Obstetrics

WASHINGTON — When equal access to epidural anesthesia is available, patient ethnicity is not a factor in choosing whether to have an epidural, according to results of a study of 797 consecutive women with singleton pregnancies at a hospital in Flushing, N.Y.

Although epidural anesthesia is widely available in the United States, previous studies have suggested that ethnic disparities persist in the provision of epidurals, according to Dr. Isaac P. Lowenwirt of the New York Hospital Queens, Flushing.

To describe the use of epidural anesthesia during labor in a multiethnic population, Dr. Lowenwirt and his colleagues conducted a prospective study of 800 consecutive singleton pregnancies at a single hospital.

The average age of the women across all ethnic groups ranged from 27 to 32 years. Women who had multiples, malpresentation, or planned cesarean deliveries were excluded from the study.

Complete data from 797 women were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The women were offered three options: parenteral fentanyl, patient-controlled anesthesia (bupivacaine), or no medication. The severity of pain was measured with a visual analog scale.

Overall, 82% of the patients chose an epidural.

The average baseline pain scores were higher among the women who chose an epidural, compared with those who did not (8.8 vs. 3.7). But there was no significant difference in epidural use among the ethnic groups, and patients in all groups reported similarly effective pain relief after epidural placement.

The ethnic groups were defined as white (103 patients), black (78 patients), Hispanic (150 patients), Chinese or Korean (338 patients), Indian (67 patients), and other ethnicities (61 patients).

Socioeconomic factors and maternal education were not factors in the use of an epidural, Dr. Lowenwirt reported.

In addition, nulliparous women were four times more likely to choose an epidural than multiparous women, regardless of ethnicity.

On further analysis, Chinese or Korean patients averaged the shortest duration of analgesia, and black patients averaged the longest duration (141 minutes vs. 185 minutes).

And there was a significant difference in average bupivacaine use between the group with the highest use (Hispanic patients) and the lowest use (Chinese or Korean patients).

The Hispanic patients who chose bupivacaine averaged 7.3 mg/hr, compared with an average of 5.5 mg/hr for the Chinese or Korean patients who chose bupivacaine, he said..

The results suggest that when equal access to epidural analgesia is available, women of all ethnic groups choose it in similar proportions, compared with no medication, the researchers wrote in the poster.

Dr. Lowenwirt said he had no financial conflicts to disclose.

WASHINGTON — When equal access to epidural anesthesia is available, patient ethnicity is not a factor in choosing whether to have an epidural, according to results of a study of 797 consecutive women with singleton pregnancies at a hospital in Flushing, N.Y.

Although epidural anesthesia is widely available in the United States, previous studies have suggested that ethnic disparities persist in the provision of epidurals, according to Dr. Isaac P. Lowenwirt of the New York Hospital Queens, Flushing.

To describe the use of epidural anesthesia during labor in a multiethnic population, Dr. Lowenwirt and his colleagues conducted a prospective study of 800 consecutive singleton pregnancies at a single hospital.

The average age of the women across all ethnic groups ranged from 27 to 32 years. Women who had multiples, malpresentation, or planned cesarean deliveries were excluded from the study.

Complete data from 797 women were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The women were offered three options: parenteral fentanyl, patient-controlled anesthesia (bupivacaine), or no medication. The severity of pain was measured with a visual analog scale.

Overall, 82% of the patients chose an epidural.

The average baseline pain scores were higher among the women who chose an epidural, compared with those who did not (8.8 vs. 3.7). But there was no significant difference in epidural use among the ethnic groups, and patients in all groups reported similarly effective pain relief after epidural placement.

The ethnic groups were defined as white (103 patients), black (78 patients), Hispanic (150 patients), Chinese or Korean (338 patients), Indian (67 patients), and other ethnicities (61 patients).

Socioeconomic factors and maternal education were not factors in the use of an epidural, Dr. Lowenwirt reported.

In addition, nulliparous women were four times more likely to choose an epidural than multiparous women, regardless of ethnicity.

On further analysis, Chinese or Korean patients averaged the shortest duration of analgesia, and black patients averaged the longest duration (141 minutes vs. 185 minutes).

And there was a significant difference in average bupivacaine use between the group with the highest use (Hispanic patients) and the lowest use (Chinese or Korean patients).

The Hispanic patients who chose bupivacaine averaged 7.3 mg/hr, compared with an average of 5.5 mg/hr for the Chinese or Korean patients who chose bupivacaine, he said..

The results suggest that when equal access to epidural analgesia is available, women of all ethnic groups choose it in similar proportions, compared with no medication, the researchers wrote in the poster.

Dr. Lowenwirt said he had no financial conflicts to disclose.

WASHINGTON — When equal access to epidural anesthesia is available, patient ethnicity is not a factor in choosing whether to have an epidural, according to results of a study of 797 consecutive women with singleton pregnancies at a hospital in Flushing, N.Y.

Although epidural anesthesia is widely available in the United States, previous studies have suggested that ethnic disparities persist in the provision of epidurals, according to Dr. Isaac P. Lowenwirt of the New York Hospital Queens, Flushing.

To describe the use of epidural anesthesia during labor in a multiethnic population, Dr. Lowenwirt and his colleagues conducted a prospective study of 800 consecutive singleton pregnancies at a single hospital.

The average age of the women across all ethnic groups ranged from 27 to 32 years. Women who had multiples, malpresentation, or planned cesarean deliveries were excluded from the study.

Complete data from 797 women were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The women were offered three options: parenteral fentanyl, patient-controlled anesthesia (bupivacaine), or no medication. The severity of pain was measured with a visual analog scale.

Overall, 82% of the patients chose an epidural.

