Obstetrics

When a woman who has epilepsy is pregnant or planning for pregnancy, you face the challenge of balancing the benefits and teratogenic risks of her antiseizure medication. Here is help.

About 500,000 women of childbearing age in the United States suffer from epilepsy.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma

Infants born to women who have epilepsy have a twofold to threefold increased risk of congenital malformations, compared with infants born to women who do not have the disorder. The increased risk is mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neurocognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet, discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In one recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is unknown.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancy and a neurologist or epileptologist. In reality, those who live in areas with limited access to such specialized care or who have limited health coverage may be cared for throughout pregnancy by a generalist ObGyn. This evidence-based review was developed with that reality in mind.

Switching (or stopping) AEDs before conception

Changes in AEDs are rarely made after conception. Any switches that a patient may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year before she plans to conceive so that good seizure control can be achieved by then.

Begin by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That will allow you to determine the baseline therapeutic drug level and dosage at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dosage, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

Is discontinuation of AED therapy advisable if a patient wants to become pregnant?

Stopping an AED is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, or if she has a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests that she may have recurrent seizures, explain that the risk of discontinuing the medicine is greater than the risk of fetal exposure to an AED. It is also important to point out that more than 90% of women who have epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider during the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry (http://aedpregnancyregistry.org). We recommend that physicians caring for pregnant women who have epilepsy encourage them to enroll early, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women who are taking an AED—particularly those taking a higher-risk drug such as valproate—undergo a detailed first-trimester ultrasonographic study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible. If needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill-advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk of major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ whereas a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in pregnancy. In some cases, dramatic increases—several multiples of the preconception dosage—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels

Our approach to monitoring AED levels in a pregnant woman who has epilepsy includes the following:

• Check levels at baseline—prior to conception whenever possible—and monthly throughout the pregnancy, with more frequent checks for women who have recurrent seizures and those who are taking lamotrigine
• Use the dosage at which the patient was seizure-free prior to conception as a target level during pregnancy
• Adjust the dosage as needed to maintain the preconception serum drug level.

Drug-specific considerations. Because phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin, and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the corrected level of the drug with the following formula:

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/day of folic acid for pregnant women who have epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women who have epilepsy (phytonadione 10 mg/day), starting at 36 weeks’ gestation and continuing until delivery, despite the lack of a proven benefit, because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg of vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes an AED—to prevent hemorrhagic disease.¹³

Should women taking an AED breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with an AED are generally concerned about the possibility of contaminated breast milk. Although antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with an AED.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients who have epilepsy who are being treated with an AED, and it is not contraindicated by AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women who have epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the variables to consider in the management of epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

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

When a woman who has epilepsy is pregnant or planning for pregnancy, you face the challenge of balancing the benefits and teratogenic risks of her antiseizure medication. Here is help.

About 500,000 women of childbearing age in the United States suffer from epilepsy.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma

Infants born to women who have epilepsy have a twofold to threefold increased risk of congenital malformations, compared with infants born to women who do not have the disorder. The increased risk is mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neurocognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet, discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In one recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is unknown.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancy and a neurologist or epileptologist. In reality, those who live in areas with limited access to such specialized care or who have limited health coverage may be cared for throughout pregnancy by a generalist ObGyn. This evidence-based review was developed with that reality in mind.

Switching (or stopping) AEDs before conception

Changes in AEDs are rarely made after conception. Any switches that a patient may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year before she plans to conceive so that good seizure control can be achieved by then.

Begin by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That will allow you to determine the baseline therapeutic drug level and dosage at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dosage, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

Is discontinuation of AED therapy advisable if a patient wants to become pregnant?

Stopping an AED is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, or if she has a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests that she may have recurrent seizures, explain that the risk of discontinuing the medicine is greater than the risk of fetal exposure to an AED. It is also important to point out that more than 90% of women who have epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider during the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry (http://aedpregnancyregistry.org). We recommend that physicians caring for pregnant women who have epilepsy encourage them to enroll early, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women who are taking an AED—particularly those taking a higher-risk drug such as valproate—undergo a detailed first-trimester ultrasonographic study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible. If needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill-advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk of major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ whereas a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in pregnancy. In some cases, dramatic increases—several multiples of the preconception dosage—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels

Our approach to monitoring AED levels in a pregnant woman who has epilepsy includes the following:

• Check levels at baseline—prior to conception whenever possible—and monthly throughout the pregnancy, with more frequent checks for women who have recurrent seizures and those who are taking lamotrigine
• Use the dosage at which the patient was seizure-free prior to conception as a target level during pregnancy
• Adjust the dosage as needed to maintain the preconception serum drug level.

Drug-specific considerations. Because phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin, and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the corrected level of the drug with the following formula:

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/day of folic acid for pregnant women who have epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women who have epilepsy (phytonadione 10 mg/day), starting at 36 weeks’ gestation and continuing until delivery, despite the lack of a proven benefit, because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg of vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes an AED—to prevent hemorrhagic disease.¹³

Should women taking an AED breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with an AED are generally concerned about the possibility of contaminated breast milk. Although antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with an AED.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients who have epilepsy who are being treated with an AED, and it is not contraindicated by AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women who have epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the variables to consider in the management of epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

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

When a woman who has epilepsy is pregnant or planning for pregnancy, you face the challenge of balancing the benefits and teratogenic risks of her antiseizure medication. Here is help.

About 500,000 women of childbearing age in the United States suffer from epilepsy.¹ For these patients and their physicians, family planning and pregnancy are complex and fraught with risk.

The dilemma

Infants born to women who have epilepsy have a twofold to threefold increased risk of congenital malformations, compared with infants born to women who do not have the disorder. The increased risk is mainly related to exposure to antiepileptic drugs (AEDs).² Recent studies also suggest that children exposed to AEDs such as valproate, phenobarbital, and phenytoin in utero may have neurocognitive deficits, even when there are no major congenital malformations.^1,3,4

Yet, discontinuing the drugs prior to conception or in early pregnancy is rarely a viable option. In one recent prospective study, convulsive seizures during the first trimester (the type and timing of seizure thought to have the most harmful effect on the developing fetus) were associated with malformations in 7.4% of pregnancies.² Seizures also increase the risk of both fetal and maternal death, although the extent of that risk is unknown.⁵

Ideally, pregnant women with epilepsy should be under the care of both an obstetrician experienced in high-risk pregnancy and a neurologist or epileptologist. In reality, those who live in areas with limited access to such specialized care or who have limited health coverage may be cared for throughout pregnancy by a generalist ObGyn. This evidence-based review was developed with that reality in mind.

Switching (or stopping) AEDs before conception

Changes in AEDs are rarely made after conception. Any switches that a patient may desire—from a potentially unsafe drug to a “safer” AED, for example—should be considered at least a year before she plans to conceive so that good seizure control can be achieved by then.

Begin by checking the serum drug level of the patient’s effective, yet potentially unsafe, antiseizure drug. That will allow you to determine the baseline therapeutic drug level and dosage at which the patient is seizure-free. Then add the second, safer AED and taper it up to its therapeutic dosage, guided by serum drug levels and the manufacturer’s recommended titration schedule. Once the new medication has reached the therapeutic serum level, begin titrating the older AED down. If the patient suffers a breakthrough seizure during the cross-taper, we recommend aborting the process and rapidly titrating the first drug back to the predetermined therapeutic level.

Is discontinuation of AED therapy advisable if a patient wants to become pregnant?

Stopping an AED is a clinical decision made by the treating physician in accordance with the patient’s wishes on a case-by-case basis and should be considered only when it is highly likely that seizures will not recur as a result. If the patient has a history of poorly controlled epilepsy despite adequate AED trials, or if she has a structural brain lesion, persistently abnormal electroencephalograms, or any other finding that suggests that she may have recurrent seizures, explain that the risk of discontinuing the medicine is greater than the risk of fetal exposure to an AED. It is also important to point out that more than 90% of women who have epilepsy have normal, healthy children¹⁴—and that there are other steps to take to mitigate risk.¹³

What to consider during the first trimester

Registries that aim to gather data on the outcomes of a large number of AED-exposed pregnancies are a source of reliable information regarding the risks associated with various antiseizure agents. The primary US-based registry is the AED Pregnancy Registry (http://aedpregnancyregistry.org). We recommend that physicians caring for pregnant women who have epilepsy encourage them to enroll early, before any prenatal tests are performed. Explain to your patient that by joining the registry, she will be helping others like her make informed decisions about prenatal care.

Prenatal testing. We also recommend that pregnant women who are taking an AED—particularly those taking a higher-risk drug such as valproate—undergo a detailed first-trimester ultrasonographic study between 16 and 20 weeks’ gestation. Amniocentesis should be avoided, if possible. If needed, however, amniotic alpha-fetoprotein levels may be determined for additional risk assessment.¹⁵

Medication changes. Once a woman is pregnant, stopping or switching AEDs requires a higher level of caution and is usually ill-advised. We generally avoid medication switches after conception. But if a patient explicitly requests a change to a “safer” agent, we may attempt a cross-taper, as we would before pregnancy. Evidence suggests, however, that it may be too late to avoid the risk of major congenital malformations, which typically develop very early in pregnancy.^1,3

Avoid untried AEDs. We advise against changing a pregnant woman’s seizure medication to an agent she has not tried before, because of the risks of both common adverse effects, such as allergies, and rare idiosyncratic reactions leading to aplastic anemia and Stevens-Johnson syndrome.

AED dosing throughout pregnancy

When seizures are well controlled prior to conception, they usually remain controlled during pregnancy, although both increases and decreases in seizure frequency have been reported.¹⁶ Seizure exacerbations are usually due to decreased AED levels; this may be the result of decreased plasma protein binding, decreased albumin concentration, or increased drug clearance,¹⁶ although stress, sleep deprivation, and noncompliance may be contributing factors, as well. The changes in pharmacokinetics make it imperative that seizure frequency as well as AED levels be carefully monitored throughout pregnancy.

Although detailed information about changes in serum levels of the newer AEDs during pregnancy is not available, it can be assumed that they will decline somewhat even if the dose remains the same. Carbamazepine has the least alteration in metabolism during pregnancy,¹⁷ whereas a widely disparate effect on lamotrigine metabolism during pregnancy has been noted. In some women, serum levels of lamotrigine have been shown to decrease by as much as 60% to 90% due to induction of UDP-glucuronosyltransferase (UGT) enzymes,¹⁸ the drug’s main metabolic enzymes. Increased clearance of lamotrigine typically occurs within the first several weeks of pregnancy and returns to baseline within 2 weeks after birth.

As a result, incremental dosing of lamotrigine is usually required early in pregnancy. In some cases, dramatic increases—several multiples of the preconception dosage—may be needed, followed by a rapid decrease after delivery.¹⁸

Monitoring drug levels

Our approach to monitoring AED levels in a pregnant woman who has epilepsy includes the following:

• Check levels at baseline—prior to conception whenever possible—and monthly throughout the pregnancy, with more frequent checks for women who have recurrent seizures and those who are taking lamotrigine
• Use the dosage at which the patient was seizure-free prior to conception as a target level during pregnancy
• Adjust the dosage as needed to maintain the preconception serum drug level.

Drug-specific considerations. Because phenytoin and valproate are highly protein-bound, we follow free levels during pregnancy rather than total levels alone. (If your facility is not equipped to track free drug levels, it is important to realize that total levels of these AEDs may not accurately reflect the drug level.) If your patient is taking phenytoin, and you’re unable to obtain this information, you can use the patient’s albumin level and the total phenytoin level to estimate the corrected level of the drug with the following formula:

Provide vitamin K augmentation late in pregnancy. In addition to routinely prescribing 4 mg/day of folic acid for pregnant women who have epilepsy, we recommend oral augmentation of vitamin K as another protective measure.

AEDs that induce hepatic CYP enzymes also induce vitamin K metabolism, thereby reducing the effectiveness of vitamin K-dependent clotting factors and predisposing newborns to hemorrhagic disease.¹³ It remains unclear whether only women who are taking CYP enzyme-inducing AEDs or all women taking AEDs should receive oral vitamin K supplementation in the last few weeks of pregnancy. We recommend oral vitamin K supplementation for all pregnant women who have epilepsy (phytonadione 10 mg/day), starting at 36 weeks’ gestation and continuing until delivery, despite the lack of a proven benefit, because it is safe and carries little, if any, risk.

An intramuscular injection of 1 mg of vitamin K is generally given to all newborns—regardless of whether the mother has epilepsy and takes an AED—to prevent hemorrhagic disease.¹³

Should women taking an AED breastfeed?

The advantages of breastfeeding are largely undisputed, but women being treated with an AED are generally concerned about the possibility of contaminated breast milk. Although antiepileptic agents such as gabapentin, lamotrigine, levetiracetam, and topiramate are excreted in breast milk in potentially clinically important amounts, no short-term adverse effects have been observed in nursing infants of women being treated with an AED.¹³ Little information is available regarding long-term effects, and the AAN and AES state that further study is needed. Nonetheless, breastfeeding is generally believed to be a relatively safe option for patients who have epilepsy who are being treated with an AED, and it is not contraindicated by AAN/AES guidelines.¹³

Indeed, pregnancy itself is relatively safe for women who have epilepsy. When you’re involved in their care, your awareness of the teratogenicity of various AEDs, the variables to consider in the management of epilepsy and pregnancy, and the steps to take to mitigate risk will help you maximize the chance of a positive outcome.

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

Dr. Sibai reports no financial relationships relevant to this article.

By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.

Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.

In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.

1. Plan and rehearse a step-by-step approach

Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.

It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.

2. Know the signs and symptoms of severe hemorrhage

Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.

Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.

Signs and symptoms of postpartum hemorrhage

3. Call for help within 10 minutes after making
the diagnosis of PPH

Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.

In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.

4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction

O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.

Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.

In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:

• number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
• placenta previa (OR, 13.5; 95% CI, 7.7–184)
• placenta accreta (OR, 37.7; 95% CI, 7.7–184)
• uterine rupture (OR, 7.25; 95% CI, 1.25–42)
• number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).

5. Perform uterine-compression sutures within 1 hour
after delivery

Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.

Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.

6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team

Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.

Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).

7. Consider conservative management of placenta accreta
and placenta percreta in carefully selected women
who desire future fertility

Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.

Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:

• stepwise uterine devascularization
• pelvic vessel ligation or embolization
• uterine-compression sutures
• administration of methotrexate and antibiotics.

Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.

Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.

8. Beware of von Willebrand disease

Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.

This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.

Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.

9. Have fibrinogen concentrate on hand

Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.

Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.

This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.

10. Implement a protocol for massive transfusion

Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.

A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:

• administration of adequate blood and blood products
• maintenance of tissue perfusion
• ensuring adequate oxygen delivery
• correction of DIC.

These objectives are vital while the team is working to control the source of bleeding.

For a related malpractice case, read Medical Verdicts.

