Obstetrics

Disclosures: Dr. Alghonaim said he had no financial conflicts of interest.

SAN DIEGO — Although pregnant women with chronic kidney disease face an elevated risk of adverse maternal and fetal outcomes, most are able to deliver a surviving newborn, according to results from a multicenter study.

The current analysis is believed to be the second largest of its kind and supports earlier findings in the medical literature, Dr. Mohammed Alghonaim said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“These women need vigilant care,” said Dr. Alghonaim of the nephrology section in the department of medicine at King Saud University, Riyadh, Saudi Arabia. “If they've had a previous pregnancy, I would not advise them to get pregnant again if they have advanced-stage chronic kidney disease because of the potential for adverse maternal and fetal outcomes.”

In a study led by his associate at the university, Dr. Abdulkareem Alsuwaida, researchers at five tertiary hospitals in the Middle East reviewed 101 pregnancies in women (mean age, 32 years) with chronic kidney disease to estimate the rate of fetal, maternal, and neonatal complications.

The mean serum preconception creatinine concentration was 81.2 μmol/L, and the mean 24-hour urine proteinuria was 1.97 g/day. A total of 21 women (21%) had renal impairment, with a mean serum creatinine of 144 μmol/L.

In 10 pregnancies (10%), levels of serum creatinine rose more than 25% from preconception levels. Overall maternal and fetal complications included cesarean section (39%), preeclampsia (23%), preterm delivery (22%, with 4% delivered at less than 30 weeks' gestation), and intrauterine growth retardation (19%). Six infants (6%) were stillborn.

“Renal impairment was the most important predictor for both maternal and fetal complications,” Dr. Alghonaim said.

'Renal impairment was the most important predictor for both maternal and fetal complications.'

Source DR. ALGHONAIM

Disclosures: Dr. Alghonaim said he had no financial conflicts of interest.

SAN DIEGO — Although pregnant women with chronic kidney disease face an elevated risk of adverse maternal and fetal outcomes, most are able to deliver a surviving newborn, according to results from a multicenter study.

The current analysis is believed to be the second largest of its kind and supports earlier findings in the medical literature, Dr. Mohammed Alghonaim said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“These women need vigilant care,” said Dr. Alghonaim of the nephrology section in the department of medicine at King Saud University, Riyadh, Saudi Arabia. “If they've had a previous pregnancy, I would not advise them to get pregnant again if they have advanced-stage chronic kidney disease because of the potential for adverse maternal and fetal outcomes.”

In a study led by his associate at the university, Dr. Abdulkareem Alsuwaida, researchers at five tertiary hospitals in the Middle East reviewed 101 pregnancies in women (mean age, 32 years) with chronic kidney disease to estimate the rate of fetal, maternal, and neonatal complications.

The mean serum preconception creatinine concentration was 81.2 μmol/L, and the mean 24-hour urine proteinuria was 1.97 g/day. A total of 21 women (21%) had renal impairment, with a mean serum creatinine of 144 μmol/L.

In 10 pregnancies (10%), levels of serum creatinine rose more than 25% from preconception levels. Overall maternal and fetal complications included cesarean section (39%), preeclampsia (23%), preterm delivery (22%, with 4% delivered at less than 30 weeks' gestation), and intrauterine growth retardation (19%). Six infants (6%) were stillborn.

“Renal impairment was the most important predictor for both maternal and fetal complications,” Dr. Alghonaim said.

'Renal impairment was the most important predictor for both maternal and fetal complications.'

Source DR. ALGHONAIM

Disclosures: Dr. Alghonaim said he had no financial conflicts of interest.

SAN DIEGO — Although pregnant women with chronic kidney disease face an elevated risk of adverse maternal and fetal outcomes, most are able to deliver a surviving newborn, according to results from a multicenter study.

The current analysis is believed to be the second largest of its kind and supports earlier findings in the medical literature, Dr. Mohammed Alghonaim said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“These women need vigilant care,” said Dr. Alghonaim of the nephrology section in the department of medicine at King Saud University, Riyadh, Saudi Arabia. “If they've had a previous pregnancy, I would not advise them to get pregnant again if they have advanced-stage chronic kidney disease because of the potential for adverse maternal and fetal outcomes.”

In a study led by his associate at the university, Dr. Abdulkareem Alsuwaida, researchers at five tertiary hospitals in the Middle East reviewed 101 pregnancies in women (mean age, 32 years) with chronic kidney disease to estimate the rate of fetal, maternal, and neonatal complications.

The mean serum preconception creatinine concentration was 81.2 μmol/L, and the mean 24-hour urine proteinuria was 1.97 g/day. A total of 21 women (21%) had renal impairment, with a mean serum creatinine of 144 μmol/L.

In 10 pregnancies (10%), levels of serum creatinine rose more than 25% from preconception levels. Overall maternal and fetal complications included cesarean section (39%), preeclampsia (23%), preterm delivery (22%, with 4% delivered at less than 30 weeks' gestation), and intrauterine growth retardation (19%). Six infants (6%) were stillborn.

“Renal impairment was the most important predictor for both maternal and fetal complications,” Dr. Alghonaim said.

'Renal impairment was the most important predictor for both maternal and fetal complications.'

Source DR. ALGHONAIM

Disclosures: Dr. Lesham and associates reported no conflicts of interest.

SAN FRANCISCO — Infants most often acquire Staphylococcus aureus infections from their mothers horizontally after birth and not vertically during birth, based on a prospective, longitudinal study of 158 pregnant women and their offspring.

Of the participating women, 54 (34%) were S. aureus carriers, and 17 of the children born to them (31%) acquired S. aureus before discharge, Dr. Eyal Leshem and colleagues at Chaim Sheba Medical Center, Tel Hashomer, Israel, wrote in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

By contrast, only 3% of the children born to noncarrier mothers acquired S. aureus. The investigators found that the mother's carriage status was a very strong predictor of the infant's status. Children born to carriers were 22 times more likely to acquire S. aureus than other children. The investigators controlled for the sex of the child, carriage status of the mother, breastfeeding, gestational age, antibiotic treatment, type of delivery, and smoking status. This increase in risk was highly statistically significant. The only other statistically significant predictor of mother-to-infant transmission was smoking status.

Of the 54 maternal carriers, 38 were nasal carriers, 9 were vaginal carriers, and 7 were both vaginal and nasal carriers. Among 11 of the newborns who acquired S. aureus from their carrier mothers, 9 had strains that were genetically identical to the mother's nasal strain, but only 2 had strains identical to the mother's vaginal strain. This suggests that the transmission was horizontal rather than vertical.

Two other pieces of evidence supported the hypothesis that most transmission was horizontal. Only 5% of newborns had acquired S. aureus by 1 hour after birth, but this figure increased to 8% at 24-48 hours and to 12% by 72-100 hours. Also, there were no significant differences in transmission rates between infants born vaginally and those born by cesarean section. If a vertical transmission were dominant, one would expect a greater rate of transmission in vaginal births.

Disclosures: Dr. Lesham and associates reported no conflicts of interest.

SAN FRANCISCO — Infants most often acquire Staphylococcus aureus infections from their mothers horizontally after birth and not vertically during birth, based on a prospective, longitudinal study of 158 pregnant women and their offspring.

Of the participating women, 54 (34%) were S. aureus carriers, and 17 of the children born to them (31%) acquired S. aureus before discharge, Dr. Eyal Leshem and colleagues at Chaim Sheba Medical Center, Tel Hashomer, Israel, wrote in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

By contrast, only 3% of the children born to noncarrier mothers acquired S. aureus. The investigators found that the mother's carriage status was a very strong predictor of the infant's status. Children born to carriers were 22 times more likely to acquire S. aureus than other children. The investigators controlled for the sex of the child, carriage status of the mother, breastfeeding, gestational age, antibiotic treatment, type of delivery, and smoking status. This increase in risk was highly statistically significant. The only other statistically significant predictor of mother-to-infant transmission was smoking status.

Of the 54 maternal carriers, 38 were nasal carriers, 9 were vaginal carriers, and 7 were both vaginal and nasal carriers. Among 11 of the newborns who acquired S. aureus from their carrier mothers, 9 had strains that were genetically identical to the mother's nasal strain, but only 2 had strains identical to the mother's vaginal strain. This suggests that the transmission was horizontal rather than vertical.

Two other pieces of evidence supported the hypothesis that most transmission was horizontal. Only 5% of newborns had acquired S. aureus by 1 hour after birth, but this figure increased to 8% at 24-48 hours and to 12% by 72-100 hours. Also, there were no significant differences in transmission rates between infants born vaginally and those born by cesarean section. If a vertical transmission were dominant, one would expect a greater rate of transmission in vaginal births.