The average baseline pain scores were higher among the women who chose an epidural, compared with those who did not (8.8 vs. 3.7). But there was no significant difference in epidural use among the ethnic groups, and patients in all groups reported similarly effective pain relief after epidural placement.

The ethnic groups were defined as white (103 patients), black (78 patients), Hispanic (150 patients), Chinese or Korean (338 patients), Indian (67 patients), and other ethnicities (61 patients).

Socioeconomic factors and maternal education were not factors in the use of an epidural, Dr. Lowenwirt reported.

In addition, nulliparous women were four times more likely to choose an epidural than multiparous women, regardless of ethnicity.

On further analysis, Chinese or Korean patients averaged the shortest duration of analgesia, and black patients averaged the longest duration (141 minutes vs. 185 minutes).

And there was a significant difference in average bupivacaine use between the group with the highest use (Hispanic patients) and the lowest use (Chinese or Korean patients).

The Hispanic patients who chose bupivacaine averaged 7.3 mg/hr, compared with an average of 5.5 mg/hr for the Chinese or Korean patients who chose bupivacaine, he said..

The results suggest that when equal access to epidural analgesia is available, women of all ethnic groups choose it in similar proportions, compared with no medication, the researchers wrote in the poster.

Dr. Lowenwirt said he had no financial conflicts to disclose.

WASHINGTON — Women who were able to bite down on a mouth guard had a significantly shorter second stage of labor, compared with women who didn't use a mouth guard, based on the results of a randomized trial of 64 women with uncomplicated singleton pregnancies.

Developing a way to help women push harder may shorten the second stage of labor and reduce the number of cesarean or instrumental deliveries that are associated with a longer second stage, Dr. Janna Mudd said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“We wanted to come up with a method that would maximize maternal expulsive effort,” she explained.

Previous studies have shown that wearing a mouth guard increases the isometric strength of different muscle groups, and the researchers hypothesized that the device (a plastic mouth guard similar to those used in sports) would encourage women to push harder during the second stage of labor.

To test this theory, Dr. Mudd and her colleagues at the University of Maryland in Baltimore randomized women at a single hospital in Baltimore to wear or not wear a mouth guard during the second stage of labor. The women were nulliparous with uncomplicated singleton term pregnancies, and an average gestational age of 39 weeks. There were no significant obstetrical demographic differences between the two groups, Dr. Mudd commented.

The researchers excluded women with diabetes, preeclampsia, or other comorbidities; those whose babies were large for gestational age; or those who had shoulder dystocia or other potential complications. A total of 38 women (19 in each group) were evaluated during the second stage of labor. Overall, the average duration of the second stage was 19 minutes in the mouth guard group vs. 31 minutes in the control group.

Each of the women in the study had received an epidural, and their pushing was directed by a doctor or midwife. The women were instructed to start pushing when they were deemed fully dilated based on a digital exam.

There were no significant differences in birth weight, head circumference, Apgar scores, umbilical arterial and venous pH, and rate of NICU admission among infants of women who used the mouth guards, compared with those women who did not wear a mouth guard.

“We also were very interested in patient satisfaction,” Dr. Mudd said. “I was surprised how many people seemed very enthusiastic and willing to try anything to avoid an operative deliver,”

Overall, the patients were very satisfied with the device and said they thought that wearing it helped them to focus while pushing, although some women reported discomfort and nausea while using the mouth guard. On average, the women who used the mouth guards rated their satisfaction as 4 on a scale of 1–5.

The researchers considered three possible mechanisms of action for the impact of a mouth guard on the second stage of labor: a direct effect on the muscles, a secondary effect on posture, and increased endurance during isometric muscle activity.

In response to a question from the audience, Dr. Mudd noted that she had no explanation for why the second stage of labor in the study population as a whole was shorter than average for nulliparous women. (The American Pregnancy Association says the second stage lasts anywhere from approximately 20 minutes to 2 hours.)

The study was limited by its small size, and more research is needed to confirm the results, Dr. Mudd said. Factors to consider in future studies include measuring the uterine pressure to identify whether the expulsive effort is greater in women who wear mouth guards during the second stage of labor, she commented.

The researchers had no financial conflicts to disclose related to the study.

WASHINGTON — Women who were able to bite down on a mouth guard had a significantly shorter second stage of labor, compared with women who didn't use a mouth guard, based on the results of a randomized trial of 64 women with uncomplicated singleton pregnancies.

Developing a way to help women push harder may shorten the second stage of labor and reduce the number of cesarean or instrumental deliveries that are associated with a longer second stage, Dr. Janna Mudd said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“We wanted to come up with a method that would maximize maternal expulsive effort,” she explained.

Previous studies have shown that wearing a mouth guard increases the isometric strength of different muscle groups, and the researchers hypothesized that the device (a plastic mouth guard similar to those used in sports) would encourage women to push harder during the second stage of labor.

To test this theory, Dr. Mudd and her colleagues at the University of Maryland in Baltimore randomized women at a single hospital in Baltimore to wear or not wear a mouth guard during the second stage of labor. The women were nulliparous with uncomplicated singleton term pregnancies, and an average gestational age of 39 weeks. There were no significant obstetrical demographic differences between the two groups, Dr. Mudd commented.

The researchers excluded women with diabetes, preeclampsia, or other comorbidities; those whose babies were large for gestational age; or those who had shoulder dystocia or other potential complications. A total of 38 women (19 in each group) were evaluated during the second stage of labor. Overall, the average duration of the second stage was 19 minutes in the mouth guard group vs. 31 minutes in the control group.

