Obstetrics

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

The majority (88%) of postpartum women reported current use of at least one form of contraception, based on an analysis of data from more than 43,000 women.

Reducing the percentage of births within a year of a previous birth among women in the United States is one of the Center's for Disease Control and Prevention's Healthy People 2010 goals. Use of effective contraceptive methods after a recent pregnancy can help prevent unintended pregnancies, ensure adequate birth spacing, and reduce adverse maternal and infant outcomes, according to Maura Whiteman, Ph.D., and colleagues at the CDC.

The researchers reviewed data from the CDC's Pregnancy Risk Assessment Monitoring System from 2004 to 2006 from New York City and 12 states. The postpartum period was defined as 2–9 months after giving birth. The report is the first population-based study to examine differences in postpartum contraceptive use based on maternal characteristics (MMWR 2009;58:821–6).

Overall, 62% of of 43,887 postpartum women reported using highly effective contraceptive methods (such as sterilization, IUD, pill, patch, or ring).

Another 20% reported using moderately effective methods (such as condoms) and 6% reported using less effective methods (such as the rhythm method, sponge, or diaphragm), while 12% reported no postpartum contraception, they reported.

Women who were least likely to use at least one method of contraception included those who had no prenatal care, women aged 35 years and older, women who said they wanted to get pregnant sooner, and women who identified themselves as Asian/Pacific Islander.

Highly effective postpartum contraception use by age ranged from a low of 53% among women aged 35 and older to a high of 73% among women younger than 20 years.

When the data were broken down by race, highly effective postpartum contraception use ranged from a low of 35% among Asian/Pacific Islanders to a high of 71% among black women and American Indian/Alaska Native women.

In addition, women with Medicaid coverage prior to pregnancy were more likely to use highly effective contraception postpartum than women without Medicaid, while women with no prenatal care were less likely to use highly effective contraception postpartum than those who had any prenatal care.

The study was limited by several factors, including the use of self- reports, a lack of data from all parts of the United States, and a lack of data on several additional contraceptive methods such as spermicides, emergency contraception, and lactational amenorrhea.

But the results can help clinicians identify women who need more information about postpartum contraception, the researchers noted.

“Health care providers should consider encouraging postpartum women to use highly effective contraceptive methods to increase the proportion of pregnancies that are intended and promote healthy birth spacing,” they said.

Women taking antidepressants who are thinking about getting pregnant might consider tapering or discontinuing drug therapy if they have experienced only mild or no symptoms for at least 6 months, depending on their psychiatric history, according to a new report on the treatment of depression during pregnancy.

The report, issued jointly by the American Psychiatric Association and the American College of Obstetricians and Gynecologists, also said medication discontinuation might not be appropriate for women with a history of severe recurrent depression or those who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts.

The report was published in the September issue of Obstetrics and Gynecology, and produced by an APA/ACOG work group convened to evaluate and summarize information about the risks associated with depression and antidepressant therapy during pregnancy. Representatives from both professional associations, along with a consulting developmental pediatrician, conducted a critical review of published literature on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing.

The authors concluded that the symptoms of depression and exposure to antidepressant therapy might be linked to certain fetal growth and development changes, “but the available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors that can adversely affect pregnancy,” wrote lead author Dr. Kimberly A. Yonkers of Yale University, New Haven, Conn., and her colleagues (Obstet. Gynecol. 2009;114:703–13). The report is being published concurrently in the September/October issue of General Hospital Psychiatry (doi:10.1016/j.genhosppsych.2009.04.003

For preconceptional patients receiving pharmacologic treatment for depression, a determination of the severity of symptoms should guide management recommendations, the authors wrote. Patients with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment and counseled to wait a period of time after achieving euthymia before conceiving.

Similarly, patients with moderate to severe symptoms should continue and optimize antidepressant therapy and wait for a period of time before conceiving.

“While it is difficult to specify an exact or optimal length of time for all patients, guidelines such as those from the [Agency for Healthcare Research and Quality] suggest antidepressant treatment for a first, acute episode of depression should endure at least 6–12 months,” they wrote.

For women with mild or no symptoms for at least 6 months who are candidates for medication discontinuation, the decision to initiate a treatment hiatus should be made in consultation with her psychiatrist, and the subsequent taper should be slow—such as a 25% reduction in dose every 1–2 weeks with close monitoring for relapse, the authors said.

The obstetrical care of women with a history of severe, recurrent mood disorders who continue drug treatment should also be coordinated with the psychiatric provider to monitor for illness relapse, they wrote, noting also that some women may benefit from individual or group psychotherapy, alone or in combination with medication.

Women with untreated depression that is diagnosed during pregnancy and those with depression who have discontinued their medication should similarly be evaluated for symptom severity and, if necessary, referred for psychiatric consultation, according to the report.

For patients with severe depressive, suicidal, or psychotic symptoms, the use of antiepileptic agents, newer antipsychotic drugs, and antidepressants should be avoided in the first trimester, if possible, because of the teratogenic potential of the antiepileptics and relative lack of reproductive safety information for the newer antipsychotics and antidepressants, the authors stated.

Those women who are not “gravely disabled or at high risk of relapse” may benefit from psychotherapy, and those with bipolar affective disorder should be managed by a psychiatrist because of the risk that antidepressant monotherapy could trigger mania and psychosis, they wrote.

In all women who begin antidepressant treatment during pregnancy, the treatment choice should be guided by the drugs' safety profile and the stage of gestation, as well as the patient's symptoms, history, and preferences, the authors stressed.

For women who are taking antidepressant medication when they become pregnant, “if the patient is willing to consider discontinuation of medication and she is not currently having symptoms, then, depending upon the individual's psychiatric history, a trial of medication taper may be appropriate,” the authors wrote. They noted, however, that “women with a history of severe, recurrent depression, even if currently asymptomatic or minimally symptomatic, are at a high risk of relapse if medication is discontinued.” For those women who prefer to continue medication, “discuss risk/benefit issues and document this discussion and the patient's choice, in her medical record,” they advised.

If a woman being treated for severe depression refuses to continue medication, alternative treatment, such as psychotherapy, and close monitoring are advised. Similarly, women with depressive symptoms or recurrent depression despite medication, might benefit from the addition of psychotherapy, the authors wrote.

In addition to the recommendations, the report addresses several frequently asked questions about antidepressant treatment during pregnancy. In evaluating the cumulative research related to antidepressant use in pregnancy, the authors noted several limitations. Specifically, few of the studies that assessed associations between antidepressant treatment and birth outcomes included information on maternal psychiatric illness and confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, which occur at a higher rate among depressed vs. nondepressed women, were often not controlled.

Some of the report authors disclosed having received research support and consultants fees from various pharmaceutical companies, including Eli Lilly, Pfizer, Wyeth, Boehringer Ingelheim, Bayer Schering Pharma AG, Berlex, and GlaxoSmithKline.

Women taking antidepressants who are thinking about getting pregnant might consider tapering or discontinuing drug therapy if they have experienced only mild or no symptoms for at least 6 months, depending on their psychiatric history, according to a new report on the treatment of depression during pregnancy.

The report, issued jointly by the American Psychiatric Association and the American College of Obstetricians and Gynecologists, also said medication discontinuation might not be appropriate for women with a history of severe recurrent depression or those who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts.

The report was published in the September issue of Obstetrics and Gynecology, and produced by an APA/ACOG work group convened to evaluate and summarize information about the risks associated with depression and antidepressant therapy during pregnancy. Representatives from both professional associations, along with a consulting developmental pediatrician, conducted a critical review of published literature on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing.

The authors concluded that the symptoms of depression and exposure to antidepressant therapy might be linked to certain fetal growth and development changes, “but the available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors that can adversely affect pregnancy,” wrote lead author Dr. Kimberly A. Yonkers of Yale University, New Haven, Conn., and her colleagues (Obstet. Gynecol. 2009;114:703–13). The report is being published concurrently in the September/October issue of General Hospital Psychiatry (doi:10.1016/j.genhosppsych.2009.04.003

For preconceptional patients receiving pharmacologic treatment for depression, a determination of the severity of symptoms should guide management recommendations, the authors wrote. Patients with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment and counseled to wait a period of time after achieving euthymia before conceiving.

Similarly, patients with moderate to severe symptoms should continue and optimize antidepressant therapy and wait for a period of time before conceiving.

“While it is difficult to specify an exact or optimal length of time for all patients, guidelines such as those from the [Agency for Healthcare Research and Quality] suggest antidepressant treatment for a first, acute episode of depression should endure at least 6–12 months,” they wrote.

For women with mild or no symptoms for at least 6 months who are candidates for medication discontinuation, the decision to initiate a treatment hiatus should be made in consultation with her psychiatrist, and the subsequent taper should be slow—such as a 25% reduction in dose every 1–2 weeks with close monitoring for relapse, the authors said.

The obstetrical care of women with a history of severe, recurrent mood disorders who continue drug treatment should also be coordinated with the psychiatric provider to monitor for illness relapse, they wrote, noting also that some women may benefit from individual or group psychotherapy, alone or in combination with medication.

Women with untreated depression that is diagnosed during pregnancy and those with depression who have discontinued their medication should similarly be evaluated for symptom severity and, if necessary, referred for psychiatric consultation, according to the report.

For patients with severe depressive, suicidal, or psychotic symptoms, the use of antiepileptic agents, newer antipsychotic drugs, and antidepressants should be avoided in the first trimester, if possible, because of the teratogenic potential of the antiepileptics and relative lack of reproductive safety information for the newer antipsychotics and antidepressants, the authors stated.