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

Dr. Sibai reports no financial relationships relevant to this article.

By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.

Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.

In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.

1. Plan and rehearse a step-by-step approach

Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.

It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.

2. Know the signs and symptoms of severe hemorrhage

Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.

Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.

Signs and symptoms of postpartum hemorrhage

3. Call for help within 10 minutes after making
the diagnosis of PPH

Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.

In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.

4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction

O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.

Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.

In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:

• number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
• placenta previa (OR, 13.5; 95% CI, 7.7–184)
• placenta accreta (OR, 37.7; 95% CI, 7.7–184)
• uterine rupture (OR, 7.25; 95% CI, 1.25–42)
• number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).

5. Perform uterine-compression sutures within 1 hour
after delivery

Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.

Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.

6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team

Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.

Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).

7. Consider conservative management of placenta accreta
and placenta percreta in carefully selected women
who desire future fertility

Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.

Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:

• stepwise uterine devascularization
• pelvic vessel ligation or embolization
• uterine-compression sutures
• administration of methotrexate and antibiotics.

Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.

Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.

8. Beware of von Willebrand disease

Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.

This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.

Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.

9. Have fibrinogen concentrate on hand

Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.

Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.

This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.

10. Implement a protocol for massive transfusion

Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.

A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:

• administration of adequate blood and blood products
• maintenance of tissue perfusion
• ensuring adequate oxygen delivery
• correction of DIC.

These objectives are vital while the team is working to control the source of bleeding.

For a related malpractice case, read Medical Verdicts.

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

Dr. Sibai reports no financial relationships relevant to this article.

By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.

Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.

In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.

1. Plan and rehearse a step-by-step approach

Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.

It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.

2. Know the signs and symptoms of severe hemorrhage

Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.

Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.

Signs and symptoms of postpartum hemorrhage

3. Call for help within 10 minutes after making
the diagnosis of PPH

Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.

In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.

4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction

O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.

Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.

In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:

• number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
• placenta previa (OR, 13.5; 95% CI, 7.7–184)
• placenta accreta (OR, 37.7; 95% CI, 7.7–184)
• uterine rupture (OR, 7.25; 95% CI, 1.25–42)
• number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).

5. Perform uterine-compression sutures within 1 hour
after delivery

Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.

Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.

6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team

Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.

Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).

7. Consider conservative management of placenta accreta
and placenta percreta in carefully selected women
who desire future fertility

Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.

Extirpative surgery in the form of hysterectomy—with or without partial bladder resection—is usually considered the treatment of choice for these conditions. A retrospective multicenter study reported maternal outcomes after conservative treatment of 167 women who had placenta accreta or percreta (18% had percreta). Conservative management included one or more of the following:

• stepwise uterine devascularization
• pelvic vessel ligation or embolization
• uterine-compression sutures
• administration of methotrexate and antibiotics.

Conservative treatment was successful in 131 (78.5%) cases. Eighteen women underwent primary hysterectomy, and 18 women underwent delayed hysterectomy. One woman died after intraumbilical methotrexate administration, and 10 women (6%) experienced severe morbidity.

Conservative management should be offered only in centers that have adequate equipment and resources for patients who are properly counseled and who are motivated and agree to close follow-up. Planned cesarean hysterectomy remains the treatment of choice for multiparous women, as well as for women who have multiple cesarean deliveries with accreta, and those who do not accept the risks or who are not motivated to undergo close and prolonged follow-up.

8. Beware of von Willebrand disease

Pacheco LD, Costantine M, Saade GR, et al. von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment. Am J Obstet Gynecol. 2010;203(3):194–200.

This disease can cause immediate and delayed postpartum hemorrhage and has a prevalence of approximately 1% in the general population. Sixteen percent to 29% of women who have von Willebrand disease will experience PPH within 24 hours after delivery, and 20% to 29% will experience delayed postpartum bleeding.

Patients who have this disease should be managed in consultation with a hematologist and blood bank personnel. It entails use of desmopressin, plasma concentrates that contain von Willebrand factor (Humate-P), or cryoprecipitate.

9. Have fibrinogen concentrate on hand

Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anaesth. 2010;19(2):218–223.

Rahe-Mayer N, Sørensen B. Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5.

This product can correct hypofibrinogenemia very rapidly. In women who have severe PPH, hypofibrinogenemia may develop as a result of dilutional coagulopathy or hypofibrinogemia in conditions such as abruptio placentae with fetal demise, acute fatty liver of pregnancy, or amniotic fluid embolism. Treatment requires a high volume of fresh frozen plasma or cryoprecipitate. Fibrinogen concentrate is stored at room temperature, requires no cross-matching, and can be prepared and infused within 3 minutes.

10. Implement a protocol for massive transfusion

Sibai BM. Evaluation and management of postpartum hemorrhage. In: Management of Acute Obstetric Emergencies. New York, NY: Elsevier; 2011:41–70.

A delay in the treatment of hypovolemic shock can cause ischemic injury to the kidneys, liver, myocardium, and brain and can lead to diffuse intravascular coagulation (DIC), adult respiratory distress syndrome, and death. The objectives for having a protocol for massive transfusion include:

• administration of adequate blood and blood products
• maintenance of tissue perfusion
• ensuring adequate oxygen delivery
• correction of DIC.

These objectives are vital while the team is working to control the source of bleeding.

For a related malpractice case, read Medical Verdicts.

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

Dr. Tita reports receiving research support from the NIH. Dr. Subramaniam and Dr. Andrews report no financial relationships relevant to this article.

Despite continuing advances in obstetric and neonatal care, including the use of antimicrobials, infection remains a major cause of maternal and perinatal morbidity and death. Indeed, infection is among the top five causes of maternal death in the United States, with 10% to 15% of deaths directly linked to it. Maternal and fetal infections are also a common cause of perinatal death. Clearly, interventions to prevent infection or minimize its effect during pregnancy and postpartum are a priority.

This article focuses on three notable developments of the past year:

• release of revised guidelines on the prevention of perinatal group B streptococcal disease (GBS)
• publication of surveillance data on 2009 influenza A(H1N1) among pregnant women, which reveals the life-threatening nature of the flu in this population
• publication of a Committee Opinion from ACOG on the timing of antimicrobial prophylaxis for cesarean delivery, in which administration within 60 minutes of the start of the procedure is recommended.

There’s room for improvement in GBS screening and prophylaxis,
says CDC

Verani JR, McGee L, Schrag SJ, National Center for Immunization and Respiratory Diseases. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1–36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.

The latest revision of CDC guidelines on screening and prophylaxis for perinatal group B streptococcal disease were developed by a multidisciplinary working group representing several professional organizations, including ACOG. Information that has come to light since the most recent guidelines were released in 2002 was incorporated, and areas that have seen suboptimal implementation or interpretation were addressed here as well.

Although the use of prophylactic antibiotics during labor reduces the incidence of invasive GBS during the first week of life, GBS remains a leading cause of neonatal morbidity and death in the United States and elsewhere. Universal screening and intrapartum antibiotic prophylaxis for women who test positive for GBS remain the cornerstone of prevention of early-onset neonatal GBS disease. Penicillin G is still the agent of choice, and ampicillin is an acceptable alternative. When prophylaxis is warranted, intravenous antibiotic administration at least 4 hours before delivery is recommended.

Other recommendations from the CDC include:

• Women who have GBS bacteriuria (≥10⁴ colony-forming units/mL) any time during pregnancy, and women who had a previous infant with invasive GBS disease, should receive intrapartum antibiotic prophylaxis. In these cases, third-trimester screening for GBS is unnecessary.
• All other women should be screened at 35 to 37 weeks’ gestation for rectovaginal GBS colonization.
• At the onset of labor or rupture of membranes, antibiotic prophylaxis should be given to all women who tested positive for GBS—with the exception of women who are undergoing cesarean delivery, at any gestational age, with intact membranes.
• If GBS status is unknown, intrapartum prophylaxis should be given for gestational ages below 37 weeks, membrane rupture lasting 18 hours or longer, or temperature of 100.4°F (38.0°C) or above.
• Health-care providers should inform women of their GBS screening results and the recommended interventions.

Some updates to the guidelines clarify areas in which there was some confusion. For example, the guidelines delineate that women who have preterm labor or preterm premature rupture of the membranes (PPROM) should be screened for GBS and started on prophylaxis immediately, unless they have received a negative screen within the preceding 5 weeks. Antibiotics should be discontinued if a woman who has intact membranes is found not to be in true labor or if the GBS culture is negative.

For the woman who has PPROM, antibiotics to prolong latency are sufficient, provided they include adequate GBS coverage; otherwise, GBS prophylaxis is warranted for as long as 48 hours.

In addition:

• Women who are allergic to penicillin and who have no history of anaphylaxis, angioedema, respiratory distress, or urticaria in response to penicillin or a cephalosporin, should be given cefazolin for GBS prophylaxis. Women at risk of anaphylaxis should undergo antimicrobial susceptibility testing. For these women, clindamycin is acceptable if the GBS isolate is susceptible to both clindamycin and erythromycin or resistant to erythromycin with negative inducible clindamycin resistance. Otherwise, vancomycin is recommended. Erythromycin is not acceptable because of a high prevalence of resistance.
• The dosage of penicillin is 5 million U initially, followed by 2.5 million to 3 million U every 4 hours.
• If a laboratory providing nucleic acid amplification testing (NAAT) is available, intrapartum testing for women who have unknown GBS status and no intrapartum risk factors (i.e., gestational age <37 weeks, membrane rupture for 18 hours or longer, or temperature ≥100.4°F) is an option.

Be vigilant for influenza among your pregnant patients—
and take necessary action

Siston AM, Rasmussen SA, Honein MA, et al, for the Pandemic H1N1 Influenza in Pregnancy Working Group. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517–1525.

The recent H1N1 pandemic highlighted the status of influenza as a major public health problem, not only among children and the elderly but especially among pregnant women. This report by Siston and colleagues describes the US experience of the pandemic. To ascertain the severity of infection during pregnancy, the authors analyzed data from 788 pregnant women who developed symptoms of H1N1 infection between April and August 2009. These women were identified through the CDC national surveillance system. Data from an additional 165 women who developed symptoms through December 2011 and who were admitted to an ICU because of influenza were also analyzed.

Siston and colleagues found a high case-fatality rate (5%) among pregnant women who had influenza. Almost one fourth (22.6%) of women who were hospitalized with influenza were admitted to an ICU because of severe illness.

The timing of antiviral treatment influenced the course of the illness. For example, women who received antiviral treatment within 2 days of the onset of symptoms had a significantly lower risk of death (0.5%), compared with women who received treatment within 3 to 4 days (5%) and with women who were treated after 4 days (27%). Women who were not treated at all also had an elevated risk of ICU admission and death, although that risk was not as high as it was among women treated 4 days or longer after the onset of symptoms. This finding suggests that severity of illness may play a role in determining who receives antiviral treatment.

ACOG: Give prophylactic antimicrobials before the incision
in cesarean delivery

ACOG committee opinion no. 465: Antimicrobial prophylaxis for cesarean delivery: timing of administration. Obstet Gynecol. 2010;116(3):791–792.

The use of antimicrobial prophylaxis for cesarean delivery is associated with a reduction of 50% or more in the rates of postcesarean infection and severe adverse outcomes, including maternal death. However, there has been some controversy surrounding the question of timing of antimicrobial administration. Should the drugs be administered at the time the cord is clamped or prior to the cesarean skin incision? And, if the latter, just how long before the incision should antimicrobials be given?

ACOG weighed in on this question in September 2010 in a Committee Opinion based on a review of data. It recommended that, whenever feasible, antimicrobials should be administered within 60 minutes before the start of the procedure.

In the past, antimicrobial administration at the time of cord clamping was proposed to reduce fetal exposure and prevent the masking of neonatal infection (falsely negative culture results). However, the data ACOG reviewed from randomized, clinical trials indicate that pre-incision antimicrobials may further reduce the risk of infection (including endometritis and wound infection) without apparent perinatal harm.

First-generation cephalosporins (commonly, 1 g of cefazolin) remain the antibiotic of choice, but the combination of clindamycin and gentamicin was suggested as an acceptable alternative for women who are allergic to penicillin.

ACOG reviewed studies by Thigpen and colleagues and Sullivan and coworkers, as well as a meta-analysis by Costantine and associates.^2-4 The relatively small size of these studies and the mixed results of other studies point to the need for further investigation, a fact acknowledged by ACOG. Nevertheless, the committee concluded that “preoperative administration significantly reduces endometritis and total maternal infectious morbidity, compared with administration of antimicrobials after umbilical cord clamping.”

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

Dr. Tita reports receiving research support from the NIH. Dr. Subramaniam and Dr. Andrews report no financial relationships relevant to this article.

Despite continuing advances in obstetric and neonatal care, including the use of antimicrobials, infection remains a major cause of maternal and perinatal morbidity and death. Indeed, infection is among the top five causes of maternal death in the United States, with 10% to 15% of deaths directly linked to it. Maternal and fetal infections are also a common cause of perinatal death. Clearly, interventions to prevent infection or minimize its effect during pregnancy and postpartum are a priority.

This article focuses on three notable developments of the past year:

• release of revised guidelines on the prevention of perinatal group B streptococcal disease (GBS)
• publication of surveillance data on 2009 influenza A(H1N1) among pregnant women, which reveals the life-threatening nature of the flu in this population
• publication of a Committee Opinion from ACOG on the timing of antimicrobial prophylaxis for cesarean delivery, in which administration within 60 minutes of the start of the procedure is recommended.

There’s room for improvement in GBS screening and prophylaxis,
says CDC

Verani JR, McGee L, Schrag SJ, National Center for Immunization and Respiratory Diseases. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1–36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.

The latest revision of CDC guidelines on screening and prophylaxis for perinatal group B streptococcal disease were developed by a multidisciplinary working group representing several professional organizations, including ACOG. Information that has come to light since the most recent guidelines were released in 2002 was incorporated, and areas that have seen suboptimal implementation or interpretation were addressed here as well.

Although the use of prophylactic antibiotics during labor reduces the incidence of invasive GBS during the first week of life, GBS remains a leading cause of neonatal morbidity and death in the United States and elsewhere. Universal screening and intrapartum antibiotic prophylaxis for women who test positive for GBS remain the cornerstone of prevention of early-onset neonatal GBS disease. Penicillin G is still the agent of choice, and ampicillin is an acceptable alternative. When prophylaxis is warranted, intravenous antibiotic administration at least 4 hours before delivery is recommended.

Other recommendations from the CDC include:

• Women who have GBS bacteriuria (≥10⁴ colony-forming units/mL) any time during pregnancy, and women who had a previous infant with invasive GBS disease, should receive intrapartum antibiotic prophylaxis. In these cases, third-trimester screening for GBS is unnecessary.
• All other women should be screened at 35 to 37 weeks’ gestation for rectovaginal GBS colonization.
• At the onset of labor or rupture of membranes, antibiotic prophylaxis should be given to all women who tested positive for GBS—with the exception of women who are undergoing cesarean delivery, at any gestational age, with intact membranes.
• If GBS status is unknown, intrapartum prophylaxis should be given for gestational ages below 37 weeks, membrane rupture lasting 18 hours or longer, or temperature of 100.4°F (38.0°C) or above.
• Health-care providers should inform women of their GBS screening results and the recommended interventions.