Each of the women in the study had received an epidural, and their pushing was directed by a doctor or midwife. The women were instructed to start pushing when they were deemed fully dilated based on a digital exam.

There were no significant differences in birth weight, head circumference, Apgar scores, umbilical arterial and venous pH, and rate of NICU admission among infants of women who used the mouth guards, compared with those women who did not wear a mouth guard.

“We also were very interested in patient satisfaction,” Dr. Mudd said. “I was surprised how many people seemed very enthusiastic and willing to try anything to avoid an operative deliver,”

Overall, the patients were very satisfied with the device and said they thought that wearing it helped them to focus while pushing, although some women reported discomfort and nausea while using the mouth guard. On average, the women who used the mouth guards rated their satisfaction as 4 on a scale of 1–5.

The researchers considered three possible mechanisms of action for the impact of a mouth guard on the second stage of labor: a direct effect on the muscles, a secondary effect on posture, and increased endurance during isometric muscle activity.

In response to a question from the audience, Dr. Mudd noted that she had no explanation for why the second stage of labor in the study population as a whole was shorter than average for nulliparous women. (The American Pregnancy Association says the second stage lasts anywhere from approximately 20 minutes to 2 hours.)

The study was limited by its small size, and more research is needed to confirm the results, Dr. Mudd said. Factors to consider in future studies include measuring the uterine pressure to identify whether the expulsive effort is greater in women who wear mouth guards during the second stage of labor, she commented.

The researchers had no financial conflicts to disclose related to the study.

WASHINGTON — Women who were able to bite down on a mouth guard had a significantly shorter second stage of labor, compared with women who didn't use a mouth guard, based on the results of a randomized trial of 64 women with uncomplicated singleton pregnancies.

Developing a way to help women push harder may shorten the second stage of labor and reduce the number of cesarean or instrumental deliveries that are associated with a longer second stage, Dr. Janna Mudd said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“We wanted to come up with a method that would maximize maternal expulsive effort,” she explained.

Previous studies have shown that wearing a mouth guard increases the isometric strength of different muscle groups, and the researchers hypothesized that the device (a plastic mouth guard similar to those used in sports) would encourage women to push harder during the second stage of labor.

To test this theory, Dr. Mudd and her colleagues at the University of Maryland in Baltimore randomized women at a single hospital in Baltimore to wear or not wear a mouth guard during the second stage of labor. The women were nulliparous with uncomplicated singleton term pregnancies, and an average gestational age of 39 weeks. There were no significant obstetrical demographic differences between the two groups, Dr. Mudd commented.

The researchers excluded women with diabetes, preeclampsia, or other comorbidities; those whose babies were large for gestational age; or those who had shoulder dystocia or other potential complications. A total of 38 women (19 in each group) were evaluated during the second stage of labor. Overall, the average duration of the second stage was 19 minutes in the mouth guard group vs. 31 minutes in the control group.

Each of the women in the study had received an epidural, and their pushing was directed by a doctor or midwife. The women were instructed to start pushing when they were deemed fully dilated based on a digital exam.

There were no significant differences in birth weight, head circumference, Apgar scores, umbilical arterial and venous pH, and rate of NICU admission among infants of women who used the mouth guards, compared with those women who did not wear a mouth guard.

“We also were very interested in patient satisfaction,” Dr. Mudd said. “I was surprised how many people seemed very enthusiastic and willing to try anything to avoid an operative deliver,”

Overall, the patients were very satisfied with the device and said they thought that wearing it helped them to focus while pushing, although some women reported discomfort and nausea while using the mouth guard. On average, the women who used the mouth guards rated their satisfaction as 4 on a scale of 1–5.

The researchers considered three possible mechanisms of action for the impact of a mouth guard on the second stage of labor: a direct effect on the muscles, a secondary effect on posture, and increased endurance during isometric muscle activity.

In response to a question from the audience, Dr. Mudd noted that she had no explanation for why the second stage of labor in the study population as a whole was shorter than average for nulliparous women. (The American Pregnancy Association says the second stage lasts anywhere from approximately 20 minutes to 2 hours.)

The study was limited by its small size, and more research is needed to confirm the results, Dr. Mudd said. Factors to consider in future studies include measuring the uterine pressure to identify whether the expulsive effort is greater in women who wear mouth guards during the second stage of labor, she commented.

The researchers had no financial conflicts to disclose related to the study.

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

NEW ORLEANS — Most obstetrical care providers agree that at-risk women should undergo early screening for gestational diabetes mellitus, and the majority use the 50-g, 1-hour oral glucose challenge test, results from a single-center survey showed.

“Our data suggest early screening detects a significant proportion of women with GDM [gestational diabetes mellitus],” Dr. Kimberly K. Vesco of the center for health research at Kaiser Permanente Northwest, Portland, Ore., reported in a poster at the annual scientific sessions of the American Diabetes Association. “Formal protocols for early screening of at-risk women should be established and evaluated to determine whether they lead to improvement in early screening and detection of GDM.”

Although both the American College of Obstetricians and Gynecologists and the ADA recommend screening pregnant women at risk for diabetes at the first prenatal visit, “neither organization specifies what lab test to use for early screening, e.g., fasting plasma glucose [FPG]; the 50-g, 1-hour oral glucose challenge test [OGCT]; or both,” wrote the researchers, who said they had no disclosures to report.

To find out how and why clinicians screen for diabetes in early pregnancy, the researchers surveyed 92 obstetrical care providers at Kaiser Permanente Northwest in 2007 about their first- and second-trimester GDM screening practices. They analyzed medical records of women who gave birth there from 2004 to 2006 to determine the prevalence of GDM and the proportion of women with GDM diagnosed before 24 weeks' gestation.