Disclosures: Dr. Lesham and associates reported no conflicts of interest.

SAN FRANCISCO — Infants most often acquire Staphylococcus aureus infections from their mothers horizontally after birth and not vertically during birth, based on a prospective, longitudinal study of 158 pregnant women and their offspring.

Of the participating women, 54 (34%) were S. aureus carriers, and 17 of the children born to them (31%) acquired S. aureus before discharge, Dr. Eyal Leshem and colleagues at Chaim Sheba Medical Center, Tel Hashomer, Israel, wrote in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology.

By contrast, only 3% of the children born to noncarrier mothers acquired S. aureus. The investigators found that the mother's carriage status was a very strong predictor of the infant's status. Children born to carriers were 22 times more likely to acquire S. aureus than other children. The investigators controlled for the sex of the child, carriage status of the mother, breastfeeding, gestational age, antibiotic treatment, type of delivery, and smoking status. This increase in risk was highly statistically significant. The only other statistically significant predictor of mother-to-infant transmission was smoking status.

Of the 54 maternal carriers, 38 were nasal carriers, 9 were vaginal carriers, and 7 were both vaginal and nasal carriers. Among 11 of the newborns who acquired S. aureus from their carrier mothers, 9 had strains that were genetically identical to the mother's nasal strain, but only 2 had strains identical to the mother's vaginal strain. This suggests that the transmission was horizontal rather than vertical.

Two other pieces of evidence supported the hypothesis that most transmission was horizontal. Only 5% of newborns had acquired S. aureus by 1 hour after birth, but this figure increased to 8% at 24-48 hours and to 12% by 72-100 hours. Also, there were no significant differences in transmission rates between infants born vaginally and those born by cesarean section. If a vertical transmission were dominant, one would expect a greater rate of transmission in vaginal births.

Disclosures: The NEAD study is funded by the National Institutes of Health. Dr. Baker said he had no financial disclosures.

BANGKOK, THAILAND — Expressive and receptive language abilities are significantly poorer in 3-year-olds who were exposed to sodium valproate in utero than they are in children who were exposed to other individual antiepileptic drugs during gestation, based on a subanalysis of the Neurodevelopmental Effects of Antiepileptic Drugs study.

Valproate exposure was associated with a 10-point difference on both language measures compared with exposure to phenytoin, carbamazepine, or lamotrigine—a difference that is not only statistically significant, but clinically important as well, Gus A. Baker, Ph.D., said at the World Congress of Neurology.

The differences apparent in these 3-year-old subjects will likely expand as the groups grow older, said Dr. Baker, director of the division of neurosciences at the Walton Centre for Neurology and Neurosurgery in Liverpool, England. “We can expect the difference in the magnitude to get greater and not smaller with age,” he said. Already, Dr. Baker noted, valproate-exposed 3-year-olds in the U.K. portion of the study are lagging behind a group of matched controls. “Well over a third of those exposed to valproate have been referred for speech therapy, so we see that this 10-point difference has real meaning in terms of day-to-day practice.”

The prospective, observational Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study included 303 pregnant women who were taking sodium valproate, carbamazepine, lamotrigine, or phenytoin as monotherapy. Enrollment occurred during 1999-2004 in 25 epilepsy centers in the United States and the United Kingdom. Separate investigations in the United States and the United Kingdom were later combined. The primary outcome was cognitive performance of the children at 6 years of age.

Dr. Baker, a primary investigator in the U.K. study and coinvestigator in the overall study, presented the results of the drugs' effect on expressive and receptive language development among 234 children who were 3 years old at assessment. The children all underwent testing of verbal and nonverbal communication, including expressive and receptive language, visual motor construction, and nonverbal intellectual ability.

Their abilities in these areas were determined by calculating subscores on screening tests called the Differential Ability Scales (2nd ed.) and the Preschool Language Scale (4th Ed.). The scores were adjusted for factors known to affect child intellect.

“We saw that maternal IQ, antiepileptic drug (AED) dose, maternal age, gestational age, and preconceptional exposure to folate were significant factors predicting the scores, as we would expect,” he said. “But we also showed that overall, the scores for valproate-exposed children were significantly lower than all other drugs and the magnitude of the effect was greater for verbal than nonverbal language.”

Testing showed that the children exposed to valproate scored significantly lower on measures of expressive language (mean score of 91 vs. 102 for carbamazepine, 104 for lamotrigine, and 101 for phenytoin) and receptive language (mean score of 89 vs. 97 for carbamazepine, 101 for lamotrigine, and 101 for phenytoin). On visual motor construction and nonverbal intellectual ability, children exposed to valproate scored lower, but not significantly lower, than children exposed to the other drugs.

In terms of developmental milestones, this finding could bode ill for the valproate-exposed children, said Dr. Baker. “Without a cohesive and intact language system, a child's neurodevelopmental progress will be limited.”

Unlike the physical results of in utero valproate exposure, which can be surgically corrected to at least some degree, the cognitive effects cannot be erased, he pointed out. The best hope for such children is early identification and intervention. “If we identify them now, we have to think about an appropriate intervention now. If we leave it for later, the gains they might make will be limited.”

“For women for whom sodium valproate is the first choice because of the nature of their seizures, we should be thinking about reducing the dose to the least possible effective level,” he said.

“In an ideal world, we would have preconception counseling and would be thinking of an alternative drug several years before pregnancy.”

Disclosures: The NEAD study is funded by the National Institutes of Health. Dr. Baker said he had no financial disclosures.

BANGKOK, THAILAND — Expressive and receptive language abilities are significantly poorer in 3-year-olds who were exposed to sodium valproate in utero than they are in children who were exposed to other individual antiepileptic drugs during gestation, based on a subanalysis of the Neurodevelopmental Effects of Antiepileptic Drugs study.

Valproate exposure was associated with a 10-point difference on both language measures compared with exposure to phenytoin, carbamazepine, or lamotrigine—a difference that is not only statistically significant, but clinically important as well, Gus A. Baker, Ph.D., said at the World Congress of Neurology.

The differences apparent in these 3-year-old subjects will likely expand as the groups grow older, said Dr. Baker, director of the division of neurosciences at the Walton Centre for Neurology and Neurosurgery in Liverpool, England. “We can expect the difference in the magnitude to get greater and not smaller with age,” he said. Already, Dr. Baker noted, valproate-exposed 3-year-olds in the U.K. portion of the study are lagging behind a group of matched controls. “Well over a third of those exposed to valproate have been referred for speech therapy, so we see that this 10-point difference has real meaning in terms of day-to-day practice.”

The prospective, observational Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study included 303 pregnant women who were taking sodium valproate, carbamazepine, lamotrigine, or phenytoin as monotherapy. Enrollment occurred during 1999-2004 in 25 epilepsy centers in the United States and the United Kingdom. Separate investigations in the United States and the United Kingdom were later combined. The primary outcome was cognitive performance of the children at 6 years of age.

Dr. Baker, a primary investigator in the U.K. study and coinvestigator in the overall study, presented the results of the drugs' effect on expressive and receptive language development among 234 children who were 3 years old at assessment. The children all underwent testing of verbal and nonverbal communication, including expressive and receptive language, visual motor construction, and nonverbal intellectual ability.

Their abilities in these areas were determined by calculating subscores on screening tests called the Differential Ability Scales (2nd ed.) and the Preschool Language Scale (4th Ed.). The scores were adjusted for factors known to affect child intellect.

“We saw that maternal IQ, antiepileptic drug (AED) dose, maternal age, gestational age, and preconceptional exposure to folate were significant factors predicting the scores, as we would expect,” he said. “But we also showed that overall, the scores for valproate-exposed children were significantly lower than all other drugs and the magnitude of the effect was greater for verbal than nonverbal language.”

Testing showed that the children exposed to valproate scored significantly lower on measures of expressive language (mean score of 91 vs. 102 for carbamazepine, 104 for lamotrigine, and 101 for phenytoin) and receptive language (mean score of 89 vs. 97 for carbamazepine, 101 for lamotrigine, and 101 for phenytoin). On visual motor construction and nonverbal intellectual ability, children exposed to valproate scored lower, but not significantly lower, than children exposed to the other drugs.

In terms of developmental milestones, this finding could bode ill for the valproate-exposed children, said Dr. Baker. “Without a cohesive and intact language system, a child's neurodevelopmental progress will be limited.”

Unlike the physical results of in utero valproate exposure, which can be surgically corrected to at least some degree, the cognitive effects cannot be erased, he pointed out. The best hope for such children is early identification and intervention. “If we identify them now, we have to think about an appropriate intervention now. If we leave it for later, the gains they might make will be limited.”