Some updates to the guidelines clarify areas in which there was some confusion. For example, the guidelines delineate that women who have preterm labor or preterm premature rupture of the membranes (PPROM) should be screened for GBS and started on prophylaxis immediately, unless they have received a negative screen within the preceding 5 weeks. Antibiotics should be discontinued if a woman who has intact membranes is found not to be in true labor or if the GBS culture is negative.

For the woman who has PPROM, antibiotics to prolong latency are sufficient, provided they include adequate GBS coverage; otherwise, GBS prophylaxis is warranted for as long as 48 hours.

In addition:

• Women who are allergic to penicillin and who have no history of anaphylaxis, angioedema, respiratory distress, or urticaria in response to penicillin or a cephalosporin, should be given cefazolin for GBS prophylaxis. Women at risk of anaphylaxis should undergo antimicrobial susceptibility testing. For these women, clindamycin is acceptable if the GBS isolate is susceptible to both clindamycin and erythromycin or resistant to erythromycin with negative inducible clindamycin resistance. Otherwise, vancomycin is recommended. Erythromycin is not acceptable because of a high prevalence of resistance.
• The dosage of penicillin is 5 million U initially, followed by 2.5 million to 3 million U every 4 hours.
• If a laboratory providing nucleic acid amplification testing (NAAT) is available, intrapartum testing for women who have unknown GBS status and no intrapartum risk factors (i.e., gestational age <37 weeks, membrane rupture for 18 hours or longer, or temperature ≥100.4°F) is an option.

Be vigilant for influenza among your pregnant patients—
and take necessary action

Siston AM, Rasmussen SA, Honein MA, et al, for the Pandemic H1N1 Influenza in Pregnancy Working Group. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517–1525.

The recent H1N1 pandemic highlighted the status of influenza as a major public health problem, not only among children and the elderly but especially among pregnant women. This report by Siston and colleagues describes the US experience of the pandemic. To ascertain the severity of infection during pregnancy, the authors analyzed data from 788 pregnant women who developed symptoms of H1N1 infection between April and August 2009. These women were identified through the CDC national surveillance system. Data from an additional 165 women who developed symptoms through December 2011 and who were admitted to an ICU because of influenza were also analyzed.

Siston and colleagues found a high case-fatality rate (5%) among pregnant women who had influenza. Almost one fourth (22.6%) of women who were hospitalized with influenza were admitted to an ICU because of severe illness.

The timing of antiviral treatment influenced the course of the illness. For example, women who received antiviral treatment within 2 days of the onset of symptoms had a significantly lower risk of death (0.5%), compared with women who received treatment within 3 to 4 days (5%) and with women who were treated after 4 days (27%). Women who were not treated at all also had an elevated risk of ICU admission and death, although that risk was not as high as it was among women treated 4 days or longer after the onset of symptoms. This finding suggests that severity of illness may play a role in determining who receives antiviral treatment.

ACOG: Give prophylactic antimicrobials before the incision
in cesarean delivery

ACOG committee opinion no. 465: Antimicrobial prophylaxis for cesarean delivery: timing of administration. Obstet Gynecol. 2010;116(3):791–792.

The use of antimicrobial prophylaxis for cesarean delivery is associated with a reduction of 50% or more in the rates of postcesarean infection and severe adverse outcomes, including maternal death. However, there has been some controversy surrounding the question of timing of antimicrobial administration. Should the drugs be administered at the time the cord is clamped or prior to the cesarean skin incision? And, if the latter, just how long before the incision should antimicrobials be given?

ACOG weighed in on this question in September 2010 in a Committee Opinion based on a review of data. It recommended that, whenever feasible, antimicrobials should be administered within 60 minutes before the start of the procedure.

In the past, antimicrobial administration at the time of cord clamping was proposed to reduce fetal exposure and prevent the masking of neonatal infection (falsely negative culture results). However, the data ACOG reviewed from randomized, clinical trials indicate that pre-incision antimicrobials may further reduce the risk of infection (including endometritis and wound infection) without apparent perinatal harm.

First-generation cephalosporins (commonly, 1 g of cefazolin) remain the antibiotic of choice, but the combination of clindamycin and gentamicin was suggested as an acceptable alternative for women who are allergic to penicillin.

ACOG reviewed studies by Thigpen and colleagues and Sullivan and coworkers, as well as a meta-analysis by Costantine and associates.^2-4 The relatively small size of these studies and the mixed results of other studies point to the need for further investigation, a fact acknowledged by ACOG. Nevertheless, the committee concluded that “preoperative administration significantly reduces endometritis and total maternal infectious morbidity, compared with administration of antimicrobials after umbilical cord clamping.”

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

Dr. Tita reports receiving research support from the NIH. Dr. Subramaniam and Dr. Andrews report no financial relationships relevant to this article.

Despite continuing advances in obstetric and neonatal care, including the use of antimicrobials, infection remains a major cause of maternal and perinatal morbidity and death. Indeed, infection is among the top five causes of maternal death in the United States, with 10% to 15% of deaths directly linked to it. Maternal and fetal infections are also a common cause of perinatal death. Clearly, interventions to prevent infection or minimize its effect during pregnancy and postpartum are a priority.

This article focuses on three notable developments of the past year:

• release of revised guidelines on the prevention of perinatal group B streptococcal disease (GBS)
• publication of surveillance data on 2009 influenza A(H1N1) among pregnant women, which reveals the life-threatening nature of the flu in this population
• publication of a Committee Opinion from ACOG on the timing of antimicrobial prophylaxis for cesarean delivery, in which administration within 60 minutes of the start of the procedure is recommended.

There’s room for improvement in GBS screening and prophylaxis,
says CDC

Verani JR, McGee L, Schrag SJ, National Center for Immunization and Respiratory Diseases. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1–36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.

The latest revision of CDC guidelines on screening and prophylaxis for perinatal group B streptococcal disease were developed by a multidisciplinary working group representing several professional organizations, including ACOG. Information that has come to light since the most recent guidelines were released in 2002 was incorporated, and areas that have seen suboptimal implementation or interpretation were addressed here as well.

Although the use of prophylactic antibiotics during labor reduces the incidence of invasive GBS during the first week of life, GBS remains a leading cause of neonatal morbidity and death in the United States and elsewhere. Universal screening and intrapartum antibiotic prophylaxis for women who test positive for GBS remain the cornerstone of prevention of early-onset neonatal GBS disease. Penicillin G is still the agent of choice, and ampicillin is an acceptable alternative. When prophylaxis is warranted, intravenous antibiotic administration at least 4 hours before delivery is recommended.

Other recommendations from the CDC include:

• Women who have GBS bacteriuria (≥10⁴ colony-forming units/mL) any time during pregnancy, and women who had a previous infant with invasive GBS disease, should receive intrapartum antibiotic prophylaxis. In these cases, third-trimester screening for GBS is unnecessary.
• All other women should be screened at 35 to 37 weeks’ gestation for rectovaginal GBS colonization.
• At the onset of labor or rupture of membranes, antibiotic prophylaxis should be given to all women who tested positive for GBS—with the exception of women who are undergoing cesarean delivery, at any gestational age, with intact membranes.
• If GBS status is unknown, intrapartum prophylaxis should be given for gestational ages below 37 weeks, membrane rupture lasting 18 hours or longer, or temperature of 100.4°F (38.0°C) or above.
• Health-care providers should inform women of their GBS screening results and the recommended interventions.

Some updates to the guidelines clarify areas in which there was some confusion. For example, the guidelines delineate that women who have preterm labor or preterm premature rupture of the membranes (PPROM) should be screened for GBS and started on prophylaxis immediately, unless they have received a negative screen within the preceding 5 weeks. Antibiotics should be discontinued if a woman who has intact membranes is found not to be in true labor or if the GBS culture is negative.

For the woman who has PPROM, antibiotics to prolong latency are sufficient, provided they include adequate GBS coverage; otherwise, GBS prophylaxis is warranted for as long as 48 hours.

In addition:

• Women who are allergic to penicillin and who have no history of anaphylaxis, angioedema, respiratory distress, or urticaria in response to penicillin or a cephalosporin, should be given cefazolin for GBS prophylaxis. Women at risk of anaphylaxis should undergo antimicrobial susceptibility testing. For these women, clindamycin is acceptable if the GBS isolate is susceptible to both clindamycin and erythromycin or resistant to erythromycin with negative inducible clindamycin resistance. Otherwise, vancomycin is recommended. Erythromycin is not acceptable because of a high prevalence of resistance.
• The dosage of penicillin is 5 million U initially, followed by 2.5 million to 3 million U every 4 hours.
• If a laboratory providing nucleic acid amplification testing (NAAT) is available, intrapartum testing for women who have unknown GBS status and no intrapartum risk factors (i.e., gestational age <37 weeks, membrane rupture for 18 hours or longer, or temperature ≥100.4°F) is an option.

Be vigilant for influenza among your pregnant patients—
and take necessary action

Siston AM, Rasmussen SA, Honein MA, et al, for the Pandemic H1N1 Influenza in Pregnancy Working Group. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517–1525.

The recent H1N1 pandemic highlighted the status of influenza as a major public health problem, not only among children and the elderly but especially among pregnant women. This report by Siston and colleagues describes the US experience of the pandemic. To ascertain the severity of infection during pregnancy, the authors analyzed data from 788 pregnant women who developed symptoms of H1N1 infection between April and August 2009. These women were identified through the CDC national surveillance system. Data from an additional 165 women who developed symptoms through December 2011 and who were admitted to an ICU because of influenza were also analyzed.

Siston and colleagues found a high case-fatality rate (5%) among pregnant women who had influenza. Almost one fourth (22.6%) of women who were hospitalized with influenza were admitted to an ICU because of severe illness.

The timing of antiviral treatment influenced the course of the illness. For example, women who received antiviral treatment within 2 days of the onset of symptoms had a significantly lower risk of death (0.5%), compared with women who received treatment within 3 to 4 days (5%) and with women who were treated after 4 days (27%). Women who were not treated at all also had an elevated risk of ICU admission and death, although that risk was not as high as it was among women treated 4 days or longer after the onset of symptoms. This finding suggests that severity of illness may play a role in determining who receives antiviral treatment.

ACOG: Give prophylactic antimicrobials before the incision
in cesarean delivery

ACOG committee opinion no. 465: Antimicrobial prophylaxis for cesarean delivery: timing of administration. Obstet Gynecol. 2010;116(3):791–792.

The use of antimicrobial prophylaxis for cesarean delivery is associated with a reduction of 50% or more in the rates of postcesarean infection and severe adverse outcomes, including maternal death. However, there has been some controversy surrounding the question of timing of antimicrobial administration. Should the drugs be administered at the time the cord is clamped or prior to the cesarean skin incision? And, if the latter, just how long before the incision should antimicrobials be given?

ACOG weighed in on this question in September 2010 in a Committee Opinion based on a review of data. It recommended that, whenever feasible, antimicrobials should be administered within 60 minutes before the start of the procedure.

In the past, antimicrobial administration at the time of cord clamping was proposed to reduce fetal exposure and prevent the masking of neonatal infection (falsely negative culture results). However, the data ACOG reviewed from randomized, clinical trials indicate that pre-incision antimicrobials may further reduce the risk of infection (including endometritis and wound infection) without apparent perinatal harm.

First-generation cephalosporins (commonly, 1 g of cefazolin) remain the antibiotic of choice, but the combination of clindamycin and gentamicin was suggested as an acceptable alternative for women who are allergic to penicillin.

ACOG reviewed studies by Thigpen and colleagues and Sullivan and coworkers, as well as a meta-analysis by Costantine and associates.^2-4 The relatively small size of these studies and the mixed results of other studies point to the need for further investigation, a fact acknowledged by ACOG. Nevertheless, the committee concluded that “preoperative administration significantly reduces endometritis and total maternal infectious morbidity, compared with administration of antimicrobials after umbilical cord clamping.”

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

Obstetricians are trained to manage key aspects of the birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, our initial support for the newborn has included:

• suctioning the oronasopharynx
• immediate clamping of the cord
• providing 100% oxygen if resuscitation is necessary.

The American Academy of Pediatrics recently modified its recommendations on initial support to emphasize several alternative practices.¹ Here is a roundup of what the Academy recommends now.

For normal term birth

Reduce, or eliminate, the practice of suctioning the fetal oronasopharynx

During the past half century, the first action an OB took after delivering the fetal head was to perform oronasopharyngeal suctioning, using a bulb or DeLee device. The aim has been to remove secretions that might interfere with initial breathing by the newborn.

Recent expert guidance, however, recommends that OBs cease this practice¹: For a healthy newborn, suctioning appears to do more harm than good because it can cause cardiorespiratory complications.

Study results were clear. In a randomized clinical trial, 140 newborns born by cesarean delivery were randomized to oronasopharyngeal suctioning or no suctioning. At 2 minutes and at 6 minutes after birth, infants who were treated with oronasopharyngeal suctioning had a lower mean O₂ saturation and a higher mean heart rate than those who were not suctioned. In addition, the Apgar score was, on average, one point lower at 5 minutes in infants who were suctioned.²

Given a lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.

For term and preterm births

Stop immediate clamping of the cord

At birth, when a newborn is placed on the maternal abdomen or held below the vaginal introitus and the cord is not clamped, approximately 25 mL of blood for every kilogram of birth weight is transfused from the placenta-cord into the newborn. Most of that transfusion occurs in the first 2 minutes after birth; in some infants, transfusion continues for as long as 5 minutes.³

Autotransfusion significantly increases hemoglobin concentration in a newborn. It’s notable that the newborn obtains benefit from delayed clamping whether it has been placed on its mother’s abdomen or held below the vaginal introitus⁴—suggesting that gravity alone isn’t responsible for cord-to-newborn transfusion. Although delayed cord clamping has been studied for 70 years,⁵ only 1% of OBs who participated in a recent survey in the United Kingdom reported that they delay cord clamping for at least 1 minute.⁶

Pluses & minuses. Evidence from many clinical trials indicates that delaying cord clamping carries benefits and risks^4,7—but that the benefits outweigh risks, in most cases (TABLE).

Delayed cord clamping presents both benefits and risks to the baby

In addition, delayed cord clamping is associated with delayed administration of a postpartum uterine tocolytic. This delay does not, however, appear to increase the risk of postpartum hemorrhage.

Note: If you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion.⁸

Who benefits the most? Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks’ gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in a study in which 72 mother-infant pairs were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group.⁹

In a healthy term infant who has access to good postnatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobin concentration. The problem with delayed cord clamping in a healthy term infant is an increased risk of jaundice and need for phototherapy.⁷

In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.

Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning

Most obstetric providers have been trained to aspirate the upper airway—first the oropharynx, then the nares—of infants who have been born through meconium-stained amniotic fluid. Why? It was long believed that suctioning would reduce the risk of meconium aspiration syndrome.

Recent expert guidelines, however, no longer recommend that you suction the upper airway of vigorous infants born through meconium-stained fluid.^1,10

Findings from a clinical trial. Fetuses from 2,514 term pregnancies that were characterized by meconium-stained amniotic fluid were randomized to 1) suctioning of the oropharynx, nasopharynx, and hypopharynx before delivery of the shoulders or 2) no suctioning. No differences in outcome were observed between the two groups—including no difference in the incidence of meconium aspiration syndrome; need for mechanical ventilation or duration of mechanical ventilation; oxygen dependency; and length of stay.¹¹

The same guidelines recommend endotracheal suctioning in nonvigorous newborns,^1,10—even though strong evidence to support the practice is lacking. Of course, suctioning is always warranted when the airway is clearly obstructed.

For preterm birth

Keep the preterm newborn warm with a polythene wrap

Obstetrical providers and pediatricians know: It’s important to keep preterm newborns warm because they are at high risk of hypothermia. The preterm infant has poorly developed thermoregulatory mechanisms and a very high surface area, which increase the rate of heat transfer from the newborn to the environment.

A new recommendation is that every preterm newborn who was born earlier than 28 weeks’ gestation should be kept 1) wet and 2) wrapped up to its neck in a polythene garment (known as a “life-support pouch”) to decrease the risk of hypothermia. Only the head should be dried. In a timely manner, the infant should then be placed under a radiant heater and resuscitated or stabilized, if this is indicated.

That approach has been demonstrated to be superior to drying and placing the newborn under a radiant heater as a means to prevent hypothermia.¹²

If wrapping is not possible, use of an exothermic mattress helps to reduce the risk of hypothermia. However, use of both polythene wrapping and an exothermic mattress may increase the risk of hyperthermia. Timely placement of a newborn under a radiant heater competes with the recommendation (discussed above) to delay clamping of the cord.

Reduce the use of 100% O₂ during resuscitation

Surprisingly, use of 100% oxygen may be associated with more harm than benefit when a newborn requires resuscitation. Why? 100% oxygen may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% oxygen is associated with an increased risk of neonatal mortality.^13,14

When a newborn requires resuscitation, AAP recommends:

• Initiate resuscitation with blended O₂; if this is not available, use ambient air
• Adjust the O₂ concentration to achieve SpO₂ targets that are based on minutes-since-birth
• Use 100% oxygen if the infant’s heart rate is below 60/min at 90 seconds of resuscitation—but only until the heartbeat reaches a normal rate.¹

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

Obstetricians are trained to manage key aspects of the birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, our initial support for the newborn has included:

• suctioning the oronasopharynx
• immediate clamping of the cord
• providing 100% oxygen if resuscitation is necessary.

The American Academy of Pediatrics recently modified its recommendations on initial support to emphasize several alternative practices.¹ Here is a roundup of what the Academy recommends now.

For normal term birth

Reduce, or eliminate, the practice of suctioning the fetal oronasopharynx

During the past half century, the first action an OB took after delivering the fetal head was to perform oronasopharyngeal suctioning, using a bulb or DeLee device. The aim has been to remove secretions that might interfere with initial breathing by the newborn.

Recent expert guidance, however, recommends that OBs cease this practice¹: For a healthy newborn, suctioning appears to do more harm than good because it can cause cardiorespiratory complications.

Study results were clear. In a randomized clinical trial, 140 newborns born by cesarean delivery were randomized to oronasopharyngeal suctioning or no suctioning. At 2 minutes and at 6 minutes after birth, infants who were treated with oronasopharyngeal suctioning had a lower mean O₂ saturation and a higher mean heart rate than those who were not suctioned. In addition, the Apgar score was, on average, one point lower at 5 minutes in infants who were suctioned.²

Given a lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.

For term and preterm births

Stop immediate clamping of the cord

At birth, when a newborn is placed on the maternal abdomen or held below the vaginal introitus and the cord is not clamped, approximately 25 mL of blood for every kilogram of birth weight is transfused from the placenta-cord into the newborn. Most of that transfusion occurs in the first 2 minutes after birth; in some infants, transfusion continues for as long as 5 minutes.³

Autotransfusion significantly increases hemoglobin concentration in a newborn. It’s notable that the newborn obtains benefit from delayed clamping whether it has been placed on its mother’s abdomen or held below the vaginal introitus⁴—suggesting that gravity alone isn’t responsible for cord-to-newborn transfusion. Although delayed cord clamping has been studied for 70 years,⁵ only 1% of OBs who participated in a recent survey in the United Kingdom reported that they delay cord clamping for at least 1 minute.⁶

Pluses & minuses. Evidence from many clinical trials indicates that delaying cord clamping carries benefits and risks^4,7—but that the benefits outweigh risks, in most cases (TABLE).

Delayed cord clamping presents both benefits and risks to the baby

In addition, delayed cord clamping is associated with delayed administration of a postpartum uterine tocolytic. This delay does not, however, appear to increase the risk of postpartum hemorrhage.

Note: If you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion.⁸

Who benefits the most? Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks’ gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in a study in which 72 mother-infant pairs were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group.⁹

In a healthy term infant who has access to good postnatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobin concentration. The problem with delayed cord clamping in a healthy term infant is an increased risk of jaundice and need for phototherapy.⁷

In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.

Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning

Most obstetric providers have been trained to aspirate the upper airway—first the oropharynx, then the nares—of infants who have been born through meconium-stained amniotic fluid. Why? It was long believed that suctioning would reduce the risk of meconium aspiration syndrome.

Recent expert guidelines, however, no longer recommend that you suction the upper airway of vigorous infants born through meconium-stained fluid.^1,10

Findings from a clinical trial. Fetuses from 2,514 term pregnancies that were characterized by meconium-stained amniotic fluid were randomized to 1) suctioning of the oropharynx, nasopharynx, and hypopharynx before delivery of the shoulders or 2) no suctioning. No differences in outcome were observed between the two groups—including no difference in the incidence of meconium aspiration syndrome; need for mechanical ventilation or duration of mechanical ventilation; oxygen dependency; and length of stay.¹¹

The same guidelines recommend endotracheal suctioning in nonvigorous newborns,^1,10—even though strong evidence to support the practice is lacking. Of course, suctioning is always warranted when the airway is clearly obstructed.

For preterm birth

Keep the preterm newborn warm with a polythene wrap

Obstetrical providers and pediatricians know: It’s important to keep preterm newborns warm because they are at high risk of hypothermia. The preterm infant has poorly developed thermoregulatory mechanisms and a very high surface area, which increase the rate of heat transfer from the newborn to the environment.

A new recommendation is that every preterm newborn who was born earlier than 28 weeks’ gestation should be kept 1) wet and 2) wrapped up to its neck in a polythene garment (known as a “life-support pouch”) to decrease the risk of hypothermia. Only the head should be dried. In a timely manner, the infant should then be placed under a radiant heater and resuscitated or stabilized, if this is indicated.

That approach has been demonstrated to be superior to drying and placing the newborn under a radiant heater as a means to prevent hypothermia.¹²

If wrapping is not possible, use of an exothermic mattress helps to reduce the risk of hypothermia. However, use of both polythene wrapping and an exothermic mattress may increase the risk of hyperthermia. Timely placement of a newborn under a radiant heater competes with the recommendation (discussed above) to delay clamping of the cord.

Reduce the use of 100% O₂ during resuscitation

Surprisingly, use of 100% oxygen may be associated with more harm than benefit when a newborn requires resuscitation. Why? 100% oxygen may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% oxygen is associated with an increased risk of neonatal mortality.^13,14

When a newborn requires resuscitation, AAP recommends:

• Initiate resuscitation with blended O₂; if this is not available, use ambient air
• Adjust the O₂ concentration to achieve SpO₂ targets that are based on minutes-since-birth
• Use 100% oxygen if the infant’s heart rate is below 60/min at 90 seconds of resuscitation—but only until the heartbeat reaches a normal rate.¹

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

Obstetricians are trained to manage key aspects of the birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, our initial support for the newborn has included:

• suctioning the oronasopharynx
• immediate clamping of the cord
• providing 100% oxygen if resuscitation is necessary.

The American Academy of Pediatrics recently modified its recommendations on initial support to emphasize several alternative practices.¹ Here is a roundup of what the Academy recommends now.

For normal term birth

Reduce, or eliminate, the practice of suctioning the fetal oronasopharynx

During the past half century, the first action an OB took after delivering the fetal head was to perform oronasopharyngeal suctioning, using a bulb or DeLee device. The aim has been to remove secretions that might interfere with initial breathing by the newborn.

Recent expert guidance, however, recommends that OBs cease this practice¹: For a healthy newborn, suctioning appears to do more harm than good because it can cause cardiorespiratory complications.

Study results were clear. In a randomized clinical trial, 140 newborns born by cesarean delivery were randomized to oronasopharyngeal suctioning or no suctioning. At 2 minutes and at 6 minutes after birth, infants who were treated with oronasopharyngeal suctioning had a lower mean O₂ saturation and a higher mean heart rate than those who were not suctioned. In addition, the Apgar score was, on average, one point lower at 5 minutes in infants who were suctioned.²

Given a lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.

For term and preterm births

Stop immediate clamping of the cord

At birth, when a newborn is placed on the maternal abdomen or held below the vaginal introitus and the cord is not clamped, approximately 25 mL of blood for every kilogram of birth weight is transfused from the placenta-cord into the newborn. Most of that transfusion occurs in the first 2 minutes after birth; in some infants, transfusion continues for as long as 5 minutes.³

Autotransfusion significantly increases hemoglobin concentration in a newborn. It’s notable that the newborn obtains benefit from delayed clamping whether it has been placed on its mother’s abdomen or held below the vaginal introitus⁴—suggesting that gravity alone isn’t responsible for cord-to-newborn transfusion. Although delayed cord clamping has been studied for 70 years,⁵ only 1% of OBs who participated in a recent survey in the United Kingdom reported that they delay cord clamping for at least 1 minute.⁶

Pluses & minuses. Evidence from many clinical trials indicates that delaying cord clamping carries benefits and risks^4,7—but that the benefits outweigh risks, in most cases (TABLE).

Delayed cord clamping presents both benefits and risks to the baby

In addition, delayed cord clamping is associated with delayed administration of a postpartum uterine tocolytic. This delay does not, however, appear to increase the risk of postpartum hemorrhage.

Note: If you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion.⁸

Who benefits the most? Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks’ gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in a study in which 72 mother-infant pairs were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group.⁹

In a healthy term infant who has access to good postnatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobin concentration. The problem with delayed cord clamping in a healthy term infant is an increased risk of jaundice and need for phototherapy.⁷

In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.

Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning

Most obstetric providers have been trained to aspirate the upper airway—first the oropharynx, then the nares—of infants who have been born through meconium-stained amniotic fluid. Why? It was long believed that suctioning would reduce the risk of meconium aspiration syndrome.

Recent expert guidelines, however, no longer recommend that you suction the upper airway of vigorous infants born through meconium-stained fluid.^1,10

Findings from a clinical trial. Fetuses from 2,514 term pregnancies that were characterized by meconium-stained amniotic fluid were randomized to 1) suctioning of the oropharynx, nasopharynx, and hypopharynx before delivery of the shoulders or 2) no suctioning. No differences in outcome were observed between the two groups—including no difference in the incidence of meconium aspiration syndrome; need for mechanical ventilation or duration of mechanical ventilation; oxygen dependency; and length of stay.¹¹

The same guidelines recommend endotracheal suctioning in nonvigorous newborns,^1,10—even though strong evidence to support the practice is lacking. Of course, suctioning is always warranted when the airway is clearly obstructed.

For preterm birth

Keep the preterm newborn warm with a polythene wrap

Obstetrical providers and pediatricians know: It’s important to keep preterm newborns warm because they are at high risk of hypothermia. The preterm infant has poorly developed thermoregulatory mechanisms and a very high surface area, which increase the rate of heat transfer from the newborn to the environment.

A new recommendation is that every preterm newborn who was born earlier than 28 weeks’ gestation should be kept 1) wet and 2) wrapped up to its neck in a polythene garment (known as a “life-support pouch”) to decrease the risk of hypothermia. Only the head should be dried. In a timely manner, the infant should then be placed under a radiant heater and resuscitated or stabilized, if this is indicated.

That approach has been demonstrated to be superior to drying and placing the newborn under a radiant heater as a means to prevent hypothermia.¹²

If wrapping is not possible, use of an exothermic mattress helps to reduce the risk of hypothermia. However, use of both polythene wrapping and an exothermic mattress may increase the risk of hyperthermia. Timely placement of a newborn under a radiant heater competes with the recommendation (discussed above) to delay clamping of the cord.

Reduce the use of 100% O₂ during resuscitation

Surprisingly, use of 100% oxygen may be associated with more harm than benefit when a newborn requires resuscitation. Why? 100% oxygen may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% oxygen is associated with an increased risk of neonatal mortality.^13,14

When a newborn requires resuscitation, AAP recommends:

• Initiate resuscitation with blended O₂; if this is not available, use ambient air
• Adjust the O₂ concentration to achieve SpO₂ targets that are based on minutes-since-birth
• Use 100% oxygen if the infant’s heart rate is below 60/min at 90 seconds of resuscitation—but only until the heartbeat reaches a normal rate.¹

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

Major Finding: Maternal colonization with Staphylococcus aureus had no significant impact on the rate of S. aureus colonization in neonates.

Data Source: Review of 2,789 infants born to 2,702 women in New York during 2009.

Disclosures: Dr. Top and Dr. Saiman said they had no relevant financial disclosures.

PHILADELPHIA – Neonates do not face an increased risk of colonization or infection by Staphylococcus aureus when they are born to mothers who have anovaginal colonization with this pathogen, based on a review of more than 2,700 deliveries.

The low 1% rate of transmission of S. aureus from colonized mothers to their children precludes the need to routinely screen pregnant women for anovaginal S. aureus colonization, Dr. Karina A. Top said. “Maternal anovaginal S. aureus colonization may be a risk factor for maternal infections, but it does not appear to be associated with neonatal infections,” said Dr. Top, a pediatric infectious disease physician at Columbia University and New York-Presbyterian Hospital in New York.

“People have been saying that maybe we should culture pregnant women” to determine whether they have anovaginal S. aureus colonization, “but it's a huge expense, and you'd have to really convince yourself that it matters,” said Dr. Lisa Saiman, a professor of clinical pediatrics at the university and a collaborator on the study. “S. aureus is normal flora. If there is a skin break it can lead to infection, but usually not. You don't want people to worry about what's normal. The message [from these results] is that there is no role for routine screening of pregnant women and neonates, because these are normal flora” she said in an interview.

