Obstetrics

Major Finding: During the first stage of labor, mean verbal analog scale pain score was significantly less in the SE group compared with EA (1.36 vs. 1.89), but the difference was not significant by the end of the second stage.

Data Source: A randomized, controlled trial of 800 women.

Disclosures: Dr. Gambling said he had no financial disclosures to report.

SAN ANTONIO — Combined spinal-epidural anesthesia was superior to traditional epidural for first-stage anesthesia but there were no differences in second stage or in delivery pain in a randomized, controlled comparison of the two methods among 800 women.

The Epidural Analgesia and Spinal Epidural Analgesia (EASE) study also showed that concerns about epidurals failing with combined spinal-epidural (SE) because of the inability to provide a test dose are unfounded, Dr. David R. Gambling reported.

Previous studies comparing the techniques have had mixed results. A Cochrane review showed that CSE had less rescue analgesia and less urinary retention but more pruritis (Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2]). Compared with low-dose epidural anesthesia (EA), combined SE had faster-onset analgesia, more pruritis, and lower umbilical cord artery pH, but there was no mention of progress of cervical dilation, noted Dr. Gambling of the Sharp Mary Birch Hospital for Women and Newborns and the University of California, San Diego.

In EASE, 398 women received EA, consisting of 10 mL 0.125% bupivacaine with 2 mcg/mL fentanyl in two 5-mL doses via epidural needle, followed by 5 mL of the same solution via epidural catheter (total dose 15 mL). The 402 in the SE group were given 2.5 mL 0.125% isobaric bupivacaine plus 2 mcg/mL fentanyl via 26-g GM spinal needle prior to epidural catheter placement.

In both groups, medications were administered at first request for neuraxial anesthesia. Labor was managed by registered nurses and obstetricians who were blinded to group assignment.

There were no significant differences between the groups in age, height, weight, body mass index, estimated gestational age, cervical dilation at epidural insertion, or pre-epidural verbal analog scale (VAS) pain scores. However, the time to complete analgesia (from initial EA and SE injection until patient reported VAS scores of 0 or 1 was significantly less with the SE group, 11 vs. 22 minutes.

The second stage of labor was statistically significantly shorter with EA (68 vs. 78 minutes), but the difference may not be clinically significant. There were no significant differences in time from epidural induction until cervical dilation reached 10 cm, duration of pushing, or rate of cervical dilation. There were also no differences in the use of instrumentation with vaginal delivery or need for cesarean section.

During the first stage of labor, the mean VAS pain score was significantly less in the SE group. compared with EA (1.36 vs. 1.89) and also at 1 hour of labor (0.26 vs. 0.72), despite a slightly lower rate of patient-controlled analgesia use during the first stage (10 vs. 11 mL/hr). The proportion of women with mean VAS scores of zero at the end of stage 1 was significantly higher with SE (42% vs. 31% with EA), but the difference was not significant by the end of the second stage, he said.

Need for epidural top-up was greater in the EA group (26% vs. 16%), as was the need for more than one top-up (21% vs. 9%). Only a small proportion of each group (2% EA and 1.2% SE) required replacement of the epidural catheter, suggesting that there should not be concern about epidurals failing with SE because of inability to provide a test dose, he commented.

Fetal heart rate decelerations within 30 minutes of analgesic induction were more common in the SE group (8.5% vs. 4.5%), but none required emergency c-section. The proportions with Apgar scores below 7 at 1 and 5 minutes were less than 5% and less than 0.5%, respectively, in both groups.

Patient satisfaction with their mode of analgesia did not differ, at 98% for SE and 96% for EA, Dr. Gambling reported.

Patient satisfaction with their mode of analgesia did not differ between the two groups.

Source DR. GAMBLING

Major Finding: During the first stage of labor, mean verbal analog scale pain score was significantly less in the SE group compared with EA (1.36 vs. 1.89), but the difference was not significant by the end of the second stage.

Data Source: A randomized, controlled trial of 800 women.

Disclosures: Dr. Gambling said he had no financial disclosures to report.

SAN ANTONIO — Combined spinal-epidural anesthesia was superior to traditional epidural for first-stage anesthesia but there were no differences in second stage or in delivery pain in a randomized, controlled comparison of the two methods among 800 women.

The Epidural Analgesia and Spinal Epidural Analgesia (EASE) study also showed that concerns about epidurals failing with combined spinal-epidural (SE) because of the inability to provide a test dose are unfounded, Dr. David R. Gambling reported.

Previous studies comparing the techniques have had mixed results. A Cochrane review showed that CSE had less rescue analgesia and less urinary retention but more pruritis (Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2]). Compared with low-dose epidural anesthesia (EA), combined SE had faster-onset analgesia, more pruritis, and lower umbilical cord artery pH, but there was no mention of progress of cervical dilation, noted Dr. Gambling of the Sharp Mary Birch Hospital for Women and Newborns and the University of California, San Diego.

In EASE, 398 women received EA, consisting of 10 mL 0.125% bupivacaine with 2 mcg/mL fentanyl in two 5-mL doses via epidural needle, followed by 5 mL of the same solution via epidural catheter (total dose 15 mL). The 402 in the SE group were given 2.5 mL 0.125% isobaric bupivacaine plus 2 mcg/mL fentanyl via 26-g GM spinal needle prior to epidural catheter placement.

In both groups, medications were administered at first request for neuraxial anesthesia. Labor was managed by registered nurses and obstetricians who were blinded to group assignment.

There were no significant differences between the groups in age, height, weight, body mass index, estimated gestational age, cervical dilation at epidural insertion, or pre-epidural verbal analog scale (VAS) pain scores. However, the time to complete analgesia (from initial EA and SE injection until patient reported VAS scores of 0 or 1 was significantly less with the SE group, 11 vs. 22 minutes.

The second stage of labor was statistically significantly shorter with EA (68 vs. 78 minutes), but the difference may not be clinically significant. There were no significant differences in time from epidural induction until cervical dilation reached 10 cm, duration of pushing, or rate of cervical dilation. There were also no differences in the use of instrumentation with vaginal delivery or need for cesarean section.

During the first stage of labor, the mean VAS pain score was significantly less in the SE group. compared with EA (1.36 vs. 1.89) and also at 1 hour of labor (0.26 vs. 0.72), despite a slightly lower rate of patient-controlled analgesia use during the first stage (10 vs. 11 mL/hr). The proportion of women with mean VAS scores of zero at the end of stage 1 was significantly higher with SE (42% vs. 31% with EA), but the difference was not significant by the end of the second stage, he said.

Need for epidural top-up was greater in the EA group (26% vs. 16%), as was the need for more than one top-up (21% vs. 9%). Only a small proportion of each group (2% EA and 1.2% SE) required replacement of the epidural catheter, suggesting that there should not be concern about epidurals failing with SE because of inability to provide a test dose, he commented.

Fetal heart rate decelerations within 30 minutes of analgesic induction were more common in the SE group (8.5% vs. 4.5%), but none required emergency c-section. The proportions with Apgar scores below 7 at 1 and 5 minutes were less than 5% and less than 0.5%, respectively, in both groups.

Patient satisfaction with their mode of analgesia did not differ, at 98% for SE and 96% for EA, Dr. Gambling reported.

Patient satisfaction with their mode of analgesia did not differ between the two groups.

Source DR. GAMBLING

Major Finding: During the first stage of labor, mean verbal analog scale pain score was significantly less in the SE group compared with EA (1.36 vs. 1.89), but the difference was not significant by the end of the second stage.

Data Source: A randomized, controlled trial of 800 women.

Disclosures: Dr. Gambling said he had no financial disclosures to report.

SAN ANTONIO — Combined spinal-epidural anesthesia was superior to traditional epidural for first-stage anesthesia but there were no differences in second stage or in delivery pain in a randomized, controlled comparison of the two methods among 800 women.

The Epidural Analgesia and Spinal Epidural Analgesia (EASE) study also showed that concerns about epidurals failing with combined spinal-epidural (SE) because of the inability to provide a test dose are unfounded, Dr. David R. Gambling reported.

Previous studies comparing the techniques have had mixed results. A Cochrane review showed that CSE had less rescue analgesia and less urinary retention but more pruritis (Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2]). Compared with low-dose epidural anesthesia (EA), combined SE had faster-onset analgesia, more pruritis, and lower umbilical cord artery pH, but there was no mention of progress of cervical dilation, noted Dr. Gambling of the Sharp Mary Birch Hospital for Women and Newborns and the University of California, San Diego.

In EASE, 398 women received EA, consisting of 10 mL 0.125% bupivacaine with 2 mcg/mL fentanyl in two 5-mL doses via epidural needle, followed by 5 mL of the same solution via epidural catheter (total dose 15 mL). The 402 in the SE group were given 2.5 mL 0.125% isobaric bupivacaine plus 2 mcg/mL fentanyl via 26-g GM spinal needle prior to epidural catheter placement.

In both groups, medications were administered at first request for neuraxial anesthesia. Labor was managed by registered nurses and obstetricians who were blinded to group assignment.

There were no significant differences between the groups in age, height, weight, body mass index, estimated gestational age, cervical dilation at epidural insertion, or pre-epidural verbal analog scale (VAS) pain scores. However, the time to complete analgesia (from initial EA and SE injection until patient reported VAS scores of 0 or 1 was significantly less with the SE group, 11 vs. 22 minutes.

The second stage of labor was statistically significantly shorter with EA (68 vs. 78 minutes), but the difference may not be clinically significant. There were no significant differences in time from epidural induction until cervical dilation reached 10 cm, duration of pushing, or rate of cervical dilation. There were also no differences in the use of instrumentation with vaginal delivery or need for cesarean section.

During the first stage of labor, the mean VAS pain score was significantly less in the SE group. compared with EA (1.36 vs. 1.89) and also at 1 hour of labor (0.26 vs. 0.72), despite a slightly lower rate of patient-controlled analgesia use during the first stage (10 vs. 11 mL/hr). The proportion of women with mean VAS scores of zero at the end of stage 1 was significantly higher with SE (42% vs. 31% with EA), but the difference was not significant by the end of the second stage, he said.

Need for epidural top-up was greater in the EA group (26% vs. 16%), as was the need for more than one top-up (21% vs. 9%). Only a small proportion of each group (2% EA and 1.2% SE) required replacement of the epidural catheter, suggesting that there should not be concern about epidurals failing with SE because of inability to provide a test dose, he commented.

Fetal heart rate decelerations within 30 minutes of analgesic induction were more common in the SE group (8.5% vs. 4.5%), but none required emergency c-section. The proportions with Apgar scores below 7 at 1 and 5 minutes were less than 5% and less than 0.5%, respectively, in both groups.

Patient satisfaction with their mode of analgesia did not differ, at 98% for SE and 96% for EA, Dr. Gambling reported.

Patient satisfaction with their mode of analgesia did not differ between the two groups.

Source DR. GAMBLING

Major Finding: Total bupivacaine consumption per hour of analgesia was significantly lower among patients who received 10 mL over 60 minutes (10.3 mg/hour), compared with 11.3 mg/hour for those receiving 2.5 mL/15 minutes and 11.1 mg/hour for 5 mL/30 minutes.

Data Source: Randomized, controlled, double-blinded trial of 180 laboring women.

Disclosures: Dr. Wong said she had no financial conflicts of interest.

SAN ANTONIO — Providing epidural anesthesia in programmed boluses of higher volume with a longer duration between doses decreased total anesthetic consumption and variability without decreasing patient satisfaction in a randomized, controlled, double-blinded study of 180 laboring women.

Increasing evidence suggests that delivery of epidural anesthesia via intermittent bolus provides more effective anesthesia than does continuous infusion, said Dr. Cynthia A. Wong of Northwestern University, Chicago.

In a previous study, Dr. Wong and her colleagues reported that the currently available pumps used for patient-controlled epidural anesthesia (PCEA) also can be programmed to automatically deliver boluses at regular intervals, and that this “programmed intermittent epidural bolus” (PIEB) resulted in similar analgesia but with a smaller bupivacaine dose and better patient satisfaction, compared with continuous epidural infusion (CEI) for maintenance of epidural labor analgesia (Anesth. Analg. 2006;102:904-9).