“For women for whom sodium valproate is the first choice because of the nature of their seizures, we should be thinking about reducing the dose to the least possible effective level,” he said.

“In an ideal world, we would have preconception counseling and would be thinking of an alternative drug several years before pregnancy.”

Disclosures: The NEAD study is funded by the National Institutes of Health. Dr. Baker said he had no financial disclosures.

BANGKOK, THAILAND — Expressive and receptive language abilities are significantly poorer in 3-year-olds who were exposed to sodium valproate in utero than they are in children who were exposed to other individual antiepileptic drugs during gestation, based on a subanalysis of the Neurodevelopmental Effects of Antiepileptic Drugs study.

Valproate exposure was associated with a 10-point difference on both language measures compared with exposure to phenytoin, carbamazepine, or lamotrigine—a difference that is not only statistically significant, but clinically important as well, Gus A. Baker, Ph.D., said at the World Congress of Neurology.

The differences apparent in these 3-year-old subjects will likely expand as the groups grow older, said Dr. Baker, director of the division of neurosciences at the Walton Centre for Neurology and Neurosurgery in Liverpool, England. “We can expect the difference in the magnitude to get greater and not smaller with age,” he said. Already, Dr. Baker noted, valproate-exposed 3-year-olds in the U.K. portion of the study are lagging behind a group of matched controls. “Well over a third of those exposed to valproate have been referred for speech therapy, so we see that this 10-point difference has real meaning in terms of day-to-day practice.”

The prospective, observational Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study included 303 pregnant women who were taking sodium valproate, carbamazepine, lamotrigine, or phenytoin as monotherapy. Enrollment occurred during 1999-2004 in 25 epilepsy centers in the United States and the United Kingdom. Separate investigations in the United States and the United Kingdom were later combined. The primary outcome was cognitive performance of the children at 6 years of age.

Dr. Baker, a primary investigator in the U.K. study and coinvestigator in the overall study, presented the results of the drugs' effect on expressive and receptive language development among 234 children who were 3 years old at assessment. The children all underwent testing of verbal and nonverbal communication, including expressive and receptive language, visual motor construction, and nonverbal intellectual ability.

Their abilities in these areas were determined by calculating subscores on screening tests called the Differential Ability Scales (2nd ed.) and the Preschool Language Scale (4th Ed.). The scores were adjusted for factors known to affect child intellect.

“We saw that maternal IQ, antiepileptic drug (AED) dose, maternal age, gestational age, and preconceptional exposure to folate were significant factors predicting the scores, as we would expect,” he said. “But we also showed that overall, the scores for valproate-exposed children were significantly lower than all other drugs and the magnitude of the effect was greater for verbal than nonverbal language.”

Testing showed that the children exposed to valproate scored significantly lower on measures of expressive language (mean score of 91 vs. 102 for carbamazepine, 104 for lamotrigine, and 101 for phenytoin) and receptive language (mean score of 89 vs. 97 for carbamazepine, 101 for lamotrigine, and 101 for phenytoin). On visual motor construction and nonverbal intellectual ability, children exposed to valproate scored lower, but not significantly lower, than children exposed to the other drugs.

In terms of developmental milestones, this finding could bode ill for the valproate-exposed children, said Dr. Baker. “Without a cohesive and intact language system, a child's neurodevelopmental progress will be limited.”

Unlike the physical results of in utero valproate exposure, which can be surgically corrected to at least some degree, the cognitive effects cannot be erased, he pointed out. The best hope for such children is early identification and intervention. “If we identify them now, we have to think about an appropriate intervention now. If we leave it for later, the gains they might make will be limited.”

“For women for whom sodium valproate is the first choice because of the nature of their seizures, we should be thinking about reducing the dose to the least possible effective level,” he said.

“In an ideal world, we would have preconception counseling and would be thinking of an alternative drug several years before pregnancy.”

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

Disclosures: Dr. Caughey disclosed having no potential conflicts of interest related to his presentation.

SAN FRANCISCO — Paternal race may play as big a role in the risk for gestational diabetes as maternal race, according to the results of preliminary studies.

Among white, Asian, and interracial white-Asian couples who delivered babies at Stanford University's Lucile Packard Children's Hospital from 2000 to 2005, the risk for gestational diabetes was 1.6% for 5,575 white couples, 3.4% for 178 couples with a white mother and Asian father, 3.9% for 690 couples with an Asian mother and white father, and 5.7% for Asian couples, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Compared with white couples, the adjusted odds ratio for gestational diabetes was 2.4 in white mother and Asian father couples, 2.6 in Asian mother and white father couples, and 4.7 in Asian couples, the retrospective cohort study found (Am. J. Obstet. Gynecol. 2008;199:385.e1-385.e5).

Some of the difference in risk might be due to sociocultural differences, such as diet, said Dr. Caughey, a study coinvestigator and medical director of the Diabetes and Pregnancy Program at the University of California. However, diet “doesn't seem likely, when you think of the Asian diet versus the Western diet.”

He posited that the association between paternal race and gestational diabetes risk may be influenced by placental hormones that are driven through a genetic association with the father.

Using data from Kaiser Permanente, Dr. Caughey reproduced the finding of an association between paternal race and the risk for gestational diabetes. “I found that in Latinas, the paternal ethnicity is even more important than the maternal ethnicity, which I think is kind of surprising and interesting,” he said. Those findings have not been published.

Maternal race is one of five widely accepted risk factors for gestational diabetes, though there is some controversy. (The other risk factors include age, body mass index, a history of diabetes, and a history of macrosomia.)

Women who have Latina, Native American, south or east Asian, or Pacific Island heritage are at increased risk for gestational diabetes, compared with white women. Older studies that indicated that African American race was associated with gestational diabetes have been called into question because many were conducted in the southern United States, where the prevalence of obesity is high. And the studies did not control for body mass index, Dr. Caughey said.

He and associates looked at Kaiser Permanente data in the San Francisco Bay Area and found no difference in gestational diabetes risk between African Americans and whites. Another recent study in Boston, however, did find an association between African American race and gestational diabetes risk.

It is not clear at this point whether African American race is a risk factor for gestational diabetes. “I think it might be a risk factor, but it's probably very low,” he said.

Race also plays a role in setting screening thresholds for gestational diabetes and deciding which patients to send for diagnostic testing. In general, if the screening threshold is a glucose challenge test result of 140 mg/dL, 14% of women will screen positive (for 80% sensitivity). If the threshold is 130 mg/dL, 23% will screen positive (for 90% sensitivity).

The sensitivity and specificity can vary, however, by ethnicity. Choosing the appropriate screen-positive threshold “really depends on what your goal is,” Dr. Caughey said.

To reach at least 90% sensitivity in all racial groups, the threshold must be lowered from 140 mg/dL to 135 mg/dL. On the other hand, if the goal is a 10% screen-positive rate (specificity), the threshold must go as high as 150 mg/dL for Asians and as low as 135 mg/dL for African Americans, he said. Variations can be seen when stratifying patients by obesity or age, not just race.

Disclosures: The study was funded by the American Diabetes Association. Coauthor Dr. Teresa A. Hillier was funded by a 1-year ADA-European Association for the Study of Diabetes Trans-Atlantic Fellowship.

Women of Korean, Chinese, and Filipino descent are more than twice as likely to develop gestational diabetes as Caucasian or African American women, according to a data analysis of more than 16,000 pregnant women in Hawaii.

Gestational diabetes occurs in 4%-8% of all pregnant women, wrote Kathryn L. Pedula and her colleagues. Data from a pair of recent U.S. studies suggested that Asians have a higher prevalence of gestational diabetes mellitus (GDM) than do other ethnicities, but differences among subcategories of Asian populations have not been well studied.

Ms. Pedula and her associates at the Center for Health Research, Kaiser Permanente Northwest in Portland, Ore., reviewed 10 years' worth of data from 22,110 pregnancies in 16,757 women. Hawaii was chosen for the study because of its ethnically diverse population (Ethn. Dis. 2009;19:414-9).

A total of 353 women had pre-existing diabetes. The remaining women underwent screening for GDM between 24 and 28 weeks of pregnancy, using the 50-gram, 1-hour glucose challenge test (GCT). Women with plasma glucose levels greater than 200 mg/dL on the GCT were deemed to have GDM and were not tested further. The remaining women with a GCT value greater than 140 mg/dL underwent the 100-gram, 3-hour oral glucose tolerance test.

Overall, 20.9% of the women had a positive GCT (plasma glucose at least 140 mg/dL). Approximately 4% had GDM based on the National Diabetes Data Group (NDDG) criteria, and 7% had GDM based on the Carpenter and Coustan (C&C) criteria.