This is the first study to systematically look at mother-to-neonate transmission of S. aureus, she added.

The current analysis is based on a prior study by Dr. Top of 2,921 pregnant woman in New York during 2009 that found colonization with methicillin-sensitive S. aureus (MSSA) in 345 women (12%) and colonization with methicillin-resistant S. aureus (MRSA) in 18 women (0.6%). Dr. Top and her associates collected specimens from these women at 35–37 weeks' gestation. Subsequently, 2,702 of these women delivered an infant, resulting in 2,789 live births.

Collection and analysis of specimens from the infants during their first 3 months of life revealed 10 cases of definite S. aureus infection in the neonates, 8 cases of probable infection, and 7 cases of S. aureus colonization. Dr. Top's analysis showed a 1.1% rate of neonatal infection or colonization in babies born to colonized mothers, and a 0.9% rate in those born to uncolonized mothers, a difference that was not significant. The median age for the first positive S. aureus culture in these infants occurred at 27 days.

Delivery mode, cesarean or vaginal, had no significant impact on S. aureus transmission to the infants, but three other variables did significantly link with an increased rate of positive cultures: preterm birth (less than 37 weeks), multiple gestations, and admission to the neonatal ICU. Each of these three factors increased the rate of S. aureus colonization by 6- to 17-fold. In contrast, maternal colonization had a statistically significant impact on the rate of maternal infection with S. aureus following delivery. Colonized women had a 2.1% rate of postpartum infection, more than threefold higher than the rate in uncolonized women. Women who had a caesarean delivery were significantly more likely to become infected than women with a vaginal delivery.

The low 1% transmission rate from colonized mothers to their children precludes the need to screen pregnant women.

Source DR. TOP

Major Finding: Maternal colonization with Staphylococcus aureus had no significant impact on the rate of S. aureus colonization in neonates.

Data Source: Review of 2,789 infants born to 2,702 women in New York during 2009.

Disclosures: Dr. Top and Dr. Saiman said they had no relevant financial disclosures.

PHILADELPHIA – Neonates do not face an increased risk of colonization or infection by Staphylococcus aureus when they are born to mothers who have anovaginal colonization with this pathogen, based on a review of more than 2,700 deliveries.

The low 1% rate of transmission of S. aureus from colonized mothers to their children precludes the need to routinely screen pregnant women for anovaginal S. aureus colonization, Dr. Karina A. Top said. “Maternal anovaginal S. aureus colonization may be a risk factor for maternal infections, but it does not appear to be associated with neonatal infections,” said Dr. Top, a pediatric infectious disease physician at Columbia University and New York-Presbyterian Hospital in New York.

“People have been saying that maybe we should culture pregnant women” to determine whether they have anovaginal S. aureus colonization, “but it's a huge expense, and you'd have to really convince yourself that it matters,” said Dr. Lisa Saiman, a professor of clinical pediatrics at the university and a collaborator on the study. “S. aureus is normal flora. If there is a skin break it can lead to infection, but usually not. You don't want people to worry about what's normal. The message [from these results] is that there is no role for routine screening of pregnant women and neonates, because these are normal flora” she said in an interview.

This is the first study to systematically look at mother-to-neonate transmission of S. aureus, she added.

The current analysis is based on a prior study by Dr. Top of 2,921 pregnant woman in New York during 2009 that found colonization with methicillin-sensitive S. aureus (MSSA) in 345 women (12%) and colonization with methicillin-resistant S. aureus (MRSA) in 18 women (0.6%). Dr. Top and her associates collected specimens from these women at 35–37 weeks' gestation. Subsequently, 2,702 of these women delivered an infant, resulting in 2,789 live births.

Collection and analysis of specimens from the infants during their first 3 months of life revealed 10 cases of definite S. aureus infection in the neonates, 8 cases of probable infection, and 7 cases of S. aureus colonization. Dr. Top's analysis showed a 1.1% rate of neonatal infection or colonization in babies born to colonized mothers, and a 0.9% rate in those born to uncolonized mothers, a difference that was not significant. The median age for the first positive S. aureus culture in these infants occurred at 27 days.

Delivery mode, cesarean or vaginal, had no significant impact on S. aureus transmission to the infants, but three other variables did significantly link with an increased rate of positive cultures: preterm birth (less than 37 weeks), multiple gestations, and admission to the neonatal ICU. Each of these three factors increased the rate of S. aureus colonization by 6- to 17-fold. In contrast, maternal colonization had a statistically significant impact on the rate of maternal infection with S. aureus following delivery. Colonized women had a 2.1% rate of postpartum infection, more than threefold higher than the rate in uncolonized women. Women who had a caesarean delivery were significantly more likely to become infected than women with a vaginal delivery.

The low 1% transmission rate from colonized mothers to their children precludes the need to screen pregnant women.

Source DR. TOP

Major Finding: Maternal colonization with Staphylococcus aureus had no significant impact on the rate of S. aureus colonization in neonates.

Data Source: Review of 2,789 infants born to 2,702 women in New York during 2009.

Disclosures: Dr. Top and Dr. Saiman said they had no relevant financial disclosures.

PHILADELPHIA – Neonates do not face an increased risk of colonization or infection by Staphylococcus aureus when they are born to mothers who have anovaginal colonization with this pathogen, based on a review of more than 2,700 deliveries.

The low 1% rate of transmission of S. aureus from colonized mothers to their children precludes the need to routinely screen pregnant women for anovaginal S. aureus colonization, Dr. Karina A. Top said. “Maternal anovaginal S. aureus colonization may be a risk factor for maternal infections, but it does not appear to be associated with neonatal infections,” said Dr. Top, a pediatric infectious disease physician at Columbia University and New York-Presbyterian Hospital in New York.

“People have been saying that maybe we should culture pregnant women” to determine whether they have anovaginal S. aureus colonization, “but it's a huge expense, and you'd have to really convince yourself that it matters,” said Dr. Lisa Saiman, a professor of clinical pediatrics at the university and a collaborator on the study. “S. aureus is normal flora. If there is a skin break it can lead to infection, but usually not. You don't want people to worry about what's normal. The message [from these results] is that there is no role for routine screening of pregnant women and neonates, because these are normal flora” she said in an interview.

This is the first study to systematically look at mother-to-neonate transmission of S. aureus, she added.

The current analysis is based on a prior study by Dr. Top of 2,921 pregnant woman in New York during 2009 that found colonization with methicillin-sensitive S. aureus (MSSA) in 345 women (12%) and colonization with methicillin-resistant S. aureus (MRSA) in 18 women (0.6%). Dr. Top and her associates collected specimens from these women at 35–37 weeks' gestation. Subsequently, 2,702 of these women delivered an infant, resulting in 2,789 live births.

Collection and analysis of specimens from the infants during their first 3 months of life revealed 10 cases of definite S. aureus infection in the neonates, 8 cases of probable infection, and 7 cases of S. aureus colonization. Dr. Top's analysis showed a 1.1% rate of neonatal infection or colonization in babies born to colonized mothers, and a 0.9% rate in those born to uncolonized mothers, a difference that was not significant. The median age for the first positive S. aureus culture in these infants occurred at 27 days.

Delivery mode, cesarean or vaginal, had no significant impact on S. aureus transmission to the infants, but three other variables did significantly link with an increased rate of positive cultures: preterm birth (less than 37 weeks), multiple gestations, and admission to the neonatal ICU. Each of these three factors increased the rate of S. aureus colonization by 6- to 17-fold. In contrast, maternal colonization had a statistically significant impact on the rate of maternal infection with S. aureus following delivery. Colonized women had a 2.1% rate of postpartum infection, more than threefold higher than the rate in uncolonized women. Women who had a caesarean delivery were significantly more likely to become infected than women with a vaginal delivery.

The low 1% transmission rate from colonized mothers to their children precludes the need to screen pregnant women.

Source DR. TOP

Pregnant women taking antiepileptic drugs have higher odds for preeclampsia, bleeding, labor induction, caesarean section, and major malformations of the newborn, Norwegian researchers have learned.

The findings add to mounting evidence that pregnancy risks for epileptic women may be linked to antiepileptic drugs (AEDs) rather than epilepsy itself.

Dr. Ingrid Borthen of Haukeland University Hospital, in Bergen, Norway, and her associates retrospectively compared obstetric outcomes for 205 deliveries by 170 women with a past or present history of epilepsy (57% of whom were taking AEDs) and 205 matched, nonepileptic control patients.

The women in both groups had a mean age of 28 years.

Epileptic women taking AEDs had higher odds of severe preeclampsia (odds ratio, 5.0; 95% confidence interval, 1.3–19.9), bleeding in early pregnancy (OR, 6.4; 95% CI, 2.7–15.2), labor induction (OR, 2.3; 95% CI, 1.2–4.3), c-section (OR, 2.5; 95% CI, 1.4–4.7), and malformations in the offspring (OR, 7.1; 95% CI, 1.4–36.6).

The comparisons of outcomes between the two groups were controlled for confounding factors, including smoking during pregnancy, mother's age, highest maternal education, parity, body mass index of 30 kg/m

Women with active epilepsy (defined as seizures within 5 years of conception) not using the drugs did not have increased odds for any of these outcomes; however, they did have higher odds for vaginal forceps delivery and preterm birth.

Which specific drugs may be implicated is still difficult to say, said Dr. Borthen, but the study showed that lamotrigine is associated with a higher risk (BJOG 2011 [doi:10.1111/j.1471-0528.2011. 03004.x]).

Dr. Borthen and her colleagues noted that the proportion of women using AEDs during pregnancy may represent a larger group than epileptic women, as there is “growing use of AEDs for pain and psychiatric conditions.”

One limitation of the study, Dr. Borthen and her colleagues wrote in their analysis, was a lack of data on seizure type and severity.

The study was funded by the Norwegian Research Council. Dr. Borthen and her colleagues declared that they had no conflicts of interest.

Pregnant women taking antiepileptic drugs have higher odds for preeclampsia, bleeding, labor induction, caesarean section, and major malformations of the newborn, Norwegian researchers have learned.

The findings add to mounting evidence that pregnancy risks for epileptic women may be linked to antiepileptic drugs (AEDs) rather than epilepsy itself.

Dr. Ingrid Borthen of Haukeland University Hospital, in Bergen, Norway, and her associates retrospectively compared obstetric outcomes for 205 deliveries by 170 women with a past or present history of epilepsy (57% of whom were taking AEDs) and 205 matched, nonepileptic control patients.

The women in both groups had a mean age of 28 years.

Epileptic women taking AEDs had higher odds of severe preeclampsia (odds ratio, 5.0; 95% confidence interval, 1.3–19.9), bleeding in early pregnancy (OR, 6.4; 95% CI, 2.7–15.2), labor induction (OR, 2.3; 95% CI, 1.2–4.3), c-section (OR, 2.5; 95% CI, 1.4–4.7), and malformations in the offspring (OR, 7.1; 95% CI, 1.4–36.6).

The comparisons of outcomes between the two groups were controlled for confounding factors, including smoking during pregnancy, mother's age, highest maternal education, parity, body mass index of 30 kg/m

Women with active epilepsy (defined as seizures within 5 years of conception) not using the drugs did not have increased odds for any of these outcomes; however, they did have higher odds for vaginal forceps delivery and preterm birth.

Which specific drugs may be implicated is still difficult to say, said Dr. Borthen, but the study showed that lamotrigine is associated with a higher risk (BJOG 2011 [doi:10.1111/j.1471-0528.2011. 03004.x]).

Dr. Borthen and her colleagues noted that the proportion of women using AEDs during pregnancy may represent a larger group than epileptic women, as there is “growing use of AEDs for pain and psychiatric conditions.”

One limitation of the study, Dr. Borthen and her colleagues wrote in their analysis, was a lack of data on seizure type and severity.

The study was funded by the Norwegian Research Council. Dr. Borthen and her colleagues declared that they had no conflicts of interest.

Pregnant women taking antiepileptic drugs have higher odds for preeclampsia, bleeding, labor induction, caesarean section, and major malformations of the newborn, Norwegian researchers have learned.

The findings add to mounting evidence that pregnancy risks for epileptic women may be linked to antiepileptic drugs (AEDs) rather than epilepsy itself.

Dr. Ingrid Borthen of Haukeland University Hospital, in Bergen, Norway, and her associates retrospectively compared obstetric outcomes for 205 deliveries by 170 women with a past or present history of epilepsy (57% of whom were taking AEDs) and 205 matched, nonepileptic control patients.

The women in both groups had a mean age of 28 years.

Epileptic women taking AEDs had higher odds of severe preeclampsia (odds ratio, 5.0; 95% confidence interval, 1.3–19.9), bleeding in early pregnancy (OR, 6.4; 95% CI, 2.7–15.2), labor induction (OR, 2.3; 95% CI, 1.2–4.3), c-section (OR, 2.5; 95% CI, 1.4–4.7), and malformations in the offspring (OR, 7.1; 95% CI, 1.4–36.6).

The comparisons of outcomes between the two groups were controlled for confounding factors, including smoking during pregnancy, mother's age, highest maternal education, parity, body mass index of 30 kg/m

Women with active epilepsy (defined as seizures within 5 years of conception) not using the drugs did not have increased odds for any of these outcomes; however, they did have higher odds for vaginal forceps delivery and preterm birth.

Which specific drugs may be implicated is still difficult to say, said Dr. Borthen, but the study showed that lamotrigine is associated with a higher risk (BJOG 2011 [doi:10.1111/j.1471-0528.2011. 03004.x]).

Dr. Borthen and her colleagues noted that the proportion of women using AEDs during pregnancy may represent a larger group than epileptic women, as there is “growing use of AEDs for pain and psychiatric conditions.”

One limitation of the study, Dr. Borthen and her colleagues wrote in their analysis, was a lack of data on seizure type and severity.

The study was funded by the Norwegian Research Council. Dr. Borthen and her colleagues declared that they had no conflicts of interest.

Major Finding: In terms of gestational weight gain, 20% of black women undergained, 27% appropriately gained, and 54% overgained. The statistics were, respectively, 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Data Source: A retrospective study using automated labor and delivery records of 11,992 women.

Disclosures: Ms. Holland said that she had no relevant financial disclosures.

WASHINGTON – Adherence to gestational weight gain recommendations and prepregnancy body mass index varies significantly depending on race and ethnicity, Erica Holland reported.

In addition, black women were at the greatest risk of prepregnancy overweight or obesity while Asian women were at the greatest risk of being underweight. Meanwhile, the majority of black, white, and Hispanic women overgained weight during pregnancy.

When adjusted for age, marital status, and several other factors, Asian, black, and Hispanic women had significantly decreased odds of gaining excessive weight compared with white women, even though the majority of black and Hispanic women gained weight excessively during pregnancy, according to study results presented at the meeting.