Those women who are not “gravely disabled or at high risk of relapse” may benefit from psychotherapy, and those with bipolar affective disorder should be managed by a psychiatrist because of the risk that antidepressant monotherapy could trigger mania and psychosis, they wrote.

In all women who begin antidepressant treatment during pregnancy, the treatment choice should be guided by the drugs' safety profile and the stage of gestation, as well as the patient's symptoms, history, and preferences, the authors stressed.

For women who are taking antidepressant medication when they become pregnant, “if the patient is willing to consider discontinuation of medication and she is not currently having symptoms, then, depending upon the individual's psychiatric history, a trial of medication taper may be appropriate,” the authors wrote. They noted, however, that “women with a history of severe, recurrent depression, even if currently asymptomatic or minimally symptomatic, are at a high risk of relapse if medication is discontinued.” For those women who prefer to continue medication, “discuss risk/benefit issues and document this discussion and the patient's choice, in her medical record,” they advised.

If a woman being treated for severe depression refuses to continue medication, alternative treatment, such as psychotherapy, and close monitoring are advised. Similarly, women with depressive symptoms or recurrent depression despite medication, might benefit from the addition of psychotherapy, the authors wrote.

In addition to the recommendations, the report addresses several frequently asked questions about antidepressant treatment during pregnancy. In evaluating the cumulative research related to antidepressant use in pregnancy, the authors noted several limitations. Specifically, few of the studies that assessed associations between antidepressant treatment and birth outcomes included information on maternal psychiatric illness and confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, which occur at a higher rate among depressed vs. nondepressed women, were often not controlled.

Some of the report authors disclosed having received research support and consultants fees from various pharmaceutical companies, including Eli Lilly, Pfizer, Wyeth, Boehringer Ingelheim, Bayer Schering Pharma AG, Berlex, and GlaxoSmithKline.

Women taking antidepressants who are thinking about getting pregnant might consider tapering or discontinuing drug therapy if they have experienced only mild or no symptoms for at least 6 months, depending on their psychiatric history, according to a new report on the treatment of depression during pregnancy.

The report, issued jointly by the American Psychiatric Association and the American College of Obstetricians and Gynecologists, also said medication discontinuation might not be appropriate for women with a history of severe recurrent depression or those who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts.

The report was published in the September issue of Obstetrics and Gynecology, and produced by an APA/ACOG work group convened to evaluate and summarize information about the risks associated with depression and antidepressant therapy during pregnancy. Representatives from both professional associations, along with a consulting developmental pediatrician, conducted a critical review of published literature on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing.

The authors concluded that the symptoms of depression and exposure to antidepressant therapy might be linked to certain fetal growth and development changes, “but the available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors that can adversely affect pregnancy,” wrote lead author Dr. Kimberly A. Yonkers of Yale University, New Haven, Conn., and her colleagues (Obstet. Gynecol. 2009;114:703–13). The report is being published concurrently in the September/October issue of General Hospital Psychiatry (doi:10.1016/j.genhosppsych.2009.04.003

For preconceptional patients receiving pharmacologic treatment for depression, a determination of the severity of symptoms should guide management recommendations, the authors wrote. Patients with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment and counseled to wait a period of time after achieving euthymia before conceiving.

Similarly, patients with moderate to severe symptoms should continue and optimize antidepressant therapy and wait for a period of time before conceiving.

“While it is difficult to specify an exact or optimal length of time for all patients, guidelines such as those from the [Agency for Healthcare Research and Quality] suggest antidepressant treatment for a first, acute episode of depression should endure at least 6–12 months,” they wrote.

For women with mild or no symptoms for at least 6 months who are candidates for medication discontinuation, the decision to initiate a treatment hiatus should be made in consultation with her psychiatrist, and the subsequent taper should be slow—such as a 25% reduction in dose every 1–2 weeks with close monitoring for relapse, the authors said.

The obstetrical care of women with a history of severe, recurrent mood disorders who continue drug treatment should also be coordinated with the psychiatric provider to monitor for illness relapse, they wrote, noting also that some women may benefit from individual or group psychotherapy, alone or in combination with medication.

Women with untreated depression that is diagnosed during pregnancy and those with depression who have discontinued their medication should similarly be evaluated for symptom severity and, if necessary, referred for psychiatric consultation, according to the report.

For patients with severe depressive, suicidal, or psychotic symptoms, the use of antiepileptic agents, newer antipsychotic drugs, and antidepressants should be avoided in the first trimester, if possible, because of the teratogenic potential of the antiepileptics and relative lack of reproductive safety information for the newer antipsychotics and antidepressants, the authors stated.

Those women who are not “gravely disabled or at high risk of relapse” may benefit from psychotherapy, and those with bipolar affective disorder should be managed by a psychiatrist because of the risk that antidepressant monotherapy could trigger mania and psychosis, they wrote.

In all women who begin antidepressant treatment during pregnancy, the treatment choice should be guided by the drugs' safety profile and the stage of gestation, as well as the patient's symptoms, history, and preferences, the authors stressed.

For women who are taking antidepressant medication when they become pregnant, “if the patient is willing to consider discontinuation of medication and she is not currently having symptoms, then, depending upon the individual's psychiatric history, a trial of medication taper may be appropriate,” the authors wrote. They noted, however, that “women with a history of severe, recurrent depression, even if currently asymptomatic or minimally symptomatic, are at a high risk of relapse if medication is discontinued.” For those women who prefer to continue medication, “discuss risk/benefit issues and document this discussion and the patient's choice, in her medical record,” they advised.

If a woman being treated for severe depression refuses to continue medication, alternative treatment, such as psychotherapy, and close monitoring are advised. Similarly, women with depressive symptoms or recurrent depression despite medication, might benefit from the addition of psychotherapy, the authors wrote.

In addition to the recommendations, the report addresses several frequently asked questions about antidepressant treatment during pregnancy. In evaluating the cumulative research related to antidepressant use in pregnancy, the authors noted several limitations. Specifically, few of the studies that assessed associations between antidepressant treatment and birth outcomes included information on maternal psychiatric illness and confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, which occur at a higher rate among depressed vs. nondepressed women, were often not controlled.

Some of the report authors disclosed having received research support and consultants fees from various pharmaceutical companies, including Eli Lilly, Pfizer, Wyeth, Boehringer Ingelheim, Bayer Schering Pharma AG, Berlex, and GlaxoSmithKline.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

WASHINGTON — Adding epinephrine to epidural bupivacaine and fentanyl significantly reduced the breakthrough pain of women in labor, based on supplemental pain relief data from a randomized study of 107 women with uncomplicated singleton pregnancies.

Previous studies have shown that epinephrine enhances the analgesic effects of local anesthesia during labor, but the effect of epinephrine added during the epidural infusion has not been well studied, noted Dr. Philip E. Hess of Harvard Medical School, Boston.

In this study, Dr. Hess and his colleagues enrolled women in active labor who were at least 7 cm dilated. The average age of the women was 32 years. All the patients received a standard epidural with bupivacaine and fentanyl, and then were randomized to receive or not to receive 1.66 mcg/mL epinephrine (1:600,000) as part of the epidural solution. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“The primary outcome was the need for the treatment of breakthrough pain,” Dr. Hess said during an oral review of posters. Overall, the mean number of boluses of supplemental pain medication was significantly lower in the epinephrine group compared with the control group (1.16 vs. 0.74), and the bolus rate was significantly lower in the epinephrine group compared with the controls.

But there were no significant differences in the duration of labor or in the occurrence of side effects (including hypotension, nausea, and vomiting) between the two groups. Pain scores were recorded every 15 minutes during labor using the visual analog scale. The results suggest that adding epidural epinephrine at the beginning of labor significantly reduced the need for extra anesthesia to manage breakthrough pain, noted Dr. Hess, who said he had no conflicts to disclose.

SAN FRANCISCO — A growing body of evidence suggests that the oral agent glyburide may not be as safe as injected insulin to treat gestational diabetes, and that perceived barriers to women using insulin are unsubstantiated.

“The standard of care was insulin. Then everybody changed to glyburide based on an underpowered study” of 404 women with gestational diabetes who were randomized to glyburide or insulin therapy, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The study reported similar glycemic control and neonatal outcomes between groups (N. Engl. J. Med. 2000;343:1134–8). “A lot of people that use glyburide base it on this one prospective, randomized trial” that was too small and showed some worrisome trends, said Dr. Caughey, medical director of the Diabetes and Pregnancy Program at the university.

A closer look at the results reveals multiple trends toward worse neonatal outcomes with glyburide, although none are statistically significant, he said. In the glyburide group, 7% of babies had birth weights above 4,000 grams, compared with 4% of the insulin group. Lung complications were reported in 8% of the glyburide group and in 6% on insulin. Hypoglycemia occurred in 9% on glyburide and 6% on placebo. Hyperbilirubinemia rates were 6% on glyburide and 4% on placebo.

More recently, a retrospective cohort study of 584 women with gestational diabetes in the Kaiser Permanente system found significantly worse rates of preeclampsia (12%) and phototherapy for hyperbilirubinemia (9%) in women treated with glyburide, compared with those given insulin (6% and 5%, respectively). That study also found a nonsignificant trend toward a higher rate of birth injury with glyburide (3%) than with insulin (1%), all of which was “concerning,” he said (Am. J. Obstet. Gynecol. 2005;193:118–24).