After adjusting for age, the investigators found that 10% of the Korean women had GDM based on the C&C criteria, followed by 9.8% of Chinese women and 8.3% among Filipino women. The prevalence was lowest among African Americans (3.3%) and Caucasians (4.2%).

Based on the NDDG criteria, Puerto Rican women had the highest age-adjusted prevalence of GDM (7.4%), but this was barely higher than the average when C&C criteria were applied. However, Korean, Filipino, and Chinese women had the next highest prevalences of GDM, at 6.4%, 5.8%, and 5.6%, respectively, based on the NDDG criteria. Again, Caucasians and African Americans had the lowest prevalence of GDM, at 2.5% and 2.2%, respectively.

The study included women aged 13-39 years who gave birth in Hawaii between 1995 and 2003. The Asian population was divided into five subgroups: Korean, Chinese, Japanese, Vietnamese, and Filipino. Additional groups included Samoan, Puerto Rican, Native Hawaiian, Caucasian, African American, Native American, other Hispanic, and other Pacific Islander.

The results suggest that the risks for developing GDM may vary greatly depending on specific ethnic background. “These findings point to the need for further research along several avenues, such as maternal-child outcome differences and perhaps ethnic-specific guidelines for GDM diagnosis,” the researchers said.

Chinese women had a high gestational diabetes prevalence at 5.6%.

Source ©Thye Aun Ngo/Fotolia.com

Disclosures: The study was funded by the American Diabetes Association. Coauthor Dr. Teresa A. Hillier was funded by a 1-year ADA-European Association for the Study of Diabetes Trans-Atlantic Fellowship.

Women of Korean, Chinese, and Filipino descent are more than twice as likely to develop gestational diabetes as Caucasian or African American women, according to a data analysis of more than 16,000 pregnant women in Hawaii.

Gestational diabetes occurs in 4%-8% of all pregnant women, wrote Kathryn L. Pedula and her colleagues. Data from a pair of recent U.S. studies suggested that Asians have a higher prevalence of gestational diabetes mellitus (GDM) than do other ethnicities, but differences among subcategories of Asian populations have not been well studied.

Ms. Pedula and her associates at the Center for Health Research, Kaiser Permanente Northwest in Portland, Ore., reviewed 10 years' worth of data from 22,110 pregnancies in 16,757 women. Hawaii was chosen for the study because of its ethnically diverse population (Ethn. Dis. 2009;19:414-9).

A total of 353 women had pre-existing diabetes. The remaining women underwent screening for GDM between 24 and 28 weeks of pregnancy, using the 50-gram, 1-hour glucose challenge test (GCT). Women with plasma glucose levels greater than 200 mg/dL on the GCT were deemed to have GDM and were not tested further. The remaining women with a GCT value greater than 140 mg/dL underwent the 100-gram, 3-hour oral glucose tolerance test.

Overall, 20.9% of the women had a positive GCT (plasma glucose at least 140 mg/dL). Approximately 4% had GDM based on the National Diabetes Data Group (NDDG) criteria, and 7% had GDM based on the Carpenter and Coustan (C&C) criteria.

After adjusting for age, the investigators found that 10% of the Korean women had GDM based on the C&C criteria, followed by 9.8% of Chinese women and 8.3% among Filipino women. The prevalence was lowest among African Americans (3.3%) and Caucasians (4.2%).

Based on the NDDG criteria, Puerto Rican women had the highest age-adjusted prevalence of GDM (7.4%), but this was barely higher than the average when C&C criteria were applied. However, Korean, Filipino, and Chinese women had the next highest prevalences of GDM, at 6.4%, 5.8%, and 5.6%, respectively, based on the NDDG criteria. Again, Caucasians and African Americans had the lowest prevalence of GDM, at 2.5% and 2.2%, respectively.

The study included women aged 13-39 years who gave birth in Hawaii between 1995 and 2003. The Asian population was divided into five subgroups: Korean, Chinese, Japanese, Vietnamese, and Filipino. Additional groups included Samoan, Puerto Rican, Native Hawaiian, Caucasian, African American, Native American, other Hispanic, and other Pacific Islander.

The results suggest that the risks for developing GDM may vary greatly depending on specific ethnic background. “These findings point to the need for further research along several avenues, such as maternal-child outcome differences and perhaps ethnic-specific guidelines for GDM diagnosis,” the researchers said.

Chinese women had a high gestational diabetes prevalence at 5.6%.

Source ©Thye Aun Ngo/Fotolia.com

Disclosures: The study was funded by the American Diabetes Association. Coauthor Dr. Teresa A. Hillier was funded by a 1-year ADA-European Association for the Study of Diabetes Trans-Atlantic Fellowship.

Women of Korean, Chinese, and Filipino descent are more than twice as likely to develop gestational diabetes as Caucasian or African American women, according to a data analysis of more than 16,000 pregnant women in Hawaii.

Gestational diabetes occurs in 4%-8% of all pregnant women, wrote Kathryn L. Pedula and her colleagues. Data from a pair of recent U.S. studies suggested that Asians have a higher prevalence of gestational diabetes mellitus (GDM) than do other ethnicities, but differences among subcategories of Asian populations have not been well studied.

Ms. Pedula and her associates at the Center for Health Research, Kaiser Permanente Northwest in Portland, Ore., reviewed 10 years' worth of data from 22,110 pregnancies in 16,757 women. Hawaii was chosen for the study because of its ethnically diverse population (Ethn. Dis. 2009;19:414-9).

A total of 353 women had pre-existing diabetes. The remaining women underwent screening for GDM between 24 and 28 weeks of pregnancy, using the 50-gram, 1-hour glucose challenge test (GCT). Women with plasma glucose levels greater than 200 mg/dL on the GCT were deemed to have GDM and were not tested further. The remaining women with a GCT value greater than 140 mg/dL underwent the 100-gram, 3-hour oral glucose tolerance test.

Overall, 20.9% of the women had a positive GCT (plasma glucose at least 140 mg/dL). Approximately 4% had GDM based on the National Diabetes Data Group (NDDG) criteria, and 7% had GDM based on the Carpenter and Coustan (C&C) criteria.

After adjusting for age, the investigators found that 10% of the Korean women had GDM based on the C&C criteria, followed by 9.8% of Chinese women and 8.3% among Filipino women. The prevalence was lowest among African Americans (3.3%) and Caucasians (4.2%).

Based on the NDDG criteria, Puerto Rican women had the highest age-adjusted prevalence of GDM (7.4%), but this was barely higher than the average when C&C criteria were applied. However, Korean, Filipino, and Chinese women had the next highest prevalences of GDM, at 6.4%, 5.8%, and 5.6%, respectively, based on the NDDG criteria. Again, Caucasians and African Americans had the lowest prevalence of GDM, at 2.5% and 2.2%, respectively.

The study included women aged 13-39 years who gave birth in Hawaii between 1995 and 2003. The Asian population was divided into five subgroups: Korean, Chinese, Japanese, Vietnamese, and Filipino. Additional groups included Samoan, Puerto Rican, Native Hawaiian, Caucasian, African American, Native American, other Hispanic, and other Pacific Islander.

The results suggest that the risks for developing GDM may vary greatly depending on specific ethnic background. “These findings point to the need for further research along several avenues, such as maternal-child outcome differences and perhaps ethnic-specific guidelines for GDM diagnosis,” the researchers said.

Chinese women had a high gestational diabetes prevalence at 5.6%.

Source ©Thye Aun Ngo/Fotolia.com

Disclosures: Dr. Stephenson disclosed receiving faculty honorarium from EMD Serono Inc. The study was supported by the Canadian Blood Services/Bayer Partnership Fund, the National Institutes of Health, and Talecris BioTherapeutics.

ATLANTA — Intravenous immunoglobulin was not beneficial in the treatment of idiopathic secondary recurrent miscarriage in the largest prospective randomized IVIG trial in this setting.

The live birth rate was 70% for women who received intravenous immunoglobulin and 63% for those given saline in the phase III multicenter trial of 77 women with a history of pregnancy of at least 20 weeks followed by at least three unexplained miscarriages of less than 20 weeks, all with the current partner. The difference was not statistically significant.

Once a pregnancy reached 6 weeks' gestation, the live birth rate was 94% in both groups, said Dr. Mary D. Stephenson, director of the recurrent pregnancy loss program at the University of Chicago.

Mean birth weights were significantly higher in the IVIG group at 3,711 g vs. 3,140 g in the control group (P value less than .010). When preterm infants and twins were excluded, however, birth weights were not statistically different (3,711 g vs. 3,358 g).

The study was designed to enroll 178 women, but was stopped early based on these interim results, said Dr. Stephenson, who called the key finding surprising.