As a follow-up, the current study investigated the effect of specific combinations of bolus volumes and time intervals to determine which is optimal. The subjects were healthy nulliparas with cervical dilation 2-5 cm. All received combined spinal-epidural anesthesia comprising intrathecal bupivacaine 1.25 mg/fentanyl 15 mcg and a test dose of epidural lidocaine 45 mg/epinephrine 15 mcg. The epidural maintenance solution consisted of bupivacaine 0.0625% with fentanyl 2 mcg/mL. Breakthrough pain was treated with PCEA and if needed, a manual bolus dose by the anesthesiologist.

The maintenance epidural technique was initiated 15 minutes after the intrathecal injection. Patients were randomized to one of three groups: 66 received 2.5 mL by the pump every 15 minutes (2.5/15), 60 received 5 mL every 30 minutes (5/30), and 54 got 10 mL every 60 minutes (10/60). Thus, all patients received the same total volume of drug but it was distributed differently, Dr. Wong noted.

All of the women had successful analgesia, and there were no differences in maximum oxytocin dose or mode of delivery among the groups.

The primary outcome, total bupivacaine consumption per hour of analgesia, was significantly lower in the 10/60 group compared with the other two, with a mean of 10.3 mg/hr versus 11.3 mg/hr for the 2.5/15 patients and 11.1 mg/hr with 5/30. There was also less variability in dosing from hour to hour in the 10/60 group, she noted.

There were no significant differences in any secondary variable, including Visual Analog Pain score, motor block (Bromage greater than 0), number of PCEA requests, time to first request for manual bolus, number of subjects requiring manual bolus, patient satisfaction score, or extent of sensory blockade, as measured by both cold stimulus and von Frey hair threshold tests.

The mechanism isn't entirely clear. All studies of PIEB have shown that the technique provides equal or better analgesia than does CIE with a lower dose of drug. But, if as hypothesized, the reason is that boluses provides better spread in the epidural space, then it is “interesting” that this study found no difference in the extent of sensory blockade among the three groups. Indeed, data on the extent of sensory blockade in other studies of PIEB have been inconsistent, she said.

Other variables, such as differences in catheter design or patient demographics, might also contribute to the variability in extent of analgesia, she added.

In response to a question from the audience about whether these findings have changed her clinical practice, Dr. Wong noted that there is currently no commercially available pump that delivers both PCEA and PIEB.

However, her institution has “considerably backed off using continuous infusion rate” and now relies more on patient-controlled bolusing, resulting in a lower manual re-bolus rate. “There's very solid evidence that giving the drug as a bolus, by whatever means—by the patient, the machine, or the anesthesiologist—is a more efficient technique.

There is currently no commercially available pump that delivers both PCEA and PIEB.

Source DR. WONG

Major Finding: Total bupivacaine consumption per hour of analgesia was significantly lower among patients who received 10 mL over 60 minutes (10.3 mg/hour), compared with 11.3 mg/hour for those receiving 2.5 mL/15 minutes and 11.1 mg/hour for 5 mL/30 minutes.

Data Source: Randomized, controlled, double-blinded trial of 180 laboring women.

Disclosures: Dr. Wong said she had no financial conflicts of interest.

SAN ANTONIO — Providing epidural anesthesia in programmed boluses of higher volume with a longer duration between doses decreased total anesthetic consumption and variability without decreasing patient satisfaction in a randomized, controlled, double-blinded study of 180 laboring women.

Increasing evidence suggests that delivery of epidural anesthesia via intermittent bolus provides more effective anesthesia than does continuous infusion, said Dr. Cynthia A. Wong of Northwestern University, Chicago.

In a previous study, Dr. Wong and her colleagues reported that the currently available pumps used for patient-controlled epidural anesthesia (PCEA) also can be programmed to automatically deliver boluses at regular intervals, and that this “programmed intermittent epidural bolus” (PIEB) resulted in similar analgesia but with a smaller bupivacaine dose and better patient satisfaction, compared with continuous epidural infusion (CEI) for maintenance of epidural labor analgesia (Anesth. Analg. 2006;102:904-9).

As a follow-up, the current study investigated the effect of specific combinations of bolus volumes and time intervals to determine which is optimal. The subjects were healthy nulliparas with cervical dilation 2-5 cm. All received combined spinal-epidural anesthesia comprising intrathecal bupivacaine 1.25 mg/fentanyl 15 mcg and a test dose of epidural lidocaine 45 mg/epinephrine 15 mcg. The epidural maintenance solution consisted of bupivacaine 0.0625% with fentanyl 2 mcg/mL. Breakthrough pain was treated with PCEA and if needed, a manual bolus dose by the anesthesiologist.

The maintenance epidural technique was initiated 15 minutes after the intrathecal injection. Patients were randomized to one of three groups: 66 received 2.5 mL by the pump every 15 minutes (2.5/15), 60 received 5 mL every 30 minutes (5/30), and 54 got 10 mL every 60 minutes (10/60). Thus, all patients received the same total volume of drug but it was distributed differently, Dr. Wong noted.

All of the women had successful analgesia, and there were no differences in maximum oxytocin dose or mode of delivery among the groups.

The primary outcome, total bupivacaine consumption per hour of analgesia, was significantly lower in the 10/60 group compared with the other two, with a mean of 10.3 mg/hr versus 11.3 mg/hr for the 2.5/15 patients and 11.1 mg/hr with 5/30. There was also less variability in dosing from hour to hour in the 10/60 group, she noted.

There were no significant differences in any secondary variable, including Visual Analog Pain score, motor block (Bromage greater than 0), number of PCEA requests, time to first request for manual bolus, number of subjects requiring manual bolus, patient satisfaction score, or extent of sensory blockade, as measured by both cold stimulus and von Frey hair threshold tests.

The mechanism isn't entirely clear. All studies of PIEB have shown that the technique provides equal or better analgesia than does CIE with a lower dose of drug. But, if as hypothesized, the reason is that boluses provides better spread in the epidural space, then it is “interesting” that this study found no difference in the extent of sensory blockade among the three groups. Indeed, data on the extent of sensory blockade in other studies of PIEB have been inconsistent, she said.

Other variables, such as differences in catheter design or patient demographics, might also contribute to the variability in extent of analgesia, she added.

In response to a question from the audience about whether these findings have changed her clinical practice, Dr. Wong noted that there is currently no commercially available pump that delivers both PCEA and PIEB.

However, her institution has “considerably backed off using continuous infusion rate” and now relies more on patient-controlled bolusing, resulting in a lower manual re-bolus rate. “There's very solid evidence that giving the drug as a bolus, by whatever means—by the patient, the machine, or the anesthesiologist—is a more efficient technique.

There is currently no commercially available pump that delivers both PCEA and PIEB.

Source DR. WONG

Major Finding: Total bupivacaine consumption per hour of analgesia was significantly lower among patients who received 10 mL over 60 minutes (10.3 mg/hour), compared with 11.3 mg/hour for those receiving 2.5 mL/15 minutes and 11.1 mg/hour for 5 mL/30 minutes.

Data Source: Randomized, controlled, double-blinded trial of 180 laboring women.

Disclosures: Dr. Wong said she had no financial conflicts of interest.

SAN ANTONIO — Providing epidural anesthesia in programmed boluses of higher volume with a longer duration between doses decreased total anesthetic consumption and variability without decreasing patient satisfaction in a randomized, controlled, double-blinded study of 180 laboring women.

Increasing evidence suggests that delivery of epidural anesthesia via intermittent bolus provides more effective anesthesia than does continuous infusion, said Dr. Cynthia A. Wong of Northwestern University, Chicago.

In a previous study, Dr. Wong and her colleagues reported that the currently available pumps used for patient-controlled epidural anesthesia (PCEA) also can be programmed to automatically deliver boluses at regular intervals, and that this “programmed intermittent epidural bolus” (PIEB) resulted in similar analgesia but with a smaller bupivacaine dose and better patient satisfaction, compared with continuous epidural infusion (CEI) for maintenance of epidural labor analgesia (Anesth. Analg. 2006;102:904-9).

As a follow-up, the current study investigated the effect of specific combinations of bolus volumes and time intervals to determine which is optimal. The subjects were healthy nulliparas with cervical dilation 2-5 cm. All received combined spinal-epidural anesthesia comprising intrathecal bupivacaine 1.25 mg/fentanyl 15 mcg and a test dose of epidural lidocaine 45 mg/epinephrine 15 mcg. The epidural maintenance solution consisted of bupivacaine 0.0625% with fentanyl 2 mcg/mL. Breakthrough pain was treated with PCEA and if needed, a manual bolus dose by the anesthesiologist.

The maintenance epidural technique was initiated 15 minutes after the intrathecal injection. Patients were randomized to one of three groups: 66 received 2.5 mL by the pump every 15 minutes (2.5/15), 60 received 5 mL every 30 minutes (5/30), and 54 got 10 mL every 60 minutes (10/60). Thus, all patients received the same total volume of drug but it was distributed differently, Dr. Wong noted.

All of the women had successful analgesia, and there were no differences in maximum oxytocin dose or mode of delivery among the groups.

The primary outcome, total bupivacaine consumption per hour of analgesia, was significantly lower in the 10/60 group compared with the other two, with a mean of 10.3 mg/hr versus 11.3 mg/hr for the 2.5/15 patients and 11.1 mg/hr with 5/30. There was also less variability in dosing from hour to hour in the 10/60 group, she noted.

There were no significant differences in any secondary variable, including Visual Analog Pain score, motor block (Bromage greater than 0), number of PCEA requests, time to first request for manual bolus, number of subjects requiring manual bolus, patient satisfaction score, or extent of sensory blockade, as measured by both cold stimulus and von Frey hair threshold tests.

The mechanism isn't entirely clear. All studies of PIEB have shown that the technique provides equal or better analgesia than does CIE with a lower dose of drug. But, if as hypothesized, the reason is that boluses provides better spread in the epidural space, then it is “interesting” that this study found no difference in the extent of sensory blockade among the three groups. Indeed, data on the extent of sensory blockade in other studies of PIEB have been inconsistent, she said.

Other variables, such as differences in catheter design or patient demographics, might also contribute to the variability in extent of analgesia, she added.

In response to a question from the audience about whether these findings have changed her clinical practice, Dr. Wong noted that there is currently no commercially available pump that delivers both PCEA and PIEB.

However, her institution has “considerably backed off using continuous infusion rate” and now relies more on patient-controlled bolusing, resulting in a lower manual re-bolus rate. “There's very solid evidence that giving the drug as a bolus, by whatever means—by the patient, the machine, or the anesthesiologist—is a more efficient technique.

There is currently no commercially available pump that delivers both PCEA and PIEB.

Source DR. WONG

SAN ANTONIO — Restless legs syndrome is extremely common in pregnancy, and one-third of affected women experience severe symptoms on four or more nights per week, according to a large prospective study.

Moreover, the presence of restless legs syndrome (RLS) doubles a pregnant woman's odds of experiencing poor sleep quality or poor daytime functioning, Dr. Qurratul Shamim-Uzzaman reported at the meeting.

These findings suggest targeting RLS offers potential opportunities to improve women's sleep during pregnancy, according to Dr. Shamim-Uzzaman, a sleep medicine fellow in the department of neurology at the University of Michigan, Ann Arbor.

She presented a study of 1,489 women who were surveyed in their third trimester about their sleep. The validated screening questionnaires utilized in the study included a four-item Brief Restless Legs Scale, the Epworth Sleepiness Scale, and the General Sleep Disturbance Scale.

Thirty-five percent of the pregnant women reported having symptoms of RLS, typically peaking in the third trimester. Seventy percent of affected women had symptoms 2 or more nights per week, and 16% experienced symptoms 6-7 nights per week. The prevalence of RLS in the general population of nonpregnant women has been pegged at 14%-16% in prior studies, suggesting that the rate more than doubles in pregnancy.

One of the questions the Michigan study set out to answer is whether the prevalence of RLS in pregnancy varies by race. This indeed proved to be the case. The prevalence was highest in whites at 38%, compared with 27% in blacks and 33% in Asian-Indian women.

A score of 10 or more on the Epworth Sleepiness Scale, indicative of excessive daytime sleepiness, was achieved by 48% of women with RLS, compared with 38% without RLS. The presence of RLS resulted in impaired daytime functioning. Poor daytime functioning was experienced by 67% of pregnant women without RLS, 69% with RLS symptoms less than 2 nights per week, and 87% of those with RLS at least 4 nights weekly.