Of 92 clinicians, 62 (67%) returned the survey, including 33 obstetricians, 16 nurse-midwives, and 9 nurse practitioners. Four respondents did not report their degree.

The majority of providers indicated they would order GDM screening for women with a history of GDM (97% in the first trimester vs. 87% in the second trimester), those with a history of delivering a macrosomic infant (82% in the first trimester vs. 77% in the second trimester), and those who are obese (81% in the first trimester vs. 73% in the second trimester).

The 50-g OGCT was the preferred test of respondents for early screening (71% in the first trimester vs. 77% in the second trimester), followed by the FPG test (26% in the first trimester vs. 10% in the second trimester), and a combination of the two tests (8% in the first and second trimesters).

Between 2004 and 2006, 436 women were diagnosed with GDM, for a prevalence of 3.8%. The prevalence was significantly higher among obese women compared with nonobese women (6.7% vs. 2.9%).

Overall, just 4.6% of GDM diagnoses were made before 12 weeks' gestation and 10.9% prior to 24 weeks' gestation. Among obese women with GDM, 5.4% were diagnosed prior to 12 weeks and 14.8% prior to 24 weeks' gestation. In addition, the researchers wrote, “despite the majority of providers indicating that they would screen obese women at the first prenatal visit, the proportion of obese women screened was only 16% prior to 12 weeks and 29% prior to 24 weeks.”

The 50-g, 1-hour OGCT was most commonly used for all study participants (in 75% prior to 12 weeks' gestation, in 90% between 12 and 23 weeks' gestation and in 99.6% at 24 weeks' gestation and beyond), followed by FPG (in 24% prior to 12 weeks' gestation, in 9% between 12 and 23 weeks' gestation, and in 0.4% at week 24 of gestation and beyond) and the 100-g, 3-hour oral glucose tolerance test (in 0.4% prior to 12 weeks' gestation, in 1.2% between 12 and 23 weeks' gestation, and in 0.1% at week 24 of gestation and beyond).

The rate of cesarean delivery in the United States reached its highest level yet— 31.8%—in 2007.¹ At more than 1.2 million procedures each year, cesarean delivery is the most common major surgery performed, but few studies have explored the techniques involved. Recent investigations have focused on whether it is advisable to close the peritoneum at the time of cesarean section,² how to perform and close the hysterotomy,³ and the timing of prophylactic antibiotics.^4,5 But we need more evidence to optimize outcomes.

Rousseau and colleagues have made a commendable effort to sift through one of the many unanswered questions regarding cesarean technique: What is the best skin closure? Their prospective, randomized, controlled trial compared staple closure with subcuticular closure using 4-0 Monocryl.

The authors did many things we have come to expect from clinical trials, including:

• a priori sample-size calculation to ensure adequate statistical power
• randomization by group of 8
• stratification of randomization by primary and repeat cesarean delivery
• assessment of wound cosmesis in a blinded, masked fashion.

They found a “statistically significant” difference in the pain score at 6 postoperative weeks between staples and sutures, with staples having the lower mean score (0.2 vs 0.5; P=.04). They also demonstrated shorter operative time for staple closure (32 vs 41 minutes; P<.001).

When such a study is published, it is easy to assume that the issue has been settled and to change or not change practice, depending on your existing technique—but that is often unwise. Every study has limitations. Even when statistically significant benefits are demonstrated, as they are in this study, it may not always be clear whether your patients match the patients in the study, or whether your technique matches what has been administered during the investigation.

In this case, a few problems need to be pointed out:

• Although the evaluation of cosmesis was by masked clinicians, assessment of the primary outcome—pain—was conducted by the patients themselves, who were not masked. One can easily see that awareness of a suture retained beneath the skin might bias a patient’s perception of pain and discomfort. It would be relatively easy to mask the type of closure—even from patients—on postoperative day 1, but masking would become much more difficult when the staples needed to be removed.
• The issue of statistical analysis can sometimes be dull, but is occasionally paramount in determining validity of a study. In this case, the primary outcome—the pain scale—was considered a continuous outcome and compared using a Student’s t-test. An important assumption in this test is that the data are normally distributed. However, the authors do not make it clear whether they tested the data for normalcy. Particularly at the 6-week evaluation, when the mean value was between 0 and 1 for both groups, it seems unlikely that the data were normally distributed. As a result, the difference in pain scores—0.2 vs 0.5—could have been driven by a few high values in one group. Statistically, this would have been easy to manage by changing the comparison to a Wilcoxon rank-sum test.

Despite these limitations, it does seem unlikely that the pain at 6 weeks would have been worse in the staple group.

These findings contrast those of another study of the same topic, which found less pain in the subcuticular suture group.⁶ In that unmasked study, subcuticular closure was determined to be more “cosmetically attractive” by the patients and their physicians. Again, one needs to be concerned about bias.

The rate of cesarean delivery in the United States reached its highest level yet— 31.8%—in 2007.¹ At more than 1.2 million procedures each year, cesarean delivery is the most common major surgery performed, but few studies have explored the techniques involved. Recent investigations have focused on whether it is advisable to close the peritoneum at the time of cesarean section,² how to perform and close the hysterotomy,³ and the timing of prophylactic antibiotics.^4,5 But we need more evidence to optimize outcomes.

Rousseau and colleagues have made a commendable effort to sift through one of the many unanswered questions regarding cesarean technique: What is the best skin closure? Their prospective, randomized, controlled trial compared staple closure with subcuticular closure using 4-0 Monocryl.

