are rare, and shoulder dystocia emergencies are not very teachable moments. Dr. Guise and her colleagues wanted to see if training on a birth simulator would help clinicians get a feel for how much force to use.

Twenty-eight obstetricians, six family physicians, and six certified midwives, with experience ranging from 6 months to 34 years, were trained on a PROMPT birthing simulator with force monitoring, made by Limbs & Things Ltd. (Bristol, England). Initially, they were blinded to the force-monitoring screen; 38 (95%) pulled with more than 100 N, 30 (75%) with more than 150 N, and 21 (53%) with more than 200 N. Greater force was used as time wore on.

Then, while watching the screen and then from memory, participants pulled with 50 N and then 100 N several times, to get a feel for what those levels of force felt like. At 100 N, Dr. Guise told them, “this is the most you should ever feel, so pay attention” to what it feels like: “If you're starting to shake, how your facial muscles feel,” and so on.

To see if the training took, participants went through surprise simulations. During their shifts, a nurse came running up saying, “I need a doctor, I need a doctor!” Trainees were pulled into a triage room, “but didn't exactly know why,” Dr. Guise said. In the room, they faced the PROMPT simulator again, but this time with an actress playing the part of a frantic mother during a shoulder dystocia delivery. Participants couldn't see the force-monitoring screen. “We plummeted the heart rate and tried to get everything as realistic as it could be. The actress was really acting it up,” she said.

Even under pressure, training made a significant difference. Although 33 (82%) of the participants used more than 100 N, only 17 (43%) used more than 150 N, and 11 (28%) used more than 200 N. “There was a reduction in overall forces applied after simulation training. Participants were able to gauge forces applied after training,” Dr. Guise and her colleagues concluded in the study abstract.

“It's nice to find a way to teach providers to modulate the amount of force in a moment that's not as critical,” she said.