Analyses of statewide data from the California Diabetes and Pregnancy Program (known as Sweet Success) in 2007 by Dr. Caughey's associates at the university also found some significantly worse outcomes in women given oral agents compared with insulin for gestational diabetes. They found a 35% higher risk for birth weights above 4,000 g, a 40% higher risk for admission to the neonatal intensive care unit, and a 52% higher risk for preterm delivery before 34 weeks' gestation in women taking oral agents after adjusting for the effects of maternal age, ethnicity, parity, education, gestational age at delivery or at diagnosis of gestational diabetes, body mass index, and gestational weight gain.

Among women diagnosed with gestational diabetes early in pregnancy—at less than 24 weeks' gestation—the increased risk with oral agents was even more pronounced, including more than a threefold higher risk for intrauterine fetal demise compared with the insulin group.

Some clinicians say they prefer to treat gestational diabetes with glyburide because they believe that patients with little formal education cannot understand how to use insulin, or that patients whose primary language is not English will have difficulty, noted Dr. Caughey, who said he had no conflicts of interest related to this topic. When they stratified the Sweet Success data to profile women who had less than 9 years of education or whose primary language was Spanish, those on oral agents still had significantly worse outcomes.

“In my practice, we have one person a year [who will] not be able to use insulin and [who has] to use an oral agent. It's pretty rare.” At UCSF, gestational diabetes management begins with nutritional counseling and a prescription to take a short walk after each meal. If borderline or mild glucose elevations persist, they offer the patient insulin and will consider the alternative of oral metformin, but only in patients who are unlikely to have pre-existing diabetes mellitus, who have been diagnosed with gestational diabetes at 26–32 weeks' gestation, and who have been counseled about an increased preterm delivery risk associated with metformin.

SAN FRANCISCO — A growing body of evidence suggests that the oral agent glyburide may not be as safe as injected insulin to treat gestational diabetes, and that perceived barriers to women using insulin are unsubstantiated.

“The standard of care was insulin. Then everybody changed to glyburide based on an underpowered study” of 404 women with gestational diabetes who were randomized to glyburide or insulin therapy, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The study reported similar glycemic control and neonatal outcomes between groups (N. Engl. J. Med. 2000;343:1134–8). “A lot of people that use glyburide base it on this one prospective, randomized trial” that was too small and showed some worrisome trends, said Dr. Caughey, medical director of the Diabetes and Pregnancy Program at the university.

A closer look at the results reveals multiple trends toward worse neonatal outcomes with glyburide, although none are statistically significant, he said. In the glyburide group, 7% of babies had birth weights above 4,000 grams, compared with 4% of the insulin group. Lung complications were reported in 8% of the glyburide group and in 6% on insulin. Hypoglycemia occurred in 9% on glyburide and 6% on placebo. Hyperbilirubinemia rates were 6% on glyburide and 4% on placebo.

More recently, a retrospective cohort study of 584 women with gestational diabetes in the Kaiser Permanente system found significantly worse rates of preeclampsia (12%) and phototherapy for hyperbilirubinemia (9%) in women treated with glyburide, compared with those given insulin (6% and 5%, respectively). That study also found a nonsignificant trend toward a higher rate of birth injury with glyburide (3%) than with insulin (1%), all of which was “concerning,” he said (Am. J. Obstet. Gynecol. 2005;193:118–24).

Analyses of statewide data from the California Diabetes and Pregnancy Program (known as Sweet Success) in 2007 by Dr. Caughey's associates at the university also found some significantly worse outcomes in women given oral agents compared with insulin for gestational diabetes. They found a 35% higher risk for birth weights above 4,000 g, a 40% higher risk for admission to the neonatal intensive care unit, and a 52% higher risk for preterm delivery before 34 weeks' gestation in women taking oral agents after adjusting for the effects of maternal age, ethnicity, parity, education, gestational age at delivery or at diagnosis of gestational diabetes, body mass index, and gestational weight gain.

Among women diagnosed with gestational diabetes early in pregnancy—at less than 24 weeks' gestation—the increased risk with oral agents was even more pronounced, including more than a threefold higher risk for intrauterine fetal demise compared with the insulin group.

Some clinicians say they prefer to treat gestational diabetes with glyburide because they believe that patients with little formal education cannot understand how to use insulin, or that patients whose primary language is not English will have difficulty, noted Dr. Caughey, who said he had no conflicts of interest related to this topic. When they stratified the Sweet Success data to profile women who had less than 9 years of education or whose primary language was Spanish, those on oral agents still had significantly worse outcomes.

“In my practice, we have one person a year [who will] not be able to use insulin and [who has] to use an oral agent. It's pretty rare.” At UCSF, gestational diabetes management begins with nutritional counseling and a prescription to take a short walk after each meal. If borderline or mild glucose elevations persist, they offer the patient insulin and will consider the alternative of oral metformin, but only in patients who are unlikely to have pre-existing diabetes mellitus, who have been diagnosed with gestational diabetes at 26–32 weeks' gestation, and who have been counseled about an increased preterm delivery risk associated with metformin.

SAN FRANCISCO — A growing body of evidence suggests that the oral agent glyburide may not be as safe as injected insulin to treat gestational diabetes, and that perceived barriers to women using insulin are unsubstantiated.

“The standard of care was insulin. Then everybody changed to glyburide based on an underpowered study” of 404 women with gestational diabetes who were randomized to glyburide or insulin therapy, Dr. Aaron B. Caughey said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The study reported similar glycemic control and neonatal outcomes between groups (N. Engl. J. Med. 2000;343:1134–8). “A lot of people that use glyburide base it on this one prospective, randomized trial” that was too small and showed some worrisome trends, said Dr. Caughey, medical director of the Diabetes and Pregnancy Program at the university.

A closer look at the results reveals multiple trends toward worse neonatal outcomes with glyburide, although none are statistically significant, he said. In the glyburide group, 7% of babies had birth weights above 4,000 grams, compared with 4% of the insulin group. Lung complications were reported in 8% of the glyburide group and in 6% on insulin. Hypoglycemia occurred in 9% on glyburide and 6% on placebo. Hyperbilirubinemia rates were 6% on glyburide and 4% on placebo.

More recently, a retrospective cohort study of 584 women with gestational diabetes in the Kaiser Permanente system found significantly worse rates of preeclampsia (12%) and phototherapy for hyperbilirubinemia (9%) in women treated with glyburide, compared with those given insulin (6% and 5%, respectively). That study also found a nonsignificant trend toward a higher rate of birth injury with glyburide (3%) than with insulin (1%), all of which was “concerning,” he said (Am. J. Obstet. Gynecol. 2005;193:118–24).

Analyses of statewide data from the California Diabetes and Pregnancy Program (known as Sweet Success) in 2007 by Dr. Caughey's associates at the university also found some significantly worse outcomes in women given oral agents compared with insulin for gestational diabetes. They found a 35% higher risk for birth weights above 4,000 g, a 40% higher risk for admission to the neonatal intensive care unit, and a 52% higher risk for preterm delivery before 34 weeks' gestation in women taking oral agents after adjusting for the effects of maternal age, ethnicity, parity, education, gestational age at delivery or at diagnosis of gestational diabetes, body mass index, and gestational weight gain.

Among women diagnosed with gestational diabetes early in pregnancy—at less than 24 weeks' gestation—the increased risk with oral agents was even more pronounced, including more than a threefold higher risk for intrauterine fetal demise compared with the insulin group.

Some clinicians say they prefer to treat gestational diabetes with glyburide because they believe that patients with little formal education cannot understand how to use insulin, or that patients whose primary language is not English will have difficulty, noted Dr. Caughey, who said he had no conflicts of interest related to this topic. When they stratified the Sweet Success data to profile women who had less than 9 years of education or whose primary language was Spanish, those on oral agents still had significantly worse outcomes.

“In my practice, we have one person a year [who will] not be able to use insulin and [who has] to use an oral agent. It's pretty rare.” At UCSF, gestational diabetes management begins with nutritional counseling and a prescription to take a short walk after each meal. If borderline or mild glucose elevations persist, they offer the patient insulin and will consider the alternative of oral metformin, but only in patients who are unlikely to have pre-existing diabetes mellitus, who have been diagnosed with gestational diabetes at 26–32 weeks' gestation, and who have been counseled about an increased preterm delivery risk associated with metformin.

SAN FRANCISCO — Combining an ultrasound exam and quantitative beta-hCG measurements may be the most efficient and effective way to diagnose an ectopic pregnancy, said Dr. Amy “Meg” Autry.

A decision-analysis study found that performing transvaginal ultrasound, followed by measuring beta-hCG when ultrasound results were nondiagnostic, identified all ectopic pregnancies in the fastest time (1.46 days) with the fewest interrupted intrauterine pregnancies (less than 1%). Some other diagnostic strategies were faster but less sensitive or interrupted more normal pregnancies (Obstet. Gynecol. 2001;97:464–70).

“In our hospital, in reality, we're getting ultrasound and hCGs at the same time” for women with suspected ectopic pregnancy, Dr. Autry said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco. Some ultrasounds will show evidence of intrauterine pregnancies even when the beta-hCG results are below the “discriminatory zone”—the hCG level above which a normal intrauterine pregnancy can be visualized consistently.

Combined, the ultrasound and beta-hCG results are 97%–100% sensitive and 95%–99% specific in diagnosing ectopic pregnancy. “This is predicated on a reliable and consistent ultrasonographer—whether it's an ob.gyn. or radiologist—and you have to know what your discriminatory zone is at your institution,” said Dr. Autry of the university. At her hospital, the discriminatory zone is 1,500–1,800 mIU/mL, using an endovaginal probe.