The authors did many things we have come to expect from clinical trials, including:

• a priori sample-size calculation to ensure adequate statistical power
• randomization by group of 8
• stratification of randomization by primary and repeat cesarean delivery
• assessment of wound cosmesis in a blinded, masked fashion.

They found a “statistically significant” difference in the pain score at 6 postoperative weeks between staples and sutures, with staples having the lower mean score (0.2 vs 0.5; P=.04). They also demonstrated shorter operative time for staple closure (32 vs 41 minutes; P<.001).

When such a study is published, it is easy to assume that the issue has been settled and to change or not change practice, depending on your existing technique—but that is often unwise. Every study has limitations. Even when statistically significant benefits are demonstrated, as they are in this study, it may not always be clear whether your patients match the patients in the study, or whether your technique matches what has been administered during the investigation.

In this case, a few problems need to be pointed out:

• Although the evaluation of cosmesis was by masked clinicians, assessment of the primary outcome—pain—was conducted by the patients themselves, who were not masked. One can easily see that awareness of a suture retained beneath the skin might bias a patient’s perception of pain and discomfort. It would be relatively easy to mask the type of closure—even from patients—on postoperative day 1, but masking would become much more difficult when the staples needed to be removed.
• The issue of statistical analysis can sometimes be dull, but is occasionally paramount in determining validity of a study. In this case, the primary outcome—the pain scale—was considered a continuous outcome and compared using a Student’s t-test. An important assumption in this test is that the data are normally distributed. However, the authors do not make it clear whether they tested the data for normalcy. Particularly at the 6-week evaluation, when the mean value was between 0 and 1 for both groups, it seems unlikely that the data were normally distributed. As a result, the difference in pain scores—0.2 vs 0.5—could have been driven by a few high values in one group. Statistically, this would have been easy to manage by changing the comparison to a Wilcoxon rank-sum test.

Despite these limitations, it does seem unlikely that the pain at 6 weeks would have been worse in the staple group.

These findings contrast those of another study of the same topic, which found less pain in the subcuticular suture group.⁶ In that unmasked study, subcuticular closure was determined to be more “cosmetically attractive” by the patients and their physicians. Again, one needs to be concerned about bias.

The rate of cesarean delivery in the United States reached its highest level yet— 31.8%—in 2007.¹ At more than 1.2 million procedures each year, cesarean delivery is the most common major surgery performed, but few studies have explored the techniques involved. Recent investigations have focused on whether it is advisable to close the peritoneum at the time of cesarean section,² how to perform and close the hysterotomy,³ and the timing of prophylactic antibiotics.^4,5 But we need more evidence to optimize outcomes.

Rousseau and colleagues have made a commendable effort to sift through one of the many unanswered questions regarding cesarean technique: What is the best skin closure? Their prospective, randomized, controlled trial compared staple closure with subcuticular closure using 4-0 Monocryl.

The authors did many things we have come to expect from clinical trials, including:

• a priori sample-size calculation to ensure adequate statistical power
• randomization by group of 8
• stratification of randomization by primary and repeat cesarean delivery
• assessment of wound cosmesis in a blinded, masked fashion.

They found a “statistically significant” difference in the pain score at 6 postoperative weeks between staples and sutures, with staples having the lower mean score (0.2 vs 0.5; P=.04). They also demonstrated shorter operative time for staple closure (32 vs 41 minutes; P<.001).

When such a study is published, it is easy to assume that the issue has been settled and to change or not change practice, depending on your existing technique—but that is often unwise. Every study has limitations. Even when statistically significant benefits are demonstrated, as they are in this study, it may not always be clear whether your patients match the patients in the study, or whether your technique matches what has been administered during the investigation.

In this case, a few problems need to be pointed out:

• Although the evaluation of cosmesis was by masked clinicians, assessment of the primary outcome—pain—was conducted by the patients themselves, who were not masked. One can easily see that awareness of a suture retained beneath the skin might bias a patient’s perception of pain and discomfort. It would be relatively easy to mask the type of closure—even from patients—on postoperative day 1, but masking would become much more difficult when the staples needed to be removed.
• The issue of statistical analysis can sometimes be dull, but is occasionally paramount in determining validity of a study. In this case, the primary outcome—the pain scale—was considered a continuous outcome and compared using a Student’s t-test. An important assumption in this test is that the data are normally distributed. However, the authors do not make it clear whether they tested the data for normalcy. Particularly at the 6-week evaluation, when the mean value was between 0 and 1 for both groups, it seems unlikely that the data were normally distributed. As a result, the difference in pain scores—0.2 vs 0.5—could have been driven by a few high values in one group. Statistically, this would have been easy to manage by changing the comparison to a Wilcoxon rank-sum test.

Despite these limitations, it does seem unlikely that the pain at 6 weeks would have been worse in the staple group.

These findings contrast those of another study of the same topic, which found less pain in the subcuticular suture group.⁶ In that unmasked study, subcuticular closure was determined to be more “cosmetically attractive” by the patients and their physicians. Again, one needs to be concerned about bias.

WASHINGTON — No significant differences in neonatal outcomes were found among premature infants of women who had spinal anesthesia versus general anesthesia for cesarean delivery, based on the results of a study of 78 deliveries.

Most data on anesthesia and elective C-sections come from studies of term infants, said Dr. Robin Russell and colleagues at the John Radcliffe Hospital in Oxford, England. Data from one recent review of premature infants suggested that neonatal mortality risk was greater with spinal anesthesia than with general anesthesia, the researchers noted.

In this study, Dr. Russell and associates reviewed information from 78 women who were delivered at less than 33 weeks' gestation at a single hospital (69 singleton and 9 twin deliveries); the average age of the women was 31 years. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Spinal anesthesia (SA) was used in 58 cases, general anesthesia (GA) in 18 cases, and an epidural in 2 cases. The researchers compared the outcomes for the SA and GA cases based on Apgar scores and umbilical blood gas levels.