Black women were 1.56 times more likely to be overweight and 1.61 times more likely to be obese prior to pregnancy than their white counterparts. Hispanic women were 1.28 times more likely to be overweight, and 1.23 times more likely to be obese compared with white women. Asian women were 2.25 times more likely to be underweight and less likely to be overweight or obese compared with their white counterparts.

The findings have opened the door for further research on maternal and neonatal outcomes based on race and ethnicity and on gestational weight gain (GWG) adherence, which could in turn change recommendations, said Ms. Holland, a third-year medical student at the University of Massachusetts, Worcester, who presented the study findings.

She speculated that the variation could be caused by various factors such as cultural differences, maybe a genetic component, and disparities in weight gain advice given to women based on their race.

Evidence suggests GWG nonadherence is a risk factor for adverse birth outcomes. The Institute of Medicine updated its recommendations for GWG in 2009, giving a range based on the mother's body mass index (BMI). Women at a normal weight for their height (BMI of 18.5–24.9) should gain 25–35 pounds during pregnancy, underweight women (BMI less than 18.5) should gain 28–40 pounds, and overweight women (BMI of 25–29.9) should gain 15–25 pounds, according to the 2009 IOM guidelines. The recommendations, however, are not tailored based on race and ethnicity, Ms. Holland said.

To find the association of race and ethnicity with prepregnancy BMI and GWG adherence, researchers conducted a retrospective study using automated labor and delivery records of 11,992 women with a mean age of 29 years. In total, 70% of the women were multigravida, 69% were white, 18% Hispanic, 9% black, and 5% Asian; 91% of the women delivered full term.

In total, 3.8% of the population was underweight and 21% were obese before pregnancy. A quarter gained weight properly during pregnancy, said Ms. Holland, but 68% overgained weight during pregnancy. Prior to pregnancy, 2% of black women were underweight, 39% were normal weight, and 59% were overweight or obese. The statistics were, respectively, 3%, 51%, and 46% for white women; 9%, 73%, and 18% for Asian women; and 5%, 47%, and 48% for Hispanic women.

For GWG, 20% of black women undergained, 27% appropriately gained, and 54% over gained. The statistics were 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Major Finding: In terms of gestational weight gain, 20% of black women undergained, 27% appropriately gained, and 54% overgained. The statistics were, respectively, 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Data Source: A retrospective study using automated labor and delivery records of 11,992 women.

Disclosures: Ms. Holland said that she had no relevant financial disclosures.

WASHINGTON – Adherence to gestational weight gain recommendations and prepregnancy body mass index varies significantly depending on race and ethnicity, Erica Holland reported.

In addition, black women were at the greatest risk of prepregnancy overweight or obesity while Asian women were at the greatest risk of being underweight. Meanwhile, the majority of black, white, and Hispanic women overgained weight during pregnancy.

When adjusted for age, marital status, and several other factors, Asian, black, and Hispanic women had significantly decreased odds of gaining excessive weight compared with white women, even though the majority of black and Hispanic women gained weight excessively during pregnancy, according to study results presented at the meeting.

Black women were 1.56 times more likely to be overweight and 1.61 times more likely to be obese prior to pregnancy than their white counterparts. Hispanic women were 1.28 times more likely to be overweight, and 1.23 times more likely to be obese compared with white women. Asian women were 2.25 times more likely to be underweight and less likely to be overweight or obese compared with their white counterparts.

The findings have opened the door for further research on maternal and neonatal outcomes based on race and ethnicity and on gestational weight gain (GWG) adherence, which could in turn change recommendations, said Ms. Holland, a third-year medical student at the University of Massachusetts, Worcester, who presented the study findings.

She speculated that the variation could be caused by various factors such as cultural differences, maybe a genetic component, and disparities in weight gain advice given to women based on their race.

Evidence suggests GWG nonadherence is a risk factor for adverse birth outcomes. The Institute of Medicine updated its recommendations for GWG in 2009, giving a range based on the mother's body mass index (BMI). Women at a normal weight for their height (BMI of 18.5–24.9) should gain 25–35 pounds during pregnancy, underweight women (BMI less than 18.5) should gain 28–40 pounds, and overweight women (BMI of 25–29.9) should gain 15–25 pounds, according to the 2009 IOM guidelines. The recommendations, however, are not tailored based on race and ethnicity, Ms. Holland said.

To find the association of race and ethnicity with prepregnancy BMI and GWG adherence, researchers conducted a retrospective study using automated labor and delivery records of 11,992 women with a mean age of 29 years. In total, 70% of the women were multigravida, 69% were white, 18% Hispanic, 9% black, and 5% Asian; 91% of the women delivered full term.

In total, 3.8% of the population was underweight and 21% were obese before pregnancy. A quarter gained weight properly during pregnancy, said Ms. Holland, but 68% overgained weight during pregnancy. Prior to pregnancy, 2% of black women were underweight, 39% were normal weight, and 59% were overweight or obese. The statistics were, respectively, 3%, 51%, and 46% for white women; 9%, 73%, and 18% for Asian women; and 5%, 47%, and 48% for Hispanic women.

For GWG, 20% of black women undergained, 27% appropriately gained, and 54% over gained. The statistics were 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Major Finding: In terms of gestational weight gain, 20% of black women undergained, 27% appropriately gained, and 54% overgained. The statistics were, respectively, 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Data Source: A retrospective study using automated labor and delivery records of 11,992 women.

Disclosures: Ms. Holland said that she had no relevant financial disclosures.

WASHINGTON – Adherence to gestational weight gain recommendations and prepregnancy body mass index varies significantly depending on race and ethnicity, Erica Holland reported.

In addition, black women were at the greatest risk of prepregnancy overweight or obesity while Asian women were at the greatest risk of being underweight. Meanwhile, the majority of black, white, and Hispanic women overgained weight during pregnancy.

When adjusted for age, marital status, and several other factors, Asian, black, and Hispanic women had significantly decreased odds of gaining excessive weight compared with white women, even though the majority of black and Hispanic women gained weight excessively during pregnancy, according to study results presented at the meeting.

Black women were 1.56 times more likely to be overweight and 1.61 times more likely to be obese prior to pregnancy than their white counterparts. Hispanic women were 1.28 times more likely to be overweight, and 1.23 times more likely to be obese compared with white women. Asian women were 2.25 times more likely to be underweight and less likely to be overweight or obese compared with their white counterparts.

The findings have opened the door for further research on maternal and neonatal outcomes based on race and ethnicity and on gestational weight gain (GWG) adherence, which could in turn change recommendations, said Ms. Holland, a third-year medical student at the University of Massachusetts, Worcester, who presented the study findings.

She speculated that the variation could be caused by various factors such as cultural differences, maybe a genetic component, and disparities in weight gain advice given to women based on their race.

Evidence suggests GWG nonadherence is a risk factor for adverse birth outcomes. The Institute of Medicine updated its recommendations for GWG in 2009, giving a range based on the mother's body mass index (BMI). Women at a normal weight for their height (BMI of 18.5–24.9) should gain 25–35 pounds during pregnancy, underweight women (BMI less than 18.5) should gain 28–40 pounds, and overweight women (BMI of 25–29.9) should gain 15–25 pounds, according to the 2009 IOM guidelines. The recommendations, however, are not tailored based on race and ethnicity, Ms. Holland said.

To find the association of race and ethnicity with prepregnancy BMI and GWG adherence, researchers conducted a retrospective study using automated labor and delivery records of 11,992 women with a mean age of 29 years. In total, 70% of the women were multigravida, 69% were white, 18% Hispanic, 9% black, and 5% Asian; 91% of the women delivered full term.

In total, 3.8% of the population was underweight and 21% were obese before pregnancy. A quarter gained weight properly during pregnancy, said Ms. Holland, but 68% overgained weight during pregnancy. Prior to pregnancy, 2% of black women were underweight, 39% were normal weight, and 59% were overweight or obese. The statistics were, respectively, 3%, 51%, and 46% for white women; 9%, 73%, and 18% for Asian women; and 5%, 47%, and 48% for Hispanic women.

For GWG, 20% of black women undergained, 27% appropriately gained, and 54% over gained. The statistics were 15%, 26%, and 60% for white women; 22%, 38%, and 41% for Asian women; and 20%, 27%, and 54% for Hispanic women.

Major Finding: The combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the 411 women in the Foley catheter group, compared with the 408 women who received vaginal prostaglandin gel (12% vs. 18%), while the former group had less maternal and neonatal morbidity. In the other trial, the rate of delivery within 24 hours was highest in the Foley plus oxytocin group of 92 women, at 94%. It was statistically similar at 87% in the Foley plus misoprostol group of 85 women, but significantly lower at 74% in the misoprostol-only group of 88 women.

Data Source: Two randomized controlled trials involving 819 pregnant women and 265 pregnant women, respectively. The women in both groups were at term with an indication for labor induction and an unfavorable cervix.

Disclosures: Dr. JóŸwiak and Dr. Dionne did not report any relevant financial disclosures.

SAN FRANCISCO – In women with term pregnancies and an unfavorable cervix, different methods of labor induction have their pros and cons, according to the results of a pair of randomized trials reported at the meeting.

A trial conducted in the Netherlands found that roughly one-fifth of women eventually had a cesarean section whether labor was induced with a Foley catheter or with vaginal prostaglandin gel. But there was less maternal and neonatal morbidity with the former.

And a trial conducted in Canada found that a Foley catheter plus oxytocin or misoprostol was associated with a higher rate of delivery within 24 hours than misoprostol alone. However, the misoprostol methods were associated with a lower cesarean rate.

Dutch Trial

U.S. and Dutch guidelines indicate that both prostaglandin E analogues and Foley catheters are options for inducing labor, said Dr. Marta JóŸwiak, an obstetrician at the Groene Hart Hospital in Gouda, the Netherlands.

As a result, clinical practice varies. Although these methods have been compared, questions remain about their relative benefits and drawbacks, including complications and their costs.

Dr. JóŸwiak and her coinvestigators conducted a trial called PROBAAT (Prostaglandins or Balloon for Induction of Labor at Term) in 819 women with a term pregnancy who had a vital singleton fetus in cephalic presentation, intact membranes, and an unfavorable cervix, defined as a Bishop score of less than 6.

The women were 31 years old, on average, and 81% were white. The median gestational age was 40 weeks. Two-thirds were nulliparous, and most (83%) had a Bishop score of 3 or less. The leading indications for labor induction were postterm pregnancy (36%) and hypertensive disorders (34%). Patients were excluded from the study if they had had a cesarean delivery, or had placenta previa, a fetus with congenital anomalies, or hypersensitivity to either of the products used for labor induction.

The investigators randomized the women in equal numbers to nonblinded treatment with a transcervical Foley catheter or vaginal prostaglandin E2 gel. Analyses were based on 411 women in the former group and 408 in the latter group.

Trial results showed that the rate of cesarean section, the primary outcome, was 23% in the Foley catheter group and 20% in the prostaglandin gel group, a difference that was not significant, Dr. JóŸwiak reported.

The rate of vaginal instrumental delivery did not differ, but the combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the Foley group (12% vs. 18%). The rate of maternal infection during labor also was lower in that group (2% vs. 4%).

The groups were similar with respect to rates of other maternal outcomes (hyperstimulation, postpartum hemorrhage, and blood transfusion). There were two cases of uterine rupture, both in the prostaglandin group.

In terms of neonatal outcomes, neonates in the Foley group were significantly less likely than their counterparts in the prostaglandin group to be admitted to the ward (12% vs. 19%), while rates of intensive care unit admission were identical.

The groups were similar with respect to rates of other neonatal outcomes, such as Apgar scores, umbilical cord blood pH, reasons for admission, and length of admission.

Subgroup analyses are still ongoing, according to Dr. JóŸwiak, but preliminary results suggest that the Foley catheter was the more successful of the two methods in nulliparous women, who are more likely to have trouble with labor induction.

“Induction with a Foley catheter is, in terms of cesarean section, as effective as induction with prostaglandin E2 gel, with less neonatal and maternal morbidity,” she concluded.

“We recommend considering the Foley catheter as a first choice for induction of labor at term in women with an unfavorable cervix,” Dr. JóŸwiak said.

Canadian Trial

Elective induction of labor now occurs in 21%–30% of all births, noted Dr. Marie-Danielle Dionne, a fetal-maternal medicine specialist at the University of Montreal. “An improved Bishop score before induction increases the rate of vaginal birth.”

She and her coinvestigators enrolled women with a normal singleton pregnancy at term who had intact membranes and an unfavorable cervix, with a Bishop score of 5 or less. Women were ineligible if they had prostaglandin hypersensitivity, previous uterine surgery, a noncephalic fetal presentation, or nonreassuring fetal cardiac monitoring.

The women were randomized in equal numbers to nonblinded treatment with a Foley catheter plus intravenous oxytocin infusion, a Foley catheter plus intravaginal misoprostol, or intravaginal misoprostol alone.

The trial was stopped early because of an elevated rate of cesarean deliveries in the first group, according to Dr. Dionne.

Intention-to-treat analyses were based on 92 women in the Foley plus oxytocin group, 85 women in the Foley plus misoprostol group, and 88 women in the misoprostol-only group.

On average, the women were 30 years old, and the median gestational age was 40.5 weeks. About three-fourths of the women were nulliparous. The mean Bishop score was 3. The leading indications for induction were a postdate pregnancy (54%) and diabetes (27%).

Trial results showed that the rate of delivery within 24 hours, the primary outcome, was highest in the Foley plus oxytocin group at 94%, Dr. Dionne reported. It was statistically similar in the Foley plus misoprostol group at 87%, but significantly lower in the misoprostol-only group at 74%.

However, the rate of cesarean delivery was 44% in the Foley plus oxytocin group. It was significantly lower in both the Foley plus misoprostol group at 24%, and in the misoprostol-only group at 28%.

The three groups did not differ with respect to rates of maternal complications (postpartum hemorrhage, hyperstimulation, receipt of antibiotics, and placental retention) and fetal and neonatal outcomes (Apgar scores, cord blood arterial pH, admission to the neonatal intensive care unit, meconium in amniotic fluid, receipt of antibiotics, and nonreassuring fetal monitoring).

“We can say that in our institutions, the use of a Foley catheter is associated with more deliveries within 24 hours,” said Dr. Dionne.

“This is mostly due to a smaller delay from induction to labor,” she said.

“Misoprostol use significantly reduced the rate of c-section, with or without a Foley catheter,” she further noted.

Dr. Dionne speculated that the higher rate of cesareans with the Foley catheter plus oxytocin, despite the more rapid delivery, was due to inadequate cervical ripening in the face of contractions. “There is a small change in the cervix and there are regular contractions, but it is probably not as physiological as with the misoprostol,” she said.

“So we have to decide which is best: more deliveries within 24 hours or more vaginal births,” Dr. Dionne concluded. “The answer is easy for me: We think more vaginal births is better.”