Even in patients with beta-hCG levels below the discriminatory zone, ultrasound can identify 33% of normal intrauterine pregnancies, 28% of spontaneous miscarriages, and 25% of ectopic pregnancies, a separate study found (Obstet. Gynecol. 1999;94:583–7).

In normal early pregnancies up to 41 days' gestational age, beta-hCG levels double in 48 hours. “But once you're at 6 weeks' [gestation], you should be following by ultrasound,” Dr. Autry said, because beta-hCG levels increasingly become less accurate for identifying normal pregnancies. At 41–57 days' gestation, the beta-hCG level will increase 33% in 48 hours in normal pregnancies. At 57–65 days' gestation, beta-hCG level increases only 5% in 48 hours in normal pregnancies.

Previous data have shown that 64% of women with ectopic pregnancy up to 41 days' gestation will have normal doubling of beta-hCG, emphasizing the additional value of ultrasound examination. In early pregnancy, a beta-hCG increase of less than 50% in 48 hours invariably indicates a nonviable pregnancy, but doesn't tell you where the pregnancy is.

When ultrasound results are indeterminate, the presence of echogenic material (“I call it schmutz”) in the uterus indicates a low likelihood of a normal intrauterine pregnancy, she added. Free fluid in the cul de sac suggests a moderate risk for ectopic pregnancy, a risk that increases with increased volume or echogenicity.

Other signs in indeterminate ultrasounds can be worrisome, she said. A thick endometrial stripe with a beta-hCG level below 1,000 mIU/mL predicts an increased risk for ectopic pregnancy. An empty uterus increases the risk for ectopic pregnancy fivefold. An empty uterus plus a beta-hCG rate of change of less than 66% suggests a 25-fold increased risk for ectopic pregnancy.

Other predictors of ectopic pregnancy include a history of ectopic pregnancy or miscarriage, older age, and bleeding. Dr. Autry said she has no conflicts of interest related to these topics.

Combined, ultrasound and beta-hCG were 95%–99% specific for diagnosis.

Source DR. AUTRY

SAN FRANCISCO — Combining an ultrasound exam and quantitative beta-hCG measurements may be the most efficient and effective way to diagnose an ectopic pregnancy, said Dr. Amy “Meg” Autry.

A decision-analysis study found that performing transvaginal ultrasound, followed by measuring beta-hCG when ultrasound results were nondiagnostic, identified all ectopic pregnancies in the fastest time (1.46 days) with the fewest interrupted intrauterine pregnancies (less than 1%). Some other diagnostic strategies were faster but less sensitive or interrupted more normal pregnancies (Obstet. Gynecol. 2001;97:464–70).

“In our hospital, in reality, we're getting ultrasound and hCGs at the same time” for women with suspected ectopic pregnancy, Dr. Autry said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco. Some ultrasounds will show evidence of intrauterine pregnancies even when the beta-hCG results are below the “discriminatory zone”—the hCG level above which a normal intrauterine pregnancy can be visualized consistently.

Combined, the ultrasound and beta-hCG results are 97%–100% sensitive and 95%–99% specific in diagnosing ectopic pregnancy. “This is predicated on a reliable and consistent ultrasonographer—whether it's an ob.gyn. or radiologist—and you have to know what your discriminatory zone is at your institution,” said Dr. Autry of the university. At her hospital, the discriminatory zone is 1,500–1,800 mIU/mL, using an endovaginal probe.

Even in patients with beta-hCG levels below the discriminatory zone, ultrasound can identify 33% of normal intrauterine pregnancies, 28% of spontaneous miscarriages, and 25% of ectopic pregnancies, a separate study found (Obstet. Gynecol. 1999;94:583–7).

In normal early pregnancies up to 41 days' gestational age, beta-hCG levels double in 48 hours. “But once you're at 6 weeks' [gestation], you should be following by ultrasound,” Dr. Autry said, because beta-hCG levels increasingly become less accurate for identifying normal pregnancies. At 41–57 days' gestation, the beta-hCG level will increase 33% in 48 hours in normal pregnancies. At 57–65 days' gestation, beta-hCG level increases only 5% in 48 hours in normal pregnancies.

Previous data have shown that 64% of women with ectopic pregnancy up to 41 days' gestation will have normal doubling of beta-hCG, emphasizing the additional value of ultrasound examination. In early pregnancy, a beta-hCG increase of less than 50% in 48 hours invariably indicates a nonviable pregnancy, but doesn't tell you where the pregnancy is.

When ultrasound results are indeterminate, the presence of echogenic material (“I call it schmutz”) in the uterus indicates a low likelihood of a normal intrauterine pregnancy, she added. Free fluid in the cul de sac suggests a moderate risk for ectopic pregnancy, a risk that increases with increased volume or echogenicity.

Other signs in indeterminate ultrasounds can be worrisome, she said. A thick endometrial stripe with a beta-hCG level below 1,000 mIU/mL predicts an increased risk for ectopic pregnancy. An empty uterus increases the risk for ectopic pregnancy fivefold. An empty uterus plus a beta-hCG rate of change of less than 66% suggests a 25-fold increased risk for ectopic pregnancy.

Other predictors of ectopic pregnancy include a history of ectopic pregnancy or miscarriage, older age, and bleeding. Dr. Autry said she has no conflicts of interest related to these topics.

Combined, ultrasound and beta-hCG were 95%–99% specific for diagnosis.

Source DR. AUTRY

SAN FRANCISCO — Combining an ultrasound exam and quantitative beta-hCG measurements may be the most efficient and effective way to diagnose an ectopic pregnancy, said Dr. Amy “Meg” Autry.

A decision-analysis study found that performing transvaginal ultrasound, followed by measuring beta-hCG when ultrasound results were nondiagnostic, identified all ectopic pregnancies in the fastest time (1.46 days) with the fewest interrupted intrauterine pregnancies (less than 1%). Some other diagnostic strategies were faster but less sensitive or interrupted more normal pregnancies (Obstet. Gynecol. 2001;97:464–70).

“In our hospital, in reality, we're getting ultrasound and hCGs at the same time” for women with suspected ectopic pregnancy, Dr. Autry said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco. Some ultrasounds will show evidence of intrauterine pregnancies even when the beta-hCG results are below the “discriminatory zone”—the hCG level above which a normal intrauterine pregnancy can be visualized consistently.

Combined, the ultrasound and beta-hCG results are 97%–100% sensitive and 95%–99% specific in diagnosing ectopic pregnancy. “This is predicated on a reliable and consistent ultrasonographer—whether it's an ob.gyn. or radiologist—and you have to know what your discriminatory zone is at your institution,” said Dr. Autry of the university. At her hospital, the discriminatory zone is 1,500–1,800 mIU/mL, using an endovaginal probe.

Even in patients with beta-hCG levels below the discriminatory zone, ultrasound can identify 33% of normal intrauterine pregnancies, 28% of spontaneous miscarriages, and 25% of ectopic pregnancies, a separate study found (Obstet. Gynecol. 1999;94:583–7).

In normal early pregnancies up to 41 days' gestational age, beta-hCG levels double in 48 hours. “But once you're at 6 weeks' [gestation], you should be following by ultrasound,” Dr. Autry said, because beta-hCG levels increasingly become less accurate for identifying normal pregnancies. At 41–57 days' gestation, the beta-hCG level will increase 33% in 48 hours in normal pregnancies. At 57–65 days' gestation, beta-hCG level increases only 5% in 48 hours in normal pregnancies.

Previous data have shown that 64% of women with ectopic pregnancy up to 41 days' gestation will have normal doubling of beta-hCG, emphasizing the additional value of ultrasound examination. In early pregnancy, a beta-hCG increase of less than 50% in 48 hours invariably indicates a nonviable pregnancy, but doesn't tell you where the pregnancy is.

When ultrasound results are indeterminate, the presence of echogenic material (“I call it schmutz”) in the uterus indicates a low likelihood of a normal intrauterine pregnancy, she added. Free fluid in the cul de sac suggests a moderate risk for ectopic pregnancy, a risk that increases with increased volume or echogenicity.

Other signs in indeterminate ultrasounds can be worrisome, she said. A thick endometrial stripe with a beta-hCG level below 1,000 mIU/mL predicts an increased risk for ectopic pregnancy. An empty uterus increases the risk for ectopic pregnancy fivefold. An empty uterus plus a beta-hCG rate of change of less than 66% suggests a 25-fold increased risk for ectopic pregnancy.

Other predictors of ectopic pregnancy include a history of ectopic pregnancy or miscarriage, older age, and bleeding. Dr. Autry said she has no conflicts of interest related to these topics.

Combined, ultrasound and beta-hCG were 95%–99% specific for diagnosis.

Source DR. AUTRY

The use of metoclopramide to control nausea and vomiting in the first trimester does not increase the risk for congenital malformations, low birth weight, or perinatal death, according to a report in the New England Journal of Medicine.

These findings from a large retrospective cohort study “provide reassurance about the safety of metoclopramide,” which has not been convincingly established until now, wrote Ilan Matok of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and associates.

“Despite its extensive use, only a few studies have assessed the safety to the fetus of maternal exposure to metoclopramide during the first trimester, and the relatively small sizes of these studies limited their power to detect adverse effects of the drug,” they noted.

The researchers assessed singleton deliveries between 1998 and 2007 at the largest HMO in Israel, where metoclopramide is the antiemetic drug of choice during pregnancy. Approximately half of the 81,703 infants in the study were born to Jewish parents and half to Bedouin Muslim parents.