Overall, Apgar scores were not significantly different between the spinal and general anesthesia groups. The median 1-minute Apgar score was 8 in the SA group (range, 2-10) and 7 in the GA group (range, 3-9), and the median 5-minute Apgar scores were 8 in the SA group and 9 in the GA group.

Measures of umbilical venous gases were available for 49 SA deliveries and 15 GA deliveries, and measures of umbilical arterial gases were available for 51 SA deliveries and 13 GA deliveries. Based on these measures, there were no significant differences between the groups.

In addition, the birth weights were similar between the two groups, and no significant differences were observed in the health of the infants at 28 days or 3 months of age.

The results contrast with findings from previous research, but the study was limited by its small size and retrospective design, the researchers said. “Further work is needed to determine the optimal mode of anesthesia for cesarean section in premature infants,” they wrote. The investigators reported that they had no financial conflicts to disclose.

WASHINGTON — No significant differences in neonatal outcomes were found among premature infants of women who had spinal anesthesia versus general anesthesia for cesarean delivery, based on the results of a study of 78 deliveries.

Most data on anesthesia and elective C-sections come from studies of term infants, said Dr. Robin Russell and colleagues at the John Radcliffe Hospital in Oxford, England. Data from one recent review of premature infants suggested that neonatal mortality risk was greater with spinal anesthesia than with general anesthesia, the researchers noted.

In this study, Dr. Russell and associates reviewed information from 78 women who were delivered at less than 33 weeks' gestation at a single hospital (69 singleton and 9 twin deliveries); the average age of the women was 31 years. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Spinal anesthesia (SA) was used in 58 cases, general anesthesia (GA) in 18 cases, and an epidural in 2 cases. The researchers compared the outcomes for the SA and GA cases based on Apgar scores and umbilical blood gas levels.

Overall, Apgar scores were not significantly different between the spinal and general anesthesia groups. The median 1-minute Apgar score was 8 in the SA group (range, 2-10) and 7 in the GA group (range, 3-9), and the median 5-minute Apgar scores were 8 in the SA group and 9 in the GA group.

Measures of umbilical venous gases were available for 49 SA deliveries and 15 GA deliveries, and measures of umbilical arterial gases were available for 51 SA deliveries and 13 GA deliveries. Based on these measures, there were no significant differences between the groups.

In addition, the birth weights were similar between the two groups, and no significant differences were observed in the health of the infants at 28 days or 3 months of age.

The results contrast with findings from previous research, but the study was limited by its small size and retrospective design, the researchers said. “Further work is needed to determine the optimal mode of anesthesia for cesarean section in premature infants,” they wrote. The investigators reported that they had no financial conflicts to disclose.

WASHINGTON — No significant differences in neonatal outcomes were found among premature infants of women who had spinal anesthesia versus general anesthesia for cesarean delivery, based on the results of a study of 78 deliveries.

Most data on anesthesia and elective C-sections come from studies of term infants, said Dr. Robin Russell and colleagues at the John Radcliffe Hospital in Oxford, England. Data from one recent review of premature infants suggested that neonatal mortality risk was greater with spinal anesthesia than with general anesthesia, the researchers noted.

In this study, Dr. Russell and associates reviewed information from 78 women who were delivered at less than 33 weeks' gestation at a single hospital (69 singleton and 9 twin deliveries); the average age of the women was 31 years. The results were presented in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Spinal anesthesia (SA) was used in 58 cases, general anesthesia (GA) in 18 cases, and an epidural in 2 cases. The researchers compared the outcomes for the SA and GA cases based on Apgar scores and umbilical blood gas levels.

Overall, Apgar scores were not significantly different between the spinal and general anesthesia groups. The median 1-minute Apgar score was 8 in the SA group (range, 2-10) and 7 in the GA group (range, 3-9), and the median 5-minute Apgar scores were 8 in the SA group and 9 in the GA group.

Measures of umbilical venous gases were available for 49 SA deliveries and 15 GA deliveries, and measures of umbilical arterial gases were available for 51 SA deliveries and 13 GA deliveries. Based on these measures, there were no significant differences between the groups.

In addition, the birth weights were similar between the two groups, and no significant differences were observed in the health of the infants at 28 days or 3 months of age.

The results contrast with findings from previous research, but the study was limited by its small size and retrospective design, the researchers said. “Further work is needed to determine the optimal mode of anesthesia for cesarean section in premature infants,” they wrote. The investigators reported that they had no financial conflicts to disclose.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

CHICAGO — The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists. Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all 3 calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

Positive ultrasound markers are highly predictive of a successful pregnancy outcome very early in pregnancy, providing reassurance to patients who have suffered from infertility or recurrent pregnancy losses, researchers reported in two studies.

Fetal cardiac activity, gestational sac diameter, and yolk sac diameter on postconception days 33-36 were all significantly associated with a viable pregnancy beyond 20 weeks' gestation, reported Dr. Soyoung Bae of the University of Toledo (Ohio) Medical Center.

Dr. Bae and Dr. Joseph V. Karnitis of the Fertility Center of Northwest Ohio, also in Toledo, retrospectively evaluated ultrasound results of 1,092 early pregnancies, tracking findings present in those that resulted in a successful pregnancy at 20 weeks' gestation and beyond.

“The majority of these pregnancies were conceived using infertility treatments, and the date of conception was clearly known,” said Dr. Bae during an award-winning paper presentation at the annual meeting of the American College of Obstetricians and Gynecologists.