In a multivariate regression model that controlled for age, race, snoring, and body mass index (BMI), RLS was an independent predictor of poor sleep quality, with an associated twofold increase in the odds of experiencing poor sleep. Similarly, in an analysis that controlledv for age, race, and BMI, RLS was an independent predictor of poor daytime function, with an odds ratio of 1.8.

Disclosures: Dr. Shamim-Uzzamam reported having no financial conflicts in connection with the study, which was funded by the University of Michigan Institute for Research on Women and Gender; the National Heart, Lung, and Blood Institute; and the Gilmore Fund.

SAN ANTONIO — Restless legs syndrome is extremely common in pregnancy, and one-third of affected women experience severe symptoms on four or more nights per week, according to a large prospective study.

Moreover, the presence of restless legs syndrome (RLS) doubles a pregnant woman's odds of experiencing poor sleep quality or poor daytime functioning, Dr. Qurratul Shamim-Uzzaman reported at the meeting.

These findings suggest targeting RLS offers potential opportunities to improve women's sleep during pregnancy, according to Dr. Shamim-Uzzaman, a sleep medicine fellow in the department of neurology at the University of Michigan, Ann Arbor.

She presented a study of 1,489 women who were surveyed in their third trimester about their sleep. The validated screening questionnaires utilized in the study included a four-item Brief Restless Legs Scale, the Epworth Sleepiness Scale, and the General Sleep Disturbance Scale.

Thirty-five percent of the pregnant women reported having symptoms of RLS, typically peaking in the third trimester. Seventy percent of affected women had symptoms 2 or more nights per week, and 16% experienced symptoms 6-7 nights per week. The prevalence of RLS in the general population of nonpregnant women has been pegged at 14%-16% in prior studies, suggesting that the rate more than doubles in pregnancy.

One of the questions the Michigan study set out to answer is whether the prevalence of RLS in pregnancy varies by race. This indeed proved to be the case. The prevalence was highest in whites at 38%, compared with 27% in blacks and 33% in Asian-Indian women.

A score of 10 or more on the Epworth Sleepiness Scale, indicative of excessive daytime sleepiness, was achieved by 48% of women with RLS, compared with 38% without RLS. The presence of RLS resulted in impaired daytime functioning. Poor daytime functioning was experienced by 67% of pregnant women without RLS, 69% with RLS symptoms less than 2 nights per week, and 87% of those with RLS at least 4 nights weekly.

In a multivariate regression model that controlled for age, race, snoring, and body mass index (BMI), RLS was an independent predictor of poor sleep quality, with an associated twofold increase in the odds of experiencing poor sleep. Similarly, in an analysis that controlledv for age, race, and BMI, RLS was an independent predictor of poor daytime function, with an odds ratio of 1.8.

Disclosures: Dr. Shamim-Uzzamam reported having no financial conflicts in connection with the study, which was funded by the University of Michigan Institute for Research on Women and Gender; the National Heart, Lung, and Blood Institute; and the Gilmore Fund.

SAN ANTONIO — Restless legs syndrome is extremely common in pregnancy, and one-third of affected women experience severe symptoms on four or more nights per week, according to a large prospective study.

Moreover, the presence of restless legs syndrome (RLS) doubles a pregnant woman's odds of experiencing poor sleep quality or poor daytime functioning, Dr. Qurratul Shamim-Uzzaman reported at the meeting.

These findings suggest targeting RLS offers potential opportunities to improve women's sleep during pregnancy, according to Dr. Shamim-Uzzaman, a sleep medicine fellow in the department of neurology at the University of Michigan, Ann Arbor.

She presented a study of 1,489 women who were surveyed in their third trimester about their sleep. The validated screening questionnaires utilized in the study included a four-item Brief Restless Legs Scale, the Epworth Sleepiness Scale, and the General Sleep Disturbance Scale.

Thirty-five percent of the pregnant women reported having symptoms of RLS, typically peaking in the third trimester. Seventy percent of affected women had symptoms 2 or more nights per week, and 16% experienced symptoms 6-7 nights per week. The prevalence of RLS in the general population of nonpregnant women has been pegged at 14%-16% in prior studies, suggesting that the rate more than doubles in pregnancy.

One of the questions the Michigan study set out to answer is whether the prevalence of RLS in pregnancy varies by race. This indeed proved to be the case. The prevalence was highest in whites at 38%, compared with 27% in blacks and 33% in Asian-Indian women.

A score of 10 or more on the Epworth Sleepiness Scale, indicative of excessive daytime sleepiness, was achieved by 48% of women with RLS, compared with 38% without RLS. The presence of RLS resulted in impaired daytime functioning. Poor daytime functioning was experienced by 67% of pregnant women without RLS, 69% with RLS symptoms less than 2 nights per week, and 87% of those with RLS at least 4 nights weekly.

In a multivariate regression model that controlled for age, race, snoring, and body mass index (BMI), RLS was an independent predictor of poor sleep quality, with an associated twofold increase in the odds of experiencing poor sleep. Similarly, in an analysis that controlledv for age, race, and BMI, RLS was an independent predictor of poor daytime function, with an odds ratio of 1.8.

Disclosures: Dr. Shamim-Uzzamam reported having no financial conflicts in connection with the study, which was funded by the University of Michigan Institute for Research on Women and Gender; the National Heart, Lung, and Blood Institute; and the Gilmore Fund.

SAN FRANCISCO — From the front lines of war comes a new protocol for preserving life during massive blood transfusion to treat maternal hemorrhage.

Physicians providing trauma care during the Iraq war noticed that giving fresh frozen plasma earlier to patients requiring massive transfusion and making a few other changes in conventional transfusion protocols decreased coagulopathy and improved the well-being of patients, Dr. Mark D. Rollins said at the meeting sponsored by the University of California, San Francisco.

Subsequent retrospective studies in civilians and a prospective study that was completed this year supported the military's suggestion that increasing ratios of plasma and platelets to red blood cells (RBCs) would improve survival in massive transfusions.

Responding to these new ideas, the California Maternal Quality Care Collaborative convened an Obstetric Hemorrhage Expert Task Force, which incorporated these cutting-edge recommendations into a free Obstetric Hemorrhage Toolkit (available at www.cmqcc.org/ob_hemorrhage

“I'm not saying we have a ton of evidence,” but the limited evidence available was sufficient to justify modifying protocols for managing maternal hemorrhage, said Dr. Rollins, an obstetric anesthesiologist at the university and a member of the California Maternal Hemorrhage Collaborative.

The military observations, published in 2007 (J. Trauma 2007;62:112-9), were followed by a retrospective study of 466 civilians who underwent massive transfusions at 16 U.S. trauma centers (Ann. Surg. 2008;248:447-59). That study found better survival using increased ratios of plasma and platelets to RBCs in massive transfusions.

Conventional guidelines called for a 1:3 ratio of plasma to RBCs, and the military called for a 1:1 ratio, with no recommendation for the ratio of platelets to RBCs. The civilian study found 30-day survival was 60% in patients who received more than 1 U of plasma or platelets with every 2 U of RBCs, compared with 40% survival with lower ratios of plasma or platelets to RBCs, so the investigators recommended a 1:1:1 ratio of plasma, platelets, and RBCs in massive transfusions.

A randomized, controlled trial of 214 civilian trauma patients, completed this year by Dr. Rollins and his associates, found significantly increased 30-day survival rates with higher ratios of plasma, platelets, or cryoprecipitate to RBCs in massive transfusions, defined as more than 10 RBC products transfused within 24 hours (Transfusion 2010;50:493-500).

Survival was 59% after transfusions with at least 1 U of plasma per 2 of RBCs, compared with 44% with ratios of 1:3 or more. For platelets, survival rates were 63% with at least 1:1 ratios, compared with 33% with ratios of 1:2 or more. Higher ratios of cryoprecipitate to RBCs improved survival, compared with lower ratios: 66% vs. 41%, respectively.

In developed countries, hemorrhage causes 13% of maternal deaths and is the third-leading cause of maternal death, with higher rates in other countries, according to a World Health Organization report (Lancet 2006;367:1066-74).

Death rates from postpartum hemorrhage have increased from approximately 2% in 1994 to 3% in 2006 in the United States, and from 4% to 5% in Canada during that time period.

“In the past couple of years, we've had two or three deaths right here in the San Francisco Bay Area in our hospitals from maternal hemorrhage,” he said.

Disclosures: He reported having no conflicts of interest related to these topics.

Managing Massive Transfusions

For best management of massive obstetric transfusions, consider these steps, Dr. Rollins said:

▸ Get into good communication with your blood bank, and ask for supplies for massive transfusions in packs of multiple units of RBCs and fresh frozen plasma—potentially even platelets—that arrive together. “This just helps remind everyone as those packs arrive that they should be giving the fresh frozen plasma with the red cells,” he said. Make sure the blood bank knows exactly which room you're in.

▸ Have a team ready to mobilize, including a second anesthesiologist, a second surgeon, additional nurses, and runners for laboratory tests and blood products.

▸ Move expeditiously to an operating room if you're not already in one.

▸ If you're considering options such as interventional radiology, call those teams early to give them time to set up.

▸ Place large-bore IVs (16-14 gauge). “I like to think that goes without saying, but plenty of times I've had people come in with just 20-gauge IVs put in, and you can't transfuse enough through them to make a difference,” Dr. Rollins said.

▸ Place invasive monitoring equipment.

▸ Repeat laboratory tests frequently, but don't wait for results to proceed with transfusion. Results will be useful later to assess how the case developed. Use point-of-care testing if it's available for faster results.

▸ Consider using fluid warmers and forced-air warmers to keep patients from becoming hypothermic and more coagulopathic.

▸ Have rapid infusion pumps or pressure bags available to speed the transfusion.

▸ Prepare for general anesthesia.

▸ Have vasopressors and uterotonics immediately available.

▸ Have a supply of calcium chloride on hand to prevent the low levels of ionized calcium that can occur after rapid transfusion. Citrates in blood products bind with calcium, increasing the risk of extreme hypotension and depressed heart function.

▸ Have a Foley catheter (for measuring urine output) and compression stockings available.

▸ Reserve an ICU bed.

▸ Ask for additional packs of blood products if needed.

▸ Consider giving cryoprecipitate (fibrinogen less than 100 mg/dL).

▸ Consider off-label treatment with recombinant factor VIIa only after the patient has received approximately 10 U of packed RBCs and full factor replacement. “It's not a first-line drug. There's plenty of morbidity and mortality that can occur” with factor VIIa, he noted. “Having said that, I do believe that it is very effective in certain situations.”

▸ Designate someone to tally and record the use of blood products and estimated blood loss.

▸ Bring the “code cart” into the OR early.

▸ Afterward, meet for 3-5 minutes with everyone who worked on the case to review what went well, what didn't, and ideas for improvement.

SAN FRANCISCO — From the front lines of war comes a new protocol for preserving life during massive blood transfusion to treat maternal hemorrhage.

Physicians providing trauma care during the Iraq war noticed that giving fresh frozen plasma earlier to patients requiring massive transfusion and making a few other changes in conventional transfusion protocols decreased coagulopathy and improved the well-being of patients, Dr. Mark D. Rollins said at the meeting sponsored by the University of California, San Francisco.

Subsequent retrospective studies in civilians and a prospective study that was completed this year supported the military's suggestion that increasing ratios of plasma and platelets to red blood cells (RBCs) would improve survival in massive transfusions.

Responding to these new ideas, the California Maternal Quality Care Collaborative convened an Obstetric Hemorrhage Expert Task Force, which incorporated these cutting-edge recommendations into a free Obstetric Hemorrhage Toolkit (available at www.cmqcc.org/ob_hemorrhage

“I'm not saying we have a ton of evidence,” but the limited evidence available was sufficient to justify modifying protocols for managing maternal hemorrhage, said Dr. Rollins, an obstetric anesthesiologist at the university and a member of the California Maternal Hemorrhage Collaborative.

The military observations, published in 2007 (J. Trauma 2007;62:112-9), were followed by a retrospective study of 466 civilians who underwent massive transfusions at 16 U.S. trauma centers (Ann. Surg. 2008;248:447-59). That study found better survival using increased ratios of plasma and platelets to RBCs in massive transfusions.