She suggested that the favorable live birth rates in both groups may have been due to close monitoring with ultrasound in the first trimester and supportive care throughout the pregnancy, which have been shown to be advantageous in women with recurrent miscarriage.

“I also think it could be because we're not yet there in being able to select the most appropriate patients that could benefit from such immunotherapy,” she said. “Only 18% of prior miscarriages had been sent for chromosome testing, so that raises the question as to whether there were too many miscarriages that may have had random chromosome errors.”

A recent meta-analysis of eight randomized trials involving 442 women found a significant increase in live births following IVIG use in women with a secondary recurrent miscarriage (odds ratio, 2.71), while women with a primary miscarriage did not have the same benefit (OR, 0.66). The authors recommended further randomized trials, however, as the studies had small sample sizes and lacked homogeneity (BJOG 2007;114:134-42). When data from the current study were combined with data from the four prior secondary miscarriage trials in the meta-analysis, the odds ratio for a live birth was 2.16, favoring IVIG, Dr. Stephenson said.

The current study enrolled 82 women and after 5 withdrawals, randomized 38 women to IVIG (Gamunex or Gamimune) 500 mg/kg and 39 women to an equivalent volume of normal saline infused prior to ovulation for a maximum of six cycles and continued every 4 weeks until 18-20 weeks of pregnancy.

There were 23 pregnancies in the IVIG group and 24 in the control group. There was no difference in mean maternal age (36 vs. 35 years), mean body mass index (26 vs. 25 kg/m

Disclosures: Dr. Stephenson disclosed receiving faculty honorarium from EMD Serono Inc. The study was supported by the Canadian Blood Services/Bayer Partnership Fund, the National Institutes of Health, and Talecris BioTherapeutics.

ATLANTA — Intravenous immunoglobulin was not beneficial in the treatment of idiopathic secondary recurrent miscarriage in the largest prospective randomized IVIG trial in this setting.

The live birth rate was 70% for women who received intravenous immunoglobulin and 63% for those given saline in the phase III multicenter trial of 77 women with a history of pregnancy of at least 20 weeks followed by at least three unexplained miscarriages of less than 20 weeks, all with the current partner. The difference was not statistically significant.

Once a pregnancy reached 6 weeks' gestation, the live birth rate was 94% in both groups, said Dr. Mary D. Stephenson, director of the recurrent pregnancy loss program at the University of Chicago.

Mean birth weights were significantly higher in the IVIG group at 3,711 g vs. 3,140 g in the control group (P value less than .010). When preterm infants and twins were excluded, however, birth weights were not statistically different (3,711 g vs. 3,358 g).

The study was designed to enroll 178 women, but was stopped early based on these interim results, said Dr. Stephenson, who called the key finding surprising.

She suggested that the favorable live birth rates in both groups may have been due to close monitoring with ultrasound in the first trimester and supportive care throughout the pregnancy, which have been shown to be advantageous in women with recurrent miscarriage.

“I also think it could be because we're not yet there in being able to select the most appropriate patients that could benefit from such immunotherapy,” she said. “Only 18% of prior miscarriages had been sent for chromosome testing, so that raises the question as to whether there were too many miscarriages that may have had random chromosome errors.”

A recent meta-analysis of eight randomized trials involving 442 women found a significant increase in live births following IVIG use in women with a secondary recurrent miscarriage (odds ratio, 2.71), while women with a primary miscarriage did not have the same benefit (OR, 0.66). The authors recommended further randomized trials, however, as the studies had small sample sizes and lacked homogeneity (BJOG 2007;114:134-42). When data from the current study were combined with data from the four prior secondary miscarriage trials in the meta-analysis, the odds ratio for a live birth was 2.16, favoring IVIG, Dr. Stephenson said.

The current study enrolled 82 women and after 5 withdrawals, randomized 38 women to IVIG (Gamunex or Gamimune) 500 mg/kg and 39 women to an equivalent volume of normal saline infused prior to ovulation for a maximum of six cycles and continued every 4 weeks until 18-20 weeks of pregnancy.

There were 23 pregnancies in the IVIG group and 24 in the control group. There was no difference in mean maternal age (36 vs. 35 years), mean body mass index (26 vs. 25 kg/m

Disclosures: Dr. Stephenson disclosed receiving faculty honorarium from EMD Serono Inc. The study was supported by the Canadian Blood Services/Bayer Partnership Fund, the National Institutes of Health, and Talecris BioTherapeutics.

ATLANTA — Intravenous immunoglobulin was not beneficial in the treatment of idiopathic secondary recurrent miscarriage in the largest prospective randomized IVIG trial in this setting.

The live birth rate was 70% for women who received intravenous immunoglobulin and 63% for those given saline in the phase III multicenter trial of 77 women with a history of pregnancy of at least 20 weeks followed by at least three unexplained miscarriages of less than 20 weeks, all with the current partner. The difference was not statistically significant.

Once a pregnancy reached 6 weeks' gestation, the live birth rate was 94% in both groups, said Dr. Mary D. Stephenson, director of the recurrent pregnancy loss program at the University of Chicago.

Mean birth weights were significantly higher in the IVIG group at 3,711 g vs. 3,140 g in the control group (P value less than .010). When preterm infants and twins were excluded, however, birth weights were not statistically different (3,711 g vs. 3,358 g).

The study was designed to enroll 178 women, but was stopped early based on these interim results, said Dr. Stephenson, who called the key finding surprising.

She suggested that the favorable live birth rates in both groups may have been due to close monitoring with ultrasound in the first trimester and supportive care throughout the pregnancy, which have been shown to be advantageous in women with recurrent miscarriage.

“I also think it could be because we're not yet there in being able to select the most appropriate patients that could benefit from such immunotherapy,” she said. “Only 18% of prior miscarriages had been sent for chromosome testing, so that raises the question as to whether there were too many miscarriages that may have had random chromosome errors.”

A recent meta-analysis of eight randomized trials involving 442 women found a significant increase in live births following IVIG use in women with a secondary recurrent miscarriage (odds ratio, 2.71), while women with a primary miscarriage did not have the same benefit (OR, 0.66). The authors recommended further randomized trials, however, as the studies had small sample sizes and lacked homogeneity (BJOG 2007;114:134-42). When data from the current study were combined with data from the four prior secondary miscarriage trials in the meta-analysis, the odds ratio for a live birth was 2.16, favoring IVIG, Dr. Stephenson said.

The current study enrolled 82 women and after 5 withdrawals, randomized 38 women to IVIG (Gamunex or Gamimune) 500 mg/kg and 39 women to an equivalent volume of normal saline infused prior to ovulation for a maximum of six cycles and continued every 4 weeks until 18-20 weeks of pregnancy.

There were 23 pregnancies in the IVIG group and 24 in the control group. There was no difference in mean maternal age (36 vs. 35 years), mean body mass index (26 vs. 25 kg/m

Disclosures: The Calcium for Preeclampsia Prevention trial and the substudy presented here were funded by the National Institutes of Health. The substudy of the Nord-Trondelag Health Study was supported by the Norwegian University of Science and Technology and by the Central Norway Regional Health Authority. One of the investigators has financial ties to several pharmaceutical companies and has been named coinventor on several patents related to preeclampsia.

New evidence has strengthened the link between preeclampsia and reduced thyroid function during pregnancy, and has shown that the association persists for decades.

Women who have had preeclampsia should be monitored for reduced thyroid function after pregnancy, according to Dr. Richard J. Levine.

“We can't say for sure until we have some other studies out there that will link it more tightly,” Dr. Levine of the National Institute of Child Health and Human Development's division of epidemiology, statistics, and prevention research, said in an interview. “But I think it's worthwhile to look for reduced thyroid function in these women now. It's such an easy test to do, and the treatment is so cheap. I think it should be done.”

In an article published online in BMJ, two separate studies were reported (2009 Nov. 17 [doi:10.1136/bmj.b4336]). In the first Dr. Levine and his colleagues examined stored blood samples from a U.S. trial, Calcium for Preeclampsia Prevention, to check TSH levels early and later in pregnancy, in a comparison of 141 women who developed preeclampsia with 141 controls.

Whereas TSH did not vary significantly between the two groups early in pregnancy, by the time of delivery, those who developed preeclampsia had twice the risk of exhibiting high TSH levels, compared with controls.

Moreover, the increase in TSH level was significantly associated with increasing quartiles of soluble fms-like tyrosine kinase 1 (sFlt-1), which “may be responsible for the clinical phenotype of preeclampsia,” the investigators wrote.

In the second study, Dr. Levine and his colleagues analyzed the Norwegian Nord-Trondelag Health Study of 7,121 women who had given birth to a first child in 1967 or later, and measurements of thyroid function 20 or more years later. They found that those who had preeclampsia in their first pregnancy were 70% more likely to have high thyroid-stimulating hormone concentrations years later than were women who had not had preeclampsia. Those who had preeclampsia in two pregnancies had a nearly sixfold increased risk of high TSH levels.