Major Finding: The combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the 411 women in the Foley catheter group, compared with the 408 women who received vaginal prostaglandin gel (12% vs. 18%), while the former group had less maternal and neonatal morbidity. In the other trial, the rate of delivery within 24 hours was highest in the Foley plus oxytocin group of 92 women, at 94%. It was statistically similar at 87% in the Foley plus misoprostol group of 85 women, but significantly lower at 74% in the misoprostol-only group of 88 women.

Data Source: Two randomized controlled trials involving 819 pregnant women and 265 pregnant women, respectively. The women in both groups were at term with an indication for labor induction and an unfavorable cervix.

Disclosures: Dr. JóŸwiak and Dr. Dionne did not report any relevant financial disclosures.

SAN FRANCISCO – In women with term pregnancies and an unfavorable cervix, different methods of labor induction have their pros and cons, according to the results of a pair of randomized trials reported at the meeting.

A trial conducted in the Netherlands found that roughly one-fifth of women eventually had a cesarean section whether labor was induced with a Foley catheter or with vaginal prostaglandin gel. But there was less maternal and neonatal morbidity with the former.

And a trial conducted in Canada found that a Foley catheter plus oxytocin or misoprostol was associated with a higher rate of delivery within 24 hours than misoprostol alone. However, the misoprostol methods were associated with a lower cesarean rate.

Dutch Trial

U.S. and Dutch guidelines indicate that both prostaglandin E analogues and Foley catheters are options for inducing labor, said Dr. Marta JóŸwiak, an obstetrician at the Groene Hart Hospital in Gouda, the Netherlands.

As a result, clinical practice varies. Although these methods have been compared, questions remain about their relative benefits and drawbacks, including complications and their costs.

Dr. JóŸwiak and her coinvestigators conducted a trial called PROBAAT (Prostaglandins or Balloon for Induction of Labor at Term) in 819 women with a term pregnancy who had a vital singleton fetus in cephalic presentation, intact membranes, and an unfavorable cervix, defined as a Bishop score of less than 6.

The women were 31 years old, on average, and 81% were white. The median gestational age was 40 weeks. Two-thirds were nulliparous, and most (83%) had a Bishop score of 3 or less. The leading indications for labor induction were postterm pregnancy (36%) and hypertensive disorders (34%). Patients were excluded from the study if they had had a cesarean delivery, or had placenta previa, a fetus with congenital anomalies, or hypersensitivity to either of the products used for labor induction.

The investigators randomized the women in equal numbers to nonblinded treatment with a transcervical Foley catheter or vaginal prostaglandin E2 gel. Analyses were based on 411 women in the former group and 408 in the latter group.

Trial results showed that the rate of cesarean section, the primary outcome, was 23% in the Foley catheter group and 20% in the prostaglandin gel group, a difference that was not significant, Dr. JóŸwiak reported.

The rate of vaginal instrumental delivery did not differ, but the combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the Foley group (12% vs. 18%). The rate of maternal infection during labor also was lower in that group (2% vs. 4%).

The groups were similar with respect to rates of other maternal outcomes (hyperstimulation, postpartum hemorrhage, and blood transfusion). There were two cases of uterine rupture, both in the prostaglandin group.

In terms of neonatal outcomes, neonates in the Foley group were significantly less likely than their counterparts in the prostaglandin group to be admitted to the ward (12% vs. 19%), while rates of intensive care unit admission were identical.

The groups were similar with respect to rates of other neonatal outcomes, such as Apgar scores, umbilical cord blood pH, reasons for admission, and length of admission.

Subgroup analyses are still ongoing, according to Dr. JóŸwiak, but preliminary results suggest that the Foley catheter was the more successful of the two methods in nulliparous women, who are more likely to have trouble with labor induction.

“Induction with a Foley catheter is, in terms of cesarean section, as effective as induction with prostaglandin E2 gel, with less neonatal and maternal morbidity,” she concluded.

“We recommend considering the Foley catheter as a first choice for induction of labor at term in women with an unfavorable cervix,” Dr. JóŸwiak said.

Canadian Trial

Elective induction of labor now occurs in 21%–30% of all births, noted Dr. Marie-Danielle Dionne, a fetal-maternal medicine specialist at the University of Montreal. “An improved Bishop score before induction increases the rate of vaginal birth.”

She and her coinvestigators enrolled women with a normal singleton pregnancy at term who had intact membranes and an unfavorable cervix, with a Bishop score of 5 or less. Women were ineligible if they had prostaglandin hypersensitivity, previous uterine surgery, a noncephalic fetal presentation, or nonreassuring fetal cardiac monitoring.

The women were randomized in equal numbers to nonblinded treatment with a Foley catheter plus intravenous oxytocin infusion, a Foley catheter plus intravaginal misoprostol, or intravaginal misoprostol alone.

The trial was stopped early because of an elevated rate of cesarean deliveries in the first group, according to Dr. Dionne.

Intention-to-treat analyses were based on 92 women in the Foley plus oxytocin group, 85 women in the Foley plus misoprostol group, and 88 women in the misoprostol-only group.

On average, the women were 30 years old, and the median gestational age was 40.5 weeks. About three-fourths of the women were nulliparous. The mean Bishop score was 3. The leading indications for induction were a postdate pregnancy (54%) and diabetes (27%).

Trial results showed that the rate of delivery within 24 hours, the primary outcome, was highest in the Foley plus oxytocin group at 94%, Dr. Dionne reported. It was statistically similar in the Foley plus misoprostol group at 87%, but significantly lower in the misoprostol-only group at 74%.

However, the rate of cesarean delivery was 44% in the Foley plus oxytocin group. It was significantly lower in both the Foley plus misoprostol group at 24%, and in the misoprostol-only group at 28%.

The three groups did not differ with respect to rates of maternal complications (postpartum hemorrhage, hyperstimulation, receipt of antibiotics, and placental retention) and fetal and neonatal outcomes (Apgar scores, cord blood arterial pH, admission to the neonatal intensive care unit, meconium in amniotic fluid, receipt of antibiotics, and nonreassuring fetal monitoring).

“We can say that in our institutions, the use of a Foley catheter is associated with more deliveries within 24 hours,” said Dr. Dionne.

“This is mostly due to a smaller delay from induction to labor,” she said.

“Misoprostol use significantly reduced the rate of c-section, with or without a Foley catheter,” she further noted.

Dr. Dionne speculated that the higher rate of cesareans with the Foley catheter plus oxytocin, despite the more rapid delivery, was due to inadequate cervical ripening in the face of contractions. “There is a small change in the cervix and there are regular contractions, but it is probably not as physiological as with the misoprostol,” she said.

“So we have to decide which is best: more deliveries within 24 hours or more vaginal births,” Dr. Dionne concluded. “The answer is easy for me: We think more vaginal births is better.”

Major Finding: The combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the 411 women in the Foley catheter group, compared with the 408 women who received vaginal prostaglandin gel (12% vs. 18%), while the former group had less maternal and neonatal morbidity. In the other trial, the rate of delivery within 24 hours was highest in the Foley plus oxytocin group of 92 women, at 94%. It was statistically similar at 87% in the Foley plus misoprostol group of 85 women, but significantly lower at 74% in the misoprostol-only group of 88 women.

Data Source: Two randomized controlled trials involving 819 pregnant women and 265 pregnant women, respectively. The women in both groups were at term with an indication for labor induction and an unfavorable cervix.

Disclosures: Dr. JóŸwiak and Dr. Dionne did not report any relevant financial disclosures.

SAN FRANCISCO – In women with term pregnancies and an unfavorable cervix, different methods of labor induction have their pros and cons, according to the results of a pair of randomized trials reported at the meeting.

A trial conducted in the Netherlands found that roughly one-fifth of women eventually had a cesarean section whether labor was induced with a Foley catheter or with vaginal prostaglandin gel. But there was less maternal and neonatal morbidity with the former.

And a trial conducted in Canada found that a Foley catheter plus oxytocin or misoprostol was associated with a higher rate of delivery within 24 hours than misoprostol alone. However, the misoprostol methods were associated with a lower cesarean rate.

Dutch Trial

U.S. and Dutch guidelines indicate that both prostaglandin E analogues and Foley catheters are options for inducing labor, said Dr. Marta JóŸwiak, an obstetrician at the Groene Hart Hospital in Gouda, the Netherlands.

As a result, clinical practice varies. Although these methods have been compared, questions remain about their relative benefits and drawbacks, including complications and their costs.

Dr. JóŸwiak and her coinvestigators conducted a trial called PROBAAT (Prostaglandins or Balloon for Induction of Labor at Term) in 819 women with a term pregnancy who had a vital singleton fetus in cephalic presentation, intact membranes, and an unfavorable cervix, defined as a Bishop score of less than 6.

The women were 31 years old, on average, and 81% were white. The median gestational age was 40 weeks. Two-thirds were nulliparous, and most (83%) had a Bishop score of 3 or less. The leading indications for labor induction were postterm pregnancy (36%) and hypertensive disorders (34%). Patients were excluded from the study if they had had a cesarean delivery, or had placenta previa, a fetus with congenital anomalies, or hypersensitivity to either of the products used for labor induction.

The investigators randomized the women in equal numbers to nonblinded treatment with a transcervical Foley catheter or vaginal prostaglandin E2 gel. Analyses were based on 411 women in the former group and 408 in the latter group.

Trial results showed that the rate of cesarean section, the primary outcome, was 23% in the Foley catheter group and 20% in the prostaglandin gel group, a difference that was not significant, Dr. JóŸwiak reported.

The rate of vaginal instrumental delivery did not differ, but the combined rate of cesarean and vaginal instrumental deliveries specifically for fetal distress was significantly lower in the Foley group (12% vs. 18%). The rate of maternal infection during labor also was lower in that group (2% vs. 4%).

The groups were similar with respect to rates of other maternal outcomes (hyperstimulation, postpartum hemorrhage, and blood transfusion). There were two cases of uterine rupture, both in the prostaglandin group.

In terms of neonatal outcomes, neonates in the Foley group were significantly less likely than their counterparts in the prostaglandin group to be admitted to the ward (12% vs. 19%), while rates of intensive care unit admission were identical.

The groups were similar with respect to rates of other neonatal outcomes, such as Apgar scores, umbilical cord blood pH, reasons for admission, and length of admission.

Subgroup analyses are still ongoing, according to Dr. JóŸwiak, but preliminary results suggest that the Foley catheter was the more successful of the two methods in nulliparous women, who are more likely to have trouble with labor induction.

“Induction with a Foley catheter is, in terms of cesarean section, as effective as induction with prostaglandin E2 gel, with less neonatal and maternal morbidity,” she concluded.

“We recommend considering the Foley catheter as a first choice for induction of labor at term in women with an unfavorable cervix,” Dr. JóŸwiak said.

Canadian Trial

Elective induction of labor now occurs in 21%–30% of all births, noted Dr. Marie-Danielle Dionne, a fetal-maternal medicine specialist at the University of Montreal. “An improved Bishop score before induction increases the rate of vaginal birth.”

She and her coinvestigators enrolled women with a normal singleton pregnancy at term who had intact membranes and an unfavorable cervix, with a Bishop score of 5 or less. Women were ineligible if they had prostaglandin hypersensitivity, previous uterine surgery, a noncephalic fetal presentation, or nonreassuring fetal cardiac monitoring.

The women were randomized in equal numbers to nonblinded treatment with a Foley catheter plus intravenous oxytocin infusion, a Foley catheter plus intravaginal misoprostol, or intravaginal misoprostol alone.

The trial was stopped early because of an elevated rate of cesarean deliveries in the first group, according to Dr. Dionne.

Intention-to-treat analyses were based on 92 women in the Foley plus oxytocin group, 85 women in the Foley plus misoprostol group, and 88 women in the misoprostol-only group.

On average, the women were 30 years old, and the median gestational age was 40.5 weeks. About three-fourths of the women were nulliparous. The mean Bishop score was 3. The leading indications for induction were a postdate pregnancy (54%) and diabetes (27%).

Trial results showed that the rate of delivery within 24 hours, the primary outcome, was highest in the Foley plus oxytocin group at 94%, Dr. Dionne reported. It was statistically similar in the Foley plus misoprostol group at 87%, but significantly lower in the misoprostol-only group at 74%.

However, the rate of cesarean delivery was 44% in the Foley plus oxytocin group. It was significantly lower in both the Foley plus misoprostol group at 24%, and in the misoprostol-only group at 28%.

The three groups did not differ with respect to rates of maternal complications (postpartum hemorrhage, hyperstimulation, receipt of antibiotics, and placental retention) and fetal and neonatal outcomes (Apgar scores, cord blood arterial pH, admission to the neonatal intensive care unit, meconium in amniotic fluid, receipt of antibiotics, and nonreassuring fetal monitoring).

“We can say that in our institutions, the use of a Foley catheter is associated with more deliveries within 24 hours,” said Dr. Dionne.

“This is mostly due to a smaller delay from induction to labor,” she said.

“Misoprostol use significantly reduced the rate of c-section, with or without a Foley catheter,” she further noted.

Dr. Dionne speculated that the higher rate of cesareans with the Foley catheter plus oxytocin, despite the more rapid delivery, was due to inadequate cervical ripening in the face of contractions. “There is a small change in the cervix and there are regular contractions, but it is probably not as physiological as with the misoprostol,” she said.

“So we have to decide which is best: more deliveries within 24 hours or more vaginal births,” Dr. Dionne concluded. “The answer is easy for me: We think more vaginal births is better.”

CHICAGO – The risk of gallbladder disease was more than twice as high in pregnant women in the top quartile of carbohydrate consumption, compared with those in the bottom quartile, based on data from a prospective study of 3,070 pregnant women.

Female sex is a risk factor for gallstones, and pregnancy is an especially high-risk time for gallstone development, Dr. Alexander Wong of the University of Washington, Seattle, said at a press conference.

“Gallbladder disease is the most common nonobstetrical cause of maternal rehospitalization the first 60 days after delivery,” said Dr. Wong.

“Carbohydrate intake has been linked to increased risk of cholecystectomy in women.

“However, the effect of carbohydrate intake on gallbladder disease during pregnancy is unclear,” he commented.

To determine the effect of diet during pregnancy on gallstone formation, Dr. Wong and his colleages performed ultrasounds on pregnant women during each trimester and at 4–6 weeks post partum.

The average age of the women was 25 years, and each had at least two interpretable ultrasounds. Women who had gallstones at the first ultrasound and those with a history of gallstones were excluded.

Overall, the cumulative incidence of new gallstones or biliary sludge indicative of gallbladder disease was 10%. In addition, women in the highest quartile of starch consumption were 80% more likely than those in the lowest quartile to show signs of gallbladder disease.

In addition, those in the highest quartile of fructose consumption had double the risk, compared with the lowest quartile, of showing signs of gallbladder disease. Dietary factors were assessed using standard food composition data.

Women who formed sludge or stones were more likely to have a higher caffeine and alcohol intake, be of Hispanic origin, and gain less weight during pregnancy.