Conventional guidelines called for a 1:3 ratio of plasma to RBCs, and the military called for a 1:1 ratio, with no recommendation for the ratio of platelets to RBCs. The civilian study found 30-day survival was 60% in patients who received more than 1 U of plasma or platelets with every 2 U of RBCs, compared with 40% survival with lower ratios of plasma or platelets to RBCs, so the investigators recommended a 1:1:1 ratio of plasma, platelets, and RBCs in massive transfusions.

A randomized, controlled trial of 214 civilian trauma patients, completed this year by Dr. Rollins and his associates, found significantly increased 30-day survival rates with higher ratios of plasma, platelets, or cryoprecipitate to RBCs in massive transfusions, defined as more than 10 RBC products transfused within 24 hours (Transfusion 2010;50:493-500).

Survival was 59% after transfusions with at least 1 U of plasma per 2 of RBCs, compared with 44% with ratios of 1:3 or more. For platelets, survival rates were 63% with at least 1:1 ratios, compared with 33% with ratios of 1:2 or more. Higher ratios of cryoprecipitate to RBCs improved survival, compared with lower ratios: 66% vs. 41%, respectively.

In developed countries, hemorrhage causes 13% of maternal deaths and is the third-leading cause of maternal death, with higher rates in other countries, according to a World Health Organization report (Lancet 2006;367:1066-74).

Death rates from postpartum hemorrhage have increased from approximately 2% in 1994 to 3% in 2006 in the United States, and from 4% to 5% in Canada during that time period.

“In the past couple of years, we've had two or three deaths right here in the San Francisco Bay Area in our hospitals from maternal hemorrhage,” he said.

Disclosures: He reported having no conflicts of interest related to these topics.

Managing Massive Transfusions

For best management of massive obstetric transfusions, consider these steps, Dr. Rollins said:

▸ Get into good communication with your blood bank, and ask for supplies for massive transfusions in packs of multiple units of RBCs and fresh frozen plasma—potentially even platelets—that arrive together. “This just helps remind everyone as those packs arrive that they should be giving the fresh frozen plasma with the red cells,” he said. Make sure the blood bank knows exactly which room you're in.

▸ Have a team ready to mobilize, including a second anesthesiologist, a second surgeon, additional nurses, and runners for laboratory tests and blood products.

▸ Move expeditiously to an operating room if you're not already in one.

▸ If you're considering options such as interventional radiology, call those teams early to give them time to set up.

▸ Place large-bore IVs (16-14 gauge). “I like to think that goes without saying, but plenty of times I've had people come in with just 20-gauge IVs put in, and you can't transfuse enough through them to make a difference,” Dr. Rollins said.

▸ Place invasive monitoring equipment.

▸ Repeat laboratory tests frequently, but don't wait for results to proceed with transfusion. Results will be useful later to assess how the case developed. Use point-of-care testing if it's available for faster results.

▸ Consider using fluid warmers and forced-air warmers to keep patients from becoming hypothermic and more coagulopathic.

▸ Have rapid infusion pumps or pressure bags available to speed the transfusion.

▸ Prepare for general anesthesia.

▸ Have vasopressors and uterotonics immediately available.

▸ Have a supply of calcium chloride on hand to prevent the low levels of ionized calcium that can occur after rapid transfusion. Citrates in blood products bind with calcium, increasing the risk of extreme hypotension and depressed heart function.

▸ Have a Foley catheter (for measuring urine output) and compression stockings available.

▸ Reserve an ICU bed.

▸ Ask for additional packs of blood products if needed.

▸ Consider giving cryoprecipitate (fibrinogen less than 100 mg/dL).

▸ Consider off-label treatment with recombinant factor VIIa only after the patient has received approximately 10 U of packed RBCs and full factor replacement. “It's not a first-line drug. There's plenty of morbidity and mortality that can occur” with factor VIIa, he noted. “Having said that, I do believe that it is very effective in certain situations.”

▸ Designate someone to tally and record the use of blood products and estimated blood loss.

▸ Bring the “code cart” into the OR early.

▸ Afterward, meet for 3-5 minutes with everyone who worked on the case to review what went well, what didn't, and ideas for improvement.

SAN FRANCISCO — From the front lines of war comes a new protocol for preserving life during massive blood transfusion to treat maternal hemorrhage.

Physicians providing trauma care during the Iraq war noticed that giving fresh frozen plasma earlier to patients requiring massive transfusion and making a few other changes in conventional transfusion protocols decreased coagulopathy and improved the well-being of patients, Dr. Mark D. Rollins said at the meeting sponsored by the University of California, San Francisco.

Subsequent retrospective studies in civilians and a prospective study that was completed this year supported the military's suggestion that increasing ratios of plasma and platelets to red blood cells (RBCs) would improve survival in massive transfusions.

Responding to these new ideas, the California Maternal Quality Care Collaborative convened an Obstetric Hemorrhage Expert Task Force, which incorporated these cutting-edge recommendations into a free Obstetric Hemorrhage Toolkit (available at www.cmqcc.org/ob_hemorrhage

“I'm not saying we have a ton of evidence,” but the limited evidence available was sufficient to justify modifying protocols for managing maternal hemorrhage, said Dr. Rollins, an obstetric anesthesiologist at the university and a member of the California Maternal Hemorrhage Collaborative.

The military observations, published in 2007 (J. Trauma 2007;62:112-9), were followed by a retrospective study of 466 civilians who underwent massive transfusions at 16 U.S. trauma centers (Ann. Surg. 2008;248:447-59). That study found better survival using increased ratios of plasma and platelets to RBCs in massive transfusions.

Conventional guidelines called for a 1:3 ratio of plasma to RBCs, and the military called for a 1:1 ratio, with no recommendation for the ratio of platelets to RBCs. The civilian study found 30-day survival was 60% in patients who received more than 1 U of plasma or platelets with every 2 U of RBCs, compared with 40% survival with lower ratios of plasma or platelets to RBCs, so the investigators recommended a 1:1:1 ratio of plasma, platelets, and RBCs in massive transfusions.

A randomized, controlled trial of 214 civilian trauma patients, completed this year by Dr. Rollins and his associates, found significantly increased 30-day survival rates with higher ratios of plasma, platelets, or cryoprecipitate to RBCs in massive transfusions, defined as more than 10 RBC products transfused within 24 hours (Transfusion 2010;50:493-500).

Survival was 59% after transfusions with at least 1 U of plasma per 2 of RBCs, compared with 44% with ratios of 1:3 or more. For platelets, survival rates were 63% with at least 1:1 ratios, compared with 33% with ratios of 1:2 or more. Higher ratios of cryoprecipitate to RBCs improved survival, compared with lower ratios: 66% vs. 41%, respectively.

In developed countries, hemorrhage causes 13% of maternal deaths and is the third-leading cause of maternal death, with higher rates in other countries, according to a World Health Organization report (Lancet 2006;367:1066-74).

Death rates from postpartum hemorrhage have increased from approximately 2% in 1994 to 3% in 2006 in the United States, and from 4% to 5% in Canada during that time period.

“In the past couple of years, we've had two or three deaths right here in the San Francisco Bay Area in our hospitals from maternal hemorrhage,” he said.

Disclosures: He reported having no conflicts of interest related to these topics.

Managing Massive Transfusions

For best management of massive obstetric transfusions, consider these steps, Dr. Rollins said:

▸ Get into good communication with your blood bank, and ask for supplies for massive transfusions in packs of multiple units of RBCs and fresh frozen plasma—potentially even platelets—that arrive together. “This just helps remind everyone as those packs arrive that they should be giving the fresh frozen plasma with the red cells,” he said. Make sure the blood bank knows exactly which room you're in.

▸ Have a team ready to mobilize, including a second anesthesiologist, a second surgeon, additional nurses, and runners for laboratory tests and blood products.

▸ Move expeditiously to an operating room if you're not already in one.

▸ If you're considering options such as interventional radiology, call those teams early to give them time to set up.

▸ Place large-bore IVs (16-14 gauge). “I like to think that goes without saying, but plenty of times I've had people come in with just 20-gauge IVs put in, and you can't transfuse enough through them to make a difference,” Dr. Rollins said.

▸ Place invasive monitoring equipment.

▸ Repeat laboratory tests frequently, but don't wait for results to proceed with transfusion. Results will be useful later to assess how the case developed. Use point-of-care testing if it's available for faster results.

▸ Consider using fluid warmers and forced-air warmers to keep patients from becoming hypothermic and more coagulopathic.

▸ Have rapid infusion pumps or pressure bags available to speed the transfusion.

▸ Prepare for general anesthesia.

▸ Have vasopressors and uterotonics immediately available.

▸ Have a supply of calcium chloride on hand to prevent the low levels of ionized calcium that can occur after rapid transfusion. Citrates in blood products bind with calcium, increasing the risk of extreme hypotension and depressed heart function.

▸ Have a Foley catheter (for measuring urine output) and compression stockings available.

▸ Reserve an ICU bed.

▸ Ask for additional packs of blood products if needed.

▸ Consider giving cryoprecipitate (fibrinogen less than 100 mg/dL).

▸ Consider off-label treatment with recombinant factor VIIa only after the patient has received approximately 10 U of packed RBCs and full factor replacement. “It's not a first-line drug. There's plenty of morbidity and mortality that can occur” with factor VIIa, he noted. “Having said that, I do believe that it is very effective in certain situations.”

▸ Designate someone to tally and record the use of blood products and estimated blood loss.

▸ Bring the “code cart” into the OR early.

▸ Afterward, meet for 3-5 minutes with everyone who worked on the case to review what went well, what didn't, and ideas for improvement.

Major Finding: Compared with women who had not had gestational diabetes, women who had the condition were 41% more likely to develop hypertension during a period of up to 14 years.

Data Source: A nested prospective cohort study of 26,384 women initially aged 25-44 years who had at least one singleton pregnancy.

Disclosures: Ms. Tobias reported that she had no relevant conflicts of interest.

SEATTLE — Women who have had gestational diabetes may be at elevated risk for hypertension even after established risk factors are taken into account, a nested cohort study has shown.

Using data from the Nurses' Health Study II, researchers followed more than 26,000 women from an index pregnancy for up to 14 years. Those who had gestational diabetes during that pregnancy were 41% more likely to develop hypertension even after adjustment for potential confounders such as body mass index, diet, and a family history of hypertension.

“These women may represent a target group for intervention to prevent or delay the onset of hypertension, which is a public health concern in the United States,” lead investigator Deirdre K. Tobias said at the meeting.

“The mechanism by which gestational diabetes mellitus could lead to an increased risk of hypertension and other metabolic complications is not yet established,” said Ms. Tobias, a doctoral student at Harvard School of Public Health in Boston.

One possibility is that these conditions have shared risk factors, she noted. Another is that gestational diabetes itself increases the risk of hypertension, for example, by causing vascular damage that manifests later in time.

The Nurses' Health Study II is a prospective cohort study of women 25-44 years old at baseline that began in 1989.

Women in the study complete extensive questionnaires at baseline and biennially, which include questions about physician-diagnosed gestational diabetes and hypertension.

Ms. Tobias and her colleagues included in their sample the 26,384 women who reported having at least one singleton pregnancy between 1991 (the first year in which dietary data were collected) and 2005, did not have type 2 diabetes or hypertension, had not had gestational diabetes in a previous pregnancy, and had not had previous cardiovascular disease.

Study results showed that 6% of the women had gestational diabetes during their index pregnancy. Both the women with and without gestational diabetes had a mean age of 32 years at baseline, and 7% in each group were current smokers.

However, those with gestational diabetes had a higher body mass index (25 vs. 23 kg/m

Overall, 9% of the women developed hypertension during follow-up, and the cumulative incidence was higher among those who had had gestational diabetes.

After adjustment for a dozen potential confounders, women who had gestational diabetes still had a 41% higher risk of developing hypertension (hazard ratio, 1.41).

Moreover, compared with women who had neither gestational diabetes nor type 2 diabetes, those who had both had a near tripling of the risk of developing hypertension (HR, 2.95).

“It is possible that there was residual or unmeasured confounding,” acknowledged Ms. Tobias. “For example, in our cohort, we were unable to capture pregnancy-related characteristics, such as weight gain or severity of gestational diabetes.”

In addition, she noted, the generalizability of the study's findings may be limited, given the women's somewhat higher age at baseline and the fact that most were white.