A total of 3,458 (4%) of these infants were exposed to metoclopramide during the first trimester. The mean duration of exposure was 1 week.

The rate of major congenital malformations was 5.3% among exposed infants, compared with 4.9% among unexposed infants, a nonsignificant difference. This difference remained nonsignificant when data from pregnancies that were terminated were included in the analysis.

The rates of minor congenital malformations (3.8% vs. 3.5%) and of multiple malformations (2.5% vs. 2.3%) also were similar between exposed and nonexposed infants. There also were no significant associations between subclasses of congenital malformations and metoclopramide exposure, nor was there any clustering of anomalies among exposed infants.

When the data were analyzed according to subjects' ethnic backgrounds, the drug did not raise risks to infants of either Jewish or Bedouin Muslim parents (N. Engl. J. Med. 2009;360:2528–35).

Metoclopramide also was not associated with an increased risk of preterm birth, low Apgar scores, perinatal death, or low birth weight.

A subgroup of 758 mothers who took metoclopramide refilled their prescriptions at least once. No dose-response effect of exposure to the drug was found.

The researchers reported having no relevant conflicts of interest.

The use of metoclopramide to control nausea and vomiting in the first trimester does not increase the risk for congenital malformations, low birth weight, or perinatal death, according to a report in the New England Journal of Medicine.

These findings from a large retrospective cohort study “provide reassurance about the safety of metoclopramide,” which has not been convincingly established until now, wrote Ilan Matok of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and associates.

“Despite its extensive use, only a few studies have assessed the safety to the fetus of maternal exposure to metoclopramide during the first trimester, and the relatively small sizes of these studies limited their power to detect adverse effects of the drug,” they noted.

The researchers assessed singleton deliveries between 1998 and 2007 at the largest HMO in Israel, where metoclopramide is the antiemetic drug of choice during pregnancy. Approximately half of the 81,703 infants in the study were born to Jewish parents and half to Bedouin Muslim parents.

A total of 3,458 (4%) of these infants were exposed to metoclopramide during the first trimester. The mean duration of exposure was 1 week.

The rate of major congenital malformations was 5.3% among exposed infants, compared with 4.9% among unexposed infants, a nonsignificant difference. This difference remained nonsignificant when data from pregnancies that were terminated were included in the analysis.

The rates of minor congenital malformations (3.8% vs. 3.5%) and of multiple malformations (2.5% vs. 2.3%) also were similar between exposed and nonexposed infants. There also were no significant associations between subclasses of congenital malformations and metoclopramide exposure, nor was there any clustering of anomalies among exposed infants.

When the data were analyzed according to subjects' ethnic backgrounds, the drug did not raise risks to infants of either Jewish or Bedouin Muslim parents (N. Engl. J. Med. 2009;360:2528–35).

Metoclopramide also was not associated with an increased risk of preterm birth, low Apgar scores, perinatal death, or low birth weight.

A subgroup of 758 mothers who took metoclopramide refilled their prescriptions at least once. No dose-response effect of exposure to the drug was found.

The researchers reported having no relevant conflicts of interest.

The use of metoclopramide to control nausea and vomiting in the first trimester does not increase the risk for congenital malformations, low birth weight, or perinatal death, according to a report in the New England Journal of Medicine.

These findings from a large retrospective cohort study “provide reassurance about the safety of metoclopramide,” which has not been convincingly established until now, wrote Ilan Matok of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and associates.

“Despite its extensive use, only a few studies have assessed the safety to the fetus of maternal exposure to metoclopramide during the first trimester, and the relatively small sizes of these studies limited their power to detect adverse effects of the drug,” they noted.

The researchers assessed singleton deliveries between 1998 and 2007 at the largest HMO in Israel, where metoclopramide is the antiemetic drug of choice during pregnancy. Approximately half of the 81,703 infants in the study were born to Jewish parents and half to Bedouin Muslim parents.

A total of 3,458 (4%) of these infants were exposed to metoclopramide during the first trimester. The mean duration of exposure was 1 week.

The rate of major congenital malformations was 5.3% among exposed infants, compared with 4.9% among unexposed infants, a nonsignificant difference. This difference remained nonsignificant when data from pregnancies that were terminated were included in the analysis.

The rates of minor congenital malformations (3.8% vs. 3.5%) and of multiple malformations (2.5% vs. 2.3%) also were similar between exposed and nonexposed infants. There also were no significant associations between subclasses of congenital malformations and metoclopramide exposure, nor was there any clustering of anomalies among exposed infants.

When the data were analyzed according to subjects' ethnic backgrounds, the drug did not raise risks to infants of either Jewish or Bedouin Muslim parents (N. Engl. J. Med. 2009;360:2528–35).

Metoclopramide also was not associated with an increased risk of preterm birth, low Apgar scores, perinatal death, or low birth weight.

A subgroup of 758 mothers who took metoclopramide refilled their prescriptions at least once. No dose-response effect of exposure to the drug was found.

The researchers reported having no relevant conflicts of interest.

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

"Stat" Order for Antibiotics Never Completed
Four months after receiving a diagnosis of leukemia, a man was admitted to undergo chemotherapy treatments. Three days after his discharge, he began to experience nausea, diarrhea, and extreme abdominal pain. His wife called the hospital and was advised by an oncology fellow to try OTC medications.

When the man did not respond to these agents, he was brought to the emergency department (ED) at the same hospital. His treating physician, informed of the man's presence in the ED, consulted with ED physicians. They agreed that antibiotic medications should be ordered and administered "stat." An IV antibiotics bag was attached to the patient's gurney and a peripherally inserted central catheter (PICC) line was in place, but the antibiotics were never attached to the PICC line—apparently because the man was taken for CT shortly after the medications arrived and before the nurse could attach the IV bag. The patient was taken for CT, then admitted without administration of antibiotics.

About two hours after the antibiotics were ordered, the patient experienced cardiac arrest. The next morning, after being informed that he was brain dead and would not recover, his wife consented to termination of life support.

The plaintiff claimed that the decedent was suffering from an infection in the colon, associated with a low white blood cell count resulting from the chemotherapy. The plaintiff contended that prompt administration of antibiotics would have saved the decedent's life.

The defendant claimed that the decedent's condition in the ED did not necessitate administration of antibiotics. The defendant also claimed that the decedent would have died of leukemia in any event.

According to a published report, a $950,000 settlement was reached.

Slow Response to Symptoms of Postpartum Stroke
One day after the delivery of her third child, a 38-year-old woman experienced a stroke. Earlier that morning, she had noticed weakness in her face, her right hand, and her right leg. She summoned a nurse, who reported the complaint. About two and a half hours later, the patient underwent CT, but the stroke had already occurred.

The woman suffers residual hemiparesis, affecting the right side of her body. She has undergone extensive, intensive rehabilitation and physical therapy but continues to have partial disability of the right arm, hand, and leg, and residual weakness of the face.

The plaintiff claimed that her pregnancy had been complicated by pregnancy-induced hypertension, which should have prompted immediate testing when she reported her symptoms. She claimed that if testing had been done on a timely basis, clot-dissolving medication could have been administered, which would have prevented the stroke.

The matter ultimately proceeded against the hospital alone. The defendant argued that proper care was given and that clot-dissolving medication is not appropriate in postpartum patients.

According to a published account, a $1.3 million settlement was reached.

Amitriptyline Toxicity Identified Too Late
In September 2001, a 64-year-old woman with a medical history significant for hypertension and depression was seen by her primary care provider for a gastrointestinal illness. She had been taking medication for high blood pressure and 150 mg/d of amitriptyline for depression. She weighed 112.5 lb.

After this illness, she began to experience intermittent episodes of lightheadedness and dizziness when she got up too fast. She mentioned these symptoms to her provider on several occasions between September 2001 and April 2002. She reported that she had had similar episodes about three times a year for a number of years and had never been given a diagnosis.

Her provider attributed these symptoms to a variety of possible etiologies, including an ear infection with labrynthitis, blood pressure medication changes, and metabolic abnormalities. By May 2002, after further adjustment to her hypertension medication and an otorhinolaryngology evaluation without unusual findings, the patient was feeling well with no further episodes of dizziness.

Between May 2002 and June 2003, the woman complained repeatedly of anorexia and weight loss during several visits with her primary care provider, with no further documented episodes of dizziness. After an extensive gastrointestinal workup, she was given a diagnosis of Barrett's esophagus. In June 2003 she again began to complain of dizziness; in response, her provider changed her blood pressure medication once again, but the woman's symptoms persisted. In July 2003 the primary care provider ordered an anorexia workup with negative results, and the woman denied feeling depressed. Her provider ordered a Holter monitor to rule out a cardiac etiology for her dizziness, but results were negative.

At a December 2003 visit, the patient again complained of lightheadedness. Her blood pressure was measured at 164/84 mm Hg when she lay down, 146/80 mm Hg while she was seated, and 90/50 when she stood up. The primary care provider noted significant orthostasis and autonomic dysfunction. Fludrocortisone was prescribed, as were thigh-high compression stockings. Results of blood work (which did not include an amitriptyline level) were essentially normal.

The patient was seen by her provider in April 2004 for nausea and vomiting. She had significant orthostasis and blood pressure as low as 72/50 mm Hg; she was too weak to walk. She was hospitalized, with admission orders indicating that she was still taking amitriptyline at bedtime. During her week-long hospitalization, the patient continued to experience significant orthostasis, with complaints of dizziness on standing. She was seen by a neurologist, who ordered blood work (again, with no amitriptyline level).