By contrast, the highest quartile of galactose intake was independently associated with a decreased risk of gallbladder disease, compared with the lowest quartile, noted coauthor Dr. Cynthia Ko, also of the university, who presented the study results at the press conference. The results held after control for variables including age, prepregnancy weight, ethnicity, smoking, diabetes, total calorie intake, alcohol intake, and weight gain during pregnancy.

“We believe that high carbohydrate intake during pregnancy may stimulate even more insulin release, therefore increasing the negative effects of hyperinsulinemia on bile composition,” Dr. Wong said.

“The fructose finding is fairly novel,” added Dr. Ko.

“We hypothesize that fructose is metabolized differently than many other carbohydrates,” she said.

High fructose intake can cause insulin resistance, which can predispose individuals to gallstone formation, she noted.

“The galactose finding is quite novel, and we don't have a good scientific explanation for why we found that,” Dr. Ko added. “This is a very preliminary finding that needs further confirmation and explanation.”

The results suggest that cutting down on refined, processed carbohydrates during pregnancy might reduce a woman's risk of gallstones, Dr. Ko commented.

Dr. Ko said she had no relevant financial disclosures.

CHICAGO – The risk of gallbladder disease was more than twice as high in pregnant women in the top quartile of carbohydrate consumption, compared with those in the bottom quartile, based on data from a prospective study of 3,070 pregnant women.

Female sex is a risk factor for gallstones, and pregnancy is an especially high-risk time for gallstone development, Dr. Alexander Wong of the University of Washington, Seattle, said at a press conference.

“Gallbladder disease is the most common nonobstetrical cause of maternal rehospitalization the first 60 days after delivery,” said Dr. Wong.

“Carbohydrate intake has been linked to increased risk of cholecystectomy in women.

“However, the effect of carbohydrate intake on gallbladder disease during pregnancy is unclear,” he commented.

To determine the effect of diet during pregnancy on gallstone formation, Dr. Wong and his colleages performed ultrasounds on pregnant women during each trimester and at 4–6 weeks post partum.

The average age of the women was 25 years, and each had at least two interpretable ultrasounds. Women who had gallstones at the first ultrasound and those with a history of gallstones were excluded.

Overall, the cumulative incidence of new gallstones or biliary sludge indicative of gallbladder disease was 10%. In addition, women in the highest quartile of starch consumption were 80% more likely than those in the lowest quartile to show signs of gallbladder disease.

In addition, those in the highest quartile of fructose consumption had double the risk, compared with the lowest quartile, of showing signs of gallbladder disease. Dietary factors were assessed using standard food composition data.

Women who formed sludge or stones were more likely to have a higher caffeine and alcohol intake, be of Hispanic origin, and gain less weight during pregnancy.

By contrast, the highest quartile of galactose intake was independently associated with a decreased risk of gallbladder disease, compared with the lowest quartile, noted coauthor Dr. Cynthia Ko, also of the university, who presented the study results at the press conference. The results held after control for variables including age, prepregnancy weight, ethnicity, smoking, diabetes, total calorie intake, alcohol intake, and weight gain during pregnancy.

“We believe that high carbohydrate intake during pregnancy may stimulate even more insulin release, therefore increasing the negative effects of hyperinsulinemia on bile composition,” Dr. Wong said.

“The fructose finding is fairly novel,” added Dr. Ko.

“We hypothesize that fructose is metabolized differently than many other carbohydrates,” she said.

High fructose intake can cause insulin resistance, which can predispose individuals to gallstone formation, she noted.

“The galactose finding is quite novel, and we don't have a good scientific explanation for why we found that,” Dr. Ko added. “This is a very preliminary finding that needs further confirmation and explanation.”

The results suggest that cutting down on refined, processed carbohydrates during pregnancy might reduce a woman's risk of gallstones, Dr. Ko commented.

Dr. Ko said she had no relevant financial disclosures.

CHICAGO – The risk of gallbladder disease was more than twice as high in pregnant women in the top quartile of carbohydrate consumption, compared with those in the bottom quartile, based on data from a prospective study of 3,070 pregnant women.

Female sex is a risk factor for gallstones, and pregnancy is an especially high-risk time for gallstone development, Dr. Alexander Wong of the University of Washington, Seattle, said at a press conference.

“Gallbladder disease is the most common nonobstetrical cause of maternal rehospitalization the first 60 days after delivery,” said Dr. Wong.

“Carbohydrate intake has been linked to increased risk of cholecystectomy in women.

“However, the effect of carbohydrate intake on gallbladder disease during pregnancy is unclear,” he commented.

To determine the effect of diet during pregnancy on gallstone formation, Dr. Wong and his colleages performed ultrasounds on pregnant women during each trimester and at 4–6 weeks post partum.

The average age of the women was 25 years, and each had at least two interpretable ultrasounds. Women who had gallstones at the first ultrasound and those with a history of gallstones were excluded.

Overall, the cumulative incidence of new gallstones or biliary sludge indicative of gallbladder disease was 10%. In addition, women in the highest quartile of starch consumption were 80% more likely than those in the lowest quartile to show signs of gallbladder disease.

In addition, those in the highest quartile of fructose consumption had double the risk, compared with the lowest quartile, of showing signs of gallbladder disease. Dietary factors were assessed using standard food composition data.

Women who formed sludge or stones were more likely to have a higher caffeine and alcohol intake, be of Hispanic origin, and gain less weight during pregnancy.

By contrast, the highest quartile of galactose intake was independently associated with a decreased risk of gallbladder disease, compared with the lowest quartile, noted coauthor Dr. Cynthia Ko, also of the university, who presented the study results at the press conference. The results held after control for variables including age, prepregnancy weight, ethnicity, smoking, diabetes, total calorie intake, alcohol intake, and weight gain during pregnancy.

“We believe that high carbohydrate intake during pregnancy may stimulate even more insulin release, therefore increasing the negative effects of hyperinsulinemia on bile composition,” Dr. Wong said.

“The fructose finding is fairly novel,” added Dr. Ko.

“We hypothesize that fructose is metabolized differently than many other carbohydrates,” she said.

High fructose intake can cause insulin resistance, which can predispose individuals to gallstone formation, she noted.

“The galactose finding is quite novel, and we don't have a good scientific explanation for why we found that,” Dr. Ko added. “This is a very preliminary finding that needs further confirmation and explanation.”

The results suggest that cutting down on refined, processed carbohydrates during pregnancy might reduce a woman's risk of gallstones, Dr. Ko commented.

Dr. Ko said she had no relevant financial disclosures.

Major Finding: Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission. In contrast, in the control group there were seven late wound complications and three readmissions. The difference in late wound complications was significant.

Data Source: A chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

Disclosures: Dr. Miranda-Seijo reported that he had no relevant financial disclosures.

WASHINGTON – Modified panniculectomy at the time of cesarean section may be a useful adjunct for decreasing postoperative morbidity in morbidly obese patients, based on results of a small case series.

“We found that women who underwent panniculectomy at the time of cesarean section were less likely to have significant wound complications than controls that did not undergo panniculectomy,” Dr. Pedro Miranda-Seijo said in a poster presentation at the meeting.

He and his coinvestigators conducted a chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

The definition of morbidly obese was a body mass index (BMI) of greater than 42 kg/m

“The decision to perform a panniculectomy was made originally by me before starting surgery, at which time I would obtain informed consent,” Dr. Miranda-Seijo said in an interview.

“After I'd done the first 10 or 15 cases, the residents and other attending began trying to schedule elective cases on morbidly obese patients on days that I would be available; often I would see these patients during their antepartum visit and discuss the procedure with them,” said Dr. Miranda-Seijo, who is an obstetrician at Denver Health and Hospitals.

“I am the only attending that does these procedures; [patients] understand that if they come in labor and I'm not available, they would not be getting a panniculectomy,” he said.

Also “when a morbidly obese patient who is in labor needs a cesarean section, if I'm available, I often get called to do it,” he commented.

“If the indication is urgent but not emergent – say failure to descend or secondary arrest of dilation – and I will be available in a few hours, the case is often held for me to do when I arrive,” he said.

Notably, the women in this series who underwent panniculectomy had significantly greater BMIs – a mean of 54 vs. 49 kg/m

Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission.

In contrast, in the control group there were seven late wound complications and three readmissions.

The difference in late wound complications was significant.

There was a nonsignificant difference in operative time, with a mean of 66 minutes with a panniculectomy compared with 63 minutes for cesarean section alone.

Panniculectomy did not significantly increase blood loss.

“The extra time needed to infiltrate the skin, remove the pannus, and [close] the large incision is offset by the greater speed achieved in accessing the uterus, delivering the baby, and closing the uterus and fascia, due to better exposure and easier access,” he commented.

Several questions were raised by the study: Does the removal of so much adipose tissue have an effect on glucose tolerance, and could this procedure be used by patients as a starting point to initiate healthier lifestyle changes?

Additional research will be needed to provide answers, Dr. Miranda-Seijo said.

Modified panniculectomy at the time of cesarean section on morbidly obese patients did not significantly increase blood loss.

Source Photos courtesy Dr. Pedro Miranda-Seijo

Women who underwent panniculectomy at the time of c-section were less likely to have significant wound infections than those who did not have the procedure.

Major Finding: Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission. In contrast, in the control group there were seven late wound complications and three readmissions. The difference in late wound complications was significant.

Data Source: A chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

Disclosures: Dr. Miranda-Seijo reported that he had no relevant financial disclosures.

WASHINGTON – Modified panniculectomy at the time of cesarean section may be a useful adjunct for decreasing postoperative morbidity in morbidly obese patients, based on results of a small case series.

“We found that women who underwent panniculectomy at the time of cesarean section were less likely to have significant wound complications than controls that did not undergo panniculectomy,” Dr. Pedro Miranda-Seijo said in a poster presentation at the meeting.

He and his coinvestigators conducted a chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

The definition of morbidly obese was a body mass index (BMI) of greater than 42 kg/m

“The decision to perform a panniculectomy was made originally by me before starting surgery, at which time I would obtain informed consent,” Dr. Miranda-Seijo said in an interview.

“After I'd done the first 10 or 15 cases, the residents and other attending began trying to schedule elective cases on morbidly obese patients on days that I would be available; often I would see these patients during their antepartum visit and discuss the procedure with them,” said Dr. Miranda-Seijo, who is an obstetrician at Denver Health and Hospitals.

“I am the only attending that does these procedures; [patients] understand that if they come in labor and I'm not available, they would not be getting a panniculectomy,” he said.

Also “when a morbidly obese patient who is in labor needs a cesarean section, if I'm available, I often get called to do it,” he commented.

“If the indication is urgent but not emergent – say failure to descend or secondary arrest of dilation – and I will be available in a few hours, the case is often held for me to do when I arrive,” he said.

Notably, the women in this series who underwent panniculectomy had significantly greater BMIs – a mean of 54 vs. 49 kg/m

Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission.

In contrast, in the control group there were seven late wound complications and three readmissions.

The difference in late wound complications was significant.

There was a nonsignificant difference in operative time, with a mean of 66 minutes with a panniculectomy compared with 63 minutes for cesarean section alone.

Panniculectomy did not significantly increase blood loss.

“The extra time needed to infiltrate the skin, remove the pannus, and [close] the large incision is offset by the greater speed achieved in accessing the uterus, delivering the baby, and closing the uterus and fascia, due to better exposure and easier access,” he commented.

Several questions were raised by the study: Does the removal of so much adipose tissue have an effect on glucose tolerance, and could this procedure be used by patients as a starting point to initiate healthier lifestyle changes?

Additional research will be needed to provide answers, Dr. Miranda-Seijo said.

Modified panniculectomy at the time of cesarean section on morbidly obese patients did not significantly increase blood loss.

Source Photos courtesy Dr. Pedro Miranda-Seijo

Women who underwent panniculectomy at the time of c-section were less likely to have significant wound infections than those who did not have the procedure.

Major Finding: Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission. In contrast, in the control group there were seven late wound complications and three readmissions. The difference in late wound complications was significant.

Data Source: A chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

Disclosures: Dr. Miranda-Seijo reported that he had no relevant financial disclosures.

WASHINGTON – Modified panniculectomy at the time of cesarean section may be a useful adjunct for decreasing postoperative morbidity in morbidly obese patients, based on results of a small case series.

“We found that women who underwent panniculectomy at the time of cesarean section were less likely to have significant wound complications than controls that did not undergo panniculectomy,” Dr. Pedro Miranda-Seijo said in a poster presentation at the meeting.

He and his coinvestigators conducted a chart review during 2004 that included 30 morbidly obese patients who underwent incidental panniculectomy during cesarean section and a control group of 29 morbidly obese women who underwent a cesarean section without a panniculectomy.

The definition of morbidly obese was a body mass index (BMI) of greater than 42 kg/m

“The decision to perform a panniculectomy was made originally by me before starting surgery, at which time I would obtain informed consent,” Dr. Miranda-Seijo said in an interview.

“After I'd done the first 10 or 15 cases, the residents and other attending began trying to schedule elective cases on morbidly obese patients on days that I would be available; often I would see these patients during their antepartum visit and discuss the procedure with them,” said Dr. Miranda-Seijo, who is an obstetrician at Denver Health and Hospitals.

“I am the only attending that does these procedures; [patients] understand that if they come in labor and I'm not available, they would not be getting a panniculectomy,” he said.

Also “when a morbidly obese patient who is in labor needs a cesarean section, if I'm available, I often get called to do it,” he commented.

“If the indication is urgent but not emergent – say failure to descend or secondary arrest of dilation – and I will be available in a few hours, the case is often held for me to do when I arrive,” he said.

Notably, the women in this series who underwent panniculectomy had significantly greater BMIs – a mean of 54 vs. 49 kg/m

Of the 30 women who underwent modified panniculectomy at the time of cesarean section, there was one operative site infection that required readmission.

In contrast, in the control group there were seven late wound complications and three readmissions.

The difference in late wound complications was significant.

There was a nonsignificant difference in operative time, with a mean of 66 minutes with a panniculectomy compared with 63 minutes for cesarean section alone.

Panniculectomy did not significantly increase blood loss.

“The extra time needed to infiltrate the skin, remove the pannus, and [close] the large incision is offset by the greater speed achieved in accessing the uterus, delivering the baby, and closing the uterus and fascia, due to better exposure and easier access,” he commented.

Several questions were raised by the study: Does the removal of so much adipose tissue have an effect on glucose tolerance, and could this procedure be used by patients as a starting point to initiate healthier lifestyle changes?

Additional research will be needed to provide answers, Dr. Miranda-Seijo said.

Modified panniculectomy at the time of cesarean section on morbidly obese patients did not significantly increase blood loss.

Source Photos courtesy Dr. Pedro Miranda-Seijo

Women who underwent panniculectomy at the time of c-section were less likely to have significant wound infections than those who did not have the procedure.