Major Finding: Compared with women who had not had gestational diabetes, women who had the condition were 41% more likely to develop hypertension during a period of up to 14 years.

Data Source: A nested prospective cohort study of 26,384 women initially aged 25-44 years who had at least one singleton pregnancy.

Disclosures: Ms. Tobias reported that she had no relevant conflicts of interest.

SEATTLE — Women who have had gestational diabetes may be at elevated risk for hypertension even after established risk factors are taken into account, a nested cohort study has shown.

Using data from the Nurses' Health Study II, researchers followed more than 26,000 women from an index pregnancy for up to 14 years. Those who had gestational diabetes during that pregnancy were 41% more likely to develop hypertension even after adjustment for potential confounders such as body mass index, diet, and a family history of hypertension.

“These women may represent a target group for intervention to prevent or delay the onset of hypertension, which is a public health concern in the United States,” lead investigator Deirdre K. Tobias said at the meeting.

“The mechanism by which gestational diabetes mellitus could lead to an increased risk of hypertension and other metabolic complications is not yet established,” said Ms. Tobias, a doctoral student at Harvard School of Public Health in Boston.

One possibility is that these conditions have shared risk factors, she noted. Another is that gestational diabetes itself increases the risk of hypertension, for example, by causing vascular damage that manifests later in time.

The Nurses' Health Study II is a prospective cohort study of women 25-44 years old at baseline that began in 1989.

Women in the study complete extensive questionnaires at baseline and biennially, which include questions about physician-diagnosed gestational diabetes and hypertension.

Ms. Tobias and her colleagues included in their sample the 26,384 women who reported having at least one singleton pregnancy between 1991 (the first year in which dietary data were collected) and 2005, did not have type 2 diabetes or hypertension, had not had gestational diabetes in a previous pregnancy, and had not had previous cardiovascular disease.

Study results showed that 6% of the women had gestational diabetes during their index pregnancy. Both the women with and without gestational diabetes had a mean age of 32 years at baseline, and 7% in each group were current smokers.

However, those with gestational diabetes had a higher body mass index (25 vs. 23 kg/m

Overall, 9% of the women developed hypertension during follow-up, and the cumulative incidence was higher among those who had had gestational diabetes.

After adjustment for a dozen potential confounders, women who had gestational diabetes still had a 41% higher risk of developing hypertension (hazard ratio, 1.41).

Moreover, compared with women who had neither gestational diabetes nor type 2 diabetes, those who had both had a near tripling of the risk of developing hypertension (HR, 2.95).

“It is possible that there was residual or unmeasured confounding,” acknowledged Ms. Tobias. “For example, in our cohort, we were unable to capture pregnancy-related characteristics, such as weight gain or severity of gestational diabetes.”

In addition, she noted, the generalizability of the study's findings may be limited, given the women's somewhat higher age at baseline and the fact that most were white.

Major Finding: Compared with women who had not had gestational diabetes, women who had the condition were 41% more likely to develop hypertension during a period of up to 14 years.

Data Source: A nested prospective cohort study of 26,384 women initially aged 25-44 years who had at least one singleton pregnancy.

Disclosures: Ms. Tobias reported that she had no relevant conflicts of interest.

SEATTLE — Women who have had gestational diabetes may be at elevated risk for hypertension even after established risk factors are taken into account, a nested cohort study has shown.

Using data from the Nurses' Health Study II, researchers followed more than 26,000 women from an index pregnancy for up to 14 years. Those who had gestational diabetes during that pregnancy were 41% more likely to develop hypertension even after adjustment for potential confounders such as body mass index, diet, and a family history of hypertension.

“These women may represent a target group for intervention to prevent or delay the onset of hypertension, which is a public health concern in the United States,” lead investigator Deirdre K. Tobias said at the meeting.

“The mechanism by which gestational diabetes mellitus could lead to an increased risk of hypertension and other metabolic complications is not yet established,” said Ms. Tobias, a doctoral student at Harvard School of Public Health in Boston.

One possibility is that these conditions have shared risk factors, she noted. Another is that gestational diabetes itself increases the risk of hypertension, for example, by causing vascular damage that manifests later in time.

The Nurses' Health Study II is a prospective cohort study of women 25-44 years old at baseline that began in 1989.

Women in the study complete extensive questionnaires at baseline and biennially, which include questions about physician-diagnosed gestational diabetes and hypertension.

Ms. Tobias and her colleagues included in their sample the 26,384 women who reported having at least one singleton pregnancy between 1991 (the first year in which dietary data were collected) and 2005, did not have type 2 diabetes or hypertension, had not had gestational diabetes in a previous pregnancy, and had not had previous cardiovascular disease.

Study results showed that 6% of the women had gestational diabetes during their index pregnancy. Both the women with and without gestational diabetes had a mean age of 32 years at baseline, and 7% in each group were current smokers.

However, those with gestational diabetes had a higher body mass index (25 vs. 23 kg/m

Overall, 9% of the women developed hypertension during follow-up, and the cumulative incidence was higher among those who had had gestational diabetes.

After adjustment for a dozen potential confounders, women who had gestational diabetes still had a 41% higher risk of developing hypertension (hazard ratio, 1.41).

Moreover, compared with women who had neither gestational diabetes nor type 2 diabetes, those who had both had a near tripling of the risk of developing hypertension (HR, 2.95).

“It is possible that there was residual or unmeasured confounding,” acknowledged Ms. Tobias. “For example, in our cohort, we were unable to capture pregnancy-related characteristics, such as weight gain or severity of gestational diabetes.”

In addition, she noted, the generalizability of the study's findings may be limited, given the women's somewhat higher age at baseline and the fact that most were white.

MINNEAPOLIS — In classic-course postpartum thyroiditis, the hyperthyroid phase is often missed; it's much more common to identify women in the hypothyroid phase that follows, Dr. Erin Keely said.

“In my experience, we miss the hyperthyroid phase clinically all the time because it's a little bit like the army: Don't ask, don't tell,” she said. The symptoms—anxiety, insomnia, fatigue, weight loss, and irritability—are normal for most new moms.

The classic course of postpartum thyroiditis (PPT) is hyperthyroidism, which starts at about 6 weeks post partum and may last a few months, followed by hypothyroidism and then normalization.

More commonly, women present in the hypothyroid phase, which typically occurs 4-8 months after delivery and may last up to 9-12 months, said Dr. Keely, chief of endocrinology and metabolism at the Ottawa Hospital. Typical symptoms include fatigue, weight gain, constipation, dry skin, depression, and poor exercise tolerance. Women tested in the transition period might appear to have normal thyroid function, however. About 30% of women remain hyperthyroid.

Because PPT can cause both thyrotoxicosis (high serum thyroid hormone levels) and hypothyroidism (low levels) in the first year post partum, “you can't make a diagnosis of permanent thyroid disease,” at that time, said Dr. Keely. The exception is for any woman with overt thyroid disease before pregnancy.

To complicate matters, Graves' disease can flare in the postpartum period, making it difficult to tell if a woman is having a flare or PPT. However, Graves' disease is much less common than PPT, said Dr. Keely.

“So, if you were a betting person, you would bet that it's postpartum thyroiditis.” If the diagnosis is really unclear, radioiodine uptake tests can be performed but most women will likely choose to wait and see, she said.

Current data are insufficient to recommend screening all women for PPT, according to Endocrine Society guidelines (J. Clin. Endocrinol. Metab. 2007;92:s1-47). Women who are known to be positive for autoantibodies to thyroid peroxidase (TPO-Ab) should have a TSH test performed at 3 and 6 months post partum. Notably, the prevalence of PPT in women with type 1 diabetes is threefold greater than in the general population; postpartum TSH screening is recommended at 3 and 6 months.

In PPT treatment, “there is no one answer for all women,” said Dr. Keely. However, in 2002, Dr. Alex S. Stagnaro-Green, now senior associate dean for education at George Washington University, Washington, proposed a PPT treatment algorithm (J. Clin. Endocrinol. Metab. 2002;87:4042-7). In this algorithm, treatment is indicated for a TSH of 4 mU/mL or greater in the first postpartum year. Dr. Keely added that “one of the most important aspects is to continue the treatment until [the woman] has completed her family.”

If TPO-Ab are found in the first trimester, the risk of PPT is 30%-55%. “It's interesting though, that 25% of women who are positive in the first trimester become negative by the third trimester,” she said. Women may become negative by term but rebound in the postpartum period. If TPO-Ab is positive in the third trimester, the risk of PPT is greater than 80%; if negative, the risk is only 0%-5%.

Finally, “postpartum thyroiditis is a very strong predictor of long term Hashimoto's thyroiditis,” said Dr. Keely. About 30% of these women develop Hashimoto's thyroiditis within 3 years.

Disclosures: Dr. Keely reported that she had no relevant financial relationships.

MINNEAPOLIS — In classic-course postpartum thyroiditis, the hyperthyroid phase is often missed; it's much more common to identify women in the hypothyroid phase that follows, Dr. Erin Keely said.

“In my experience, we miss the hyperthyroid phase clinically all the time because it's a little bit like the army: Don't ask, don't tell,” she said. The symptoms—anxiety, insomnia, fatigue, weight loss, and irritability—are normal for most new moms.

The classic course of postpartum thyroiditis (PPT) is hyperthyroidism, which starts at about 6 weeks post partum and may last a few months, followed by hypothyroidism and then normalization.

More commonly, women present in the hypothyroid phase, which typically occurs 4-8 months after delivery and may last up to 9-12 months, said Dr. Keely, chief of endocrinology and metabolism at the Ottawa Hospital. Typical symptoms include fatigue, weight gain, constipation, dry skin, depression, and poor exercise tolerance. Women tested in the transition period might appear to have normal thyroid function, however. About 30% of women remain hyperthyroid.

Because PPT can cause both thyrotoxicosis (high serum thyroid hormone levels) and hypothyroidism (low levels) in the first year post partum, “you can't make a diagnosis of permanent thyroid disease,” at that time, said Dr. Keely. The exception is for any woman with overt thyroid disease before pregnancy.

To complicate matters, Graves' disease can flare in the postpartum period, making it difficult to tell if a woman is having a flare or PPT. However, Graves' disease is much less common than PPT, said Dr. Keely.

“So, if you were a betting person, you would bet that it's postpartum thyroiditis.” If the diagnosis is really unclear, radioiodine uptake tests can be performed but most women will likely choose to wait and see, she said.

Current data are insufficient to recommend screening all women for PPT, according to Endocrine Society guidelines (J. Clin. Endocrinol. Metab. 2007;92:s1-47). Women who are known to be positive for autoantibodies to thyroid peroxidase (TPO-Ab) should have a TSH test performed at 3 and 6 months post partum. Notably, the prevalence of PPT in women with type 1 diabetes is threefold greater than in the general population; postpartum TSH screening is recommended at 3 and 6 months.

In PPT treatment, “there is no one answer for all women,” said Dr. Keely. However, in 2002, Dr. Alex S. Stagnaro-Green, now senior associate dean for education at George Washington University, Washington, proposed a PPT treatment algorithm (J. Clin. Endocrinol. Metab. 2002;87:4042-7). In this algorithm, treatment is indicated for a TSH of 4 mU/mL or greater in the first postpartum year. Dr. Keely added that “one of the most important aspects is to continue the treatment until [the woman] has completed her family.”

If TPO-Ab are found in the first trimester, the risk of PPT is 30%-55%. “It's interesting though, that 25% of women who are positive in the first trimester become negative by the third trimester,” she said. Women may become negative by term but rebound in the postpartum period. If TPO-Ab is positive in the third trimester, the risk of PPT is greater than 80%; if negative, the risk is only 0%-5%.

Finally, “postpartum thyroiditis is a very strong predictor of long term Hashimoto's thyroiditis,” said Dr. Keely. About 30% of these women develop Hashimoto's thyroiditis within 3 years.

Disclosures: Dr. Keely reported that she had no relevant financial relationships.

MINNEAPOLIS — In classic-course postpartum thyroiditis, the hyperthyroid phase is often missed; it's much more common to identify women in the hypothyroid phase that follows, Dr. Erin Keely said.

“In my experience, we miss the hyperthyroid phase clinically all the time because it's a little bit like the army: Don't ask, don't tell,” she said. The symptoms—anxiety, insomnia, fatigue, weight loss, and irritability—are normal for most new moms.