On discharge, the patient was feeling better and able to ambulate without dizziness. Subsequently, however, she continued to report significant orthostasis and dizziness at every visit with her primary care provider. In May 2004, she reported worsening anorexia, nausea, vomiting, watery diarrhea, and episodes of syncope. She had fallen several times and was bruised all over her body.

She was hospitalized once again. On admission, the patient was pale and cachectic, with blood pressure as low as 60/40 mm Hg when she stood; she was also noted to have tremors. She was given a diagnosis of profound orthostatic hypotension with syncope/autonomic dysfunction and a question of Shy-Drager syndrome.

During this hospitalization, she was examined by another neurologist, who believed the woman had multiple systems atrophy with Shy-Drager syndrome, Parkinson's disease, and dementia, as well as spells suggestive of seizures. A covering physician ordered blood work to check the woman's amitriptyline level, which was found to be abnormally elevated. Amitriptyline was discontinued and the level returned to normal therapeutic range, then fell to zero.

The woman developed severe respiratory compromise with probable adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later as a result of respiratory failure.

The primary care provider claimed that amitriptyline toxicity is extraordinarily rare and is almost always associated with intentional overdose; thus, it was acceptable not to consider this explanation for the decedent's illness, especially with regard to the broad differential diagnosis available. The defendant also suggested that the decedent had been taking amitriptyline more often than prescribed without telling the primary care provider.

A $1 million settlement was reached.     

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

"Stat" Order for Antibiotics Never Completed
Four months after receiving a diagnosis of leukemia, a man was admitted to undergo chemotherapy treatments. Three days after his discharge, he began to experience nausea, diarrhea, and extreme abdominal pain. His wife called the hospital and was advised by an oncology fellow to try OTC medications.

When the man did not respond to these agents, he was brought to the emergency department (ED) at the same hospital. His treating physician, informed of the man's presence in the ED, consulted with ED physicians. They agreed that antibiotic medications should be ordered and administered "stat." An IV antibiotics bag was attached to the patient's gurney and a peripherally inserted central catheter (PICC) line was in place, but the antibiotics were never attached to the PICC line—apparently because the man was taken for CT shortly after the medications arrived and before the nurse could attach the IV bag. The patient was taken for CT, then admitted without administration of antibiotics.

About two hours after the antibiotics were ordered, the patient experienced cardiac arrest. The next morning, after being informed that he was brain dead and would not recover, his wife consented to termination of life support.

The plaintiff claimed that the decedent was suffering from an infection in the colon, associated with a low white blood cell count resulting from the chemotherapy. The plaintiff contended that prompt administration of antibiotics would have saved the decedent's life.

The defendant claimed that the decedent's condition in the ED did not necessitate administration of antibiotics. The defendant also claimed that the decedent would have died of leukemia in any event.

According to a published report, a $950,000 settlement was reached.

Slow Response to Symptoms of Postpartum Stroke
One day after the delivery of her third child, a 38-year-old woman experienced a stroke. Earlier that morning, she had noticed weakness in her face, her right hand, and her right leg. She summoned a nurse, who reported the complaint. About two and a half hours later, the patient underwent CT, but the stroke had already occurred.

The woman suffers residual hemiparesis, affecting the right side of her body. She has undergone extensive, intensive rehabilitation and physical therapy but continues to have partial disability of the right arm, hand, and leg, and residual weakness of the face.

The plaintiff claimed that her pregnancy had been complicated by pregnancy-induced hypertension, which should have prompted immediate testing when she reported her symptoms. She claimed that if testing had been done on a timely basis, clot-dissolving medication could have been administered, which would have prevented the stroke.

The matter ultimately proceeded against the hospital alone. The defendant argued that proper care was given and that clot-dissolving medication is not appropriate in postpartum patients.

According to a published account, a $1.3 million settlement was reached.

Amitriptyline Toxicity Identified Too Late
In September 2001, a 64-year-old woman with a medical history significant for hypertension and depression was seen by her primary care provider for a gastrointestinal illness. She had been taking medication for high blood pressure and 150 mg/d of amitriptyline for depression. She weighed 112.5 lb.

After this illness, she began to experience intermittent episodes of lightheadedness and dizziness when she got up too fast. She mentioned these symptoms to her provider on several occasions between September 2001 and April 2002. She reported that she had had similar episodes about three times a year for a number of years and had never been given a diagnosis.

Her provider attributed these symptoms to a variety of possible etiologies, including an ear infection with labrynthitis, blood pressure medication changes, and metabolic abnormalities. By May 2002, after further adjustment to her hypertension medication and an otorhinolaryngology evaluation without unusual findings, the patient was feeling well with no further episodes of dizziness.

Between May 2002 and June 2003, the woman complained repeatedly of anorexia and weight loss during several visits with her primary care provider, with no further documented episodes of dizziness. After an extensive gastrointestinal workup, she was given a diagnosis of Barrett's esophagus. In June 2003 she again began to complain of dizziness; in response, her provider changed her blood pressure medication once again, but the woman's symptoms persisted. In July 2003 the primary care provider ordered an anorexia workup with negative results, and the woman denied feeling depressed. Her provider ordered a Holter monitor to rule out a cardiac etiology for her dizziness, but results were negative.

At a December 2003 visit, the patient again complained of lightheadedness. Her blood pressure was measured at 164/84 mm Hg when she lay down, 146/80 mm Hg while she was seated, and 90/50 when she stood up. The primary care provider noted significant orthostasis and autonomic dysfunction. Fludrocortisone was prescribed, as were thigh-high compression stockings. Results of blood work (which did not include an amitriptyline level) were essentially normal.

The patient was seen by her provider in April 2004 for nausea and vomiting. She had significant orthostasis and blood pressure as low as 72/50 mm Hg; she was too weak to walk. She was hospitalized, with admission orders indicating that she was still taking amitriptyline at bedtime. During her week-long hospitalization, the patient continued to experience significant orthostasis, with complaints of dizziness on standing. She was seen by a neurologist, who ordered blood work (again, with no amitriptyline level).

On discharge, the patient was feeling better and able to ambulate without dizziness. Subsequently, however, she continued to report significant orthostasis and dizziness at every visit with her primary care provider. In May 2004, she reported worsening anorexia, nausea, vomiting, watery diarrhea, and episodes of syncope. She had fallen several times and was bruised all over her body.

She was hospitalized once again. On admission, the patient was pale and cachectic, with blood pressure as low as 60/40 mm Hg when she stood; she was also noted to have tremors. She was given a diagnosis of profound orthostatic hypotension with syncope/autonomic dysfunction and a question of Shy-Drager syndrome.

During this hospitalization, she was examined by another neurologist, who believed the woman had multiple systems atrophy with Shy-Drager syndrome, Parkinson's disease, and dementia, as well as spells suggestive of seizures. A covering physician ordered blood work to check the woman's amitriptyline level, which was found to be abnormally elevated. Amitriptyline was discontinued and the level returned to normal therapeutic range, then fell to zero.

The woman developed severe respiratory compromise with probable adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later as a result of respiratory failure.

The primary care provider claimed that amitriptyline toxicity is extraordinarily rare and is almost always associated with intentional overdose; thus, it was acceptable not to consider this explanation for the decedent's illness, especially with regard to the broad differential diagnosis available. The defendant also suggested that the decedent had been taking amitriptyline more often than prescribed without telling the primary care provider.

A $1 million settlement was reached.     

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

"Stat" Order for Antibiotics Never Completed
Four months after receiving a diagnosis of leukemia, a man was admitted to undergo chemotherapy treatments. Three days after his discharge, he began to experience nausea, diarrhea, and extreme abdominal pain. His wife called the hospital and was advised by an oncology fellow to try OTC medications.

When the man did not respond to these agents, he was brought to the emergency department (ED) at the same hospital. His treating physician, informed of the man's presence in the ED, consulted with ED physicians. They agreed that antibiotic medications should be ordered and administered "stat." An IV antibiotics bag was attached to the patient's gurney and a peripherally inserted central catheter (PICC) line was in place, but the antibiotics were never attached to the PICC line—apparently because the man was taken for CT shortly after the medications arrived and before the nurse could attach the IV bag. The patient was taken for CT, then admitted without administration of antibiotics.

About two hours after the antibiotics were ordered, the patient experienced cardiac arrest. The next morning, after being informed that he was brain dead and would not recover, his wife consented to termination of life support.

The plaintiff claimed that the decedent was suffering from an infection in the colon, associated with a low white blood cell count resulting from the chemotherapy. The plaintiff contended that prompt administration of antibiotics would have saved the decedent's life.

The defendant claimed that the decedent's condition in the ED did not necessitate administration of antibiotics. The defendant also claimed that the decedent would have died of leukemia in any event.

According to a published report, a $950,000 settlement was reached.

Slow Response to Symptoms of Postpartum Stroke
One day after the delivery of her third child, a 38-year-old woman experienced a stroke. Earlier that morning, she had noticed weakness in her face, her right hand, and her right leg. She summoned a nurse, who reported the complaint. About two and a half hours later, the patient underwent CT, but the stroke had already occurred.

The woman suffers residual hemiparesis, affecting the right side of her body. She has undergone extensive, intensive rehabilitation and physical therapy but continues to have partial disability of the right arm, hand, and leg, and residual weakness of the face.

The plaintiff claimed that her pregnancy had been complicated by pregnancy-induced hypertension, which should have prompted immediate testing when she reported her symptoms. She claimed that if testing had been done on a timely basis, clot-dissolving medication could have been administered, which would have prevented the stroke.

The matter ultimately proceeded against the hospital alone. The defendant argued that proper care was given and that clot-dissolving medication is not appropriate in postpartum patients.