The presence of cardiac activity during early pregnancy was associated with a 90.4% ongoing pregnancy rate at 20 weeks. Gestational sac diameter of 12 mm and above was a similarly reassuring finding, associated with an ongoing pregnancy rate of 91.9% at 20 weeks. A small gestational sac, less than 8 mm in diameter, was conversely associated with a miscarriage rate of 86.1%.

A yolk sac diameter between 2 mm and 6 mm was most predictive of a successful pregnancy, associated with an ongoing pregnancy rate of 89.2% at 20 weeks. Yolk sacs less than 2 mm in diameter or larger than 6 mm in diameter were associated with poor ongoing success rates of 20.5% and 20%.

An embryo's crown-rump length and fetal heart rate greater than 100 beats per minute predicted viability at 5-6 weeks post conception in a separate study presented at the annual meeting of the Pacific Coast Reproductive Society in Indian Wells, Calif.

Despite positive results on home pregnancy tests, anxiety runs high in couples who have struggled to become pregnant, said Dr. Charles C. Coddington, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

During ultrasounds at 5-6 weeks to establish the intrauterine location of the pregnancy, many patients want an estimate ofthe chances the pregnancy will progress, he said.

While conventional wisdom traditionally held that a fetal heart rate greater than 100 beats per minute was reassuring, there were few data to back that up. In cases where the heart rate was less than 100, “we didn't know whether to be reassuring or concerned,” he explained in an interview.

Dr. Coddington and his associates conducted a retrospective analysis of infertility patients who had undergone early first-trimester ultrasounds with duplex color Doppler imaging.

Viability was 100% in 38 pregnancies in which fetal heart rates exceeded 100 beats per minute and embryos were determined to be growing appropriately at 5-6 weeks based on crown-rump length on ultrasound, explained Dr. Coddington. Among pregnancies with a fetal heart rate less than 100 beats per minute at the first scan, just 5 of 11 progressed.

Fetal heart rate and crown-rump length were strongly correlated, with an R value coefficient of 0.736 and a P value of less than .0001.

When the 5- to 6-week ultrasound shows a reassuring crown-rump length and a fetal heart rate over 100, “we can give very positive reinforcement to couples, which is a wonderful thing you can do for them,” Dr. Coddington said.

Women who undergo thyroid or parathyroid surgery during pregnancy have more operative complications and require longer hospitalizations than do nonpregnant women who have such surgery, as well as relatively high rates of maternal and fetal complications.

These findings, from “the first population-based study to examine predictors of clinical and economic outcomes” in this patient group, suggest that thyroid and parathyroid surgery are not the low-risk procedures in pregnant women that they are in the general population, said Dr. SreyRam Kuy of Yale University, New Haven, Conn., and associates.

The investigators assessed thyroid and parathyroid procedures in pregnancy because the subject had not been well studied before now, even though most disorders that necessitate such surgery occur in women of childbearing age. In addition, recent attention has focused on developing practice guidelines for pregnant women with endocrine disorders, and there was a glaring lack of evidence on this issue in the literature.

Dr. Kuy and colleagues performed a retrospective cross-sectional analysis of hospital discharge data using “the largest all-payer inpatient database in the United States, with records from approximately 8 million hospital stays each year.” They compared outcomes of 201 pregnant women and 31,155 age-matched nonpregnant women who underwent the surgery for benign thyroid disease, malignant thyroid disease, and hyperparathyroidism between 1999 and 2005.

Pregnant patients had significantly higher rates of surgical complications (24%) than did nonpregnant women (10%), including double the rate of endocrine complications (16% vs. 8%). Pregnant women also had significantly longer median hospital stays (2 days vs. 1 day) and inpatient costs (&dollar;6,873 vs. &dollar;5,963).

In the subset of women who underwent thyroidectomy, those who were pregnant had a higher rate of surgical complications for both benign disease (27% vs. 14%) and malignant disease (21% vs. 8%), the investigators said (Arch. Surg. 2009;144:399-406).

Although these procedures are considered low risk in the general population, women who underwent thyroid or parathyroid surgery while they were pregnant had a relatively high rate of pregnancy complications. The maternal complication rate was 4.5%, and the fetal complication rate was 5.5%.

Pregnant patients of surgeons who performed a high volume of thyroid and parathyroid procedures showed significantly lower rates of both maternal and fetal complications than did those of less-experienced surgeons. In contrast, hospital volume exerted no effect on complication rates.

“It appears to be essential that pregnant patients who require thyroidectomy or parathyroidectomy be directed to high-volume surgeons to optimize their outcomes,” the researchers said.

Given these findings, the risks and benefits of thyroid and parathyroid surgery must be weighed carefully in pregnant women.

“Thyroidectomy is rarely indicated on an urgent basis unless there is significant concern about the well-being of the mother. For example, airway obstruction from large goiters in symptomatic pregnant women with already compromised breathing from uterine expansion, advanced differentiated thyroid cancer, and poorly differentiated cancers could justify proceeding to thyroidectomy prior to delivery,” the researchers advised.

Similarly, parathyroidectomy during pregnancy is indicated to protect the fetus and prevent neonatal hypoparathyroidism and tetany, they said.

This study was supported by the Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs. The investigators reported that they had no financial conflicts of interest.

Women who undergo thyroid or parathyroid surgery during pregnancy have more operative complications and require longer hospitalizations than do nonpregnant women who have such surgery, as well as relatively high rates of maternal and fetal complications.

These findings, from “the first population-based study to examine predictors of clinical and economic outcomes” in this patient group, suggest that thyroid and parathyroid surgery are not the low-risk procedures in pregnant women that they are in the general population, said Dr. SreyRam Kuy of Yale University, New Haven, Conn., and associates.

