Obstetrics

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, based on a study of almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized clinical trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women who had mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339–48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target glucose thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia. Individual rates of these complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) also did not differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

“Increased birth weight and neonatal fat mass may have long-term health implications for the offspring of mothers with gestational diabetes mellitus, including an increased risk of impaired glucose tolerance and childhood obesity. Long-term follow-up studies are needed to determine whether treatment of gestational diabetes mellitus can reduce the risk of these complications,” Dr. Landon and his associates wrote.

In the meantime, these study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” they said.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, based on a study of almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized clinical trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women who had mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339–48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target glucose thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia. Individual rates of these complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) also did not differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

“Increased birth weight and neonatal fat mass may have long-term health implications for the offspring of mothers with gestational diabetes mellitus, including an increased risk of impaired glucose tolerance and childhood obesity. Long-term follow-up studies are needed to determine whether treatment of gestational diabetes mellitus can reduce the risk of these complications,” Dr. Landon and his associates wrote.

In the meantime, these study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” they said.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, based on a study of almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized clinical trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women who had mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339–48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target glucose thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia. Individual rates of these complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) also did not differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

“Increased birth weight and neonatal fat mass may have long-term health implications for the offspring of mothers with gestational diabetes mellitus, including an increased risk of impaired glucose tolerance and childhood obesity. Long-term follow-up studies are needed to determine whether treatment of gestational diabetes mellitus can reduce the risk of these complications,” Dr. Landon and his associates wrote.

In the meantime, these study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” they said.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

CHICAGO — A five-factor scoring system that identifies women who nearly die from obstetric morbidity could potentially offer a more meaningful way to measure maternal health care quality between institutions, according to Dr. Whitney You of Northwestern University's Feinberg School of Medicine in Chicago.

Obstetric mortality has lost most of its value as a measure of maternal health care quality because it is so rare now in the United States, Dr. You said at the annual research meeting of AcademyHealth.

As an objective measure of near-miss obstetric morbidity, the scoring system could hold potential as an outcome measure for hospital case review as well as a reproducible maternal health measure for epidemiologic research aimed at identifying trends and risk factors, she said.

“I'm hoping to use it to figure out who is at greatest risk … where the disparity lies and why,” she said in an interview. Morbidity covers a range from mild fever to near death. “Where is that level where women are very ill, the next step before death?” she asked.

In their study, Dr. You and colleagues used ICD-9 codes to identify 815 women with a high potential for significant obstetric morbidity in a high-volume, urban, tertiary care center over a 2-year period (2001-2002). A maternal-fetal medicine specialist categorized cases according to clinical impression of degree of morbidity: no morbidity (23%), minor morbidity (52%), severe morbidity (19%), and near-miss morbidity (5%), Dr. You explained. The cases then were scored using the five-factor weighted scoring system, in which a score of 8 or more is considered a case of near-miss morbidity. (See table.)

Use of the five-factor scoring system revealed a near-miss obstetric morbidity rate of 4.2% (34 patients). The weighted scoring system showed a 63% sensitivity rate for near-miss morbidity, 99% specificity, positive predictive value of 71% and negative predictive value of 98%, according to results from a poster Dr. You presented at a meeting.

The study is the second to validate the Geller scoring system, developed by Dr. Stacie E. Geller of the University of Illinois at Chicago. “Most of the work has been done with a population at UIC. We wanted to see what would happen with a different population,” Dr. You said.

In Dr. Geller's original work, five clinical factors (organ system failure, ICU admission, transfusion of more than 3 units, extended intubation for more than 12 hours and surgical intervention) were grouped into several scoring system alternatives. A scoring system based on all five factors showed the highest specificity (93%), but even a four-factor system, which eliminated organ system failure, achieved a specificity of 78% (J. Clin. Epidemiol. 2004;57:716-20).

Additional studies can help determine whether other factors could be added to identify cases of near-miss morbidity missed in this investigation, Dr. You noted.