According to a published account, a $1.3 million settlement was reached.

Amitriptyline Toxicity Identified Too Late
In September 2001, a 64-year-old woman with a medical history significant for hypertension and depression was seen by her primary care provider for a gastrointestinal illness. She had been taking medication for high blood pressure and 150 mg/d of amitriptyline for depression. She weighed 112.5 lb.

After this illness, she began to experience intermittent episodes of lightheadedness and dizziness when she got up too fast. She mentioned these symptoms to her provider on several occasions between September 2001 and April 2002. She reported that she had had similar episodes about three times a year for a number of years and had never been given a diagnosis.

Her provider attributed these symptoms to a variety of possible etiologies, including an ear infection with labrynthitis, blood pressure medication changes, and metabolic abnormalities. By May 2002, after further adjustment to her hypertension medication and an otorhinolaryngology evaluation without unusual findings, the patient was feeling well with no further episodes of dizziness.

Between May 2002 and June 2003, the woman complained repeatedly of anorexia and weight loss during several visits with her primary care provider, with no further documented episodes of dizziness. After an extensive gastrointestinal workup, she was given a diagnosis of Barrett's esophagus. In June 2003 she again began to complain of dizziness; in response, her provider changed her blood pressure medication once again, but the woman's symptoms persisted. In July 2003 the primary care provider ordered an anorexia workup with negative results, and the woman denied feeling depressed. Her provider ordered a Holter monitor to rule out a cardiac etiology for her dizziness, but results were negative.

At a December 2003 visit, the patient again complained of lightheadedness. Her blood pressure was measured at 164/84 mm Hg when she lay down, 146/80 mm Hg while she was seated, and 90/50 when she stood up. The primary care provider noted significant orthostasis and autonomic dysfunction. Fludrocortisone was prescribed, as were thigh-high compression stockings. Results of blood work (which did not include an amitriptyline level) were essentially normal.

The patient was seen by her provider in April 2004 for nausea and vomiting. She had significant orthostasis and blood pressure as low as 72/50 mm Hg; she was too weak to walk. She was hospitalized, with admission orders indicating that she was still taking amitriptyline at bedtime. During her week-long hospitalization, the patient continued to experience significant orthostasis, with complaints of dizziness on standing. She was seen by a neurologist, who ordered blood work (again, with no amitriptyline level).

On discharge, the patient was feeling better and able to ambulate without dizziness. Subsequently, however, she continued to report significant orthostasis and dizziness at every visit with her primary care provider. In May 2004, she reported worsening anorexia, nausea, vomiting, watery diarrhea, and episodes of syncope. She had fallen several times and was bruised all over her body.

She was hospitalized once again. On admission, the patient was pale and cachectic, with blood pressure as low as 60/40 mm Hg when she stood; she was also noted to have tremors. She was given a diagnosis of profound orthostatic hypotension with syncope/autonomic dysfunction and a question of Shy-Drager syndrome.

During this hospitalization, she was examined by another neurologist, who believed the woman had multiple systems atrophy with Shy-Drager syndrome, Parkinson's disease, and dementia, as well as spells suggestive of seizures. A covering physician ordered blood work to check the woman's amitriptyline level, which was found to be abnormally elevated. Amitriptyline was discontinued and the level returned to normal therapeutic range, then fell to zero.

The woman developed severe respiratory compromise with probable adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later as a result of respiratory failure.

The primary care provider claimed that amitriptyline toxicity is extraordinarily rare and is almost always associated with intentional overdose; thus, it was acceptable not to consider this explanation for the decedent's illness, especially with regard to the broad differential diagnosis available. The defendant also suggested that the decedent had been taking amitriptyline more often than prescribed without telling the primary care provider.

A $1 million settlement was reached.     

WASHINGTON — Pregnant women's snoring has no apparent negative impact on fetal outcomes, despite some differences in fetal umbilical arterial blood gases, based on data from two studies including more than 600 women.

Previous research has suggested that habitual snoring in pregnant women may be a risk factor for poor fetal outcomes, but the available data were primarily from case studies, said Dr. Alexandra Bullough and Louise O'Brien, Ph.D., of the University of Michigan in Ann Arbor.

As part of a larger study of the impact of sleep-disordered breathing (SDB) on both maternal and fetal outcomes, the researchers recruited 380 women aged 18 years and older in the third trimester of singleton, uncomplicated pregnancies to complete sleep questionnaires. This study is the first known to examine the impact of maternal SDB on fetal outcomes after delivery, based on umbilical blood gas values for arterial pH, partial pressure of carbon dioxide (PCO₂), HCO₃, and base excess.

Overall, 129 women met the criteria for SDB, and they were compared with 251 nonsnoring controls. The women with SDB averaged a significantly higher body mass index than controls both before pregnancy (35 kg/m

In this study, there were no significant differences between the SDB and control groups in average measures of arterial pH (7.3 vs. 7.3), PCO₂ (54.4 mm Hg vs. 57.4 mm Hg), HCO₃ (23.6 mmol/L vs. 24.4 mmol/L), and base excess (−1.82 mmol vs. −1.85 mmol).

These preliminary findings suggest that maternal SDB may not be associated with adverse fetal outcomes. But the study is ongoing, and data that haven't yet been fully analyzed suggest a possible association. “We're not sure how [maternal SDB] might affect fetal outcome,” Dr. Bullough said in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Habitual snoring was not significantly associated with low birth weight or Apgar scores, based on a second study of 429 women with uncomplicated singleton pregnancies. In this study, also conducted by Dr. O'Brien and Dr. Bullough, 35% of the women reported habitual snoring (at least 3 nights each week) and 25% were obese (with a BMI of at least 30 kg/m

Overall, habitual snoring was not significantly associated with low birth weight and Apgar scores. These results held after controlling for variables including maternal diabetes, age, and race. Only the gestational age at delivery and the mother's BMI before pregnancy were independent significant predictors of birth weight and 1-minute Apgar scores, and only gestational age at delivery was an independent and significant predictor of 5-minute Apgar scores. Regardless of sleep apnea status, “women with high BMI were going to have bigger babies,” Dr. Bullough said.

These results contrasted with previous studies suggesting that maternal sleep apnea may predict poor infant outcomes, and more research is needed to evaluate the association.

The researchers said they had no financial conflicts to disclose.

WASHINGTON — Pregnant women's snoring has no apparent negative impact on fetal outcomes, despite some differences in fetal umbilical arterial blood gases, based on data from two studies including more than 600 women.

Previous research has suggested that habitual snoring in pregnant women may be a risk factor for poor fetal outcomes, but the available data were primarily from case studies, said Dr. Alexandra Bullough and Louise O'Brien, Ph.D., of the University of Michigan in Ann Arbor.

As part of a larger study of the impact of sleep-disordered breathing (SDB) on both maternal and fetal outcomes, the researchers recruited 380 women aged 18 years and older in the third trimester of singleton, uncomplicated pregnancies to complete sleep questionnaires. This study is the first known to examine the impact of maternal SDB on fetal outcomes after delivery, based on umbilical blood gas values for arterial pH, partial pressure of carbon dioxide (PCO₂), HCO₃, and base excess.

Overall, 129 women met the criteria for SDB, and they were compared with 251 nonsnoring controls. The women with SDB averaged a significantly higher body mass index than controls both before pregnancy (35 kg/m

In this study, there were no significant differences between the SDB and control groups in average measures of arterial pH (7.3 vs. 7.3), PCO₂ (54.4 mm Hg vs. 57.4 mm Hg), HCO₃ (23.6 mmol/L vs. 24.4 mmol/L), and base excess (−1.82 mmol vs. −1.85 mmol).

These preliminary findings suggest that maternal SDB may not be associated with adverse fetal outcomes. But the study is ongoing, and data that haven't yet been fully analyzed suggest a possible association. “We're not sure how [maternal SDB] might affect fetal outcome,” Dr. Bullough said in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Habitual snoring was not significantly associated with low birth weight or Apgar scores, based on a second study of 429 women with uncomplicated singleton pregnancies. In this study, also conducted by Dr. O'Brien and Dr. Bullough, 35% of the women reported habitual snoring (at least 3 nights each week) and 25% were obese (with a BMI of at least 30 kg/m

Overall, habitual snoring was not significantly associated with low birth weight and Apgar scores. These results held after controlling for variables including maternal diabetes, age, and race. Only the gestational age at delivery and the mother's BMI before pregnancy were independent significant predictors of birth weight and 1-minute Apgar scores, and only gestational age at delivery was an independent and significant predictor of 5-minute Apgar scores. Regardless of sleep apnea status, “women with high BMI were going to have bigger babies,” Dr. Bullough said.

These results contrasted with previous studies suggesting that maternal sleep apnea may predict poor infant outcomes, and more research is needed to evaluate the association.

The researchers said they had no financial conflicts to disclose.

WASHINGTON — Pregnant women's snoring has no apparent negative impact on fetal outcomes, despite some differences in fetal umbilical arterial blood gases, based on data from two studies including more than 600 women.

Previous research has suggested that habitual snoring in pregnant women may be a risk factor for poor fetal outcomes, but the available data were primarily from case studies, said Dr. Alexandra Bullough and Louise O'Brien, Ph.D., of the University of Michigan in Ann Arbor.

As part of a larger study of the impact of sleep-disordered breathing (SDB) on both maternal and fetal outcomes, the researchers recruited 380 women aged 18 years and older in the third trimester of singleton, uncomplicated pregnancies to complete sleep questionnaires. This study is the first known to examine the impact of maternal SDB on fetal outcomes after delivery, based on umbilical blood gas values for arterial pH, partial pressure of carbon dioxide (PCO₂), HCO₃, and base excess.