The investigators assessed thyroid and parathyroid procedures in pregnancy because the subject had not been well studied before now, even though most disorders that necessitate such surgery occur in women of childbearing age. In addition, recent attention has focused on developing practice guidelines for pregnant women with endocrine disorders, and there was a glaring lack of evidence on this issue in the literature.

Dr. Kuy and colleagues performed a retrospective cross-sectional analysis of hospital discharge data using “the largest all-payer inpatient database in the United States, with records from approximately 8 million hospital stays each year.” They compared outcomes of 201 pregnant women and 31,155 age-matched nonpregnant women who underwent the surgery for benign thyroid disease, malignant thyroid disease, and hyperparathyroidism between 1999 and 2005.

Pregnant patients had significantly higher rates of surgical complications (24%) than did nonpregnant women (10%), including double the rate of endocrine complications (16% vs. 8%). Pregnant women also had significantly longer median hospital stays (2 days vs. 1 day) and inpatient costs (&dollar;6,873 vs. &dollar;5,963).

In the subset of women who underwent thyroidectomy, those who were pregnant had a higher rate of surgical complications for both benign disease (27% vs. 14%) and malignant disease (21% vs. 8%), the investigators said (Arch. Surg. 2009;144:399-406).

Although these procedures are considered low risk in the general population, women who underwent thyroid or parathyroid surgery while they were pregnant had a relatively high rate of pregnancy complications. The maternal complication rate was 4.5%, and the fetal complication rate was 5.5%.

Pregnant patients of surgeons who performed a high volume of thyroid and parathyroid procedures showed significantly lower rates of both maternal and fetal complications than did those of less-experienced surgeons. In contrast, hospital volume exerted no effect on complication rates.

“It appears to be essential that pregnant patients who require thyroidectomy or parathyroidectomy be directed to high-volume surgeons to optimize their outcomes,” the researchers said.

Given these findings, the risks and benefits of thyroid and parathyroid surgery must be weighed carefully in pregnant women.

“Thyroidectomy is rarely indicated on an urgent basis unless there is significant concern about the well-being of the mother. For example, airway obstruction from large goiters in symptomatic pregnant women with already compromised breathing from uterine expansion, advanced differentiated thyroid cancer, and poorly differentiated cancers could justify proceeding to thyroidectomy prior to delivery,” the researchers advised.

Similarly, parathyroidectomy during pregnancy is indicated to protect the fetus and prevent neonatal hypoparathyroidism and tetany, they said.

This study was supported by the Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs. The investigators reported that they had no financial conflicts of interest.

Women who undergo thyroid or parathyroid surgery during pregnancy have more operative complications and require longer hospitalizations than do nonpregnant women who have such surgery, as well as relatively high rates of maternal and fetal complications.

These findings, from “the first population-based study to examine predictors of clinical and economic outcomes” in this patient group, suggest that thyroid and parathyroid surgery are not the low-risk procedures in pregnant women that they are in the general population, said Dr. SreyRam Kuy of Yale University, New Haven, Conn., and associates.

The investigators assessed thyroid and parathyroid procedures in pregnancy because the subject had not been well studied before now, even though most disorders that necessitate such surgery occur in women of childbearing age. In addition, recent attention has focused on developing practice guidelines for pregnant women with endocrine disorders, and there was a glaring lack of evidence on this issue in the literature.

Dr. Kuy and colleagues performed a retrospective cross-sectional analysis of hospital discharge data using “the largest all-payer inpatient database in the United States, with records from approximately 8 million hospital stays each year.” They compared outcomes of 201 pregnant women and 31,155 age-matched nonpregnant women who underwent the surgery for benign thyroid disease, malignant thyroid disease, and hyperparathyroidism between 1999 and 2005.

Pregnant patients had significantly higher rates of surgical complications (24%) than did nonpregnant women (10%), including double the rate of endocrine complications (16% vs. 8%). Pregnant women also had significantly longer median hospital stays (2 days vs. 1 day) and inpatient costs (&dollar;6,873 vs. &dollar;5,963).

In the subset of women who underwent thyroidectomy, those who were pregnant had a higher rate of surgical complications for both benign disease (27% vs. 14%) and malignant disease (21% vs. 8%), the investigators said (Arch. Surg. 2009;144:399-406).

Although these procedures are considered low risk in the general population, women who underwent thyroid or parathyroid surgery while they were pregnant had a relatively high rate of pregnancy complications. The maternal complication rate was 4.5%, and the fetal complication rate was 5.5%.

Pregnant patients of surgeons who performed a high volume of thyroid and parathyroid procedures showed significantly lower rates of both maternal and fetal complications than did those of less-experienced surgeons. In contrast, hospital volume exerted no effect on complication rates.

“It appears to be essential that pregnant patients who require thyroidectomy or parathyroidectomy be directed to high-volume surgeons to optimize their outcomes,” the researchers said.

Given these findings, the risks and benefits of thyroid and parathyroid surgery must be weighed carefully in pregnant women.

“Thyroidectomy is rarely indicated on an urgent basis unless there is significant concern about the well-being of the mother. For example, airway obstruction from large goiters in symptomatic pregnant women with already compromised breathing from uterine expansion, advanced differentiated thyroid cancer, and poorly differentiated cancers could justify proceeding to thyroidectomy prior to delivery,” the researchers advised.

Similarly, parathyroidectomy during pregnancy is indicated to protect the fetus and prevent neonatal hypoparathyroidism and tetany, they said.

This study was supported by the Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs. The investigators reported that they had no financial conflicts of interest.