The classic course of postpartum thyroiditis (PPT) is hyperthyroidism, which starts at about 6 weeks post partum and may last a few months, followed by hypothyroidism and then normalization.

More commonly, women present in the hypothyroid phase, which typically occurs 4-8 months after delivery and may last up to 9-12 months, said Dr. Keely, chief of endocrinology and metabolism at the Ottawa Hospital. Typical symptoms include fatigue, weight gain, constipation, dry skin, depression, and poor exercise tolerance. Women tested in the transition period might appear to have normal thyroid function, however. About 30% of women remain hyperthyroid.

Because PPT can cause both thyrotoxicosis (high serum thyroid hormone levels) and hypothyroidism (low levels) in the first year post partum, “you can't make a diagnosis of permanent thyroid disease,” at that time, said Dr. Keely. The exception is for any woman with overt thyroid disease before pregnancy.

To complicate matters, Graves' disease can flare in the postpartum period, making it difficult to tell if a woman is having a flare or PPT. However, Graves' disease is much less common than PPT, said Dr. Keely.

“So, if you were a betting person, you would bet that it's postpartum thyroiditis.” If the diagnosis is really unclear, radioiodine uptake tests can be performed but most women will likely choose to wait and see, she said.

Current data are insufficient to recommend screening all women for PPT, according to Endocrine Society guidelines (J. Clin. Endocrinol. Metab. 2007;92:s1-47). Women who are known to be positive for autoantibodies to thyroid peroxidase (TPO-Ab) should have a TSH test performed at 3 and 6 months post partum. Notably, the prevalence of PPT in women with type 1 diabetes is threefold greater than in the general population; postpartum TSH screening is recommended at 3 and 6 months.

In PPT treatment, “there is no one answer for all women,” said Dr. Keely. However, in 2002, Dr. Alex S. Stagnaro-Green, now senior associate dean for education at George Washington University, Washington, proposed a PPT treatment algorithm (J. Clin. Endocrinol. Metab. 2002;87:4042-7). In this algorithm, treatment is indicated for a TSH of 4 mU/mL or greater in the first postpartum year. Dr. Keely added that “one of the most important aspects is to continue the treatment until [the woman] has completed her family.”

If TPO-Ab are found in the first trimester, the risk of PPT is 30%-55%. “It's interesting though, that 25% of women who are positive in the first trimester become negative by the third trimester,” she said. Women may become negative by term but rebound in the postpartum period. If TPO-Ab is positive in the third trimester, the risk of PPT is greater than 80%; if negative, the risk is only 0%-5%.

Finally, “postpartum thyroiditis is a very strong predictor of long term Hashimoto's thyroiditis,” said Dr. Keely. About 30% of these women develop Hashimoto's thyroiditis within 3 years.

Disclosures: Dr. Keely reported that she had no relevant financial relationships.

Major Finding: Normal-weight women who took multivitamins in the periconceptional period were 16% less likely to give birth preterm than were women who did not take them; the benefit was due to a reduced risk of preterm birth after spontaneous preterm labor.

Data Source: An observational study of 27,259 women with singleton pregnancies enrolled in the Danish National Birth Cohort.

Disclosures: Dr. Catov reported that she had no relevant conflicts of interest.

SEATTLE — Use of multivitamins around the time of conception may protect against preterm birth, but the benefit depends on a woman's weight and the type of preterm birth, according to findings of a cohort study among more than 27,000 Danish women.

Normal-weight women were 16% less likely to give birth preterm if they took multivitamins in the periconceptional period. This reduction was due to a lower risk of preterm birth after spontaneous (idiopathic) preterm labor. In contrast, overweight women were not less likely to have a preterm birth if they took multivitamins periconceptionally. Also, use did not reduce the risk of preterm births that were medically indicated or that occurred after premature rupture of membranes (PROM).

“Our data suggest that multivitamin use around the time of conception and implantation may reduce risk of idiopathic preterm labor among normal-weight women,” lead investigator Janet M. Catov, Ph.D., said at the meeting. The dose of vitamins may have been insufficient in overweight women or perhaps they had higher levels of systemic inflammation, she speculated. “As we better understand the complexity of overweight and obesity in pregnancy, I hope that we might better understand that.”

“The fact that we did not see a relationship to membrane rupture suggests that what we might be describing are more sort of early and important characteristics of pregnancy that may… set the stage, if you will, for successful pregnancy or less successful pregnancy,” she commented.

Explaining the rationale for the study, Dr. Catov, assistant professor of epidemiology at the University of Pittsburgh, noted that women's nutritional status is likely important for placentation, and abnormal placentation has been associated with both spontaneous and medically indicated preterm births. “Previous work by our group and others has suggested that periconceptional multivitamin use is related to reduced risk for preeclampsia, early preterm birth, and growth restriction.”

The investigators analyzed data from the Danish National Birth Cohort, which enrolled pregnant women in Denmark between 1997 and 2003.

Analyses were based on women who were recruited at more than 5 weeks' but less than 24 weeks' gestation of a singleton pregnancy, provided detailed information on vitamin use in the periconceptional period (extending from 4 weeks before the last menstrual period to 8 weeks after), and had a live birth.

To look more closely at the issue of timing of multivitamin use, they subdivided the periconceptional period into a preconceptional period (4 weeks before last menstrual period to 2 weeks after) and a postconceptional period (2 weeks after last menstrual period to 8 weeks after). To look at the issue of frequency of multivitamin use, within each 6-week period, they classified use as partial (3 weeks or less) or regular (4 weeks or more).

A total of 19,677 women reported at least some use of multivitamins periconceptionally, and 7,582 did not report any use. Users were somewhat less likely to be younger than age 25 than were nonusers (13% vs. 19%, respectively), to be overweight, defined as having a prepregnancy body mass index of 25 kg/m

Overall, in adjusted analyses, multivitamin users were significantly less likely than nonusers to give birth preterm, meaning before 37 weeks' gestation (hazard ratio, 0.88). But after stratification by weight, this benefit was seen only among women who were of normal weight, defined as having a prepregnancy BMI of less than 25 kg/m

Timing and frequency of multivitamin use were important, according to Dr. Catov. Normal-weight women were significantly less likely to have a preterm birth if they partially used multivitamins preconception and regularly used them post conception (HR, 0.77) or regularly used them in both periods (HR, 0.82). However, they did not have a significant reduction in risk if they only used them regularly post conception or used them partially in both periods.

“Future studies are needed to determine the actual nutrients that might be involved … and to really understand what mechanisms might be involved,” she concluded. “We also need to better understand the relationship between periconceptional multivitamin use and adverse events, and that work is actually under way with our colleagues in Denmark.”

The effect was limited to idiopathic preterm labor in normal-weight women.

Source ©dragon fang/Fotolia.com

Major Finding: Normal-weight women who took multivitamins in the periconceptional period were 16% less likely to give birth preterm than were women who did not take them; the benefit was due to a reduced risk of preterm birth after spontaneous preterm labor.

Data Source: An observational study of 27,259 women with singleton pregnancies enrolled in the Danish National Birth Cohort.

Disclosures: Dr. Catov reported that she had no relevant conflicts of interest.

SEATTLE — Use of multivitamins around the time of conception may protect against preterm birth, but the benefit depends on a woman's weight and the type of preterm birth, according to findings of a cohort study among more than 27,000 Danish women.

Normal-weight women were 16% less likely to give birth preterm if they took multivitamins in the periconceptional period. This reduction was due to a lower risk of preterm birth after spontaneous (idiopathic) preterm labor. In contrast, overweight women were not less likely to have a preterm birth if they took multivitamins periconceptionally. Also, use did not reduce the risk of preterm births that were medically indicated or that occurred after premature rupture of membranes (PROM).

“Our data suggest that multivitamin use around the time of conception and implantation may reduce risk of idiopathic preterm labor among normal-weight women,” lead investigator Janet M. Catov, Ph.D., said at the meeting. The dose of vitamins may have been insufficient in overweight women or perhaps they had higher levels of systemic inflammation, she speculated. “As we better understand the complexity of overweight and obesity in pregnancy, I hope that we might better understand that.”

“The fact that we did not see a relationship to membrane rupture suggests that what we might be describing are more sort of early and important characteristics of pregnancy that may… set the stage, if you will, for successful pregnancy or less successful pregnancy,” she commented.

Explaining the rationale for the study, Dr. Catov, assistant professor of epidemiology at the University of Pittsburgh, noted that women's nutritional status is likely important for placentation, and abnormal placentation has been associated with both spontaneous and medically indicated preterm births. “Previous work by our group and others has suggested that periconceptional multivitamin use is related to reduced risk for preeclampsia, early preterm birth, and growth restriction.”

The investigators analyzed data from the Danish National Birth Cohort, which enrolled pregnant women in Denmark between 1997 and 2003.

Analyses were based on women who were recruited at more than 5 weeks' but less than 24 weeks' gestation of a singleton pregnancy, provided detailed information on vitamin use in the periconceptional period (extending from 4 weeks before the last menstrual period to 8 weeks after), and had a live birth.

To look more closely at the issue of timing of multivitamin use, they subdivided the periconceptional period into a preconceptional period (4 weeks before last menstrual period to 2 weeks after) and a postconceptional period (2 weeks after last menstrual period to 8 weeks after). To look at the issue of frequency of multivitamin use, within each 6-week period, they classified use as partial (3 weeks or less) or regular (4 weeks or more).

A total of 19,677 women reported at least some use of multivitamins periconceptionally, and 7,582 did not report any use. Users were somewhat less likely to be younger than age 25 than were nonusers (13% vs. 19%, respectively), to be overweight, defined as having a prepregnancy body mass index of 25 kg/m

Overall, in adjusted analyses, multivitamin users were significantly less likely than nonusers to give birth preterm, meaning before 37 weeks' gestation (hazard ratio, 0.88). But after stratification by weight, this benefit was seen only among women who were of normal weight, defined as having a prepregnancy BMI of less than 25 kg/m

Timing and frequency of multivitamin use were important, according to Dr. Catov. Normal-weight women were significantly less likely to have a preterm birth if they partially used multivitamins preconception and regularly used them post conception (HR, 0.77) or regularly used them in both periods (HR, 0.82). However, they did not have a significant reduction in risk if they only used them regularly post conception or used them partially in both periods.

“Future studies are needed to determine the actual nutrients that might be involved … and to really understand what mechanisms might be involved,” she concluded. “We also need to better understand the relationship between periconceptional multivitamin use and adverse events, and that work is actually under way with our colleagues in Denmark.”

The effect was limited to idiopathic preterm labor in normal-weight women.

Source ©dragon fang/Fotolia.com

Major Finding: Normal-weight women who took multivitamins in the periconceptional period were 16% less likely to give birth preterm than were women who did not take them; the benefit was due to a reduced risk of preterm birth after spontaneous preterm labor.

Data Source: An observational study of 27,259 women with singleton pregnancies enrolled in the Danish National Birth Cohort.

Disclosures: Dr. Catov reported that she had no relevant conflicts of interest.

SEATTLE — Use of multivitamins around the time of conception may protect against preterm birth, but the benefit depends on a woman's weight and the type of preterm birth, according to findings of a cohort study among more than 27,000 Danish women.

Normal-weight women were 16% less likely to give birth preterm if they took multivitamins in the periconceptional period. This reduction was due to a lower risk of preterm birth after spontaneous (idiopathic) preterm labor. In contrast, overweight women were not less likely to have a preterm birth if they took multivitamins periconceptionally. Also, use did not reduce the risk of preterm births that were medically indicated or that occurred after premature rupture of membranes (PROM).

“Our data suggest that multivitamin use around the time of conception and implantation may reduce risk of idiopathic preterm labor among normal-weight women,” lead investigator Janet M. Catov, Ph.D., said at the meeting. The dose of vitamins may have been insufficient in overweight women or perhaps they had higher levels of systemic inflammation, she speculated. “As we better understand the complexity of overweight and obesity in pregnancy, I hope that we might better understand that.”

“The fact that we did not see a relationship to membrane rupture suggests that what we might be describing are more sort of early and important characteristics of pregnancy that may… set the stage, if you will, for successful pregnancy or less successful pregnancy,” she commented.

Explaining the rationale for the study, Dr. Catov, assistant professor of epidemiology at the University of Pittsburgh, noted that women's nutritional status is likely important for placentation, and abnormal placentation has been associated with both spontaneous and medically indicated preterm births. “Previous work by our group and others has suggested that periconceptional multivitamin use is related to reduced risk for preeclampsia, early preterm birth, and growth restriction.”