Overall, 129 women met the criteria for SDB, and they were compared with 251 nonsnoring controls. The women with SDB averaged a significantly higher body mass index than controls both before pregnancy (35 kg/m

In this study, there were no significant differences between the SDB and control groups in average measures of arterial pH (7.3 vs. 7.3), PCO₂ (54.4 mm Hg vs. 57.4 mm Hg), HCO₃ (23.6 mmol/L vs. 24.4 mmol/L), and base excess (−1.82 mmol vs. −1.85 mmol).

These preliminary findings suggest that maternal SDB may not be associated with adverse fetal outcomes. But the study is ongoing, and data that haven't yet been fully analyzed suggest a possible association. “We're not sure how [maternal SDB] might affect fetal outcome,” Dr. Bullough said in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Habitual snoring was not significantly associated with low birth weight or Apgar scores, based on a second study of 429 women with uncomplicated singleton pregnancies. In this study, also conducted by Dr. O'Brien and Dr. Bullough, 35% of the women reported habitual snoring (at least 3 nights each week) and 25% were obese (with a BMI of at least 30 kg/m

Overall, habitual snoring was not significantly associated with low birth weight and Apgar scores. These results held after controlling for variables including maternal diabetes, age, and race. Only the gestational age at delivery and the mother's BMI before pregnancy were independent significant predictors of birth weight and 1-minute Apgar scores, and only gestational age at delivery was an independent and significant predictor of 5-minute Apgar scores. Regardless of sleep apnea status, “women with high BMI were going to have bigger babies,” Dr. Bullough said.

These results contrasted with previous studies suggesting that maternal sleep apnea may predict poor infant outcomes, and more research is needed to evaluate the association.

The researchers said they had no financial conflicts to disclose.

CHICAGO — Many women with severe hyperemesis gravidarum experience clinical symptoms that persist well beyond delivery, a survey shows.

A 2-year online survey coordinated through the nonprofit Hyperemesis Education & Research Foundation compared postpartum symptoms in 891 women diagnosed with hyperemesis gravidarum (HG) (162 of whom received parenteral nutrition) and 541 controls who did not experience weight loss during pregnancy from severe nausea and vomiting, researchers reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Highly significant differences were seen in both the prevalence and duration of numerous postpartum symptoms between women with HG and controls, reported Dr. Gerson D. Hernandez of the University of Southern California, Los Angeles.

These symptoms included:

▸ Food aversions (34% vs. 6%).

▸ Gastroesophageal reflux (23% vs. 5%).

▸ Digestive problems (21% vs. 3%).

▸ Continued nausea (13% vs. 5%).

▸ Gallbladder problems (9% vs. 2%).

▸ Persistent fatigue (52% vs. 25%).

▸ Muscle weakness (24% vs. 8%).

The subgroup of women who required parenteral nutrition during pregnancy had the highest prevalence of persistent postpartum nausea, fatigue, and muscle weakness—symptoms that in some cases lasted months or even longer.

Fatigue, for example, persisted beyond a year in 23% of these women, and food aversions, in 17%.

“It has been the common clinical impression that all symptoms associated with HG resolve after pregnancy. This is the case for the majority of HG cases, but not all, as we can see in our results,” Dr. Hernandez said in an interview.

Clearly, more needs to be known about what is different about the subgroup of women with severe HG, particularly those with long-lasting postpartum symptoms, he added.

“The etiology of these symptoms, as well as the cause of their intensity and duration in this subgroup of the pregnant population remains unknown,” he said.

Hypotheses range from psychological—behavior modification during months of pregnancy leading to long-term food aversion—to physical, including theories about long-term consequences of “the marked nutritional deprivation that these women undergo,” Dr. Hernandez noted.

“We do know that there is something different about them that makes them still have problems after pregnancy,” he said.

A goal of the research team is to focus on ways to identify women most at risk for severe HG and to develop and implement a comprehensive management plan for them during and after their pregnancies, said Dr. Hernandez.

He was assisted in the research by associates from the USC department of obstetrics and gynecology and division of maternal-fetal medicine in Los Angeles, and the Hyperemesis Education & Research Foundation of Leesburg, Va.

None of the investigators reported conflicts of interest relevant to the study.

Fatigue persisted beyond a year in 23% of these women, and food aversions, in 17%.

Source DR. HERNANDEZ

CHICAGO — Many women with severe hyperemesis gravidarum experience clinical symptoms that persist well beyond delivery, a survey shows.

A 2-year online survey coordinated through the nonprofit Hyperemesis Education & Research Foundation compared postpartum symptoms in 891 women diagnosed with hyperemesis gravidarum (HG) (162 of whom received parenteral nutrition) and 541 controls who did not experience weight loss during pregnancy from severe nausea and vomiting, researchers reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Highly significant differences were seen in both the prevalence and duration of numerous postpartum symptoms between women with HG and controls, reported Dr. Gerson D. Hernandez of the University of Southern California, Los Angeles.

These symptoms included:

▸ Food aversions (34% vs. 6%).

▸ Gastroesophageal reflux (23% vs. 5%).

▸ Digestive problems (21% vs. 3%).

▸ Continued nausea (13% vs. 5%).

▸ Gallbladder problems (9% vs. 2%).

▸ Persistent fatigue (52% vs. 25%).

▸ Muscle weakness (24% vs. 8%).

The subgroup of women who required parenteral nutrition during pregnancy had the highest prevalence of persistent postpartum nausea, fatigue, and muscle weakness—symptoms that in some cases lasted months or even longer.

Fatigue, for example, persisted beyond a year in 23% of these women, and food aversions, in 17%.

“It has been the common clinical impression that all symptoms associated with HG resolve after pregnancy. This is the case for the majority of HG cases, but not all, as we can see in our results,” Dr. Hernandez said in an interview.

Clearly, more needs to be known about what is different about the subgroup of women with severe HG, particularly those with long-lasting postpartum symptoms, he added.

“The etiology of these symptoms, as well as the cause of their intensity and duration in this subgroup of the pregnant population remains unknown,” he said.

Hypotheses range from psychological—behavior modification during months of pregnancy leading to long-term food aversion—to physical, including theories about long-term consequences of “the marked nutritional deprivation that these women undergo,” Dr. Hernandez noted.

“We do know that there is something different about them that makes them still have problems after pregnancy,” he said.

A goal of the research team is to focus on ways to identify women most at risk for severe HG and to develop and implement a comprehensive management plan for them during and after their pregnancies, said Dr. Hernandez.

He was assisted in the research by associates from the USC department of obstetrics and gynecology and division of maternal-fetal medicine in Los Angeles, and the Hyperemesis Education & Research Foundation of Leesburg, Va.

None of the investigators reported conflicts of interest relevant to the study.

Fatigue persisted beyond a year in 23% of these women, and food aversions, in 17%.

Source DR. HERNANDEZ

CHICAGO — Many women with severe hyperemesis gravidarum experience clinical symptoms that persist well beyond delivery, a survey shows.

A 2-year online survey coordinated through the nonprofit Hyperemesis Education & Research Foundation compared postpartum symptoms in 891 women diagnosed with hyperemesis gravidarum (HG) (162 of whom received parenteral nutrition) and 541 controls who did not experience weight loss during pregnancy from severe nausea and vomiting, researchers reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Highly significant differences were seen in both the prevalence and duration of numerous postpartum symptoms between women with HG and controls, reported Dr. Gerson D. Hernandez of the University of Southern California, Los Angeles.

These symptoms included:

▸ Food aversions (34% vs. 6%).

▸ Gastroesophageal reflux (23% vs. 5%).

▸ Digestive problems (21% vs. 3%).

▸ Continued nausea (13% vs. 5%).

▸ Gallbladder problems (9% vs. 2%).

▸ Persistent fatigue (52% vs. 25%).

▸ Muscle weakness (24% vs. 8%).

The subgroup of women who required parenteral nutrition during pregnancy had the highest prevalence of persistent postpartum nausea, fatigue, and muscle weakness—symptoms that in some cases lasted months or even longer.

Fatigue, for example, persisted beyond a year in 23% of these women, and food aversions, in 17%.

“It has been the common clinical impression that all symptoms associated with HG resolve after pregnancy. This is the case for the majority of HG cases, but not all, as we can see in our results,” Dr. Hernandez said in an interview.

Clearly, more needs to be known about what is different about the subgroup of women with severe HG, particularly those with long-lasting postpartum symptoms, he added.

“The etiology of these symptoms, as well as the cause of their intensity and duration in this subgroup of the pregnant population remains unknown,” he said.

Hypotheses range from psychological—behavior modification during months of pregnancy leading to long-term food aversion—to physical, including theories about long-term consequences of “the marked nutritional deprivation that these women undergo,” Dr. Hernandez noted.

“We do know that there is something different about them that makes them still have problems after pregnancy,” he said.

A goal of the research team is to focus on ways to identify women most at risk for severe HG and to develop and implement a comprehensive management plan for them during and after their pregnancies, said Dr. Hernandez.

He was assisted in the research by associates from the USC department of obstetrics and gynecology and division of maternal-fetal medicine in Los Angeles, and the Hyperemesis Education & Research Foundation of Leesburg, Va.

None of the investigators reported conflicts of interest relevant to the study.

Fatigue persisted beyond a year in 23% of these women, and food aversions, in 17%.

Source DR. HERNANDEZ