In this study, a single maternal-fetal medicine provider reviewed all the cases. Since then, an obstetric anesthesiologist and another experienced maternal-fetal medicine specialist have reviewed the cases as well. Dr. You and her associates plan to calculate sensitivity and specificity based on these additional reviews. “After we get that information, we can decide if it can be a good tool to use in other settings,” she said.

Adapting the scoring system to other types of institutions presents a key challenge.

“We need to figure out how it works in a rural setting or community hospital,” she said. These smaller facilities often refer severely ill patients to tertiary care institutions, “so they may never get a patient that needs multiple transfusions or intubation for an extended time. Our hope is to level the grading system, just because it's so hard to compare one hospital to another.”

Dr. You conducted this study while she was a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies under an award from the Agency for Healthcare Research and Quality.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — A five-factor scoring system that identifies women who nearly die from obstetric morbidity could potentially offer a more meaningful way to measure maternal health care quality between institutions, according to Dr. Whitney You of Northwestern University's Feinberg School of Medicine in Chicago.

Obstetric mortality has lost most of its value as a measure of maternal health care quality because it is so rare now in the United States, Dr. You said at the annual research meeting of AcademyHealth.

As an objective measure of near-miss obstetric morbidity, the scoring system could hold potential as an outcome measure for hospital case review as well as a reproducible maternal health measure for epidemiologic research aimed at identifying trends and risk factors, she said.

“I'm hoping to use it to figure out who is at greatest risk … where the disparity lies and why,” she said in an interview. Morbidity covers a range from mild fever to near death. “Where is that level where women are very ill, the next step before death?” she asked.

In their study, Dr. You and colleagues used ICD-9 codes to identify 815 women with a high potential for significant obstetric morbidity in a high-volume, urban, tertiary care center over a 2-year period (2001-2002). A maternal-fetal medicine specialist categorized cases according to clinical impression of degree of morbidity: no morbidity (23%), minor morbidity (52%), severe morbidity (19%), and near-miss morbidity (5%), Dr. You explained. The cases then were scored using the five-factor weighted scoring system, in which a score of 8 or more is considered a case of near-miss morbidity. (See table.)

Use of the five-factor scoring system revealed a near-miss obstetric morbidity rate of 4.2% (34 patients). The weighted scoring system showed a 63% sensitivity rate for near-miss morbidity, 99% specificity, positive predictive value of 71% and negative predictive value of 98%, according to results from a poster Dr. You presented at a meeting.

The study is the second to validate the Geller scoring system, developed by Dr. Stacie E. Geller of the University of Illinois at Chicago. “Most of the work has been done with a population at UIC. We wanted to see what would happen with a different population,” Dr. You said.

In Dr. Geller's original work, five clinical factors (organ system failure, ICU admission, transfusion of more than 3 units, extended intubation for more than 12 hours and surgical intervention) were grouped into several scoring system alternatives. A scoring system based on all five factors showed the highest specificity (93%), but even a four-factor system, which eliminated organ system failure, achieved a specificity of 78% (J. Clin. Epidemiol. 2004;57:716-20).

Additional studies can help determine whether other factors could be added to identify cases of near-miss morbidity missed in this investigation, Dr. You noted.

In this study, a single maternal-fetal medicine provider reviewed all the cases. Since then, an obstetric anesthesiologist and another experienced maternal-fetal medicine specialist have reviewed the cases as well. Dr. You and her associates plan to calculate sensitivity and specificity based on these additional reviews. “After we get that information, we can decide if it can be a good tool to use in other settings,” she said.

Adapting the scoring system to other types of institutions presents a key challenge.

“We need to figure out how it works in a rural setting or community hospital,” she said. These smaller facilities often refer severely ill patients to tertiary care institutions, “so they may never get a patient that needs multiple transfusions or intubation for an extended time. Our hope is to level the grading system, just because it's so hard to compare one hospital to another.”

Dr. You conducted this study while she was a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies under an award from the Agency for Healthcare Research and Quality.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — A five-factor scoring system that identifies women who nearly die from obstetric morbidity could potentially offer a more meaningful way to measure maternal health care quality between institutions, according to Dr. Whitney You of Northwestern University's Feinberg School of Medicine in Chicago.