The investigators analyzed data from the Danish National Birth Cohort, which enrolled pregnant women in Denmark between 1997 and 2003.

Analyses were based on women who were recruited at more than 5 weeks' but less than 24 weeks' gestation of a singleton pregnancy, provided detailed information on vitamin use in the periconceptional period (extending from 4 weeks before the last menstrual period to 8 weeks after), and had a live birth.

To look more closely at the issue of timing of multivitamin use, they subdivided the periconceptional period into a preconceptional period (4 weeks before last menstrual period to 2 weeks after) and a postconceptional period (2 weeks after last menstrual period to 8 weeks after). To look at the issue of frequency of multivitamin use, within each 6-week period, they classified use as partial (3 weeks or less) or regular (4 weeks or more).

A total of 19,677 women reported at least some use of multivitamins periconceptionally, and 7,582 did not report any use. Users were somewhat less likely to be younger than age 25 than were nonusers (13% vs. 19%, respectively), to be overweight, defined as having a prepregnancy body mass index of 25 kg/m

Overall, in adjusted analyses, multivitamin users were significantly less likely than nonusers to give birth preterm, meaning before 37 weeks' gestation (hazard ratio, 0.88). But after stratification by weight, this benefit was seen only among women who were of normal weight, defined as having a prepregnancy BMI of less than 25 kg/m

Timing and frequency of multivitamin use were important, according to Dr. Catov. Normal-weight women were significantly less likely to have a preterm birth if they partially used multivitamins preconception and regularly used them post conception (HR, 0.77) or regularly used them in both periods (HR, 0.82). However, they did not have a significant reduction in risk if they only used them regularly post conception or used them partially in both periods.

“Future studies are needed to determine the actual nutrients that might be involved … and to really understand what mechanisms might be involved,” she concluded. “We also need to better understand the relationship between periconceptional multivitamin use and adverse events, and that work is actually under way with our colleagues in Denmark.”

The effect was limited to idiopathic preterm labor in normal-weight women.

Source ©dragon fang/Fotolia.com

Antimicrobial prophylaxis now should be given within 60 minutes of the start of a cesarean delivery, rather than after cord clamping,

The recommended change in practice comes from a new opinion by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice as Committee Opinion No. 465 (Obstet. Gynecol. 2010;116:791-2).

“Based on the latest data, prophylactic antibiotics given to pregnant women before a cesarean significantly reduce maternal infections and do not appear to harm newborns,” Dr. William H. Barth Jr., chair of the committee, said in a statement.

“Anytime you have invasive surgery, you have an increased risk of developing an infection at the incision site,” he said. Infection is the most common complication of cesarean delivery and can occur in an estimated 10%-40% of women who undergo cesarean delivery, compared with 1%-3% of women who deliver vaginally, according to ACOG.

The committee recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics. When it is not possible to begin administration within 60 minutes of the first incision—as with emergent delivery—prophylaxis should be administered as soon as possible.

Antimicrobial prophylaxis has been a common practice for cesarean deliveries. However, intraoperative antibiotics have been administered after umbilical clamping due to concerns about neonatal exposure to antibiotics. In particular, it has been theorized that antibiotics in neonatal serum could mask positive bacterial culture results in newborns and that fetal antibiotic exposure could lead to increased newborn colonization or infection with antibiotic-resistant organisms.

Older studies had suggested that when prophylactic antibiotics were given before the cesarean, pediatricians tended to do more invasive neonatal sepsis evaluations and costs were increased, Dr. Barth said in an interview. “This was based on the fear that the antibiotics given to the mother would cross rapidly to the fetus and then mask the signs of infection in the newborn child.” Pediatricians feared that the usual signs of sepsis might be masked by these antibiotics. Given this fear, tests such as blood draws and lumbar punctures that are useful in making a diagnosis of newborn sepsis tended to be used more frequently.

“However, based on recent randomized clinical trials and systematic reviews, giving the mother the antibiotics before the cesarean incision does not appear to increase problems in the newborn. None of the studies were large enough to say that definitively, but given the overall benefit to the mother, our committee—which included pediatricians—felt that this was the right thing to do,” said Dr. Barth, chief of maternal-fetal medicine at Massachusetts General Hospital, Boston.

In fact, preoperative antimicrobial prophylaxis “does not appear to have any deleterious effects on mother or neonate,” the committee wrote. Timing really does make a difference. In the studies reviewed, preoperative administration significantly reduced the rates of endometritis and total maternal infectious morbidity, compared with administration after cord clamping. Just as importantly, preoperative administration was not associated with an increase in neonatal infectious morbidity or the selection of antimicrobial-resistant bacteria causing neonatal sepsis.

The committee recommends that the infusion be timed so that a bactericidal serum level is reached by the time of skin incision. Therapeutic antibiotic levels should be maintained throughout the operation. Readministration is indicated at intervals of one or two times the half-life of the drug during longer procedures. The committee recommends using narrow-spectrum drugs that are effective against gram-positive and gram-negative bacteria and against some anaerobic bacteria – such as first-generation cephalosporins. Notably, obese women may require doses larger than the recommended 1 gram intravenous cefazolin (with a therapeutic dose maintained for 3-4 hours). Clindamycin with gentamicin is an acceptable alternative for women with significant allergies to beta-lactam antibiotics.

Disclosures: Dr. Barth said he had no conflicts of interest to disclose.

Antimicrobial prophylaxis now should be given within 60 minutes of the start of a cesarean delivery, rather than after cord clamping,

The recommended change in practice comes from a new opinion by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice as Committee Opinion No. 465 (Obstet. Gynecol. 2010;116:791-2).

“Based on the latest data, prophylactic antibiotics given to pregnant women before a cesarean significantly reduce maternal infections and do not appear to harm newborns,” Dr. William H. Barth Jr., chair of the committee, said in a statement.

“Anytime you have invasive surgery, you have an increased risk of developing an infection at the incision site,” he said. Infection is the most common complication of cesarean delivery and can occur in an estimated 10%-40% of women who undergo cesarean delivery, compared with 1%-3% of women who deliver vaginally, according to ACOG.

The committee recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics. When it is not possible to begin administration within 60 minutes of the first incision—as with emergent delivery—prophylaxis should be administered as soon as possible.

Antimicrobial prophylaxis has been a common practice for cesarean deliveries. However, intraoperative antibiotics have been administered after umbilical clamping due to concerns about neonatal exposure to antibiotics. In particular, it has been theorized that antibiotics in neonatal serum could mask positive bacterial culture results in newborns and that fetal antibiotic exposure could lead to increased newborn colonization or infection with antibiotic-resistant organisms.

Older studies had suggested that when prophylactic antibiotics were given before the cesarean, pediatricians tended to do more invasive neonatal sepsis evaluations and costs were increased, Dr. Barth said in an interview. “This was based on the fear that the antibiotics given to the mother would cross rapidly to the fetus and then mask the signs of infection in the newborn child.” Pediatricians feared that the usual signs of sepsis might be masked by these antibiotics. Given this fear, tests such as blood draws and lumbar punctures that are useful in making a diagnosis of newborn sepsis tended to be used more frequently.

“However, based on recent randomized clinical trials and systematic reviews, giving the mother the antibiotics before the cesarean incision does not appear to increase problems in the newborn. None of the studies were large enough to say that definitively, but given the overall benefit to the mother, our committee—which included pediatricians—felt that this was the right thing to do,” said Dr. Barth, chief of maternal-fetal medicine at Massachusetts General Hospital, Boston.

In fact, preoperative antimicrobial prophylaxis “does not appear to have any deleterious effects on mother or neonate,” the committee wrote. Timing really does make a difference. In the studies reviewed, preoperative administration significantly reduced the rates of endometritis and total maternal infectious morbidity, compared with administration after cord clamping. Just as importantly, preoperative administration was not associated with an increase in neonatal infectious morbidity or the selection of antimicrobial-resistant bacteria causing neonatal sepsis.

The committee recommends that the infusion be timed so that a bactericidal serum level is reached by the time of skin incision. Therapeutic antibiotic levels should be maintained throughout the operation. Readministration is indicated at intervals of one or two times the half-life of the drug during longer procedures. The committee recommends using narrow-spectrum drugs that are effective against gram-positive and gram-negative bacteria and against some anaerobic bacteria – such as first-generation cephalosporins. Notably, obese women may require doses larger than the recommended 1 gram intravenous cefazolin (with a therapeutic dose maintained for 3-4 hours). Clindamycin with gentamicin is an acceptable alternative for women with significant allergies to beta-lactam antibiotics.

Disclosures: Dr. Barth said he had no conflicts of interest to disclose.

Antimicrobial prophylaxis now should be given within 60 minutes of the start of a cesarean delivery, rather than after cord clamping,

The recommended change in practice comes from a new opinion by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice as Committee Opinion No. 465 (Obstet. Gynecol. 2010;116:791-2).

“Based on the latest data, prophylactic antibiotics given to pregnant women before a cesarean significantly reduce maternal infections and do not appear to harm newborns,” Dr. William H. Barth Jr., chair of the committee, said in a statement.

“Anytime you have invasive surgery, you have an increased risk of developing an infection at the incision site,” he said. Infection is the most common complication of cesarean delivery and can occur in an estimated 10%-40% of women who undergo cesarean delivery, compared with 1%-3% of women who deliver vaginally, according to ACOG.

The committee recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics. When it is not possible to begin administration within 60 minutes of the first incision—as with emergent delivery—prophylaxis should be administered as soon as possible.

Antimicrobial prophylaxis has been a common practice for cesarean deliveries. However, intraoperative antibiotics have been administered after umbilical clamping due to concerns about neonatal exposure to antibiotics. In particular, it has been theorized that antibiotics in neonatal serum could mask positive bacterial culture results in newborns and that fetal antibiotic exposure could lead to increased newborn colonization or infection with antibiotic-resistant organisms.

Older studies had suggested that when prophylactic antibiotics were given before the cesarean, pediatricians tended to do more invasive neonatal sepsis evaluations and costs were increased, Dr. Barth said in an interview. “This was based on the fear that the antibiotics given to the mother would cross rapidly to the fetus and then mask the signs of infection in the newborn child.” Pediatricians feared that the usual signs of sepsis might be masked by these antibiotics. Given this fear, tests such as blood draws and lumbar punctures that are useful in making a diagnosis of newborn sepsis tended to be used more frequently.

“However, based on recent randomized clinical trials and systematic reviews, giving the mother the antibiotics before the cesarean incision does not appear to increase problems in the newborn. None of the studies were large enough to say that definitively, but given the overall benefit to the mother, our committee—which included pediatricians—felt that this was the right thing to do,” said Dr. Barth, chief of maternal-fetal medicine at Massachusetts General Hospital, Boston.

In fact, preoperative antimicrobial prophylaxis “does not appear to have any deleterious effects on mother or neonate,” the committee wrote. Timing really does make a difference. In the studies reviewed, preoperative administration significantly reduced the rates of endometritis and total maternal infectious morbidity, compared with administration after cord clamping. Just as importantly, preoperative administration was not associated with an increase in neonatal infectious morbidity or the selection of antimicrobial-resistant bacteria causing neonatal sepsis.

The committee recommends that the infusion be timed so that a bactericidal serum level is reached by the time of skin incision. Therapeutic antibiotic levels should be maintained throughout the operation. Readministration is indicated at intervals of one or two times the half-life of the drug during longer procedures. The committee recommends using narrow-spectrum drugs that are effective against gram-positive and gram-negative bacteria and against some anaerobic bacteria – such as first-generation cephalosporins. Notably, obese women may require doses larger than the recommended 1 gram intravenous cefazolin (with a therapeutic dose maintained for 3-4 hours). Clindamycin with gentamicin is an acceptable alternative for women with significant allergies to beta-lactam antibiotics.

Disclosures: Dr. Barth said he had no conflicts of interest to disclose.

AUGUST 2010—An analysis of more than 200,000 deliveries finds that babies born between 34 weeks and 37 weeks are more likely to have severe respiratory illness than those born at term, and that this risk decreases with each added week of gestational age during the late preterm period. The report of the study was published in the July 28 issue of JAMA.