“Increased circulating concentrations of [sFlt-1], most notably after onset of preeclampsia, were associated with subtle abnormalities of the thyroid during pregnancy. “These in turn may predispose to the development of reduced thyroid function and possibly overt hypothyroidism in later life,” they wrote.

“The hypothesis is fascinating and has to be explored further,” said Dr. Marshall D. Lindheimer, professor emeritus of obstetrics and gynecology and of medicine at the University of Chicago.

Disclosures: The Calcium for Preeclampsia Prevention trial and the substudy presented here were funded by the National Institutes of Health. The substudy of the Nord-Trondelag Health Study was supported by the Norwegian University of Science and Technology and by the Central Norway Regional Health Authority. One of the investigators has financial ties to several pharmaceutical companies and has been named coinventor on several patents related to preeclampsia.

New evidence has strengthened the link between preeclampsia and reduced thyroid function during pregnancy, and has shown that the association persists for decades.

Women who have had preeclampsia should be monitored for reduced thyroid function after pregnancy, according to Dr. Richard J. Levine.

“We can't say for sure until we have some other studies out there that will link it more tightly,” Dr. Levine of the National Institute of Child Health and Human Development's division of epidemiology, statistics, and prevention research, said in an interview. “But I think it's worthwhile to look for reduced thyroid function in these women now. It's such an easy test to do, and the treatment is so cheap. I think it should be done.”

In an article published online in BMJ, two separate studies were reported (2009 Nov. 17 [doi:10.1136/bmj.b4336]). In the first Dr. Levine and his colleagues examined stored blood samples from a U.S. trial, Calcium for Preeclampsia Prevention, to check TSH levels early and later in pregnancy, in a comparison of 141 women who developed preeclampsia with 141 controls.

Whereas TSH did not vary significantly between the two groups early in pregnancy, by the time of delivery, those who developed preeclampsia had twice the risk of exhibiting high TSH levels, compared with controls.

Moreover, the increase in TSH level was significantly associated with increasing quartiles of soluble fms-like tyrosine kinase 1 (sFlt-1), which “may be responsible for the clinical phenotype of preeclampsia,” the investigators wrote.

In the second study, Dr. Levine and his colleagues analyzed the Norwegian Nord-Trondelag Health Study of 7,121 women who had given birth to a first child in 1967 or later, and measurements of thyroid function 20 or more years later. They found that those who had preeclampsia in their first pregnancy were 70% more likely to have high thyroid-stimulating hormone concentrations years later than were women who had not had preeclampsia. Those who had preeclampsia in two pregnancies had a nearly sixfold increased risk of high TSH levels.

“Increased circulating concentrations of [sFlt-1], most notably after onset of preeclampsia, were associated with subtle abnormalities of the thyroid during pregnancy. “These in turn may predispose to the development of reduced thyroid function and possibly overt hypothyroidism in later life,” they wrote.

“The hypothesis is fascinating and has to be explored further,” said Dr. Marshall D. Lindheimer, professor emeritus of obstetrics and gynecology and of medicine at the University of Chicago.

Disclosures: The Calcium for Preeclampsia Prevention trial and the substudy presented here were funded by the National Institutes of Health. The substudy of the Nord-Trondelag Health Study was supported by the Norwegian University of Science and Technology and by the Central Norway Regional Health Authority. One of the investigators has financial ties to several pharmaceutical companies and has been named coinventor on several patents related to preeclampsia.

New evidence has strengthened the link between preeclampsia and reduced thyroid function during pregnancy, and has shown that the association persists for decades.

Women who have had preeclampsia should be monitored for reduced thyroid function after pregnancy, according to Dr. Richard J. Levine.

“We can't say for sure until we have some other studies out there that will link it more tightly,” Dr. Levine of the National Institute of Child Health and Human Development's division of epidemiology, statistics, and prevention research, said in an interview. “But I think it's worthwhile to look for reduced thyroid function in these women now. It's such an easy test to do, and the treatment is so cheap. I think it should be done.”

In an article published online in BMJ, two separate studies were reported (2009 Nov. 17 [doi:10.1136/bmj.b4336]). In the first Dr. Levine and his colleagues examined stored blood samples from a U.S. trial, Calcium for Preeclampsia Prevention, to check TSH levels early and later in pregnancy, in a comparison of 141 women who developed preeclampsia with 141 controls.

Whereas TSH did not vary significantly between the two groups early in pregnancy, by the time of delivery, those who developed preeclampsia had twice the risk of exhibiting high TSH levels, compared with controls.

Moreover, the increase in TSH level was significantly associated with increasing quartiles of soluble fms-like tyrosine kinase 1 (sFlt-1), which “may be responsible for the clinical phenotype of preeclampsia,” the investigators wrote.

In the second study, Dr. Levine and his colleagues analyzed the Norwegian Nord-Trondelag Health Study of 7,121 women who had given birth to a first child in 1967 or later, and measurements of thyroid function 20 or more years later. They found that those who had preeclampsia in their first pregnancy were 70% more likely to have high thyroid-stimulating hormone concentrations years later than were women who had not had preeclampsia. Those who had preeclampsia in two pregnancies had a nearly sixfold increased risk of high TSH levels.

“Increased circulating concentrations of [sFlt-1], most notably after onset of preeclampsia, were associated with subtle abnormalities of the thyroid during pregnancy. “These in turn may predispose to the development of reduced thyroid function and possibly overt hypothyroidism in later life,” they wrote.

“The hypothesis is fascinating and has to be explored further,” said Dr. Marshall D. Lindheimer, professor emeritus of obstetrics and gynecology and of medicine at the University of Chicago.

Disclosures: Dr. Gabrielli disclosed no conflicts of interest.

HAMBURG, GERMANY — Magnetic resonance imaging has a limited role when added to ultrasound in the prenatal diagnosis of fetal anomalies, results of a prospective cohort study suggested.

“Prenatal ultrasound is accurate in over 90% of cases, and MRI adds significant information in [only] a minority of cases,” lead author Dr. Sandro Gabrielli said at the 19th World Congress on Ultrasound in Obstetrics and Gynecology.

In 273 consecutive patients, MRI was performed to evaluate its accuracy compared with ultrasound in cases that were included because they were complex, because they were difficult to diagnose with ultrasound, or because ultrasound quality was poor.

Both ultrasound and MRI findings were in agreement with postnatal diagnoses in 90% of cases. Ultrasound was better than MRI in an additional 1% of cases and MRI was better in an additional 6%. Both modalities missed anomalies in 3%.

MRI was performed by expert pediatric neuroradiologists and radiologists, who were blinded to the ultrasound findings. The mean gestational age at diagnosis was 28 weeks for ultrasound and 30 weeks for MRI, at a range of 24-32 and 26-34 weeks, respectively.

“It is impossible to identify specific indications for MRI, apart from cases in which ultrasound gives suboptimal results,” said Dr. Gabrielli of the department of obstetrics and gynecology at St. Orsola University Hospital in Bologna, Italy.

Relevant additional information was provided by MRI in 2 of 126 central nervous system anomalies, 4 of 42 thoracic defects, and 2 of 35 abdominal malformations. Ultrasound provided extra information in one CNS anomaly, one thoracic defect, and one abdominal malformation. The seven cases in which both modalities failed to reveal anomalies were three cases of the rare cerebro-oculo-facio-skeletal syndrome, three CNS anomalies, and one abdominal malformation.

During a discussion of the study, audience members noted that both techniques are highly operator dependent. The ultrasound and MRI examiners in the study were all experts, responded Dr. Gabrielli, who added that results did improve over the course of the series, which ran from 2001 to 2009.

Dr. Ilan Timor-Tritsch, who also presented during the session and is director of obstetrical and gynecological ultrasound at New York University Medical Center, called for the development of teams of obstetricians interested in all aspects of fetal ultrasound and MRI to improve diagnostic accuracy. “MRI, at least in the United States, is in many, many places the replacement for a poor ultrasound.”

Disclosures: Dr. Gabrielli disclosed no conflicts of interest.

HAMBURG, GERMANY — Magnetic resonance imaging has a limited role when added to ultrasound in the prenatal diagnosis of fetal anomalies, results of a prospective cohort study suggested.

“Prenatal ultrasound is accurate in over 90% of cases, and MRI adds significant information in [only] a minority of cases,” lead author Dr. Sandro Gabrielli said at the 19th World Congress on Ultrasound in Obstetrics and Gynecology.