Obstetric mortality has lost most of its value as a measure of maternal health care quality because it is so rare now in the United States, Dr. You said at the annual research meeting of AcademyHealth.

As an objective measure of near-miss obstetric morbidity, the scoring system could hold potential as an outcome measure for hospital case review as well as a reproducible maternal health measure for epidemiologic research aimed at identifying trends and risk factors, she said.

“I'm hoping to use it to figure out who is at greatest risk … where the disparity lies and why,” she said in an interview. Morbidity covers a range from mild fever to near death. “Where is that level where women are very ill, the next step before death?” she asked.

In their study, Dr. You and colleagues used ICD-9 codes to identify 815 women with a high potential for significant obstetric morbidity in a high-volume, urban, tertiary care center over a 2-year period (2001-2002). A maternal-fetal medicine specialist categorized cases according to clinical impression of degree of morbidity: no morbidity (23%), minor morbidity (52%), severe morbidity (19%), and near-miss morbidity (5%), Dr. You explained. The cases then were scored using the five-factor weighted scoring system, in which a score of 8 or more is considered a case of near-miss morbidity. (See table.)

Use of the five-factor scoring system revealed a near-miss obstetric morbidity rate of 4.2% (34 patients). The weighted scoring system showed a 63% sensitivity rate for near-miss morbidity, 99% specificity, positive predictive value of 71% and negative predictive value of 98%, according to results from a poster Dr. You presented at a meeting.

The study is the second to validate the Geller scoring system, developed by Dr. Stacie E. Geller of the University of Illinois at Chicago. “Most of the work has been done with a population at UIC. We wanted to see what would happen with a different population,” Dr. You said.

In Dr. Geller's original work, five clinical factors (organ system failure, ICU admission, transfusion of more than 3 units, extended intubation for more than 12 hours and surgical intervention) were grouped into several scoring system alternatives. A scoring system based on all five factors showed the highest specificity (93%), but even a four-factor system, which eliminated organ system failure, achieved a specificity of 78% (J. Clin. Epidemiol. 2004;57:716-20).

Additional studies can help determine whether other factors could be added to identify cases of near-miss morbidity missed in this investigation, Dr. You noted.

In this study, a single maternal-fetal medicine provider reviewed all the cases. Since then, an obstetric anesthesiologist and another experienced maternal-fetal medicine specialist have reviewed the cases as well. Dr. You and her associates plan to calculate sensitivity and specificity based on these additional reviews. “After we get that information, we can decide if it can be a good tool to use in other settings,” she said.

Adapting the scoring system to other types of institutions presents a key challenge.

“We need to figure out how it works in a rural setting or community hospital,” she said. These smaller facilities often refer severely ill patients to tertiary care institutions, “so they may never get a patient that needs multiple transfusions or intubation for an extended time. Our hope is to level the grading system, just because it's so hard to compare one hospital to another.”

Dr. You conducted this study while she was a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies under an award from the Agency for Healthcare Research and Quality.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

The Agency for Healthcare Research and Quality is offering guides to help women with gestational diabetes and their doctors make informed decisions about treatment. The consumer guide is “Gestational Diabetes: A Guide for Pregnant Women,” and the clinical guide is “Gestational Diabetes: Medications, Delivery, and Development of Type 2 Diabetes.” For more information, call AHRQ at 800-358-9295.

The Agency for Healthcare Research and Quality is offering guides to help women with gestational diabetes and their doctors make informed decisions about treatment. The consumer guide is “Gestational Diabetes: A Guide for Pregnant Women,” and the clinical guide is “Gestational Diabetes: Medications, Delivery, and Development of Type 2 Diabetes.” For more information, call AHRQ at 800-358-9295.

The Agency for Healthcare Research and Quality is offering guides to help women with gestational diabetes and their doctors make informed decisions about treatment. The consumer guide is “Gestational Diabetes: A Guide for Pregnant Women,” and the clinical guide is “Gestational Diabetes: Medications, Delivery, and Development of Type 2 Diabetes.” For more information, call AHRQ at 800-358-9295.