Late preterm birth (34 0/7 to 36 6/7 weeks’ gestation) accounts for 9.1% of all deliveries and 75% of all preterm births in the United States. Considerable evidence has shown that short-term illnesses are prevalent; however, much of the supporting data for that evidence is more than a decade old or drawn from small populations, according to background information in the article.

Judith U. Hibbard, MD, of the University of Illinois at Chicago, and colleagues of the National Institutes of Health’s Consortium on Safe Labor, conducted a study to determine the rate of respiratory illness among late preterm births by analyzing recent data from a large group of late preterm infants. The study included electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all newborns with respiratory problems admitted to a neonatal intensive care unit (NICU), and late preterm births were compared with term births in regard to resuscitation, respiratory support, and respiratory diagnoses.

Of 19,334 late preterm births, 7,055 (36.5%) were admitted to a NICU and 2,032 had respiratory compromise. Of 165,993 term infants, 11,980 (7.2%) were admitted to a NICU, 1,874 with respiratory illness. The researchers found that respiratory distress syndrome (RDS) was the most common respiratory illness, occurring in 10.5% (n = 390) of 34-week deliveries, decreasing with gestational age to 0.3% (n = 140/41,764) at 38 weeks. Transient tachypnea of the newborn was the second most common morbidity at 6.4% (n = 236) at 34 weeks, reaching a low of 0.3% (n = 207/ 62,295) at 39 weeks. Also decreasing from 34 weeks were pneumonia, from 1.5% to 0.1% at 39 weeks, and overall respiratory failure, from 1.6% to 0.09% at 40 weeks. The percentage of infants who had respiratory illness decreased significantly as gestational age increased until 39 to 40 weeks.

Additional analysis found that newborns born at 34 weeks had a 40-fold increase in the odds of RDS; that risk decreased with each advancing week of gestation until 38 weeks.

“Even at 37 weeks, the odds of RDS were still 3-fold greater than that of a 39- or 40-week birth. Similar patterns were seen for transient tachypnea of the newborn, pneumonia, standard or high-frequency ventilator requirements, and respiratory failure,” according to the authors of the report.

“We suggest that future studies should focus on indications for late preterm birth. Only by more completely understanding reasons for rising rates of late preterm birth might clinicians be able to initiate salutary interventions to decrease neonatal respiratory morbidity. Improved pregnancy dating through early ultrasound confirmation of estimated due date may help prevent neonatal morbidity associated with erroneous delivery of a neonate that is actually at an earlier gestational age. Finally, a better understanding of the effect of mode of delivery on neonates may help with future interventions to decrease morbidity.”

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

AUGUST 2010—An analysis of more than 200,000 deliveries finds that babies born between 34 weeks and 37 weeks are more likely to have severe respiratory illness than those born at term, and that this risk decreases with each added week of gestational age during the late preterm period. The report of the study was published in the July 28 issue of JAMA.

Late preterm birth (34 0/7 to 36 6/7 weeks’ gestation) accounts for 9.1% of all deliveries and 75% of all preterm births in the United States. Considerable evidence has shown that short-term illnesses are prevalent; however, much of the supporting data for that evidence is more than a decade old or drawn from small populations, according to background information in the article.

Judith U. Hibbard, MD, of the University of Illinois at Chicago, and colleagues of the National Institutes of Health’s Consortium on Safe Labor, conducted a study to determine the rate of respiratory illness among late preterm births by analyzing recent data from a large group of late preterm infants. The study included electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all newborns with respiratory problems admitted to a neonatal intensive care unit (NICU), and late preterm births were compared with term births in regard to resuscitation, respiratory support, and respiratory diagnoses.

Of 19,334 late preterm births, 7,055 (36.5%) were admitted to a NICU and 2,032 had respiratory compromise. Of 165,993 term infants, 11,980 (7.2%) were admitted to a NICU, 1,874 with respiratory illness. The researchers found that respiratory distress syndrome (RDS) was the most common respiratory illness, occurring in 10.5% (n = 390) of 34-week deliveries, decreasing with gestational age to 0.3% (n = 140/41,764) at 38 weeks. Transient tachypnea of the newborn was the second most common morbidity at 6.4% (n = 236) at 34 weeks, reaching a low of 0.3% (n = 207/ 62,295) at 39 weeks. Also decreasing from 34 weeks were pneumonia, from 1.5% to 0.1% at 39 weeks, and overall respiratory failure, from 1.6% to 0.09% at 40 weeks. The percentage of infants who had respiratory illness decreased significantly as gestational age increased until 39 to 40 weeks.

Additional analysis found that newborns born at 34 weeks had a 40-fold increase in the odds of RDS; that risk decreased with each advancing week of gestation until 38 weeks.

“Even at 37 weeks, the odds of RDS were still 3-fold greater than that of a 39- or 40-week birth. Similar patterns were seen for transient tachypnea of the newborn, pneumonia, standard or high-frequency ventilator requirements, and respiratory failure,” according to the authors of the report.

“We suggest that future studies should focus on indications for late preterm birth. Only by more completely understanding reasons for rising rates of late preterm birth might clinicians be able to initiate salutary interventions to decrease neonatal respiratory morbidity. Improved pregnancy dating through early ultrasound confirmation of estimated due date may help prevent neonatal morbidity associated with erroneous delivery of a neonate that is actually at an earlier gestational age. Finally, a better understanding of the effect of mode of delivery on neonates may help with future interventions to decrease morbidity.”

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

AUGUST 2010—An analysis of more than 200,000 deliveries finds that babies born between 34 weeks and 37 weeks are more likely to have severe respiratory illness than those born at term, and that this risk decreases with each added week of gestational age during the late preterm period. The report of the study was published in the July 28 issue of JAMA.

Late preterm birth (34 0/7 to 36 6/7 weeks’ gestation) accounts for 9.1% of all deliveries and 75% of all preterm births in the United States. Considerable evidence has shown that short-term illnesses are prevalent; however, much of the supporting data for that evidence is more than a decade old or drawn from small populations, according to background information in the article.

Judith U. Hibbard, MD, of the University of Illinois at Chicago, and colleagues of the National Institutes of Health’s Consortium on Safe Labor, conducted a study to determine the rate of respiratory illness among late preterm births by analyzing recent data from a large group of late preterm infants. The study included electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all newborns with respiratory problems admitted to a neonatal intensive care unit (NICU), and late preterm births were compared with term births in regard to resuscitation, respiratory support, and respiratory diagnoses.

Of 19,334 late preterm births, 7,055 (36.5%) were admitted to a NICU and 2,032 had respiratory compromise. Of 165,993 term infants, 11,980 (7.2%) were admitted to a NICU, 1,874 with respiratory illness. The researchers found that respiratory distress syndrome (RDS) was the most common respiratory illness, occurring in 10.5% (n = 390) of 34-week deliveries, decreasing with gestational age to 0.3% (n = 140/41,764) at 38 weeks. Transient tachypnea of the newborn was the second most common morbidity at 6.4% (n = 236) at 34 weeks, reaching a low of 0.3% (n = 207/ 62,295) at 39 weeks. Also decreasing from 34 weeks were pneumonia, from 1.5% to 0.1% at 39 weeks, and overall respiratory failure, from 1.6% to 0.09% at 40 weeks. The percentage of infants who had respiratory illness decreased significantly as gestational age increased until 39 to 40 weeks.

Additional analysis found that newborns born at 34 weeks had a 40-fold increase in the odds of RDS; that risk decreased with each advancing week of gestation until 38 weeks.

“Even at 37 weeks, the odds of RDS were still 3-fold greater than that of a 39- or 40-week birth. Similar patterns were seen for transient tachypnea of the newborn, pneumonia, standard or high-frequency ventilator requirements, and respiratory failure,” according to the authors of the report.

“We suggest that future studies should focus on indications for late preterm birth. Only by more completely understanding reasons for rising rates of late preterm birth might clinicians be able to initiate salutary interventions to decrease neonatal respiratory morbidity. Improved pregnancy dating through early ultrasound confirmation of estimated due date may help prevent neonatal morbidity associated with erroneous delivery of a neonate that is actually at an earlier gestational age. Finally, a better understanding of the effect of mode of delivery on neonates may help with future interventions to decrease morbidity.”

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From February 2005 to February 2009, Knight and associates identified a total of 60 cases of AFE in the UK Obstetric Surveillance System. Their analysis of these cases, along with the cases of 1,227 women in the control group, is a valuable contribution to our understanding of AFE—an entity that few obstetricians will have the occasion to manage in their professional careers. One of the strengths of the study is the use of a comprehensive database, which made it possible to exclude 26 additional cases originally diagnosed as AFE but determined to be another entity. Scrutiny of these cases suggests that AFE may be over-reported.

Although the findings of this study are interesting—particularly the association between AFE and induction of labor, twin gestation, cesarean delivery, and the combination of older age and ethnic-minority status—they must be interpreted with caution. The study was an elegant mathematical exercise, but I would hesitate to join the authors in sounding too many alarms. For example, without a biological explanation, I would be reluctant to tell clinicians to look for any increased risk of AFE among ethnic minorities.

I would be just as hesitant to “warn” obstetricians about induction of labor. If the risk of AFE attributable to induction is 35%, as the authors maintain, the elimination of induction altogether would only lower the rate of AFE from 2 cases to 1.3 cases for every 100,000 deliveries. Moreover, some of the variables that contribute to the need for induction could also contribute to an increased risk of AFE.

Postpartum cases that occur after cesarean delivery could actually be air embolism misclassified as AFE, especially if the uterus was exteriorized for repair—a phenomenon that has been reported.²

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

From February 2005 to February 2009, Knight and associates identified a total of 60 cases of AFE in the UK Obstetric Surveillance System. Their analysis of these cases, along with the cases of 1,227 women in the control group, is a valuable contribution to our understanding of AFE—an entity that few obstetricians will have the occasion to manage in their professional careers. One of the strengths of the study is the use of a comprehensive database, which made it possible to exclude 26 additional cases originally diagnosed as AFE but determined to be another entity. Scrutiny of these cases suggests that AFE may be over-reported.

Although the findings of this study are interesting—particularly the association between AFE and induction of labor, twin gestation, cesarean delivery, and the combination of older age and ethnic-minority status—they must be interpreted with caution. The study was an elegant mathematical exercise, but I would hesitate to join the authors in sounding too many alarms. For example, without a biological explanation, I would be reluctant to tell clinicians to look for any increased risk of AFE among ethnic minorities.

I would be just as hesitant to “warn” obstetricians about induction of labor. If the risk of AFE attributable to induction is 35%, as the authors maintain, the elimination of induction altogether would only lower the rate of AFE from 2 cases to 1.3 cases for every 100,000 deliveries. Moreover, some of the variables that contribute to the need for induction could also contribute to an increased risk of AFE.

Postpartum cases that occur after cesarean delivery could actually be air embolism misclassified as AFE, especially if the uterus was exteriorized for repair—a phenomenon that has been reported.²

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

From February 2005 to February 2009, Knight and associates identified a total of 60 cases of AFE in the UK Obstetric Surveillance System. Their analysis of these cases, along with the cases of 1,227 women in the control group, is a valuable contribution to our understanding of AFE—an entity that few obstetricians will have the occasion to manage in their professional careers. One of the strengths of the study is the use of a comprehensive database, which made it possible to exclude 26 additional cases originally diagnosed as AFE but determined to be another entity. Scrutiny of these cases suggests that AFE may be over-reported.

Although the findings of this study are interesting—particularly the association between AFE and induction of labor, twin gestation, cesarean delivery, and the combination of older age and ethnic-minority status—they must be interpreted with caution. The study was an elegant mathematical exercise, but I would hesitate to join the authors in sounding too many alarms. For example, without a biological explanation, I would be reluctant to tell clinicians to look for any increased risk of AFE among ethnic minorities.

I would be just as hesitant to “warn” obstetricians about induction of labor. If the risk of AFE attributable to induction is 35%, as the authors maintain, the elimination of induction altogether would only lower the rate of AFE from 2 cases to 1.3 cases for every 100,000 deliveries. Moreover, some of the variables that contribute to the need for induction could also contribute to an increased risk of AFE.

Postpartum cases that occur after cesarean delivery could actually be air embolism misclassified as AFE, especially if the uterus was exteriorized for repair—a phenomenon that has been reported.²

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