In 273 consecutive patients, MRI was performed to evaluate its accuracy compared with ultrasound in cases that were included because they were complex, because they were difficult to diagnose with ultrasound, or because ultrasound quality was poor.

Both ultrasound and MRI findings were in agreement with postnatal diagnoses in 90% of cases. Ultrasound was better than MRI in an additional 1% of cases and MRI was better in an additional 6%. Both modalities missed anomalies in 3%.

MRI was performed by expert pediatric neuroradiologists and radiologists, who were blinded to the ultrasound findings. The mean gestational age at diagnosis was 28 weeks for ultrasound and 30 weeks for MRI, at a range of 24-32 and 26-34 weeks, respectively.

“It is impossible to identify specific indications for MRI, apart from cases in which ultrasound gives suboptimal results,” said Dr. Gabrielli of the department of obstetrics and gynecology at St. Orsola University Hospital in Bologna, Italy.

Relevant additional information was provided by MRI in 2 of 126 central nervous system anomalies, 4 of 42 thoracic defects, and 2 of 35 abdominal malformations. Ultrasound provided extra information in one CNS anomaly, one thoracic defect, and one abdominal malformation. The seven cases in which both modalities failed to reveal anomalies were three cases of the rare cerebro-oculo-facio-skeletal syndrome, three CNS anomalies, and one abdominal malformation.

During a discussion of the study, audience members noted that both techniques are highly operator dependent. The ultrasound and MRI examiners in the study were all experts, responded Dr. Gabrielli, who added that results did improve over the course of the series, which ran from 2001 to 2009.

Dr. Ilan Timor-Tritsch, who also presented during the session and is director of obstetrical and gynecological ultrasound at New York University Medical Center, called for the development of teams of obstetricians interested in all aspects of fetal ultrasound and MRI to improve diagnostic accuracy. “MRI, at least in the United States, is in many, many places the replacement for a poor ultrasound.”

Disclosures: Dr. Gabrielli disclosed no conflicts of interest.

HAMBURG, GERMANY — Magnetic resonance imaging has a limited role when added to ultrasound in the prenatal diagnosis of fetal anomalies, results of a prospective cohort study suggested.

“Prenatal ultrasound is accurate in over 90% of cases, and MRI adds significant information in [only] a minority of cases,” lead author Dr. Sandro Gabrielli said at the 19th World Congress on Ultrasound in Obstetrics and Gynecology.

In 273 consecutive patients, MRI was performed to evaluate its accuracy compared with ultrasound in cases that were included because they were complex, because they were difficult to diagnose with ultrasound, or because ultrasound quality was poor.

Both ultrasound and MRI findings were in agreement with postnatal diagnoses in 90% of cases. Ultrasound was better than MRI in an additional 1% of cases and MRI was better in an additional 6%. Both modalities missed anomalies in 3%.

MRI was performed by expert pediatric neuroradiologists and radiologists, who were blinded to the ultrasound findings. The mean gestational age at diagnosis was 28 weeks for ultrasound and 30 weeks for MRI, at a range of 24-32 and 26-34 weeks, respectively.

“It is impossible to identify specific indications for MRI, apart from cases in which ultrasound gives suboptimal results,” said Dr. Gabrielli of the department of obstetrics and gynecology at St. Orsola University Hospital in Bologna, Italy.

Relevant additional information was provided by MRI in 2 of 126 central nervous system anomalies, 4 of 42 thoracic defects, and 2 of 35 abdominal malformations. Ultrasound provided extra information in one CNS anomaly, one thoracic defect, and one abdominal malformation. The seven cases in which both modalities failed to reveal anomalies were three cases of the rare cerebro-oculo-facio-skeletal syndrome, three CNS anomalies, and one abdominal malformation.

During a discussion of the study, audience members noted that both techniques are highly operator dependent. The ultrasound and MRI examiners in the study were all experts, responded Dr. Gabrielli, who added that results did improve over the course of the series, which ran from 2001 to 2009.

Dr. Ilan Timor-Tritsch, who also presented during the session and is director of obstetrical and gynecological ultrasound at New York University Medical Center, called for the development of teams of obstetricians interested in all aspects of fetal ultrasound and MRI to improve diagnostic accuracy. “MRI, at least in the United States, is in many, many places the replacement for a poor ultrasound.”

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SAN FRANCISCO — Many women experience minor skin conditions such as pruritus, stretch marks, and melasma during pregnancy, but several serious skin diseases can emerge.

When it comes to treating skin conditions in pregnant women, it is important to remember that there is a great deal of variation in how these patients experience symptoms, Dr. Kristin M. Leiferman explained at a meeting sponsored by Skin Disease Education Foundation.

Many mothers-to-be will endure some degree of skin discomfort such as itching, rather than take medications, she said. “But pregnant women need to be monitored closely for secondary problems associated with skin disorders, including cutaneous infection, fluid balance problems, excessive blistering or erosion, and lack of sleep due to discomfort from itching.”

Dr. Kristin M. Leiferman of the University of Utah, Salt Lake City, reviewed several dermatoses of pregnancy, including:

▸ Polymorphic eruption of pregnancy/pruritic urticarial papules and plaques of pregnancy (PEP/PUPPP). The pathogenesis of PEP/PUPPP remains unknown but many theories persist, including those citing the role of hormones, fetal DNA, and placental factors, Dr. Leiferman said. The condition has a nonspecific inflammatory pattern, and there may be perivascular lymphocytic infiltration in the upper and middle dermis.

The differential diagnosis for PEP/PUPPP should start by ruling out scabies, Dr. Leiferman noted. Once scabies is ruled out, a dermatologist's differential should include pemphigoid gestationis, atopic eruption of pregnancy, contact dermatitis, drug eruption, erythema multiforme, and pityriasis rosea, she said.

▸ Pemphigoid gestationis. This condition is an autoimmune disorder that typically begins with urticaria or blistering around the umbilicus, Dr. Leiferman noted. Until or unless blistering occurs, this condition may be difficult to distinguish from PEP/PUPPP, she said, although PEP/PUPPP does not usually involve the area immediately around the umbilicus.

Pemphigoid gestationis may occur during or immediately after pregnancy, or it can occur with hormone use. The condition can present with urticarial, arch-shaped plaques in addition to dermatitis and blisters. The current evidence suggests that pemphigoid gestationis occurs when the protection of a fetus from the mother's immune response breaks down. When diagnosing pemphigoid gestationis, be sure to rule out varicella and pemphigus vulgaris, Dr. Leiferman emphasized.

▸ Cholestasis of pregnancy. This condition is characterized by a sudden onset of itching, first on the palms and soles, and then the itching becomes generalized. Cholestasis of pregnancy does not include primary skin lesions, but it can have serious effects for both mother and fetus. It may cause gallstones or jaundice in the mother, and increased levels of serum bile salts can enter the fetal circulation and cause a reduction in the level of oxygen in the placenta. The oxygen dip can lead to cardiac depression and increase the risk of prematurity, fetal distress, and stillbirth.

▸ Atopic eruption of pregnancy. This condition encompasses three previously recognized distinct skin conditions—prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema of pregnancy, Dr. Leiferman explained. Most patients have atopic dermatitis, from which the name derives. Studies suggest that approximately half of these patients have signs of eczema and approximately one-third have signs of papules and prurigo.

The histology of atopic eruption of pregnancy is nonspecific, and debate continues as to whether the condition should be considered a distinct dermatosis of pregnancy or an exacerbation of a skin disease with pregnancy, said Dr. Leiferman.

▸ Impetigo herpetiformis. Another disorder previously thought to be a dermatosis of pregnancy is impetigo herpetiformis, now generally regarded as a variant of pustular psoriasis, Dr. Leiferman stated. It rapidly resolves after delivery, but recurrences in subsequent pregnancies are common and are more severe with earlier onset. Neonatal death or stillbirth may result from placental insufficiency. Recurrences with menses can occur for years, she said.

With pregnancy-associated dermatoses, “treatment should be tailored to the symptoms and to the disease with the least amount [of] and least potentially toxic medications that will keep the mother comfortable and the baby safe,” Dr. Leiferman said in an interview.

“Certain pregnancy-associated dermatoses may respond to skin care that helps reduce itching, and to topical medications from which little is absorbed internally,” she explained. By contrast, when the skin is blistered or eroded, more aggressive treatments are needed.

Systemic glucocorticoids, such as prednisone, are the main therapy for pemphigoid gestationis and other severe pregnancy-related skin problems, said Dr. Leiferman. “Their use in pregnancy is well studied, and they generally are tolerated, but they may be associated with placental calcifications and low-birth-weight infants.”

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Many women experience minor skin conditions such as pruritus, stretch marks, and melasma during pregnancy, but several serious skin diseases can emerge.