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert

SAN FRANCISCO — During prenatal visits at the University of California, San Francisco, pregnant women meet not only with clinicians but with a new “Video Doctor” designed to help them stay fit and avoid excessive weight gain during pregnancy.

The women use a laptop and headphones in the clinic to view video clips of an actress who plays a physician and asks them about their diet and physical activities and then provides motivational counseling in an interactive format.

“This really is a nice adjunct to the counseling that we do in the clinic,” Dr. Naomi E. Stotland said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The Video Doctor program prints a “Provider Alert” sheet that the woman can bring to her clinician “so the clinician can see what's going on and reinforce the counseling,” said Dr. Stotland of the university.

She said she hopes the Video Doctor experiment will provide an effective, low-cost way of implementing basic strategies to limit excessive weight gain in pregnancy.

Recent studies suggest that working with a dietitian plus intensified monitoring and counseling by an ob.gyn. may reduce excessive weight gain in pregnancy in some populations, but these interventions are expensive and time consuming, she noted.

One randomized, controlled trial found that stepped-care behavioral interventions reduced excessive weight gain, compared with routine care, but only in women who had a normal body mass index before they became pregnant, she said.

Another study compared women who received provider counseling, plus a mailed patient-education newsletter, with historical controls and found that the intervention reduced the rate of excessive weight gain during pregnancy only in low-income women.

Most recently, investigators randomized 100 pregnant women to intensive dietary and lifestyle counseling or routine care with no extra counseling.

The intervention was similar to recommendations by the American College of Obstetricians and Gynecologists for routine weight gain monitoring and counseling.

Patients in the intervention group gained significantly less weight in pregnancy than did controls (29 vs. 36 pounds) but did not meet the primary outcome of a significant improvement in the percentage of women whose gestational weight gain fell within limits recommended by the Institute of Medicine (Am. J. Obstet. Gynecol. 2009;113:305-12).

“We have a long way to go,” Dr. Stotland said, “and these are kind of expensive things to implement. It's much, much more intensive counseling” than usual.

The Video Doctor may help with this, but a preliminary study showed only partial promise.

When used as a one-time intervention around the 20th week of pregnancy in a randomized, controlled trial, the Video Doctor was not associated with a difference in weight gain, but the women in the Video Doctor group did report better diets and physical activity behaviors and increased discussions about these topics at follow-up visits, Dr. Stotland said.

A new study will use a revised version of the Video Doctor that starts earlier in pregnancy and engages pregnant women in a serial fashion throughout pregnancy. The study also will incorporate other strategies such as self-monitoring of weight.

“We're hoping that as a package, this will reduce excessive weight gain in pregnancy, but we need to do more research,” she said.

A large proportion of U.S. women gain excessive weight during pregnancy.

In a recent study of nearly 53,000 women in the United States who gave birth to term singletons in 2004-2005, 42% of those who were normal weight at baseline and 64% of those who were overweight at baseline gained more pounds during pregnancy than were recommended in the 1990 Institute of Medicine guidelines.

Among women who were obese at baseline, 46% gained more than 25 pounds above the Institue of Medicine-recommended amount (Am. J. Obstet. Gynecol. 2009;200:271.e1-7).

The Institute of Medicine in May 2009 revised its recommendations for weight gain in pregnancy to add an upper limit to recommendations for pregnant women who are obese at baseline.

In a comparison of the Institute of Medicine guidelines with 2002-2003 data from the Pregnancy Risk Assessment Monitoring System, overweight women gained a median of 30 pounds during pregnancy, compared with 20 pounds recommended by the IOM, and obese women gained 25 pounds, compared with the recommended median of 15.5 pounds, the Institute of Medicine found.

Dr. Stotland reported that she has no conflicts of interest related to these topics.

'This really is a nice adjunct to the counseling that we do in the clinic.'

Source Dr. Stotland

A woman in a prenatal clinic connects with the Video Doctor for counseling on weight gain during pregnancy.

Source Courtesy Kristin Gerbert