When it comes to treating skin conditions in pregnant women, it is important to remember that there is a great deal of variation in how these patients experience symptoms, Dr. Kristin M. Leiferman explained at a meeting sponsored by Skin Disease Education Foundation.

Many mothers-to-be will endure some degree of skin discomfort such as itching, rather than take medications, she said. “But pregnant women need to be monitored closely for secondary problems associated with skin disorders, including cutaneous infection, fluid balance problems, excessive blistering or erosion, and lack of sleep due to discomfort from itching.”

Dr. Kristin M. Leiferman of the University of Utah, Salt Lake City, reviewed several dermatoses of pregnancy, including:

▸ Polymorphic eruption of pregnancy/pruritic urticarial papules and plaques of pregnancy (PEP/PUPPP). The pathogenesis of PEP/PUPPP remains unknown but many theories persist, including those citing the role of hormones, fetal DNA, and placental factors, Dr. Leiferman said. The condition has a nonspecific inflammatory pattern, and there may be perivascular lymphocytic infiltration in the upper and middle dermis.

The differential diagnosis for PEP/PUPPP should start by ruling out scabies, Dr. Leiferman noted. Once scabies is ruled out, a dermatologist's differential should include pemphigoid gestationis, atopic eruption of pregnancy, contact dermatitis, drug eruption, erythema multiforme, and pityriasis rosea, she said.

▸ Pemphigoid gestationis. This condition is an autoimmune disorder that typically begins with urticaria or blistering around the umbilicus, Dr. Leiferman noted. Until or unless blistering occurs, this condition may be difficult to distinguish from PEP/PUPPP, she said, although PEP/PUPPP does not usually involve the area immediately around the umbilicus.

Pemphigoid gestationis may occur during or immediately after pregnancy, or it can occur with hormone use. The condition can present with urticarial, arch-shaped plaques in addition to dermatitis and blisters. The current evidence suggests that pemphigoid gestationis occurs when the protection of a fetus from the mother's immune response breaks down. When diagnosing pemphigoid gestationis, be sure to rule out varicella and pemphigus vulgaris, Dr. Leiferman emphasized.

▸ Cholestasis of pregnancy. This condition is characterized by a sudden onset of itching, first on the palms and soles, and then the itching becomes generalized. Cholestasis of pregnancy does not include primary skin lesions, but it can have serious effects for both mother and fetus. It may cause gallstones or jaundice in the mother, and increased levels of serum bile salts can enter the fetal circulation and cause a reduction in the level of oxygen in the placenta. The oxygen dip can lead to cardiac depression and increase the risk of prematurity, fetal distress, and stillbirth.

▸ Atopic eruption of pregnancy. This condition encompasses three previously recognized distinct skin conditions—prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema of pregnancy, Dr. Leiferman explained. Most patients have atopic dermatitis, from which the name derives. Studies suggest that approximately half of these patients have signs of eczema and approximately one-third have signs of papules and prurigo.

The histology of atopic eruption of pregnancy is nonspecific, and debate continues as to whether the condition should be considered a distinct dermatosis of pregnancy or an exacerbation of a skin disease with pregnancy, said Dr. Leiferman.

▸ Impetigo herpetiformis. Another disorder previously thought to be a dermatosis of pregnancy is impetigo herpetiformis, now generally regarded as a variant of pustular psoriasis, Dr. Leiferman stated. It rapidly resolves after delivery, but recurrences in subsequent pregnancies are common and are more severe with earlier onset. Neonatal death or stillbirth may result from placental insufficiency. Recurrences with menses can occur for years, she said.

With pregnancy-associated dermatoses, “treatment should be tailored to the symptoms and to the disease with the least amount [of] and least potentially toxic medications that will keep the mother comfortable and the baby safe,” Dr. Leiferman said in an interview.

“Certain pregnancy-associated dermatoses may respond to skin care that helps reduce itching, and to topical medications from which little is absorbed internally,” she explained. By contrast, when the skin is blistered or eroded, more aggressive treatments are needed.

Systemic glucocorticoids, such as prednisone, are the main therapy for pemphigoid gestationis and other severe pregnancy-related skin problems, said Dr. Leiferman. “Their use in pregnancy is well studied, and they generally are tolerated, but they may be associated with placental calcifications and low-birth-weight infants.”

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Many women experience minor skin conditions such as pruritus, stretch marks, and melasma during pregnancy, but several serious skin diseases can emerge.

When it comes to treating skin conditions in pregnant women, it is important to remember that there is a great deal of variation in how these patients experience symptoms, Dr. Kristin M. Leiferman explained at a meeting sponsored by Skin Disease Education Foundation.

Many mothers-to-be will endure some degree of skin discomfort such as itching, rather than take medications, she said. “But pregnant women need to be monitored closely for secondary problems associated with skin disorders, including cutaneous infection, fluid balance problems, excessive blistering or erosion, and lack of sleep due to discomfort from itching.”

Dr. Kristin M. Leiferman of the University of Utah, Salt Lake City, reviewed several dermatoses of pregnancy, including:

▸ Polymorphic eruption of pregnancy/pruritic urticarial papules and plaques of pregnancy (PEP/PUPPP). The pathogenesis of PEP/PUPPP remains unknown but many theories persist, including those citing the role of hormones, fetal DNA, and placental factors, Dr. Leiferman said. The condition has a nonspecific inflammatory pattern, and there may be perivascular lymphocytic infiltration in the upper and middle dermis.

The differential diagnosis for PEP/PUPPP should start by ruling out scabies, Dr. Leiferman noted. Once scabies is ruled out, a dermatologist's differential should include pemphigoid gestationis, atopic eruption of pregnancy, contact dermatitis, drug eruption, erythema multiforme, and pityriasis rosea, she said.

▸ Pemphigoid gestationis. This condition is an autoimmune disorder that typically begins with urticaria or blistering around the umbilicus, Dr. Leiferman noted. Until or unless blistering occurs, this condition may be difficult to distinguish from PEP/PUPPP, she said, although PEP/PUPPP does not usually involve the area immediately around the umbilicus.

Pemphigoid gestationis may occur during or immediately after pregnancy, or it can occur with hormone use. The condition can present with urticarial, arch-shaped plaques in addition to dermatitis and blisters. The current evidence suggests that pemphigoid gestationis occurs when the protection of a fetus from the mother's immune response breaks down. When diagnosing pemphigoid gestationis, be sure to rule out varicella and pemphigus vulgaris, Dr. Leiferman emphasized.

▸ Cholestasis of pregnancy. This condition is characterized by a sudden onset of itching, first on the palms and soles, and then the itching becomes generalized. Cholestasis of pregnancy does not include primary skin lesions, but it can have serious effects for both mother and fetus. It may cause gallstones or jaundice in the mother, and increased levels of serum bile salts can enter the fetal circulation and cause a reduction in the level of oxygen in the placenta. The oxygen dip can lead to cardiac depression and increase the risk of prematurity, fetal distress, and stillbirth.

▸ Atopic eruption of pregnancy. This condition encompasses three previously recognized distinct skin conditions—prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema of pregnancy, Dr. Leiferman explained. Most patients have atopic dermatitis, from which the name derives. Studies suggest that approximately half of these patients have signs of eczema and approximately one-third have signs of papules and prurigo.

The histology of atopic eruption of pregnancy is nonspecific, and debate continues as to whether the condition should be considered a distinct dermatosis of pregnancy or an exacerbation of a skin disease with pregnancy, said Dr. Leiferman.

▸ Impetigo herpetiformis. Another disorder previously thought to be a dermatosis of pregnancy is impetigo herpetiformis, now generally regarded as a variant of pustular psoriasis, Dr. Leiferman stated. It rapidly resolves after delivery, but recurrences in subsequent pregnancies are common and are more severe with earlier onset. Neonatal death or stillbirth may result from placental insufficiency. Recurrences with menses can occur for years, she said.

With pregnancy-associated dermatoses, “treatment should be tailored to the symptoms and to the disease with the least amount [of] and least potentially toxic medications that will keep the mother comfortable and the baby safe,” Dr. Leiferman said in an interview.

“Certain pregnancy-associated dermatoses may respond to skin care that helps reduce itching, and to topical medications from which little is absorbed internally,” she explained. By contrast, when the skin is blistered or eroded, more aggressive treatments are needed.

Systemic glucocorticoids, such as prednisone, are the main therapy for pemphigoid gestationis and other severe pregnancy-related skin problems, said Dr. Leiferman. “Their use in pregnancy is well studied, and they generally are tolerated, but they may be associated with placental calcifications and low-birth-weight infants.”

SDEF and this news organization are owned by Elsevier.